CMS-10398 #10 BN Table Shell

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

10 - Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx

GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application

OMB: 0938-1148

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Overview

Historic Data
WOW
WW
DSH
Summary
Dropdown


Sheet 1: Historic Data

5 YEARS OF HISTORIC DATA












SPECIFY TIME PERIOD AND ELIGIBILITY GROUP DEPICTED:












Medicaid Pop 1 HY 1 HY 2 HY 3 HY 4 HY 5 5-YEARS
TOTAL EXPENDITURES




$-
ELIGIBLE MEMBER MONTHS





PMPM COST #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TREND RATES




5-YEAR



ANNUAL CHANGE

AVERAGE
TOTAL EXPENDITURE
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
ELIGIBLE MEMBER MONTHS
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM COST
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!







Medicaid Pop 2 HY 1 HY 2 HY 3 HY 4 HY 5 5-YEARS
TOTAL EXPENDITURES




$-
ELIGIBLE MEMBER MONTHS





PMPM COST #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TREND RATES




5-YEAR



ANNUAL CHANGE

AVERAGE
TOTAL EXPENDITURE
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
ELIGIBLE MEMBER MONTHS
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM COST
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!







Medicaid Pop 3 HY 1 HY 2 HY 3 HY 4 HY 5 5-YEARS
TOTAL EXPENDITURES




$-
ELIGIBLE MEMBER MONTHS





PMPM COST #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TREND RATES




5-YEAR



ANNUAL CHANGE

AVERAGE
TOTAL EXPENDITURE
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
ELIGIBLE MEMBER MONTHS
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM COST
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!







Other Data HY 1 HY 2 HY 3 HY 4 HY 5 5-YEARS
TOTAL EXPENDITURES




$-
ELIGIBLE MEMBER MONTHS





PMPM COST #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TREND RATES




5-YEAR



ANNUAL CHANGE

AVERAGE
TOTAL EXPENDITURE
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
ELIGIBLE MEMBER MONTHS
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM COST
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Sheet 2: WOW

DEMONSTRATION WITHOUT WAIVER (WOW) BUDGET PROJECTION: COVERAGE COSTS FOR POPULATIONS






















ELIGIBILITY TREND MONTHS BASE YEAR TREND DEMONSTRATION YEARS (DY)



TOTAL
GROUP RATE 1 OF AGING DY 00 RATE 2 DY 01 DY 02 DY 03 DY 04 DY 05 WOW











Medicaid Pop 1









Pop Type: Medicaid








Eligible Member Months #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM Cost #DIV/0! 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Total Expenditure



#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!











Medicaid Pop 2









Pop Type: Medicaid








Eligible Member Months #DIV/0! 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM Cost #DIV/0! 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Total Expenditure



#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!











Medicaid Pop 3









Pop Type: Medicaid








Eligible Member Months #DIV/0! 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM Cost #DIV/0! 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Total Expenditure



#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Sheet 3: WW

DEMONSTRATION WITH WAIVER (WW) BUDGET PROJECTION: COVERAGE COSTS FOR POPULATIONS





















DEMONSTRATION YEARS (DY)



TOTAL WW
ELIGIBILITY GROUP DY 00 DEMO TREND RATE DY 01 DY 02 DY 03 DY 04 DY 05









Medicaid Pop 1







Pop Type: Medicaid






Eligible Member Months #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM Cost #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Total Expenditure

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!









Medicaid Pop 2







Pop Type: Medicaid






Eligible Member Months #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM Cost #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Total Expenditure

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!









Medicaid Pop 3







Pop Type: Medicaid






Eligible Member Months #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMPM Cost #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Total Expenditure

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!









Exp Pop 1







Pop Type: Expansion






Eligible Member Months







PMPM Cost







Total Expenditure

$- $- $- $- $- $-









Exp Pop 2







Pop Type: Expansion






Eligible Member Months







PMPM Cost







Total Expenditure

$- $- $- $- $- $-

Sheet 4: DSH

Panel 1: Historic DSH Claims for the Last Five Fiscal Years:





RECENT PAST FEDERAL FISCAL YEARS






20__ 20__ 20__ 20__ 20__
State DSH Allotment (Federal share)





State DSH Claim Amount (Federal share)





DSH Allotment Left Unspent (Federal share) $- $- $- $- $-







Panel 2: Projected Without Waiver DSH Expenditures for FFYs That Overlap the Demonstration Period





FEDERAL FISCAL YEARS THAT OVERLAP DEMONSTRATION YEARS






FFY 00 (20__) FFY 01 (20__) FFY 02 (20__) FFY 03 (20__) FFY 04 (20__) FFY 05 (20__)
State DSH Allotment (Federal share)





State DSH Claim Amount (Federal share)





DSH Allotment Projected to be Unused (Federal share) $- $- $- $- $- $-







Panel 3: Projected With Waiver DSH Expenditures for FFYs That Overlap the Demonstration Period





FEDERAL FISCAL YEARS THAT OVERLAP DEMONSTRATION YEARS






FFY 00 (20__) FFY 01 (20__) FFY 02 (20__) FFY 03 (20__) FFY 04 (20__) FFY 05 (20__)
State DSH Allotment (Federal share) $- $- $- $- $- $-
State DSH Claim Amount (Federal share)





Maximum DSH Allotment Available for Diversion (Federal share)





Total DSH Alltoment Diverted (Federal share) $- $- $- $- $- $-
DSH Allotment Available for DSH Diversion Less Amount Diverted (Federal share, must be non-negative) $- $- $- $- $- $-
DSH Allotment Projected to be Unused (Federal share, must be non-negative) $- $- $- $- $- $-







Panel 4: Projected DSH Diversion Allocated to DYs





DEMONSTRATION YEARS







DY 01 DY 02 DY 03 DY 04 DY 05
DSH Diversion to Leading FFY (total computable)





FMAP for Leading FFY












DSH Diversion to Trailing FFY (total computable)





FMAP for Trailing FFY












Total Demo Spending From Diverted DSH (total computable)
$- $- $- $- $-

Sheet 5: Summary

Budget Neutrality Summary












Without-Waiver Total Expenditures






DEMONSTRATION YEARS (DY)



TOTAL

DY 01 DY 02 DY 03 DY 04 DY 05
Medicaid Populations





Medicaid Pop 1 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Medicaid Pop 2 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Medicaid Pop 3 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!





















TOTAL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!







With-Waiver Total Expenditures






DEMONSTRATION YEARS (DY)



TOTAL

DY 01 DY 02 DY 03 DY 04 DY 05
Medicaid Populations





Medicaid Pop 1 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Medicaid Pop 2 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Medicaid Pop 3 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!







Expansion Populations





Exp Pop 1 $- $- $- $- $- $-
Exp Pop 2 $- $- $- $- $- $-














TOTAL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!







VARIANCE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Sheet 6: Dropdown

Population Status Drop-Down
Medicaid
Expansion
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