| PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0938-1053 (Expires: TBD). The time required to complete this information collection is estimated to average 24 hours per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. | ||||||||||
| MFP DEMONSTRATION FINANCIAL FORM A | ||||||||||||||
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | ||||||||||||||
| D E M O N S T R A T I O N E X P E N D I T U R E S B Y T Y P E O F S E R V I C E F O R T H E M O N E Y F O L L O W S T H E P E R S O N D E M O N S T R A T I O N P R O G R A M E X P E N D I T U R E S FOR THE QUARTER ENDING ___________(ex: December 31, 2008) |
||||||||||||||
| State: | TOTAL STATE SHARE | E N H A N C E D F M A P | Reg. FMAP | ADJUSTMENTS for PRIOR PERIODS - Qualified HCBS Services | ADJUSTMENTS for PRIOR PERIODS - Demonstration Services | ADJUSTMENTS for PRIOR PERIODS - Supplemental Services | TOTAL FEDERAL SHARE | |||||||
| TOTAL | *Qualified HCBS | **Demonstration Services | ***Supplemental Services | |||||||||||
| COMPUTABLE | ||||||||||||||
| ____% | ____% | _____% | ||||||||||||
| I. State Plan Services | (a) | (b) | (c)' | (d) | (e) | (f) | (g) | (h) | (i) | |||||
| 5. CLINIC SERVICES* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 6. TARGETED CASE MANAGEMENT FOR LONG TERM CARE* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 7. PACE* (PROGRAM FOR ALL INCLUSIVE CARE FOR THE ELDERLY) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 8. REHABILITATION SERVICES* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 9. HOME HEALTH SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 10. HOSPICE* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 11. PERSONAL CARE SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 12. OPTIONAL MEDICAID PLAN SERVICES* (detail on Form B) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| TOTALS-State Plan Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| II. Waiver Services | (a) | (b) | (c)' | (d) | (e) | (f) | (g) | (h) | (i) | |||||
| 1. CASE MANAGEMENT | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 2. HOMEMAKER SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 3. HOME HEALTH AIDE SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 4. PERSONAL CARE | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 5. ADULT DAY HEALTH | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 6. HABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| a. RESIDENTIAL HABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| b. DAY HABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 7. EXPANDED HABILITATION SERVICES (42 CFR §440.180(c)) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| a. PREVOCATIONAL SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| b. SUPPORTED EMPLOYMENT | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| c. EDUCATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 8. RESPITE CARE | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 9. DAY TREATMENT | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 10. PARTIAL HOSPITALIZATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 11. PSYCHOSOCIAL REHABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 12. CLINIC SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 13. LIVE-IN CAREGIVER (42 CFR §441.303(f)(8)) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 14. CAPITATED PAYMENTS FOR LONG TERM CARE SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 15. OTHER* (detail on Form B) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| TOTALS-Waiver Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| TOTALS-Both Waiver & State Plan Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| ADMINISTRATIVE SERVICES (detail on Form C) | $0 | $0 | $0 | |||||||||||
| TOTALS-Waiver, State Plan & Administrative Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| * Qualified HCBS Services are HCBS waiver services that will cotinue once the MFP demonstration has ended | ||||||||||||||
| ** Demonstration Services are services that can be covered under Medicaid that will only be billed during an individuals 12 month transition period. | ||||||||||||||
| *** Supplemental services are services that will only be available for the MFP Demonstration period and are not covered by Medicaid. | ||||||||||||||
| MEDICAL ASSSISTANCE PAYMENT (PRIOR QUARTERS) MACROS | ||||||||||||||
| MACRO | ||||||||||||||
| TITLE | MACRO | DESCRIPTION | ||||||||||||
| ----- | ----------------------------- | --------------------------------- | ||||||||||||
| \T | {goto}Q145~{goto}TOP~ | Sets titles to allow viewing | ||||||||||||
| {r}{down 5}/wtb | during input. | |||||||||||||
| \Z | /wtc | Clears worksheet titles. | ||||||||||||
| \I | {goto}aa1~ | Imports the matrix for printing | ||||||||||||
| /fccnMATRIX~ | ||||||||||||||
| {?}~ | ||||||||||||||
| /wgpd | Removes the protection, temporarily | |||||||||||||
| /rvaa10~e16~ | Copies the matching rates | |||||||||||||
| /rvab10~k17~ | ||||||||||||||
| {goto}e16~ | Centers the matching rates | |||||||||||||
| {edit}{home}{del}^~ | ||||||||||||||
| {goto}k17~ | ||||||||||||||
| {edit}{home}{del}^~ | ||||||||||||||
| /wgpe | Restores the protection | |||||||||||||
| {goto}A1~ | ||||||||||||||
| {calc} | ||||||||||||||
| /wgpd | Copies heading from updated page 1 | |||||||||||||
| /cTITLE1~TITLE2~/wgpe | to page 2. | |||||||||||||
| {calc} | Prints worksheet and allows user | |||||||||||||
| /ppcarPAGE1~os\015\027\048 | to compress print and print eight | |||||||||||||
| {?}~mr226~p88~ | lines per inch. | |||||||||||||
| qa~gprPAGE2~a~gpq | ||||||||||||||
| MFP DEMONSTRATION FINANCIAL FORM B | |||||||||
| Detail for Optional Medicaid State Plan Services & "Other" Waiver Services | |||||||||
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | |||||||||
| D E M O N S T R A T I O N E X P E N D I T U R E S B Y T Y P E O F S E R V I C E F O R T H E M O N E Y F O L L O W S T H E P E R S O N D E M O N S T R A T I O N P R O G R A M E X P E N D I T U R E S FOR THE QUARTER ENDING ___________(ex: December 31, 2008) |
|||||||||
| State: | TOTAL STATE SHARE | ENHANCED FMAP | ENHANCED FMAP | Reg. FMAP | ADJUSTMENTS for PRIOR PERIODS - Qualified HCBS | ADJUSTMENTS for PRIOR PERIODS - Demonstration Services | ADJUSTMENTS for PRIOR PERIODS - Supplemental Services | TOTAL FEDERAL SHARE | |
| TOTAL | *Qualified HCBS | **Demonstration Services | ***Supplemental Services | ||||||
| I. State Plan Services OPTIONAL MEDICAID PLAN SERVICES* | COMPUTABLE | ||||||||
| _____% | _____% | _____% | |||||||
| (Detail for Form A, Line I,12) | (a) | (b) | (c) | (d) | (e) | (f) | (g) | (h) | (i) |
| a. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| b. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| c. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| d. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| e. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS - Optional Plan Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| II. "Other" Services, Demo & Supplemental Services (Detail for Form A, Section II, line 15) | (a) | (b) | (c) | (d) | (e) | (f) | (g) | (h) | (i) |
| a. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| b. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| c. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| d. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| e. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| f. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| g. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| h. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| i. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| j. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| k. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| l. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| m. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| n. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| o. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| p. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| q. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| r. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| s. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| t. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| u. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS - "Other" , Demo, & Supplemental Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS - Optional, "Other" , Demo & Supplemental Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| * Qualified HCBS Services are HCBS waiver services that will cotinue once the MFP demonstration has ended | |||||||||
| ** Demonstration Services are services that can be covered under Medicaid that will only be billed during an individuals 12 month transition period. | |||||||||
| *** Supplemental services are services that will only be available for the MFP Demonstration period and are not covered by Medicaid. | |||||||||
| MFP DEMONSTRATION FINANCIAL FORM C | |||||||||
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | |||||||||
| D E M O N S T R A T I O N E X P E N D I T U R E S B Y T Y P E O F S E R V I C E F O R T H E M O N E Y F O L L O W S T H E P E R S O N D E M O N S T R A T I O N P R O G R A M E X P E N D I T U R E S THE QUARTER ENDING ___________(ex: December 31, 2008) |
|||||||||
| State: | TOTAL STATE SHARE | A D M I N I S T R A T I V E F M A P | QoL Survey | ADJUSTMENTS for PRIOR PERIODS | TOTAL FEDERAL SHARE | ||||
| TOTAL | |||||||||
| COMPUTABLE | Normal Rate | SPMP | Enhanced | Other | Reimbursement @$100 per survey | ||||
| 50% | 75% | 90% | 100% | ||||||
| III. Administrative | (a) | (b) | (c)' | (d) | (e) | (f) | (g) | (h) | (i) |
| a. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| b. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| c. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| d. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| e. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| f. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| g. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| h. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| i. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| j. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| k. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| l. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| m. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| n. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| o. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| p. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| q. | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Administration - Normal should include all costs that adhere to CFR Title 42, Section 433(b)(7) | |||||||||
| Administrative Skilled Professional Medical Personnel (SPMP) - 75% should include all costs that adhere to CFR Title 42, Sections 433(b)(4) and 433(b)(10) | |||||||||
| Administrative Enhanced - 90% should include all costs that adhere to CFR Title 42 Section 433(b)(3) | |||||||||
| DEPARTMENT OF HEALTH & HUMAN SERVICES | ||||||||
| CENTERS FOR MEDICARE & MEDICAID SERVICES | ||||||||
| MFP DEMONSTRATION FINANCIAL FORM D | ||||||||
| NARRATIVE EXPLANATIONS | ||||||||
| STATE | QUARTER ENDING | |||||||
| NARRATIVE | ||||||||
| MFP FINANCIAL FORM D - NARRATIVE | ||||||||
| File Type | application/vnd.ms-excel |
| Author | Mitch Bryman |
| Last Modified By | Mitch Bryman |
| File Modified | 2018-09-06 |
| File Created | 2000-12-06 |