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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State Estimate of Quarterly Grant Awards (In Thousands)
Submission Date:
State:
Contact Name for Information:
Certification Qtr:
Medical Assistance Payments
Fiscal Quarter
Tot. Comp.
Federal Share
State Share
State & Local Administration
Tot. Comp.
Federal Share
State Share
Federal Share
M-CHIP
Fiscal Year: 2017
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
Fiscal Year: 2018
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
I certify that:
1. I am the executive officer of the state agency or his/her designate authorized by the state to submit this form.
2. The fiscal year budget estimates only include expenditures under the Medicaid program under Title XIX of the Social Security Act (the Act),
and as applicable, under the Children’s Health Insurance Program (CHIP) under Title XXI of the Act, that are allow able in accordance w ith
applicable implementing federal, state, and local statutes, regulations, policies, and the state plan approved by the Secretary and in effect
during the fiscal year under Title XIX of the Act for the Medicaid program, and as applicable, under Title XXI of the Act for the CHIP.
3. The budget estimates are based upon the most reliable information available to the state.
4. The state and/or local funds required to match the state’s allow able expenditures during the certification quarter w ill be available, and such
state and/or local funds are in accordance w ith all applicable federal requirements for the non-federal share match of expenditures.
5. The amount of state and local funds available for quarter for the Medicaid program is .
6. Federal matching funds are not being requested for the certification quarter to match expenditures under any Medicaid state plan
amendment under Title XIX of the Act and/or Children Health Plan amendment under Title XXI of the Act that w as submitted after January 2,
2001, and that has not been approved by the Secretary effective for the certification quarter.
7. The information show n above and on the Form CMS-37 Summary Sheet and the Supporting Schedules is correct to the best of my
know ledge and belief.
Date:
Signature:
Title:
User Performing Certification:
Footnotes:
The completed Budget, Expenditure and supporting forms are to be submitted via the on-line MBES/CBES system to the Centers for Medicare & Medicaid
Services, Center for Medicaid and State Operations, Finance, Systems and Quality Group, Division of Financial Management, located at Mailstop S3-13-15,
7500 Security Blvd., Baltimore, Maryland 21244-1850.
Form CMS 37.1
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State Estimate of Health Information Technology Grants (In Thousands)
Submission Date:
Certification Qtr:
State:
Health Information Technology Incentive Payments
Fiscal Quarter
Tot. Comp.
Federal Share
State Share
Health Information Technology Administration
Tot. Comp.
Federal Share
State Share
Fiscal Year: 2017
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
Fiscal Year: 2018
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
Form CMS 37.1HIT
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
1A
Inpatient Hospital / Regular Payment
1B
Inpatient Hospital / DSH Adj. Payment
1C
Inpatient Hospital / SupplementalPayments
1D
Inpatient Hospital - GME Payments
2A
Mental Health / Regular Payment
2B
Mental Health / DSH Adj. Payment
2C
Certified Community Behavior Health Clinic Payments
3A
Nursing Facility / Regular Payments
3B
Nursing Facility / SupplementalPayments
4A
Int. Care Facility - Ind. with Intellectual Disabi lities: Public Pmnts
4B
Int. Care Facility - Ind. with Intellectual Disabi lities: Priv. Pmnts
4C
Int. Care Facility - Ind. with Intellectual Disabi lities: Suppl.
Pmnts
5A
Physician and Surgical / RegularPayments
5B
Physician and Surgical / SupplementalPayments
5C
Physician & Surgical Services - Evaluation andManagement
5D
Physician & Surgical Services - Vaccine codes
6A
Outpatient Hospital / Regular Services
6B
Outpatient Hospital / Supplemental Services
7
Prescribed Drugs
7A1
Drug Rebate / Natl. Agreement
7A2
Drug Rebate / State Agreement
7A3
MCO - National Agreement
Form CMS 37.3
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
7A4
MCO - State Sidebar Agreement
7A5
Increased ACA OFFSET - Fee for Service -100%
7A6
Increased ACA OFFSET - MCO - 100%
8
Dental Services
9A
Other Practitioners' Services / RegularPayment
9B
Other Practitioners' Services -Suppl. Payment
10
Clinic Services
11
Lab/Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions
15
EPSDT Screenings
16
Rural Health Clinic
17A
Medicare HIP / Part A Prem.
17B
Medicare HIP / Part B Prem.
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
17C1 Medicare Qual Individuals 120%-134% Poverty
17D Medicare HIP / Coinsurance
18 Medicaid HIP / MCO
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
18A3 Medicaid MCO - Community First Choice
18A4 Medicaid MCO - Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Form CMS 37.3
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
18A5 Medicaid MCO - Certified Community Behavior Health Clinic
Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and Management
a
18B1 Prepaid Ambulatory Health Plan
18B1 Medicaid PAHP - Certified Community Behavior Health Clinic
e
Payments
18B1 MCO PAHP - Evaluation and Management
a
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
18B2 Medicaid PIHP - Certified Community Behavior Health Clinic
e
Payments
18B1 MCO PAHP - Preventive Services Grade A OR B, ACIP
d
Vaccines and their Admin
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and Management
a
18B2 MCO PIHP - Vaccine codes
b
18B2 MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services Grade A OR B, ACIP Vaccines
d
and their Admin
18C Medicaid HIP / Group
Form CMS 37.3
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2017
Budget Year 2018
Total Computable
Federal Share
Total Computable
Federal Share
18D Medicaid HIP / Coinsurance
18E
Medicaid HIP / Other
19A
Home-Comm Serv/Regular Payment (Waiver)
19B
Home-Comm Serv/State Pl 1915(i) Only Payment
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Form CMS 37.3
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
19D Home & Community Based Services State Plan 1915(k)
Community First Choice
22
All-Inclusive Care for Elders
23A
Personal Care / Regular Payments
23B
Personal Care / SDS 1915(j)
24A
Targeted Case Mgmt. / Community Case-Mgmt.
24B
Case Mgmt. / State Wide
25
Primary Care Case Mgmt. Services
26
Hospice Benefits
27
Emeg. Service Undoc. Aliens
28
Federally Qual. Health Center
29
Non-Emergency Medical Transportation
30
Physical Therapy
31
Occupational Therapy
35
Nurse Mid-Wife
Form CMS 37.3
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2017
Budget Year 2018
Total Computable
36
Emergency Hospital Services
37
Critical Access Hospitals
38
Nurse Practitioner Services
39
School Based Services
40
Rehabilitative Services (non-school-based)
41
Private Duty Nursing
42
Freestanding Birth Center
43
Health Home for Enrollees w Chronic Conditions
44
Tobacco Cessation for Preg Women
49
Other Care Services
50
Subtotal
51
Collections
52
Prior Period Adjustments
53
Total Medicaid (non-M-CHIP)
54
M-CHIP Expansions
55
Total Medicaid
Form CMS 37.3
Federal Share
Total Computable
Federal Share
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
Total Administration
State And Local Administration
FFP
Rates
1
Family Planning
90
2A
Design, Develop or Install MMIS: Inhouse
and Other State Activities
90
2B
Design, Develop or Install MMIS: Private
Sector Contractors
90
2C
Design, Develop or Install MMIS: Drug
Claims System
90
3A
Skilled Professional Medical Personnel Single State Agency
75
3B
Skilled Professional Medical Personnel Other Agencies
75
4A
Operation of an Approved MMIS: Inhouse
and Other State Activities
75
4B
Operation of an Approved MMIS: Private
Sector Contractors
75
5A
Non-MMIS Systems: Inhouse and Other
State Activities
50
5B
Non-MMIS Systems: Private Sector
Contractors
50
5C
Mechanized Systems, not Approved under
MMIS Procedures: Interagency
50
6
Quality Improvement Organizations
75
7A
TPL-Billing Offset
50
7B
Assignment of Rights-Billing Offset
50
8
Immigration Status System
100
9
Nurse Aide Training and Competency
Evaluation Programs Costs
50
Total Administration
Fiscal Year 2017
Total Comp.
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
* HIT lines excluded f rom total
Form CMS 37.9
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
FFP
Rates
10
Preadmission Screening Costs
75
11
Resident Review Activities
75
12
Drug Use Review Program
50
13
Out stationed Eligibility Workers
50
14
TANF Base Allocation
90
15
TANF Secondary Allocation - 90%
90
16
TANF Secondary Allocation - 75%
75
17
External Quality Review s
75
18
Enrollment Brokers
50
19
School Based Administration
50
20
Program Integrity/Fraud, Waste, and Abuse
Activities
50
21
County/Local ADM Costs
50
22
Interagency Costs
50
23
Translation and Interpretation
75
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
Total Administration
Fiscal Year 2017
Total Comp.
Total Administration
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
90
* HIT lines excluded f rom total
Form CMS 37.9
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
FFP
Rates
24B
HIT: Planning: Cost of Private Contractors
90
24C
HIT: Implementation and Operation: Cost of
In-house Activities
90
24D
HIT: Implementation and Operation: Cost of
Private Contractors
90
24E
HIT Incentive Payments - Eligible
Professionals
100
24F
HIT Incentive Payments - Eligible Hospitals
100
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
90
25B
CVT Operation - CHIPRA
75
26
Planning for Health Homes for Enrollees
w ith Chronic Conditions
27
Recovery Audit Contractors State
Administration
50
28A
Design Development/Installation of
Medicaid Elig. Determ. Sys. – Cost of
In-house Activities
90
28B
Design Development/Installation of
Medicaid Elig. Determ. Sys. – Cost of
Private Sec. Contractors
90
28C
Operation of an Approved Medicaid
Eligibility Determination Systems – Cost of
In-house Activities
75
28D
Operation of an Approved Medicaid
Eligibility Determination Sys. – Cost of
Private Sec. Contractors
75
28E
Eligibility Determination Staff – Cost of
In-house Activities
75
28F
Eligibility Determination Staff – Cost of
Private Sector Contractors
75
Total Administration
Fiscal Year 2017
Total Comp.
Total Administration
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
* HIT lines excluded f rom total
Form CMS 37.9
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
FFP
Rates
28G
Eligibility Determination Staff – Cost of
In-house Activities – 50% FFP
50
28H
Eligibility Determination Staff – Cost of
Private Sector Contractors – 50% FFP
50
29
Non-Emergency Medical Transportation
50
49
Other Financial Participation
50
50
Sub-total (Line 1 - 49)
51
Collections
52
Prior Period Adjust
53
Total
Total Administration
Fiscal Year 2017
Total Comp.
Total Administration
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
* HIT lines excluded f rom total
Form CMS 37.9
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Family Planning
2A
Design, Develop or Install MMIS: Inhouse
and Other State Activities
90
2B
Design, Develop or Install MMIS: Private
Sector Contractors
90
2C
Design, Develop or Install MMIS: Drug
Claims System
90
3A
Skilled Prof essional Medical Personnel Single State Agency
75
3B
Skilled Prof essional Medical Personnel Other Agencies
75
4A
Operation of an Approved MMIS: Inhouse
and Other State Activities
75
4B
Operation of an Approved MMIS: Private
Sector Contractors
75
5A
Non-MMIS Sy stems: Inhouse and Other
State Activities
50
5B
Non-MMIS Sy stems: Private Sector
Contractors
50
5C
Mechanized Sy stems, not Approved under
MMIS Procedures: Interagency
50
6
Quality ImprovementOrganizations
7A
TPL-Billing Of fset
7B
Assignment of Rights-Billing Offset
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
1
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
90
75
50
50
* HIT lines excluded f rom total
Form CMS 37.10
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Immigration StatusSystem
9
Nurse Aide Training and Competency
Ev aluation Programs Costs
10
Preadmission Screening Costs
11
Resident Review Activities
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base Allocation
15
TANF Secondary Allocation - 90%
16
TANF Secondary Allocation - 75%
17
External Quality Reviews
18
Enrollment Brokers
19
School Based Administration
20
Program Integrity/Fraud, Waste, and
Abuse Activities
21
County /Local ADM Costs
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
8
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
100
50
75
75
50
50
90
90
75
75
50
50
50
50
* HIT lines excluded f rom total
Form CMS 37.10
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost
of In-house Activities
90
24D
HIT: Implementation and Operation: Cost
of Priv ate Contractors
90
24E
HIT Incentive Payments- Eligible
Prof essionals
100
24F
HIT Incentive Payments- Eligible
Hospitals
100
25
Citizenship Verification Technology - CHIPRA
25A
CVT Dev elopment - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning f or Health Homes for Enrollees
with Chronic Conditions
27
Recov ery Audit Contractors State
Administration
50
28A
Design Development/Installation of
Medicaid Elig. Determ. Sys. – Cost of
90
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
22
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
50
75
90
90
90
75
* HIT lines excluded f rom total
Form CMS 37.10
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
State And Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Fiscal Year 2018
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
In-house Activities
28B
Design Development/Installation of
Medicaid Elig. Determ. Sys. – Cost of
Priv ate Sec. Contractors
90
28C
Operation of an Approved Medicaid
Eligibility Determination Systems – Cost of
In-house Activities
75
28D
Operation of an Approved Medicaid
Eligibility Determination Sys. – Cost of
Priv ate Sec. Contractors
75
28E
Eligibility Determination Staff – Cost of
In-house Activities
75
28F
Eligibility Determination Staff – Cost of
Priv ate Sector Contractors
75
28G
Eligibility Determination Staff – Cost of
In-house Activities – 50% FFP
50
28H
Eligibility Determination Staff – Cost of
Priv ate Sector Contractors – 50% FFP
50
29
Non-Emergency Medical Transportation
49
Other Financial Participation
50
Sub-total (Line 1 - 49)
51
Collections
52
Prior Period Adjust
53
Total
50
50
* HIT lines excluded f rom total
Form CMS 37.10
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Other Budget Narratives
State:
Submission Date:
Other Narrative Explanations
Form CMS 37.12
Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Program:
1A
Inpatient Hospital / Regular Payment
1B
Inpatient Hospital / DSH Adj. Payment
1C
Inpatient Hospital / SupplementalPayments
1D
Inpatient Hospital - GME Payments
2A
Mental Health / Regular Payment
2B
Mental Health / DSH Adj. Payment
2C
Certified Community Behavior Health Clinic Payments
3A
Nursing Facility / Regular Payments
3B
Nursing Facility / SupplementalPayments
4A
Int. Care Facility - Ind. with Intellectual Disabilities: Public Pmnts
4B
Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Pmnts
4C
5A
Int. Care Facility - Ind. with Intellectual Disabilities: Suppl.
Pmnts
Physician and Surgical / RegularPayments
5B
Physician and Surgical / SupplementalPayments
5C
Physician & Surgical Services - Evaluation andManagement
5D
Physician & Surgical Services - Vaccine codes
6A
Outpatient Hospital / Regular Services
6B
Outpatient Hospital / Supplemental Services
7
Prescribed Drugs
7A1
Drug Rebate / Natl. Agreement
7A2
Drug Rebate / State Agreement
7A3
MCO - National Agreement
Form CMS 37.3I
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Program:
7A4
MCO - State Sidebar Agreement
7A5
Increased ACA OFFSET - Fee for Service -100%
7A6
Increased ACA OFFSET - MCO - 100%
8
Dental Services
9A
Other Practitioners' Services / RegularPayment
9B
Other Practitioners' Services -Suppl. Payment
10
Clinic Services
11
Lab/Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions
15
EPSDT Screenings
16
Rural Health Clinic
17A
Medicare HIP / Part A Prem.
17B
Medicare HIP / Part B Prem.
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
17C1 Medicare Qual Individuals 120%-134% Poverty
17D Medicare HIP / Coinsurance
18A
Medicaid HIP / MCO
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
18A3 Medicaid MCO - Community First Choice
18A4 Medicaid MCO - Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Form CMS 37.3I
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Program:
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
18A5 Medicaid MCO - Certified Community Behavior Health Clinic
Payments
18B1 Medicaid PAHP - Certified Community Behavior Health Clinic
e
Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and Management
18B2 Medicaid PIHP - Certified Community Behavior Health Clinic
e
Payments
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
18B1 MCO PAHP - Preventive Services Grade A OR B, ACIP
d
Vaccines and their Admin
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and Management
a
18B2 MCO PIHP - Vaccine codes
b
18B2 MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services Grade A OR B, ACIP Vaccines
d
and their Admin
18C Medicaid HIP / Group
18D Medicaid HIP / Coinsurance
18E
Medicaid HIP / Other
19A
Home-Comm Serv/Regular Payment (Waiver)
19B
Home-Comm Serv/State Pl 1915(i) Only Payment
19C Home-Comm Serv/State Pl 1915(j) Only Payment
18C Medicaid HIP / Group
18D Medicaid HIP / Coinsurance
Form CMS 37.3I
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Program:
Type of Service
Program:
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2017
Budget Year 2018
Total Computable
Federal Share
Total Computable
Federal Share
Total Budgeted Services
Total Budgeted Services
Current Year 2017
Budget Year 2018
Total Computable
Federal Share
Total Computable
Federal Share
19D Home & Community Based Services State Plan 1915(k)
Community First Choice
22
All-Inclusive Care for Elders
23A
Personal Care / Regular Payments
23B
Personal Care / SDS 1915(j)
24A
Targeted Case Mgmt. / Community Case-Mgmt.
24B
Case Mgmt. / State Wide
25
Primary Care Case Mgmt. Services
26
Hospice Benefits
27
Emeg. Service Undoc. Aliens
28
Federally Qual. Health Center
29
Non-Emergency Medical Transportation
30
Physical Therapy
31
Occupational Therapy
32
Services for Speech, Hearing and Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
Diagnostic Screening & Preventive Services
34A
35
Preventive Services Grade A OR B, ACIP Vaccinesand their
Admin
Nurse Mid-Wife
36
Emergency Hospital Services
Form CMS 37.3I
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Program:
37
Critical Access Hospitals
38
Nurse Practitioner Services
39
School Based Services
Form CMS 37.3I
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2017
Budget Year 2018
Total Computable
Federal Share
Total Computable
Federal Share
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - Estimated Medical Assistance by Type of Service (In Thousands)
State:
Type of Service
Program:
40
Rehabilitative Services (non-school-based)
41
Private Duty Nursing
42
Freestanding Birth Center
43
Health Home for Enrollees w Chronic Conditions
44
Tobacco Cessation for Preg Women
49
Other Care Services
50
Subtotal
51
Collections
52
Prior Period Adjustments
53
Total Medicaid (non-M-CHIP)
54
M-CHIP Expansions
55
Total Medicaid
Form CMS 37.3I
Submission Date:
Total Budgeted Services
Current Year 2017
Total Computable
Federal Share
Total Budgeted Services
Budget Year 2018
Total Computable
Federal Share
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - State and Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Program:
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Family Planning
2A
Design, Develop or Install MMIS: Inhouse
and Other State Activities
90
2B
Design, Develop or Install MMIS: Private
Sector Contractors
90
2C
Design, Develop or Install MMIS: Drug
Claims System
90
3A
Skilled Prof essional Medical Personnel Single State Agency
75
3B
Skilled Prof essional Medical Personnel Other Agencies
75
4A
Operation of an Approved MMIS: Inhouse
and Other State Activities
75
4B
Operation of an Approved MMIS: Private
Sector Contractors
75
5A
Non-MMIS Sy stems: Inhouse and Other
State Activities
50
5B
Non-MMIS Sy stems: Private Sector
Contractors
50
5C
Mechanized Sy stems, not Approved under
MMIS Procedures: Interagency
50
6
Quality ImprovementOrganizations
7A
TPL-Billing Of fset
7B
Assignment of Rights-Billing Offset
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
1
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
90
75
50
50
* HIT lines excluded f rom total
Form CMS 37.10I
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - State and Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Program:
8
Immigration StatusSystem
9
Nurse Aide Training and Competency
Ev aluation Programs Costs
10
Preadmission Screening Costs
11
Resident Review Activities
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base Allocation
15
TANF Secondary Allocation - 90%
16
TANF Secondary Allocation - 75%
17
External Quality Reviews
18
Enrollment Brokers
19
School Based Administration
20
Program Integrity/Fraud, Waste, and
Abuse Activities
21
County /Local ADM Costs
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Fiscal Year 2018
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
100
50
75
75
50
50
90
90
75
75
50
50
50
50
* HIT lines excluded f rom total
Form CMS 37.10I
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - State and Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Program:
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost
of In-house Activities
90
24D
HIT: Implementation and Operation: Cost
of Priv ate Contractors
90
24E
HIT Incentive Payments- Eligible
Prof essionals
100
24F
HIT Incentive Payments- Eligible
Hospitals
100
25
Citizenship Verification Technology - CHIPRA
25A
CVT Dev elopment - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning f or Health Homes for Enrollees
with Chronic Conditions
27
Recov ery Audit Contractors State
Administration
50
28A
Design Development/Installation of
Medicaid Elig. Determ. Sys. – Cost of
90
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
22
Fiscal Year 2018
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
50
75
90
90
90
75
* HIT lines excluded f rom total
Form CMS 37.10I
Report Date: Wednesday, September 13, 2017 - 09:23 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Medicaid Program Budget Report
Information - State and Local Administration (In Thousands)
State:
Submission Date:
State And Local Administration
Program:
Fiscal Year 2017
FFP
Rates
Salaries And Expenses
Fiscal Year 2018
Salaries And Expenses
Other Administration
Other Administration
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
FTE's
Total Comp.
Fed. Share
Total Comp.
Fed. Share
In-house Activities
28B
Design Development/Installation of
Medicaid Elig. Determ. Sys. – Cost of
Priv ate Sec. Contractors
90
28C
Operation of an Approved Medicaid
Eligibility Determination Systems – Cost of
In-house Activities
75
28D
Operation of an Approved Medicaid
Eligibility Determination Sys. – Cost of
Priv ate Sec. Contractors
75
28E
Eligibility Determination Staff – Cost of
In-house Activities
75
28F
Eligibility Determination Staff – Cost of
Priv ate Sector Contractors
75
28G
Eligibility Determination Staff – Cost of
In-house Activities – 50% FFP
50
28H
Eligibility Determination Staff – Cost of
Priv ate Sector Contractors – 50% FFP
50
29
Non-Emergency Medical Transportation
49
Other Financial Participation
50
Sub-total (Line 1 - 49)
51
Collections
52
Prior Period Adjust
53
Total
50
50
* HIT lines excluded f rom total
Form CMS 37.10I
Report Date: Wednesday, September 13, 2017 - 09:23 AM
| File Type | application/pdf |
| File Title | 37 Blank Forms |
| Author | REBECCA HENSLEY |
| File Modified | 2017-09-26 |
| File Created | 2017-09-26 |