CMS-64 Unfilled Form

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 04/30/2021

Quarterly Medicaid Assistance Expenditures
For the Medical Assistance Program
State:

Quarter Ended: 06/30/2019
Certification
Medical Assistance Payments

CMS 64 Summary Sheet

State and Local Administration

Total

Federal Share

Total

Federal Share

(A)

(B)

(C)

(D)

Net Expenditures Reported In This Period (Sum of Items
6, 7 and 8 Less 9 and 10)

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. This report only includes 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 allowable in accordance with applicable
implementing federal, state, and local statutes, regulations, policies, and the state plan approved by the Secretary and in effect during the
Quarter Ended indicated above under Title XIX of the Act for the Medicaid program, and as applicable, under Title XXI of the Act for the CHIP.
3. The expenditures included in this report are based on the state's accounting of actual recorded expenditures, and are not based on
estimates.
4. The required amount of state and/or local funds were available and used to match the state’s allowable expenditures included in this report,
and such state and/or local funds were in accordance with all applicable federal requirements for the non-federal share match of expenditures.
5. Federal matching funds are not being claimed on this report to match any expenditure under any Medicaid and/or CHIP state plan
amendment that was submitted after January 2, 2001, and that has not been approved by the Secretary effective for the Quarter Ended
indicated above.
6. The information shown above and on the Form CMS-64 Summary Sheet and the Supporting Schedules is correct to the best of my
knowledge and belief.
Date:

Signature:

Title:

User Performing Certification:
Footnotes:

Form CMS 64 Certification

Report Date: Tuesday, May 21, 2019 - 09:28 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 04/30/2021

Quarterly Medicaid Statement of Expenditures
For the Medical Assistance
Program Summary Sheet

Total
Computable
(A)

Medical Assistance Payments
Federal Share
Medicaid
ARRA
BIPP
(B)
(C)
(D)

Quarter Ended:
State and Local
Administration
Total
(E)

Total Computable Federal Share

(F)

(G)

Section A. Quarterly Status of Funding
1

Awards Received During The Quarter For The Quarter Being
Reported And Prior Quarters

2

Awards Received During The Quarter For Subsequent Quarters

3A

Interest: Received On Medicaid Recoveries

3B

Interest: Assessed On Disallowances

4

Medicare Overpayment Collection Under Sec. 1914 and 42 CFR
447.30

5

Other

Section B. Expenditures Reported for Period
6

Expenditures In This Quarter

7

Adjustments Increasing Claims For Prior Quarters

8

Other Expenditures

9A

Collections: Third Party Liability

9B

Collections: Probate

9C1

Recoveries: Fraud, Waste and Abuse Efforts

9C2

Recoveries: OIG Compliant False Claims Act

9D

Collections: Other

9E

RAC Collections

9F

PERM Collections

Form CMS 64 Summary

Report Date: Tuesday, May 21, 2019 - 09:28 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 04/30/2021

Quarterly Medicaid Statement of Expenditures
For the Medical Assistance
Program Summary Sheet

Total
Computable
(A)
9G

State and Local
Administration
Total
(E)

Total Computable Federal Share

(F)

(G)

MEQC Collections

10A

Adjustments Decreasing Claims For Prior Quarters: Federal Audit

10B

Adjustments Decreasing Claims For Prior Quarters: Other

10C

Adjustments Decreasing Claims For Prior Quarters: Overpayment
Adjustments (Attach 64.9O)

10D

Adjustments/Decreasing Prior Qtrs - Perm

10E

Adjustments/Decreasing Prior Qtrs - RAC

10F

Adjustments/Decreasing Prior Qtrs - Fraud, Waste and Abuse
Overpayments

10G

Adjustments/Decreasing Prior Qtrs - OMEQC

11

Medical Assistance Payments
Federal Share
Medicaid
ARRA
BIPP
(B)
(C)
(D)

Quarter Ended:

Net Expenditures Reported In This Period (Sum of Items 6, 7 and 8
Less 9 and 10)

Form CMS 64 Summary

Report Date: Tuesday, May 21, 2019 - 09:28 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 04/30/2021

Medicaid Eligibility Quality Control Collections and Overpayment
State:

Quarter Ended:
Total

Federal Share

Computable
Overpayment Activity

(A)

Total

FY

FY

FY

FY

(B)

(C)

(D)

(E)

Federal
(F)

1 Overpayments Not Collected Or
Adjusted But Refunded Because Of
The Expiration Of The 1 Year Time
Limit
VIII:

VIII:

VIII:

VIII:
VIII:

2 Decreasing Adjustments To Amounts
Previously Reported On Line 1

VIII:

VIII:

VIII:

VIII:
VIII:

3 SubTotal

VIII:

VIII:

VIII:

VIII:
VIII:

4 Previously Reported Overpayments
To Providers Certified This Quarter
As Bankrupt Or Out Of Business
VIII:

VIII:

VIII:

VIII:
VIII:

5 Total Overpayment Adjustments This
Quarter

VIII:

VIII:

VIII:

VIII:
VIII:

Form CMS 64.9OMEQC

Tuesday, May 21, 2019 - 09:28 AM