CMS-10249 MFP Financial Reporting Forms ABCD

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Form # CMS-10249
OMB Control #0938-1053

MFP DEMONSTRATION FINANCIAL FORM A
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

DEMONSTRATION EXPENDITURES BY TYPE OF SERVICE
FOR THE MONEY FOLLOWS THE PERSON DEMONSTRATION PROGRAM
E X P E N D I T U R E S FOR THE QUARTER ENDING ___________(ex: December 31, 2008)
ENHANCED

State:

FMAP

Reg. FMAP
ADJUSTMENTS for
PRIOR PERIODS Qualified HCBS
Services

ADJUSTMENTS for
PRIOR PERIODS Demonstration Services

ADJUSTMENTS for
PRIOR PERIODS Supplemental Services

TOTAL
FEDERAL
SHARE

COMPUTABLE

TOTAL STATE
SHARE

____%

____%

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

$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0

TOTAL

6. TARGETED CASE MANAGEMENT FOR LONG TERM CARE*
7. PACE* (PROGRAM FOR ALL INCLUSIVE CARE FOR THE ELDERLY)
8. REHABILITATION SERVICES*
9. HOME HEALTH SERVICES
10. HOSPICE*
11. PERSONAL CARE SERVICES
12. OPTIONAL MEDICAID PLAN SERVICES* (detail on Form B)
TOTALS-State Plan Services

*Qualified HCBS

**Demonstration
Services

***Supplemental
Services
_____%

II. Waiver Services

(a)

(b)

(c)'

(d)

(e)

(f)

(g)

(h)

(i)

1. CASE MANAGEMENT

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0

$0

$0

$0

$0

$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

2. HOMEMAKER SERVICES
3. HOME HEALTH AIDE SERVICES
4. PERSONAL CARE
5. ADULT DAY HEALTH
6. HABILITATION
a. RESIDENTIAL HABILITATION
b. DAY HABILITATION
7. EXPANDED HABILITATION SERVICES (42 CFR §440.180(c))
a. PREVOCATIONAL SERVICES
b. SUPPORTED EMPLOYMENT
c. EDUCATION
8. RESPITE CARE
9. DAY TREATMENT
10. PARTIAL HOSPITALIZATION
11. PSYCHOSOCIAL REHABILITATION
12. CLINIC SERVICES
13. LIVE-IN CAREGIVER (42 CFR §441.303(f)(8))
14. CAPITATED PAYMENTS FOR LONG TERM CARE SERVICES
15. OTHER* (detail on Form B)
TOTALS-Waiver Services
TOTALS-Both Waiver & State Plan Services
ADMINISTRATIVE SERVICES (detail on Form C)
TOTALS-Waiver, State Plan & Administrative Services

* 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.

Form # CMS-10249
OMB Control #0938-1053

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

DEMONSTRATION EXPENDITURES BY TYPE OF SERVICE
FOR THE MONEY FOLLOWS THE PERSON DEMONSTRATION PROGRAM
E X P E N D I T U R E S FOR THE QUARTER ENDING ___________(ex: December 31, 2008)
State:

ENHANCED FMAP

COMPUTABLE

TOTAL STATE
SHARE

(a)

(b)

$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0

TOTAL

I. State Plan Services
OPTIONAL MEDICAID PLAN SERVICES*
(Detail for Form A, Line I,12)
a.
b.
c.
d.
e.
TOTALS - Optional Plan Services

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

*Qualified HCBS

**Demonstration Services

***Supplemental
Services

_____%

_____%

_____%

(c)

(d)

(e)

(f)

(g)

(h)

(i)

$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0

$0
$0
$0
$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.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
TOTALS - "Other" , Demo, & Supplemental Services
TOTALS - Optional, "Other" , Demo & Supplemental Services

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$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.

Form #CMS-10249
OMB Control #0938-1053

MFP DEMONSTRATION FINANCIAL FORM C
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

DEMONSTRATION EXPENDITURES BY TYPE OF SERVICE
FOR THE MONEY FOLLOWS THE PERSON DEMONSTRATION PROGRAM
E X P E N D I T U R E S THE QUARTER ENDING ___________(ex: December 31, 2008)
State:
COMPUTABLE

TOTAL STATE
SHARE

(a)

(b)

TOTAL

III. Administrative
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.

TOTALS

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

ADMINISTRATIVE
Normal Rate
50%

SPMP
75%

(c)'

(d)

$0
$0
$0
$0
$0
$0
$0
$0
$0
$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)

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

FMAP

QoL Survey

Enhanced
90%

Other
100%

(e)

(f)

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Reimbursement @$100
per survey
(g)

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

ADJUSTMENTS for
PRIOR PERIODS

(h)

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

TOTAL
FEDERAL
SHARE
(i)

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Form #CMS-10249
OMB Control #0938-1053

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