CMS-64.9i, -64.9pi Quarterly Expenditures

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:

Total
Computable
1A
1B
1C
1D
2A
2B
2C

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

5C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management

5D

Physician & Surgical Services - Vaccine codes

5A
5B

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Inpatient Hospital Services - GME Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments

3B

4C

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments

Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments

3A

FMAP

Family
Planning
I.H.S. Services Services

Form CMS 64.9I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:

Total
Computable

6b
7
7A1

Outpatient Hospital Services - Regular Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Dental Services

6A

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
9B
Clinic Services
10
Laboratory And Radiological Services
11
Home Health Services
12
Sterilizations
13
Abortions No.
14
EPSDT Screening Services
15
Rural Health Clinic Screening
16
Medicare Health Insurance Payments - Part A
17A Premiums
Medicare Health Insurance Payments - Part B
17B Premiums
17C1 120% - 134% Of Poverty
17D Coinsurance And Deductibles
Medicaid Health Insurance Payments: Managed
18A Care Organizations (MCO)
9A

18A1 Medicaid MCO - Evaluation and Management

Form CMS 64.9I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

18A2 Medicaid MCO - Vaccine codes
18A3 Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A OR
18A4 B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
18A5 Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
18B1c MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
18B1d ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
18B1e Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
18B2c MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
18B2d ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
18B2e Health Clinic Payments
Medicaid Health Insurance Payments: Group
18C Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance And Deductibles
18E
19A
19B
19C

Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment

Form CMS 64.9I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:

Total
Computable

24A
24B
25
26

Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

27
28
29
30
31

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy

32
33

Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses

34
34A
35
36
37
38
39

Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services

40
41
42

Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center

43

Health Home for Enrollees w Chronic Conditions

19D
22
23A
23B

Form CMS 64.9I

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:

Total
Computable
44
45
49
50

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
Other Care Services
Total

Form CMS 64.9I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:

Total
Computable
1A
1B
1C
1D
2A
2B
2C

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

5C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management

5D

Physician & Surgical Services - Vaccine codes

5A
5B

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Inpatient Hospital Services - GME Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments

3B

4C

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Inpatient Hospital Services: Regular Payments
Inpatient Hospital Services: DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments

Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments

3A

FMAP

Family
Planning
I.H.S. Services Services

Form CMS 64.9PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:

Total
Computable

6b
7
7A1

Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
Medicare Health Insurance Payments: Part A
Premiums
Medicare Health Insurance Payments: Part B
Premiums

6A

9B
10
11
12
13
14
15
16
17A
17B

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Medicare Health Insurance Payments:
17C1 Qualifying Individuals/120% - 134% of Poverty
Medicare Health Insurance Payments:
17D Coinsurance and Deductibles
Medicaid Health Insurance Payments: Managed
18A Care Organizations

Form CMS 64.9PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
18A3 Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
18A4 OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
18A5 Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
18B1c MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
18B1d ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
18B1e Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
18B2c MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
18B2d ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
18B2e Health Clinic Payments
Medicaid Health Insurance Payments: Group
18C Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance and Deductibles
18E
19A
19B

Medicaid Health Insurance Program: Other
Home and Community-Based Services - Regular
Payment (Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment

Form CMS 64.9PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:

Total
Computable
19C

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Home and Community-Based Services - State
Plan 1915(j) Only Payment

24A
24B
25
26

Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

27
28
29
30
31

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy

32
33

Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses

34
34A
35
36
37
38
39

Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services

40
41
42

Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center

19D
22
23A
23B

FMAP

Family
Planning
I.H.S. Services Services

Form CMS 64.9PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:

Total
Computable
43
44
45
49
50

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
Other Care Services
Total

Form CMS 64.9PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10I - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:
Total
Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Cost of In-House Activities
2A
Design Development Or Installation Of MMIS:
Cost of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Costs of InHouse Activities Plus State Agencies And
Institutions
4A
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
4B

5A

5B
5C
6
7A

OMB No. 0938-1265
Expires 4/30/2021

FFP Federal
Share

Other %

Total Federal
Federal Share Share

Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset

Form CMS 64.10I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10I - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:
Total
Computable
Third Party Liability: Assignment Of Rights Billing Offset
7B
Immigration Status Verification System Costs
(100% FFP)
8
Nurse Aide Training Costs
9
Preadmission Screening Costs
10
Resident Review Activities Costs
11
Drug Use Review Program
12
Outstationed Eligibility Workers
13
TANF Base
14
TANF Secondary 90%
15
TANF Secondary 75%
16
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23
24
24A
24B
24C

OMB No. 0938-1265
Expires 4/30/2021

FFP Federal
Share

Other %

Total Federal
Federal Share Share

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities

Form CMS 64.10I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10I - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:
Total
Computable
HIT: Implementation and Operation: Cost of
24D Private Contractors
24E

HIT Incentive Payments - Eligible Professionals

24F

HIT Incentive Payments - Eligible Hospitals

25
25A
25B

Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration

26
27

28A

28B

28C

28D

OMB No. 0938-1265
Expires 4/30/2021

FFP Federal
Share

Other %

Total Federal
Federal Share Share

Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors

Form CMS 64.10I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10I - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 9/30/2019
Program:
Total
Computable
Eligibility Determination Staff – Cost of In28E house Activities
Eligibility Determination Staff – Cost of Private
28F Sector Contractors
Eligibility Determination Staff – Cost of In28G house Activities – 50% FFP
Eligibility Determination Staff – Cost of Private
28H Sector Contractors – 50% FFP
Non-Emergency Medical Transportation
29

30
49
50

OMB No. 0938-1265
Expires 4/30/2021

FFP Federal
Share

Other %

Total Federal
Federal Share Share

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
Other Financial Participation
Total

Form CMS 64.10I

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10PI - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:
Total
FFP Federal
Computable Share
Family Planning
1
Design Development Or Installation Of MMIS:
Costs Of In-House Activities
2A
Design Development Or Installation Of MMIS:
Costs Of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Cost Of InHouse Activities
4A
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
4B

5A

5B
5C
6
7A

OMB No. 0938-1265
Expires 4/30/2021

Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset

Form CMS 64.10PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10PI - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:
Total
FFP Federal
Computable Share
Third Party Liability: Assignment Of Rights Billing Offset
7B
Immigration Status Verification System Costs
(100% FFP)
8
Nurse Aide Training
9
Preadmission Screening Costs
10
Resident Review Activities Cost
11
Drug Use Review Program
12
Outstationed Eligibility Workers
13
TANF Base
14
TANF Secondary (90%)
15
TANF Secondary (75%)
16
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23
24
24A
24B

OMB No. 0938-1265
Expires 4/30/2021

Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors

Form CMS 64.10PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10PI - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:
Total
FFP Federal
Computable Share
HIT: Implementation and Operation: Cost of In24C house Activities
HIT: Implementation and Operation: Cost of
24D Private Contractors
24E

HIT Incentive Payments - Eligible Professionals

24F

HIT Incentive Payments - Eligible Hospitals

25
25A
25B

Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration

26
27

28A

28B

OMB No. 0938-1265
Expires 4/30/2021

Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors

Form CMS 64.10PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10PI - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 9/30/2019
Prior Qtr/FYR:
Line:
Program:
Total
FFP Federal
Computable Share
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
28C Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
28D Contractors
Eligibility Determination Staff – Cost of In28E house Activities
Eligibility Determination Staff – Cost of Private
28F Sector Contractors
Eligibility Determination Staff – Cost of In28G house Activities – 50% FFP
Eligibility Determination Staff – Cost of Private
28H Sector Contractors – 50% FFP
Non-Emergency Medical Transportation
29

30
49
50

OMB No. 0938-1265
Expires 4/30/2021

Other %

Total Federal
Federal Share Share

Deferral or
CIN Number

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
Other Financial Participation
Total

Form CMS 64.10PI

Report Date: Tuesday, October 29, 2019 - 12:00 AM