CMS-64.9T Quarterly Medicaid Assistance Program Expenditures by Ty

State: New Hampshire
Agency: CMS

CMS 64.9T
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in this Quarter

Medical Assistance Payments

Total Computable

(A)
1A) Inpatient Hospital - Reg. Payments
1B) Inpatient Hospital - DSH
1C) Inpatient Hospital - Sup. Payments
1D) Inpatient Hospital - GME Sup Payments
2A) Mental Health Facility Services - Reg.
Payments
2B) Mental Health Facility - DSH
2C) Certified Community Behavior Health
Clinic Payments
3A) Nursing Facility Services - Reg.
Payments
3B) Nursing Facility Services - Sup.
Payments
4A) Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public
Providers
4B) Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers
4C) Intermediate Care Facility Services Supplemental Payments
5A) Physician & Surgical Services - Reg.
Payments
5B) Physician & Surgical Services - Sup.
Payments
5C) Physician & Surgical Services Evaluation and Management
5D) Physician & Surgical Services - Vaccine
codes
6A) Outpatient Hospital Services - Reg.
Payments
6B) Outpatient Hospital Services - Sup.
Payments
7) Prescribed Drugs
7A1) Drug Rebate Offset - National
7A2) Drug Rebate Offset - State Sidebar
Agreement
7A3) MCO - National Agreement
7A4) MCO - State Sidebar Agreement
7A5) Increased ACA OFFSET - Fee for
Service - 100%
7A6) Increased ACA OFFSET - MCO - 100%
7A7) Drug Rebate Offset - Value Based
Purchasing
8) Dental Services

____________________________________.
Quarter/Year: Qtr 1st 2023
Quarter Ended: 12/31/2022

Federal Share
Medicaid and CHIP
Medicaid FMAP
50%
FMAP 50%
COVID FMAP 61.2%
(B)
(C)

Applied against the
CHIP Amount

(D)

9A) Other Practitioners Services - Reg.
Payments
9B) Other Practitioners Services - Sup.
Payments
10A) Clinic Services - Reg. Payments
10B) Clinic Services - Sup. Payments
11) Laboratory/Radiological
12) Home Health Services
13) Sterilizations
14) Abortions
15) EPSDT Screening
16) Rural Health
17A) Medicare - Part A
17B) Medicare - Part B
17C1) 120% - 134% Of Poverty
17D) Coinsurance
18A) Medicaid - 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
18A5) Medicaid MCO - Certified Community
Behavior Health Clinic Payments
18A6) Medicaid MCO - Services Subject to
Electronic Visit Verification Requirements
18B1) Prepaid Ambulatory Health Plan
18B1a) MCO PAHP - Evaluation and
Management
18B1b) MCO PAHP - Vaccine codes
18B1c) MCO PAHP - Community First Choice
18B1d) MCO PAHP - Preventive Services
Grade A OR B, ACIP Vaccines and their
Admin
18B1e) Medicaid PAHP - Certified
Community Behavior Health Clinic
Payments
18B1f) MCO PAHP - Services Subject to
Electronic Visit Verification Requirements
18B2) Prepaid Inpatient Health Plan
18B2a) MCO PIHP - Evaluation and
Management
18B2b) MCO PIHP - Vaccine codes
18B2c) MCO PIHP - Community First Choice
18B2d) MCO PIHP - Preventive Services
Grade A OR B, ACIP Vaccines and their
Admin
18B2e) Medicaid PIHP - Certified
Community Behavior Health Clinic
Payments
18B2f) MCO PIHP - Services Subject to
Electronic Visit Verification Requirements

18C) Medicaid - Group Health
18D) Medicaid - Coinsurance
18E) Medicaid - Other
19A) Home & Community-Based Services Regular Payment (1915(c) Waiver)
19B) Home & Community-Based Services St. Plan 1915(i) Only Pay.
19C) Home & Community-Based Services St. Plan 1915(j) Only Pay.
19D) Home & Community Based Services
State Plan 1915(k) Community First Choice
22) All-Inclusive Care Elderly
23A) Personal Care Services - Reg.
Payments
23B) Personal Care Services - SDS 1915(j)
24A) Targeted Case Management Services Com. Case-Man.
24B) Case Management - State Wide
25) Primary Care Case Management
26) Hospice Benefits
27) Emergency Services for Undocumented
Aliens
28) Federally-Qualified Health Center
29A) Non-Emergency Medical
Transportation - Reg. Payments
29B) Non-Emergency Medical
Transportation - Sup. Payments
30) Physical Therapy
31) Occupational Therapy
32) Services for Speech, Hearing &
Language
33) Prosthetic Devices, Dentures, Eyeglasses
34) Diagnostic Screening & Preventive
Services
34A) Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
35) Nurse Mid-Wife
36) Emergency Hospital Services
37A) Critical Access Hospitals - Reg.
Payments
37B) Critical Access Hospitals Inpatient Sup. Payments
37C) Critical Access Hospitals Outpatient Sup. Payments
38) Nurse Practitioner Services
39) School Based Services
40) Rehabilitative Services (non-schoolbased)
41) Private Duty Nursing
42) Freestanding Birth Center
43) Health Home for Enrollees w Chronic
Conditions
44) Tobacco Cessation for Preg Women
45) Health Home for Enrollees w SubstanceUse-Disorder
46) OUD Medicaid Assisted Treatment –
Drugs

46A1) OUD MAT DRUG REBATE/National
Agreement
46A2) OUD MAT DRUG REBATE/State
Sidebar
46A3) OUD MAT DRUG REBATE MCO
/National Agreement
46A4) OUD MAT DRUG REBATE MCO /State
Sidebar
46A5) OUD MAT DRUG REBATE/Increased
ACA Offset Fee for Service - 100%
46A6) OUD MAT DRUG REBATE/Increased
ACA Offset MCO – 100%
46B) OUD Medicaid Assisted Treatment
Services
47) ARP Section 9811 COVID
Vaccine/Vaccine Administration
48) ARP Section 9813 Qualified Community
Based Mobile Crisis Intervention – 85%
49) Health Homes for Children with
Medically Complex Conditions
69) Other Care Services
70) Total
Remaining Balance: 553,740