CMS-64.9 ARP Section 9811 (Line 47)

CMS 64.9 BASE

State: Amer. Samoa
Agency: CMS

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

Quarter/Year: Qtr 4th 2021
Quarter Ended: 9/30/2021
Federal Share

Medical Assistance Payments

Total Computable

(A)
1A) Inpatient Hospital - Reg. Payments
1B) Inpatient Hospital - DSH
1C) Inpatient Hospital - Sup. Payments
1D) Inpatient Hospital - GME 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 - Ind. with
Intellectual Disabilities: 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

FMAP
83%

I.H.S Facility Services
100%

Family Planning Services
90%

Total
Federal Share

Other %
(*)
Optional Breast or Cervical Cancer*

COVID FMAP
89.2% **
(B)

Federal Share
NON COVID FMAP (#)

(C)

(D)

(E)

(F)

F

(G)

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%
8) Dental Services
9A) Other Practitioners Services - Reg. Payments
9B) Other Practitioners Services - Sup. Payments
10) Clinic Services
11) Laboratory/Radiological
12) Home Health Services
13) Sterilizations
14) Abortions No. 0
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. CaseMan.
24B) Case Management - State Wide
25) Primary Care Case Management
26) Hospice Benefits
27) Emergency Services for Undocumented Aliens
28) Federally-Qualified Health Center
29) Non-Emergency Medical Transportation
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
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
45) Health Home for Enrollees w Substance-UseDisorder
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
49) Other Care Services
50) Total
* Optional Breast & Cervical Cancer Services calculated at an Enhanced FMAP rate of 85% and/or the IHS Services rate of 100%
** Lines are calculated at the COVID FMAP rate of 89.2%
* = Other , # = NON COVID FMAP