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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State Estimate of Quarterly Grant Awards
State:
Contact Name for Information:
State
Estimate
Fiscal
of
Quarterly
Grant
Quarter
Awards
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Certification Qtr:
Medical Assistance Payments
State & Local Administration
Total
Federal
State
Total
Federal
State
Computable
Share
Share
Computable
Share
Share
Federal Share MCHIP
Fiscal Year: 2022
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
Fiscal Year: 2023
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
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. The fiscal year budget estimates only include 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 fiscal year under Title XIX of the
Act for the Medicaid program, and as applicable, under Title XXI of the Act for the CHIP.
3. The budget estimates are based upon the most reliable information available to the state.
4. The state and/or local funds required to match the state’s allowable expenditures during the certification quarter will be available, and such state and/or
local funds are in accordance with all applicable federal requirements for the non-federal share match of expenditures.
5. The amount of state and local funds available for quarter 1/2023 for the Medicaid program is .
6. Federal matching funds are not being requested for the certification quarter to match expenditures under any Medicaid state plan amendment under Title
XIX of the Act and/or Children Health Plan amendment under Title XXI of the Act that was submitted after January 2, 2001, and that has not been approved
by the Secretary effective for the certification quarter.
7. The information shown above and on the Form CMS-37 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 37.1
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
OMB No. 0938-1265
Centers for Medicare & Medicaid Services
Expires 04/30/2024
Medicaid Program Budget Report
State Estimate of Health Information Technology Grants
State:
Submission Date:
Certification Qtr:
State
Health Information
Estimate
ofFiscal Quarter
Health
Total Computable
Information
Technology
Fiscal Year: 2022
Grants
Technology Incentive Payments
Federal Share
State Share
Health Information Technology Administration
Total Computable Federal Share State Share
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
Fiscal Year: 2023
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
Form CMS 37.1 HIT
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Estimated
Medical
Assistance
by
Type
of
Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2022
Budget Year 2023
Total
Federal
Total
Federal
Computable
Share
Computable
Share
Type of Service
1A Inpatient Hospital / Regular Payment
$0
$0
1B Inpatient Hospital / DSH Adj. Payment
1C Inpatient Hospital / Supplemental Payments
1D Inpatient Hospital - GME Payments
2A Mental Health / Regular Payment
2B Mental Health / DSH Adj. Payment
2C Certified Community Behavior Health Clinic Payments
3A Nursing Facility / Regular Payments
3B Nursing Facility / Supplemental Payments
4A Int. Care Facility - Ind. with Intellectual Disabilities: Public Pmnts
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Pmnts
4C Int. Care Facility - Ind. with Intellectual Disabilities: Suppl. Pmnts
5A Physician and Surgical / Regular Payments
5B Physician and Surgical / Supplemental Payments
5C Physician & Surgical Services - Evaluation and Management
5D Physician & Surgical Services - Vaccine codes
6A Outpatient Hospital / Regular Services
6B Outpatient Hospital / Supplemental Services
7 Prescribed Drugs
7A1 Drug Rebate / Natl. Agreement
7A2 Drug Rebate / State Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
7A5 Increased ACA OFFSET - Fee for Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%
Form CMS 37.3
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2022
Budget Year 2023
Total
Federal
Total
Federal
Computable
Share
Computable
Share
Type of Service
7A7 Drug Rebate Offset - Value Based Purchasing
8 Dental Services
9A Other Practitioners' Services / Regular Payment
9B Other Practitioners' Services - Suppl. Payment
10 Clinic Services
10A Clinic Services – Regular
10B Clinic Service – Supplemental
11 Lab/Radiological Services
12 Home Health Services
13 Sterilizations
14 Abortions
15 EPSDT Screenings
16 Rural Health Clinic
17A Medicare HIP / Part A Prem.
17B Medicare HIP / Part B Prem.
17C1 Medicare Qual Individuals 120%-134% Poverty
17D Medicare HIP / Coinsurance
18A Medicaid HIP / 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
Form CMS 37.3
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2022
Budget Year 2023
Total
Federal
Total
Federal
Computable
Share
Computable
Share
Type of Service
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 HIP / Group
18D Medicaid HIP / Coinsurance
18E Medicaid HIP / Other
19A Home-Comm Serv/Regular Payment (Waiver)
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Form CMS 37.3
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2022
Budget Year 2023
Total
Federal
Total
Federal
Computable
Share
Computable
Share
Type of Service
19C Home-Comm Serv/State Pl 1915(j) Only Payment
19D Home & Community Based Services State Plan 1915(k) Community
First Choice
22 All-Inclusive Care for Elders
23A Personal Care / Regular Payments
23B Personal Care / SDS 1915(j)
24A Targeted Case Mgmt. / Community Case-Mgmt.
24B Case Mgmt. / State Wide
25 Primary Care Case Mgmt. Services
26 Hospice Benefits
27 Emeg. Service Undoc. Aliens
28 Federally Qual. Health Center
29 Non-Emergency Medical Transportation
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 and 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
37A Critical Access Hospitals – Reg. Payments
Form CMS 37.3
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2022
Budget Year 2023
Total
Federal
Total
Federal
Computable
Share
Computable
Share
Type of Service
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-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-Use-Disorder
46 OUD Medication 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
49 Health Homes for ACE Kids
69 Other Care Services
70 Subtotal
$0
$0
71 Collections
Form CMS 37.3
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2022
Budget Year 2023
Total
Federal
Total
Federal
Computable
Share
Computable
Share
Type of Service
72 Prior Period Adjustments
SAP Support Act 1003 Payment (CMS-64.9-SAP)
73 Total Medicaid (non-M-CHIP)
$0
$0
$0
$0
74 M-CHIP Expansions
75 Qualifying States
76 Total Medicaid
Form CMS 37.3
Report Date: Tuesday, November 08, 2022 - 11:43 AM
State: OMB No.
CMS 37.3 Summary
0938-1265 Expires
04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
Submission Date:
Total Budgeted Services for Quarter Ending 12/31/2022
ARP and FFCRA Sections
Total Computable
Federal Share
1 ARP Section 9811 COVID Vaccine and Vaccine Administration 100%
FMAP (excluding MCHIP)
2 ARP Section 9813 Mobile Crisis Intervention
3 ARP Section 9814 New Medicaid Expansion - 5 Percentage Point FMAP
increase
4 ARP Section 9815 100% FMAP
5 ARP Section 9817 HCBS 10 Percentage Point FMAP Increase
10 Total ARP Sections
11 FFCRA Section 6004 Uninsured Testing Group 100% FMAP
12 FFCRA Section 6008 6.2 Percentage Point FMAP Increase
20 Total FFCRA Sections
50 Total ARP and FFCRA Sections
Form CMS 37.3 Summary
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
State
And
Local
Administration
State And Local Administration
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2024
Budget Year 2025
FFP Rate
Total
Federal
Total
Federal
Computable
Share
Computable
Share
1 Family Planning
2A DDI-MMIS In-House Oth
2B DDI-MMIS PRI-SEC-CONT
2C Drug Claims System
3A Skilled Professional Medical Personnel - Single State Agency
3B Skilled Professional Medical Personnel - Other Agencies
4A OAA-MMIS In-House Oth
4B OAA-MMIS Prv-Contract
5A Non-MMIS In-House Oth
5B Non-MMIS Prv-Contract
5C Mechanized Systems, not Approved under MMIS Procedures:
Interagency
6 Quality Improvement Organizations (QIO)
7A TPL-Billing Offset
7B Asgn-Of-Rights-Bill-Of
8 Immigration Stat Syst
9 Nurse Aide Training
10 Pre-Admission Screen
11 Resident Review
12 Drug Use Review Prog
13 Outsta Elig Workers
14 Tanf Base Allocation
15 Tanf 2nd Alloc 90%
16 Tanf 2nd Alloc 75%
Form CMS 37.9
Report Date: Thursday, December 21, 2023 - 10:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
State And Local Administration
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2024
Budget Year 2025
FFP Rate
Total
Federal
Total
Federal
Computable
Share
Computable
Share
17 Ext Qual Review
18 Enrollment Brokers
19 School Based Administration
20 Program Integrity/Fraud, Waste, and Abuse Activities
21 County/Local ADM Costs
22 Interagency Costs
23 Translation and Interpretation
24 Health Information Technology Administration
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
24C HIT: Implementation and Operation: Cost of In-house Activities
24D HIT: Implementation and Operation: Cost of Private Contractors
24E HIT Incentive Payments: Eligible Professionals
24F HIT Incentive Payments: Eligible Hospitals
25 Citizenship Verification Technology - CHIPRA
25A CVT Development - CHIPRA
25B CVT Operation - CHIPRA
26 Planning for Health Homes for Enrollees with Chronic Conditions
27 Recovery Audit Contractors State Administration
28A Design Development/Installation of Medicaid Elig. Determ. Sys. –
Cost of In-house Activities
28B Design Development/Installation of Medicaid Elig. Determ. Sys. –
Cost of Private Sec. Contractors
28C Operation of an Approved Medicaid Eligibility Determination
Systems – Cost of In-house Activities
28D Operation of an Approved Medicaid Eligibility Determination Sys.
Form CMS 37.9
Report Date: Thursday, December 21, 2023 - 10:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
State And Local Administration
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Total Budgeted Services
Total Budgeted Services
Current Year 2024
Budget Year 2025
FFP Rate
Total
Federal
Total
Federal
Computable
Share
Computable
Share
– Cost of Private Sec. Contractors
28E Eligibility Determination Staff – Cost of In-house Activities
28F Eligibility Determination Staff – Cost of Private Sector Contractors
28G Eligibility Determination Staff – Cost of In-house Activities –
FFP
28H Eligibility Determination Staff – Cost of Private Sector
Contractors –
FFP
29 Non-Emergency Medical Transportation
30 Design Development/Implementation of Prescription Drug
Monitoring Program Systems
31 CAA 2023 Section 5101
49 Other Financial Participation
50 Sub-total (Line 1 - 49) excluding 24s
51 Collections
52 Prior Period Adjust
$0
$0
53 Total (excluding 24s)
$0
$0
Form CMS 37.9
Report Date: Thursday, December 21, 2023 - 10:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q1/2023
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
3B Nursing Facility / Supplemental Payments
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
6A Outpatient Hospital / Regular Services
Federal Share
Total Computable
6B Outpatient Hospital / Supplemental Services
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
7A5 Increased ACA OFFSET - Fee for Service - 100%
Form CMS 37.3I
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Federal Share
Total Computable
7A7 Drug Rebate Offset - Value Based Purchasing
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
10B Clinic Service – Supplemental
Total Computable
Federal Share
Total Computable
11 Lab/Radiological Services
Federal Share
Total Computable
12 Home Health Services
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
17A Medicare HIP / Part A Prem.
Form CMS 37.3I
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Federal Share
Total Computable
17D Medicare HIP / Coinsurance
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Form CMS 37.3I
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Form CMS 37.3I
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Total Computable
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
23A Personal Care / Regular Payments
Form CMS 37.3I
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Total Computable
26 Hospice Benefits
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
29 Non-Emergency Medical Transportation
Total Computable
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Total Computable
32 Services for Speech, Hearing and Language
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
34 Diagnostic Screening & Preventive Services
Form CMS 37.3I
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Total Computable
37B Critical Access Hospitals Inpatient – Sup. Payments
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Plannin
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
38 Nurse Practitioner Services
Total Computable
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
Total Computable
44 Tobacco Cessation for Preg Women
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
46 OUD Medication Assisted Treatment - Drugs
Form CMS 37.3I
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Total Computable
46B OUD Medicaid Assisted Treatment Services
Federal Share
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
73 Total Medicaid (non-M-CHIP)
Total Computable
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3I
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Program: 1935 (a) & (b)
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
Total Computable
1 Family Planning
Federal Share
Total Computable
Federal Share
Total Computable
2A DD MM S n House Oth
Federal Share
Total Computable
Federal Share
Total Computable
Federal Share
Total Computable
2B DD MM S PR SEC CONT
Federal Share
Total Computable
Federal Share
Total Computable
2C Drug Claims System
Federal Share
3A Skilled Professional Medical Personnel Single
Total Computable
State Agency
Federal Share
3B Skilled Professional Medical Personnel Other
Total Computable
Agencies
Federal Share
Total Computable
4A OAA MM S n House Oth
Federal Share
Total Computable
4B OAA MM S Prv Contract
Federal Share
Total Computable
5A Non MM S n House Oth
Federal Share
Form CMS 37.9I
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
Submission Date:
Program: 1935 (a) & (b)
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
5B Non MM S Prv Contract
OMB No. 0938-1265
Expires 04/30/2024
Total Computable
Federal Share
5C Mechanized Systems not Approved under MM S
Total Computable
Procedures nteragency
Federal Share
Total Computable
6 Quality mprovement Organizations (Q O)
Federal Share
Total Computable
7A TPL Billing Offset
Federal Share
Total Computable
7B Asgn Of Rights Bill Of
Federal Share
Total Computable
8 mmigration Stat Syst
Federal Share
Total Computable
9 Nurse Aide Training
Federal Share
Total Computable
10 Pre Admission Screen
Federal Share
Total Computable
11 Resident Review
Federal Share
Total Computable
12 Drug Use Review Prog
Federal Share
Total Computable
13 Outsta Elig Workers
Federal Share
14 Tanf Base Allocation
15 Tanf 2nd Alloc 90%
16 Tanf 2nd Alloc 75%
17 Ext Qual Review
Form CMS 37.9I
Total Computable
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Program: 1935 (a) & (b)
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
Federal Share
Total Computable
Federal Share
Total Computable
18 Enrollment Brokers
Federal Share
Total Computable
19 School Based Administration
Federal Share
20 Program ntegrity/Fraud Waste and Abuse
Total Computable
Activities
Federal Share
Total Computable
21 County/Local ADM Costs
Federal Share
Total Computable
22 nteragency Costs
Federal Share
Total Computable
23 Translation and nterpretation
Federal Share
24 Health nformation Technology Administration
24A H T Planning Cost of n house Activities
24B H T Planning Cost of Private Contractors
24C H T mplementation and Operation Cost of n
Total Computable
house Activities
Federal Share
24D H T mplementation and Operation Cost of
Total Computable
Private Contractors
Federal Share
24E H T ncentive Payments Eligible Professionals
24F H T ncentive Payments Eligible Hospitals
25 Citizenship Verification Technology CH PRA
25A CVT Development CH PRA
Form CMS 37.9I
Total Computable
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Program: 1935 (a) & (b)
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
Federal Share
Total Computable
25B CVT Operation CH PRA
Federal Share
26 Planning for Health Homes for Enrollees with
Total Computable
Chronic Conditions
Federal Share
Total Computable
27 Recovery Audit Contractors State Administration
Federal Share
Total Computable
Federal Share
28A Design Development/ nstallation of Medicaid
Total Computable
Elig Determ Sys
Federal Share
Cost of n house Activities
Total Computable
Federal Share
Total Computable
Federal Share
28B Design Development/ nstallation of Medicaid
Total Computable
Elig Determ Sys
Federal Share
Cost of Private Sec Contractors
Total Computable
Federal Share
28C Operation of an Approved Medicaid Eligibility
Total Computable
Determination Systems
Federal Share
Cost of n house Activities
28D Operation of an Approved Medicaid Eligibility
Total Computable
Determination Sys
Federal Share
Cost of Private Sec Contractors
28E Eligibility Determination Staff
Cost of n house
Activities
28F Eligibility Determination Staff
Form CMS 37.9I
Total Computable
Federal Share
Cost of Private
Total Computable
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
Cost of n house
50% FFP
Total of Federal
Computable
Share
Total Computable
Federal Share
28H Eligibility Determination Staff
Sector Contractors
Total of Total
Federal Share
28G Eligibility Determination Staff
Activities
Submission Date:
Program: 1935 (a) & (b)
Total Administration Costs
Rate
Sector Contractors
OMB No. 0938-1265
Expires 04/30/2024
Cost of Private
50% FFP
Total Computable
Federal Share
Total Computable
29 Non Emergency Medical Transportation
Federal Share
30 Design Development/ mplementation of
Prescription Drug Monitoring Program Systems
Total Computable
31 CAA 2023 Section 5101
Federal Share
Total Computable
49 Other Financial Participation
Federal Share
Total Computable
50 Sub total (Line 1 49) excluding 24s
Federal Share
Total Computable
51 Collections
Federal Share
Total Computable
52 Prior Period Adjust
Federal Share
Total Computable
53 Total (excluding 24s)
Federal Share
Form CMS 37.9I
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Program: Sec 208 CAA 2021 COFA
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
Total Computable
1 Family Planning
Federal Share
Total Computable
Federal Share
Total Computable
2A DD MM S n House Oth
Federal Share
Total Computable
Federal Share
Total Computable
Federal Share
Total Computable
2B DD MM S PR SEC CONT
Federal Share
Total Computable
Federal Share
Total Computable
2C Drug Claims System
Federal Share
3A Skilled Professional Medical Personnel Single
Total Computable
State Agency
Federal Share
3B Skilled Professional Medical Personnel Other
Total Computable
Agencies
Federal Share
Total Computable
4A OAA MM S n House Oth
Federal Share
Total Computable
4B OAA MM S Prv Contract
Federal Share
Total Computable
5A Non MM S n House Oth
Federal Share
Form CMS 37.9I
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
Submission Date:
Program: Sec 208 CAA 2021 COFA
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
5B Non MM S Prv Contract
OMB No. 0938-1265
Expires 04/30/2024
Total Computable
Federal Share
5C Mechanized Systems not Approved under MM S
Total Computable
Procedures nteragency
Federal Share
Total Computable
6 Quality mprovement Organizations (Q O)
Federal Share
Total Computable
7A TPL Billing Offset
Federal Share
Total Computable
7B Asgn Of Rights Bill Of
Federal Share
Total Computable
8 mmigration Stat Syst
Federal Share
Total Computable
9 Nurse Aide Training
Federal Share
Total Computable
10 Pre Admission Screen
Federal Share
Total Computable
11 Resident Review
Federal Share
Total Computable
12 Drug Use Review Prog
Federal Share
Total Computable
13 Outsta Elig Workers
Federal Share
14 Tanf Base Allocation
15 Tanf 2nd Alloc 90%
16 Tanf 2nd Alloc 75%
17 Ext Qual Review
Form CMS 37.9I
Total Computable
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Program: Sec 208 CAA 2021 COFA
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
Federal Share
Total Computable
Federal Share
Total Computable
18 Enrollment Brokers
Federal Share
Total Computable
19 School Based Administration
Federal Share
20 Program ntegrity/Fraud Waste and Abuse
Total Computable
Activities
Federal Share
Total Computable
21 County/Local ADM Costs
Federal Share
Total Computable
22 nteragency Costs
Federal Share
Total Computable
23 Translation and nterpretation
Federal Share
24 Health nformation Technology Administration
24A H T Planning Cost of n house Activities
24B H T Planning Cost of Private Contractors
24C H T mplementation and Operation Cost of n
Total Computable
house Activities
Federal Share
24D H T mplementation and Operation Cost of
Total Computable
Private Contractors
Federal Share
24E H T ncentive Payments Eligible Professionals
24F H T ncentive Payments Eligible Hospitals
25 Citizenship Verification Technology CH PRA
25A CVT Development CH PRA
Form CMS 37.9I
Total Computable
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Program: Sec 208 CAA 2021 COFA
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
Federal Share
Total Computable
25B CVT Operation CH PRA
Federal Share
26 Planning for Health Homes for Enrollees with
Total Computable
Chronic Conditions
Federal Share
Total Computable
27 Recovery Audit Contractors State Administration
Federal Share
Total Computable
Federal Share
28A Design Development/ nstallation of Medicaid
Total Computable
Elig Determ Sys
Federal Share
Cost of n house Activities
Total Computable
Federal Share
Total Computable
Federal Share
28B Design Development/ nstallation of Medicaid
Total Computable
Elig Determ Sys
Federal Share
Cost of Private Sec Contractors
Total Computable
Federal Share
28C Operation of an Approved Medicaid Eligibility
Total Computable
Determination Systems
Federal Share
Cost of n house Activities
28D Operation of an Approved Medicaid Eligibility
Total Computable
Determination Sys
Federal Share
Cost of Private Sec Contractors
28E Eligibility Determination Staff
Cost of n house
Activities
28F Eligibility Determination Staff
Form CMS 37.9I
Total Computable
Federal Share
Cost of Private
Total Computable
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
Cost of n house
50% FFP
Total of Federal
Computable
Share
Total Computable
Federal Share
28H Eligibility Determination Staff
Sector Contractors
Total of Total
Federal Share
28G Eligibility Determination Staff
Activities
Submission Date:
Program: Sec 208 CAA 2021 COFA
Total Administration Costs
Rate
Sector Contractors
OMB No. 0938-1265
Expires 04/30/2024
Cost of Private
50% FFP
Total Computable
Federal Share
Total Computable
29 Non Emergency Medical Transportation
Federal Share
30 Design Development/ mplementation of
Prescription Drug Monitoring Program Systems
Total Computable
31 CAA 2023 Section 5101
Federal Share
Total Computable
49 Other Financial Participation
Federal Share
Total Computable
50 Sub total (Line 1 49) excluding 24s
Federal Share
Total Computable
51 Collections
Federal Share
Total Computable
52 Prior Period Adjust
Federal Share
Total Computable
53 Total (excluding 24s)
Federal Share
Form CMS 37.9I
Report Date: Friday, December 22, 2023 - 09:52 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q1/2022
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
3B Nursing Facility / Supplemental Payments
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
6A Outpatient Hospital / Regular Services
Federal Share
Total Computable
6B Outpatient Hospital / Supplemental Services
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
7A5 Increased ACA OFFSET - Fee for Service - 100%
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Federal Share
Total Computable
7A7 Drug Rebate Offset - Value Based Purchasing
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
10B Clinic Service – Supplemental
Total Computable
Federal Share
Total Computable
11 Lab/Radiological Services
Federal Share
Total Computable
12 Home Health Services
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
17A Medicare HIP / Part A Prem.
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Federal Share
Total Computable
17D Medicare HIP / Coinsurance
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Total Computable
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
23A Personal Care / Regular Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Total Computable
26 Hospice Benefits
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
29 Non-Emergency Medical Transportation
Total Computable
Federal Share
29A Non-Emergency Medical Transportation – Reg.
Payments
29B Non-Emergency Medical Transportation – Sup.
Payments
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Total Computable
32 Services for Speech, Hearing and Language
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
34 Diagnostic Screening & Preventive Services
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
37A Critical Access Hospitals – Reg. Payments
37B Critical Access Hospitals Inpatient – Sup. Payments
37C Critical Access Hospitals Outpatient – Sup. Payments
Total Computable
38 Nurse Practitioner Services
Federal Share
39 School Based Services
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
Total Computable
44 Tobacco Cessation for Preg Women
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
Total Computable
46 OUD Medication Assisted Treatment - Drugs
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Total Computable
46B OUD Medicaid Assisted Treatment Services
Federal Share
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile Total Computable
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Total Computable
73 Total Medicaid (non-M-CHIP)
Federal Share
74 M-CHIP Expansions
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q2/2022
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
3B Nursing Facility / Supplemental Payments
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
6A Outpatient Hospital / Regular Services
Federal Share
Total Computable
6B Outpatient Hospital / Supplemental Services
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
7A5 Increased ACA OFFSET - Fee for Service - 100%
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Federal Share
Total Computable
7A7 Drug Rebate Offset - Value Based Purchasing
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
10B Clinic Service – Supplemental
Total Computable
Federal Share
Total Computable
11 Lab/Radiological Services
Federal Share
Total Computable
12 Home Health Services
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
17A Medicare HIP / Part A Prem.
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Federal Share
Total Computable
17D Medicare HIP / Coinsurance
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Total Computable
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
23A Personal Care / Regular Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Total Computable
26 Hospice Benefits
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
29 Non-Emergency Medical Transportation
Total Computable
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Total Computable
32 Services for Speech, Hearing and Language
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
34 Diagnostic Screening & Preventive Services
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Total Computable
37B Critical Access Hospitals Inpatient – Sup. Payments
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
38 Nurse Practitioner Services
Total Computable
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
Total Computable
44 Tobacco Cessation for Preg Women
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
46 OUD Medication Assisted Treatment - Drugs
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Total Computable
46B OUD Medicaid Assisted Treatment Services
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
73 Total Medicaid (non-M-CHIP)
Total Computable
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q3/2022
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
3B Nursing Facility / Supplemental Payments
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
6A Outpatient Hospital / Regular Services
Federal Share
Total Computable
6B Outpatient Hospital / Supplemental Services
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
7A5 Increased ACA OFFSET - Fee for Service - 100%
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Federal Share
Total Computable
7A7 Drug Rebate Offset - Value Based Purchasing
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
10B Clinic Service – Supplemental
Total Computable
Federal Share
Total Computable
11 Lab/Radiological Services
Federal Share
Total Computable
12 Home Health Services
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
17A Medicare HIP / Part A Prem.
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Federal Share
Total Computable
17D Medicare HIP / Coinsurance
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Total Computable
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
23A Personal Care / Regular Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Total Computable
26 Hospice Benefits
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
29 Non-Emergency Medical Transportation
Total Computable
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Total Computable
32 Services for Speech, Hearing and Language
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
34 Diagnostic Screening & Preventive Services
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Total Computable
37B Critical Access Hospitals Inpatient – Sup. Payments
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
38 Nurse Practitioner Services
Total Computable
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
Total Computable
44 Tobacco Cessation for Preg Women
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
46 OUD Medication Assisted Treatment - Drugs
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Total Computable
46B OUD Medicaid Assisted Treatment Services
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
73 Total Medicaid (non-M-CHIP)
Total Computable
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q4/2022
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
3B Nursing Facility / Supplemental Payments
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
6A Outpatient Hospital / Regular Services
Federal Share
Total Computable
6B Outpatient Hospital / Supplemental Services
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
7A5 Increased ACA OFFSET - Fee for Service - 100%
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Federal Share
Total Computable
7A7 Drug Rebate Offset - Value Based Purchasing
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
10B Clinic Service – Supplemental
Total Computable
Federal Share
Total Computable
11 Lab/Radiological Services
Federal Share
Total Computable
12 Home Health Services
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
17A Medicare HIP / Part A Prem.
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Federal Share
Total Computable
17D Medicare HIP / Coinsurance
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Total Computable
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
23A Personal Care / Regular Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Total Computable
26 Hospice Benefits
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
29 Non-Emergency Medical Transportation
Total Computable
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Total Computable
32 Services for Speech, Hearing and Language
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
34 Diagnostic Screening & Preventive Services
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Total Computable
37B Critical Access Hospitals Inpatient – Sup. Payments
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
38 Nurse Practitioner Services
Total Computable
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
Total Computable
44 Tobacco Cessation for Preg Women
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
46 OUD Medication Assisted Treatment - Drugs
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Total Computable
46B OUD Medicaid Assisted Treatment Services
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
73 Total Medicaid (non-M-CHIP)
Total Computable
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q1/2023
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
3B Nursing Facility / Supplemental Payments
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
6A Outpatient Hospital / Regular Services
Federal Share
Total Computable
6B Outpatient Hospital / Supplemental Services
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
7A5 Increased ACA OFFSET - Fee for Service - 100%
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Federal Share
Total Computable
7A7 Drug Rebate Offset - Value Based Purchasing
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
10B Clinic Service – Supplemental
Total Computable
Federal Share
Total Computable
11 Lab/Radiological Services
Federal Share
Total Computable
12 Home Health Services
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
17A Medicare HIP / Part A Prem.
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Federal Share
Total Computable
17D Medicare HIP / Coinsurance
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Total Computable
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
23A Personal Care / Regular Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Total Computable
26 Hospice Benefits
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
29 Non-Emergency Medical Transportation
Total Computable
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Total Computable
32 Services for Speech, Hearing and Language
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
34 Diagnostic Screening & Preventive Services
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Total Computable
37B Critical Access Hospitals Inpatient – Sup. Payments
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
38 Nurse Practitioner Services
Total Computable
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
Total Computable
44 Tobacco Cessation for Preg Women
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
46 OUD Medication Assisted Treatment - Drugs
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Total Computable
46B OUD Medicaid Assisted Treatment Services
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
73 Total Medicaid (non-M-CHIP)
Total Computable
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q2/2023
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning @
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
3B Nursing Facility / Supplemental Payments
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
6A Outpatient Hospital / Regular Services
Federal Share
Total Computable
6B Outpatient Hospital / Supplemental Services
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
7A5 Increased ACA OFFSET - Fee for Service - 100%
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Federal Share
Total Computable
7A7 Drug Rebate Offset - Value Based Purchasing
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
10B Clinic Service – Supplemental
Total Computable
Federal Share
Total Computable
11 Lab/Radiological Services
Federal Share
Total Computable
12 Home Health Services
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
17A Medicare HIP / Part A Prem.
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Federal Share
Total Computable
17D Medicare HIP / Coinsurance
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Total Computable
19C Home-Comm Serv/State Pl 1915(j) Only Payment
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
23A Personal Care / Regular Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Total Computable
26 Hospice Benefits
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
29 Non-Emergency Medical Transportation
Total Computable
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Total Computable
32 Services for Speech, Hearing and Language
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
34 Diagnostic Screening & Preventive Services
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Total Computable
37B Critical Access Hospitals Inpatient – Sup. Payments
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
38 Nurse Practitioner Services
Total Computable
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
Total Computable
44 Tobacco Cessation for Preg Women
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
46 OUD Medication Assisted Treatment - Drugs
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Total Computable
46B OUD Medicaid Assisted Treatment Services
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
VIII Group
Family
Regular
Type of Service
Breast &
Indian Health
VIII Group
Planning
Not Newly-
Cervical
Other
Newly
Total
Non-Exp
.
73 Total Medicaid (non-M-CHIP)
Total Computable
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q3/2023
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
3B Nursing Facility / Supplemental Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Total Computable
6A Outpatient Hospital / Regular Services
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
6B Outpatient Hospital / Supplemental Services
VIII Group
Total Computable
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
Total Computable
7A5 Increased ACA OFFSET - Fee for Service - 100%
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
7A7 Drug Rebate Offset - Value Based Purchasing
VIII Group
Total Computable
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Total Computable
10B Clinic Service – Supplemental
Federal Share
Total Computable
11 Lab/Radiological Services
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
12 Home Health Services
VIII Group
Total Computable
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
Total Computable
17A Medicare HIP / Part A Prem.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
17D Medicare HIP / Coinsurance
VIII Group
Total Computable
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Federal Share
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
19C Home-Comm Serv/State Pl 1915(j) Only Payment
VIII Group
Total Computable
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
Total Computable
23A Personal Care / Regular Payments
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
26 Hospice Benefits
VIII Group
Total Computable
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Total Computable
29 Non-Emergency Medical Transportation
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
32 Services for Speech, Hearing and Language
VIII Group
Total Computable
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
Total Computable
34 Diagnostic Screening & Preventive Services
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
37B Critical Access Hospitals Inpatient – Sup. Payments
VIII Group
Total Computable
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Total Computable
38 Nurse Practitioner Services
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
44 Tobacco Cessation for Preg Women
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
Total Computable
46 OUD Medication Assisted Treatment - Drugs
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
46B OUD Medicaid Assisted Treatment Services
VIII Group
Total Computable
Federal Share
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile
Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Total Computable
73 Total Medicaid (non-M-CHIP)
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Estimated
Medical
Assistance
by
Type
of
Service
Q4/2023
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
Total Computable
1A Inpatient Hospital / Regular Payment
Federal Share
Total Computable
1B Inpatient Hospital / DSH Adj. Payment
Federal Share
Total Computable
1C Inpatient Hospital / Supplemental Payments
Federal Share
Total Computable
1D Inpatient Hospital - GME Payments
Federal Share
Total Computable
2A Mental Health / Regular Payment
Federal Share
Total Computable
2B Mental Health / DSH Adj. Payment
Federal Share
2C Certified Community Behavior Health Clinic Payments
Total Computable
3A Nursing Facility / Regular Payments
Federal Share
3B Nursing Facility / Supplemental Payments
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
Federal Share
4A Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Public Pmnts
Federal Share
4B Int. Care Facility - Ind. with Intellectual Disabilities: Priv. Total Computable
Pmnts
Federal Share
4C Int. Care Facility - Ind. with Intellectual Disabilities:
Total Computable
Suppl. Pmnts
Federal Share
Total Computable
5A Physician and Surgical / Regular Payments
Federal Share
Total Computable
5B Physician and Surgical / Supplemental Payments
Federal Share
5C Physician & Surgical Services - Evaluation and
Management
5D Physician & Surgical Services - Vaccine codes
Total Computable
6A Outpatient Hospital / Regular Services
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
6B Outpatient Hospital / Supplemental Services
VIII Group
Total Computable
Federal Share
Total Computable
7 Prescribed Drugs
Federal Share
Total Computable
7A1 Drug Rebate / Natl. Agreement
Federal Share
Total Computable
7A2 Drug Rebate / State Agreement
Federal Share
Total Computable
7A3 MCO - National Agreement
Federal Share
Total Computable
7A4 MCO - State Sidebar Agreement
Federal Share
Total Computable
7A5 Increased ACA OFFSET - Fee for Service - 100%
Federal Share
Total Computable
7A6 Increased ACA OFFSET - MCO - 100%
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
7A7 Drug Rebate Offset - Value Based Purchasing
VIII Group
Total Computable
Federal Share
Total Computable
8 Dental Services
Federal Share
Total Computable
9A Other Practitioners' Services / Regular Payment
Federal Share
Total Computable
9B Other Practitioners' Services - Suppl. Payment
Federal Share
Total Computable
10 Clinic Services
Federal Share
Total Computable
10A Clinic Services – Regular
Federal Share
Total Computable
10B Clinic Service – Supplemental
Federal Share
Total Computable
11 Lab/Radiological Services
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
12 Home Health Services
VIII Group
Total Computable
Federal Share
Total Computable
13 Sterilizations
Federal Share
Total Computable
14 Abortions
Federal Share
Total Computable
15 EPSDT Screenings
Federal Share
Total Computable
16 Rural Health Clinic
Federal Share
Total Computable
17A Medicare HIP / Part A Prem.
Federal Share
Total Computable
17B Medicare HIP / Part B Prem.
Federal Share
Total Computable
17C1 Medicare Qual Individuals 120%-134% Poverty
Form CMS 37.3 Quarterly Data
Federal Share
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
17D Medicare HIP / Coinsurance
VIII Group
Total Computable
Federal Share
Total Computable
18A Medicaid HIP / MCO
Federal Share
18A1 Medicaid MCO - Evaluation and Management
18A2 Medicaid MCO - Vaccine codes
Total Computable
18A3 Medicaid MCO - Community First Choice
Federal Share
18A4 Medicaid MCO - Preventive Services Grade A OR B, Total Computable
ACIP Vaccines and their Admin
Federal Share
18A5 Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Total Computable
18A6 Medicaid MCO - Services subject to electronic visit
verification requirements
Federal Share
Total Computable
18B1 Prepaid Ambulatory Health Plan
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
18B1a MCO PAHP - Evaluation and Management
18B1b MCO PAHP - Vaccine codes
Total Computable
18B1c MCO PAHP - Community First Choice
Federal Share
18B1d MCO PAHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B1e Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1f MCO PAHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18B2 Prepaid Inpatient Health Plan
Federal Share
18B2a MCO PIHP - Evaluation and Management
18B2b MCO PIHP - Vaccine codes
Total Computable
18B2c MCO PIHP - Community First Choice
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
18B2d MCO PIHP - Preventive Services Grade A OR B,
Total Computable
ACIP Vaccines and their Admin
Federal Share
18B2e Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2f MCO PIHP - Services subject to electronic visit
Total Computable
verification requirements
Federal Share
Total Computable
18C Medicaid HIP / Group
Federal Share
Total Computable
18D Medicaid HIP / Coinsurance
Federal Share
Total Computable
18E Medicaid HIP / Other
Federal Share
Total Computable
19A Home-Comm Serv/Regular Payment (Waiver)
Federal Share
Total Computable
19B Home-Comm Serv/State Pl 1915(i) Only Payment
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
19C Home-Comm Serv/State Pl 1915(j) Only Payment
VIII Group
Total Computable
Federal Share
19D Home & Community Based Services State Plan
Total Computable
1915(k) Community First Choice
Federal Share
Total Computable
22 All-Inclusive Care for Elders
Federal Share
Total Computable
23A Personal Care / Regular Payments
Federal Share
Total Computable
23B Personal Care / SDS 1915(j)
Federal Share
Total Computable
24A Targeted Case Mgmt. / Community Case-Mgmt.
Federal Share
Total Computable
24B Case Mgmt. / State Wide
Federal Share
Total Computable
25 Primary Care Case Mgmt. Services
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
26 Hospice Benefits
VIII Group
Total Computable
Federal Share
Total Computable
27 Emeg. Service Undoc. Aliens
Federal Share
Total Computable
28 Federally Qual. Health Center
Federal Share
Total Computable
29 Non-Emergency Medical Transportation
Federal Share
Total Computable
29A Non-Emergency Medical Transportation – Reg.
Payments
Federal Share
29B Non-Emergency Medical Transportation – Sup.
Total Computable
Payments
Federal Share
Total Computable
30 Physical Therapy
Federal Share
Total Computable
31 Occupational Therapy
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
32 Services for Speech, Hearing and Language
VIII Group
Total Computable
Federal Share
Total Computable
33 Prosthetic Devices, Dentures, Eyeglasses
Federal Share
Total Computable
34 Diagnostic Screening & Preventive Services
Federal Share
34A Preventive Services Grade A OR B, ACIP Vaccines
Total Computable
and their Admin
Federal Share
Total Computable
35 Nurse Mid-Wife
Federal Share
Total Computable
36 Emergency Hospital Services
Federal Share
Total Computable
37 Critical Access Hospitals
Federal Share
Total Computable
37A Critical Access Hospitals – Reg. Payments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
37B Critical Access Hospitals Inpatient – Sup. Payments
VIII Group
Total Computable
Federal Share
Total Computable
37C Critical Access Hospitals Outpatient – Sup. Payments
Federal Share
Total Computable
38 Nurse Practitioner Services
Federal Share
Total Computable
39 School Based Services
Federal Share
Total Computable
40 Rehabilitative Services (non-school-based)
Federal Share
Total Computable
41 Private Duty Nursing
Federal Share
Total Computable
42 Freestanding Birth Center
Federal Share
43 Health Home for Enrollees w Chronic Conditions
44 Tobacco Cessation for Preg Women
Form CMS 37.3 Quarterly Data
Total Computable
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
Federal Share
45 Health Home for Enrollees w Substance-Use-Disorder
Total Computable
46 OUD Medication Assisted Treatment - Drugs
Federal Share
Total Computable
46A1 OUD MAT DRUG REBATE/National Agreement
Federal Share
Total Computable
46A2 OUD MAT DRUG REBATE/State Sidebar
Federal Share
46A3 OUD MAT DRUG REBATE MCO /National
Total Computable
Agreement
Federal Share
Total Computable
46A4 OUD MAT DRUG REBATE MCO /State Sidebar
Federal Share
46A5 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
Fee for Service -100%
Federal Share
46A6 OUD MAT DRUG REBATE/Increased ACA Offset
Total Computable
MCO – 100%
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
Planning
Newly- NonCervical
Total
Newly
Exp
.
46B OUD Medicaid Assisted Treatment Services
VIII Group
Total Computable
Federal Share
47 ARP Section 9811 COVID Vaccine/ Vaccine
Total Computable
Administration
Federal Share
48 ARP Section 9813 Qualified Community Based Mobile
Total Computable
Crisis Intervention
Federal Share
Total Computable
49 Health Homes for ACE Kids
Federal Share
Total Computable
69 Other Care Services
Federal Share
Total Computable
70 Subtotal
Federal Share
Total Computable
71 Collections
Federal Share
Total Computable
72 Prior Period Adjustments
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 04/30/2024
Medicaid Program Budget Report
Estimated Medical Assistance by Type of Service
State:
Submission Date:
Family
Indian Health
Type of Service
Regular
VIII Group Not
Breast &
VIII Group
Planning
Newly- NonCervical
Total
Newly
Exp
.
SAP Support Act 1003 Payment (CMS-64.9-SAP)
Total Computable
73 Total Medicaid (non-M-CHIP)
Federal Share
Total Computable
74 M-CHIP Expansions
Federal Share
Total Computable
75 Qualifying States
Federal Share
Total Computable
76 Total Medicaid
Federal Share
Form CMS 37.3 Quarterly Data
Report Date: Tuesday, November 08, 2022 - 11:43 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
State
And
Local
Administration
Q1/2024
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Quarter 1 FFY 2024
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
.
Total Computable
1 Family Planning
Federal Share
Total Computable
Federal Share
Total Computable
2A DDI-MMIS In-House Oth
Federal Share
Total Computable
Federal Share
Total Computable
Federal Share
Total Computable
2B DDI-MMIS PRI-SEC-CONT
Federal Share
Total Computable
Federal Share
Total Computable
2C Drug Claims System
Federal Share
3A Skilled Professional Medical Personnel - Single
Total Computable
State Agency
Federal Share
3B Skilled Professional Medical Personnel - Other
Total Computable
Agencies
Federal Share
Total Computable
4A OAA-MMIS In-House Oth
Federal Share
Total Computable
4B OAA-MMIS Prv-Contract
Federal Share
Total Computable
5A Non-MMIS In-House Oth
Federal Share
Form CMS 37.9 Quarterly Data
Report Date: Thursday, December 21, 2023 - 10:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Quarter 1 FFY 2024
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
.
5B Non-MMIS Prv-Contract
Total Computable
Federal Share
5C Mechanized Systems, not Approved under MMIS
Total Computable
Procedures: Interagency
Federal Share
Total Computable
6 Quality Improvement Organizations (QIO)
Federal Share
Total Computable
7A TPL-Billing Offset
Federal Share
Total Computable
7B Asgn-Of-Rights-Bill-Of
Federal Share
Total Computable
8 Immigration Stat Syst
Federal Share
Total Computable
9 Nurse Aide Training
Federal Share
Total Computable
10 Pre-Admission Screen
Federal Share
Total Computable
11 Resident Review
Federal Share
Total Computable
12 Drug Use Review Prog
Federal Share
Total Computable
13 Outsta Elig Workers
Federal Share
14 Tanf Base Allocation
15 Tanf 2nd Alloc 90%
16 Tanf 2nd Alloc 75%
17 Ext Qual Review
Form CMS 37.9 Quarterly Data
Total Computable
Report Date: Thursday, December 21, 2023 - 10:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Quarter 1 FFY 2024
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
.
Federal Share
Total Computable
Federal Share
Total Computable
18 Enrollment Brokers
Federal Share
Total Computable
19 School Based Administration
Federal Share
20 Program Integrity/Fraud, Waste, and Abuse
Total Computable
Activities
Federal Share
Total Computable
21 County/Local ADM Costs
Federal Share
Total Computable
22 Interagency Costs
Federal Share
Total Computable
23 Translation and Interpretation
Federal Share
24 Health Information Technology Administration
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
24C HIT: Implementation and Operation: Cost of In-
Total Computable
house Activities
Federal Share
24D HIT: Implementation and Operation: Cost of
Total Computable
Private Contractors
Federal Share
24E HIT Incentive Payments: Eligible Professionals
24F HIT Incentive Payments: Eligible Hospitals
25 Citizenship Verification Technology - CHIPRA
25A CVT Development - CHIPRA
Form CMS 37.9 Quarterly Data
Total Computable
Report Date: Thursday, December 21, 2023 - 10:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
FFP
Type of Service
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Quarter 1 FFY 2024
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
.
Federal Share
Total Computable
25B CVT Operation - CHIPRA
Federal Share
26 Planning for Health Homes for Enrollees with
Total Computable
Chronic Conditions
Federal Share
Total Computable
27 Recovery Audit Contractors State Administration
Federal Share
Total Computable
Federal Share
28A Design Development/Installation of Medicaid
Total Computable
Elig. Determ. Sys. – Cost of In-house Activities
Federal Share
Total Computable
Federal Share
Total Computable
Federal Share
28B Design Development/Installation of Medicaid
Total Computable
Elig. Determ. Sys. – Cost of Private Sec. Contractors
Federal Share
Total Computable
Federal Share
28C Operation of an Approved Medicaid Eligibility
Total Computable
Determination Systems – Cost of In-house Activities
Federal Share
28D Operation of an Approved Medicaid Eligibility
Total Computable
Determination Sys. – Cost of Private Sec. Contractors
Federal Share
28E Eligibility Determination Staff – Cost of In-house
Total Computable
Activities
Federal Share
28F Eligibility Determination Staff – Cost of Private
Total Computable
Form CMS 37.9 Quarterly Data
Report Date: Thursday, December 21, 2023 - 10:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medicaid Program Budget Report
State And Local Administration
State:
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Quarter 1 FFY 2024
FFP
Type of Service
Total of Total
Total of Federal
Computable
Share
Total Administration Costs
Rate
.
Sector Contractors
Federal Share
28G Eligibility Determination Staff – Cost of In-house
Total Computable
Activities –
Federal Share
FFP
28H Eligibility Determination Staff – Cost of Private
Total Computable
Sector Contractors –
Federal Share
FFP
Total Computable
29 Non-Emergency Medical Transportation
Federal Share
30 Design Development/Implementation of
Prescription Drug Monitoring Program Systems
Total Computable
31 CAA 2023 Section 5101
Federal Share
Total Computable
49 Other Financial Participation
Federal Share
Total Computable
50 Sub-total (Line 1 - 49) excluding 24s
Federal Share
Total Computable
51 Collections
Federal Share
Total Computable
$0
Federal Share
$0
Total Computable
$0
Federal Share
$0
52 Prior Period Adjust
53 Total (excluding 24s)
Form CMS 37.9 Quarterly Data
$0
$0
$0
$0
Report Date: Thursday, December 21, 2023 - 10:04 AM
| File Type | application/pdf |
| File Modified | 2024-01-26 |
| File Created | 2022-11-08 |