CMS-10249 Medical Assistance Expenditures by Type of Service

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Overview

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Sheet 1: 649i-1

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB NO. 0938-0067

CENTERS FOR MEDICARE & MEDICAID SERVICES

M E D I C A L A S S I S T A N C E E X P E N D I T U R E S B Y T Y P E O F S E R V I C E

STATE

F O R T H E M E D I C A L A S S I S T A N C E P R O G R A M

AGENCY

E X P E N D I T U R E S I N T H I S Q U A R T E R

QUARTER ENDED

F E D E R A L S H A R E

MEDICAL ASSISTANCE PAYMENTS

TOTAL

SPECIAL ISSUES REPORTING

COMPUTABLE

FMAP

I.H.S. FACILITY

FAMILY PLANNING

BREAST & CERVICAL

TOTAL

TYPE OF PROGRAM _______________________

_____%

SERVICES

SERVICES

CANCER

FEDERAL

FEDERAL

100%

90%

PRESUMPTIVE ELIGIBILITY

____%

SHARE

SHARE

(a)

(b)

(c)

(d)

(e)

(f)

(g)

1. INPATIENT HOSPITAL SERVICES

Enhanced

A. Regular Payments

I.H.S.

B. DSH Adjustment Payments

2. MENTAL HEALTH FACILITY SERVICES

A. Regular Payments

B. DSH Adjustment Payments

3. NURSING FACILITY SERVICES

4. INTERMEDIATE CARE FACILITY SERVICES

- MENTALLY RETARDED:

A. PUBLIC PROVIDERS

B. PRIVATE PROVIDERS

5. PHYSICIANS' SERVICES

6. OUTPATIENT HOSPITAL SERVICES

7. PRESCRIBED DRUGS

7A. DRUG REBATE OFFSET

1. NATIONAL AGREEMENT

2. STATE SIDEBAR AGREEMENT

8. DENTAL SERVICES

9. OTHER PRACTITIONERS' SERVICES

10. CLINIC SERVICES

11. LABORATORY AND RADIOLOGICAL SERVICES

12. HOME HEALTH SERVICES

13. STERILIZATIONS

FORM CMS-64.9I

PAGE 1 OF 2

MEDICAL ASSSISTANCE PAYMENT (PRIOR QUARTERS) MACROS

MACRO

TITLE

MACRO

DESCRIPTION

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\T

{goto}Q145~{goto}TOP~

Sets titles to allow viewing

{r}{down 5}/wtb

during input.

\Z

/wtc

Clears worksheet titles.

\I

{goto}aa1~

Imports the matrix for printing

/fccnMATRIX~

{?}~

/wgpd

Removes the protection, temporarily

/rvaa10~e16~

Copies the matching rates

/rvab10~k17~

{goto}e16~

Centers the matching rates

{edit}{home}{del}^~

{goto}k17~

{edit}{home}{del}^~

/wgpe

Restores the protection

{goto}A1~

{calc}

/wgpd

Copies heading from updated page 1

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to page 2.

{calc}

Prints worksheet and allows user

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to compress print and print eight

{?}~mr226~p88~

lines per inch.

qa~gprPAGE2~a~gpq

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Sheet 2: 649i-2

DEPARTMENT OF HEALTH AND HUMAN SERVICES							OMB NO. 0938-0067
CENTERS FOR MEDICARE & MEDICAID SERVICES
M E D I C A L A S S I S T A N C E E X P E N D I T U R E S B Y T Y P E O F S E R V I C E				STATE
F O R T H E M E D I C A L A S S I S T A N C E P R O G R A M				AGENCY
E X P E N D I T U R E S I N T H I S Q U A R T E R				QUARTER ENDED
			F E D E R A L S H A R E
MEDICAL ASSISTANCE PAYMENTS	TOTAL
SPECIAL ISSUES REPORTING	COMPUTABLE	FMAP	I.H.S. FACILITY	FAMILY PLANNING	BREAST & CERVICAL			TOTAL
TYPE OF PROGRAM _______________________		_____%	SERVICES	SERVICES	CANCER		FEDERAL	FEDERAL
			100%	90%	PRESUMPTIVE ELIGIBILITY	____%	SHARE	SHARE
	(a)	(b)	(c)	(d)	(e)		(f)	(g)
14. ABORTIONS NO. ______
15. EPSDT SCREENING SERVICES
16. RURAL HEALTH CLINIC SERVICES
17. MEDICARE HEALTH INSURANCE PAYMENTS:
(A) PART A PREMIUMS
(B) PART B PREMIUMS
(C) QUALIFYING INDIVIDUALS
(1) 120% -134% OF POVERTY
(2) 135% -175% OF POVERTY
(D) COINSURANCE AND DEDUCTIBLES
18. MEDICAID HEALTH INSURANCE PAYMENTS:
(A) MANAGED CARE ORGANIZATIONS (MCO)
(B) PREPAID HEALTH PLANS (PHP)
(C) GROUP HEALTH PLAN PAYMENTS
(D) COINSURANCE AND DEDUCTIBLES
(E) OTHER
19. HOME AND COMMUNITY-BASED SERVICES 1
20. H&CB CARE FOR FUNCTIONALLY
DISABLED ELDERLY
21. COMMUNITY SUPPORTED LIVING SERVICES
22. PROGRAMS OF ALL-INCLUSIVE CARE ELDERLY
23. PERSONAL CARE SERVICES
24. TARGETED CASE MANAGEMENT SERVICES
25. PRIMARY CARE CASE MANAGEMENT SERVICES
26. HOSPICE BENEFITS
27. EMERGENCY SERVICES UNDOCUMENTED ALIENS
28. FEDERALLY-QUALIFIED HEALTH CENTER
29. OTHER CARE SERVICES
30. TOTAL (ENTER COLUMNS (a) AND (f) ON
SUMMARY SHEET, LINE 7, 8, 10.A. OR 10.B.,
COLUMNS (a) AND (b) AS APPROPRIATE).
1 IF STATE HAS MORE THAN ONE APPROVED HCBS WAIVER, ATTACH SCHEDULE SHOWING EXPENDITURES FOR EACH APPROVED WAIVER
FORM CMS-64.9I								PAGE 2 OF 2

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Sheet 3: 649pi-1

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB NO. 0938-0067

CENTERS FOR MEDICARE & MEDICAID SERVICES

M E D I C A L A S S I S T A N C E E X P E N D I T U R E S B Y T Y P E O F S E R V I C E

STATE

F O R T H E M E D I C A L A S S I S T A N C E P R O G R A M

QUARTER ENDED

PRIOR PERIOD ADJUSTMENTS I N T H I S Q U A R T E R

FISCAL YEAR

CHECK ONE:

LINE 7

LINE 8

LINE 10A

LINE 10B

F E D E R A L S H A R E

DEFERRAL

MEDICAL ASSISTANCE PAYMENTS

TOTAL

OR

SPECIAL ISSUES REPORTING

COMPUTABLE

FMAP

I.H.S. FACILITY

FAMILY PLANNING

BREAST & CERVICAL

TOTAL

C.I.N.

TYPE OF PROGRAM _______________________

_____%

SERVICES

SERVICES

CANCER

FEDERAL

FEDERAL

NUMBER

100%

90%

PRESUMPTIVE ELIGIBILITY

____%

SHARE

SHARE

(a)

(b)

(c)

(d)

(e)

(f)

(g)

{h}

1. INPATIENT HOSPITAL SERVICES

Enhanced

A. Regular Payments

I.H.S.

B. DSH Adjustment Payments

2. MENTAL HEALTH FACILITY SERVICES

A. Regular Payments

B. DSH Adjustment Payments

3. NURSING FACILITY SERVICES

4. INTERMEDIATE CARE FACILITY SERVICES

- MENTALLY RETARDED:

A. PUBLIC PROVIDERS

B. PRIVATE PROVIDERS

5. PHYSICIANS' SERVICES

6. OUTPATIENT HOSPITAL SERVICES

7. PRESCRIBED DRUGS

7A. DRUG REBATE OFFSET

1. NATIONAL AGREEMENT

2. STATE SIDEBAR AGREEMENT

8. DENTAL SERVICES

9. OTHER PRACTITIONERS' SERVICES

10. CLINIC SERVICES

11. LABORATORY AND RADIOLOGICAL SERVICES

12. HOME HEALTH SERVICES

13. STERILIZATIONS

FORM CMS-64.9PI

PAGE 1 OF 2

MEDICAL ASSSISTANCE PAYMENT (PRIOR QUARTERS) MACROS

MACRO

TITLE

MACRO

DESCRIPTION

-----

-----------------------------

---------------------------------

\T

{goto}Q145~{goto}TOP~

Sets titles to allow viewing

{r}{down 5}/wtb

during input.

\Z

/wtc

Clears worksheet titles.

\I

{goto}aa1~

Imports the matrix for printing

/fccnMATRIX~

{?}~

/wgpd

Removes the protection, temporarily

/rvaa10~e16~

Copies the matching rates

/rvab10~k17~

{goto}e16~

Centers the matching rates

{edit}{home}{del}^~

{goto}k17~

{edit}{home}{del}^~

/wgpe

Restores the protection

{goto}A1~

{calc}

/wgpd

Copies heading from updated page 1

/cTITLE1~TITLE2~/wgpe

to page 2.

{calc}

Prints worksheet and allows user

/ppcarPAGE1~os\015\027\048

to compress print and print eight

{?}~mr226~p88~

lines per inch.

qa~gprPAGE2~a~gpq

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Sheet 4: 649pi-2

DEPARTMENT OF HEALTH AND HUMAN SERVICES								OMB NO. 0938-0067
HEALTH CARE FINANCING ADMINISTRATION
M E D I C A L A S S I S T A N C E E X P E N D I T U R E S B Y T Y P E O F S E R V I C E				STATE
F O R T H E M E D I C A L A S S I S T A N C E P R O G R A M				QUARTER ENDED
PRIOR PERIOD ADJUSTMENTS I N T H I S Q U A R T E R				FISCAL YEAR
CHECK ONE:	LINE 7		LINE 8		LINE 10A		LINE 10B
	TOTAL								DEFERRAL
MEDICAL ASSISTANCE PAYMENTS	COMPUTABLE	FMAP	I.H.S. FACILITY	FAMILY PLANNING	BREAST & CERVICAL			TOTAL	OR
SPECIAL ISSUES REPORTING		_____%	SERVICES	SERVICES	CANCER		FEDERAL	FEDERAL	C.I.N.
TYPE OF PROGRAM _______________________			100%	90%	PRESUMPTIVE ELIGIBILITY	____%	SHARE	SHARE	NUMBER
	(a)	(b)	(c)	(d)	(e)		(f)	(g)	{h}
15. EPSDT SCREENING SERVICES
16. RURAL HEALTH CLINIC SERVICES
17. MEDICARE HEALTH INSURANCE PAYMENTS:
(A) PART A PREMIUMS
(B) PART B PREMIUMS
(C) QUALIFYING INDIVIDUALS
(1) 120% -134% OF POVERTY
(2) 135% -175% OF POVERTY
(D) COINSURANCE AND DEDUCTIBLES
18. MEDICAID HEALTH INSURANCE PAYMENTS:
(A) MANAGED CARE ORGANIZATIONS (MCO)
(B) PREPAID HEALTH PLANS (PHP)
(C) GROUP HEALTH PLAN PAYMENTS
(D) COINSURANCE AND DEDUCTIBLES
(E) OTHER
19. HOME AND COMMUNITY-BASED SERVICES 1
20. H&CB CARE FOR FUNCTIONALLY
DISABLED ELDERLY
21. COMMUNITY SUPPORTED LIVING SERVICES
22. PROGRAMS OF ALL-INCLUSIVE CARE ELDERLY
23. PERSONAL CARE SERVICES
24. TARGETED CASE MANAGEMENT SERVICES
25. PRIMARY CARE CASE MANAGEMENT SERVICES
26. HOSPICE BENEFITS
27. EMERGENCY SERVICES UNDOCUMENTED ALIENS
28. FEDERALLY-QUALIFIED HEALTH CENTER
29. OTHER CARE SERVICES
30. TOTAL (ENTER COLUMNS (a) AND (f) ON
SUMMARY SHEET, LINE 7, 8, 10.A. OR 10.B.,
COLUMNS (a) AND (b) AS APPROPRIATE).
1 IF STATE HAS MORE THAN ONE APPROVED HCBS WAIVER, ATTACH SCHEDULE SHOWING EXPENDITURES FOR EACH APPROVED WAIVER
FORM HCFA-64.9PI								PAGE 2 OF 2

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Sheet 5: 6410I

DEPARTMENT OF HEALTH AND HUMAN SERVICES				OMB NO. 0938-0067
CENTERS FOR MEDICARE & MEDICAID SERVICES
E X P E N D I T U R E S F O R S T A T E A N D L O C A L A D M I N I S T R A T I O N				STATE
F O R T H E M E D I C A L A S S I S T A N C E P R O G R A M
E X P E N D I T U R E S I N T H I S Q U A R T E R				QUARTER ENDED
ADMINISTRATION			F E D E R A L S H A R E				TOTAL
SPECIAL ISSUES REPORTING						FEDERAL	FEDERAL
TYPE OF PROGRAM _______________________	TOTAL COMPUTABLE	90%	75%	50%	__%	SHARE	SHARE
	(a)	(b)	(c)	(d)		(e)	(f)
1. FAMILY PLANNING
2. DESIGN DEVELOPMENT OR INSTALLATION OF MMIS
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
C. DRUG CLAIMS SYSTEM
3. SKILLED PROFESSIONAL MEDICAL PERSONNEL
4. OPERATION OF AN APPROVED MMIS:
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
5. MECHANIZED SYSTEMS, NOT APPROVED UNDER
MMIS PROCEDURES:
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
6. PEER REVIEW ORGANIZATIONS (PRO)
7. A. THIRD PARTY LIABILITY
RECOVERY PROCEDURE - BILLING OFFSET
B. ASSIGNMENT OF RIGHTS - BILLING OFFSET
8. IMMIGRATION STATUS VERIFICATION SYSTEM COSTS
(100% FFP)
9. NURSE AIDE TRAINING COSTS
10. PREADMISSION SCREENING COSTS
11. RESIDENT REVIEW ACTIVITIES COSTS
12. DRUG USE REVIEW PROGRAM
13. OUTSTATIONED ELIGIBILITY WORKERS
14. TANF BASE
15. TANF SECONDARY 90%
16. TANF SECONDARY 75%
17. EXTERNAL REVIEW
18. ENROLLMENT BROKERS
19. OTHER FINANCIAL PARTICIPATION
20. TOTAL (ENTER COLUMNS (a) AND (f) ON SUMMARY
SHEET LINE 6 COLUMNS (c) AND (d))
FORM CMS-64.10I, (LINE 6)

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Sheet 6: R6410Pi

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB NO. 0938-0067

CENTERS FOR MEDICARE & MEDICAID SERVICES

E X P E N D I T U R E S F O R S T A T E A N D L O C A L A D M I N I S T R A T I O N

STATE

F O R T H E M E D I C A L A S S I S T A N C E P R O G R A M

QUARTER ENDED

P R I O R P E R I O D A D J U S T M E N T S

FISCAL YEAR

ADMINISTRATION

LINE 7.

LINE 8.

LINE 10.A.

LINE 10.B.

SPECIAL ISSUES REPORTING

F E D E R A L S H A R E

DEFERRAL,

TYPE OF PROGRAM _______________________

TOTAL

TOTAL

DISALLOWANCE

COMPUTABLE

FEDERAL

FEDERAL

OR

90%

75%

50%

__%

SHARE

SHARE

C.I.N. NO.

(a)

(b)

(c)

(d)

(e)

(f)

(g)

1. FAMILY PLANNING

2. DESIGN DEVELOPMENT OR INSTALLATION OF MMIS:

A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER

STATE AGENCIES AND INSTITUTIONS

B. COSTS OF PRIVATE SECTOR CONTRACTORS

C. DRUG CLAIMS SYSTEM

3. SKILLED PROFESSIONAL MEDICAL PERSONNEL

4. OPERATION OF AN APPROVED MMIS:

A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER

STATE AGENCIES AND INSTITUTIONS

B. COST OF PRIVATE SECTOR CONTRACTORS

5. MECHANIZED SYSTEMS, NOT APPROVED UNDER

MMIS PROCEDURES:

A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER

STATE AGENCIES AND INSTITUTIONS

B. COST OF PRIVATE SECTOR CONTRACTORS

6. PEER REVIEW ORGANIZATIONS (PRO)

7. A. THIRD PARTY LIABILITY

RECOVERY PROCEDURE - BILLING OFFSET

B. ASSIGNMENT OF RIGHTS - BILLING OFFSET

8. IMMIGRATION STATUS VERIFICATION SYSTEM COSTS

(100% FFP)

9. NURSE AIDE TRAINING COSTS

10. PREADMISSION SCREENING COSTS

11. RESIDENT REVIEW ACTIVITIES COST

12. DRUG USE REVIEW PROGRAM

13. OUTSTATIONED ELIGIBILITY WORKERS

14. TANF BASE

15. TANF SECONDARY 90%

16. TANF SECONDARY 75%

17. EXTERNAL REVIEW

18. ENROLLMENT BROKERS

19. OTHER FINANCIAL PARTICIPATION

20. TOTAL (ENTER COLUMNS (a) AND (f) ON SUMMARY

SHEET LINE 7, 8, 10.A., OR 10.B. COLUMNS

(c) AND (d))

FORM CMS-64 10pI

ADMINISTRATIVE COST MACROS (Prior Quarters)

MACRO

TITLE

MACRO

DESCRIPTION

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\T

{goto}Q145~{goto}TOP~

Sets titles to allow viewing

{r}{down 2}/wtb

during input.

\Z

/wtc

Clears worksheet titles.

\A

/RP~

Automatically protects column.

{DOWN}

/XG\A~

\I

{goto}aa1~

Imports the matrix for printing

/fccnMATRIX~

{?}~

/wgpd

Removes the protection, temporarily

/rvab11~k16~

Copies the matching rates

{goto}k16~

Centers the matching rates

{edit}{home}{del}^~

/wgpe

Restores the protection

{goto}A1~

{calc}

Prints worksheet and allows user

/ppcarPAGE1~os\015\027\048

to compress print and print eight

{?}~mr226~p88~

lines per inch.

qa~gpq