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Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64 Summary - Quarterly Medicaid Statement of ExpendituresFor the Medical Assistance ProgramSummary SheetState:Quarter Ended: icaidARRA Federal BIPP FederalFederal Share ShareShareTotalFederal Share ComputableFederal ShareAwards Received During The Quarter For TheQuarter Being Reported And Prior QuartersAwards Received During The Quarter ForSubsequent QuartersInterest: Received On Medicaid RecoveriesInterest: Assessed On DisallowancesMedicare Overpayment Collection Under Sec.1914 and 42 CFR 447.30OtherExpenditures In This QuarterAdjustments Increasing Claims For PriorQuartersOther ExpendituresCollections: Third Party LiabilityCollections: Probate9.C.1. Recoveries: Fraud, Waste and Abuse EffortsRecoveries: OIG Compliant False Claims ActCollections: OtherRAC CollectionsPERM CollectionsMEQC CollectionsAdjustments Decreasing Claims For Prior10.A. Quarters: Federal AuditAdjustments Decreasing Claims For Prior10.B. Quarters: Other9.C.2.9.D.9.E.9.F.9GForm CMS 64 SummaryReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64 Summary - Quarterly Medicaid Statement of ExpendituresFor the Medical Assistance ProgramSummary SheetState:Quarter Ended: 9/30/2019TotalComputableMedicaidARRA Federal BIPP FederalFederal Share ShareShareTotalFederal Share ComputableFederal ShareAdjustments Decreasing Claims For PriorQuarters: Overpayment Adjustments (Attach10.C. 64.9O)10.D. Adjustments/Decreasing Prior Qtrs - Perm10.E. Adjustments/Decreasing Prior Qtrs - RACAdjustments/Decreasing Prior Qtrs - Fraud,10.F. Waste and Abuse Overpayments10G11Adjustments/Decreasing Prior Qtrs - OMEQCNet Expenditures Reported In This Period (Sumof Items 6, 7 and 8 Less 9 and 10)Form CMS 64 SummaryReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: te Care Facility Services - Ind. withIntellectual Disabilities: Public Providers4BIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Private Providers5A5B5C5D6A6bOpt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareInpatient Hospital Services - GME PaymentsMental Health Facility Services - RegularPaymentsMental Health Facility Services - DSHAdjustment PaymentsCertified Community Behavior Health ClinicPayments3B4COpt. Breast orCervicalCancer Srvcs(ENH Rate)Inpatient Hospital Services - Regular PaymentsInpatient Hospital Service - DSH AdjustmentPaymentsInpatient Hospital Services - SupplementalPaymentsNursing Facility Services - Regular PaymentsNursing Facility Services - SupplementalPayments3AFMAPFamilyPlanningI.H.S. Services ServicesIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Supplemental PaymentsPhysician and Surgical Services - RegularPaymentsPhysician and Surgical Services - SupplementalPaymentsPhysician & Surgical Services - Evaluation andManagementPhysician & Surgical Services - Vaccine codesOutpatient Hospital Services - RegularPaymentsOutpatient Hospital Services - SupplementalPaymentsForm CMS 64.9 BASEReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019TotalComputable77A1Prescribed DrugsDrug Rebate Offset - National Agreement7A27A37A4Drug Rebate Offset - State Sidebar AgreementMCO - National AgreementMCO - State Sidebar Agreement7A57A68Increased ACA OFFSET - Fee for Service - 100%Increased ACA OFFSET - MCO - 100%Dental ServicesFMAPFamilyPlanningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareOther Practitioners Services - Regular PaymentsOther Practitioners Services - SupplementalPayments9BClinic Services10Laboratory And Radiological Services11Home Health Services12Sterilizations13Abortions No.14EPSDT Screening Services15Rural Health Clinic Screening16Medicare Health Insurance Payments - Part A17A PremiumsMedicare Health Insurance Payments - Part B17B Premiums17C1 120% - 134% Of Poverty17D Coinsurance And DeductiblesMedicaid Health Insurance Payments: Managed18A Care Organizations (MCO)9A18A1 Medicaid MCO - Evaluation and Management18A2 Medicaid MCO - Vaccine codes18A3 Medicaid MCO - Community First ChoiceMedicaid MCO - Preventive Services Grade A18A4 OR B, ACIP Vaccines and their AdminMedicaid MCO - Certified Community Behavior18A5 Health Clinic Payments18B1 Prepaid Ambulatory Health PlanForm CMS 64.9 BASEReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019TotalComputableFMAPFamilyPlanningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShare18B1a MCO PAHP - Evaluation and Management18B1b MCO PAHP - Vaccine codes18B1c MCO PAHP - Community First ChoiceMCO PAHP - Preventive Services Grade A OR B,18B1d ACIP Vaccines and their AdminMedicaid PAHP - Certified Community Behavior18B1e Health Clinic Payments18B2 Prepaid Inpatient Health Plan18B2a MCO PIHP - Evaluation and Management18B2b MCO PIHP - Vaccine codes18B2c MCO PIHP - Community First ChoiceMCO PIHP - Preventive Services Grade A OR B,18B2d ACIP Vaccines and their AdminMedicaid PIHP - Certified Community Behavior18B2e Health Clinic PaymentsMedicaid Health Insurance Payments: Group18C Health Plan PaymentsMedicaid Health Insurance Payments:18D Coinsurance And id Health Insurance Payments: OtherHome and Community-Based Services - RegularPayment (Waiver)Home and Community-Based Services - StatePlan 1915(i) Only PaymentHome and Community-Based Services - StatePlan 1915(j) Only PaymentHome and Community Based Services StatePlan 1915(k) Community First ChoicePrograms Of All-Inclusive Care ElderlyPersonal Care Services - Regular PaymentPersonal Care Services - SDS 1915(j)Targeted Case Management Services Community Case-ManagementCase Management - State WidePrimary Care Case Management ServicesHospice BenefitsForm CMS 64.9 BASEReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019TotalComputable2728293031Emergency Services for Undocumented AliensFederally-Qualified Health CenterNon-Emergency Medical TransportationPhysical TherapyOccupational Therapy3233Services for Speech, Hearing and LanguageProsthetic Devices, Dentures, Eyeglasses34Diagnostic Screening & Preventive ServicesPreventive Services Grade A OR B, ACIPVaccines and their AdminNurse Mid-WifeEmergency Hospital ServicesCritical Access HospitalsNurse Practitioner ServicesSchool Based nningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareRehabilitative Services (non-school-based)Private Duty NursingFreestanding Birth CenterHealth Home for Enrollees w ChronicConditionsTobacco Cessation for Preg WomenHealth Home for Enrollees w Substance-UseDisorderOther Care ServicesTotalForm CMS 64.9 BASEReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019Waiver Type:Waiver Number:Waiver Name:TotalComputable1A1B1C1D2A2B2C4AIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Public Providers4BIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Private Providers5CIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Supplemental PaymentsPhysician and Surgical Services - RegularPaymentsPhysician and Surgical Services - SupplementalPaymentsPhysician & Surgical Services - Evaluation andManagement5DPhysician & Surgical Services - Vaccine codes5A5BOpt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareInpatient Hospital Services - GME PaymentsMental Health Facility Services - RegularPaymentsMental Health Facility Services - DSHAdjustment PaymentsCertified Community Behavior Health ClinicPayments3B4COpt. Breast orCervicalCancer Srvcs(ENH Rate)Inpatient Hospital Services - Regular PaymentsInpatient Hospital Service - DSH AdjustmentPaymentsInpatient Hospital Services - SupplementalPaymentsNursing Facility Services - Regular PaymentsNursing Facility Services - SupplementalPayments3AFMAPFamilyPlanningI.H.S. Services ServicesForm CMS 64.9 WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019Waiver Type:Waiver Number:Waiver Name:TotalComputable6b77A1Outpatient Hospital Services - RegularPaymentsOutpatient Hospital Services - SupplementalPaymentsPrescribed DrugsDrug Rebate Offset - National Agreement7A27A37A4Drug Rebate Offset - State Sidebar AgreementMCO - National AgreementMCO - State Sidebar Agreement7A57A68Increased ACA OFFSET - Fee for Service - 100%Increased ACA OFFSET - MCO - 100%Dental Services6AFMAPFamilyPlanningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareOther Practitioners Services - Regular PaymentsOther Practitioners Services - SupplementalPayments9BClinic Services10Laboratory And Radiological Services11Home Health Services12Sterilizations13Abortions No.14EPSDT Screening Services15Rural Health Clinic Screening16Medicare Health Insurance Payments - Part A17A PremiumsMedicare Health Insurance Payments - Part B17B Premiums17C1 120% - 134% Of Poverty17D Coinsurance And DeductiblesMedicaid Health Insurance Payments: Managed18A Care Organizations (MCO)9A18A1 Medicaid MCO - Evaluation and Management18A2 Medicaid MCO - Vaccine codesForm CMS 64.9 WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019Waiver Type:Waiver Number:Waiver Name:TotalComputableFMAPFamilyPlanningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShare18A3 Medicaid MCO - Community First ChoiceMedicaid MCO - Preventive Services Grade A18A4 OR B, ACIP Vaccines and their AdminMedicaid MCO - Certified Community Behavior18A5 Health Clinic Payments18B1 Prepaid Ambulatory Health Plan18B1a MCO PAHP - Evaluation and Management18B1b MCO PAHP - Vaccine codes18B1c MCO PAHP - Community First ChoiceMCO PAHP - Preventive Services Grade A OR B,18B1d ACIP Vaccines and their AdminMedicaid PAHP - Certified Community Behavior18B1e Health Clinic Payments18B2 Prepaid Inpatient Health Plan18B2a MCO PIHP - Evaluation and Management18B2b MCO PIHP - Vaccine codes18B2c MCO PIHP - Community First ChoiceMCO PIHP - Preventive Services Grade A OR B,18B2d ACIP Vaccines and their AdminMedicaid PIHP - Certified Community Behavior18B2e Health Clinic PaymentsMedicaid Health Insurance Payments: Group18C Health Plan PaymentsMedicaid Health Insurance Payments:18D Coinsurance And Deductibles18E19A19B19CMedicaid Health Insurance Payments: OtherHome and Community-Based Services - RegularPayment (Waiver)Home and Community-Based Services - StatePlan 1915(i) Only PaymentHome and Community-Based Services - StatePlan 1915(j) Only PaymentForm CMS 64.9 WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019Waiver Type:Waiver Number:Waiver Name:TotalComputable24A24B2526Home and Community Based Services StatePlan 1915(k) Community First ChoicePrograms Of All-Inclusive Care ElderlyPersonal Care Services - Regular PaymentPersonal Care Services - SDS 1915(j)Targeted Case Management Services Community Case-ManagementCase Management - State WidePrimary Care Case Management ServicesHospice Benefits2728293031Emergency Services for Undocumented AliensFederally-Qualified Health CenterNon-Emergency Medical TransportationPhysical TherapyOccupational Therapy3233Services for Speech, Hearing and LanguageProsthetic Devices, Dentures, Eyeglasses34Diagnostic Screening & Preventive ServicesPreventive Services Grade A OR B, ACIPVaccines and their AdminNurse Mid-WifeEmergency Hospital ServicesCritical Access HospitalsNurse Practitioner ServicesSchool Based lyPlanningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareRehabilitative Services (non-school-based)Private Duty NursingFreestanding Birth CenterHealth Home for Enrollees w ChronicConditionsTobacco Cessation for Preg WomenForm CMS 64.9 WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramExpenditures in This QuarterState:Quarter Ended: 9/30/2019Waiver Type:Waiver Number:Waiver Name:TotalComputable454950FMAPFamilyPlanningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareHealth Home for Enrollees w Substance-UseDisorderOther Care ServicesTotalForm CMS 64.9 WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior rmediate Care Facility Services - Ind. withIntellectual Disabilities: Public Providers4BIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Private Providers5B5C5D6A6b77A1Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumberInpatient Hospital Services - GME PaymentsMental Health Facility Services: RegularPaymentsMental Health Facility Services: DSHAdjustment PaymentsCertified Community Behavior Health ClinicPayments3B5AOpt. Breast orCervicalCancer Srvcs(ENH Rate)Inpatient Hospital Services: Regular PaymentsInpatient Hospital Services: DSH AdjustmentPaymentsInpatient Hospital Services - SupplementalPaymentsNursing Facility Services - Regular PaymentsNursing Facility Services - SupplementalPayments4CFMAPFamilyPlanningI.H.S. Services ServicesIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Supplemental PaymentsPhysician and Surgical Services - RegularPaymentsPhysician and Surgical Services - SupplementalPaymentsPhysician & Surgical Services - Evaluation andManagementPhysician & Surgical Services - Vaccine codesOutpatient Hospital Services - RegularPaymentsOutpatient Hospital Services - SupplementalPaymentsPrescribed DrugsDrug Rebate Offset - National AgreementForm CMS 64.9PReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior Qtr/FYR:Line:TotalComputable7A27A37A4Drug Rebate Offset - State Sidebar AgreementMCO - National AgreementMCO - State Sidebar Agreement7A57A68Increased ACA OFFSET - Fee for Service - 100%Increased ACA OFFSET - MCO - 100%Dental Services9AOther Practitioners Services - Regular PaymentsOther Practitioners Services - SupplementalPaymentsClinic ServicesLaboratory And Radiological ServicesHome Health ServicesSterilizationsAbortionsEPSDT Screening ServicesRural Health Clinic ServicesMedicare Health Insurance Payments: Part APremiumsMedicare Health Insurance Payments: Part .H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumberMedicare Health Insurance Payments:17C1 Qualifying Individuals/120% - 134% of PovertyMedicare Health Insurance Payments:17D Coinsurance and DeductiblesMedicaid Health Insurance Payments: Managed18A Care Organizations18A1 Medicaid MCO - Evaluation and Management18A2 Medicaid MCO - Vaccine codes18A3 Medicaid MCO - Community First ChoiceMedicaid MCO - Preventive Services Grade A18A4 OR B, ACIP Vaccines and their AdminMedicaid MCO - Certified Community Behavior18A5 Health Clinic Payments18B1 Prepaid Ambulatory Health Plan18B1a MCO PAHP - Evaluation and ManagementForm CMS 64.9PReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumber18B1b MCO PAHP - Vaccine codes18B1c MCO PAHP - Community First ChoiceMCO PAHP - Preventive Services Grade A OR B,18B1d ACIP Vaccines and their AdminMedicaid PAHP - Certified Community Behavior18B1e Health Clinic Payments18B2 Prepaid Inpatient Health Plan18B2a MCO PIHP - Evaluation and Management18B2b MCO PIHP - Vaccine codes18B2c MCO PIHP - Community First ChoiceMCO PIHP - Preventive Services Grade A OR B,18B2d ACIP Vaccines and their AdminMedicaid PIHP - Certified Community Behavior18B2e Health Clinic PaymentsMedicaid Health Insurance Payments: Group18C Health Plan PaymentsMedicaid Health Insurance Payments:18D Coinsurance and Deductibles18E19A19B19CMedicaid Health Insurance Program: OtherHome and Community-Based Services - RegularPayment (Waiver)Home and Community-Based Services - StatePlan 1915(i) Only PaymentHome and Community-Based Services - StatePlan 1915(j) Only Payment24A24B2526Home and Community Based Services StatePlan 1915(k) Community First ChoicePrograms Of All-Inclusive Care ElderlyPersonal Care Services - Regular PaymentPersonal Care Services - SDS 1915(j)Targeted Case Management Services Community Case-ManagementCase Management - State WidePrimary Care Case Management ServicesHospice Benefits272829Emergency Services for Undocumented AliensFederally-Qualified Health CenterNon-Emergency Medical Transportation19D2223A23BForm CMS 64.9PReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior Qtr/FYR:Line:TotalComputable3031Physical TherapyOccupational Therapy3233Services for Speech, Hearing and LanguageProsthetic Devices, Dentures, Eyeglasses34Diagnostic Screening & Preventive ServicesPreventive Services Grade A OR B, ACIPVaccines and their AdminNurse Mid-WifeEmergency Hospital ServicesCritical Access HospitalsNurse Practitioner ServicesSchool Based nningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumberRehabilitative Services (non-school-based)Private Duty NursingFreestanding Birth CenterHealth Home for Enrollees w ChronicConditionsTobacco Cessation for Preg WomenHealth Home for Enrollees w Substance-UseDisorderOther Care ServicesTotalForm CMS 64.9PReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior Qtr/FYR:Line:Waiver Type:Waiver Number:Waiver Name:TotalComputable1A1B1C1D2A2B2C3A4AIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Public Providers4BIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Private Providers5B5C5D6AOpt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumberInpatient Hospital Services - GME PaymentsMental Health Facility Services: RegularPaymentsMental Health Facility Services: DSHAdjustment PaymentsCertified Community Behavior Health ClinicPayments3B5AOpt. Breast orCervicalCancer Srvcs(ENH Rate)Inpatient Hospital Services: Regular PaymentsInpatient Hospital Services: DSH AdjustmentPaymentsInpatient Hospital Services - SupplementalPaymentsNursing Facility Services - Regular PaymentsNursing Facility Services - SupplementalPayments4CFMAPFamilyPlanningI.H.S. Services ServicesIntermediate Care Facility Services - Ind. withIntellectual Disabilities: Supplemental PaymentsPhysician and Surgical Services - RegularPaymentsPhysician and Surgical Services - SupplementalPaymentsPhysician & Surgical Services - Evaluation andManagementPhysician & Surgical Services - Vaccine codesOutpatient Hospital Services - RegularPaymentsForm CMS 64.9P WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior Qtr/FYR:Line:Waiver Type:Waiver Number:Waiver Name:TotalComputable6b77A17A27A37A4Outpatient Hospital Services - SupplementalPaymentsPrescribed DrugsDrug Rebate - National AgreementDrug Rebate - State Sidebar AgreementMCO - National AgreementMCO - State Sidebar Agreement7A57A68Increased ACA OFFSET - Fee for Service - 100%Increased ACA OFFSET - MCO - 100%Dental Services9AOther Practitioners Services - Regular PaymentsOther Practitioners Services - SupplementalPaymentsClinic ServicesLaboratory And Radiological ServicesHome HealthSterilizationsAbortionsEPSDT Screening ServicesRural Health Clinic ServicesMedicare Health Insurance Payments: Part APremiumsMedicare Health Insurance Payments: Part .H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumberMedicare Health Insurance Payments:17C1 Qualifying Individuals/120% - 134% of PovertyMedicare Health Insurance Payments:17D Coinsurance and DeductiblesMedicaid Health Insurance Payments: Managed18A Care Organizations18A1 Medicaid MCO - Evaluation and Management18A2 Medicaid MCO - Vaccine codes18A3 Medicaid MCO - Community First ChoiceForm CMS 64.9P WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior Qtr/FYR:Line:Waiver Type:Waiver Number:Waiver Name:TotalComputableFMAPFamilyPlanningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumberMedicaid MCO - Preventive Services Grade A18A4 OR B, ACIP Vaccines and their AdminMedicaid MCO - Certified Community Behavior18A5 Health Clinic Payments18B1 Prepaid Ambulatory Health Plan18B1a MCO PAHP - Evaluation and Management18B1b MCO PAHP - Vaccine codes18B1c MCO PAHP - Community First ChoiceMCO PAHP - Preventive Services Grade A OR B,18B1d ACIP Vaccines and their AdminMedicaid PAHP - Certified Community Behavior18B1e Health Clinic Payments18B2 Prepaid Inpatient Health Plan18B2a MCO PIHP - Evaluation and Management18B2b MCO PIHP - Vaccine codes18B2c MCO PIHP - Community First ChoiceMCO PIHP - Preventive Services Grade A OR B,18B2d ACIP Vaccines and their AdminMedicaid PIHP - Certified Community Behavior18B2e Health Clinic PaymentsMedicaid Health Insurance Payments: Group18C Health Plan PaymentsMedicaid Health Insurance Payments:18D Coinsurance and Deductibles18E19CMedicaid Health Insurance Program: OtherHome and Community-Based Services - RegularPayment (Waiver)Home and Community-Based Services - StatePlan 1915(i) Only PaymentHome and Community-Based Services - StatePlan 1915(j) Only Payment19D2223AHome and Community Based Services StatePlan 1915(k) Community First ChoicePrograms Of All-Inclusive Care ElderlyPersonal Care Services - Regular Payment19A19BForm CMS 64.9P WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of ServiceFor the Medical Assistance ProgramPrior Period Adjustments in This QuarterState:Quarter Ended: 9/30/2019Prior Qtr/FYR:Line:Waiver Type:Waiver Number:Waiver Name:TotalComputable23B24A24B2526Personal Care Services - SDS 1915(j)Targeted Case Management Services Community Case-ManagementCase Management - State WidePrimary Care Case Management ServicesHospice Benefits2728293031Emergency Services for Undocumented AliensFederally-Qualified Health CenterNon-Emergency Medical TransportationPhysical TherapyOccupational Therapy3233Services for Speech, Hearing and LanguageProsthetic Devices, Dentures, Eyeglasses34Diagnostic Screening & Preventive ServicesPreventive Services Grade A OR B, ACIPVaccines and their AdminNurse Mid-WifeEmergency Hospital ServicesCritical Access HospitalsNurse Practitioner ServicesSchool Based nningI.H.S. Services ServicesOpt. Breast orCervicalCancer Srvcs(ENH Rate)Opt. Breast orCervicalCancer Srvcs(IHS Rate)Other %PromptFederal Share PaymentTotal FederalShareDeferral or CINNumberRehabilitative Services (non-school-based)Private Duty NursingFreestanding Birth CenterHealth Home for Enrollees w ChronicConditionsTobacco Cessation for Preg WomenHealth Home for Enrollees w Substance-UseDisorderOther Care ServicesTotalForm CMS 64.9P WAIVReport Date: Tuesday, October 29, 2019 - 12:00 AM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 04/30/2021Medicaid Overpayment AdjustmentState:Quarter Ended:TotalFederal ShareComputableOverpayment Activity(A)TotalFYFYFYFY(B)(C)(D)(E)Federal(F)1 Overpayments Not Collected OrAdjusted But Refunded Because OfThe Expiration Of The 1 Year III:0VIII:222 Decreasing Adjustments To AmountsPreviously Reported On Line 1VIII:VIII:VIII:VIII:3 SubtotalVIII:VIII:VIII:VIII:4 Previously Reported OverpaymentsTo Providers Certified This QuarterAs Bankrupt Or Out Of BusinessVIII:VIII:VIII:VIII:5 Total Overpayment Adjustments ThisQuarterVIII:Form CMS 64.9OVIII:VIII:VIII:Tuesday, October 29, 2019 - 01:17 PM
Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesOMB No. 0938-1265Expires 4/30/2021Fraud, Waste & Abuse Amounts Overpayments - Federal Credit DueFrom Medicaid Program Integrity ActivitiesState:Quarter Ended: 9/30/2019TotalComputable11A1B1C234Amounts Identified from State PI activitiesData mining activitiesPI Provider auditsOtherMFCU InvestigationsSettlements/JudgmentsCivil Monetary Penalties5678CMS Medicaid Integrity Contractors (MICs)OtherSub-TotalDecreasing Adjustments
18E Medicaid Health Insurance Payments: Other 19A Home and Community-Based Services - Regular Payment (Waiver) 19B Home and Community-Based Services - State . 18B2c MCO PIHP - Community First Choice 18B2d MCO PIHP - Preventive Services Grade A OR B, ACIP Vaccines and their Admin 18B2e
