Form CMS-64 Medical Assistance Expenditures by Type of Service For t

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64 Summary - Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Awards Received During The Quarter For The
Quarter Being Reported And Prior Quarters
1
Awards Received During The Quarter For
Subsequent Quarters
2
Interest: Received On Medicaid Recoveries
3.A.
Interest: Assessed On Disallowances
3.B.
Medicare Overpayment Collection Under Sec.
1914 and 42 CFR 447.30
4
Other
5
Expenditures In This Quarter
6
Adjustments Increasing Claims For Prior
Quarters
7
Other Expenditures
8
Collections: Third Party Liability
9.A.
Collections: Probate
9.B.
Recoveries: Fraud, Waste and Abuse Efforts
9.C.1.
Recoveries: OIG Compliant False Claims Act
9.C.2.
Collections: Other
9.D.
RAC Collections
9.E.
PERM Collections
9.F.
MEQC Collections
9G
Adjustments Decreasing Claims For Prior
Quarters: Federal Audit
10.A.
Adjustments Decreasing Claims For Prior
Quarters: Other
10.B.
Adjustments Decreasing Claims For Prior
Quarters: Overpayment Adjustments (Attach
64.9O)
10.C.
Adjustments/Decreasing Prior Qtrs - Perm
10.D.
Adjustments/Decreasing Prior Qtrs - RAC
10.E.
Adjustments/Decreasing Prior Qtrs - Fraud,
Waste and Abuse Overpayments
10.F.
Adjustments/Decreasing Prior Qtrs - OMEQC
10G
Net Expenditures Reported In This Period (Sum
of Items 6, 7 and 8 Less 9 and 10)
11

Form CMS 64 Summary

OMB No. 0938-1265
Expires 4/30/2024

Medicaid Federal Share

ARRA Federal Share

COVID Federal Share

Federal Share

Total Computable3

Federal Share4

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #

Line Description

1A

6b
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service - 100%

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9 BASE

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #
7A6
7A7
8

Line Description
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements

9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f

Form CMS 64.9 BASE

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33

Total
Line Description
Computable
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses

Form CMS 64.9 BASE

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 BASE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 BASE

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:

Line #

Line Description

1A

6b
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9 WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:

Line #
7A4

Line Description
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice

9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c

Form CMS 64.9 WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:

Line #

24A
24B
25
26

Line Description
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

27

Emergency Services for Undocumented Aliens

18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B

Form CMS 64.9 WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:

Line #
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5

Line Description
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%

Form CMS 64.9 WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIVER - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:

Line #
46A6
46B
47
48
49
69
70

Line Description
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

6b
7
7A1

Total
Line Description
Computable
Inpatient Hospital Services: Regular Payments
Inpatient Hospital Services: DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing

Line #
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9P

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
8
9A
9B
10A
10B
11
12
13
14
15
16
17A
17B

17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f

Line Description
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
Medicare Health Insurance Payments: Part A
Premiums
Medicare Health Insurance Payments: Part B
Premiums

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
Medicare Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements

Form CMS 64.9P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34

Total
Line Description
Computable
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services

Form CMS 64.9P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:

6b
7
7A1
7A2
7A3
7A4

Total
Line Description
Computable
Inpatient Hospital Services: Regular Payments
Inpatient Hospital Services: DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service - 100%

Line #
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9P WAIV

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:

Line #
7A6
7A7
8
9A
9B
10A
10B
11
12
13
14
15
16
17A
17B

17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c

Line Description
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
Medicare Health Insurance Payments: Part A
Premiums
Medicare Health Insurance Payments: Part B
Premiums

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
Medicare Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice

Form CMS 64.9P WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:

24A
24B
25
26

Total
Line Description
Computable
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center

Line #
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B

Form CMS 64.9P WAIV

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:

Line #
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B

Total
Line Description
Computable
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services

Form CMS 64.9P WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:

Line #
47
48
49
69
70

Line Description
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9P WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9O - Medicaid Overpayment Adjustment
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The 1
Year Time Limit
1
Decreasing Adjustments To Amounts Previously
Reported On Line 1
2
Subtotal
3
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt Or
Out Of Business
4
Total Overpayment Adjustments This Quarter
5

Form CMS 64.9O

OMB No. 0938-1265
Expires 4/30/2024

2021 And Prior

2022

2023

2024

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Fraud, Waste & Abuse Amounts Overpayments - Federal Credit Due
From Medicaid Program Integrity Activities
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Amounts Identified from State PI activities
1
Data mining activities
1A
PI Provider audits
1B
Other
1C
MFCU Investigations
2
Settlements/Judgments
3
Civil Monetary Penalties
4
CMS Medicaid Integrity Contractors (MICs)
5
Other
6
Sub-Total
7
Decreasing Adjustments to Amounts
Previously Reported on Line 7
8

9
10

OMB No. 0938-1265
Expires 4/30/2024

Medicaid (Non-VIII Group) Federal Share

Medicaid VIII Group Federal Share

ARRA Federal Share

COVID Federal Share

Federal Share

Decreasing Adjustments - Amounts Previously
Reported Overpayments to Providers Certified
this Quarter as Bankrupt or Out of Business
Total

Form CMS 64.9OFWA

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9OMEQC - Medicaid Eligibility Quality Control Collections and Overpayment
State:
Quarter Ended: 12/31/2023
Line #
Overpayment Activity
Total Computable
2021 And Prior
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The 1
Year Time Limit
1
Decreasing Adjustments To Amounts Previously
Reported On Line 1
2
SubTotal
3
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt Or
Out Of Business
4
Total Overpayment Adjustments This Quarter
5

Form CMS 64.9OMEQC

OMB No. 0938-1265
Expires 4/30/2024

2022

2023

2024

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9O PERM - Medicaid Overpayment Adjustment
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The 1
Year Time Limit
1
Decreasing Adjustments To Amounts Previously
Reported On Line 1
2
Subtotal
3
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt Or
Out Of Business
4
Total Overpayment Adjustments This Quarter
5

Form CMS 64.9OPerm

OMB No. 0938-1265
Expires 4/30/2024

2021 And Prior

2022

2023

2024

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9ORAC - Recovery Audit Contractors identified Overpayment
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The 1
Year Time Limit
1
Decreasing Adjustments To Amounts Previously
Reported On Line 1
2
Subtotal
3
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt Or
Out Of Business
4
Total Overpayment Adjustments This Quarter
5

Form CMS 64.9ORAC

OMB No. 0938-1265
Expires 4/30/2024

2021 And Prior

2022

2023

2024

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9A - Third Party Liability Collections and Cost Avoidance
State:
Quarter Ended: 12/31/2023

Line #
1.a.
b.1.
2

c.
1
2
3
4
2
1
2
3

Line Description
Amount Of Third Liabilty Collections Made In
This Quarter By Source: Medicare Title XVIII
Other Collections: Health Insurance
Other Collections: Casualty Insurance
Total Collections Under Cooperative
Agreements Section 1903(p) And Assignment
of Right Section 1912
Total Collections: Less Excess Paid To
Individuals
Net Collections To Reimburse State Title XIX
Medical Payments
Less 15% Incentive Actually Paid Under Section
1903(p)(1)
Net Federal Share Of Collections Reportable
Total Third Party Liabilty Collections
Medicare Title XVIII
Health Insurance
Other Cost Avoidance

Form CMS 64.9A

Total
Computable

Medicaid
(Non-VIII
Medicaid VIII
Group)
Group Federal ARRA Federal COVID Federal
Federal Share Share
Share
Share
Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #

Line Description

1A

6b
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service - 100%

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9 200K

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #
7A6
7A7
8

Line Description
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements

9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f

Form CMS 64.9 200K

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33

Total
Line Description
Computable
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses

Form CMS 64.9 200K

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023

Line #
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 200K

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

6b
7
7A1

Total
Line Description
Computable
Inpatient Hospital Services: Regular Payments
Inpatient Hospital Services: DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing

Line #
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9 200KP

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
8
9A
9B
10A
10B
11
12
13
14
15
16
17A
17B

17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f

Line Description
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
Medicare Health Insurance Payments: Part A
Premiums
Medicare Health Insurance Payments: Part B
Premiums

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
Medicare Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements

Form CMS 64.9 200KP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34

Total
Line Description
Computable
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services

Form CMS 64.9 200KP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P 200K - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 200KP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 BASE - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Cost of In-House Activities
2A
Design Development Or Installation Of MMIS:
Cost of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Costs of InHouse Activities Plus State Agencies And
Institutions
4A
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8
9
10
11

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)
Nurse Aide Training Costs
Preadmission Screening Costs
Resident Review Activities Costs

Form CMS 64.10 Base

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 BASE - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Drug Use Review Program
12
Outstationed Eligibility Workers
13
TANF Base
14
TANF Secondary 90%
15
TANF Secondary 75%
16
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs (State Level)
22
Translation and Interpretation
23
24
24A
24B
24C
24D
24E
24F
25
25A
25B
26
27

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors
HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration

Form CMS 64.10 Base

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 BASE - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable

28H
29

Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors
Eligibility Determination Staff – Cost of In-house
Activities
Eligibility Determination Staff – Cost of Private
Sector Contractors
Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
Non-Emergency Medical Transportation

30
31
49
50

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
CAA 2023 Section 5101
Other Financial Participation
Total

28A

28B

28C

28D
28E
28F
28G

Form CMS 64.10 Base

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 WAIVER - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Cost of In-House Activities
2A
Design Development Or Installation Of MMIS:
Cost of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Costs of InHouse Activities Plus State Agencies And
Institutions
4A
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)

Form CMS 64.10 Waiv

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 WAIVER - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Nurse Aide Training Costs
9
Preadmission Screening Costs
10
Resident Review Activities Costs
11
Drug Use Review Program
12
Outstationed Eligibility Workers
13
TANF Base
14
TANF Secondary 90%
15
TANF Secondary 75%
16
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23

24D

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors

24E
24F
25
25A

HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA

24
24A
24B
24C

Form CMS 64.10 Waiv

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 WAIVER - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
CVT Operation - CHIPRA
25B
Planning for Health Homes for Enrollees with
Chronic Conditions
26
Recovery Audit Contractors State
Administration
27

28H
29

Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors
Eligibility Determination Staff – Cost of In-house
Activities
Eligibility Determination Staff – Cost of Private
Sector Contractors
Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
Non-Emergency Medical Transportation

30

Design Development/Implementation of
Prescription Drug Monitoring Program Systems

28A

28B

28C

28D
28E
28F
28G

Form CMS 64.10 Waiv

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 WAIVER - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
CAA 2023 Section 5101
31
Other Financial Participation
49
Total
50

Form CMS 64.10 Waiv

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Costs Of In-House Activities
2A
Design Development Or Installation Of MMIS:
Costs Of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Cost Of InHouse Activities
4A
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8
9
10
11
12
13
14
15
16
17

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)
Nurse Aide Training
Preadmission Screening Costs
Resident Review Activities Cost
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary (90%)
TANF Secondary (75%)
External Review

Form CMS 64.10P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23
24
24A
24B
24C
24D
24E
24F
25
25A
25B
26
27

28A

28B

28C

28D

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors
HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors

Form CMS 64.10P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Eligibility Determination Staff – Cost of Inhouse Activities
28E
Eligibility Determination Staff – Cost of Private
Sector Contractors
28F
Eligibility Determination Staff – Cost of Inhouse Activities – 50% FFP
28G
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
28H
Non-Emergency Medical Transportation
29

30
31
49
50

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
CAA 2023 Section 5101
Other Financial Participation
Total

Form CMS 64.10P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P Waiver - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Costs Of In-House Activities
2A
Design Development Or Installation Of MMIS:
Costs Of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Cost Of InHouse Activities
4A
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8
9
10
11
12
13
14

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)
Nurse Aide Training
Preadmission Screening Costs
Resident Review Activities Cost
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base

Form CMS 64.10P Waiv

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P Waiver - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
TANF Secondary (90%)
15
TANF Secondary (75%)
16
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23
24
24A
24B
24C
24D
24E
24F
25
25A
25B
26
27

28A

28B

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors
HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors

Form CMS 64.10P Waiv

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P Waiver - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
28C
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors
28D
Eligibility Determination Staff – Cost of Inhouse Activities
28E
Eligibility Determination Staff – Cost of Private
Sector Contractors
28F
Eligibility Determination Staff – Cost of Inhouse Activities – 50% FFP
28G
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
28H
Non-Emergency Medical Transportation
29

30
31
49
50

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
CAA 2023 Section 5101
Other Financial Participation
Total

Form CMS 64.10P Waiv

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.11 - Summary Total of Receipts from Form CMS 64.11 A
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Receipts
Donations
Donations - Medicaid
1
Donations - CHIP
Donations- Outstationed Eligibility Workers Medicaid
2
Donations - Outstationed Eligibility Workers CHIP
2.A.
Taxes
Taxes
3
Fees
Fees
4
Assessments
Assessments
5
Totals
Total Donations (Lines 1+1.A.+2+2.A)
6
Total Taxes, Fees, and Assessments (Lines
3+4+5)
7

Form CMS 64.11

OMB No. 0938-1265
Expires 4/30/2024

0
0
0
0
0
0
0
0
0

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.11A - Actual Receipts by Plan Name
State:
Quarter Ended: 12/31/2023
Code
Plan Name
Receipts
No data submitted for this form

Form CMS 64.11A

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9D - Allocation of Disproportionate Share Hospital
Payment Adjusments to Applicable FFYs
State:
Quarter Ended: 12/31/2023
Total
Total
Total
Total
Line #
Line Description Computable Federal Share Computable3 Federal Share4 Computable5 Federal Share6 Computable7 Federal Share8
No data submitted for this form

Form CMS 64.9D

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9R - Medicaid Drug Rebate Schedule
State:
Quarter Ended: 12/31/2023

Line #
1
2
3
4

Line Description
Balance Of The Beginning Of The Quarter
Adjustments To Previously Reported Rebates
From Drug Labelers Included In Line 1
Rebates Invoiced In This Quarter
Subtotal

5
6

Rebates Reported On This Expenditure Report
Balance As Of The End Of The Quarter

Form CMS 64.9R

Qtr. Ending
12/31/2023

Qtr. Ending
09/30/2023

Qtr. Ending
06/30/2023

Qtr. Ending
03/31/2023

Qtr. Ending
12/31/2022
And Prior

Total

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Medicaid Program Expenditure Report
Other Narrative Explanations
State:
Quarter Ended: 12/31/2023
Narrative

Form CMS 64 Narr

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21P - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
1A
1B
1C
1D

Line Description
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost
Sharing Offset
Premiums Over 150% Of Poverty Level - Gross
Premiums Paid
Premiums Over 150% Of Poverty Level - Cost
Sharing Offset

3B
4
5
6
7
8
8A1
8A2
8A3
8A4

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Services - DSH Adjustments
Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services - DSH
Adjustments Payments
Certified Community Behavior Health Clinic
Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

8A5

Increased ACA OFFSET - Fee for Service - 100%

2
2A
3
3A

Form CMS 64.21P

Total
Computable

Family
FMAP Percent I.H.S. Services Planning

Non COVID
FMAP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21P - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:

Line #
8A6
9
10
11
12
13
14
15
16
17
18
19
20
21
21A
22
23
24
25
28

Line Description
Increased ACA OFFSET - MCO - 100%
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological services
Durable And Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Home and Community-Based Services Regular Payment (WAIVER)
Hospice
Medical Transportation
Case Management
Other Services
Total

Form CMS 64.21P

Total
Computable

Family
FMAP Percent I.H.S. Services Planning

Non COVID
FMAP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21P Waiver - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:

Line #
1A
1B
1C
1D
2
2A
3
3A
3B
4
5
6
7
8
8A1
8A2
8A3

Line Description
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost
Sharing Offset
Premiums Over 150% Of Poverty Level - Gross
Premiums Paid
Premiums Over 150% Of Poverty Level - Cost
Sharing Offset

Total
Computable

Family
FMAP Percent I.H.S. Services Planning

Non COVID
FMAP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Services - DSH Adjustments
Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services - DSH
Adjustments Payments
Certified Community Behavior Health Clinic
Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement

Form CMS 64.21P WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21P Waiver - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:

Line #
8A4

Line Description
MCO - State Sidebar Agreement

8A5
8A6
9
10
11
12
13
14
15
16
17
18
19
20
21

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological services
Durable And Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Home and Community-Based Services Regular Payment (WAIVER)
Hospice
Medical Transportation
Case Management
Other Services
Total

21A
22
23
24
25
28

Form CMS 64.21P WAIV

Total
Computable

Family
FMAP Percent I.H.S. Services Planning

Non COVID
FMAP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.21U - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2023
Type of Eligible:
Line #
Line Description
Total Computable
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
1A
Premiums Up To 150% Of Poverty Level - Cost
Sharing Offsets
1B
Premiums Over 150% Of Poverty Level - Gross
Premiums Paid
1C
Premiums Over 150% Of Poverty Level - Cost
Sharing Offsets
1D
2
2A
3
3A
3B
4
5
6
7
8
8A1
8A2
8A3
8A4

OMB No. 0938-1265
Expires 4/30/2024

FMAP Percent

CHIP

Total Federal Share

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Services - DSH Adjustments
Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

Form CMS 64.21U

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.21U - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2023
Type of Eligible:
Line #
Line Description
Total Computable
8A5
8A6
8A7
9
10
11
12
13
14
15
16
17
18
19
20
21
21A
22
23
24
26
31
48

OMB No. 0938-1265
Expires 4/30/2024

FMAP Percent

CHIP

Total Federal Share

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Home and Community-Based Services - Regular
Payment (WAIVER)
Hospice
Medical Transportation
Case Management
ARP Section 9821 COVID Vaccine/Vaccine
Administration
Other Services
Total

Form CMS 64.21U

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.21U Waiver- Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:
Line #
Line Description
Total Computable
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
1A
Premiums Up To 150% Of Poverty Level - Cost
Sharing Offsets
1B
Premiums Over 150% Of Poverty Level - Gross
Premiums Paid
1C
Premiums Over 150% Of Poverty Level - Cost
Sharing Offsets
1D
2
2A
3
3A
3B
4
5
6
7
8
8A1

OMB No. 0938-1265
Expires 4/30/2024

FMAP Percent

CHIP

Total Federal Share

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Services - DSH Adjustments
Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate - National Agreement

Form CMS 64.21U WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.21U Waiver- Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:
Line #
Line Description
Total Computable
Drug Rebate - State Sidebar Agreement
8A2
MCO - National Agreement
8A3
MCO - State Sidebar Agreement
8A4
8A5
8A6
8A7
9
10
11
12
13
14
15
16
17
18
19
20
21
21A
22
23

OMB No. 0938-1265
Expires 4/30/2024

FMAP Percent

CHIP

Total Federal Share

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Home and Community-Based Services - Regular
Payment (WAIVER)
Hospice
Medical Transportation

Form CMS 64.21U WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.21U Waiver- Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:
Line #
Line Description
Total Computable
Case Management
24
ARP Section 9821 COVID Vaccine/Vaccine
Administration
26
Other Services
31
Total
48

Form CMS 64.21U WAIV

OMB No. 0938-1265
Expires 4/30/2024

FMAP Percent

CHIP

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21UP - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
1A
1B
1C
1D
2
2A
3
3A
3B
4
5
6
7
8
8A1
8A2
8A3
8A4
8A5
8A6
8A7
9
10
11
12

Line Description
Premiums Up To 150% Of Poverty Level - Gross Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost Sharing Offsets
Premiums Over 150% Of Poverty Level - Gross Premiums Paid
Premiums Over 150% Of Poverty Level - Cost Sharing Offsets
Inpatient Hospital Services - Regular Payments
Inpatient Hospital Services - DSH Adjustments Payments
Inpatient Mental Health Facility Services - Regular Payments
Inpatient Mental Health Facility Services - DSH Adjustments
Payments
Certified Community Behavior Health Clinic Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services

Form CMS 64.21UP

Total
Computable

FMAP

CHIP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21UP - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
13
14
15
16
17
18
19
20
21
21A
22
23
24
26
31
48
49
50

Line Description
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Home and Community-Based Services - Regular Payment
(WAIVER)
Hospice
Medical Transportation
Case Management
ARP Section 9821 COVID Vaccine/Vaccine Administration
Other Services
Balance
Collections
Total

Form CMS 64.21UP

Total
Computable

FMAP

CHIP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21UP WAIVER - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
1A
1B
1C
1D
2
2A
3
3A
3B
4
5
6
7
8
8A1
8A2
8A3
8A4
8A5
8A6
8A7
9

Line Description
Premiums Up To 150% Of Poverty Level - Gross Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost Sharing Offsets
Premiums Over 150% Of Poverty Level - Gross Premiums Paid
Premiums Over 150% Of Poverty Level - Cost Sharing Offsets
Inpatient Hospital Services - Regular Payments
Inpatient Hospital Services - DSH Adjustments Payments
Inpatient Mental Health Facility Services - Regular Payments
Inpatient Mental Health Facility Services - DSH Adjustments
Payments
Certified Community Behavior Health Clinic Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

Form CMS 64.21UP WAIV

Total
Computable

FMAP

CHIP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.21UP WAIVER - Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
10
11
12
13
14
15
16
17
18
19
20
21
21A
22
23
24
26
31
48
49
50

Line Description
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Home and Community-Based Services - Regular Payment
(WAIVER)
Hospice
Medical Transportation
Case Management
ARP Section 9821 COVID Vaccine/Vaccine Administration
Other Services
Balance
Collections
Total

Form CMS 64.21UP WAIV

Total
Computable

FMAP

CHIP

Total Federal
Share

Deferral
Disallowance
C.I.N. No.

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.F - Quarterly Medical Assistance Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended: 12/31/2023
Line #
6.A.
6.A.1.
6.A.2.
6.A.3.
6.A.4.
6.A.5.
6.B.
6.C.
7.A.
7.A.1.
7.A.2.
7.A.3.
7.A.4.
7.A.5.
7.B.
7.C.
8.A.
8.A.1.
8.A.2.
8.A.3.
8.A.4.
8.A.5.
8.B.
8.C.
9
10.A.1.
10.A.1.a
10.A.1.b.
10.A.1.c.
10.A.1.d.
10.A.1.e.
10.A.2.

Line Description
From Form CMS-64.9/CMS-64.10
From Form CMS-64.9T
From Form CMS-64.9E/CMS-64.9PE
From Form CMS-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
From Form CMS-64.9SAP
From Form CMS-64.21
From Form CMS-64.21U
From Form CMS 64.9P/CMS 64.10
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
From Form CMS-64.9SAP
From Form CMS-64.21P
From Form CMS-64.21UP
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
From Form CMS-64.9SAP
From Form CMS-64.21P
From Form CMS-64.21UP
From Form CMS-64.9 Summary
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
From Form CMS-64.9SAP
From Form CMS 64.21P

Form CMS 64.F

Total
Computable

Total
Federal
Federal Share Computable3 Share4

20% Federal
Share

Total
Federal
Computable5 Share6

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.F - Quarterly Medical Assistance Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended: 12/31/2023
Line #
10.A.3.
10.B.1.
10.B.1.a
10.B.1.b.
10.B.1.c.
10.B.1.d.
10.B.1.e.
10.B.2.
10.B.3.
10.C.
10.D.
10.E.
10.F.
10.G.
11

Line Description
From Form CMS 64.21UP
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
From Form CMS-64.9SAP
From Form CMS 64.21P
From Form CMS 64.21UP
From Form CMS-64.9O/64.9O ARRA
From Form CMS-64.9OPerm
From Form CMS-64.9ORAC
From Form CMS-64.9OFWA
From Form CMS-64.MEQC
Net Expenditures Reported This Period

Form CMS 64.F

Total
Computable

Total
Federal
Federal Share Computable3 Share4

20% Federal
Share

Total
Federal
Computable5 Share6

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b
7
7A1

Form CMS 64.9I

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:

Line #

Line Description

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5

Form CMS 64.9I

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:

Line #
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A

Line Description
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment

Form CMS 64.9I

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:

Line #
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45

Line Description
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder

Form CMS 64.9I

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:

Line #
46

Line Description
OUD Medicaid Assisted Treatment – Drugs

46A1
46A2

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Form CMS 64.9I

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:

Line #
1A

6b
7
7A1

Line Description
Inpatient Hospital Services: Regular Payments
Inpatient Hospital Services: DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9PI

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:

Line #

Line Description

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
Medicare Health Insurance Payments: Part A
Premiums
Medicare Health Insurance Payments: Part B
Premiums

9B
10A
10B
11
12
13
14
15
16
17A
17B

17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or CIN
Number

Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
Medicare Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management

Form CMS 64.9PI

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:

Line #
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26

Line Description
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Form CMS 64.9PI

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:

Line #

Line Description

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or CIN
Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar

Form CMS 64.9PI

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:

Line #
46A5
46A6
46B
47
48
49
69
70

Line Description
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9PI

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10I - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Cost of In-House Activities
2A
Design Development Or Installation Of MMIS:
Cost of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Costs of InHouse Activities Plus State Agencies And
Institutions
4A
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8
9
10

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)
Nurse Aide Training Costs
Preadmission Screening Costs

Form CMS 64.10I

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10I - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:
Line #
Line Description
Total Computable
Resident Review Activities Costs
11
Drug Use Review Program
12
Outstationed Eligibility Workers
13
TANF Base
14
TANF Secondary 90%
15
TANF Secondary 75%
16
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23
24
24A
24B
24C
24D
24E
24F
25
25A
25B
26

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors
HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions

Form CMS 64.10I

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10I - Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Program:
Line #
Line Description
Total Computable
Recovery Audit Contractors State
Administration
27

28H
29

Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors
Eligibility Determination Staff – Cost of In-house
Activities
Eligibility Determination Staff – Cost of Private
Sector Contractors
Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
Non-Emergency Medical Transportation

30
31
49
50

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
CAA 2023 Section 5101
Other Financial Participation
Total

28A

28B

28C

28D
28E
28F
28G

Form CMS 64.10I

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10PI - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Costs Of In-House Activities
2A
Design Development Or Installation Of MMIS:
Costs Of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Cost Of InHouse Activities
4A
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8
9
10
11
12
13
14
15
16

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)
Nurse Aide Training
Preadmission Screening Costs
Resident Review Activities Cost
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary (90%)
TANF Secondary (75%)

Form CMS 64.10PI

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10PI - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:
Line #
Line Description
Total Computable
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23
24
24A
24B
24C
24D
24E
24F
25
25A
25B
26
27

28A

28B

28C

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors
HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities

Form CMS 64.10PI

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10PI - Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:
Line #
Line Description
Total Computable
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors
28D
Eligibility Determination Staff – Cost of Inhouse Activities
28E
Eligibility Determination Staff – Cost of Private
Sector Contractors
28F
Eligibility Determination Staff – Cost of Inhouse Activities – 50% FFP
28G
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
28H
Non-Emergency Medical Transportation
29

30
31
49
50

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
CAA 2023 Section 5101
Other Financial Participation
Total

Form CMS 64.10PI

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B
4C
5A
5B
5C

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management

Form CMS 64.9T

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Physician
&
Surgical
Services
Vaccine
codes
5D
Outpatient Hospital Services - Regular
Payments
6A
Outpatient Hospital Services - Supplemental
Payments
6b
Prescribed Drugs
7
Drug Rebate Offset - National Agreement
7A1
7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening

9B
10A
10B
11
12
13
14
15
16

Form CMS 64.9T

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Medicare Health Insurance Payments - Part A
Premiums
17A
Medicare Health Insurance Payments - Part B
Premiums
17B
120% - 134% Of Poverty
17C1
Coinsurance And Deductibles
17D
Medicaid Health Insurance Payments: Managed
Care Organizations (MCO)
18A
Medicaid MCO - Evaluation and Management
18A1
Medicaid MCO - Vaccine codes
18A2
Medicaid MCO - Community First Choice
18A3
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18A4
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
18A5
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
18A6
Prepaid Ambulatory Health Plan
18B1
MCO PAHP - Evaluation and Management
18B1a
MCO PAHP - Vaccine codes
18B1b
MCO PAHP - Community First Choice
18B1c
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B1d
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1e
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
18B1f
Prepaid Inpatient Health Plan
18B2

Form CMS 64.9T

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
MCO
PIHP
Evaluation
and
Management
18B2a
MCO PIHP - Vaccine codes
18B2b
MCO PIHP - Community First Choice
18B2c
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B2d
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2e
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
18B2f
Medicaid Health Insurance Payments: Group
Health Plan Payments
18C
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18D
Medicaid Health Insurance Payments: Other
18E
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
19A
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19B
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19C
Home and Community Based Services State
Plan 1915(k) Community First Choice
19D
Programs Of All-Inclusive Care Elderly
22
Personal Care Services - Regular Payment
23A
Personal Care Services - SDS 1915(j)
23B
Targeted Case Management Services Community Case-Management
24A
Case Management - State Wide
24B

Form CMS 64.9T

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Primary
Care
Case
Management
Services
25
Hospice Benefits
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center

Form CMS 64.9T

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Health Home for Enrollees w Chronic
Conditions
43
Tobacco Cessation for Preg Women
44
Health Home for Enrollees w Substance-UseDisorder
45
OUD Medicaid Assisted Treatment – Drugs
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9T

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B
4C
5A
5B
5C
5D
6A

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments

Form CMS 64.9TP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Outpatient Hospital Services - Supplemental
Payments
6b
Prescribed Drugs
7
Drug Rebate Offset - National Agreement
7A1
7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D

Form CMS 64.9TP

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
18A
Medicaid MCO - Evaluation and Management
18A1
Medicaid MCO - Vaccine codes
18A2
Medicaid MCO - Community First Choice
18A3
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18A4
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
18A5
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
18A6
Prepaid Ambulatory Health Plan
18B1
MCO PAHP - Evaluation and Management
18B1a
MCO PAHP - Vaccine codes
18B1b
MCO PAHP - Community First Choice
18B1c
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B1d
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
18B1e
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
18B1f
Prepaid Inpatient Health Plan
18B2
MCO PIHP - Evaluation and Management
18B2a
MCO PIHP - Vaccine codes
18B2b
MCO PIHP - Community First Choice
18B2c
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B2d
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2e
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
18B2f

Form CMS 64.9TP

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Medicaid Health Insurance Payments: Group
Health Plan Payments
18C
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18D
Medicaid Health Insurance Payments: Other
18E
Home and Community-Based Services Regular Payment (1915(c) Waiver)
19A
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19B
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19C
Home and Community Based Services State
Plan 1915(k) Community First Choice
19D
Programs Of All-Inclusive Care Elderly
22
Personal Care Services - Regular Payment
23A
Personal Care Services - SDS 1915(j)
23B
Targeted Case Management Services Community Case-Management
24A
Case Management - State Wide
24B
Primary Care Case Management Services
25
Hospice Benefits
26
27
28
29A
29B
30
31
32

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language

Form CMS 64.9TP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Prosthetic
Devices,
Dentures,
Eyeglasses
33
Diagnostic Screening & Preventive Services
34
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
34A
Nurse Mid-Wife
35
Emergency Hospital Services
36
Critical Access Hospitals - Reg. Payments
37A
Critical Access Hospitals Inpatient - Sup.
Payments
37B
Critical Access Hospitals Outpatient - Sup.
Payments
37C
Nurse Practitioner Services
38
School Based Services
39
Rehabilitative Services (non-school-based)
40
Private Duty Nursing
41
Freestanding Birth Center
42
Health Home for Enrollees w Chronic
Conditions
43
Tobacco Cessation for Preg Women
44
Health Home for Enrollees w Substance-UseDisorder
45
OUD Medicaid Assisted Treatment – Drugs
46
46A1
46A2
46A3
46A4
46A5

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%

Form CMS 64.9TP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
46A6
OUD Medicaid Assisted Treatment Services
46B
ARP Section 9811 COVID Vaccine/Vaccine
Administration
47
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
48
Health Homes for Children with Medically
Complex Conditions
49
Other Care Services
69
Total
70

Form CMS 64.9TP

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B
4C
5A
5B
5C

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management

Form CMS 64.9TPWAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Physician & Surgical Services - Vaccine codes
5D
Outpatient Hospital Services - Regular
Payments
6A
Outpatient Hospital Services - Supplemental
Payments
6b
Prescribed Drugs
7
Drug Rebate Offset - National Agreement
7A1
7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening

9A
9B
10A
10B
11
12
13
14
15
16

Form CMS 64.9TPWAIV

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Medicare Health Insurance Payments - Part A
Premiums
17A
Medicare Health Insurance Payments - Part B
Premiums
17B
120% - 134% Of Poverty
17C1
Coinsurance And Deductibles
17D
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
18A
Medicaid MCO - Evaluation and Management
18A1
Medicaid MCO - Vaccine codes
18A2
Medicaid MCO - Community First Choice
18A3
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18A4
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
18A5
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
18A6
Prepaid Ambulatory Health Plan
18B1
MCO PAHP - Evaluation and Management
18B1a
MCO PAHP - Vaccine codes
18B1b
MCO PAHP - Community First Choice
18B1c
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B1d
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
18B1e
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
18B1f
Prepaid Inpatient Health Plan
18B2

Form CMS 64.9TPWAIV

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
MCO PIHP - Evaluation and Management
18B2a
MCO PIHP - Vaccine codes
18B2b
MCO PIHP - Community First Choice
18B2c
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B2d
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2e
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
18B2f
Medicaid Health Insurance Payments: Group
Health Plan Payments
18C
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18D
Medicaid Health Insurance Payments: Other
18E
Home and Community-Based Services Regular Payment (1915(c) Waiver)
19A
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19B
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19C
Home and Community Based Services State
Plan 1915(k) Community First Choice
19D
Programs Of All-Inclusive Care Elderly
22
Personal Care Services - Regular Payment
23A
Personal Care Services - SDS 1915(j)
23B
Targeted Case Management Services Community Case-Management
24A
Case Management - State Wide
24B

Form CMS 64.9TPWAIV

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Primary Care Case Management Services
25
Hospice Benefits
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center

Form CMS 64.9TPWAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9TP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Health Home for Enrollees w Chronic
Conditions
43
Tobacco Cessation for Preg Women
44
Health Home for Enrollees w Substance-UseDisorder
45
OUD Medicaid Assisted Treatment – Drugs
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Deferral or CIN Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9TPWAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B
4C
5A

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments

Form CMS 64.9TWAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Physician and Surgical Services - Supplemental
Payments
5B
Physician & Surgical Services - Evaluation and
Management
5C
Physician & Surgical Services - Vaccine codes
5D
Outpatient Hospital Services - Regular
Payments
6A
Outpatient Hospital Services - Supplemental
Payments
6b
Prescribed Drugs
7
Drug Rebate Offset - National Agreement
7A1
7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments

9B
10A

Form CMS 64.9TWAIV

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Clinic Services - Sup. Payments
10B
Laboratory And Radiological Services
11
Home Health Services
12
Sterilizations
13
Abortions No.
14
EPSDT Screening Services
15
Rural Health Clinic Screening
16
Medicare Health Insurance Payments - Part A
Premiums
17A
Medicare Health Insurance Payments - Part B
Premiums
17B
120% - 134% Of Poverty
17C1
Coinsurance And Deductibles
17D
Medicaid Health Insurance Payments: Managed
Care Organizations (MCO)
18A
Medicaid MCO - Evaluation and Management
18A1
Medicaid MCO - Vaccine codes
18A2
Medicaid MCO - Community First Choice
18A3
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18A4
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
18A5
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
18A6
Prepaid Ambulatory Health Plan
18B1

Form CMS 64.9TWAIV

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
MCO PAHP - Evaluation and Management
18B1a
MCO PAHP - Vaccine codes
18B1b
MCO PAHP - Community First Choice
18B1c
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B1d
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
18B1e
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
18B1f
Prepaid Inpatient Health Plan
18B2
MCO PIHP - Evaluation and Management
18B2a
MCO PIHP - Vaccine codes
18B2b
MCO PIHP - Community First Choice
18B2c
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B2d
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
18B2e
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
18B2f
Medicaid Health Insurance Payments: Group
Health Plan Payments
18C
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18D
Medicaid Health Insurance Payments: Other
18E

Form CMS 64.9TWAIV

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
19A
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19B
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19C
Home and Community Based Services State
Plan 1915(k) Community First Choice
19D
Programs Of All-Inclusive Care Elderly
22
Personal Care Services - Regular Payment
23A
Personal Care Services - SDS 1915(j)
23B
Targeted Case Management Services Community Case-Management
24A
Case Management - State Wide
24B
Primary Care Case Management Services
25
Hospice Benefits
26
27
28
29A
29B
30
31

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy

Form CMS 64.9TWAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
Services for Speech, Hearing and Language
32
Prosthetic Devices, Dentures, Eyeglasses
33
Diagnostic Screening & Preventive Services
34
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
34A
Nurse Mid-Wife
35
Emergency Hospital Services
36
Critical Access Hospitals - Reg. Payments
37A
Critical Access Hospitals Inpatient - Sup.
Payments
37B
Critical Access Hospitals Outpatient - Sup.
Payments
37C
Nurse Practitioner Services
38
School Based Services
39
Rehabilitative Services (non-school-based)
40
Private Duty Nursing
41
Freestanding Birth Center
42
Health Home for Enrollees w Chronic
Conditions
43
Tobacco Cessation for Preg Women
44
Health Home for Enrollees w Substance-UseDisorder
45
OUD Medicaid Assisted Treatment – Drugs
46
46A1

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

OUD MAT DRUG REBATE/National Agreement

Form CMS 64.9TWAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.9T Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Line #
Line Description
Total Computable
OUD MAT DRUG REBATE/State Sidebar
46A2
OUD MAT DRUG REBATE MCO /National
Agreement
46A3
OUD MAT DRUG REBATE MCO /State Sidebar
46A4
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
46A5
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
46A6
OUD Medicaid Assisted Treatment Services
46B
ARP Section 9811 COVID Vaccine/Vaccine
Administration
47
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
48
Health Homes for Children with Medically
Complex Conditions
49
Other Care Services
69
Total
70

Form CMS 64.9TWAIV

OMB No. 0938-1265
Expires 4/30/2024

CHIP Rate

Increased FMAP Rate

CHIP Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9C1 - Fraud, Waste & Abuse Amounts Credited
From Medicaid Program Integrity Activities
State:
Quarter Ended: 12/31/2023

Line #
1
1A
1B
1C
2
3
4
5
6
7
8
50

Line Description
Amounts Identified from State PI activities
Data mining activities
PI Provider audits
Other
MFCU Investigations
Settlements/Judgments
Civil Monetary Penalties
CMS Medicaid Integrity Contractors (MICs)
Other
Sub-Total
Decreasing Adjustments to Amounts
Previously Reported on Line 7
Total

Form CMS 64.9C1

Total
Computable

Medicaid
(Non-VIII
Medicaid VIII
Group)
Group Federal ARRA Federal COVID Federal
Federal Share Share
Share
Share
Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9C2 - RECOVERIES FROM OIG STATE COMPLIANT FCA
State:
Quarter Ended: 12/31/2023

Line #
1
1A
1B

1C

Line Description
Recoveries from OIG Certified Compliant FCA
Total Recovery
10% Reduction FMAP Rate (to be used in the
grant award computation)
Recovery after 10% FMAP reduction to any
amounts recovered under a State action
brought under an OIG approved State law

Form CMS 64.9C2

Total
Computable

Medicaid Non- Medicaid VIII
VIII Group
Group Federal ARRA Federal COVID Federal Total Federal
Federal Share Share
Share
Share
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9QI - Allocation of Qualified Individual Part B (QIB) Benefits
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Federal Share
No data submitted for this form

Form CMS 64.9QI

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b
7
7A1

Form CMS 64.9 PE

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #

Line Description

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5

Form CMS 64.9 PE

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A

Line Description
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment

Form CMS 64.9 PE

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45

Line Description
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder

Form CMS 64.9 PE

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PE - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #
46

Line Description
OUD Medicaid Assisted Treatment – Drugs

46A1
46A2

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Form CMS 64.9 PE

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b
7

Form CMS 64.9 PEP

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
7A1

Line Description
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4

Form CMS 64.9 PEP

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C

Total
Line Description
Computable
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment

Form CMS 64.9 PEP

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41

Line Description
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing

Form CMS 64.9 PEP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 PEP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9 PEP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
6b
7
7A1

Line Description
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D

Form CMS 64.9 PEP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f

Line Description
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements

Form CMS 64.9 PEP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33

Line Description
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses

Form CMS 64.9 PEP WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B

Line Description
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services

Form CMS 64.9 PEP WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
47
48
49
69
70

Line Description
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 PEP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b

Form CMS 64.9 PE WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
7
7A1

Line Description
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3

Form CMS 64.9 PE WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A

Line Description
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)

Form CMS 64.9 PE WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B

Line Description
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments

Form CMS 64.9 PE WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PEWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 PE WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9E - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b
7
7A1

Form CMS 64.9 E

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9E - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #

Line Description

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5

Form CMS 64.9 E

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9E - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A

Line Description
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment

Form CMS 64.9 E

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9E - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45

Line Description
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder

Form CMS 64.9 E

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9E - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible:

Line #
46

Line Description
OUD Medicaid Assisted Treatment – Drugs

46A1
46A2

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Form CMS 64.9 E

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b
7

Form CMS 64.9 EP

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
7A1

Line Description
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4

Form CMS 64.9 EP

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C

Total
Line Description
Computable
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment

Form CMS 64.9 EP

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41

Line Description
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing

Form CMS 64.9 EP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible:

Line #
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 EP

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9 EP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
6b
7
7A1

Line Description
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D

Form CMS 64.9 EP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f

Line Description
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements

Form CMS 64.9 EP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33

Line Description
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses

Form CMS 64.9 EP WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B

Line Description
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services

Form CMS 64.9 EP WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EPWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
47
48
49
69
70

Line Description
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 EP WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b

Form CMS 64.9 E WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
7
7A1

Line Description
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3

Form CMS 64.9 E WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A

Line Description
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)

Form CMS 64.9 E WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B

Line Description
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments

Form CMS 64.9 E WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9EWAIV - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible:

Line #
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 E WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

CMS-64.S9RAC - RAC Collection
State:
Quarter Ended: 12/31/2023

Line #
1
2
3
4
5
6
7

Line Description
Collections Not Previously Reported on CMS64.9ORAC
Collections on Overpayment previously
reported on CMS-64.9ORAC
Total Collections
RAC CONTINGENCY FEES DEDUCTED FROM
COLLECTIONS
COLLECTIONS LESS FEES
LESS PREVIOUSLY REPORTED ON 64.9ORAC.
(Line 2)
NET COLLECTIONS

Form CMS 64.S9RAC

Total
Computable

Medicaid
(Non-VIII
Medicaid VIII
Group)
Group Federal ARRA Federal COVID Federal
Federal Share Share
Share
Share
Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.1108CAP - Territory Cap Tracking
State:
Quarter Ended: 12/31/2023
Line #
1
2
6
6.A.
6.A.1.
6.A.2.
6.B.
6.C.
6.D.
7
7.A.
7.A.1.
7.A.2.
7.B.
7.C.
7.D.
8
8.A.
8.A.1.
8.A.2.
8.B.
8.C.
8.D.
10A.
A.
10.A.1.
10.A.1.a
10.A.1.b.
10.A.2.

Line Description
FY YYYY CAP
Amount Previously reported
Expenditures in this Quarter
From Form CMS-64.9/CMS-64.10
From Form CMS-64.9T
From Form CMS-64.9E/CMS-64.9PE
From Form CMS-64.21
From Form CMS-64.21U
From Form CMS-64.9VIII
Adjustments Increasing Claims for Prior Quarters
From Form CMS 64.9P/CMS 64.10
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.21P
From Form CMS-64.21UP
From Form CMS-64.9VIIIP
Other Expenditures
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.21P
From Form CMS-64.21UP
From Form CMS-64.9VIIIP
Adjustments Decreasing Claims for Prior Quarters:
Federal Audit
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS 64.21P

Form CMS 64.1108CAP

MAP Federal
Share

ADM Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.1108CAP - Territory Cap Tracking
State:
Quarter Ended: 12/31/2023
Line #
10.A.3.
10.A.4
10B.
B.
10.B.1.
10.B.1.a
10.B.1.b.
10.B.2.
10.B.3.
10.B.4
11
12

Line Description
From Form CMS 64.21UP
From Form CMS-64.9VIIIP
Adjustments Decreasing Claims for Prior Quarters:
Federal Audit
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS 64.21P
From Form CMS 64.21UP
From Form CMS-64.9VIIIP
Net Expenditures Reported This Period
Unused CAP

Form CMS 64.1108CAP

MAP Federal
Share

ADM Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible: Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9B
10A
10B
11
12
13
14
15
16
17A

Form CMS 64.9VIII

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible: Newly

24A
24B
25
26

Total
Line Description
Computable
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Managed
Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center

Line #
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B

Form CMS 64.9VIII

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible: Newly

Line #
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Total
Line Description
Computable
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9A

Form CMS 64.9VIII

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f

Total
Line Description
Computable
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements

Form CMS 64.9VIII

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42

Line Description
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center

Form CMS 64.9VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9B
10A
10B
11
12
13
14
15
16
17A

Form CMS 64.9VIII P

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Newly

24A
24B
25
26

Total
Line Description
Computable
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center

Line #
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B

Form CMS 64.9VIII P

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Newly

Line #
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Total
Line Description
Computable
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9VIII P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9B

Form CMS 64.9VIII P

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D

Line Description
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles

Form CMS 64.9VIII P

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46

Line Description
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Form CMS 64.9VIII P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #

Line Description

46A1
46A2

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Form CMS 64.9VIII P

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9B
10A
10B
11
12
13
14
15

Form CMS 64.9VIII WAIV

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Newly

Line #
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A

Total
Line Description
Computable
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Managed
Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management

Form CMS 64.9VIII WAIV

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Newly

Line #
24B
25
26

Line Description
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9VIII WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9VIII WAIV

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #
9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d

Total
Line Description
Computable
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin

Form CMS 64.9VIII WAIV

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B

Total
Line Description
Computable
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments

Form CMS 64.9VIII WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIII Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9VIII WAIV

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9B
10A
10B
11
12
13
14
15
16

Form CMS 64.9VIII WAIV P

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Newly

Line #
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25

Line Description
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services

Form CMS 64.9VIII WAIV P

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Newly

Line #
26

Line Description
Hospice Benefits

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9VIII WAIV P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9VIII WAIV P

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #

Line Description

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin

9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d

Form CMS 64.9VIII WAIV P

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C

Line Description
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments

Form CMS 64.9VIII WAIV P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9VIIIP Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Type of Eligible: Not Newly

Line #
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9VIII WAIV P

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 200K - Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Cost of In-House Activities
2A
Design Development Or Installation Of MMIS:
Cost of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Costs of InHouse Activities Plus State Agencies And
Institutions
4A
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8
9
10
11

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)
Nurse Aide Training Costs
Preadmission Screening Costs
Resident Review Activities Costs

Form CMS 64.10 Base 200K

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 200K - Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Drug Use Review Program
12
Outstationed Eligibility Workers
13
TANF Base
14
TANF Secondary 90%
15
TANF Secondary 75%
16
External Review
17
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs (State Level)
22
Translation and Interpretation
23
24
24A
24B
24C
24D
24E
24F
25
25A
25B
26
27

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors
HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration

Form CMS 64.10 Base 200K

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10 200K - Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable

28H
29

Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors
Eligibility Determination Staff – Cost of In-house
Activities
Eligibility Determination Staff – Cost of Private
Sector Contractors
Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
Non-Emergency Medical Transportation

30
31
49
50

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
CAA 2023 Section 5101
Other Financial Participation
Total

28A

28B

28C

28D
28E
28F
28G

Form CMS 64.10 Base 200K

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P 200K - Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Family Planning
1
Design Development Or Installation Of MMIS:
Costs Of In-House Activities
2A
Design Development Or Installation Of MMIS:
Costs Of Private Sector Contractors
2B
Skilled Professional Medical Personnel-Single
State Agency
3A
Skilled Professional Medical Personnel - Other
Agency
3B
Operation Of An Approved MMIS: Cost Of InHouse Activities
4A
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
4B

5A

5B
5C
6
7A
7B
8
9
10
11
12
13
14
15
16
17

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System Costs
(100% FFP)
Nurse Aide Training
Preadmission Screening Costs
Resident Review Activities Cost
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary (90%)
TANF Secondary (75%)
External Review

Form CMS 64.10P 200K

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P 200K - Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Enrollment Brokers
18
School Based Administration
19
Program Integrity/Fraud, Waste, and Abuse
Activities
20
County/Local ADM Costs
21
Interagency Costs
22
Translation and Interpretation
23
24
24A
24B
24C
24D
24E
24F
25
25A
25B
26
27

28A

28B

28C

28D

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Health Information Technology Administration
HIT: Planning: Cost of In-house Activities
HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of Inhouse Activities
HIT: Implementation and Operation: Cost of
Private Contractors
HIT Incentive Payments - Eligible Professionals
HIT Incentive Payments - Eligible Hospitals
Citizenship Verification Technology - CHIPRA
CVT Development - CHIPRA
CVT Operation - CHIPRA
Planning for Health Homes for Enrollees with
Chronic Conditions
Recovery Audit Contractors State
Administration
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of In-house Activities
Design Development/Installation of Medicaid
Elig. Determ. Sys. – Cost of Private Sec.
Contractors
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house
Activities
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec.
Contractors

Form CMS 64.10P 200K

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 64.10P 200K - Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Line #
Line Description
Total Computable
Eligibility Determination Staff – Cost of Inhouse Activities
28E
Eligibility Determination Staff – Cost of Private
Sector Contractors
28F
Eligibility Determination Staff – Cost of Inhouse Activities – 50% FFP
28G
Eligibility Determination Staff – Cost of Private
Sector Contractors – 50% FFP
28H
Non-Emergency Medical Transportation
29

30
31
49
50

OMB No. 0938-1265
Expires 4/30/2024

FFP Federal Share

Other %

Federal Share

Total Federal Share

Deferral or CIN Number

Design Development/Implementation of
Prescription Drug Monitoring Program Systems
CAA 2023 Section 5101
Other Financial Participation
Total

Form CMS 64.10P 200K

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #

Line Description

1A

6b
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2

Drug Rebate Offset - State Sidebar Agreement

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9 WAIV DSH Diversion

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
7A3
7A4

Line Description
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management

9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a

Form CMS 64.9 WAIV DSH Diversion

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25

Line Description
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services

Form CMS 64.9 WAIV DSH Diversion

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
26

Line Description
Hospice Benefits

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement

Form CMS 64.9 WAIV DSH Diversion

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9 WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9 WAIV DSH Diversion

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b
7
7A1
7A2
7A3
7A4

Line Description
Inpatient Hospital Services: Regular Payments
Inpatient Hospital Services: DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

Form CMS 64.9P WAIV DSH Diversion

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #

Line Description

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
Medicare Health Insurance Payments: Part A
Premiums
Medicare Health Insurance Payments: Part B
Premiums

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B

17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
Medicare Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management

Form CMS 64.9P WAIV DSH Diversion

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26

Line Description
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Form CMS 64.9P WAIV DSH Diversion

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #

Line Description

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar

Form CMS 64.9P WAIV DSH Diversion

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9P WAIV DSH Diversion - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
46A5
46A6
46B
47
48
49
69
70

Line Description
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9P WAIV DSH Diversion

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Non COVID
Federal Share FMAP

Total Federal
Share

Deferral or
CIN Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #

Line Description

1A

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A
6b

Form CMS 64.9I DSH Div Waiver

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
7
7A1

Line Description
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice

9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3

Form CMS 64.9I DSH Div Waiver

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A

Line Description
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)

Form CMS 64.9I DSH Div Waiver

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B

Line Description
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments

Form CMS 64.9I DSH Div Waiver

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9I DSH Div Waiver

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Line Description
Inpatient Hospital Services: Regular Payments
Inpatient Hospital Services: DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments

Form CMS 64.9PI DSH Div Waiver

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
6b
7
7A1

Line Description
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

17B

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
Medicare Health Insurance Payments: Part A
Premiums
Medicare Health Insurance Payments: Part B
Premiums

17C1

Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty

9A
9B
10A
10B
11
12
13
14
15
16
17A

Form CMS 64.9PI DSH Div Waiver

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e

Line Description
Medicare Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community
Behavior Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

Form CMS 64.9PI DSH Div Waiver

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31

Line Description
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy

Form CMS 64.9PI DSH Div Waiver

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5

Line Description
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA
Offset Fee for Service - 100%

Form CMS 64.9PI DSH Div Waiver

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI DSH Diversion Waiver - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:

Line #
46A6
46B
47
48
49
69
70

Line Description
OUD MAT DRUG REBATE/Increased ACA
Offset MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9PI DSH Div Waiver

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)

Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %

Total Federal
Federal Share Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Medicaid Enrollees
State:
Quarter Ended: 12/31/2023
Line #
1A
1B
1C
2A
2B
2C
2D
2E
2F
2G
3
4
5
6
7A
7B
7C
8

Line Description
Parent/Caretaker Relatives
Childless Adults
Total Newly Eligible
Parent/Caretaker Relatives
Disabled Person NonInstitutionalized
Disabled Person, Institutionalized
Children Age 19 to 20
Childless Adults
Other
Total Not Newly Eligible
VIII Group Total Eligibles
Aged
Blind or Disabled
Children
Pregnancy Benefit Adults
All Other Adults not included above
Total Other Adults
Total Eligibles

Form CMS 64.ENROLL

January
CY 2023

February
CY 2023

March
CY 2023

April
CY 2023

May
CY 2023

June
CY 2023

July
CY 2023

August
CY 2023

September
CY 2023

October
CY 2023

November
CY 2023

December
CY 2023

Total

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Supplemental Payment Validation Narrative Explanation
Medicaid Program Expenditure Report
State:
Quarter Ended: 12/31/2023
Narrative
No data submitted for this form

Form CMS SPV Narrative

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Supplemental Payment Validation Providers (CMS 64.SPVProvider)
List of Providers Receiving Supplemental Payments
State:
Quarter Ended: 12/31/2023

Provider Name

Form CMS SPV Providers

Medicaid ID

NPI

Medicare ID

Ownership
Other State ID Category

Assoc
w/hosp/med
school

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Supplemental Payments by Provider (CMS 64.SPVPayment)
List of Supplemental Payments by Provider and CMS-64 form
State:
Quarter Ended: 12/31/2023
Provider Name / Medicaid ID

Form CMS SPV Payments

Category of
Service

Form

Expenditure
Type

Waiver
Information

Prior Period
Information

Program

BaseAmount

Amount

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Type of Eligible: Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9B
10A
10B
11
12
13
14
15
16

Form CMS 64.9I.VIII

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Type of Eligible: Newly

Line #
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25

Line Description
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Managed
Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services

Form CMS 64.9I.VIII

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Type of Eligible: Newly

Line #
26

Line Description
Hospice Benefits

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) +
(M)

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9I.VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9I.VIII

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #
9A
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d

Line Description
Other Practitioners Services - Regular
Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community
Behavior Health Clinic Payments
MCO PAHP - Services Subject to Electronic
Visit Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin

Form CMS 64.9I.VIII

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C

Line Description
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services Regular Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments

Form CMS 64.9I.VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9I.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Type of Eligible: Not Newly

Line #
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Total Comp
Resource Test Special
CAP COL I
Resource Test Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Applied to
Comp from Col Applied to
Enrollment
Applied to
Circumstance Total Federal
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
Newly COL J
COL K
Share

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9I.VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

9B
10A
10B
11
12
13
14
15
16

Form CMS 64.9PI.VIII

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Newly

Line #
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26

Total
Line Description
Computable
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Form CMS 64.9PI.VIII

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Newly

Line #

Line Description

27
28

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Total
Computable

FMAP

I.H.S. Services

Family
Planning
Services

Opt. Breast or
Cervical Cancer Opt. Breast or
Srvcs (ENH
Cervical Cancer
Rate)
Srvcs (IHS Rate) Other %

Federal Share

Total Newly
Federal Share

Total
Computable
Resource Test
Applied from
Not Newly

Total
Computable
Federal Share Total Comp
Federal Share Applied from
Resource Test Applied from Enrollment Cap Not Newly
Applied COL H Not Newly
applied COL J X Special
X Newly
Enrollment Cap Newly
Circumstances

Federal Share
Special
Circumstances
applied COL L X
Newly

Sum of Total
Computable
Column (A) +
(H) + (J)+ (L)

Sum of Federal
Shares Column
(G) + (I) + (K) + Deferral or CIN
(M)
Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9PI.VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #

Line Description

1A

6B
7
7A1

Inpatient Hospital Services - Regular Payments
Inpatient Hospital Service - DSH Adjustment
Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital - GME Sup Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Certified Community Behavior Health Clinic
Payments
Nursing Facility Services - Regular Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services - Supplemental
Payments
Physician & Surgical Services - Evaluation and
Management
Physician & Surgical Services - Vaccine codes
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
Drug Rebate Offset - National Agreement

7A2
7A3
7A4

Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement

7A5
7A6
7A7
8

Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Drug Rebate Offset - Value Based Purchasing
Dental Services

9A

Other Practitioners Services - Regular Payments

1B
1C
1D
2A
2B
2C
3A
3B
4A
4B

4C
5A
5B
5C
5D
6A

Form CMS 64.9PI.VIII

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #
9B
10A
10B
11
12
13
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18A6
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B1f
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18B2f

Line Description
Other Practitioners Services - Supplemental
Payments
Clinic Services - Reg. Payments
Clinic Services - Sup. Payments
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Medicaid MCO - Certified Community Behavior
Health Clinic Payments
Medicaid MCO - Services Subject to Electronic
Visit Verification Requirements
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PAHP - Certified Community Behavior
Health Clinic Payments
MCO PAHP - Services Subject to Electronic Visit
Verification Requirements
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
Medicaid PIHP - Certified Community Behavior
Health Clinic Payments
MCO PIHP - Services Subject to Electronic Visit
Verification Requirements

Form CMS 64.9PI.VIII

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #
18C
18D
18E
19A
19B
19C
19D
22
23A
23B
24A
24B
25
26
27
28
29A
29B
30
31
32
33
34
34A
35
36
37A
37B
37C
38
39
40
41
42

Line Description
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (1915(c) Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

Emergency Services for Undocumented Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation - Reg.
Payments
Non-Emergency Medical Transportation - Sup.
Payments
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals - Reg. Payments
Critical Access Hospitals Inpatient - Sup.
Payments
Critical Access Hospitals Outpatient - Sup.
Payments
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center

Form CMS 64.9PI.VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 64.9PI.VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Expenditures
Program: SUPPORT ACT SECTION 1003
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Type of Eligible: Not Newly

Line #
43
44
45
46
46A1
46A2
46A3
46A4
46A5
46A6
46B
47
48
49
69
70

Line Description
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Health Home for Enrollees w Substance-UseDisorder
OUD Medicaid Assisted Treatment – Drugs

Total
Computable

FMAP

Family
Planning
I.H.S. Services Services

Opt. Breast or
Cervical Cancer
Srvcs (ENH
Rate)

Opt. Breast or
Cervical Cancer
Srvcs (IHS
Rate)
Other %

Federal Share

Total Comp
Resource Test
Applied to
Newly Col B X

Adjusted Total
Comp from
COL B minus
Adjusted Total
Resource Test
Comp from Col
COL G Minus
B minus
Total Comp
Enrollment
Total Comp
Resource Test Special
CAP COL I
Adjusted Total Enroll Cap
Col G minus
Circumstances minus Special
Comp from Col Applied to
Enrollment Cap Applied to
Circumstance Total Federal
B NoT Newly Newly Col H X COL I
Newly COL J
COL K
Share

Deferral or CIN
Number

OUD MAT DRUG REBATE/National Agreement
OUD MAT DRUG REBATE/State Sidebar
OUD MAT DRUG REBATE MCO /National
Agreement
OUD MAT DRUG REBATE MCO /State Sidebar
OUD MAT DRUG REBATE/Increased ACA Offset
Fee for Service - 100%
OUD MAT DRUG REBATE/Increased ACA Offset
MCO – 100%
OUD Medicaid Assisted Treatment Services
ARP Section 9811 COVID Vaccine/Vaccine
Administration
ARP Section 9813 Qualified Community Based
Mobile Crisis Intervention – 85%
Health Homes for Children with Medically
Complex Conditions
Other Care Services
Total

Form CMS 64.9PI.VIII

Report Date: Friday, January 26, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form 64.9SAP - Support Act Section 1003 Payment Calculation
Section 1003 Payment Calculation Lines by Submission Period
State:
Quarter Ended: 12/31/2023
Line #
Line Description Submission Period
Total Computable

OMB No. 0938-1265
Expires 4/30/2024

FMAP

Federal Share

No data submitted for this form

Form CMS 64.9SAP

Report Date: Friday, January 26, 2024 - 12:00 AM