Which line items on the CMS 64 Form correspond to institutional and community LTSS?

Community LTSS Line Items on the 64 Form (Eligible for the Enhanced FMAP)

  • Line 12 – Home Health Services
  • Line 18A – Medicaid Health Insurance Payments: Managed Care Organizations (MCO) – new lines created for non-institutional HCBS
  • Line 18B1 – Prepaid Ambulatory Health Plan – new lines created for non-institutional HCBS
  • Line 18B2 – Prepaid Inpatient Health Plan – new lines created for non-institutional HCBS
  • Line 19A – Home and Community-Based Services – Regular Payment (Waiver)
  • Line 19B – Home and Community-Based Services – State Plan 1915i Only Payment
  • Line 19C – Home and Community-Based Services – State Plan 1915j Only Payment
  • Line 19D – Community First Choice – State Plan 1915k
  • Line 22 – Programs of All-Inclusive Care Elderly
  • Line 23A – Personal Care Services – Regular Payment
  • Line 23B – Personal Care Services – SDS 1915j
  • Line 24A – Targeted Case Management Services – Community Case-Management
  • Line 24B – Case Management State Wide
  • Line 40 – Rehabilitative Services (non-school-based) - Mental Health and Substance Use
  • Line 41 – Private Duty Nursing
  • Line 43 – Health Homes for Enrollees with Chronic Conditions
  • Community LTSS managed care payments:  self-reported by States

Institutional LTSS Line Items on the 64 Form

  • Line 3A -- Nursing Facility Services – Regular Payments
  • Line 3B -- Nursing Facility Services – Supplemental Payments
  • Line 4A -- Intermediate Care Facility Services – Mentally Retarded: Public Providers
  • Line 4B -- Intermediate Care Facility Services – Mentally Retarded: Private Providers
  • Line 4C -- Intermediate Care Facility Services - Supplemental Payments
  • Line 2A -- Mental Health Facility Services – Regular Payments
  • Line 2B -- Mental Health Facility Services – DSH Adjustment Payments
  • Institutional managed care payments:  self-reported by States