Massachusetts Medicaid Spend Reconciliation

Every CMS-64 service category for FY2024, and how much of each appears in this claims dataset.

37%High coverage

These claims represent 37.2% of Massachusetts’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

46% of enrollees are in comprehensive managed care, so most of their care is paid by capitation and never becomes a provider claim. The remainder is capitation, supplemental and DSH payments, Medicare premiums for dual eligibles, drug rebates and administration — none of which are claim-level. See the full reconciliation.

Total Medicaid spending, FY2024

$24,810,177,871

CMS-64 Total Net Expenditures, as Massachusetts filed it

Visible in claims

$9,237,830,074

37.2% of the program

Published per-enrollee spending

$1,329PMPM

CMS-64 total ÷ 1,556,021 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$12,842,435,966

Services paid as provider claims. Coverage below 100% typically means part of the category is delivered through managed care, or billed with codes this dataset does not carry.

Read the category rows as indicative, not exact. The state total above is a like-for-like comparison and is sound. Individual rows are not, because the two columns are attributed differently: claims are categorised by billing code, while the CMS-64 is categorised by the authority the state pays under. A home visit billed under a 1915(c) waiver and the same visit billed under the state plan carry identical codes, so this dataset cannot tell them apart while Massachusetts books them on different lines. That is why some rows exceed 100% while their neighbours sit near zero — it reflects where the state books the spending, not a discrepancy in the amount.

Service category	CMS-64 (state total)	Seen in claims	Coverage
Home & Community-Based Services	$4,256,700,623	$4,718,122,433	111%
Hospital (Inpatient & Outpatient)	$2,578,496,947	$840,018,590	33%
Nursing Facility	$1,626,963,890	$65,566,148	4%
Behavioral Health	$892,707,164	$1,361,572,614	153%
Other Care Services	$785,600,428	$80,790,544	10%
Prescribed Drugs	$719,064,648	$34,904,210	5%
Dental	$408,246,153	$336,406,195	82%
Physician & Surgical	$303,802,441	$451,370,586	149%
Home Health	$257,084,841	$454,512,757	177%
Non-Emergency Transportation	$254,038,309	$140,412,403	55%
Intermediate Care Facility (IID)	$181,080,109	$0	0%
Targeted Case Management	$139,639,377	$105,076,765	75%
Hospice	$114,396,057	$110,207,840	96%
Clinic Services	$102,483,729	$43,029,425	42%
FQHC & Rural Health Clinic	$92,314,547	$28,039,514	30%
School-Based Services	$36,782,737	$79,887	0%
Screening & Preventive	$31,105,337	$21,731,293	70%
Laboratory & Radiology	$22,364,702	$219,910,157	983%
DME & Supplies	$15,373,531	$100,503,268	654%
Other Practitioners	$14,538,693	$0	0%
Therapy Services	$5,378,494	$125,348,061	2331%
Family Planning	$4,273,209	$3,074	0%

Categories no claims dataset can see$11,967,741,905

These are real spending — they are simply not paid as claims to providers, so no claims-based analysis will ever contain them. This is the bulk of the difference between the two figures above.

Service category	CMS-64 (state total)
Managed Care Capitation	$12,089,868,248
Medicare Premiums (Duals)	$863,021,208
Supplemental & DSH Payments	$769,019,664
Other CMS-64 Lines	$17,131,498
Drug Rebates & Collections	-$1,771,298,713

The table adds up. The categories above sum to $24,810,177,871, which is Massachusetts’s CMS-64 Total Net Expenditures for FY2024 exactly. Every line the state filed is accounted for in one of the two tables — nothing is dropped or double-counted.

Sources: CMS-64 net expenditures from the CMS MBES/CBES quarterly expenditure reports (FY2024); enrollment from the CMS Medicaid and CHIP applications, eligibility determinations and enrollment data; managed-care share from the CMS managed care enrollment reports. Claims figures are from the public T-MSIS provider extract. Methodology.