New Jersey Medicaid Spend Reconciliation

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

36%High coverage

These claims represent 35.7% of New Jersey’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

92% 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

$23,110,303,360

CMS-64 Total Net Expenditures, as New Jersey filed it

Visible in claims

$8,252,762,071

35.7% of the program

Published per-enrollee spending

$1,135PMPM

CMS-64 total ÷ 1,697,073 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$6,644,688,220

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 New Jersey 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	$3,129,250,745	$1,732,281,039	55%
Hospital (Inpatient & Outpatient)	$614,908,552	$1,071,390,114	174%
Other Care Services	$565,812,986	$40,024,770	7%
Intermediate Care Facility (IID)	$565,108,673	$0	0%
Clinic Services	$538,729,192	$8,246,842	2%
School-Based Services	$374,727,821	$2,271	0%
Behavioral Health	$219,888,749	$2,707,968,981	1232%
Non-Emergency Transportation	$185,731,471	$28,318,052	15%
Nursing Facility	$183,222,048	$68,391,299	37%
Physician & Surgical	$123,390,762	$808,199,129	655%
Laboratory & Radiology	$48,306,833	$471,406,487	976%
Prescribed Drugs	$28,029,160	$48,350,134	173%
FQHC & Rural Health Clinic	$25,252,655	$29,708,858	118%
Targeted Case Management	$18,446,770	$466,536,544	2529%
Screening & Preventive	$9,023,157	$61,158,345	678%
Other Practitioners	$5,884,254	$0	0%
Hospice	$5,338,087	$79,022,072	1480%
Home Health	$1,598,226	$216,280,728	9999%
Dental	$761,207	$194,427,080	9999%
Therapy Services	$607,331	$97,980,396	9999%
DME & Supplies	$377,424	$122,782,759	9999%
Family Planning	$292,117	$0	0%

Categories no claims dataset can see$16,465,615,140

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	$15,788,742,252
Supplemental & DSH Payments	$1,348,792,524
Medicare Premiums (Duals)	$592,555,353
Other CMS-64 Lines	$50,895,014
Drug Rebates & Collections	-$1,315,370,003

The table adds up. The categories above sum to $23,110,303,360, which is New Jersey’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.