Pennsylvania Medicaid Spend Reconciliation

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

16%Low coverage

These claims represent 16.0% of Pennsylvania’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

93% 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

$43,221,817,294

CMS-64 Total Net Expenditures, as Pennsylvania filed it

Visible in claims

$6,933,821,683

16.0% of the program

Published per-enrollee spending

$1,212PMPM

CMS-64 total ÷ 2,971,592 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$7,430,584,671

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 Pennsylvania 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	$5,118,652,362	$171,628,464	3%
Intermediate Care Facility (IID)	$624,230,840	$0	0%
Nursing Facility	$426,612,872	$2,138,681	1%
Hospital (Inpatient & Outpatient)	$389,164,059	$50,699,374	13%
School-Based Services	$243,692,394	$103	0%
Other Care Services	$181,394,726	$40,851,674	23%
Behavioral Health	$96,148,564	$1,772,741,336	1844%
Therapy Services	$84,977,648	$420,768,069	495%
FQHC & Rural Health Clinic	$70,580,587	$141,424	0%
Targeted Case Management	$51,990,390	$234,381,792	451%
Physician & Surgical	$43,821,012	$974,136,006	2223%
Non-Emergency Transportation	$38,160,895	$206,200,757	540%
Prescribed Drugs	$26,583,993	$104,912,235	395%
Home Health	$12,208,479	$713,588,887	5845%
Dental	$6,978,778	$229,601,978	3290%
Screening & Preventive	$5,126,554	$50,940,295	994%
Clinic Services	$4,741,600	$544,537,850	9999%
Laboratory & Radiology	$3,879,082	$205,031,268	5286%
Hospice	$859,178	$2,139,504	249%
Family Planning	$385,091	$10,302	3%
Other Practitioners	$247,530	$0	0%
DME & Supplies	$148,037	$374,992,619	9999%

Categories no claims dataset can see$35,791,232,623

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	$36,579,581,490
Supplemental & DSH Payments	$1,422,275,524
Medicare Premiums (Duals)	$1,026,296,439
Drug Rebates & Collections	-$3,236,920,830

The table adds up. The categories above sum to $43,221,817,294, which is Pennsylvania’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.