Utah 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 Utah’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

79% 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

$4,907,092,673

CMS-64 Total Net Expenditures, as Utah filed it

Visible in claims

$785,422,375

16.0% of the program

Published per-enrollee spending

$1,281PMPM

CMS-64 total ÷ 319,268 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$2,265,302,287

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 Utah 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 categoryCMS-64 (state total)Seen in claimsCoverage
Home & Community-Based Services$633,282,119$39,735,424
6%
Hospital (Inpatient & Outpatient)$485,441,979$9,561,295
2%
Prescribed Drugs$285,750,580$8,251,846
3%
Nursing Facility$230,841,952$11,778,011
5%
Behavioral Health$206,419,250$219,368,954
106%
Intermediate Care Facility (IID)$86,738,749$0
0%
Screening & Preventive$81,609,929$7,663,449
9%
Physician & Surgical$67,337,103$148,400,521
220%
Home Health$48,097,549$21,276,436
44%
School-Based Services$31,171,600$59,930
0%
Other Practitioners$30,865,416$0
0%
Dental$29,342,101$33,712,362
115%
Hospice$15,026,416$4,444,336
30%
Laboratory & Radiology$15,003,568$45,018,019
300%
Non-Emergency Transportation$14,670,009$85,671,131
584%
FQHC & Rural Health Clinic$13,113,185$28,355
0%
Clinic Services$9,752,290$43,458
0%
Therapy Services$6,740,451$105,219,467
1561%
Targeted Case Management$229,875$15,482,703
6735%
Family Planning$126,407$0
0%
DME & Supplies$15,174$15,564,404
9999%
Other Care Services-$26,273,415$13,724,274—
Categories no claims dataset can see$2,641,790,386

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 categoryCMS-64 (state total)
Managed Care Capitation$2,337,980,019
Supplemental & DSH Payments$430,102,817
Medicare Premiums (Duals)$84,889,040
Other CMS-64 Lines$482,329
Drug Rebates & Collections-$211,663,819
The table adds up. The categories above sum to $4,907,092,673, which is Utah’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.