Wisconsin Medicaid Spend Reconciliation

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

15%Low coverage

These claims represent 15.4% of Wisconsin’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

67% 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

$12,226,482,492

CMS-64 Total Net Expenditures, as Wisconsin filed it

Visible in claims

$1,887,345,761

15.4% of the program

Published per-enrollee spending

$849PMPM

CMS-64 total ÷ 1,199,610 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$7,324,925,397

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 Wisconsin 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
Prescribed Drugs	$2,039,466,965	$17,375,424	1%
Home & Community-Based Services	$1,583,233,269	$152,627,989	10%
Nursing Facility	$794,575,469	$33,522,700	4%
Hospital (Inpatient & Outpatient)	$752,591,916	$58,684,071	8%
Behavioral Health	$549,943,348	$365,595,155	66%
FQHC & Rural Health Clinic	$224,393,410	$48,710,148	22%
School-Based Services	$223,535,715	$93,742	0%
Clinic Services	$217,385,518	$0	0%
Non-Emergency Transportation	$159,286,305	$45,169,786	28%
Dental	$153,525,197	$94,273,359	61%
Intermediate Care Facility (IID)	$143,918,275	$0	0%
Home Health	$95,004,173	$15,053,110	16%
Hospice	$92,282,973	$43,020,845	47%
Screening & Preventive	$85,317,102	$13,036,542	15%
Other Care Services	$59,167,042	$15,059,901	25%
Other Practitioners	$42,371,156	$0	0%
Physician & Surgical	$32,475,132	$412,304,806	1270%
Targeted Case Management	$31,015,752	$201,322,738	649%
Laboratory & Radiology	$27,762,528	$249,405,724	898%
Therapy Services	$12,020,943	$76,911,422	640%
DME & Supplies	$5,582,706	$40,173,045	720%
Family Planning	$70,503	$4,081,171	5789%

Categories no claims dataset can see$4,901,557,095

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	$5,814,427,386
Medicare Premiums (Duals)	$436,470,039
Supplemental & DSH Payments	$260,261,269
Other CMS-64 Lines	$12,314,839
Drug Rebates & Collections	-$1,621,916,438

The table adds up. The categories above sum to $12,226,482,492, which is Wisconsin’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.