West Virginia Medicaid Spend Reconciliation

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

24%Low coverage

These claims represent 24.3% of West Virginia’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

76% 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

$4,890,332,627

CMS-64 Total Net Expenditures, as West Virginia filed it

Visible in claims

$1,185,746,272

24.3% of the program

Published per-enrollee spending

$830PMPM

CMS-64 total ÷ 490,748 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$3,138,364,518

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 West Virginia 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
Nursing Facility	$1,039,328,608	$0	0%
Prescribed Drugs	$920,871,643	$3,899,471	0%
Home & Community-Based Services	$804,128,345	$206,335,764	26%
Hospital (Inpatient & Outpatient)	$153,768,333	$121,144,639	79%
Behavioral Health	$81,077,337	$218,368,010	269%
Intermediate Care Facility (IID)	$73,810,303	$0	0%
Hospice	$38,711,220	$0	0%
Non-Emergency Transportation	$38,304,252	$60,511,367	158%
Physician & Surgical	$35,890,742	$159,938,288	446%
Other Care Services	$33,091,180	$1,893,804	6%
School-Based Services	$29,794,537	$0	0%
Home Health	$24,783,897	$13,404,493	54%
FQHC & Rural Health Clinic	$19,357,148	$183,387,043	947%
Laboratory & Radiology	$6,245,827	$75,946,110	1216%
Dental	$4,746,355	$35,785,821	754%
Clinic Services	$2,788,149	$5,166,760	185%
Screening & Preventive	$1,738,897	$8,828,579	508%
Therapy Services	$1,694,333	$27,084,498	1599%
DME & Supplies	$781,217	$26,149,544	3347%
Targeted Case Management	$576,668	$37,898,519	6572%
Family Planning	$3,534	$0	0%
Other Practitioners	-$173,128,007	$0	—

Categories no claims dataset can see$1,751,968,109

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	$2,151,643,254
Medicare Premiums (Duals)	$207,748,673
Supplemental & DSH Payments	$86,830,927
Drug Rebates & Collections	-$694,254,745

The table adds up. The categories above sum to $4,890,332,627, which is West Virginia’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.