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System, eligibility system, and accounting systems for reporting on the CMS-64,

consistent with the terms of the demonstration. The Budget Neutrality Specifications

Manual will also describe how the state compiles counts of Medicaid member months. The Budget Neutrality Specifications Manual must be made available to

CMS on request. Table 4: MEG Detail for Expenditure and Member Month Reporting CMS-64.9 How Report phe Detailed A or 64.10 | Expend. Are ool Member Lose es (Waiver sas Exclusions . . or Start End Name) Description Line(s) Assigned to ADM Months Date Date To Use DY (Y/N) All expenditures for services Follow provided to standard non-pregnant, CMS . uninsured ; Childless | adults ages 19 64.10 Dateof | ap Y 10/29/24 | 12/31/29 Adult Category service through 64 . years who of Service have family Definition incomes up to 100 percent of the FPL All expenditures Follow for services standard provided to an CMS 64.9 Date of SUD individual Category ‘ MAP N 10/29/14 | 12/31/29 . . service while they are of Service a patient in an Definition IMD for SUD s treatment. All additional administrative costs that are Follow directly ; standard attributable to th CMS c 64.10 Date of ADM demonstration c ; ADM N 10/29/24 | 12/31/29 ategory payment and not : described of Service Definition elsewhere and . s are not subject to budget neutrality. ADM - administration: DY — demonstration year; MAP — medical assistance payments; MEG — Medicaid expenditure group: Wisconsin BadgerCare Reform

Approval Period: October 29, 2024 through December 31, 2029

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