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					            State of                                                                                                  Appendix D1. Member Months                                                                                                                                                  .



Row # /
Column                               B                         C                                        D                   E                   F                  G                 H                    I                   J                   K                L                 M                 N
 Letter
   2                                                                                                                    Estimated Member Month Calculations
   3                                                                                                                             State of Texas - Renewal
   4                                                                           Enrollment Projections for the Time Period October 1, 2005 - September 30, 2007 (Waiver Years 7 and 8)
   5

   6                                                     Retrospective Years - All Regions                                                                                               Prospective Years - All Regions
                                                         Retrospective       Retrospective      Projected Quarter      Projected           Projected          Projected                           Projected Quarter      Projected           Projected        Projected
   7                  Medicaid Eligibility Group (MEG)                                                                                                                        Projected Year 1                                                                                Projected Year 2 Total Projected
                                                          Year 1 (R1)         Year 2 (R2)               1              Quarter 2           Quarter 3          Quarter 4                                   5              Quarter 6           Quarter 7        Quarter 8
   8                                                     10/1/03-9/30/04     10/1/04-9/30/05     10/1/05-12/31/05     1/1/06-3/31/06     4/1/06-6/30/06      7/1/06-9/30/06         (P1)           10/1/06-12/31/06     1/1/07-3/31/07      4/1/07-6/30/07   7/1/07-9/30/07         (P2)              (H+M)

   9      SSI                                                      599,084           635,700                164,435          165,170            165,972            168,522            664,099                 172,041             172,834          173,688          176,393           694,956          1,359,055

  10      TANF                                                 2,930,432           3,117,800                815,033          830,199            835,960            855,566          3,336,758                 873,326             888,768          893,705          909,713         3,565,512          6,902,270

  11                                                                                                                                                                                          0                                                                                               0               0

  12                                                                                                                                                                                          0                                                                                               0               0

  13      Total Member Months                                  3,529,516           3,753,501                979,468          995,369          1,001,932          1,024,088          4,000,857             1,045,367          1,061,602          1,067,393        1,086,106          4,260,468         8,261,325

  14      Quarterly % Increase                                                                                                  1.6%                  0.7%             2.2%                                     2.1%                1.6%              0.5%             1.8%

  15      Annualized % Increase R1 to R2 to P1 to P2                                     6.3%                                                                                              6.6%                                                                                            6.5%

  16

  17
  18
  19
  20
  21




            'D1. Member Months'                                                                                                        Page 1 of 11                                                                                                   cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
     State of                                                                                     Appendix D2.S Services in Waiver Cost


4                                                                                                        Renewal Waiver
5      Instructions: Modify columns as applicable to the waiver entity type and structure to note services in different MEGs.
6      * Please note with a * if there are any proposed changes.
7
8                           State Plan Services
9                                                                      State Plan            1915(b)(3)               MCO                 FFS services       PCCM              PIHP            PIHP                PAHP                PAHP
10                            Service Category                         Approved               Services              Capitated              Impacted      Fee-for Service     Capitated     Fee-for Service       Capitated         Fee-for Service
11                                                                      Services                                 Reimbursement              by MCO       Reimbursement     Reimbursement   Reimbursement      Reimbursement       Reimbursement
12     Day Treatment Services (Day Activity and Health Services)            X                                                                                                   X
13     Dental (medically necessary - non routine)                           X
14     Detoxification (in-patient medical)                                  X                                                                                                   X
15     Developmental Disabilities Services (please explain)
16     Durable Medical Equipment
17                                                                      X
       Education Agency Services School Health and Related Services (SHARS)
18     Emergency Services                                                   X
19     Emergency Behavioral Health Services                                 X                                                                                                   X
20     EPSDT (General)                                                      X
21     EPSDT (Behavioral) 1                                                 X                                                                                                   X
22     Family Planning Services                                             X
23     Federally Qualified Health Center Services                           X
24     Home Health                                                          X
25     Hospice                                                              X
26     Inpatient Hospital - Psych                                           X                                                                                                   X
27     Inpatient Hospital - Other                                           X
28     Immunizations                                                        X
29     Lab and x-ray                                                        X
30     Mental Health Services (Please specify) Refer to Case Management, Other Psych Practitioner, Physician, Psychologist, and Rehabilitation Service
31     Nurse midwife                                                        X
32     Nurse practitioner                                                   X
33     Nursing Facility                                                     X
34     Obstetrical services                                                 X
35     Occupational therapy                                                 X
36     Other fee-for-service services
37     Other Outpatient Services - Please Specify
38     Other Psych Practitioner                                             X                                                                                                   X
39     Outpatient Hospital - All Other                                      X
40     Outpatient Hospital - Lab & X-ray                                    X
41     Partial Hospitalization




     'D2.S Services in Waiver Cost'                                                                                        Page 2 of 11                                                          cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
State of                                                                                                                Appendix D3. Actual Waiver Cost



          Row # /
          Column                                   B                                   C                            D                            E                       F                       G                       H                         I                        J
           Letter

              2                                                                                                    Actual Waiver Cost Renewal Comprehensive Version                                                                                                                               Ac
              3                                                                                                                 State of Texas - Renewal
              4

              5

              6
              7                                                                                                                                                          Retrospective Year 1 (R1) Aggregate Costs
              8                                                                                                  MCO/PIHP                                                                    FFS Incentive           1915(b)(3)             Administration
              9                       Medicaid Eligibility Group                       R1                      Capitated Costs                                                                   Costs              service costs              Costs
                                                                                                         (Including incentives and                                                    (not included in capitation
             10
                                                 (MEG)                               Member           risksharing payouts/withholds)      Fee-for-Service            State Plan                  rates,               (provide                                         Total Actual
             11                                                                      Months                    or PCCM Case                    Costs                Service Costs       provide documentation)     documentation)                                      Waiver Costs
             12                                                                                              Management Fees                                            (D+E)                                                                                           (F+G+H+I)
             13     SSI                                                                599,084    $                         27,047,705   $                  -   $        27,047,705   $                      -   $                  -                              $        27,047,705

             14     TANF                                                             2,930,432    $                         15,942,294   $                  -   $        15,942,294   $                      -   $                  -                              $        15,942,294

             15

             16

             17     Total                                                            3,529,516    $                         42,989,999   $                  -   $        42,989,999   $                      -   $                  -   $                      -   $        42,989,999

             18     R1 Overall PMPM Casemix for R1 (R1 MMs)


             19


             20                                                                                                                                                          Retrospective Year 2 (R2) Aggregate Costs
             21                                                                                                  MCO/PIHP                                                                    FFS Incentive           1915(b)(3)             Administration
             22                       Medicaid Eligibility Group                       R2                      Capitated Costs                                                                   Costs              service costs                Costs
                                                                                                         (Including incentives and                                                    (not included in capitation                       (Attach list using CMS
             23
                                                 (MEG)                               Member           risksharing payouts/withholds)      Fee-for-Service            State Plan                  rates,               (provide               64.10 Waiver              Total Actual
             24                                                                      Months                    or PCCM Case                    Costs                Service Costs       provide documentation)     documentation)        schedule categories)          Waiver Costs
             25                                                                                              Management Fees                                            (D+E)                                                                                           (F+G+H+I)
             26     SSI                                                                635,700    $                         28,903,135                          $        28,903,135                                                                                $        28,903,135

             27     TANF                                                             3,117,800    $                         16,229,992                          $        16,229,992                                                                                $        16,229,992

             28                                                                               -                                                                 $                 -

             29                                                                               -                                                                 $                 -

             30     Total                                                            3,753,501    $                         45,133,127   $                  -   $        45,133,127   $                      -   $                  -   $                      -   $        45,133,127

             31     R1 Overall PMPM Casemix for R2 (R2 MMs)



                    Modify Line items as necessary to fit the MEGs of the program.
                    State Completion Sections
                                                                                                  Note: The States completing the Expedited Test will only attach the most recent waiver Schedule D,
                                                                                                  and the corresponding quarters of waiver forms from the CMS-64.9 Waiver and CMS-64.21U Waiver and CMS 64.10 Waiver.
                                                                                                  Completion of this Appendix is not necessary for expedited waivers.


                                                                                                  Note: The States completing the Comprehensive Test will attach the most recent waiver Schedule D,
                                                                                                  and the corresponding quarters of waiver forms from the CMS-64.9 Waiver and CMS-64.21U Waiver and CMS 64.10 Waiver.
                                                                                                  Completion of this Appendix is required for Comprehensive Waivers.




'D3. Actual Waiver Cost'                                                                                                                 Page 3 of 11                                                                                                  cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
State of                                                                                                          Appendix D3. Actual Waiver Cost



                     Row # /
                     Column                                    B                                   C                   K                                L                         M                             N                      O
                      Letter

                           2                                                                                                         Actual Waiver Cost Renewal Comprehensive
                                                                                                                           Actual Waiver Cost Renewal Comprehensive Version Version
                           3                                                                                                                       State of Texas
                                                                                                                                        State of Texas - Renewal - Renewal
                           4

                           5

                           6
                           7                                                                                                                                    R1 Per Member Per Month (PMPM) Costs
                                                                                                                                                                        Retrospective Year 1 (R1) Aggregate Costs
                           8
                           9                      Medicaid Eligibility Group                       R1

                           10
                                                             (MEG)                               Member            State Plan                       Incentive                 1915(b)(3)                 Administration           Total Actual
                           11                                                                    Months           Service Costs                       Costs                 Service Costs                   Costs                 Waiver Costs
                           12                                                                                         (F/C)                           (G/C)                     (H/C)                        (I/C)                    (J/C)
                           13   SSI                                                                599,084    $                   45.15   $                       -   $                        -    $                     -   $                  45.15

                           14   TANF                                                             2,930,432    $                    5.44   $                       -   $                        -    $                     -   $                   5.44

                           15

                           16

                           17   Total                                                            3,529,516

                           18   R1 Overall PMPM Casemix for R1 (R1 MMs)                                       $                   12.18   $                       -   $                        -    $                     -   $                  12.18


                           19


                           20                                                                                                                                   R2 Per Member Per Month (PMPM) Costs
                                                                                                                                                                        Retrospective Year 2 (R2) Aggregate Costs
                           21
                           22                     Medicaid Eligibility Group                       R2

                           23
                                                             (MEG)                               Member            State Plan                       Incentive                 1915(b)(3)                 Administration           Total Actual
                           24                                                                    Months           Service Costs                       Costs                 Service Costs                   Costs                 Waiver Costs
                           25                                                                                         (F/C)                           (G/C)                     (H/C)                        (I/C)                    (J/C)
                           26   SSI                                                                635,700    $                   45.47   $                       -   $                        -    $                     -   $                  45.47

                           27   TANF                                                             3,117,800    $                    5.21   $                       -   $                        -    $                     -   $                   5.21

                           28                                                                             -

                           29                                                                             -

                           30   Total                                                            3,753,501

                           31   R1 Overall PMPM Casemix for R2 (R2 MMs)                                       $                   12.02   $                       -   $                        -    $                     -   $                  12.02



                                Modify Line items as necessary to fit the MEGs of the program.
                                State Completion Sections




'D3. Actual Waiver Cost'                                                                                                             Page 4 of 11                                                                                 cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
       State of                                              Appendix D4. Adjustments in Projection

Row # /
Column                                     B                                 C                                            D
 Letter
   2                                             Adjustments and Services in Waiver Cost Projection (Comprehensive and Expedited)
   3                                                                         State of Texas - Renewal
   4                                                                   Prospective Years 1 and 2 (P1 and P2)
   5                                                                                Renewal Waiver
   6                                                                          * If a change please note
   7

   8              Adjustments to the Waiver Cost Projection         Adjustments Made                           Location of Adjustment
   9                                State Plan Trend                       none
  10            State Plan Programmatic/policy/pricing changes             none
  11                       Administrative Cost Adjustment
  12                           1915(b)(3) service Trend                    none
  13               Incentives (not in cap payment) Adjustments             none
  14                                     Other                             none
  15




       'D4. Adjustments in Projection'                                           Page 5 of 11                          cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
State of                                                                                                                                                    Appendix D5. Waiver Cost Projection




              Row # /
              Column                               B                         C                       D                         E                       F                        G                            H                            I                       J                        K                     L                    M                      N                         O
               Letter

                  2                                                                                                                                  Waiver Cost Projection Renewal Waiver Comprehensive Version
                  3                                                                                                                                                     State of Texas - Renewal
                  4                                                                                                                                      Note: Complete this Appendix for all Prospective Years
                  5                                                                                                                                                      Waiver Cost Projection
                  6
                  7

                  8                                                                                                                    R2 Per Member Per Month (PMPM) Costs                                                                                                     Prospective Year 1 (P1) Projection for State Plan Services**                                                           P1 Projection for Incentive Costs no

                  9
                                       Medicaid Eligibility Group     Retrospective                                                                                                                                                  R2 PMPM                  State Plan          PMPM Effect of        Program Adjustment    PMPM Effect of       Aggregate PMPM                Total P1 PMPM

                  10
                                                (MEG)                   Year 2 (R2)              State Plan                Incentive               1915(b)(3)             Administration                Total Actual                 State Plan          Inflation Adjustment           Inflation        [Enter Description        Program             Effect of State       State Plan Service
                  11                                                     Member                Service Costs*               Costs*               Service Costs*              Costs*                    Waiver Costs*               Service Costs*          (Annual Year 1)             Adjustment              Here]              Adjustment       Plan Service Adj.             Cost Projection
                  12                                                     Months                                                                                                                                                (Same as D13-D18)         (Preprint Explains)              (IxJ)         (Preprint Explains)        ((I+K)xL)               (K+M)                      (I+N)

                  13    SSI                                                      635,700   $               45.47     $                   -   $                    -   $                     -      $                   45.47   $               45.47            0.0%               $                -          0.0%           $                -   $                     -   $                45.47

                  14    TANF                                                 3,117,800     $                  5.21   $                   -   $                    -   $                     -      $                    5.21   $                  5.21          0.0%               $                -          0.0%           $                -   $                     -   $                 5.21

                  15

                  16

                  17    Total                                                3,753,501

                  18    P1 PMPM Casemix for R2 (R2 MMs)                                    $               12.02     $                   -   $                    -   $                     -      $                   12.02   $               12.02            0.0%               $                -          0.0%           $                -   $                     -   $                12.02

                  19
                  20                                                * For comprehensive waivers, Columns D, E, F, G and H are columns K, L, M, N, and O from the Actual Waiver Cost Spreadsheet D3. For expedited waivers, sum the CMS-64.9 WAV and 64.21UWAV forms and divide by the member months for column D.
                  21                                                Sum the CMS 64.10 WAV forms and divide by the member months for Column G. Sum D+G for Column H.
                  22                                                ** If additional columns are needed in order to identify all of the adjustments being made, please insert the appropriate number of columns and label them accordingly.
                  23

                  24

                  25                                                                                                                   P1 Per Member Per Month (PMPM) Costs                                                                                                     Prospective Year 2 (P2) Projection for State Plan Services**                                                           P2 Projection for Incentive Costs no

                  26
                                       Medicaid Eligibility Group     Retrospective              P1 PMPM                   P1 PMPM                 P1 PMPM                  P1 PMPM                      P1 PMPM                     P1 PMPM                  State Plan          PMPM Effect of        Program Adjustment    PMPM Effect of       Aggregate PMPM                Total P2 PMPM

                  27
                                                (MEG)                   Year 2 (R2)              State Plan                Incentive               1915(b)(3)             Administration                Total Actual           State Plan Service        Inflation Adjustment           Inflation        [Enter Description        Program             Effect of State       State Plan Service
                  28                                                     Member                Service Costs             Service Costs           Service Costs            Service Costs                Waiver Costs                Cost Projection         (Annual Year 2)             Adjustment              Here]              Adjustment       Plan Service Adj.             Cost Projection
                  29                                                     Months            (same as O13-O18)         (same as S13-S18)       (same as W13-W18)        (same as AA13-AA18)          (same as AB13-AB18)         (Same as D30-D35)         (Preprint Explains)              (IxJ)         (Preprint Explains)        ((I+K)xL)               (K+M)                      (I+N)

                  30    SSI                                                      635,700   $               45.47     $                   -   $                    -   $                     -      $                   45.47   $               45.47            0.0%               $                -          0.0%           $                -   $                     -   $                45.47

                  31    TANF                                                 3,117,800     $                  5.21   $                   -   $                    -   $                     -      $                    5.21   $                  5.21          0.0%               $                -          0.0%           $                -   $                     -   $                 5.21

                  32

                  33

                  34    Total                                                3,753,501

                  35    P2 PMPM Casemix for R2 (R2 MMs)                                    $               12.02     $                   -   $                    -   $                     -      $                   12.02   $               12.02            0.0%               $                -          0.0%           $                -   $                     -   $                12.02
                  36




'D5. Waiver Cost Projection'                                                                                                                                                        Page 6 of 11                                                                                                                                                                   cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
State of                                                                                                                                                    Appendix D5. Waiver Cost Projection




                     Row # /
                     Column                               B                        P                       Q                     R                      S                      T                         U                      V                    W                        X                        Y                      Z                    AA                     AB
                      Letter

                         2                                                                                                                                                  Actual Waiver Cost Comprehensive Version
                                                                                                                                                         Waiver Cost Projection Renewal Waiver Conversion Renewal Comprehensive Version
                         3                                                                                                                                                                      State
                                                                                                                                                                            State of Texas - Renewal of Texas - Renewal
                         4                                                                                                                                   Note: Complete this Note: Complete this Appendix for all Prospective Years
                                                                                                                                                                                 Appendix for all Prospective Years
                         5                                                                                                                                                                       Waiver Cost Projection
                                                                                                                                                                             Waiver Cost Projection
                         6
                         7

                         8                                                                                                           R2 Per Member
                                                                                  P1 Projection for Incentive Costs not Included in Capitation Rates**Per Month (PMPM) Costs                  P1 Projection for 1915(b)(3) Service Costs**                                                   P1 Projection for Administration Costs**
                                                                                                                                                                                                1915(b)(3) Service
                         9
                                              Medicaid Eligibility Group       R2 PMPM              Incentive Cost       PMPM Effect of           Total P1 PMPM            R2 PMPM                    Costs            PMPM Effect of         Total P1 PMPM               R2 PMPM            Administration Costs   PMPM Effect of            Total P1 PMPM        Total P1 PMPM

                        10
                                                       (MEG)                   Incentive          Inflation Adjustment        Inflation           Incentive Cost           1915(b)(3)           Inflation Adjustment         Inflation       1915(b)(3) Service         Administration       Inflation Adjustment         Inflation       Administration Cost          Projected
                        11                                                      Costs*              (Annual Year 1)          Adjustment             Projection          Service Costs*            (Annual Year 1)           Adjustment        Cost Projection              Costs*              (Annual Year 1)           Adjustment             Projection          Waiver Costs
                        12                                                 (Same as E13-E18)      (Preprint Explains)          (PxQ)                  (P+R)            (Same as F13-F18)        (Preprint Explains)           (TxU)                (T+V)            (Same as G13-G18)         (Preprint Explains)          (XxY)                  (X+Z)             (O+S+W+AA)

                        13     SSI                                         $                  -          0.0%            $                -   $                    -   $                  -            0.0%             $                -   $                  -   $                    -                           $                -   $                    -   $           45.47

                        14     TANF                                        $                  -          0.0%            $                -   $                    -   $                  -            0.0%             $                -   $                  -   $                    -                           $                -   $                    -   $           5.21

                        15

                        16

                        17     Total

                        18     P1 PMPM Casemix for R2 (R2 MMs)             $                  -          0.0%            $                -   $                    -   $                  -             0.0%            $                -   $                  -   $                    -           0.0%            $                -   $                    -   $           12.02

                        19
                        20
                        21
                        22
                        23

                        24

                        25                                                                                                           P1 Per Member Per Month (PMPM) Costs
                                                                                  P2 Projection for Incentive Costs not Included in Capitation Rates**                                        P2 Projection for 1915(b)(3) Service Costs**                                                   P2 Projection for Administration Costs**
                                                                                                                                                                                                1915(b)(3) Service
                        26
                                              Medicaid Eligibility Group       P1 PMPM              Incentive Cost       PMPM Effect of           Total P2 PMPM            P1 PMPM                    Costs            PMPM Effect of         Total P2 PMPM               P1 PMPM            Administration Costs   PMPM Effect of            Total P2 PMPM        Total P2 PMPM

                        27
                                                       (MEG)                 Incentive Cost       Inflation Adjustment        Inflation           Incentive Cost       1915(b)(3) Service       Inflation Adjustment         Inflation       1915(b)(3) Service     Administration Cost      Inflation Adjustment         Inflation       Administration Cost          Projected
                        28                                                     Projection           (Annual Year 2)          Adjustment             Projection          Cost Projection           (Annual Year 2)           Adjustment        Cost Projection             Projection           (Annual Year 2)           Adjustment             Projection          Waiver Costs
                        29                                                 (Same as E30-E35)      (Preprint Explains)          (PxQ)                  (P+R)            (Same as F30-F35)        (Preprint Explains)           (TxU)                (T+V)            (Same as G30-G35)                                      (XxY)                  (X+Z)             (O+S+W+AA)

                        30     SSI                                         $                  -          0.0%            $                -   $                    -   $                  -            0.0%             $                -   $                  -   $                    -                           $                -   $                    -   $           45.47

                        31     TANF                                        $                  -          0.0%            $                -   $                    -   $                  -            0.0%             $                -   $                  -   $                    -                           $                -   $                    -   $           5.21

                        32

                        33

                        34     Total

                        35     P2 PMPM Casemix for R2 (R2 MMs)             $                  -          0.0%            $                -   $                    -   $                  -             0.0%            $                -   $                  -   $                    -           0.0%            $                -   $                    -   $           12.02
                        36




'D5. Waiver Cost Projection'                                                                                                                                                    Page 7 of 11                                                                                                                                                                  cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
                  State of                                                                                                                                                                       Appendix D6. RO Targets




Row # /
Column                                  B                          C                                D                               E                         F                              G                          H                         I                             J                      K                  L                         M                      N                     O
 Letter

   2                                                                                                                                                     Quarterly CMS Targets for RO Monitoring
   3                                                                                                                                                             State of Texas - Renewal
   4                                                                                                                                                              Projection for Upcoming Waiver Period

   5      Projected Year 1
   6                                                         Total Projected                      P1 Projected PMPM Costs from Appendix D5 (Totals weighted on Projected Year 1 Member Months)                                              Total PMPM
   7                                 Medicaid                    Year 1                        Total PMPM                     Total PMPM                Total PMPM                     Total PMPM                  Total PMPM                 Projected
   8                            Eligibility Group            Member Months                  State Plan Service                  Incentive          1915(b)(3) Service                 Administration                Projected               Service Costs
   9                                  (MEG)                       (P1)                       Cost Projection                 Cost Projection           Cost Projection                Cost Projection             Waiver Costs              (Column H-G)
  10      SSI                                                            664,099       $                    45.47        $                     -   $                         -   $                        -   $                 45.47   $               45.47
  11      TANF                                                         3,336,758       $                      5.21       $                     -   $                         -   $                        -   $                  5.21   $                 5.21
  12                                                                         -         $                         -       $                     -   $                         -   $                        -   $                    -    $                       -
  13                                                                         -         $                         -       $                     -   $                         -   $                        -   $                    -    $                       -
  14      Total                                                        4,000,857
  15      P1 Weighted Average PMPM Casemix for P1 (P1 MMs)                             $                    11.89        $                     -   $                         -   $                        -   $                 11.89

  16

  17                                                                                 Q1 Quarterly Projected Costs                                                            Q2 Quarterly Projected Costs                                                   Q3 Quarterly Projected Costs                                           Q4 Quarterly Projected Costs
  18                                 Medicaid                Member Months                  64.9W /64.21U W                   64.10 Waiver             Member Months                 64.9W /64.21U W              64.10 Waiver          Member Months                   64.9W /64.21U W          64.10 Waiver       Member Months           64.9W /64.21U W          64.10 Waiver
  19                            Eligibility Group             Projections                     Service Costs                  Administration             Projections                   Service Costs               Administration             Projections                 Service Costs           Administration      Projections             Service Costs           Administration     Total P1 Projected
  20                                  (MEG)                                                 include incentives                   Costs                                               include incentives               Costs                                             include incentives           Costs                                  include incentives           Costs              Waiver Costs
  21      SSI                                                            164,435        $           7,476,300.39         $                     -                   165,170       $           7,509,718.34     $                    -                  165,972       $           7,546,182.55     $              -             168,522   $           7,662,122.38     $              -   $      30,194,323.66
  22      TANF                                                           815,033        $           4,242,727.98         $                     -                   830,199       $           4,321,675.96     $                    -                  835,960       $           4,351,665.37     $              -             855,566   $           4,453,726.18     $              -   $      17,369,795.49
  23                                                                             -      $                            -   $                     -                         -       $                        -   $                    -                        -       $                        -   $              -                  -    $                        -   $              -   $                    -
  24                                                                             -      $                            -   $                     -                         -       $                        -   $                    -                        -       $                        -   $              -                  -    $                        -   $              -   $                    -
  25      Total                                                          979,468        $          11,719,028.37         $                     -                   995,369       $         11,831,394.30      $                    -              1,001,932         $         11,897,847.92      $              -         1,024,088     $         12,115,848.56      $              -   $      47,564,119.15

  26

  27      Projected Year 2
  28                                                         Total Projected                      P2 Projected PMPM Costs from Appendix D5 (Totals weighted on Projected Year 2 Member Months)                                              Total PMPM
  29                                 Medicaid                    Year 2                        Total PMPM                     Total PMPM                Total PMPM                     Total PMPM                  Total PMPM                 Projected
  30                            Eligibility Group            Member Months                  State Plan Service                  Incentive          1915(b)(3) Service                 Administration                Projected               Service Costs
  31                                  (MEG)                       (P2)                       Cost Projection                 Cost Projection           Cost Projection                Cost Projection             Waiver Costs              (Column H-G)
  32      MEG 1                                                          694,956       $                    45.47        $                     -   $                         -   $                        -   $                 45.47   $               45.47
  33      MEG 2                                                        3,565,512       $                      5.21       $                     -   $                         -   $                        -   $                  5.21   $                 5.21
  34      MEG 3                                                              -         $                         -       $                     -   $                         -   $                        -   $                    -    $                       -
  35      MEG 4                                                              -         $                         -       $                     -   $                         -   $                        -   $                    -    $                       -
  36      Total                                                        4,260,468
  37      P2 Weighted Average PMPM Casemix for P2 (P2 MMs)                             $                    11.77        $                     -   $                         -   $                        -   $                 11.77
  38

  39                                                                                 Q5 Quarterly Projected Costs                                                            Q6 Quarterly Projected Costs                                                   Q7 Quarterly Projected Costs                                           Q8 Quarterly Projected Costs
  40                                 Medicaid                Member Months                  64.9W /64.21U W                   64.10 Waiver             Member Months                 64.9W /64.21U W              64.10 Waiver          Member Months                   64.9W /64.21U W          64.10 Waiver       Member Months           64.9W /64.21U W          64.10 Waiver
  41                            Eligibility Group             Projections                     Service Costs                  Administration             Projections                   Service Costs               Administration             Projections                 Service Costs           Administration      Projections             Service Costs           Administration     Total P2 Projected
  42                                  (MEG)                                                 include incentives                   Costs                                               include incentives               Costs                                             include incentives           Costs                                  include incentives           Costs              Waiver Costs
  43      MEG 1                                                          172,041        $           7,822,119.35         $                     -                   172,834       $           7,858,174.36     $                    -                  173,688       $           7,897,002.84     $              -             176,393   $           8,019,989.99     $              -   $      31,597,286.54
  44      MEG 2                                                          873,326        $           4,546,177.46         $                     -                   888,768       $           4,626,562.19     $                    -                  893,705       $           4,652,262.19     $              -             909,713   $           4,735,593.28     $              -   $      18,560,595.12
  45      MEG 3                                                                  -      $                            -   $                     -                         -       $                        -   $                    -                        -       $                        -   $              -                  -    $                        -   $              -   $                    -
  46      MEG 4                                                                  -      $                            -   $                     -                         -       $                        -   $                    -                        -       $                        -   $              -                  -    $                        -   $              -   $                    -
  47      Total                                                        1,045,367        $          12,368,296.81         $                     -                  1,061,602      $         12,484,736.55      $                    -              1,067,393         $         12,549,265.03      $              -         1,086,106     $         12,755,583.27      $              -   $      50,157,881.66




                  'D6. RO Targets'                                                                                                                                                                                 8 of 11                                                                                                                                                          cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
                     State of                                                                                                                                                         Appendix D6. RO Targets




            P                                           Q                                     R                                   S                                     T                                     U


                                                                            Quarterly CMS Targets for RO CMS-64 Review Renewal                                                                                                                                 Quarterly CMS Targets for RO C
                                                                                          State of Texas - Renewal                                                                                                                                                              State of Texa
                                                                                           Projection for Upcoming Waiver Period                                                                                                                                                  Projection for Upcom

                                                                                   Projections for RO CMS-64 Certification - Aggregate Cost                                                                                                                                 Worksheet for RO PMPM Co




Projected Year 1 - 10/1/05-9/30/06




      Waiver Form                        Medicaid Eligibility Group (MEG)        Q1 Quarterly Projected Costs        Q2 Quarterly Projected Costs          Q3 Quarterly Projected Costs          Q4 Quarterly Projected Costs
                                                                                        Start 10/1/2005                     Start 1/1/2006                        Start 4/1/2006                        Start 7/1/2006
 64.21U Waiver Form         SSI                                              $                    7,476,300.39   $                      7,509,718.34   $                      7,546,182.55   $                    7,662,122.38
 64.21U Waiver Form         TANF                                             $                    4,242,727.98   $                      4,321,675.96   $                      4,351,665.37   $                    4,453,726.18
   64.9 Waiver Form                                                          $                             -     $                               -     $                               -     $                             -
   64.9 Waiver Form                                                          $                             -     $                               -     $                               -     $                             -
  64.10 Waiver Form                                                          $                             -     $                               -     $                               -     $                             -




Projected Year 2 - xx/xx/xx - xx/xx/xx




      Waiver Form                        Medicaid Eligibility Group (MEG)        Q5 Quarterly Projected Costs        Q6 Quarterly Projected Costs          Q7 Quarterly Projected Costs          Q8 Quarterly Projected Costs
                                                                                        Start 7/1/2003                      Start 10/1/2003                       Start 1/1/2004                        Start 4/1/2004
 64.21U Waiver Form         MEG 1                                            $                    7,822,119.35   $                      7,858,174.36   $                      7,897,002.84   $                    8,019,989.99
 64.21U Waiver Form         MEG 2                                            $                    4,546,177.46   $                      4,626,562.19   $                      4,652,262.19   $                    4,735,593.28
   64.9 Waiver Form         MEG 3                                            $                             -     $                               -     $                               -     $                             -
   64.9 Waiver Form         MEG 4                                            $                             -     $                               -     $                               -     $                             -
  64.10 Waiver Form                                                          $                             -     $                               -     $                               -     $                             -




                     'D6. RO Targets'                                                                                                                                                                   9 of 11                  cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
                     State of                                                                                                                                Appendix D6. RO Targets




                            V                                  W                                       X                               Y                       Z                 AA                       AB                AC              AD                     AE                   AF             AG                       AH                 AI


                                                                                                                                Quarterly CMS Targets for RO Cost-Effectiveness Monitoring
                                                                                                                                                 State of Texas - Renewal
                                                                                                                                                   Projection for Upcoming Waiver Period

                                                                                                                                           Worksheet for RO PMPM Cost-Effectiveness Monitoring
Projected Year 1 - 10/1/05-9/30/06
                                                                                                      State Completion Section - For Waiver Submission
                                                                                              P1 Projected PMPM
                     Waiver Form                 Medicaid Eligibility Group (MEG)          From Column I (services)
                                                                                        From Column G (Administration)
                 64.21U Waiver Form      SSI                                        $                                 45.47
                 64.21U Waiver Form      TANF                                       $                                  5.21
                  64.9 Waiver Form                                                  $                                    -
                  64.9 Waiver Form                                                  $                                    -
                 64.10 Waiver Form                          All MEGS                $                                    -

Projected Year 1 - 10/1/05-9/30/06                                                                     RO Completion Section - For ongoing monitoring                         RO Completion Section - For ongoing monitoring               RO Completion Section - For ongoing monitoring           RO Completion Section - For ongoing monitoring
                                                                                                                  Q1 Quarterly Actual Costs                                                  Q2 Quarterly Actual Costs                                  Q3 Quarterly Actual Costs                                  Q4 Quarterly Actual Costs
                                                                                               Member Months                         Actual                 Actual         Member Months                Actual             Actual     Member Months              Actual               Actual     Member Months                Actual             Actual

                     Waiver Form                 Medicaid Eligibility Group (MEG)                  Actuals                         Aggregate             PMPM Costs            Actuals                Aggregate          PMPM Costs       Actuals              Aggregate            PMPM Costs       Actuals                Aggregate          PMPM Costs
                                                                                                Start 10/1/2005                Waiver Form Costs                            Start 1/1/2006        Waiver Form Costs                    Start 4/1/2006      Waiver Form Costs                      Start 7/1/2006        Waiver Form Costs
                 64.21U Waiver Form      SSI                                                                                                                #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                 64.21U Waiver Form      TANF                                                                                                               #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                  64.9 Waiver Form                                                                                                                          #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                  64.9 Waiver Form                                                                                                                          #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                 64.10 Waiver Form                          All MEGS                                                                                        #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!




Projected Year 2 - xx/xx/xx - xx/xx/xx
                                                                                                      State Completion Section - For Waiver Submission
                                                                                              P1 Projected PMPM
                     Waiver Form                 Medicaid Eligibility Group (MEG)          From Column I (services)
                                                                                        From Column G (Administration)
                 64.21U Waiver Form      MEG 1                                      $                                 45.47
                 64.21U Waiver Form      MEG 2                                      $                                  5.21
                  64.9 Waiver Form       MEG 3                                      $                                    -
                  64.9 Waiver Form       MEG 4                                      $                                    -
                 64.10 Waiver Form                          All MEGS                $                                    -

Projected Year 2 - xx/xx/xx - xx/xx/xx                                                                 RO Completion Section - For ongoing monitoring                         RO Completion Section - For ongoing monitoring               RO Completion Section - For ongoing monitoring           RO Completion Section - For ongoing monitoring
                                                                                                                  Q5 Quarterly Actual Costs                                                  Q6 Quarterly Actual Costs                                  Q7 Quarterly Actual Costs                                  Q8 Quarterly Actual Costs
                                                                                               Member Months                         Actual                 Actual         Member Months                Actual             Actual     Member Months              Actual               Actual     Member Months                Actual             Actual

                     Waiver Form                 Medicaid Eligibility Group (MEG)                  Actuals                         Aggregate             PMPM Costs            Actuals                Aggregate          PMPM Costs       Actuals              Aggregate            PMPM Costs       Actuals                Aggregate          PMPM Costs
                                                                                                 Start 7/1/2003                Waiver Form Costs                            Start 10/1/2003       Waiver Form Costs                    Start 1/1/2004      Waiver Form Costs                      Start 4/1/2004        Waiver Form Costs
                 64.21U Waiver Form      MEG 1                                                                                                              #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                 64.21U Waiver Form      MEG 2                                                                                                              #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                  64.9 Waiver Form       MEG 3                                                                                                              #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                  64.9 Waiver Form       MEG 4                                                                                                              #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!
                 64.10 Waiver Form                          All MEGS                                                                                        #DIV/0!                                                        #DIV/0!                                                    #DIV/0!                                                    #DIV/0!




                     'D6. RO Targets'                                                                                                                                       10 of 11                                                                                                                                  cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls
State of                                                                                                                                                                                        Appendix D7. Summary


                Row # /
                Column                                         B                                                   C                          D                          E                         F                        G                         H                     I                       J                       K                     L                       M                     N
                 Letter

                   2                                                                                                   Cost Effectiveness Summary Sheet Renewal Waiver
                   3                                                                                                                 State of Texas - Renewal
                   4
                   5                                                                                                                                                                                                                                                                              Costs to be input below are from the prior waiver submission. Compare the prospective years
                   6                                                                                                                                                                                                                                                                              from the prior waiver submission to the retrospective years of the current waiver submission.
                   7      Retrospective Period
                   8                                                                                                                                                         R1 Per Member Per Month (PMPM) Costs                                                                                             P1 Per Member Per Month (PMPM) Costs from the prior waiver submission
                   9                                       Medicaid                                               R1                      R1 PMPM                   R1 PMPM                   R1 PMPM                   R1 PMPM                   R1 PMPM                                       P1 PMPM                 P1 PMPM               P1 PMPM                 P1 PMPM               P1 PMPM
                  10                                   Eligibility Group                                       Member                    State Plan                  Incentive                1915(b)(3)              Administration             Total Actual                                   State Plan              Incentive            1915(b)(3)             Administration         Total Actual
                  11                                         (MEG)                                             Months                   Service Costs                 Costs                 Service Costs                 Costs                  Waiver Costs                                 Service Costs              Costs              Service Costs               Costs              Waiver Costs
                  12      SSI                                                                                           599,084   $                   45.15   $                     -   $                     -   $                     -   $               45.15                        $                 45.45    $               -   $                   -   $               0.21   $              45.66
                  13      TANF                                                                                      2,930,432     $                    5.44   $                     -   $                     -   $                     -   $                 5.44                       $                   6.23   $               -   $                   -   $               0.21   $               6.45
                  14
                  15
                  16      Total                                                                                     3,529,516
                  17      R1 Overall PMPM Casemix for R1 (R1 MMs)                                                                 $                   12.18   $                     -   $                     -   $                     -   $               12.18                        $                 12.89    $               -   $                   -   $               0.21   $              13.10
                  18      Total R1 Expenditures                                                                                                                                                                                                      $42,989,999                         Total Previous P1 Projection using R1 member months                                                   $46,244,138
                  19
                  20                                                                                                                      R2 Per Member Per Month (PMPM) Costs (Totals weighted on Retrospective Year 2 Member Months)                                                                        P2 Per Member Per Month (PMPM) Costs from the prior waiver submission
                  21                                       Medicaid                                               R2                      R2 PMPM                   R2 PMPM                   R2 PMPM                   R2 PMPM                   R2 PMPM                Overall                P2 PMPM                 P2 PMPM               P2 PMPM                 P2 PMPM               P2 PMPM
                  22                                   Eligibility Group                                       Member                    State Plan                  Incentive                1915(b)(3)              Administration             Total Actual        R1 to R2 Change            State Plan              Incentive            1915(b)(3)             Administration         Total Actual
                  23                                         (MEG)                                             Months                   Service Costs                 Costs                 Service Costs                 Costs                  Waiver Costs           (annual)              Service Costs              Costs              Service Costs               Costs              Waiver Costs
                  24      SSI                                                                                           635,700   $                   45.47   $                     -   $                     -   $                     -   $               45.47         0.7%           $                 46.85    $               -   $                   -   $               0.20   $              47.05
                  25      TANF                                                                                      3,117,800     $                    5.21   $                     -   $                     -   $                     -   $                 5.21        -4.3%          $                   6.43   $               -   $                   -   $               0.20   $               6.64
                  26
                  27
                  28      Total                                                                                     3,753,501
                  29      R2 Weighted Average PMPM Casemix for R1 (R1 MMs)                                                        $                   12.04   $                     -   $                     -   $                     -   $               12.04         -1.2%
                  30      R2 OVerall PMPM Casemix for R2 (R2 MMs)                                                                 $                   12.02   $                     -   $                     -   $                     -   $               12.02         -1.3%          $                 13.28    $               -   $                   -   $               0.20   $              13.48
                  31      Total R2 Expenditures                                                                                                                                                                                                      $45,133,127                         Total Previous P2 Projection using R2 member months                                                   $50,598,972
                  32
                  33      Total Previous Waiver Period Expenditures (Casemix for R1 and R2)                                                                                                                                                          $88,123,125                                                                                                                               $96,843,110
                  34      Total Difference between Projections and Actual Waiver Cost for Previous Waiver Period                                                                                                                                      $8,719,985
                  35
                  36      Prospective Period
                  37                                                                                          Projected                             P1 Projected PMPM Costs (Totals weighted on Projected Year 1 Member Months)
                  38                                       Medicaid                                             Year 1                    P1 PMPM                   P1 PMPM                   P1 PMPM                   P1 PMPM                   P1 PMPM                Overall
                  39                                   Eligibility Group                                  Member Months               State Plan Service             Incentive          1915(b)(3) Service            Administration              Projected          R2 to P1 Change
                  40                                         (MEG)                                               (P1)                  Cost Projection            Cost Projection           Cost Projection           Cost Projection            Waiver Costs           (annual)
                  41      SSI                                                                                          664,099    $                   45.47   $                     -   $                     -   $                     -   $               45.47         0.0%
                  42      TANF                                                                                     3,336,758      $                    5.21   $                     -   $                     -   $                     -   $                 5.21        0.0%
                  43
                  44
                  45      Total                                                                                    4,000,857
                  46      P1 Weighted Average PMPM Casemix for R2 (R2 MMs)                                                        $                   12.02   $                     -   $                     -   $                     -   $               12.02         0.0%
                  47      P1 Weighted Average PMPM Casemix for P1 (P1 MMs)                                                        $                   11.89   $                     -   $                     -   $                     -   $               11.89         -1.1%
                  48      Total Projected Waiver Expenditures P1(P1 MMs)                                                                                                                                                                             $47,564,119
                  49
                  50                                                                                          Projected                             P2 Projected PMPM Costs (Totals weighted on Projected Year 2 Member Months)
                  51                                       Medicaid                                             Year 2                    P2 PMPM                   P2 PMPM                   P2 PMPM                   P2 PMPM                   P2 PMPM                Overall
                  52                                   Eligibility Group                                  Member Months               State Plan Service             Incentive          1915(b)(3) Service            Administration              Projected          P1 to P2 Change
                  53                                         (MEG)                                               (P2)                  Cost Projection            Cost Projection           Cost Projection           Cost Projection            Waiver Costs           (annual)
                  54      SSI                                                                                          694,956    $                   45.47   $                     -   $                     -   $                     -   $               45.47         0.0%
                  55      TANF                                                                                     3,565,512      $                    5.21   $                     -   $                     -   $                     -   $                 5.21        0.0%
                  56
                  57
                  58      Total                                                                                    4,260,468
                  59      P2 Weighted Average PMPM Casemix for P1 (P1 MMs)                                                        $                   11.89   $                     -   $                     -   $                     -   $               11.89         0.0%
                  60      P2 Weighted Average PMPM Casemix for P2 (P2 MMs)                                                        $                   11.77   $                     -   $                     -   $                     -   $               11.77         -1.0%
                  61      Total Projected Waiver Expenditures P2 (P2 MMs)                                                                                                                                                                            $50,157,882
                  62
                  63                                                                                          Projected
                  64                                       Medicaid                                         Year 1 and 2                                                                                                                                                 Overall                 Overall
                  65                                   Eligibility Group                                  Member Months                                                                                                                                              R1 to P2 Change         R1 to P2 Change
                  66                                         (MEG)                                             (P1 +P2)                                                                                                                                                 (monthly)              (annualized)
                  67      SSI                                                                                      1,359,055                                                                                                                                              0.0%                    0.2%
                  68      TANF                                                                                     6,902,270                                                                                                                                              -0.1%                   -1.5%
                  69
                  70
                  71      Total                                                                                    8,261,325
                  72      P2 Weighted Average PMPM Casemix for R1 (R1 MMs)                                                                                                                                                                                                0.0%                    -0.4%
                  73      P2 Weighted Average PMPM Casemix for P2 (P2 MMs)                                                                                                                                                                                                -0.1%                   -1.1%
                  74      Total Projected Waiver Expenditures P2 + P1 (Casemix for P1 and P2)                                                                                                                                                        $97,722,001
                          Modify Line items as necessary to fit the MEGs of the program.

                          State Completion Sections                                                                                                                                                                                         NUMBER OF MONTHS OF DATA
                          To modify the formulas as necessary to fit the length of the program complete this section. The formulas will automatically update given this data.                                                               R1                                      12
                          PMPM from previously approved waiver.                                                                                                                                                                             R2                                      12
                                                                                                                                                                                                                                            Gap (end of R2 to P1)                    0
                                                                                                                                                                                                                                            P1                                      12
                                                                                                                                                                                                                                            P2                                      12
                                                                                                                                                                                                                                            TOTAL                                   48
                                                                                                                                                                                                                                            (Months-12)                             36




'D7. Summary'                                                                                                                                                                                               Page 11 of 11                                                                                                                                                                                 cd6431d0-fb3d-4db8-88e5-5c0380706c33.xls

				
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