Janice K. Brewer, Governor
Thomas J. Betlach, Director

August 25, 2014

The Honorable Andy Biggs, President
Arizona State Senate
1700 West Washington
Phoenix, Arizona 85007

The Honorable Andy Tobin, Speaker
Arizona House of Representatives
1700 West Washington
Phoenix, Arizona 85007

SUBJECT: FY 2015 Appropriation Status Report for the Period Ended July 31, 2014

Dear President Biggs and Speaker Tobin:

Pursuant  to  A.R.S.  §’s  36-2920  and  36-2994,  enclosed  is  the  Arizona  Health  Care  Cost
Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended July
31, 2014.

Status Summary - AHCCCS is in the process of finalizing its Fiscal Year 2016 budget request, including an update of Fiscal Year 2015 for submission to the Governor’s Office of Strategic Planning and Budgeting pursuant to A.R.S. § 35-113. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

Enrollment Update  – July 2014 enrollment is 1,552,186 members, a 43,497 member increase over the prior month. Enrollment for August 2014 increased to 1,591,593 members, a 39,407 member increase.  Major August changes by eligibility category include: 1931 for Families and Children - increase of 12,057; SOBRA Children – increase of 7,098; Prop 204 Restoration - increase of 13,310; Adult Expansion - increase of 2,721; and Emergency Services - increase of
1,946.

Tobacco Funds Revenue Update – Tobacco tax collections through July 2014 are $0.8 million more  than  the  AHCCCS monthly projected flows.  AHCCCS will  continue to  monitor the tobacco funds revenue collections to determine any impact on the FY 2015 appropriations.

If you have any questions about this report, please do not hesitate to call me at (602) 417-4111 or
Jim Cockerham at (602) 417-4059. Sincerely,

Thomas J. Betlach
Director

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov

The Honorable Andy Biggs The Honorable Andy Tobin August 25, 2014
Page 2

Enclosure

cc:       The Honorable Janice K. Brewer, Governor
The Honorable Don Shooter, Chairman, Senate Appropriations Committee
The Honorable John Kavanagh, Chairman, House Appropriations Committee
The Honorable Nancy Barto, Chairman, Senate Health and Human Services Committee The Honorable Heather Carter, Chairman, House Health and Human Services Committee John Arnold, Director, Governor’s Office of Strategic Planning and Budgeting
Richard Stavneak, Director, Joint Legislative Budget Committee

Appropriation Status Report
(ASR)

Fiscal	Year	2015

Through July 31, 2014

Prepared by: Division of Business and Finance

Appropriation	Status	Report
Table	of	Contents

APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 2015……………………………….2
Appropriated Expenditures by Funding Source………………………………….……..3
Appropriated Revenue Received Detail Schedule………………………………………4

FOOTNOTES……………………………………………………………………………………….6

CASELOAD AND EXPENDITURES BY RATE CODE………………………………9

Appropriation Status Report

Appropriated Sources and
Uses	of	Funds

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 2014
SUMMARY OF APPROPRIATED EXPENDITURES

	(A)	(B)	(A) - (B)			
	EXPENDITURE			PROJECTED		
ANNUAL	PLAN	EXPENDITURES	VARIANCE	ANNUAL	ANNUALIZED	
APPROPRIATION	YTD	YTD	YTD	EXPENDITURES	VARIANCE	

APPROPRIATIONS:

ADMINISTRATION

AHCCCS Operating Lump Sum	$	81,923,000		$	4,480,012		$	4,480,012		$	-	$	81,923,000		$	-	
AHCCCS Prop 204 Administration	6,863,900		502,452		502,452		-	6,863,900		-	
DES Eligibility	54,874,500		4,847,006		4,847,006		-	54,874,500		-	
DES Prop 204 Eligibility	38,358,700		689,134		689,134		-	38,358,700		-	
TOTAL ADMINISTRATION	182,020,100		10,518,603		10,518,603		-	182,020,100		-	

Traditional Medicaid Services	3,816,084,500		289,618,471		289,618,471		-	3,816,084,500		-	
Proposition 204 Services	2,025,717,900		191,762,464		191,762,464		-	2,025,717,900		-	
ACA Adult Expansion	227,369,700		14,401,166		14,401,166		-	227,369,700		-	
Children's Rehabilitative Services	196,042,400		20,534,437		20,534,437		-	196,042,400		-	
KidsCare Services	6,223,000		699,730		699,730		-	6,223,000		-	
ALTCS Services	1,344,569,500		100,759,169		100,759,169		-	1,344,569,500		-	
Disproportionate Share Payments	13,487,100		-		-		-	13,487,100		-	
Rural Hospitals	22,650,000		-		-		-	22,650,000		-	
Voluntary Political Subdivision Programs	253,791,900		-		-		-	253,791,900		-	
TOTAL PROGRAMMATIC	7,905,936,000		617,775,437		617,775,437		-	7,905,936,000		-	

$	8,087,956,100		$	628,294,041		$	628,294,041		$	-	$  8,087,956,100		$	-	

TOTAL EXPENDITURES

ARIZONA  HEALTH  CARE  COST  CONTAINMENT   SYSTEM
FY 2014 APPROPRIATION STATUS REPORT For the Period Ending July 31, 2014
APPROPRIATED EXPENDITURES BY FUNDING SOURCE

(A) 	(B) 	(A) - (B)
EXPENDITURE 	PROJECTED
ANNUAL 	PLAN 	EXPENDITURES 	VARIANCE 		ANNUAL 	ANNUALIZED APPROPRIATION 	 YTD 		YTD 	      YTD 	EXPENDITURES 	  VARIANCE

STATE - GENERAL FUND

Administrative Expenditures

$ 	52,984,500 	$

3,393,574 	$

3,393,574

- 	$ 	52,984,500 	$ 	-

Proposition 204 - Administrative Expenditures 	19,658,700 	471,319 	471,319 	- 	19,658,700 	-

Programmatic Expenditures
Traditional Medicaid Services 		 883,358,000 		 70,829,693 	   70,829,693 		- 	   883,358,000 	   - Proposition 204 Services 		77,000,000 	29,448,402 	29,448,402 	- 		  77,000,000 	- Children's Rehabilitative Services 		62,248,100 		6,728,016 	  6,728,016 	- 		  62,248,100 	- KidsCare Services 		  1,257,200 		   145,657 		145,657 	- 			1,257,200 	- ALTCS Services 	167,797,400 	13,983,117 	13,983,117 	- 		167,797,400 	- DSH and Rural Hospitals 		10,099,300 			- 			- 	- 		  10,099,300 	- TOTAL GF EXPENDITURES 	1,274,403,200 	 124,999,778 	 124,999,778 		- 	1,274,403,200 	   -

FEDERAL

Administrative Expenditures 	83,696,900 	5,930,666 	5,930,666 	- 	83,696,900 	- Proposition 204 - Administrative Expenditures 	22,179,500 	   720,267 	   720,267 	- 	22,179,500 	-

Programmatic Expenditures
Traditional Medicaid Services 	   2,575,804,300 	   186,050,251 	   186,050,251 		- 	   2,575,804,300 	   - Proposition 204 Services 	1,587,663,200 	154,485,339 	154,485,339 	- 		1,587,663,200 	- ACA Adult Expansion 	   227,369,700 	  14,401,166 	  14,401,166 	- 		   227,369,700 	- Children's Rehabilitative Services 	   133,794,300 	  13,806,421 	  13,806,421 	- 		   133,794,300 	- KidsCare Services 		  4,595,800 		505,725 		505,725 	- 			4,595,800 	- ALTCS Services and Nursing Facility Assessment 	   895,343,500 	  65,305,615 	  65,305,615 	- 		   895,343,500 	- DSH and Rural Hospitals 		26,037,800 			- 			- 	- 		     26,037,800 	- Voluntary Political Subdivision Programs - See Note 5 	   173,644,800 			- 			- 	- 		   173,644,800 	- TOTAL FEDERAL EXPENDITURES 	   5,730,129,800 	   441,205,451 	   441,205,451 		- 	   5,730,129,800 	   -

COUNTY

Administrative Expenditures Proposition 204 - BNCF 	3,384,400 	- 	- 	- 	3,384,400 	- Programmatic Expenditures
Traditional Medicaid Services Acute Care 		  50,199,900 		  4,183,325 		4,183,325 		- 		50,199,900 	   - ALTCS Services 	245,196,200 	19,265,864 	19,265,864 	- 		245,196,200 	- TOTAL COUNTY EXPENDITURES 		298,780,500 		23,449,189 	   23,449,189 		- 	   298,780,500 	   -

Programmatic Expenditures

TOBACCO FUNDS

Traditional Medicaid Services Acute Care - Medically Needy 		   34,178,800 	   5,225,769 		5,225,769 		- 		34,178,800 	   - Proposition 204 Services - Emergency Health Services 		18,202,400 	1,600,493 	1,600,493 	- 		  18,202,400 	- Proposition 204 Services - Proposition 204 Protection 		38,225,000 	6,228,229 	6,228,229 	- 		  38,225,000 	- Proposition 204 Services - ATLSF 	100,000,000 		- 			- 	- 		100,000,000 	- TOTAL TOBACCO EXPENDITURES 		 190,606,200 	 13,054,492 	 13,054,492 		- 	   190,606,200 	   -

Administrative Expenditures

OTHER

Prescription Drug Rebate Program                                                                                                                116,100                                             2,777                                             2,777                                                 -                                              116,100                                                  - Programmatic Expenditures
Acute Care - Prescription Drug Rebate Program State Match 		   73,756,400 		   6,146,367 		6,146,367 		- 		 73,756,400 	   - Acute Care - Prescription Drug Rebate Program Federal Authority 	198,561,200 	17,093,443 	17,093,443 	- 		198,561,200 	- Long Term Care - Prescription Drug Rebate Program State Match 		  5,162,500 		   430,208 		430,208 	- 			5,162,500 	- Long Term Care - Prescription Drug Rebate Program Federal Authority 		13,898,100 		1,690,329 	  1,690,329 	- 		  13,898,100 	- Proposition 204 Services - Hospital Assessment 	204,627,300 			    - 			- 	- 		204,627,300 	- Traditional Medicaid Services - TPL 		     194,700 		     86,143 		  86,143 	- 			   194,700 	- ALTCS Services - TPL 				- 		     84,037 		  84,037 	- 				- 	- ALTCS Services - Nursing Facility Assessment 		17,171,800 			    - 			- 	- 		  17,171,800 	- KidsCare Services Premiums 		     370,000 		     48,348 		  48,348 	- 			   370,000 	- Freedom to Work Premiums 			31,200 			3,481 		    3,481 	- 			     31,200 	- Voluntary Political Subdivision Programs - See Note 5 		80,147,100 			    - 			- 	- 		  80,147,100 	- TOTAL OTHER  EXPENDITURES 		 594,036,400 		 25,585,131 	   25,585,131 		- 	   594,036,400 	   -

TOTAL

Administrative Expenditures                                                                                                                       182,020,100                                    10,518,603                                    10,518,603                                                 -                                      182,020,100                                                  - Acute Care                                                                                                                                               6,561,366,500                                  517,016,268                                  517,016,268                                                 -                                   6,561,366,500                                                  - Long Term Care                                                                                                                                       1,344,569,500                                  100,759,170                                  100,759,170                                                 -                                   1,344,569,500                                                  -

TOTAL EXPENDITURES

$ 	8,087,956,100 	$

628,294,041 	$

628,294,041 	$

- 	$ 	8,087,956,100 	$ 	-

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2015 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE  AND OTHER COLLECTIONS RECEIVED  DETAIL SCHEDULE For the Period Ending July 31, 2014

BUDGET 	BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,008,689,900		$	80,951,283		$	80,951,283	
Proposition 204 Services & Administrative	96,658,700		29,919,722		29,911,289	
KidsCare Services	1,257,200		145,657		145,657	
ALTCS Services	167,797,400		13,983,117		13,983,117	
TOTAL	1,274,403,200		124,999,778		124,991,345	

FEDERAL:
Acute & Administrative	4,830,190,500		375,394,110		496,819,267	
KidsCare Services	4,595,800		505,725		1,033,041	
ALTCS Services	895,343,500		65,305,615		65,656,467	
TOTAL	5,730,129,800		441,205,451		563,508,775	

COUNTY:
Acute & Administrative	53,584,300		4,183,325		4,548,895	
ALTCS Services	245,196,200		19,265,864		-	
TOTAL	298,780,500		23,449,189		4,548,895	

TOBACCO FUNDS:
Traditional Medicaid Services	34,178,800		5,225,769		5,225,769	
Proposition 204 Services	156,427,400		7,828,722		7,828,722	
TOTAL	190,606,200		13,054,492		13,054,492	

OTHER:
Administrative	116,100		2,777		2,777	
Acute Care - Prescription Drug Rebate Program	272,317,600		23,239,809		23,239,809	
Long Term Care - Prescription Drug Rebate Program	19,060,600		2,120,537		2,120,537	
Hospital Assessment	204,627,300		-		262,461	
ALTCS - Nursing Facility Assessment	17,171,800		-		-	
Acute TPL - Note 1	194,700		86,143		86,143	
LTC TPL - Note 1	-		84,037		84,037	
KidsCare TPL - Note 1	-		-		159	
Member Premiums - CHIP	370,000		48,348		64,667	
Member Premiums - Freedom to Work	31,200		3,481		3,481	
Voluntary Political Subdivision - State Match	80,147,100		-		3,796,758	
TOTAL	594,036,400		25,585,131		29,660,828	

TOTAL REVENUE

$	8,087,956,100

$	628,294,041

$	735,764,335

Appropriation Status Report

Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending July 31, 2014

Note 1:	Third Party Liability Collections: Gross Collections:	July 2014		July 2013		July 1, 2013
July 31, 2014		July 1, 2012
July 31, 2013	
	Acute	$ 	718,021		$ 	1,145,687		$ 	718,021		$ 	1,145,687	
	LTC	374,048		237,649		374,048		237,649	
	KidsCare	819		493		819		493	
	Total TPL Collections	$ 	1,092,888		$ 	1,383,829		$ 	1,092,888		$ 	1,383,829	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$ 	86,143		$ 	165,610		$ 	86,143		$ 	165,610	
LTC	84,037		52,618		84,037		52,618	
KidsCare	159		99		159		99	
Total Expenditure Offsets	$ 	170,339		$ 	218,327		$ 	170,339		$ 	218,327	

FY 15 Total

Note 2:	Authorized Positions	1,032.2	
	Actual Positions as of July 31, 2014	936.4	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending July 31, 2014

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2014

$    2,092,063

Revenues	1,414,658
Transfers-In		- Total Revenues	1,414,658

Expenditures	240,583
Transfers-out		- Total Expenditures	240,583

Ending Balance July 31, 2014

$    3,266,138

Of the $3,266,138 ending balance, $1,664,866 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through September 2014.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs and CMS Deferrals and Disallowances Liabilities.

Schedule of Outstanding Liabilities
As of July 31, 2014

Description	Amount

Type

School Based Claiming Medicaid Administrative Costs	18,941,355	HHS-OIG & AHCCCS Self Reported

School Based Claiming Direct Services Costs	19,923,489	HHS-OIG

38,864,844

Appropriation Status Report

Caseload	and	Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending July 31, 2014

TITLE XIX TRADITIONAL

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE

TOTAL

SUBTOTAL

CAPITATION - ACUTE	245,320,411	0	0	0	0	0	0	0	0	0	0	0	245,320,411	
CAPITATION - LTC	172,652,192	0	0	0	0	0	0	0	0	0	0	0	172,652,192	
MENTAL HEALTH - CHILD	22,940,496	0	0	0	0	0	0	0	0	0	0	0	22,940,496	
MENTAL HEALTH - ADULT	9,246,123	0	0	0	0	0	0	0	0	0	0	0	9,246,123	
MENTAL HEALTH - GENERAL	13,514,010	0	0	0	0	0	0	0	0	0	0	0	13,514,010	
MENTAL HEALTH - CMDP	16,576,107	0	0	0	0	0	0	0	0	0	0	0	16,576,107	
FEE FOR SERVICE - ACUTE	46,280,515	0	0	0	0	0	0	0	0	0	0	0	46,280,515	
FFS - PRIOR QUARTER COVERAGE	83,480	0	0	0	0	0	0	0	0	0	0	0	83,480	
EMERGENCY SERVICES - FEDERAL	6,645,181	0	0	0	0	0	0	0	0	0	0	0	6,645,181	
FFS MEDICAID IN PUBLIC SCHOOLS	774,806	0	0	0	0	0	0	0	0	0	0	0	774,806	
INPATIENT INMATES FFS	139,514	0	0	0	0	0	0	0	0	0	0	0	139,514	
QMB - FEE FOR SERVICE	227,508	0	0	0	0	0	0	0	0	0	0	0	227,508	
PINAL COUNTY INMATES FFS	1,230	0	0	0	0	0	0	0	0	0	0	0	1,230	
PIMA COUNTY INMATES FFS	7,294	0	0	0	0	0	0	0	0	0	0	0	7,294	
MARICOPA CTY INMATES FFS	5,034	0	0	0	0	0	0	0	0	0	0	0	5,034	
FEE FOR SERVICE - LTC	10,677,186	0	0	0	0	0	0	0	0	0	0	0	10,677,186	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,542,730	0	0	0	0	0	0	0	0	0	0	0	1,542,730	
REINSURANCE - ACUTE	10,003,289	0	0	0	0	0	0	0	0	0	0	0	10,003,289	
REINSURANCE - LTC	3,351,665	0	0	0	0	0	0	0	0	0	0	0	3,351,665	
SMIB - ACUTE	10,410,873	0	0	0	0	0	0	0	0	0	0	0	10,410,873	
HIB - ACUTE	58,792	0	0	0	0	0	0	0	0	0	0	0	58,792	
Q1	1,627,402	0	0	0	0	0	0	0	0	0	0	0	1,627,402	
SMIB - LTC	2,760,557	0	0	0	0	0	0	0	0	0	0	0	2,760,557	
HIB - LTC	121,568	0	0	0	0	0	0	0	0	0	0	0	121,568	
	574,967,964	0	0	0	0	0	0	0	0	0	0	0	574,967,964	

TITLE XIX PROP 204

CAPITATION - ACUTE	165,540,913	0	0	0	0	0	0	0	0	0	0	0	165,540,913	
MENTAL HEALTH - CHILD	198,164	0	0	0	0	0	0	0	0	0	0	0	198,164	
MENTAL HEALTH - ADULT	12,147,475	0	0	0	0	0	0	0	0	0	0	0	12,147,475	
MENTAL HEALTH - GENERAL	17,754,588	0	0	0	0	0	0	0	0	0	0	0	17,754,588	
FEE FOR SERVICE - ACUTE	26,275,199	0	0	0	0	0	0	0	0	0	0	0	26,275,199	
FFS - PRIOR QUARTER COVERAGE	51,967	0	0	0	0	0	0	0	0	0	0	0	51,967	
EMERGENCY SERVICES - FEDERAL	2,558,131	0	0	0	0	0	0	0	0	0	0	0	2,558,131	
FFS MEDICAID IN PUBLIC SCHOOLS	5,265	0	0	0	0	0	0	0	0	0	0	0	5,265	
INPATIENT INMATES FFS	487,478	0	0	0	0	0	0	0	0	0	0	0	487,478	
PIMA COUNTY INMATES FFS	4,443	0	0	0	0	0	0	0	0	0	0	0	4,443	
PINAL COUNTY INMATES FFS	82,861	0	0	0	0	0	0	0	0	0	0	0	82,861	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending July 31, 2014

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE

TOTAL

SUBTOTAL

MARICOPA CTY INMATES FFS	13,089	0	0	0	0	0	0	0	0	0	0	0	13,089	
REINSURANCE - ACUTE	2,324,980	0	0	0	0	0	0	0	0	0	0	0	2,324,980	
SMIB - ACUTE	3,453,454	0	0	0	0	0	0	0	0	0	0	0	3,453,454	
HIB - ACUTE	2,806	0	0	0	0	0	0	0	0	0	0	0	2,806	
	230,900,813	0	0	0	0	0	0	0	0	0	0	0	230,900,813	

CAPITATION - ACUTE	12,619,971	0	0	0	0	0	0	0	0	0	0	0	12,619,971	
MENTAL HEALTH - ADULT	777,287	0	0	0	0	0	0	0	0	0	0	0	777,287	
MENTAL HEALTH - GENERAL	1,136,072	0	0	0	0	0	0	0	0	0	0	0	1,136,072	
FEE FOR SERVICE - ACUTE	1,065,235	0	0	0	0	0	0	0	0	0	0	0	1,065,235	
FFS - PRIOR QUARTER COVERAGE	8,502	0	0	0	0	0	0	0	0	0	0	0	8,502	
EMERGENCY SERVICES - FEDERAL	134,592	0	0	0	0	0	0	0	0	0	0	0	134,592	
REINSURANCE - ACUTE	22,287	0	0	0	0	0	0	0	0	0	0	0	22,287	
SMIB - ACUTE	1,259	0	0	0	0	0	0	0	0	0	0	0	1,259	
	15,765,205	0	0	0	0	0	0	0	0	0	0	0	15,765,205	
	821,633,982	0	0	0	0	0	0	0	0	0	0	0	821,633,982	

TITLE XIX ACA ADULT EXPANSION

SUBTOTAL

TOTAL TITLE XIX

TITLE XXI KIDSCARE

KidsCare - CAPITATION	317,922	0	0	0	0	0	0	0	0	0	0	0	317,922	
KidsCare - FEE FOR SERVICE	20,033	0	0	0	0	0	0	0	0	0	0	0	20,033	
KidsCare - MENTAL HEALTH	73,362	0	0	0	0	0	0	0	0	0	0	0	73,362	
KidsCare - REINSURANCE	-99,947	0	0	0	0	0	0	0	0	0	0	0	-99,947	

311,369	0	0	0	0	0	0	0	0	0	0	0	311,369	

TOTAL TITLE XXI

821,945,351	0	0	0	0	0	0	0	0	0	0	0	821,945,351	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1003	TANF 06-13 M & F WIT	217.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	217.11

1006	TANF 21-44 MALE WITH	28,781.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,781.97

1007	TANF 21-44 FEMALE WI	114,269.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	114,269.17

1008	TANF 45-64 M & F WIT	84,108.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,108.25

1009	TANF 65+ M & F WITH	21,484.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,484.01

100F	TANF 21-44 MALE WITH	1,342.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,342.88

100G	TANF 21-44 FEMALE WI	3,762.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,762.11

100H	TANF 44-64 M & F WIT	8,995.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,995.65

100J	TANF 65+ M & F WITH	1,372.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,372.61

1011	TANF <1 M & F NON-ME	6,944,671.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,944,671.01

1012	TANF 01-05 M & F NON	9,414,595.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,414,595.75

1013	TANF 06-13 M & F NON	14,757,003.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,757,003.85

1014	TANF 14-20 MALE NON-	4,095,717.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,095,717.18

1015	TANF 14-20 FEMALE N O

7,425,976.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,425,976.83

1016	TANF 21-44 MALE NON-	3,488,064.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,488,064.87

1017	TANF 21-44 FEMALE N O

21,669,669.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,669,669.50

1018	TANF 45-64 M & F NON	7,373,544.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,373,544.96

1019	TANF 65+ M & F NON-M	21,729.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,729.03

101A	TANF < 1 M & F NON-M	376,288.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	376,288.07

101B	TANF 01-05 M & F NON	187,236.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	187,236.57

101C	TANF 06-13 M & F NON	223,211.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223,211.63

101D	TANF 14-20 MALE NON-	138,442.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138,442.93

101E	TANF 14-20 FEMALE N O

244,533.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	244,533.70

101F	TANF 21-44 MALE NON-	562,829.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	562,829.25

101G	TANF 21-44 FEMALE N O

1,456,806.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,456,806.28

101H	TANF 44-64 M & F NON	1,442,455.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,442,455.59

101J	TANF 65+ N & F NON-M	10,089.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,089.16

1026	TANF 21-44 MALE WITH	165.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165.98

1027	TANF 21-44 FEMALE WI	6,723.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,723.14

1028	TANF 45-64 M & F WIT	2,004.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,004.87

1029	TANF 65+ M & F WITH	727.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	727.32

2100	SSI AGED WITH MEDIC A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R
211Z	SSI AGED NON-MEDICA
R

682,116.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	682,116.95

84,778.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,778.64

4,592,127.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,592,127.22

906,703.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	906,703.14

2120	SSI AGED WITH QMB	3,619,137.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,619,137.72

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

212Z	SSI AGED WITH QMB P P
2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M

39,895.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,895.21

1,620,418.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,620,418.47

61,688.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,688.36

54,178,004.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,178,004.81

1,411,266.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,411,266.35

10,511,923.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,511,923.37

8,859.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,859.10

2300	SSI BLIND WITH MEDIC	8,180.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,180.98

230Z	SSI BLIND WITH MEDIC	153.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	153.11

2310	SSI BLIND NON-MEDIC A
231Z	SSI BLIND NON-MEDIC
A

333,362.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	333,362.58

4,907.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,907.37

2320	SSI BLIND WITH QMB	38,091.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,091.63

4301	SOBRA CHILD <1 M & F	435.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	435.64

4302	SOBRA CHILD 01-05 M	790.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	790.45

4303	SOBRA CHILD 06-13 M	104.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.88

4305	SOBRA CHILD 14-20 FE	741.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	741.22

430B	SOBRA CHILD 01-05 M	311.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	311.15

4311	SOBRA CHILD <1 M & F     14,931,100.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,931,100.78

4312	SOBRA CHILD 01-05 M	11,567,920.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,567,920.84

4313	SOBRA CHILD 06-13 M	14,237,741.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,237,741.80

4314	SOBRA CHILD 14-20 MA	5,097,057.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,097,057.78

4315	SOBRA CHILD 14-20 FE	7,623,275.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,623,275.34

431A	SOBRA CHILD < 1 M &	1,214,271.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,214,271.08

431B	SOBRA CHILD 01-05 M	627,471.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	627,471.65

431C	SOBRA CHILD 6-13 M& F

674,986.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	674,986.02

431D	SOBRA CHILD 14-20 MA	640,855.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	640,855.23

431E	SOBRA CHILD 14-20 FE	720,865.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	720,865.32

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M

21,833.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,833.03

1,697.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,697.44

411.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.89

746,510.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	746,510.58

2,581,731.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,581,731.79

20,379.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,379.89

95,588.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95,588.48

302,251.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	302,251.20

3,747.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,747.04

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

5027	SOBRA PREG 21-44 FE M
5510	SOBRA FPS FEMALE W
IT

4,767.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,767.49

-25.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-25.48

SUBTOTAL:

219,325,258.77

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	219,325,258.77

9910	TANF & SOBRA CHILDR E

6,571,134.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,571,134.40

9920	SSI W/MEDICARE KICK	59,951.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,951.62

9921	SSI W/O MEDICARE KIC	255,183.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255,183.61

9950	S.O.B.R.A. KICK PAYM	11,246,691.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,246,691.84

SUBTOTAL:

18,132,961.47

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,132,961.47

241.69	
231,959.64	
817,292.87	
1,188,948.02	
307,783.65	
4,170.55	
10,493.01	
40,061.03	
22,286.04	
19,671.67	
92,317.79	
306,399.70	
210,348.15	
643,300.84	
4,155,213.87	
13,750,105.43	
7,883,333.47	
17,823.07	
3,069.23	
1,901.09	
5,213.11	
11,719.65	
38,981.20	
670,244.78	
1,430,871.86	
1,626,074.12	
8,192.11	

1105	TANF EXPANDED 14-20	241.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	231,959.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	817,292.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	1,188,948.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1109	TANF EXPANDED 65+ M&

307,783.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110F	TANF EXPANDED 21-44	4,170.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110G	TANF EXPANDED 21-44	10,493.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110H	TANF EXPANDED 45-64	40,061.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110J	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

22,286.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

19,671.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	92,317.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	306,399.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	210,348.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	643,300.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	4,155,213.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44     13,750,105.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	7,883,333.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&
111A	TANF EXPANDED <1 M
&F

17,823.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,069.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111B	TANF EXPANDED 01-05	1,901.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111C	TANF EXPANDED 06-13	5,213.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111D	TANF EXPANDED 14-20	11,719.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111E	TANF EXPANDED 14-20	38,981.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111F	TANF EXPANDED 21-44	670,244.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111G	TANF EXPANDED 21-44	1,430,871.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111H	TANF EXPANDED 45-64	1,626,074.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111J	TANF EXPANDED 65+ M&

8,192.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1126	TANF EXPANDED 21-44	13,124.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,124.22

1127	TANF EXPANDED 21-44	28,106.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,106.94

1128	TANF EXPANDED 45-64	65,711.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,711.50

1129	TANF EXPANDED 65+ M&

20,594.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,594.42

112F	TANF EXPANDED 21-44	104.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.01

112G	TANF EXPANDED 21-44	4,554.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,554.37

112H	TANF EXPANDED 45-64	10,330.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,330.63

112J	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
241Z	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
242Z	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
260Z	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
261Z	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E

13,364.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,364.24

124,966.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	124,966.70

44,875.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,875.33

996,608.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	996,608.43

167,945.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	167,945.16

4,944,165.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,944,165.87

44,737.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,737.03

2,055.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,055.56

693.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	693.76

336,773.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	336,773.78

37,212.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,212.73

2,136,559.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,136,559.39

148,355.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148,355.71

4,542,694.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,542,694.09

10,508.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,508.92

SUBTOTAL:

47,192,060.43

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,192,060.43

9911	SB PAYMENT FOR TAN F
9922	SB PAYMENT FOR SSI
E

428,501.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	428,501.25

6,120.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,120.18

SUBTOTAL:

434,621.43

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	434,621.43

2

SUBTOTAL:

3614	AHC CARE/MI MALE 14-	-2,598.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,598.60	
3617	AHC CARE/MI FEMALE	389.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		389.72	
3618	AHC CARE/MI M&F 45-6	461.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		461.59	
361D	AHC CARE/MI MALE 14-	5,868.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,868.03	
361F	AHC CARE/MI MALE 21-	1,336.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,336.72	
	5,457.46	0.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,457.46	

3506	ADULT 40-100% MALE 2	33,464.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL	16,601.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	157,124.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

33,464.06

16,601.36
E
157,124.31

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3509	ADULT 40-100% M&F 65	32,520.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,520.39

350F	ADULT 40-100% MALE 2	16,508.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,508.10

350G	ADULT 40-100% FEMAL E

7,648.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,648.32

350H	ADULT 40-100% M&F 45	43,819.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,819.25

350J	ADULT 40-100% M&F 65	23,188.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,188.63

3514	ADULT 40-100% MALE 1	819,832.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	819,832.68

3515	ADULT 40-100% FEMAL E

1,084,483.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,084,483.92

3516	ADULT 40-100% MALE 2	5,172,698.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,172,698.34

3517	ADULT 40-100% FEMAL E

4,973,808.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,973,808.19

3518	ADULT 40-100% M&F 45    11,051,769.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,051,769.49

3519	ADULT 40-100% M&F 65	5,684.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,684.54

351D	ADULT 40-100% MALE 1	203,430.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	203,430.24

351E	ADULT 40-100% FEMAL E

270,798.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270,798.34

351F	ADULT 40-100% MALE 2	1,898,001.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,898,001.29

351G	ADULT 40-100% FEMAL E

1,700,470.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,700,470.56

351H	ADULT 40-100% M&F 45	4,854,065.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,854,065.54

351J	ADULT 40-100% M&F 65	73,691.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,691.23

3526	ADULT 40-100% MALE 2	840.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	840.56

3527	ADULT 40-100% FEMAL E

4,533.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,533.45

3528	ADULT 40-100% M&F 45	10,351.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,351.94

3529	ADULT 40-100% M&F 65	2,418.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,418.24

352F	ADULT 40-100% MALE 2	727.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	727.05

352H	ADULT 40-100% M&F 45	8,252.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,252.49

3704	ADULT <40% EXP MALE	358.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	358.14

3705	ADULT <40% EXP FEM AL

863.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	863.92

3706	ADULT <40% EXP MALE	66,342.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,342.05

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
370E	ADULT <40% EXP FEM
AL

27,895.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,895.47

151,258.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151,258.01

21,725.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,725.98

44.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44.06

370F	ADULT <40% EXP MALE	9,711.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,711.72

370G	ADULT <40% EXP FEM AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6

14,796.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,796.79

27,786.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,786.44

8,590.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,590.58

3714	ADULT <40% EXP MALE	4,660,701.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,660,701.72

3715	ADULT <40% EXP FEM AL

4,120,603.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,120,603.82

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3716	ADULT <40% EXP MALE    20,467,726.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,467,726.18

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6

13,101,290.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,101,290.86

26,828,359.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,828,359.99

17,618.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,618.55

371D	ADULT <40% EXP MALE	718,104.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	718,104.76

371E	ADULT <40% EXP FEM AL

677,187.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	677,187.15

371F	ADULT <40% EXP MALE	4,492,505.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,492,505.58

371G	ADULT <40% EXP FEM AL
371H	ADULT <40% EXP M&F
4
371J	ADULT <40% EXP M&F
6

3,159,846.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,159,846.04

6,497,274.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,497,274.23

46,866.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,866.80

3726	ADULT <40% EXP MALE	4,479.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,479.71

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
372H	ADULT <40% EXP M&F
4

1,735.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,735.34

4,216.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,216.78

2,534.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,534.24

SUBTOTAL:

117,597,157.42

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	117,597,157.42

9935	BIRTH SUPP PAYMENT A
9937	BIRTH SUPP PAYMENT
A

98,220.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,220.75

213,395.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	213,395.97

SUBTOTAL:

311,616.72

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	311,616.72

33,568.79	
26,377.26	
230,110.61	
23,148.00	
14,499.62	
2,569.58	
42,268.26	
12,169.94	
186,825.37	
218,329.41	
1,622,407.81	
1,523,387.26	
3,915,892.06	
3,917.22	
46,326.46	
55,613.58	
857,867.49	

3906	NEWLY ELIGIBLE MALE	33,568.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

26,377.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

230,110.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

23,148.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390F	NEWLY ELIGIBLE MALE	14,499.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390G	NEWLY ELIGIBLE FEMA L
390H	NEWLY ELIGIBLE M&F
4
390J	NEWLY ELIGIBLE M&F
6

2,569.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

42,268.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

12,169.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	186,825.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

218,329.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	1,622,407.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

1,523,387.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,915,892.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,917.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391D	NEWLY ELIGIBLE MALE	46,326.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391E	NEWLY ELIGIBLE FEMA L

55,613.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391F	NEWLY ELIGIBLE MALE	857,867.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

391G	NEWLY ELIGIBLE FEMA L
391H	NEWLY ELIGIBLE M&F
4
391J	NEWLY ELIGIBLE M&F
6

994,884.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	994,884.35

2,753,614.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,753,614.91

22,569.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,569.38

3926	NEWLY ELIGIBLE MALE	252.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	252.25

3928	NEWLY ELIGIBLE M&F
4
3929	NEWLY ELIGIBLE M&F
6
392H	NEWLY ELIGIBLE M&F
4

1,894.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,894.48

329.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	329.92

912.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	912.30

SUBTOTAL:

12,589,736.31

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,589,736.31

N
SUBTOTAL:

9939	BIRTH SUPP PAYMENT	30,234.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,234.40	
	30,234.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,234.40	

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

15,750.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,750.99

2,852,910.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,852,910.73

4414	SOBRA 100-133% MALE	1,102,921.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,102,921.39

4415	SOBRA 100-133% FEMA L
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

1,582,957.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,582,957.43

210.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	210.49

145,537.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,537.73

441D	SOBRA 100-133% MALE	179,041.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	179,041.42

441E	SOBRA 100-133% FEMA L

208,772.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	208,772.31

SUBTOTAL:

6,088,102.49

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,088,102.49

S
SUBTOTAL:

9944	BIRTH SUPP PAYMENT	35,479.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,479.33	
	35,479.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,479.33	

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
451H	BC PATIENT FEMALE 4
5
451J	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5
461G	CC PATIENT FEMALE 2
1
461H	CC PATIENT FEMALE 4
5

8,839.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,839.74

119,472.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119,472.32

1,473.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,473.25

448.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	448.89

88.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88.11

8,119.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,119.40

7,425.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,425.15

1,050.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,050.37

724.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	724.76

SUBTOTAL:

147,641.99

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	147,641.99

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M

111.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111.47

1,244,519.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,244,519.95

6,724.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,724.26

ACUTE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

8710	SSI DISABLED FREEDO M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

177,605.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	177,605.31

18,701.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,701.90

142,004.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,004.63

1,299.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,299.02

SUBTOTAL:

1,590,966.54

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,590,966.54

423,481,294.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	423,481,294.76	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1003	TANF 06-13 M & F WIT	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

1006	TANF 21-44 MALE WITH	104.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.67

1007	TANF 21-44 FEMALE WI	235.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	235.10

1008	TANF 45-64 M & F WIT	172.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	172.61

1009	TANF 65+ M & F WITH	55.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55.09

100F	TANF 21-44 MALE WITH	8.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.20

100G	TANF 21-44 FEMALE WI	19.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.62

100H	TANF 44-64 M & F WIT	22.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.13

100J	TANF 65+ M & F WITH	3.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.89

1011	TANF <1 M & F NON-ME	15,270.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,270.56

1012	TANF 01-05 M & F NON	84,569.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,569.28

1013	TANF 06-13 M & F NON	132,621.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132,621.53

1014	TANF 14-20 MALE NON-	25,621.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,621.38

1015	TANF 14-20 FEMALE N O

30,629.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,629.14

1016	TANF 21-44 MALE NON-	22,587.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,587.19

1017	TANF 21-44 FEMALE N O

89,032.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,032.05

1018	TANF 45-64 M & F NON	18,333.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,333.22

1019	TANF 65+ M & F NON-M	51.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.35

101A	TANF < 1 M & F NON-M	356.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	356.79

101B	TANF 01-05 M & F NON	3,295.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,295.48

101C	TANF 06-13 M & F NON	3,920.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,920.74

101D	TANF 14-20 MALE NON-	836.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	836.55

101E	TANF 14-20 FEMALE N O

1,255.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,255.72

101F	TANF 21-44 MALE NON-	3,415.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,415.15

101G	TANF 21-44 FEMALE N O

7,513.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,513.72

101H	TANF 44-64 M & F NON	3,472.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,472.14

101J	TANF 65+ N & F NON-M	25.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.59

1026	TANF 21-44 MALE WITH	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

1027	TANF 21-44 FEMALE WI	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00

1028	TANF 45-64 M & F WIT	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

1029	TANF 65+ M & F WITH	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

2100	SSI AGED WITH MEDIC A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R
211Z	SSI AGED NON-MEDICA
R

4,370.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,370.68

902.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	902.84

6,138.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,138.76

1,881.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,881.26

2120	SSI AGED WITH QMB	21,139.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,139.27

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

212Z	SSI AGED WITH QMB P P
2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M

435.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	435.63

4,292.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,292.08

659.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	659.56

58,085.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,085.69

3,034.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,034.88

25,240.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,240.50

97.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97.75

2300	SSI BLIND WITH MEDIC	32.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32.48

230Z	SSI BLIND WITH MEDIC	1.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.51

2310	SSI BLIND NON-MEDIC A
231Z	SSI BLIND NON-MEDIC
A

427.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.53

9.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.31

2320	SSI BLIND WITH QMB	204.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	204.14

4301	SOBRA CHILD <1 M & F	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

4302	SOBRA CHILD 01-05 M	1.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.51

4303	SOBRA CHILD 06-13 M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

4305	SOBRA CHILD 14-20 FE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

430B	SOBRA CHILD 01-05 M	5.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.48

4311	SOBRA CHILD <1 M & F	32,941.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,941.40

4312	SOBRA CHILD 01-05 M	99,019.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,019.99

4313	SOBRA CHILD 06-13 M	122,544.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,544.94

4314	SOBRA CHILD 14-20 MA	31,558.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,558.09

4315	SOBRA CHILD 14-20 FE	31,209.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,209.97

431A	SOBRA CHILD < 1 M &	1,170.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,170.89

431B	SOBRA CHILD 01-05 M	10,635.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,635.96

431C	SOBRA CHILD 6-13 M& F

11,649.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,649.29

431D	SOBRA CHILD 14-20 MA	3,814.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,814.47

431E	SOBRA CHILD 14-20 FE	3,680.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,680.89

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M

50.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50.81

4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

2.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.15

3,195.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,195.16

11,094.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,094.84

51.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.43

491.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	491.51

1,552.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,552.87

8.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.54

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

5027	SOBRA PREG 21-44 FE M
5510	SOBRA FPS FEMALE W
IT

5.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.99

-2.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-2.03

SUBTOTAL:

935,093.91

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	935,093.91

9910	TANF & SOBRA CHILDR E

1,113.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,113.00

9920	SSI W/MEDICARE KICK	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00

9921	SSI W/O MEDICARE KIC	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43.00

9950	S.O.B.R.A. KICK PAYM	1,908.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,908.00

SUBTOTAL:

3,074.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,074.00

1.00	
783.81	
1,727.78	
2,418.15	
761.60	
23.58	
53.63	
95.35	
55.56	
41.95	
844.18	
2,726.58	
1,344.20	
2,712.20	
27,812.41	
58,482.54	
19,991.08	
45.63	
2.76	
33.43	
91.68	
70.38	
198.05	
4,073.04	
7,379.68	
4,005.87	
21.28	

1105	TANF EXPANDED 14-20	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	783.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	1,727.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	2,418.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1109	TANF EXPANDED 65+ M&

761.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110F	TANF EXPANDED 21-44	23.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110G	TANF EXPANDED 21-44	53.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110H	TANF EXPANDED 45-64	95.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110J	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

55.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

41.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	844.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	2,726.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	1,344.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	2,712.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	27,812.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	58,482.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	19,991.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&
111A	TANF EXPANDED <1 M
&F

45.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111B	TANF EXPANDED 01-05	33.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111C	TANF EXPANDED 06-13	91.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111D	TANF EXPANDED 14-20	70.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111E	TANF EXPANDED 14-20	198.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111F	TANF EXPANDED 21-44	4,073.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111G	TANF EXPANDED 21-44	7,379.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111H	TANF EXPANDED 45-64	4,005.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111J	TANF EXPANDED 65+ M&

21.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1126	TANF EXPANDED 21-44	32.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32.93

1127	TANF EXPANDED 21-44	64.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.65

1128	TANF EXPANDED 45-64	125.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125.92

1129	TANF EXPANDED 65+ M&

49.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.26

112F	TANF EXPANDED 21-44	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.64

112G	TANF EXPANDED 21-44	23.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.31

112H	TANF EXPANDED 45-64	23.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.98

112J	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
241Z	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
242Z	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
260Z	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
261Z	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E

32.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32.48

581.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	581.54

491.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	491.82

1,309.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,309.52

347.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	347.68

21,506.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,506.00

487.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487.45

3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00

5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

603.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	603.87

395.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	395.75

1,730.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,730.47

315.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	315.29

9,091.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,091.72

113.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	113.19

SUBTOTAL:

173,132.87

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	173,132.87

9911	SB PAYMENT FOR TAN F
9922	SB PAYMENT FOR SSI
E

72.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72.00

1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

SUBTOTAL:

73.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73.00

2

SUBTOTAL:

3614	AHC CARE/MI MALE 14-	-6.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6.73	
3617	AHC CARE/MI FEMALE	0.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.96	
3618	AHC CARE/MI M&F 45-6	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00	
361D	AHC CARE/MI MALE 14-	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00	
361F	AHC CARE/MI MALE 21-	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00	
	5.23	0.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.23	

3506	ADULT 40-100% MALE 2	59.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL	35.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	348.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

59.62

35.66
E
348.51

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3509	ADULT 40-100% M&F 65	76.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.14

350F	ADULT 40-100% MALE 2	26.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.33

350G	ADULT 40-100% FEMAL E

11.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.30

350H	ADULT 40-100% M&F 45	65.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65.04

350J	ADULT 40-100% M&F 65	34.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.02

3514	ADULT 40-100% MALE 1	1,984.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,984.67

3515	ADULT 40-100% FEMAL E

2,614.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,614.51

3516	ADULT 40-100% MALE 2	12,714.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,714.59

3517	ADULT 40-100% FEMAL E

12,070.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,070.40

3518	ADULT 40-100% M&F 45	27,169.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,169.50

3519	ADULT 40-100% M&F 65	14.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.04

351D	ADULT 40-100% MALE 1	313.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	313.78

351E	ADULT 40-100% FEMAL E

403.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	403.56

351F	ADULT 40-100% MALE 2	2,859.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,859.91

351G	ADULT 40-100% FEMAL E

2,581.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,581.00

351H	ADULT 40-100% M&F 45	7,211.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,211.46

351J	ADULT 40-100% M&F 65	108.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108.10

3526	ADULT 40-100% MALE 2	1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.93

3527	ADULT 40-100% FEMAL E

6.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.45

3528	ADULT 40-100% M&F 45	26.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.71

3529	ADULT 40-100% M&F 65	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

352F	ADULT 40-100% MALE 2	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.06

352H	ADULT 40-100% M&F 45	12.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.24

3704	ADULT <40% EXP MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

3705	ADULT <40% EXP FEM AL

1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.93

3706	ADULT <40% EXP MALE	103.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103.25

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
370E	ADULT <40% EXP FEM
AL

48.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48.48

283.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	283.95

56.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.31

0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.06

370F	ADULT <40% EXP MALE	14.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.26

370G	ADULT <40% EXP FEM AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6

21.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.77

42.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.46

12.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.45

3714	ADULT <40% EXP MALE	11,007.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,007.76

3715	ADULT <40% EXP FEM AL

9,706.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,706.11

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3716	ADULT <40% EXP MALE	48,059.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,059.07

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6

30,195.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,195.28

63,522.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,522.48

44.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44.36

371D	ADULT <40% EXP MALE	1,088.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,088.95

371E	ADULT <40% EXP FEM AL

1,021.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,021.43

371F	ADULT <40% EXP MALE	6,765.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,765.74

371G	ADULT <40% EXP FEM AL
371H	ADULT <40% EXP M&F
4
371J	ADULT <40% EXP M&F
6

4,743.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,743.81

9,643.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,643.66

66.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66.80

3726	ADULT <40% EXP MALE	3.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.54

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
372H	ADULT <40% EXP M&F
4

1.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.54

10.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.28

3.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.70

SUBTOTAL:

257,226.96

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	257,226.96

9935	BIRTH SUPP PAYMENT A
9937	BIRTH SUPP PAYMENT
A

17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.00

36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36.00

SUBTOTAL:

53.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.00

62.36	
36.64	
583.32	
71.12	
42.44	
9.32	
131.86	
35.81	
622.70	
704.17	
5,431.26	
5,051.42	
13,011.73	
12.97	
139.88	
161.43	
2,612.58	

3906	NEWLY ELIGIBLE MALE	62.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

36.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

583.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

71.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390F	NEWLY ELIGIBLE MALE	42.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390G	NEWLY ELIGIBLE FEMA L
390H	NEWLY ELIGIBLE M&F
4
390J	NEWLY ELIGIBLE M&F
6

9.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

131.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

35.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	622.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

704.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	5,431.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

5,051.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

13,011.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

12.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391D	NEWLY ELIGIBLE MALE	139.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391E	NEWLY ELIGIBLE FEMA L

161.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391F	NEWLY ELIGIBLE MALE	2,612.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

391G	NEWLY ELIGIBLE FEMA L
391H	NEWLY ELIGIBLE M&F
4
391J	NEWLY ELIGIBLE M&F
6

3,026.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,026.68

8,327.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,327.51

68.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68.94

3926	NEWLY ELIGIBLE MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

3928	NEWLY ELIGIBLE M&F
4
3929	NEWLY ELIGIBLE M&F
6
392H	NEWLY ELIGIBLE M&F
4

6.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.28

1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

2.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.70

SUBTOTAL:

40,155.12

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,155.12

N
SUBTOTAL:

9939	BIRTH SUPP PAYMENT	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00	
	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

128.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	128.25

18,951.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,951.90

4414	SOBRA 100-133% MALE	6,066.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,066.89

4415	SOBRA 100-133% FEMA L
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

5,923.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,923.23

3.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.70

2,589.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,589.88

441D	SOBRA 100-133% MALE	1,092.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,092.57

441E	SOBRA 100-133% FEMA L

1,079.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,079.50

SUBTOTAL:

35,835.92

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,835.92

S
SUBTOTAL:

9944	BIRTH SUPP PAYMENT	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00	
	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
451H	BC PATIENT FEMALE 4
5
451J	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5
461G	CC PATIENT FEMALE 2
1
461H	CC PATIENT FEMALE 4
5

38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38.00

288.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	288.12

3.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.78

1.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.32

0.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.18

25.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.51

18.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.73

5.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.48

2.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.32

SUBTOTAL:

383.44

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	383.44

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M

1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

1,318.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,318.39

70.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.71

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

8710	SSI DISABLED FREEDO M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

176.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	176.19

38.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38.70

175.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	175.01

16.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.33

SUBTOTAL:

1,796.33

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,796.33

TOTAL:	1,446,840.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,446,840.78		

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	9,640.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,640.51

1010	TANF NON-MEDICARE	2,119,642.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,119,642.85

1020	TANF WITH QMB	6,677.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,677.94

2100	SSI AGED WITH MEDIC A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R
211Z	SSI AGED NON-MEDICA
R

30,836,613.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,836,613.84

615,597.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	615,597.94

2,604,038.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,604,038.91

19,614.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,614.65

2120	SSI AGED WITH QMB	17,350,133.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,350,133.73

212Z	SSI AGED WITH QMB P P
2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M

12,889.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,889.07

13,837,679.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,837,679.72

82,279.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82,279.18

84,294,536.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,294,536.39

31,789.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,789.29

19,966,282.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,966,282.88

1,541.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,541.29

2300	SSI BLIND WITH MEDIC	69,541.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,541.93

2310	SSI BLIND NON-MEDIC A

478,057.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	478,057.14

2320	SSI BLIND WITH QMB	126,705.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,705.55

SUBTOTAL:

172,463,262.81

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	172,463,262.81

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

67,556.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,556.86

101,819.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,819.57

3,309.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,309.31

16,243.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,243.89

SUBTOTAL:

188,929.63

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	188,929.63

172,652,192.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	172,652,192.44	

TOTAL:

LONG TERM CARE MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00

1010	TANF NON-MEDICARE	633.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	633.10

1020	TANF WITH QMB	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

2100	SSI AGED WITH MEDIC A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R
211Z	SSI AGED NON-MEDICA
R

11,510.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,510.64

680.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	680.99

604.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	604.41

22.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.69

2120	SSI AGED WITH QMB	6,956.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,956.11

212Z	SSI AGED WITH QMB P P
2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M

14.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.44

4,675.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,675.34

91.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91.28

24,410.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,410.73

34.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.40

6,545.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,545.92

1.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.70

2300	SSI BLIND WITH MEDIC	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.00

2310	SSI BLIND NON-MEDIC A

137.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	137.93

2320	SSI BLIND WITH QMB	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00

SUBTOTAL:

56,388.68

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,388.68

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.00

23.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.32

3.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.67

6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

SUBTOTAL:

54.99

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.99

TOTAL:	56,443.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,443.67		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	74.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74.40

1010	TANF NON-MEDICARE	10,900,567.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,900,567.20

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

37.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37.20

434,533.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	434,533.20

297.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	297.60

1,450.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,450.80

74.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74.40

10,572,984.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,572,984.00

12,648.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,648.00

SUBTOTAL:

21,922,666.80

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,922,666.80

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

198,090.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	198,090.00

74.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74.40

SUBTOTAL:

198,164.40

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	198,164.40

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,017,829.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,017,829.20	
	1,017,829.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,017,829.20	

23,138,660.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,138,660.40	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

1010	TANF NON-MEDICARE	293,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	293,026.00

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

11,681.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,681.00

8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39.00

2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

284,220.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	284,220.00

340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	340.00

SUBTOTAL:

589,319.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	589,319.00

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

5,325.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,325.00

2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

4410	SOBRA 100-133% FOR	27,361.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,361.00	
	27,361.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,361.00	

SUBTOTAL:

5,327.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,327.00

F
SUBTOTAL:

TOTAL:	622,007.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	622,007.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	17,922.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,922.18

1010	TANF NON-MEDICARE	4,703,200.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,703,200.98

1020	TANF WITH QMB	510.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	510.24

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

146,311.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,311.32

188,884.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	188,884.47

2120	SSI AGED WITH QMB	716,823.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	716,823.42

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

146,279.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,279.43

1,335,648.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,335,648.87

798,079.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	798,079.14

2300	SSI BLIND WITH MEDIC	1,148.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,148.04

2310	SSI BLIND NON-MEDIC A

13,648.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,648.92

2320	SSI BLIND WITH QMB	7,908.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,908.72

4310	SOBRA CHILD NON-ME DI
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

619,718.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	619,718.37

1,626.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,626.39

437,658.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	437,658.36

159.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	159.45

SUBTOTAL:

9,135,528.30

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,135,528.30

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

178,520.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178,520.22

3,547,634.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,547,634.94

8,291.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,291.40

16,837.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,837.92

40,277.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,277.07

693,639.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	693,639.39

95.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95.67

159.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	159.45

13,840.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,840.26

40,946.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,946.76

257,447.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	257,447.97

3610	AHC CARE EXPANDED	127.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.56	
	127.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127.56	

SUBTOTAL:

4,797,691.05

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,797,691.05

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	16,327.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	1,775,730.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	1,275.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR	15,083.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,327.68	
1,775,730.87	
1,275.60	
15,083.97	

F

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3710	AHC CARE EXPANDED FO
3720	AHC CARE EXPANDED
FO

5,540,791.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,540,791.83

446.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	446.46

SUBTOTAL:

7,349,656.41

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,349,656.41

3900	NEWLY ELIGIBLE FOR F
3910	NEWLY ELIGIBLE FOR
F
3920	NEWLY ELIGIBLE FOR
F

23,215.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

23,215.92	
753,847.71	
223.23	
777,286.86	

753,847.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

223.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4410	SOBRA 100-133% FOR	62,918.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,918.97	
	62,918.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	62,918.97	

SUBTOTAL:

777,286.86

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00

F
SUBTOTAL:

4510	BC PATIENT FOR FINA N
4610	CC PATIENT FOR FINA
N

10,236.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,236.69

1,466.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,466.94

SUBTOTAL:

11,703.63

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,703.63

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

31.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31.89

27,393.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,393.51

4,655.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,655.94

3,890.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,890.58

SUBTOTAL:

35,971.92

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,971.92

22,170,884.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,170,884.70	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	562.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	562.00

1010	TANF NON-MEDICARE	147,482.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	147,482.00

1020	TANF WITH QMB	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

4,588.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,588.00

5,923.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,923.00

2120	SSI AGED WITH QMB	22,478.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,478.00

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

4,587.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,587.00

41,883.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,883.00

25,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,026.00

2300	SSI BLIND WITH MEDIC	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36.00

2310	SSI BLIND NON-MEDIC A

428.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	428.00

2320	SSI BLIND WITH QMB	248.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.00

4310	SOBRA CHILD NON-ME DI
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

19,433.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,433.00

51.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.00

13,724.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,724.00

5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

SUBTOTAL:

286,470.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	286,470.00

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

5,598.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,598.00

111,246.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111,246.00

260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	260.00

528.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	528.00

1,263.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,263.00

21,751.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,751.00

3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00

5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

434.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	434.00

1,284.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,284.00

8,073.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,073.00

3610	AHC CARE EXPANDED	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00	
	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	

SUBTOTAL:

150,445.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	150,445.00

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	512.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	55,683.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR	473.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

512.00	
55,683.00	
40.00	
473.00	

F

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3710	AHC CARE EXPANDED FO
3720	AHC CARE EXPANDED
FO

173,747.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	173,747.00

14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00

SUBTOTAL:

230,469.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	230,469.00

3900	NEWLY ELIGIBLE FOR F
3910	NEWLY ELIGIBLE FOR
F
3920	NEWLY ELIGIBLE FOR
F

728.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

728.00	
23,639.00	
7.00	
24,374.00	

23,639.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4410	SOBRA 100-133% FOR	1,973.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,973.00	
	1,973.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,973.00	

SUBTOTAL:

24,374.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00

F
SUBTOTAL:

4510	BC PATIENT FOR FINA N
4610	CC PATIENT FOR FINA
N

321.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	321.00

46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.00

SUBTOTAL:

367.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	367.00

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

859.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	859.00

146.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146.00

122.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122.00

SUBTOTAL:

1,128.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,128.00

TOTAL:	695,230.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	695,230.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	26,194.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,194.82

1010	TANF NON-MEDICARE	6,874,136.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,874,136.02

1020	TANF WITH QMB	745.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	745.76

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

213,846.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	213,846.68

276,071.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	276,071.03

2120	SSI AGED WITH QMB	1,047,699.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,047,699.58

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

213,800.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	213,800.07

1,952,166.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,952,166.63

1,166,461.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,166,461.86

2300	SSI BLIND WITH MEDIC	1,677.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,677.96

2310	SSI BLIND NON-MEDIC A

19,949.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,949.08

2320	SSI BLIND WITH QMB	11,559.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,559.28

4310	SOBRA CHILD NON-ME DI
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

905,772.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	905,772.13

2,377.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,377.11

639,675.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	639,675.64

233.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	233.05

SUBTOTAL:

13,352,366.70

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,352,366.70

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

260,922.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	260,922.78

5,185,176.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,185,176.06

12,118.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,118.60

24,610.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,610.08

58,868.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,868.43

1,013,814.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,013,814.11

139.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139.83

233.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	233.05

20,228.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,228.74

59,847.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,847.24

376,282.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	376,282.53

3610	AHC CARE EXPANDED	186.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186.44	
	186.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	186.44	

SUBTOTAL:

7,012,241.45

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,012,241.45

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	23,864.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	2,595,384.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	1,864.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR	22,046.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

23,864.32	
2,595,384.63	
1,864.40	
22,046.53	

F

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3710	AHC CARE EXPANDED FO
3720	AHC CARE EXPANDED
FO

8,098,347.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,098,347.67

652.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	652.54

SUBTOTAL:

10,742,160.09

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,742,160.09

3900	NEWLY ELIGIBLE FOR F
3910	NEWLY ELIGIBLE FOR
F
3920	NEWLY ELIGIBLE FOR
F

33,932.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

33,932.08	
1,101,813.79	
326.27	
1,136,072.14	

1,101,813.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

326.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4410	SOBRA 100-133% FOR	91,961.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,961.53	
	91,961.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91,961.53	

SUBTOTAL:

1,136,072.14

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00

F
SUBTOTAL:

4510	BC PATIENT FOR FINA N
4610	CC PATIENT FOR FINA
N

14,961.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,961.81

2,144.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,144.06

SUBTOTAL:

17,105.87

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,105.87

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

46.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.61

40,037.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,037.99

6,805.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,805.06

5,686.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,686.42

SUBTOTAL:

52,576.08

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,576.08

32,404,670.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,404,670.30	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	562.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	562.00

1010	TANF NON-MEDICARE	147,482.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	147,482.00

1020	TANF WITH QMB	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

4,588.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,588.00

5,923.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,923.00

2120	SSI AGED WITH QMB	22,478.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,478.00

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

4,587.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,587.00

41,883.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,883.00

25,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,026.00

2300	SSI BLIND WITH MEDIC	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36.00

2310	SSI BLIND NON-MEDIC A

428.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	428.00

2320	SSI BLIND WITH QMB	248.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.00

4310	SOBRA CHILD NON-ME DI
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

19,433.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,433.00

51.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.00

13,724.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,724.00

5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

SUBTOTAL:

286,470.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	286,470.00

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

5,598.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,598.00

111,246.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111,246.00

260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	260.00

528.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	528.00

1,263.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,263.00

21,751.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,751.00

3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00

5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

434.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	434.00

1,284.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,284.00

8,073.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,073.00

3610	AHC CARE EXPANDED	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00	
	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	

SUBTOTAL:

150,445.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	150,445.00

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	512.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	55,683.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR	473.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

512.00	
55,683.00	
40.00	
473.00	

F

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3710	AHC CARE EXPANDED FO
3720	AHC CARE EXPANDED
FO

173,747.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	173,747.00

14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00

SUBTOTAL:

230,469.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	230,469.00

3900	NEWLY ELIGIBLE FOR F
3910	NEWLY ELIGIBLE FOR
F
3920	NEWLY ELIGIBLE FOR
F

728.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

728.00	
23,639.00	
7.00	
24,374.00	

23,639.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4410	SOBRA 100-133% FOR	1,973.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,973.00	
	1,973.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,973.00	

SUBTOTAL:

24,374.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00

F
SUBTOTAL:

4510	BC PATIENT FOR FINA N
4610	CC PATIENT FOR FINA
N

321.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	321.00

46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.00

SUBTOTAL:

367.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	367.00

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

859.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	859.00

146.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146.00

122.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122.00

SUBTOTAL:

1,128.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,128.00

TOTAL:	695,230.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	695,230.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	2,089,074.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,089,074.52

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

403,827.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	403,827.58

1,128.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,128.01

14,048,236.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,048,236.54

18,048.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,048.16

SUBTOTAL:

16,560,314.81

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,560,314.81

15,792.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,792.14	
15,792.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,792.14	

4410	SOBRA 100-133% FOR F
SUBTOTAL:

16,576,106.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,576,106.95	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	1,852.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,852.00

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

358.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	358.00

1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

12,454.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,454.00

16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

SUBTOTAL:

14,681.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,681.00

14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00	
14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00	

4410	SOBRA 100-133% FOR F
SUBTOTAL:

TOTAL:	14,695.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,695.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1006	TANF 21-44 MALE WITH	21,876.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,876.52

1007	TANF 21-44 FEMALE WI	23,137.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,137.76

1008	TANF 45-64 M & F WIT	23,169.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,169.55

1009	TANF 65+ M & F WITH	3,332.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,332.06

1011	TANF <1 M & F NON-ME	2,087,574.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,087,574.20

1012	TANF 01-05 M & F NON	2,916,068.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,916,068.11

1013	TANF 06-13 M & F NON	4,199,876.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,199,876.85

1014	TANF 14-20 MALE NON-	1,022,564.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,022,564.58

1015	TANF 14-20 FEMALE N O

1,309,250.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,309,250.39

1016	TANF 21-44 MALE NON-	1,650,221.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,650,221.45

1017	TANF 21-44 FEMALE N O

7,591,183.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,591,183.72

1018	TANF 45-64 M & F NON	2,302,643.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,302,643.98

1019	TANF 65+ M & F NON-M	3,798.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,798.00

1027	TANF 21-44 FEMALE WI	4,573.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,573.78

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

112,069.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	112,069.05

179,464.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	179,464.34

2120	SSI AGED WITH QMB	504,498.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	504,498.36

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

423,542.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	423,542.79

9,192,572.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,192,572.30

1,557,854.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,557,854.20

2300	SSI BLIND WITH MEDIC	2,028.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,028.97

2310	SSI BLIND NON-MEDIC A

119,577.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119,577.24

2320	SSI BLIND WITH QMB	22,834.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,834.90

4311	SOBRA CHILD <1 M & F	2,402,981.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,402,981.11

4312	SOBRA CHILD 01-05 M	1,602,715.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,602,715.67

4313	SOBRA CHILD 06-13 M	2,128,396.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,128,396.32

4314	SOBRA CHILD 14-20 MA	931,900.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	931,900.37

4315	SOBRA CHILD 14-20 FE	1,397,957.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,397,957.59

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT

1,945.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,945.85

485,491.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	485,491.24

1,579,257.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,579,257.75

-16,663.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-16,663.69

2,970.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,970.00

SUBTOTAL:

45,790,665.31

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,790,665.31

1106	TANF EXPANDED 21-44	27,367.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,367.94

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1107	TANF EXPANDED 21-44	44,839.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,839.69

1108	TANF EXPANDED 45-64	101,282.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,282.81

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

28,221.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,221.65

390.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	390.77

1112	TANF EXPANDED 01-05	13,437.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,437.17

1113	TANF EXPANDED 06-13	57,770.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,770.47

1114	TANF EXPANDED 14-20	24,761.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,761.78

1115	TANF EXPANDED 14-20	57,511.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,511.45

1116	TANF EXPANDED 21-44	796,257.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	796,257.60

1117	TANF EXPANDED 21-44	1,959,110.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,959,110.73

1118	TANF EXPANDED 45-64	1,137,517.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,137,517.50

1119	TANF EXPANDED 65+ M&

2,554.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,554.51

1127	TANF EXPANDED 21-44	151.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151.39

1128	TANF EXPANDED 45-64	9,482.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,482.43

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

5,633.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,633.26

21,197.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,197.10

147,386.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	147,386.35

470,852.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	470,852.93

-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-330.00

13,130.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,130.91

107,386.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,386.52

231,908.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	231,908.23

SUBTOTAL:

5,257,823.19

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,257,823.19

4,102.58	
793.70	
11,478.24	
16,374.52	

4

00

3316	AHC CARE MALE 21-44	4,102.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	793.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	11,478.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,374.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

-23.88	
41.99	
2,501.53	
10,196.42	
7,211.81	
20,576.90	
-6,005.41	
103,003.33	

3400	MED ELIGIBILITY W/ M	-23.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3607	AHC CARE/MI FEMALE
2

41.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3608	AHC CARE/MI M&F 45-6	2,501.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3614	AHC CARE/MI MALE 14-	10,196.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3615	AHC CARE/MI FEMALE
1

7,211.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3616	AHC CARE/MI MALE 21-	20,576.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

-6,005.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3618	AHC CARE/MI M&F 45-6	103,003.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	137,502.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	137,502.69		

3506	ADULT 40-100% MALE 2	684.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	684.00

3508	ADULT 40-100% M&F 45	22,526.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,526.34

3509	ADULT 40-100% M&F 65	7,038.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,038.51

3514	ADULT 40-100% MALE 1	12,687.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,687.18

3515	ADULT 40-100% FEMAL E

32,086.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,086.25

3516	ADULT 40-100% MALE 2	305,234.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	305,234.79

3517	ADULT 40-100% FEMAL E

436,287.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	436,287.52

3518	ADULT 40-100% M&F 45	1,438,811.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,438,811.14

3519	ADULT 40-100% M&F 65	-990.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-990.00

3528	ADULT 40-100% M&F 45	33.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.73

3529	ADULT 40-100% M&F 65	192.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	192.12

3706	ADULT <40% EXP MALE	1,792.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,792.92

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

2,767.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,767.07

42,387.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,387.39

3,535.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,535.49

3714	ADULT <40% EXP MALE	347,633.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	347,633.63

3715	ADULT <40% EXP FEM AL

438,080.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	438,080.79

3716	ADULT <40% EXP MALE	6,263,512.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,263,512.29

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL

3,575,464.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,575,464.37

7,929,765.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,929,765.21

3,910.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,910.92

57.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.07

SUBTOTAL:

20,863,498.73

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,863,498.73

3906	NEWLY ELIGIBLE MALE	282.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	282.87

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

836.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	836.82

36,628.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,628.12

735.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	735.29

3914	NEWLY ELIGIBLE MALE	4,432.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,432.09

3915	NEWLY ELIGIBLE FEMA L

8,684.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,684.59

3916	NEWLY ELIGIBLE MALE	190,656.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	190,656.56

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

152,717.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	152,717.83

668,831.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	668,831.27

1,429.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,429.82

SUBTOTAL:

1,065,235.26

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,065,235.26

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

4,977.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,977.56

235,987.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	235,987.47

4414	SOBRA 100-133% MALE	85,340.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,340.26

4415	SOBRA 100-133% FEMA L

113,390.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	113,390.65

SUBTOTAL:

439,695.94

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	439,695.94

4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

40,445.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,445.07

2,736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,736.00

SUBTOTAL:

43,181.07

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,181.07

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

3,947.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,947.35

2,758.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,758.57

266.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	266.39

SUBTOTAL:

6,972.31

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,972.31

73,620,949.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,620,949.02	

TOTAL:

FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1015	TANF 14-20 FEMALE N O

4,556.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,556.11

1016	TANF 21-44 MALE NON-	2,387.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,387.41

1017	TANF 21-44 FEMALE N O

4,275.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,275.74

1018	TANF 45-64 M & F NON	624.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	624.62

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

11,527.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,527.49

3,789.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,789.39

909.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	909.00

18,770.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,770.69

424.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	424.41

4311	SOBRA CHILD <1 M & F	15,885.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,885.00

4312	SOBRA CHILD 01-05 M	2,904.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,904.79

4313	SOBRA CHILD 06-13 M	555.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	555.73

4314	SOBRA CHILD 14-20 MA	617.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	617.95

4315	SOBRA CHILD 14-20 FE	381.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	381.31

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

1,449.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,449.77

10,432.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,432.36

SUBTOTAL:

79,491.77

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,491.77

275.40	
2,783.56	
179.28	
21.47	
73.59	
285.27	
11.55	
3,630.12	

1116	TANF EXPANDED 21-44	275.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	2,783.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	179.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2400	SSI AGED EXPANDED WI
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

21.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

73.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

285.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

11.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

3,630.12

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00

3514	ADULT 40-100% MALE 1	171.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	171.21

3516	ADULT 40-100% MALE 2	247.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	247.60

3517	ADULT 40-100% FEMAL E

1,176.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,176.50

3518	ADULT 40-100% M&F 45	8,542.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,542.82

3715	ADULT <40% EXP FEM AL

376.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	376.67

3716	ADULT <40% EXP MALE	6,067.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,067.34

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4

2,907.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,907.86

28,847.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,847.18

SUBTOTAL:

48,337.18

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,337.18

3916	NEWLY ELIGIBLE MALE	2,219.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,219.12

FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4

3,257.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,257.75

3,025.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,025.43

SUBTOTAL:

8,502.30

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,502.30

4413	SOBRA 100-133% M&F
6

2,402.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,402.45

4414	SOBRA 100-133% MALE	1,368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,368.00

8700	SSI DISABLED FREEDO	217.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217.38	
	217.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	217.38	

SUBTOTAL:

3,770.45

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,770.45

M
SUBTOTAL:

TOTAL:	143,949.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143,949.20		

FEDERAL EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1006	TANF 21-44 MALE WITH	2,820.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,820.28

1011	TANF <1 M & F NON-ME	926.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	926.83

1012	TANF 01-05 M & F NON	10,241.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,241.14

1013	TANF 06-13 M & F NON	23,681.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,681.01

1014	TANF 14-20 MALE NON-	101,456.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,456.98

1015	TANF 14-20 FEMALE N O

700,203.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700,203.94

1016	TANF 21-44 MALE NON-	131,895.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	131,895.09

1017	TANF 21-44 FEMALE N O

3,848,448.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,848,448.61

1018	TANF 45-64 M & F NON	287,422.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	287,422.21

1019	TANF 65+ M & F NON-M	1,367.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,367.38

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

8,124.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,124.92

686,565.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	686,565.89

28,071.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,071.60

811,372.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	811,372.82

2,582.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,582.38

SUBTOTAL:

6,645,181.08

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,645,181.08

1,613.67	
81.76	
1,746.90	
34.97	
11,771.70	
358,572.55	
758,042.25	
283,242.10	
214.96	
2,523.41	
1,417,844.27	

1106	TANF EXPANDED 21-44	1,613.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	81.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	1,746.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	34.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	11,771.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	358,572.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	758,042.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	283,242.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&
2610	SSI DISABLED EXPAND
E

214.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,523.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,417,844.27

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00

1,415.88	
2,289.04	
89,472.61	
14,241.72	
105,362.43	
777.07	
11,927.67	
10,875.16	

3514	ADULT 40-100% MALE 1	1,415.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

2,289.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	89,472.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

14,241.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	105,362.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP FEM AL

777.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	11,927.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

10,875.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

FEDERAL EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3716	ADULT <40% EXP MALE	331,193.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	331,193.61

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6

54,689.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,689.87

516,687.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	516,687.58

1,353.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,353.93

SUBTOTAL:

1,140,286.57

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,140,286.57

3914	NEWLY ELIGIBLE MALE	270.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270.58

3915	NEWLY ELIGIBLE FEMA L

700.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.41

3916	NEWLY ELIGIBLE MALE	68,081.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,081.76

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4

19,080.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,080.23

46,459.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,459.07

SUBTOTAL:

134,592.05

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	134,592.05

9,337,903.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,337,903.97	

TOTAL:

QMB - FEE FOR SERVICE

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	227,508.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227,508.42		
	227,508.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227,508.42		

SUBTOTAL:

TOTAL:	227,508.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227,508.42		

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1017	TANF 21-44 FEMALE N O
2100	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R

1,750.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,750.41

44,497.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,497.58

73,301.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,301.36

2120	SSI AGED WITH QMB	13,915.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,915.92

2200	SSI DISABLED WITH M E
5017	SOBRA PREG 21-44 FE
M

4,073.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,073.14

1,975.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,975.23

SUBTOTAL:

139,513.64

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139,513.64

3518	ADULT 40-100% M&F 45	172.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	172.49

3706	ADULT <40% EXP MALE	17,224.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,224.61

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4

236.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	236.17

28,660.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,660.93

3714	ADULT <40% EXP MALE	821.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	821.12

3716	ADULT <40% EXP MALE	239,576.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	239,576.63

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4

6,841.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,841.48

193,944.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	193,944.21

SUBTOTAL:

487,477.64

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487,477.64

626,991.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	626,991.28	

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

2200	SSI DISABLED WITH M E
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

3,365.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,365.09

235.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	235.45

1,433.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,433.60

SUBTOTAL:

5,034.14

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,034.14

3716	ADULT <40% EXP MALE	8,220.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,220.27

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4

4,470.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,470.06

398.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	398.58

SUBTOTAL:

13,088.91

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,088.91

TOTAL:	18,123.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,123.05		

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1017	TANF 21-44 FEMALE N O
2220	SSI DISABLED WITH Q
M
5017	SOBRA PREG 21-44 FE
M

443.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	443.20

259.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.64

6,591.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,591.20

SUBTOTAL:

7,294.04

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,294.04

3716	ADULT <40% EXP MALE	2,763.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	1,679.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,442.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

2,763.39

1,679.53
4
	00	4,442.92	
TOTAL:	11,736.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
11,736.96	

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

2200	SSI DISABLED WITH M E

1,230.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,230.46

SUBTOTAL:

1,230.46

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,230.46

2600	SSI DISABLED EXPAND E

2,451.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,451.81

SUBTOTAL:

2,451.81

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,451.81

3716	ADULT <40% EXP MALE	69,885.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,885.82

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4

416.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	416.43

10,106.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,106.81

SUBTOTAL:

80,409.06

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,409.06

TOTAL:	84,091.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,091.33		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	696.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	696.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

2,949,233.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,949,233.74

257,831.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	257,831.11

2120	SSI AGED WITH QMB	3,395,534.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,395,534.81

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

523,308.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	523,308.04

2,765,516.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,765,516.29

753,716.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	753,716.70

2300	SSI BLIND WITH MEDIC	406.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	406.36

2310	SSI BLIND NON-MEDIC A

19,566.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,566.98

2320	SSI BLIND WITH QMB	8,634.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,634.19

SUBTOTAL:

10,674,444.22

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,674,444.22

M
SUBTOTAL:

8720	SSI DISABLED FREEDO	2,742.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,742.24	
	2,742.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,742.24	

10,677,186.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,677,186.46	

TOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1012	TANF 01-05 M & F NON	79,268.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,268.59

1013	TANF 06-13 M & F NON	146,919.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,919.93

1014	TANF 14-20 MALE NON-	9,642.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,642.30

1015	TANF 14-20 FEMALE N O
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

5,937.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,937.29

285,353.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	285,353.96

-16.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-16.61

2300	SSI BLIND WITH MEDIC	199.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	199.18

2310	SSI BLIND NON-MEDIC A

1,150.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,150.83

4305	SOBRA CHILD 14-20 FE	125.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125.02

4312	SOBRA CHILD 01-05 M	85,612.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,612.86

4313	SOBRA CHILD 06-13 M	125,563.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125,563.85

4314	SOBRA CHILD 14-20 MA	8,367.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,367.62

4315	SOBRA CHILD 14-20 FE	4,600.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,600.75

1112	TANF EXPANDED 01-05	579.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		579.40	
1113	TANF EXPANDED 06-13	2,647.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,647.22	
1114	TANF EXPANDED 14-20	454.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454.98	
1115	TANF EXPANDED 14-20	332.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332.61	
2610	SSI DISABLED EXPAND	305.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		305.53	
	4,319.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,319.74	

SUBTOTAL:

752,725.57

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	752,725.57

E
SUBTOTAL:

SUBTOTAL:

3314	AHC CARE MALE 14-20	-11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11.48	
	-11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11.48	

3514	ADULT 40-100% MALE 1	155.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	155.62

3515	ADULT 40-100% FEMAL E

53.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.60

3714	ADULT <40% EXP MALE	476.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	476.23

3715	ADULT <40% EXP FEM AL

271.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	271.22

SUBTOTAL:

956.67

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	956.67

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

35.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.71

18,746.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,746.09

4414	SOBRA 100-133% MALE	1,596.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,596.05

4415	SOBRA 100-133% FEMA L

1,702.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,702.55

SUBTOTAL:

22,080.40

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,080.40

TOTAL:	780,070.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	780,070.90		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	47,470.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,470.63

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

1,412.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,412.38

1,478,954.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,478,954.03

4,777.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,777.36

10,115.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,115.61

SUBTOTAL:

1,542,730.01

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,542,730.01

TOTAL:

1,542,730.01

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,542,730.01

ACUTE REINSURANCE

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1011	TANF <1 M & F NON-ME	617,801.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	617,801.55

1012	TANF 01-05 M & F NON	226,432.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	226,432.73

1013	TANF 06-13 M & F NON	127,284.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127,284.33

1014	TANF 14-20 MALE NON-	108,649.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,649.47

1015	TANF 14-20 FEMALE N O

26,416.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,416.78

1016	TANF 21-44 MALE NON-	132,385.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132,385.08

1017	TANF 21-44 FEMALE N O

341,065.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	341,065.51

1018	TANF 45-64 M & F NON	201,160.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	201,160.52

1019	TANF 65+ M & F NON-M	1,093.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,093.03

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

-11,064.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11,064.51

128,077.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	128,077.73

20,315.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,315.85

5,320,586.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,320,586.01

2,687.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,687.38

4311	SOBRA CHILD <1 M & F	786,856.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	786,856.39

4312	SOBRA CHILD 01-05 M	42,898.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,898.59

4313	SOBRA CHILD 06-13 M	342,577.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	342,577.75

4314	SOBRA CHILD 14-20 MA	1,333,911.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,333,911.20

4315	SOBRA CHILD 14-20 FE	190,628.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	190,628.79

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

-5,501.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-5,501.24

35,660.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,660.75

SUBTOTAL:

9,969,923.69

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,969,923.69

1106	TANF EXPANDED 21-44	5,783.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,783.54

1107	TANF EXPANDED 21-44	1,873.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,873.11

1113	TANF EXPANDED 06-13	72.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72.82

1114	TANF EXPANDED 14-20	17,303.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,303.13

1116	TANF EXPANDED 21-44	157,110.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	157,110.28

1117	TANF EXPANDED 21-44	93,886.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	93,886.49

1118	TANF EXPANDED 45-64	76,199.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,199.68

2400	SSI AGED EXPANDED WI
2410	SSI AGED EXPANDED
NO
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

8,461.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,461.10

10,343.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,343.80

6,615.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,615.59

33,618.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,618.83

SUBTOTAL:

411,268.37

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411,268.37

3316	AHC CARE MALE 21-44	824.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

824.99

4

SUBTOTAL:	0

ACUTE REINSURANCE

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3317	AHC CARE FEMALE 21-	2,554.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,554.20		
3318	AHC CARE M&F 45-64 N	11,680.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,680.93		
	15,060.12	0.00		0.0		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,060.12		

3614	AHC CARE/MI MALE 14-	284.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	284.63

3616	AHC CARE/MI MALE 21-	35,449.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,449.75

3617	AHC CARE/MI FEMALE
2

2,346.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,346.33

3618	AHC CARE/MI M&F 45-6	92,677.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92,677.00

SUBTOTAL:

130,757.71

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	130,757.71

3514	ADULT 40-100% MALE 1	151,764.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151,764.97

3516	ADULT 40-100% MALE 2	110,085.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,085.04

3517	ADULT 40-100% FEMAL E

14,191.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,191.06

3518	ADULT 40-100% M&F 45	124,182.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	124,182.25

3714	ADULT <40% EXP MALE	60,063.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,063.28

3715	ADULT <40% EXP FEM AL

28,863.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,863.68

3716	ADULT <40% EXP MALE	527,880.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	527,880.83

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4

203,328.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	203,328.99

547,533.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	547,533.52

3918	NEWLY ELIGIBLE M&F	22,286.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,286.86	
	22,286.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,286.86	

SUBTOTAL:

1,767,893.62

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,767,893.62

4
SUBTOTAL:

6

SUBTOTAL:

4413	SOBRA 100-133% M&F	14,312.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,312.67	
4414	SOBRA 100-133% MALE	65.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65.18	
	14,377.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,377.85	

4518	BC PATIENT FEMALE 4
5
4618	CC PATIENT FEMALE 4
5

10,313.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,313.98

6,115.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,115.12

8710	SSI DISABLED FREEDO	2,558.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,558.36	
	2,558.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,558.36	

SUBTOTAL:

16,429.10

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,429.10

M
SUBTOTAL:

TOTAL:	12,350,555.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,350,555.68		

LONG TERM CARE REINSURANCE

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	770.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	770.44

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

444,766.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	444,766.14

94,778.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94,778.89

542,384.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	542,384.64

2,252,785.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,252,785.70

16,178.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,178.78

SUBTOTAL:

3,351,664.59

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,351,664.59

3,351,664.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,351,664.59	

TOTAL:

ACUTE SMIB

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	64,841.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,841.20

1010	TANF NON-MEDICARE	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314.70

1020	TANF WITH QMB	1,993.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,993.10

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

233,087.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	233,087.80

400,566.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	400,566.10

2120	SSI AGED WITH QMB	2,312,587.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,312,587.30

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

431,726.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	431,726.00

325,924.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	325,924.30

2,938,167.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,938,167.40

2300	SSI BLIND WITH MEDIC	2,307.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,307.80

2310	SSI BLIND NON-MEDIC A

3,356.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,356.80

2320	SSI BLIND WITH QMB	26,329.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,329.90

5020	SOBRA PREGNANT WO MAN

314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314.70

8000	SMIB ONLY NOT ELIGIB	142,941.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,941.40

8020	QMB ONLY	451,354.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	451,354.50

8040	SLMB	2,943,067.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,943,067.40

8888	SMIB ONLY NOT ELIGIB	10,545.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,545.90

9999	SMIB ONLY NOT ELIGIB	104,243.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104,243.20

SUBTOTAL:

10,393,669.50

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,393,669.50

SUBTOTAL:

9920	SSI W/MEDICARE KICK	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1100	TANF EXPANDED FPR FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	839.20

106,596.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	106,596.20

1,468.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,468.60

2,329,792.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,329,792.40

524.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524.50

49,093.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,093.20

104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.90

951,712.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	951,712.70

SUBTOTAL:

3,440,131.70

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,440,131.70

A
SUBTOTAL:

9900	HOSP. KICK PAYMENT	8,811.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,811.60	
	8,811.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,811.60	

3500	ADULT 40-100% FOR FI	419.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	3,042.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

419.60

3,042.10

ACUTE SMIB

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

3720	AHC CARE EXPANDED FO

1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,049.00

SUBTOTAL:

4,510.70

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,510.70

3920	NEWLY ELIGIBLE FOR F

1,258.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,258.80

SUBTOTAL:

1,258.80

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,258.80

8700	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,049.00

16,154.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,154.60

SUBTOTAL:

17,203.60

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,203.60

TOTAL:	13,865,585.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,865,585.90		

ACUTE HIB

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

-5,222.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-5,222.40

-7,299.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7,299.40

2120	SSI AGED WITH QMB	138,085.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138,085.50

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

-185.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-185.40

-890.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-890.50

22,759.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,759.60

2320	SSI BLIND WITH QMB	426.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	426.00

8000	SMIB ONLY NOT ELIGIB	-216.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-216.30

8010	SMIB ONLY NOT ELIGIB	-940.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-940.60

8020	QMB ONLY	1,908.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,908.80

9999	SMIB ONLY NOT ELIGIB	-89,633.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-89,633.40

SUBTOTAL:

58,791.90

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,791.90

WI
SUBTOTAL:

2420	SSI AGED EXPANDED	2,805.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,805.80	
	2,805.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,805.80	

61,597.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,597.70	

TOTAL:

Q1

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	1,614,709.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,614,709.50		
9999	SMIB ONLY NOT ELIGIB	12,692.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,692.90		
	1,627,402.40	0.00		0.0		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,627,402.40		

SUBTOTAL:	0

TOTAL:	1,627,402.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,627,402.40		

LTC SMIB

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1000	TANF WITH MEDICARE	209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209.80

1020	TANF WITH QMB	209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209.80

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

888,555.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	888,555.70

152,419.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	152,419.70

2120	SSI AGED WITH QMB	701,571.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	701,571.20

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

332,642.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	332,642.90

15,525.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,525.20

663,338.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	663,338.30

2300	SSI BLIND WITH MEDIC	1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,049.00

2310	SSI BLIND NON-MEDIC A

209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209.80

2320	SSI BLIND WITH QMB	4,300.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,300.90

SUBTOTAL:

2,760,032.30

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,760,032.30

M
SUBTOTAL:

8720	SSI DISABLED FREEDO	524.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.50	
	524.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524.50	

2,760,556.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,760,556.80	

TOTAL:

LTC HIB

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

-5,106.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-5,106.60

-6,887.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-6,887.80

2120	SSI AGED WITH QMB	148,322.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148,322.10

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

-1,539.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,539.40

-10,177.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-10,177.90

-3,868.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-3,868.30

2320	SSI BLIND WITH QMB	826.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	826.20

SUBTOTAL:

121,568.30

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121,568.30

TOTAL:	121,568.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121,568.30		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1006	TANF 21-44 MALE WITH	2,441.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,441.80

1007	TANF 21-44 FEMALE WI	7,891.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,891.55

1008	TANF 45-64 M & F WIT	688.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	688.07

1009	TANF 65+ M & F WITH	2,777.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,777.42

1011	TANF <1 M & F NON-ME	1,237,866.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,237,866.75

1012	TANF 01-05 M & F NON	2,340,612.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,340,612.57

1013	TANF 06-13 M & F NON	3,637,963.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,637,963.98

1014	TANF 14-20 MALE NON-	789,166.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	789,166.76

1015	TANF 14-20 FEMALE N O

1,078,108.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,078,108.85

1016	TANF 21-44 MALE NON-	1,173,513.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,173,513.39

1017	TANF 21-44 FEMALE N O

5,649,472.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,649,472.39

1018	TANF 45-64 M & F NON	1,634,097.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,634,097.28

1019	TANF 65+ M & F NON-M	3,798.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,798.00

1027	TANF 21-44 FEMALE WI	4,120.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,120.76

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

55,280.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,280.06

122,058.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,058.59

2120	SSI AGED WITH QMB	240,326.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	240,326.58

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

141,948.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	141,948.53

5,600,784.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,600,784.07

505,684.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	505,684.41

2300	SSI BLIND WITH MEDIC	732.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	732.05

2310	SSI BLIND NON-MEDIC A

58,811.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,811.72

2320	SSI BLIND WITH QMB	6,877.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,877.81

4311	SOBRA CHILD <1 M & F	1,346,693.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,346,693.34

4312	SOBRA CHILD 01-05 M	1,349,383.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,349,383.33

4313	SOBRA CHILD 06-13 M	1,906,239.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,906,239.87

4314	SOBRA CHILD 14-20 MA	819,236.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	819,236.05

4315	SOBRA CHILD 14-20 FE	1,262,134.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,262,134.73

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT

158.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	158.10

327,656.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	327,656.19

1,091,567.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,091,567.67

-18,468.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-18,468.00

2,970.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,970.00

SUBTOTAL:

32,382,594.67

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,382,594.67

1106	TANF EXPANDED 21-44	6,408.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,408.48

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1107	TANF EXPANDED 21-44	13,495.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,495.32

1108	TANF EXPANDED 45-64	30,378.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,378.85

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

19,280.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,280.09

342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	342.00

1112	TANF EXPANDED 01-05	9,006.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,006.00

1113	TANF EXPANDED 06-13	51,575.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,575.17

1114	TANF EXPANDED 14-20	22,170.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,170.63

1115	TANF EXPANDED 14-20	47,309.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,309.83

1116	TANF EXPANDED 21-44	591,969.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	591,969.39

1117	TANF EXPANDED 21-44	1,556,828.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,556,828.28

1118	TANF EXPANDED 45-64	886,655.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	886,655.00

1119	TANF EXPANDED 65+ M&

342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	342.00

1127	TANF EXPANDED 21-44	151.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151.39

1128	TANF EXPANDED 45-64	3,030.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,030.80

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

1,058.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,058.72

12,551.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,551.22

47,919.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,919.09

205,652.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	205,652.65

-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-330.00

7,548.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,548.42

70,066.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70,066.79

85,071.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,071.68

SUBTOTAL:

3,668,481.80

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,668,481.80

3,984.00	
2,002.28	
11,059.15	
17,045.43	

4

00

3316	AHC CARE MALE 21-44	3,984.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	2,002.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	11,059.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	17,045.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

0.00	
41.99	
0.00	
9,988.67	
6,338.94	
11,700.14	
-10,085.42	
102,440.36	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3607	AHC CARE/MI FEMALE
2

41.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3614	AHC CARE/MI MALE 14-	9,988.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3615	AHC CARE/MI FEMALE
1

6,338.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3616	AHC CARE/MI MALE 21-	11,700.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

-10,085.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3618	AHC CARE/MI M&F 45-6	102,440.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	120,424.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	120,424.68		

3506	ADULT 40-100% MALE 2	684.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	684.00

3508	ADULT 40-100% M&F 45	9,119.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,119.57

3509	ADULT 40-100% M&F 65	4,900.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,900.96

3514	ADULT 40-100% MALE 1	11,956.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,956.88

3515	ADULT 40-100% FEMAL E

30,135.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,135.72

3516	ADULT 40-100% MALE 2	214,543.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	214,543.22

3517	ADULT 40-100% FEMAL E

353,269.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	353,269.80

3518	ADULT 40-100% M&F 45	1,126,897.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,126,897.64

3519	ADULT 40-100% M&F 65	-990.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-990.00

3528	ADULT 40-100% M&F 45	23.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.40

3529	ADULT 40-100% M&F 65	192.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	192.12

3706	ADULT <40% EXP MALE	1,792.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,792.92

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

1,067.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,067.23

14,748.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,748.72

3,515.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,515.98

3714	ADULT <40% EXP MALE	239,581.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	239,581.44

3715	ADULT <40% EXP FEM AL

359,309.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	359,309.33

3716	ADULT <40% EXP MALE	3,847,800.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,847,800.35

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL

2,702,957.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,702,957.26

5,364,337.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,364,337.66

2,748.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,748.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

14,288,592.20

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,288,592.20

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

696.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	696.00

15,345.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,345.28

735.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	735.29

3914	NEWLY ELIGIBLE MALE	4,167.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,167.88

3915	NEWLY ELIGIBLE FEMA L

6,849.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,849.61

3916	NEWLY ELIGIBLE MALE	163,852.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	163,852.24

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

130,991.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	130,991.21

497,280.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	497,280.63

1,368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,368.00

SUBTOTAL:

821,286.14

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	821,286.14

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

4,638.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,638.00

220,130.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220,130.89

4414	SOBRA 100-133% MALE	72,117.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,117.92

4415	SOBRA 100-133% FEMA L

96,355.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,355.37

SUBTOTAL:

393,242.18

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	393,242.18

4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

32,045.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,045.00

2,736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,736.00

SUBTOTAL:

34,781.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,781.00

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

1,454.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,454.42

2,736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,736.00

256.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	256.13

SUBTOTAL:

4,446.55

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,446.55

51,730,894.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,730,894.65	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1006	TANF 21-44 MALE WITH	18,511.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,511.10

1007	TANF 21-44 FEMALE WI	15,246.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,246.21

1008	TANF 45-64 M & F WIT	4,700.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,700.46

1009	TANF 65+ M & F WITH	554.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	554.64

1011	TANF <1 M & F NON-ME	732,298.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	732,298.41

1012	TANF 01-05 M & F NON	531,443.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	531,443.83

1013	TANF 06-13 M & F NON	506,765.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	506,765.09

1014	TANF 14-20 MALE NON-	215,330.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215,330.10

1015	TANF 14-20 FEMALE N O

209,694.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209,694.11

1016	TANF 21-44 MALE NON-	445,479.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	445,479.43

1017	TANF 21-44 FEMALE N O

1,705,492.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,705,492.72

1018	TANF 45-64 M & F NON	635,145.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	635,145.79

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	453.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	453.02

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

52,744.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,744.87

35,489.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,489.62

2120	SSI AGED WITH QMB	242,074.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	242,074.39

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

266,485.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	266,485.96

3,163,355.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,163,355.90

1,005,134.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,005,134.11

2300	SSI BLIND WITH MEDIC	1,296.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,296.92

2310	SSI BLIND NON-MEDIC A

59,530.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,530.65

2320	SSI BLIND WITH QMB	15,673.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,673.05

4311	SOBRA CHILD <1 M & F	980,037.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	980,037.24

4312	SOBRA CHILD 01-05 M	201,675.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	201,675.08

4313	SOBRA CHILD 06-13 M	183,132.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	183,132.69

4314	SOBRA CHILD 14-20 MA	100,507.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100,507.75

4315	SOBRA CHILD 14-20 FE	122,461.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,461.08

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT

29.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.51

139,377.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139,377.14

432,998.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	432,998.83

1,755.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,755.04

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

12,024,874.74

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,024,874.74

1106	TANF EXPANDED 21-44	20,739.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,739.17

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1107	TANF EXPANDED 21-44	29,774.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,774.01

1108	TANF EXPANDED 45-64	68,920.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,920.08

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

7,438.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,438.23

48.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48.77

1112	TANF EXPANDED 01-05	4,152.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,152.37

1113	TANF EXPANDED 06-13	6,195.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,195.30

1114	TANF EXPANDED 14-20	1,476.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,476.39

1115	TANF EXPANDED 14-20	8,362.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,362.55

1116	TANF EXPANDED 21-44	160,136.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160,136.01

1117	TANF EXPANDED 21-44	325,927.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	325,927.10

1118	TANF EXPANDED 45-64	213,882.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	213,882.58

1119	TANF EXPANDED 65+ M&

2,212.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,212.51

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	6,396.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,396.35

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

4,480.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,480.09

7,771.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,771.38

97,330.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,330.44

251,590.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	251,590.15

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5,268.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,268.61

37,110.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,110.66

140,475.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140,475.36

SUBTOTAL:

1,399,688.11

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,399,688.11

118.58	
-1,208.58	
419.09	
-670.91	

4

00

3316	AHC CARE MALE 21-44	118.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	-1,208.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	419.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-670.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

-23.88	
0.00	
2,261.53	
207.75	
872.87	
5,204.61	
3,444.53	
903.34	

3400	MED ELIGIBILITY W/ M	-23.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3607	AHC CARE/MI FEMALE
2

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3608	AHC CARE/MI M&F 45-6	2,261.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3614	AHC CARE/MI MALE 14-	207.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3615	AHC CARE/MI FEMALE
1

872.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3616	AHC CARE/MI MALE 21-	5,204.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

3,444.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3618	AHC CARE/MI M&F 45-6	903.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	12,870.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,870.75		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	13,406.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,406.77

3509	ADULT 40-100% M&F 65	2,137.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,137.55

3514	ADULT 40-100% MALE 1	299.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	299.88

3515	ADULT 40-100% FEMAL E

1,481.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,481.60

3516	ADULT 40-100% MALE 2	68,950.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,950.30

3517	ADULT 40-100% FEMAL E

48,033.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,033.43

3518	ADULT 40-100% M&F 45	247,350.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	247,350.24

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	10.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.33

3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

1,699.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,699.84

25,187.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,187.13

19.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.51

3714	ADULT <40% EXP MALE	96,519.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,519.59

3715	ADULT <40% EXP FEM AL

70,257.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70,257.57

3716	ADULT <40% EXP MALE	2,056,952.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,056,952.53

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL

763,329.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	763,329.78

2,272,604.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,272,604.78

1,162.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,162.92

57.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.07

SUBTOTAL:

5,669,460.82

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,669,460.82

3906	NEWLY ELIGIBLE MALE	57.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.76

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

140.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140.82

20,470.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,470.96

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	264.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	264.21

3915	NEWLY ELIGIBLE FEMA L

1,257.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,257.16

3916	NEWLY ELIGIBLE MALE	15,313.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,313.98

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

15,483.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,483.34

112,833.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	112,833.00

61.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61.82

SUBTOTAL:

165,883.05

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165,883.05

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

255.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255.50

14,205.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,205.19

4414	SOBRA 100-133% MALE	6,204.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,204.87

4415	SOBRA 100-133% FEMA L

15,855.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,855.01

SUBTOTAL:

36,520.57

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,520.57

4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

5,769.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,769.75

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

5,769.75

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,769.75

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

2,168.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,168.55

22.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.57

10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.26

SUBTOTAL:

2,201.38

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,201.38

TOTAL:	19,316,598.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,316,598.26		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	
0.00	
0.00	
0.00	

4

00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3607	AHC CARE/MI FEMALE
2

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3615	AHC CARE/MI FEMALE
1

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4415	SOBRA 100-133% FEMA L

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	32,641.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,641.98

1012	TANF 01-05 M & F NON	9,726.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,726.79

1013	TANF 06-13 M & F NON	10,337.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,337.38

1014	TANF 14-20 MALE NON-	2,637.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,637.34

1015	TANF 14-20 FEMALE N O

9,633.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,633.77

1016	TANF 21-44 MALE NON-	-210.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-210.03

1017	TANF 21-44 FEMALE N O

25,840.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,840.81

1018	TANF 45-64 M & F NON	5,304.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,304.56

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

637.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	637.35

18,494.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,494.71

2120	SSI AGED WITH QMB	2,170.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,170.55

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

1,445.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,445.44

105,053.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105,053.82

2,636.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,636.06

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	8,105.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,105.05

4312	SOBRA CHILD 01-05 M	16,415.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,415.77

4313	SOBRA CHILD 06-13 M	8,910.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,910.38

4314	SOBRA CHILD 14-20 MA	3,167.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,167.94

4315	SOBRA CHILD 14-20 FE	7,512.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,512.52

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

355.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	355.24

8,677.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,677.15

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

279,494.58

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	279,494.58

1106	TANF EXPANDED 21-44	100.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100.87

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	556.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	556.81

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	278.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	278.80

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	1,114.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,114.76

1115	TANF EXPANDED 14-20	1,795.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,795.17

1116	TANF EXPANDED 21-44	8,190.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,190.51

1117	TANF EXPANDED 21-44	18,106.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,106.82

1118	TANF EXPANDED 45-64	12,066.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,066.69

1119	TANF EXPANDED 65+ M&

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

79.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79.87

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,266.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,266.08

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

221.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	221.18

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

504.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	504.00

SUBTOTAL:

44,281.56

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,281.56

0.00	
0.00	
0.00	
0.00	

4

00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

0.00	
0.00	
0.00	
0.00	
0.00	
2,085.47	
581.91	
-2,340.05	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3607	AHC CARE/MI FEMALE
2

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3615	AHC CARE/MI FEMALE
1

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3616	AHC CARE/MI MALE 21-	2,085.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

581.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3618	AHC CARE/MI M&F 45-6	-2,340.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	327.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	327.33		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

468.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	468.93

3516	ADULT 40-100% MALE 2	11,090.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,090.38

3517	ADULT 40-100% FEMAL E

11,245.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,245.70

3518	ADULT 40-100% M&F 45	34,728.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,728.21

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	2,032.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,032.24

3715	ADULT <40% EXP FEM AL

3,136.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,136.03

3716	ADULT <40% EXP MALE	81,484.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,484.42

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL

15,464.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,464.69

68,101.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,101.26

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

227,751.86

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227,751.86

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

225.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

577.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	577.82

3916	NEWLY ELIGIBLE MALE	10,823.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,823.55

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

169.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	169.41

45,902.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,902.49

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

57,698.27

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,698.27

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

145.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145.71

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4415	SOBRA 100-133% FEMA L

798.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	798.96

SUBTOTAL:

944.67

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	944.67

4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	610,498.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	610,498.27		

SUBTOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	20,749.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,749.45		
	20,749.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,749.45		

20,749.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,749.45	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	206,135.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,135.54		
	206,135.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206,135.54		

206,135.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206,135.54	

TOTAL:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1006	TANF 21-44 MALE WITH	923.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	923.62

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	17,781.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,781.02

1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	84,767.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,767.06

1012	TANF 01-05 M & F NON	34,284.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,284.92

1013	TANF 06-13 M & F NON	44,810.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,810.40

1014	TANF 14-20 MALE NON-	15,430.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,430.38

1015	TANF 14-20 FEMALE N O

11,813.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,813.66

1016	TANF 21-44 MALE NON-	31,438.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,438.66

1017	TANF 21-44 FEMALE N O

210,377.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	210,377.80

1018	TANF 45-64 M & F NON	28,096.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,096.35

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

3,406.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,406.77

3,421.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,421.42

2120	SSI AGED WITH QMB	19,926.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,926.84

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

13,662.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,662.86

304,798.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	304,798.51

44,399.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,399.62

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

1,234.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,234.87

2320	SSI BLIND WITH QMB	284.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	284.04

4311	SOBRA CHILD <1 M & F	68,145.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,145.48

4312	SOBRA CHILD 01-05 M	35,241.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,241.49

4313	SOBRA CHILD 06-13 M	30,113.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,113.38

4314	SOBRA CHILD 14-20 MA	8,988.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,988.63

4315	SOBRA CHILD 14-20 FE	5,849.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,849.26

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT

1,758.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,758.24

18,102.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,102.67

46,014.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,014.10

49.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.27

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,085,121.32

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,085,121.32

1106	TANF EXPANDED 21-44	119.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119.42

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1107	TANF EXPANDED 21-44	1,570.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,570.36

1108	TANF EXPANDED 45-64	1,427.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,427.07

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

1,503.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,503.33

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	43.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43.90

1116	TANF EXPANDED 21-44	35,961.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,961.69

1117	TANF EXPANDED 21-44	58,248.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,248.53

1118	TANF EXPANDED 45-64	24,913.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,913.23

1119	TANF EXPANDED 65+ M&

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	55.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55.28

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

94.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94.45

794.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	794.63

2,136.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,136.82

12,344.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,344.05

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

92.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92.70

209.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209.07

5,857.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,857.19

SUBTOTAL:

145,371.72

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,371.72

0.00	
0.00	
0.00	
0.00	

4

00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

0.00	
0.00	
240.00	
0.00	
0.00	
1,586.68	
53.57	
1,999.68	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3607	AHC CARE/MI FEMALE
2

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3608	AHC CARE/MI M&F 45-6	240.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3615	AHC CARE/MI FEMALE
1

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3616	AHC CARE/MI MALE 21-	1,586.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

53.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3618	AHC CARE/MI M&F 45-6	1,999.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	3,879.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,879.93		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	430.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	430.42

3515	ADULT 40-100% FEMAL E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	10,650.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,650.89

3517	ADULT 40-100% FEMAL E

23,738.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,738.59

3518	ADULT 40-100% M&F 45	29,835.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,835.05

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,451.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,451.54

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	9,500.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,500.36

3715	ADULT <40% EXP FEM AL

5,377.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,377.86

3716	ADULT <40% EXP MALE	277,274.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	277,274.99

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL

85,369.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,369.64

224,721.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	224,721.51

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

669,350.85

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	669,350.85

3906	NEWLY ELIGIBLE MALE	225.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225.11

3907	NEWLY ELIGIBLE FEMA L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

586.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	586.88

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	666.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	666.79

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6

6,073.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,073.87

12,815.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,815.15

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

20,367.80

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,367.80

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

84.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84.06

1,505.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,505.68

4414	SOBRA 100-133% MALE	7,017.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,017.47

4415	SOBRA 100-133% FEMA L

381.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	381.31

SUBTOTAL:

8,988.52

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,988.52

4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

2,630.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,630.32

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

2,630.32

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,630.32

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

324.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	324.38

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

324.38

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	324.38

TOTAL:	1,936,034.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,936,034.84		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	696.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	696.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

182,999.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	182,999.78

69,456.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,456.96

2120	SSI AGED WITH QMB	194,238.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194,238.72

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

45,131.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,131.68

893,176.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	893,176.80

75,691.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,691.55

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

9,875.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,875.35

2320	SSI BLIND WITH QMB	144.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144.17

SUBTOTAL:

1,471,411.01

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,471,411.01

M
SUBTOTAL:

8720	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,471,411.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,471,411.01	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

2,664,791.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,664,791.67

179,461.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	179,461.32

2120	SSI AGED WITH QMB	3,181,633.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,181,633.79

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

466,608.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	466,608.06

1,779,146.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,779,146.34

668,132.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	668,132.19

2300	SSI BLIND WITH MEDIC	379.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	379.43

2310	SSI BLIND NON-MEDIC A

9,691.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,691.63

2320	SSI BLIND WITH QMB	8,442.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,442.00

8720	SSI DISABLED FREEDO	2,742.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,742.24	
	2,742.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,742.24	

SUBTOTAL:

8,958,286.43

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,958,286.43

M
SUBTOTAL:

TOTAL:	8,961,028.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,961,028.67		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

46,355.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,355.76

8,709.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,709.42

2120	SSI AGED WITH QMB	1,098.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,098.73

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

4,865.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,865.65

28,693.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,693.95

2,249.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,249.80

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

91,973.31

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91,973.31

M
SUBTOTAL:

8720	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

91,973.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91,973.31	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R

55,086.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,086.53

203.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	203.41

2120	SSI AGED WITH QMB	18,563.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,563.57

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

6,702.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,702.65

64,499.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,499.20

7,643.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,643.16

2300	SSI BLIND WITH MEDIC	26.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.93

2310	SSI BLIND NON-MEDIC A

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	48.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48.02

8720	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

152,773.47

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	152,773.47

M
SUBTOTAL:

TOTAL:	152,773.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	152,773.47		

KidsCare - CAPITATION AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

6011	KIDS <1M&F NON MEDI C

4,524.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,524.22

6012	KIDS 1-5 M & F NON-M	3,921.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,921.57

6013	KIDS 6-13 M & F NON-	129,970.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	129,970.36

6014	KIDS 14-19 MALE NON-	69,288.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,288.89

6015	KIDS 14-19 FEMALE NO	110,216.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,216.77

SUBTOTAL:

317,921.81

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	317,921.81

TOTAL:

317,921.81

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	317,921.81

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

6011	KIDS <1M&F NON MEDI C

10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00

6012	KIDS 1-5 M & F NON-M	38.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38.83

6013	KIDS 6-13 M & F NON-	1,047.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,047.73

6014	KIDS 14-19 MALE NON-	406.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	406.52

6015	KIDS 14-19 FEMALE NO	440.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	440.63

SUBTOTAL:

1,943.71

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,943.71

TOTAL:	1,943.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,943.71		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

6011	KIDS <1M&F NON MEDI C

409.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	409.20

6012	KIDS 1-5 M & F NON-M	1,488.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,488.00

6013	KIDS 6-13 M & F NON-	38,650.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,650.80

6014	KIDS 14-19 MALE NON-	15,387.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,387.26

6015	KIDS 14-19 FEMALE NO	17,426.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,426.93

SUBTOTAL:

73,362.19

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,362.19

TOTAL:

73,362.19

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,362.19

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

6011	KIDS <1M&F NON MEDI C

11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00

6012	KIDS 1-5 M & F NON-M	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40.00

6013	KIDS 6-13 M & F NON-	1,039.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,039.00

6014	KIDS 14-19 MALE NON-	402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	402.00

6015	KIDS 14-19 FEMALE NO	450.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	450.00

SUBTOTAL:

1,942.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,942.00

TOTAL:	1,942.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,942.00		

KidsCare - FEE FOR SERVICE

For The Period Ending July 31, 2014

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL

6011	KIDS <1M&F NON MEDI C

518.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	518.72

6012	KIDS 1-5 M & F NON-M	5,220.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,220.12

6013	KIDS 6-13 M & F NON-	5,620.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,620.16

6014	KIDS 14-19 MALE NON-	1,847.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,847.16

6015	KIDS 14-19 FEMALE NO	6,826.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,826.40

SUBTOTAL:

20,032.56

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,032.56

TOTAL:

20,032.56

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,032.56

KidsCare - REINSURANCE

For The Period Ending July 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	-163,807.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-163,807.93		
6013	KIDS 6-13 M & F NON-	35,860.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,860.62		
6014	KIDS 14-19 MALE NON-	28,000.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,000.15		
	-99,947.16	0.00		0.0		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-99,947.16		

SUBTOTAL:	0

TOTAL:	-99,947.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-99,947.16		

110007 DES-DD - CAP MEMBER MONTHS

For The Period Ending July 31, 2014		
RATE CODE	DESCRIPTION	JULY	AUGUST     SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
		
1000	TANF WITH MEDICARE	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1010	TANF NON-MEDICARE	618.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		618.38		
1020	TANF WITH QMB	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2100	SSI AGED WITH MEDICA	146.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146.99		
2110	SSI AGED NON-MEDICAR	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2120	SSI AGED WITH QMB	236.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236.79		
2200	SSI DISABLED WITH ME	1,737.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,737.61		
2210	SSI DISABLED NON-MED	20,351.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,351.11		
2220	SSI DISABLED WITH QM	3,823.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,823.28		
2300	SSI BLIND WITH MEDIC	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
2310	SSI BLIND NON-MEDICA	112.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112.93		
2320	SSI BLIND WITH QMB	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
8700	SSI DISABLED FREEDOM	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
8710	SSI DISABLED FREEDOM	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
8720	SSI DISABLED FREEDOM	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
	27,092.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,092.09		
	27,092.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,092.09		

SUBTOTAL: TOTAL:

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending July 31, 2014

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL EPD
TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	378,800.20
81,832,334.90	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	378,800.20
81,832,334.90	
	82,211,135.10
90,441,057.34	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	82,211,135.10
90,441,057.34	
	90,441,057.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	90,441,057.34	
TOTAL LTC - CAP	172,652,192.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	172,652,192.44	

EPD/DD FEE-FOR-SERVICE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	10,677,186.46
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	10,677,186.46
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	10,677,186.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,677,186.46	

EPD/DD REINSURANCE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	3,104,150.55
247,514.04	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	3,104,150.55
247,514.04	
	247,514.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	247,514.04	
TOTAL LTC - REIN	3,351,664.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,351,664.59	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	2,882,125.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,882,125.10	

Note to the ASR:
1- EPD reflects the Federal and County share for both acute and LTC services.
2- AHCCCS passes through only the Federal share to DES. Neither the Federal nor the Nonfederal dollars are included on the ASR summary (page 1) because both are included in the DES appropriation.

100

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending July 31, 2014

010115	CRS FULLY INTEGRATED PLAN - CAP	14,351,926.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,351,926.69	
010145	CRS ACUTE SEMI INTEGRATED - CAP	140,282.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140,282.17	
	14,492,208.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,492,208.86	

JULY	AUGUST	SEPTEMBER     OCTOBER	NOVEMBER     DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE

TOTAL

Thursday, August 21, 2014

999155	CRS REINSURANCE ONLY	2,324,970.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,324,970.00	
	2,324,970.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,324,970.00	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC CAP	52,459.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,459.25	
	52,459.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,459.25	

Subtotal

Subtotal

16,869,638.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,869,638.11	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending July 31, 2014

010115	CRS FULLY INTEGRATED PLAN - MM	19,358.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,358.09	
010145	CRS ACUTE SEMI INTEGRATED - MM	213.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	213.57	
	19,571.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,571.66	

JULY	AUGUST	SEPTEMBER     OCTOBER	NOVEMBER     DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE

TOTAL

Thursday, August 21, 2014

010115	CRS FULLY INTEGRATED PLAN - KC MM	70.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.77	
	70.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.77	

Subtotal

Subtotal

19,642.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,642.43	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending July 31, 2014

078999	MERCY MARICOPA INTEGRATED - CAP	41,786,965.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,786,965.61	
	41,786,965.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,786,965.61	

JULY	AUGUST	SEPTEMBER     OCTOBER	NOVEMBER     DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE

TOTAL

Thursday, August 21, 2014

Subtotal

41,786,965.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,786,965.61	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending July 31, 2014

078999	MERCY MARICOPA INTEGRATED - MM	17,228.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,228.49	
	17,228.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,228.49	

JULY	AUGUST	SEPTEMBER     OCTOBER	NOVEMBER     DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE

TOTAL

Thursday, August 21, 2014

Subtotal

17,228.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,228.49	

GRAND TOTAL