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

December 23, 2014

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

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

SUBJECT: FY 2015 Appropriation Status Report for the Period Ended November 30,
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 November 30, 2014.

Status Summary - As part of the FY 2016 budget request to the Governor’s Office of Strategic Planning and Budgeting, a FY 2015 rebase was prepared.  AHCCCS is currently forecasting a FY 2015 Total Fund shortfall of $552.0 million.  The shortfall is primarily comprised of Federal Expenditure Authority ($489.7 million) and Hospital Assessment Expenditure Authority ($68.0 million).  The Agency also is currently projecting a General Fund surplus of $7.0 million and a CHIP fund shortfall of $1.3 million.  These amounts are all prior to administrative adjustments. AHCCCS continues to experience the impacts of the many program changes resulting from the Affordable Care Act (ACA).  There are several issues this fiscal year that have the potential to affect the projected shortfall. They include:
•	Continued volatility in caseload growth and prior period expenditures.
•	Ongoing implementation of the ACA primary care physician rate increase.
•	Implementation of the hospital presumptive eligibility program effective January 1, 2015.
•	Implementation of the first ACA health insurer fee payment, which became effective
January 1, 2014.
•	Potential Agency audit liabilities, which are detailed in the ASR.

AHCCCS intends to utilize surplus FY 2014 General Fund and Expenditure Authority for administrative adjustments of expenditures with dates of service prior to July 1, 2014.  These administrative adjustments will reduce the projected Expenditure Authority shortfall.

The Hospital Assessment shortfall of $68.0 million is against the FY 2015 appropriation of
$204.6 million.  However, the current assessment rate for FY 2015 is $233.1 million; therefore the shortfall to actual collections is $39.5 million.  On December 15th, AHCCCS posted a proposed rule change that would increase the FY 2015 assessment collections to $270.0 million

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 December 23, 2014
Page 2

with the increased payments beginning with the January billings.   This proposed rule can be viewed here:  http://www.azahcccs.gov/reporting/state/proposedrules.aspx.

The $552.0 million Total Fund shortfall also includes an estimated administrative shortfall of
$9.0 million Total Fund ($2.8 million General Fund) associated with the historical underfunding of the Arizona Department of Administration Data Center requirements.

Given these program changes and issues, for purposes of this report, projected annual expenditures equal the FY 2015 appropriations.

Enrollment Update  – November 2014 enrollment is 1,629,527 members, an 11,889 member decrease over the prior month.  Enrollment for December 2014 increased to 1,636,484 members, a  6,957 member increase.  Major December changes by eligibility category include: 1931 for Families and Children - decrease of 6,573; SOBRA Children – increase of 2,854; Transitional Medical Assistance – increase of 1,311; Prop 204 Restoration - increase of 5,498; Adult Expansion - increase of 1,575; and Emergency Services - increase of 1,206.

Tobacco Funds  Revenue Update  – Tobacco tax collections through November 2014 are $1.2 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

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 November 30, 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………………………………10

Appropriation Status Report

Appropriated Sources and
Uses	of	Funds

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 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		$	34,498,800		$	31,228,449		$	3,270,351		$	81,923,000		$	-	
AHCCCS Prop 204 Administration	6,863,900		2,888,600		3,014,701		(126,101)		6,863,900		-	
DES Eligibility	54,874,500		23,133,900		24,628,812		(1,494,912)		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		16,178,400		2,671,228		13,507,172		38,358,700		-	
TOTAL ADMINISTRATION	182,020,100		76,699,700		61,543,191		15,156,509		182,020,100		-	

Traditional Medicaid Services	3,816,084,500		1,420,760,900		1,339,861,032		80,899,868		3,816,084,500		-	
Proposition 204 Services	2,025,717,900		777,394,400		897,793,350		(120,398,950)		2,025,717,900		-	
ACA Adult Expansion	227,369,700		76,350,300		59,596,660		16,753,640		227,369,700		-	
Children's Rehabilitative Services	196,042,400		79,890,900		85,840,978		(5,950,078)		196,042,400		-	
KidsCare Services	6,223,000		1,546,200		2,293,421		(747,221)		6,223,000		-	
ALTCS Services	1,344,569,500		539,635,800		533,094,715		6,541,085		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		62,398,370	62,398,370	-	253,791,900		-	
TOTAL PROGRAMMATIC	7,905,936,000		2,957,976,870		2,980,878,525		(22,901,655)		7,905,936,000		-	

$	8,087,956,100		$    3,034,676,570		$   3,042,421,716		$	(7,745,145)		$  8,087,956,100		$	-	

TOTAL EXPENDITURES

ARIZONA  HEALTH  CARE  COST  CONTAINMENT   SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending November 30, 2014
APPROPRIATED EXPENDITURES BY FUNDING SOURCE

ANNUAL APPROPRIATION

STATE - GENERAL FUND	(A)	(B)	(A) - (B)		
		EXPENDITURE PLAN	
EXPENDITURES	
VARIANCE	PROJECTED ANNUAL	
ANNUALIZED	
		YTD	YTD	YTD	EXPENDITURES	VARIANCE	

Administrative Expenditures	
$ 	52,984,500	
$ 	22,329,800	
$ 	19,439,383	
2,890,417	
$ 	52,984,500	
$ 	-	
Proposition 204 - Administrative Expenditures	19,658,700	8,290,200	2,173,694	6,116,506	19,658,700	-	
Programmatic Expenditures
Traditional Medicaid Services	
883,358,000	
325,468,500	
326,042,144	
(573,644)	
883,358,000	
-	
Proposition 204 Services	77,000,000	43,202,200	37,316,080	5,886,120	77,000,000	-	
Children's Rehabilitative Services	62,248,100	25,861,300	29,249,928	(3,388,628)	62,248,100	-	
KidsCare Services	1,257,200	289,100	366,314	(77,214)	1,257,200	-	
ALTCS Services	167,797,400	67,597,600	69,935,751	(2,338,151)	167,797,400	-	
DSH and Rural Hospitals 	10,099,300 	- 	- 	- 	10,099,300 	-
TOTAL GF EXPENDITURES 	1,274,403,200 	493,038,700 	484,523,293 	8,515,407 	1,274,403,200 	-

	FEDERAL		

Administrative Expenditures		
83,696,900		
35,254,600		
36,362,040		
(1,107,440)		
83,696,900		
-	
Proposition 204 - Administrative Expenditures		22,179,500		9,349,300		3,512,236		5,837,064		22,179,500		-	
Programmatic Expenditures													
Traditional Medicaid Services		2,575,804,300		946,202,800		862,321,580		83,881,220		2,575,804,300		-	
Proposition 204 Services		1,587,663,200		607,679,800		721,119,246		(113,439,446)		1,587,663,200		-	
ACA Adult Expansion		227,369,700		76,350,300		59,596,660		16,753,640		227,369,700		-	
Children's Rehabilitative Services		133,794,300		54,029,600		56,591,050		(2,561,450)		133,794,300		-	
KidsCare Services		4,595,800		1,097,500		1,641,762		(544,262)		4,595,800		-	
ALTCS Services and Nursing Facility Assessment		895,343,500		359,028,500		344,541,108		14,487,392		895,343,500		-	
DSH and Rural Hospitals		26,037,800		-		-		-		26,037,800		-	
Voluntary Political Subdivision Programs - See Note 5		173,644,800		41,780,905		41,780,905		-		173,644,800		-	
TOTAL FEDERAL EXPENDITURES		5,730,129,800		2,130,773,305		2,127,466,586		3,306,719		5,730,129,800		-	
	COUNTY												

Traditional Medicaid Services Acute Care
ALTCS Services
TOTAL COUNTY EXPENDITURES	50,199,900		20,916,500		20,916,500		-		50,199,900		-	
	245,196,200		98,786,800		99,461,300		(674,500)		245,196,200		-	
	298,780,500		121,130,800		120,377,800		753,000		298,780,500		-	
	TOBACCO FUNDS												
Programmatic Expenditures
Traditional Medicaid Services Acute Care - Medically Needy		
34,178,800		
14,694,000		
16,841,396		
(2,147,396)		
34,178,800		
-	
Proposition 204 Services - Emergency Health Services		18,202,400		7,780,000		7,969,050		(189,050)		18,202,400		-	
Proposition 204 Services - Proposition 204 Protection
Proposition 204 Services - ATLSF		38,225,000
100,000,000		16,433,600
-		16,735,005
-		(301,405)
-		38,225,000
100,000,000		-
-	
TOTAL TOBACCO EXPENDITURES		190,606,200		38,907,600		41,545,451		(2,637,851)		190,606,200		-	
	OTHER												
Administrative Expenditures
Prescription Drug Rebate Program		
116,100		
48,300		
55,838		
(7,538)		
116,100		
-	
Acute Care - Prescription Drug Rebate Program State Match		73,756,400		30,731,700		30,731,833		(133)		73,756,400		-	
Acute Care - Prescription Drug Rebate Program Federal Authority		198,561,200		82,734,000		82,663,231		70,769		198,561,200		-	
Long Term Care - Prescription Drug Rebate Program State Match		5,162,500		2,074,200		2,151,042		(76,842)		5,162,500		-	
Long Term Care - Prescription Drug Rebate Program Federal Authori	ty	13,898,100		5,584,200		10,055,998		(4,471,798)		13,898,100		-	
Proposition 204 Services - Hospital Assessment		204,627,300		102,298,800		114,653,970		(12,355,170)		204,627,300		-	
Traditional Medicaid Services - TPL		194,700		-		326,904		(326,904)		194,700		-	
ALTCS Services - TPL		-		-		369,848		(369,848)		-		-	
ALTCS Services - Nursing Facility Assessment		17,171,800		6,564,500		6,579,668		(15,168)		17,171,800		-	
KidsCare Services Premiums		370,000		159,600		285,345		(125,745)		370,000		-	
Freedom to Work Premiums		31,200		13,400		17,443		(4,043)		31,200		-	
Voluntary Political Subdivision Programs - See Note 5		80,147,100		20,617,466		20,617,466		-		80,147,100		-	
TOTAL OTHER  EXPENDITURES 	594,036,400 	250,826,166 	268,508,586 	(17,682,420) 	594,036,400 	-	
	TOTAL												

Administrative Expenditures		
182,020,100		
76,699,700		
61,543,191		
15,156,509		
182,020,100		
-	
Acute Care		6,561,366,500		2,418,341,070		2,447,783,810		(29,442,740)		6,561,366,500		-	
Long Term Care		1,344,569,500		539,635,800		533,094,714		6,541,086		1,344,569,500		-	
TOTAL EXPENDITURES	$	8,087,956,100		$ 	3,034,676,570		$ 	3,042,421,716		$ 	(7,745,145)		$ 	8,087,956,100		$ 	-	

Administrative Expenditures Proposition 204 - BNCF 	3,384,400 	1,427,500 	- 	1,427,500 	3,384,400 	- Programmatic Expenditures

Programmatic Expenditures

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2015 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE  AND OTHER COLLECTIONS RECEIVED  DETAIL SCHEDULE For the Period Ending November  30, 2014

BUDGET 	BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,008,689,900		$	373,659,600		$	374,731,455	
Proposition 204 Services & Administrative	96,658,700		51,492,400		39,427,160	
KidsCare Services	1,257,200		289,100		366,314	
ALTCS Services	167,797,400		67,597,600		69,935,751	
TOTAL	1,274,403,200		493,038,700		484,460,679	

FEDERAL:
Acute & Administrative	4,830,190,500		1,770,647,305		2,141,275,407	
KidsCare Services	4,595,800		1,097,500		2,799,577	
ALTCS Services	895,343,500		359,028,500		345,982,097	
TOTAL	5,730,129,800		2,130,773,305		2,490,057,081	

COUNTY:
Acute & Administrative	53,584,300		22,344,000		22,182,926	
ALTCS Services	245,196,200		98,786,800		102,165,090	
TOTAL	298,780,500		121,130,800		124,348,016	

TOBACCO FUNDS:
Traditional Medicaid Services	34,178,800		14,694,000		16,841,396	
Proposition 204 Services	156,427,400		24,213,600		24,704,055	
TOTAL	190,606,200		38,907,600		41,545,451	

OTHER:
Administrative	116,100	48,300	55,838	
Acute Care - Prescription Drug Rebate Program	272,317,600	113,465,700	113,395,065	
Long Term Care - Prescription Drug Rebate Program	19,060,600	7,658,400	12,207,040	
Hospital Assessment	204,627,300	102,298,800	116,490,277	
ALTCS - Nursing Facility Assessment	17,171,800	6,564,500	7,869,012	
Acute TPL - Note 1	194,700	-	326,904	
LTC TPL - Note 1	-	-	369,848	
KidsCare TPL - Note 1	-	-	668	
Member Premiums - CHIP	370,000	159,600	293,341	
Member Premiums - Freedom to Work	31,200	13,400	17,443	
Voluntary Political Subdivision - State Match	80,147,100	20,617,466	24,414,224
TOTAL	594,036,400	250,826,166	275,439,659

TOTAL REVENUE

$	8,087,956,100

$	3,034,676,570

$	3,415,850,886

Appropriation Status Report

Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending November 30, 2014

Note 1:	Third Party Liability Collections: Gross Collections:	November 2014		November 2013		July 1, 2014
November 30, 2014		July 1, 2013
November 30, 2013	
	Acute	$ 	417,633		$ 	1,454,428		$ 	2,467,244		$ 	4,292,614	
	LTC	270,299		365,468		1,578,504		1,772,121	
	KidsCare	1,239		118		3,412		3,655	
	Total TPL Collections	$ 	689,171		$ 	1,820,014		$ 	4,049,160		$ 	6,068,390	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$ 	56,315		$ 	54,779		$ 	326,904		$ 	451,908	
LTC	60,435		88,757		369,848		433,826	
KidsCare	246		23		668		743	
Total Expenditure Offsets	$ 	116,996		$ 	143,559		$ 	697,420		$ 	886,477	

FY 15 Total
Note 2:    Authorized Positions 	1,032.2
Actual Positions as of November 30, 2014 	935.4

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending November 30, 2014

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2014	

$    2,106,203	
	Revenues	3,008,095	
	Transfers-In	73,625	
	Total Revenues	3,081,720	
	
Expenditures	
3,017,254	
	Transfers-out	247,500	
	Total Expenditures	3,264,754	

Ending Balance November 30, 2014

$    1,923,168

Of the $1,923,168 ending balance, $997,000 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through January 2015.

Note 4:

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

Schedule of Outstanding Liabilities
As of November 30, 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	
Deferral - Extrapolated Error for Adults with Medicare		999,946		CMS Region IX Financial Review	
		39,864,790			

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending November 30, 2014

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of  November 30, 2014
Expenditures

State Match 	Federal 	Total

DSH Voluntary

$ 	1,093,784 	$

2,314,688 	$

3,408,472

GME Voluntary 	16,201,076 	32,659,894 	48,860,970
Safety Net Care Pool 	3,322,606 	6,806,322 	10,128,928

Total Voluntary Political Subdivision Program Expenditures

$ 	20,617,466 	$

41,780,905 	$

62,398,370

Note 6:

The following is a summary of $189,812,646 Total Fund ($42,000,445 General Fund) administrative adjustment transactions processed through November 2014 that either pay for or transfer expenditures with dates of service prior to June 30, 2014.

	FY 2014 YTD November 30, 2014		
General	AHCCCS	Total	
Fund	Fund	Fund	

Traditional Medicaid Services	$ 	32,765,707		$ 	91,303,644		$ 	124,069,352	
Proposition 204 Services	-		46,999,659		46,999,659	
ACA Adult Expansion	-		8,877,048		8,877,048	
KidsCare - Children Services	197,502		587,991		785,493	
Children's Rehabilitative Services	9,037,236		43,858		9,081,094	

Total

$ 	42,000,445 	$

147,812,201 	$

189,812,646

Appropriation Status Report

Caseload	and	Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending November 30, 2014

TITLE XIX TRADITIONAL

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

TOTAL

SUBTOTAL

CAPITATION - ACUTE	245,320,411	239,192,585	241,768,268	250,886,513	245,752,693	0	0	0	0	0	0	0	1,222,920,470	
CAPITATION - LTC	172,652,192	182,816,155	174,463,368	175,962,165	185,797,934	0	0	0	0	0	0	0	891,691,815	
MENTAL HEALTH - CHILD	22,940,496	23,328,678	23,618,875	23,718,681	23,302,936	0	0	0	0	0	0	0	116,909,666	
MENTAL HEALTH - ADULT	9,246,123	9,421,167	9,546,463	10,182,445	10,043,576	0	0	0	0	0	0	0	48,439,774	
MENTAL HEALTH - GENERAL	13,514,010	13,769,852	13,952,983	13,247,385	13,066,716	0	0	0	0	0	0	0	67,550,947	
MENTAL HEALTH - CMDP	16,576,107	16,638,148	16,847,957	13,954,363	13,986,708	0	0	0	0	0	0	0	78,003,282	
CHILDREN'S REHAB SERVICES	0	3,438,525	3,443,676	3,631,689	3,634,760	0	0	0	0	0	0	0	14,148,649	
FEE FOR SERVICE - ACUTE	46,280,515	40,298,729	44,272,778	40,509,119	39,380,058	0	0	0	0	0	0	0	210,741,198	
FFS - PRIOR QUARTER COVERAGE	57,282	163,600	272,725	299,665	290,401	0	0	0	0	0	0	0	1,083,673	
EMERGENCY SERVICES - FEDERAL	6,645,181	5,482,311	6,208,134	4,523,950	5,454,738	0	0	0	0	0	0	0	28,314,315	
FEDERAL ESP CHRONIC SERVICES	0	0	0	866	-866	0	0	0	0	0	0	0	0	
FFS - FAMILY PLANNING	0	1,058	0	0	0	0	0	0	0	0	0	0	1,058	
FFS MEDICAID IN PUBLIC SCHOOLS	774,806	348,803	291,958	518,796	608,174	0	0	0	0	0	0	0	2,542,536	
QMB - FEE FOR SERVICE	227,508	323,662	198,991	336,158	204,441	0	0	0	0	0	0	0	1,290,760	
INPATIENT INMATES FFS	139,514	117,313	118,780	356,263	172,449	0	0	0	0	0	0	0	904,319	
PINAL COUNTY INMATES FFS	1,230	2,048	18,368	481	3,910	0	0	0	0	0	0	0	26,037	
PIMA COUNTY INMATES FFS	7,294	6,199	3,724	754	6,755	0	0	0	0	0	0	0	24,725	
MARICOPA CTY INMATES FFS	5,034	2,562	11,151	9,287	15,401	0	0	0	0	0	0	0	43,436	
COCONINO COUNTY INMATES FFS	0	0	5,262	177	7	0	0	0	0	0	0	0	5,447	
FEE FOR SERVICE - LTC	10,677,186	9,403,354	9,497,170	10,317,996	9,250,858	0	0	0	0	0	0	0	49,146,564	
LFFS - PRIOR QUARTER COVERAGE	26,197	25,830	11,048	31,446	50,419	0	0	0	0	0	0	0	144,941	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,542,730	723,907	561,690	757,325	1,048,464	0	0	0	0	0	0	0	4,634,115	
REINSURANCE - ACUTE	10,003,289	5,027,836	10,574,231	6,348,464	10,707,695	0	0	0	0	0	0	0	42,661,514	
REINSURANCE - LTC	3,351,665	3,591,474	5,326,752	4,738,880	4,481,860	0	0	0	0	0	0	0	21,490,630	
SMIB - ACUTE	10,410,873	10,627,744	9,836,640	10,393,368	10,560,534	0	0	0	0	0	0	0	51,829,159	
HIB - ACUTE	58,792	272,446	259,042	269,952	274,700	0	0	0	0	0	0	0	1,134,932	
Q1	1,627,402	1,621,788	1,982,590	1,886,090	1,928,654	0	0	0	0	0	0	0	9,046,524	
SMIB - LTC	2,760,557	2,776,428	2,783,315	2,794,573	2,815,470	0	0	0	0	0	0	0	13,930,344	
HIB - LTC	121,568	275,913	266,525	277,911	272,522	0	0	0	0	0	0	0	1,214,439	
	574,967,964	569,698,114	576,142,462	575,954,762	583,111,966	0	0	0	0	0	0	0	2,879,875,268	

TITLE XIX PROP 204

CAPITATION - ACUTE	165,540,913	158,127,081	161,630,611	164,729,420	168,280,548	0	0	0	0	0	0	0	818,308,574	
MENTAL HEALTH - CHILD	198,164	198,016	199,318	198,959	194,576	0	0	0	0	0	0	0	989,033	
MENTAL HEALTH - ADULT	12,147,475	12,671,268	13,065,174	14,220,214	14,303,623	0	0	0	0	0	0	0	66,407,754	
MENTAL HEALTH - GENERAL	17,754,588	18,520,157	19,095,884	18,500,532	18,609,047	0	0	0	0	0	0	0	92,480,208	
CHILDREN'S REHAB SERVICES	0	14,970	13,789	13,759	14,593	0	0	0	0	0	0	0	57,110	
FEE FOR SERVICE - ACUTE	26,275,199	24,092,157	26,903,237	24,234,346	22,861,010	0	0	0	0	0	0	0	124,365,950	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending November 30, 2014

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

TOTAL

SUBTOTAL

FFS - PRIOR QUARTER COVERAGE	51,967	316,151	600,030	726,185	811,441	0	0	0	0	0	0	0	2,505,775	
EMERGENCY SERVICES - FEDERAL	2,558,131	2,365,512	1,269,651	-678,159	919,746	0	0	0	0	0	0	0	6,434,881	
FFS MEDICAID IN PUBLIC SCHOOLS	5,265	1,979	1,613	4,445	4,645	0	0	0	0	0	0	0	17,947	
INPATIENT INMATES FFS	487,478	518,149	471,810	624,268	281,204	0	0	0	0	0	0	0	2,382,908	
YAVAPAI COUNTY INMATES FFS	0	0	277	0	0	0	0	0	0	0	0	0	277	
PINAL COUNTY INMATES FFS	82,861	48,485	8,563	33,510	7,205	0	0	0	0	0	0	0	180,625	
PIMA COUNTY INMATES FFS	4,443	35,007	0	0	4,290	0	0	0	0	0	0	0	43,740	
MARICOPA CTY INMATES FFS	13,089	6,331	23,649	22,129	68,390	0	0	0	0	0	0	0	133,587	
REINSURANCE - ACUTE	2,324,980	1,717,925	3,003,472	1,858,149	2,450,778	0	0	0	0	0	0	0	11,355,304	
SMIB - ACUTE	3,453,454	3,793,307	4,108,084	4,173,881	4,238,165	0	0	0	0	0	0	0	19,766,891	
HIB - ACUTE	2,806	1,938	1,938	1,938	3,216	0	0	0	0	0	0	0	11,836	
	230,900,813	222,428,433	230,397,099	228,663,575	233,052,479	0	0	0	0	0	0	0	1,145,442,399	

CAPITATION - ACUTE	12,619,971	10,570,632	11,073,861	10,138,731	10,847,740	0	0	0	0	0	0	0	55,250,934	
MENTAL HEALTH - ADULT	777,287	863,773	902,646	1,011,393	1,045,177	0	0	0	0	0	0	0	4,600,275	
MENTAL HEALTH - GENERAL	1,136,072	1,262,478	1,319,296	1,315,824	1,359,778	0	0	0	0	0	0	0	6,393,449	
FEE FOR SERVICE - ACUTE	1,065,235	970,725	1,334,264	1,086,740	955,345	0	0	0	0	0	0	0	5,412,309	
FFS - PRIOR QUARTER COVERAGE	8,502	36,286	94,224	115,698	61,348	0	0	0	0	0	0	0	316,057	
EMERGENCY SERVICES - FEDERAL	134,592	90,936	1,261,768	2,877,561	1,282,684	0	0	0	0	0	0	0	5,647,542	
FEDERAL ESP CHRONIC SERVICES	0	0	0	2,972	0	0	0	0	0	0	0	0	2,972	
INPATIENT INMATES FFS	0	0	23,257	5,476	68,758	0	0	0	0	0	0	0	97,490	
REINSURANCE - ACUTE	22,287	20,209	101,574	92,355	115,860	0	0	0	0	0	0	0	352,285	
SMIB - ACUTE	1,259	839	1,678	1,783	1,154	0	0	0	0	0	0	0	6,714	
	15,765,205	13,815,878	16,112,569	16,648,532	15,737,843	0	0	0	0	0	0	0	78,080,026	
	821,633,982	805,942,426	822,652,130	821,266,869	831,902,288	0	0	0	0	0	0	0	4,103,397,694	

TITLE XIX ACA ADULT EXPANSION

SUBTOTAL

TOTAL TITLE XIX

TITLE XXI KIDSCARE

KidsCare - CAPITATION	317,922	319,265	311,917	324,342	320,128	0	0	0	0	0	0	0	1,593,574	
KidsCare - FEE FOR SERVICE	20,033	15,148	7,669	3,767	3,981	0	0	0	0	0	0	0	50,598	
KidsCare - MENTAL HEALTH	73,362	72,703	72,045	70,846	69,737	0	0	0	0	0	0	0	358,694	
KidsCare - REINSURANCE	-99,947	14,868	81,730	564	27,047	0	0	0	0	0	0	0	24,261	
KidsCare - CHILD REHAB SERVICES	0	394	394	417	417	0	0	0	0	0	0	0	1,622	

311,369	422,379	473,754	399,936	421,310	0	0	0	0	0	0	0	2,028,748	

TOTAL TITLE XXI

821,945,351	806,364,804	823,125,884	821,666,805	832,323,598	0	0	0	0	0	0	0	4,105,426,442	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 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	217.11	104.87	110.47	110.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	760.03

1006	TANF 21-44 MALE WITH	28,781.97	29,606.16	22,489.87	24,204.78	20,700.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125,783.58

1007	TANF 21-44 FEMALE WI	114,269.17	118,106.00	119,978.28	129,844.18	125,121.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	607,318.94

1008	TANF 45-64 M & F WIT	84,108.25	89,927.78	94,307.26	104,102.12	95,198.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	467,643.90

1009	TANF 65+ M & F WITH	21,484.01	20,398.00	20,925.41	25,007.51	23,095.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,910.23

100F	TANF 21-44 MALE WITH	1,342.88	55.35	872.59	351.90	484.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,107.23

100G	TANF 21-44 FEMALE WI	3,762.11	2,684.84	841.74	3,224.55	2,067.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,581.14

100H	TANF 44-64 M & F WIT	8,995.65	2,560.05	2,390.16	4,872.53	1,031.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,849.84

100J	TANF 65+ M & F WITH	1,372.61	214.32	3,333.60	667.70	289.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,877.63

1011	TANF <1 M & F NON-ME	6,944,671.01	6,919,746.18	7,043,273.83	7,340,790.92	7,203,773.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,452,255.86

1012	TANF 01-05 M & F NON	9,414,595.75	9,457,042.75	9,464,811.82	9,900,211.41	9,687,537.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,924,198.86

1013	TANF 06-13 M & F NON	14,757,003.85    14,854,266.05     14,975,745.61     15,770,078.14     15,496,004.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,853,097.81

1014	TANF 14-20 MALE NON-	4,095,717.18	4,143,634.80	4,179,158.04	4,438,752.77	4,433,460.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,290,723.23

1015	TANF 14-20 FEMALE N O

7,425,976.83	7,468,371.33	7,533,766.81	7,964,925.01	7,859,834.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,252,874.72

1016	TANF 21-44 MALE NON-	3,488,064.87	3,556,434.91	3,606,724.83	3,781,994.65	3,718,881.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,152,100.69

1017	TANF 21-44 FEMALE N O

21,669,669.50    22,093,834.23     22,370,681.56     23,610,003.57     23,242,606.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	112,986,794.86

1018	TANF 45-64 M & F NON	7,373,544.96	7,522,689.37	7,664,363.89	8,016,120.20	8,049,355.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,626,074.16

1019	TANF 65+ M & F NON-M	21,729.03	24,032.79	24,944.73	23,717.54	22,795.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	117,219.44

101A	TANF < 1 M & F NON-M	376,288.07	381,373.40	359,779.22	411,453.00	357,013.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,885,907.53

101B	TANF 01-05 M & F NON	187,236.57	166,174.01	139,408.00	157,915.78	152,952.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	803,686.94

101C	TANF 06-13 M & F NON	223,211.63	202,174.91	168,521.24	174,604.46	172,316.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	940,829.08

101D	TANF 14-20 MALE NON-	138,442.93	139,162.10	106,459.42	113,930.58	103,773.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	601,769.02

101E	TANF 14-20 FEMALE N O

244,533.70	199,126.82	167,992.36	179,404.63	145,439.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	936,497.25

101F	TANF 21-44 MALE NON-	562,829.25	205,145.88	181,413.75	176,459.37	166,735.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,292,583.50

101G	TANF 21-44 FEMALE N O

1,456,806.28	679,825.09	617,006.12	595,290.09	617,304.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,966,232.47

101H	TANF 44-64 M & F NON	1,442,455.59	387,196.22	379,269.30	234,508.79	291,425.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,734,855.02

101J	TANF 65+ N & F NON-M	10,089.16	1,333.72	2,057.69	-382.34	1,307.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,405.69

1026	TANF 21-44 MALE WITH	165.98	324.87	567.02	909.50	3,283.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,251.36

1027	TANF 21-44 FEMALE WI	6,723.14	6,476.82	9,589.29	13,371.10	12,641.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,801.77

1028	TANF 45-64 M & F WIT	2,004.87	2,570.40	3,427.81	5,168.81	7,807.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,978.96

1029	TANF 65+ M & F WITH	727.32	729.10	1,511.49	1,532.34	1,165.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,665.52

102F	TANF 21-44 MALE WITH	0.00	0.00	59.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59.87

102J	TANF 65+ M & F WITH	0.00	0.00	10.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.55

2100	SSI AGED WITH MEDIC A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDIC
AR

682,116.95	665,548.05	675,360.22	689,644.65	673,487.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,386,157.65

84,778.64	36,520.03	17,286.95	22,552.34	15,938.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	177,076.84

4,592,127.22	4,730,015.83	4,736,543.75	5,044,668.40	5,053,970.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,157,325.85

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

211Z	SSI AGED NON-MEDIC AR

906,703.14	450,324.83	325,452.91	211,742.26	239,796.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,134,019.43

2120	SSI AGED WITH QMB	3,619,137.72	3,709,809.90	3,733,678.97	3,791,306.52	3,756,897.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,610,830.20

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	21,261.96	14,694.28	14,818.73	26,077.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116,747.74

1,620,418.47	1,652,777.49	1,640,988.05	1,802,103.68	1,697,117.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,413,405.58

61,688.36	27,741.11	18,277.11	21,663.06	16,726.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,096.17

54,178,004.81    54,186,330.75     54,140,342.06     55,990,760.45     55,929,755.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	274,425,193.67

1,411,266.35	841,644.53	641,017.98	508,757.42	536,770.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,939,456.44

10,511,923.37    10,469,394.95     10,565,310.14     10,536,986.13     10,466,175.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,549,789.68

8,859.10	9,858.59	3,731.42	3,377.54	2,464.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,291.24

2300	SSI BLIND WITH MEDIC	8,180.98	8,297.65	5,559.30	5,860.72	5,008.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,907.25

230Z	SSI BLIND WITH MEDIC	153.11	0.00	0.00	257.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	410.15

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

333,362.58	333,314.84	333,723.66	349,198.67	348,076.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,697,676.04

4,907.37	3,051.36	7,642.71	11,145.34	4,120.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,866.89

2320	SSI BLIND WITH QMB	38,091.63	39,048.80	39,534.51	39,685.51	39,537.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	195,898.10

4301	SOBRA CHILD <1 M & F	435.64	810.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,246.58

4302	SOBRA CHILD 01-05 M	790.45	949.17	26.41	99.43	99.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,964.89

4303	SOBRA CHILD 06-13 M	104.88	148.65	0.00	0.00	103.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	356.64

4304	SOBRA CHILD 14-20 MA	0.00	285.74	0.00	147.65	160.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	593.54

4305	SOBRA CHILD 14-20 FE	741.22	741.22	741.22	779.16	779.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,781.98

430A	SOBRA CHILD < 1 M &	0.00	207.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	207.66

430B	SOBRA CHILD 01-05 M	311.15	623.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	934.64

430C	SOBRA CHILD 06-13 M	0.00	517.86	0.00	0.00	291.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	809.81

430D	SOBRA CHILD 14-20 MA	0.00	299.78	0.00	168.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	468.39

4311	SOBRA CHILD <1 M & F     14,931,100.78    14,903,350.86     15,110,659.57     15,873,784.67     15,646,688.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,465,584.59

4312	SOBRA CHILD 01-05 M	11,567,920.84    11,736,190.48     11,794,150.66     12,469,827.81     12,300,762.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,868,852.47

4313	SOBRA CHILD 06-13 M	14,237,741.80    14,487,484.30     14,774,732.84     15,658,558.40     15,550,642.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,709,159.79

4314	SOBRA CHILD 14-20 MA	5,097,057.78	5,213,195.58	5,289,993.32	5,598,962.84	5,537,610.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,736,820.21

4315	SOBRA CHILD 14-20 FE	7,623,275.34	7,771,537.81	7,855,064.26	8,316,460.69	8,202,066.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,768,404.86

431A	SOBRA CHILD < 1 M &	1,214,271.08	737,223.55	823,890.18	739,897.03	859,180.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,374,462.33

431B	SOBRA CHILD 01-05 M	627,471.65	335,309.44	312,814.81	290,423.29	293,264.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,859,283.77

431C	SOBRA CHILD 6-13 M& F

674,986.02	367,543.08	325,950.59	299,186.74	278,592.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,946,259.25

431D	SOBRA CHILD 14-20 MA	640,855.23	305,564.40	248,468.19	238,815.69	227,875.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,661,579.39

431E	SOBRA CHILD 14-20 FE	720,865.32	353,182.53	322,197.87	282,684.42	275,464.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,954,394.66

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M

21,833.03	22,940.47	24,900.15	25,248.13	31,205.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,127.10

1,697.44	1,259.47	1,259.47	1,318.07	1,318.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,852.52

411.89	2,270.17	121.17	666.48	1,221.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,691.44

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT

0.00	0.00	228.55	394.56	326.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	949.18

746,510.58	755,732.48	766,591.83	774,695.29	762,603.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,806,133.39

2,581,731.79	2,593,995.79	2,553,661.22	2,670,239.86	2,604,827.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,004,456.13

20,379.89	17,127.95	17,296.31	17,117.25	17,657.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,579.38

0.00	0.00	0.00	66.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66.92

95,588.48	92,529.29	72,717.87	71,213.97	69,082.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	401,131.80

302,251.20	254,788.69	250,382.55	248,879.06	241,477.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,297,779.13

3,747.04	650.37	4,050.44	1,776.35	1,800.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,024.80

4,767.49	3,535.74	3,779.29	3,550.08	6,644.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,276.96

0.00	407.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	407.18

-25.48	-222.08	-215.19	0.00	-39.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-502.02

SUBTOTAL:

219,325,258.77

215,820,558.09   216,718,395.63   225,832,636.97   223,739,145.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,101,435,994.96

31,621,250.15	
285,144.46	
1,001,291.45	
54,254,126.43	
87,161,812.49	

E

00

9910	TANF & SOBRA CHILDR	6,571,134.40	6,179,708.87	6,623,616.05	6,325,435.24	5,921,355.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	59,951.62	40,761.17	88,298.65	65,641.81	30,491.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	255,183.61	158,774.68	186,447.87	224,873.16	176,012.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	11,246,691.84	10,572,592.25	11,574,315.84	11,668,848.01	9,191,678.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	18,132,961.47	16,951,836.97	18,472,678.41	18,284,798.22	15,319,537.42	0.00	0.00	0.00	0.00	0.00	0.00	0.	

3100	TRANSPLANT OPTION
1
310Z	TRANSPLANT OPTION
1
3200	TRANSPLANT OPTION
2
320Z	TRANSPLANT OPTION
2

0.00	0.00	19.80	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85.80

0.00	0.00	29.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.70

0.00	0.00	0.00	0.00	15.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.40

0.00	0.00	0.00	0.00	17.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.60

SUBTOTAL:

0.00

0.00	49.50	33.00	66.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148.50

483.38	
1,124,446.16	
4,082,451.72	
6,306,825.69	
1,634,072.88	
23,826.10	
57,744.61	
152,162.24	
87,665.03	
95,015.90	
483,022.41	
1,554,199.17	
1,094,503.98	

1105	TANF EXPANDED 14-20	241.69	241.69	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	226,951.86	222,746.09	219,504.55	223,284.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	817,292.87	819,595.12	817,436.20	822,876.51	805,251.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	1,188,948.02	1,207,276.68	1,226,773.77	1,395,304.48	1,288,522.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1109	TANF EXPANDED 65+ M&

307,783.65	314,163.72	319,878.40	350,014.76	342,232.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110F	TANF EXPANDED 21-44	4,170.55	6,266.21	4,516.62	5,266.65	3,606.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110G	TANF EXPANDED 21-44	10,493.01	11,934.24	13,184.65	9,947.80	12,184.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110H	TANF EXPANDED 45-64	40,061.03	34,896.43	17,264.31	36,776.45	23,164.02	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	20,455.08	7,163.10	17,804.09	19,956.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00

19,671.67	17,536.46	18,187.21	18,144.58	21,475.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	92,317.79	94,334.79	94,771.51	100,017.96	101,580.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	306,399.70	307,071.24	301,164.82	322,580.64	316,982.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	210,348.15	214,471.08	216,431.16	227,941.59	225,312.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

1115	TANF EXPANDED 14-20	643,300.84	649,418.38	646,818.69	682,783.70	652,895.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,275,217.19

1116	TANF EXPANDED 21-44	4,155,213.87	4,251,758.44	4,286,958.66	4,499,685.24	4,405,812.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,599,428.68

1117	TANF EXPANDED 21-44     13,750,105.43    14,061,633.60     14,293,502.96     15,193,624.17     15,009,717.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,308,583.78

1118	TANF EXPANDED 45-64	7,883,333.47	8,136,354.70	8,279,127.20	8,722,446.81	8,693,794.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,715,057.12

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

17,823.07	20,468.09	20,106.66	25,686.73	19,036.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,121.33

3,069.23	2,215.08	4,340.03	4,089.78	4,743.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,457.59

111B	TANF EXPANDED 01-05	1,901.09	1,697.03	1,174.41	2,744.56	1,035.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,552.79

111C	TANF EXPANDED 06-13	5,213.11	5,167.03	3,167.11	7,318.93	4,226.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,092.33

111D	TANF EXPANDED 14-20	11,719.65	11,908.96	9,975.30	11,162.66	8,442.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53,209.41

111E	TANF EXPANDED 14-20	38,981.20	28,821.18	17,611.10	22,052.24	19,825.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127,291.24

111F	TANF EXPANDED 21-44	670,244.78	312,184.10	235,633.03	223,770.09	203,735.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,645,567.32

111G	TANF EXPANDED 21-44	1,430,871.86	666,063.85	503,599.59	501,095.66	467,003.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,568,634.52

111H	TANF EXPANDED 45-64	1,626,074.12	515,761.49	396,398.89	399,312.44	400,134.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,337,681.11

111J	TANF EXPANDED 65+ M&

8,192.11	5,842.05	2,447.64	10,469.17	714.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,665.35

1126	TANF EXPANDED 21-44	13,124.22	16,899.08	21,161.04	24,738.82	23,241.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,164.56

1127	TANF EXPANDED 21-44	28,106.94	29,980.28	31,155.61	34,168.88	48,526.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	171,937.94

1128	TANF EXPANDED 45-64	65,711.50	74,359.91	89,279.62	100,211.86	107,212.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	436,775.86

1129	TANF EXPANDED 65+ M&

20,594.42	25,749.49	30,073.08	35,123.44	38,148.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	149,688.79

112F	TANF EXPANDED 21-44	104.01	1,379.49	1,028.72	1,618.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,130.39

112G	TANF EXPANDED 21-44	4,554.37	932.81	169.53	913.80	-849.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,721.42

112H	TANF EXPANDED 45-64	10,330.63	14,843.52	3,145.66	5,317.31	1,623.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,260.82

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	4,278.10	73.05	0.00	3,219.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,934.64

124,966.70	108,716.83	115,454.14	130,698.88	123,815.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	603,651.87

44,875.33	35,043.96	57,888.79	48,623.03	40,920.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227,351.46

996,608.43	969,583.79	952,406.57	1,083,088.18	1,051,233.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,052,920.82

167,945.16	118,708.69	148,067.44	181,653.43	119,651.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	736,026.21

4,944,165.87	4,948,750.29	4,920,506.37	4,992,810.54	4,934,065.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,740,298.74

44,737.03	42,857.94	33,476.24	38,538.79	43,511.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	203,121.73

2,055.56	2,055.56	1,374.99	1,431.39	1,431.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,348.89

693.76	329.64	329.64	248.57	248.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,850.18

336,773.78	334,318.28	334,763.54	370,682.01	322,978.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,699,515.85

37,212.73	33,070.90	21,806.80	27,527.25	17,907.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	137,525.45

2,136,559.39	2,124,308.69	2,046,689.85	1,924,487.10	1,680,665.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,912,710.62

148,355.71	70,917.72	82,751.94	45,675.28	40,247.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	387,948.09

4,542,694.09	4,650,545.08	4,820,226.36	4,950,694.96	5,072,447.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,036,607.62

10,508.92	9,697.93	9,674.68	7,947.47	9,878.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,707.98

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	47,192,060.43	45,561,816.56	45,681,882.77	47,838,621.40	46,954,797.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	233,229,178.96		

9911	SB PAYMENT FOR TAN F
9922	SB PAYMENT FOR SSI
E
9923	SB PAYMENT FOR SSI
E

428,501.25	401,669.98	522,606.09	543,298.08	363,461.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,259,537.14	
36,821.70	
5,731.51	
2,302,090.35	

6,120.18	0.00	11,960.62	12,580.34	6,160.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	5,731.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

434,621.43

407,401.49	534,566.71	555,878.42	369,622.30	0.00	0.00	0.00	0.00	0.00	0.00

0.00

3308	AHC CARE M&F 45-64
W
330H	AHC CARE M&F 45-64
W

0.00	0.00	0.00	-1,341.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,341.18

0.00	0.00	0.00	2,308.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,308.38

3318	AHC CARE M&F 45-64 N	0.00	-425.41	0.00	-335.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-760.44

331D	AHC CARE MALE 14-20	0.00	0.00	697.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	697.08

331E	AHC CARE FEMALE 14-
2

0.00	0.00	6,631.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,631.50

331F	AHC CARE MALE 21-44	0.00	0.00	1,737.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,737.54

331G	AHC CARE FEMALE 21-
4

0.00	0.00	1,953.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,953.33

331H	AHC CARE M&F 45-64 N	0.00	683.56	0.00	-34.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	649.40

3329	AHC CARE M&F 65+ W/	0.00	0.00	0.00	-404.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-404.14

SUBTOTAL:

0.00

258.15	11,019.45	193.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,471.47

3609	AHC CARE/MI M&F 65+	0.00	0.00	0.00	801.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	801.40

3614	AHC CARE/MI MALE 14-	-2,598.60	400.70	400.70	390.16	-237.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,645.01

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	227.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227.15

3617	AHC CARE/MI FEMALE
2

389.72	759.41	401.27	416.26	416.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,382.92

3618	AHC CARE/MI M&F 45-6	461.59	-389.23	461.59	-736.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-202.45

361D	AHC CARE/MI MALE 14-	5,868.03	0.00	5,548.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,416.42

361E	AHC CARE/MI FEMALE
1

0.00	0.00	1,447.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,447.03

361F	AHC CARE/MI MALE 21-	1,336.72	-426.98	8,189.22	6,152.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,251.00

361G	AHC CARE/MI FEMALE
2

0.00	769.46	697.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,466.54

361H	AHC CARE/MI M&F 45-6	0.00	1,737.54	11,895.88	2,734.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,367.66

SUBTOTAL:

5,457.46

2,850.90	29,041.16	9,757.70	405.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,512.66

3506	ADULT 40-100% MALE
2
3507	ADULT 40-100% FEMAL
E

33,464.06	34,621.07	27,069.30	-1,570.91	32,195.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00

125,778.69	
79,832.91	
629,175.68	
96,591.42	
23,831.49	
14,141.52	
104,640.99	
63,350.37	

16,601.36	20,427.03	20,973.32	-5,640.58	27,471.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	157,124.31	164,602.55	156,469.87	437.47	150,541.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	32,520.39	31,127.48	17,308.81	-18,967.54	34,602.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350F	ADULT 40-100% MALE
2
350G	ADULT 40-100% FEMAL
E

16,508.10	3,026.60	3,425.67	871.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

7,648.32	8,772.26	2,144.63	-4,813.18	389.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350H	ADULT 40-100% M&F 45	43,819.25	31,098.90	30,467.30	-15,902.10	15,157.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350J	ADULT 40-100% M&F 65	23,188.63	10,146.73	14,551.60	7,012.79	8,450.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

819,832.68	842,828.88	840,953.28	876,800.15	893,590.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,274,005.24

1,084,483.92	1,096,915.46	1,118,914.49	1,178,156.71	1,209,908.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,688,379.24

5,172,698.34	5,528,748.17	5,767,825.62	6,142,511.46	6,309,689.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,921,473.38

4,973,808.19	5,313,599.25	5,519,892.97	5,890,072.39	6,020,533.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,717,906.54

3518	ADULT 40-100% M&F 45    11,051,769.49    11,588,667.01     11,968,092.26     12,477,221.13     12,862,482.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,948,232.11

3519	ADULT 40-100% M&F 65	5,684.54	6,036.37	14,886.80	103,787.27	6,287.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136,682.23

351D	ADULT 40-100% MALE
1
351E	ADULT 40-100% FEMAL
E
351F	ADULT 40-100% MALE
2
351G	ADULT 40-100% FEMAL
E

203,430.24	118,278.59	111,979.61	102,431.85	86,409.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	622,530.08

270,798.34	157,446.11	188,301.23	129,680.95	143,841.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	890,067.64

1,898,001.29	1,359,172.37	1,160,997.99	765,475.81	840,442.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,024,090.24

1,700,470.56	1,138,581.49	1,048,087.89	670,281.19	793,715.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,351,136.75

351H	ADULT 40-100% M&F 45	4,854,065.54	2,249,064.42	2,039,563.20	1,250,329.65	1,194,492.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,587,515.05

351J	ADULT 40-100% M&F 65	73,691.23	17,095.07	33,084.44	25,538.43	23,653.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	173,062.48

3526	ADULT 40-100% MALE
2
3527	ADULT 40-100% FEMAL
E

840.56	1,183.72	1,278.98	982.13	4,190.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,475.64

4,533.45	4,844.31	1,758.24	-127.71	1,012.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,020.62

3528	ADULT 40-100% M&F 45	10,351.94	12,732.82	9,529.39	-8,931.52	9,835.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,517.67

3529	ADULT 40-100% M&F 65	2,418.24	5,799.29	2,157.44	-888.39	3,354.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,841.25

352F	ADULT 40-100% MALE
2
352G	ADULT 40-100% FEMAL
E

727.05	0.00	0.00	-1,658.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-931.64

0.00	0.00	0.00	-1,153.77	507.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-646.17

352H	ADULT 40-100% M&F 45	8,252.49	753.78	1,894.65	-2,837.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,063.81

352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	-644.57	10,415.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,770.64

3704	ADULT <40% EXP MAL E
3705	ADULT <40% EXP FEM
AL
3706	ADULT <40% EXP MAL
E
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
370F	ADULT <40% EXP MAL
E
370G	ADULT <40% EXP FEM
AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4

358.14	358.14	767.56	372.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,856.45

863.92	891.67	891.67	924.53	924.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,496.32

66,342.05	90,906.49	64,804.70	11,629.81	85,235.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	318,918.25

27,895.47	28,762.05	25,344.58	5,617.72	34,819.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,439.13

151,258.01	181,061.18	141,318.22	19,911.72	170,772.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	664,322.02

21,725.98	17,546.12	8,954.75	-5,051.05	8,994.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,170.74

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

9,711.72	8,915.14	7,256.19	4,079.50	3,031.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,993.64

14,796.79	2,816.57	2,643.56	-3,666.11	847.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,438.52

27,786.44	11,083.34	18,874.57	2,755.54	17,182.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77,681.97

8,590.58	1,057.53	5,885.27	-3,132.01	2,174.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,575.74

4,660,701.72	4,609,307.78	4,699,719.76	4,983,993.27	4,967,501.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,921,224.14

4,120,603.82	4,068,860.79	4,176,043.28	4,436,003.45	4,455,880.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,257,391.82

20,467,726.18    21,642,151.29     22,652,596.64     24,114,702.02     24,867,544.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	113,744,720.65

13,101,290.86    13,787,135.05     14,316,548.26     15,186,356.28     15,607,747.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71,999,077.65

26,828,359.99    27,999,678.77     28,886,381.41     30,342,374.67     31,102,100.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,158,895.15

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

3719	ADULT <40% EXP M&F
6
371D	ADULT <40% EXP MAL
E
371E	ADULT <40% EXP FEM
AL
371F	ADULT <40% EXP MAL
E
371G	ADULT <40% EXP FEM
AL
371H	ADULT <40% EXP M&F
4
371J	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6
372F	ADULT <40% EXP MAL
E
372G	ADULT <40% EXP FEM
AL
372H	ADULT <40% EXP M&F
4
372J	ADULT <40% EXP M&F
6

17,618.55	21,642.08	28,214.43	57,106.51	24,073.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148,655.14

718,104.76	492,931.75	652,804.50	440,084.96	362,409.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,666,335.34

677,187.15	455,966.63	525,225.14	423,286.82	321,422.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,403,088.26

4,492,505.58	3,143,839.58	3,233,348.06	2,433,416.79	3,018,935.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,322,045.26

3,159,846.04	1,948,048.39	1,745,769.58	1,455,033.81	1,885,867.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,194,565.40

6,497,274.23	3,447,635.99	3,511,604.06	2,317,267.87	2,806,468.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,580,250.24

46,866.80	16,446.84	12,678.13	9,267.39	17,007.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	102,267.03

4,479.71	7,147.16	6,661.04	-10,771.62	2,016.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,532.48

1,735.34	5,609.88	7,359.90	1,302.88	3,335.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,343.96

4,216.78	4,186.26	13,184.14	-141.68	8,772.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,217.84

0.00	408.64	0.00	886.78	813.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,108.92

0.00	1,191.11	963.60	-89.39	160.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,225.70

0.00	0.00	0.00	736.84	412.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,149.24

2,534.24	3,919.74	140.02	-2,674.87	4,129.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,048.24

0.00	0.00	0.00	551.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	551.63

SUBTOTAL:

117,597,157.42

111,745,075.69   114,847,592.00   115,780,591.10   120,463,750.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	580,434,166.80

A

1,515.27	
66,611.51	
38,530.59	
434,947.12	
88,044.07	
19,491.70	
4,875.56	
77,839.02	
29,231.21	
999,850.56	
1,113,044.97	
9,491,865.15	
8,933,896.12	
22,182,296.76	
26,575.36	
177,188.87	

SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	98,220.75	87,414.00	107,601.65	153,761.10	103,593.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		550,591.09	
9937	BIRTH SUPP PAYMENT	213,395.97	322,263.74	418,907.69	390,616.39	388,378.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,733,562.20	
	311,616.72	409,677.74	526,509.34	544,377.49	491,972.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,284,153.29	

3905	NEWLY ELIGIBLE FEMA L

0.00	0.00	0.00	1,515.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3906	NEWLY ELIGIBLE MALE	33,568.79	28,521.13	2,763.94	-1,369.14	3,126.79	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	15,963.72	563.90	-5,494.61	1,120.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00

230,110.61	166,419.22	43,827.86	-47,085.20	41,674.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00

23,148.00	31,406.89	16,258.53	3,892.58	13,338.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390F	NEWLY ELIGIBLE MALE	14,499.62	2,357.06	922.36	-1,824.98	3,537.64	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	2,416.36	-154.91	44.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00

42,268.26	29,329.86	8,224.62	-13,824.53	11,840.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00

12,169.94	9,110.02	3,334.84	1,236.00	3,380.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	186,825.37	184,621.02	198,527.96	205,639.05	224,237.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

218,329.41	212,160.64	223,623.18	224,423.89	234,507.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	1,622,407.81	1,745,702.45	1,909,203.18	2,054,118.54	2,160,433.17	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	1,659,829.76	1,794,161.03	1,917,666.25	2,038,851.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,915,892.06	4,196,713.89	4,477,443.72	4,721,147.87	4,871,099.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,917.22	4,915.93	6,153.79	7,352.95	4,235.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391D	NEWLY ELIGIBLE MALE	46,326.46	37,457.78	56,245.94	12,760.03	24,398.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

391E	NEWLY ELIGIBLE FEMA L

55,613.58	25,265.46	58,955.65	22,327.63	27,362.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	189,525.31

391F	NEWLY ELIGIBLE MALE	857,867.49	510,673.93	582,071.35	235,075.81	247,439.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,433,127.62

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

994,884.35	500,397.47	530,077.84	215,322.26	293,231.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,533,913.89

2,753,614.91	1,167,503.66	1,110,174.16	543,175.68	566,920.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,141,388.80

22,569.38	10,407.41	10,604.84	5,326.54	3,361.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,269.24

3926	NEWLY ELIGIBLE MALE	252.25	252.25	0.00	-298.76	315.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	521.71

3927	NEWLY ELIGIBLE FEMA L
3928	NEWLY ELIGIBLE M&F
4
3929	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	-1,421.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,421.61

1,894.48	3,803.61	1,958.94	-5,879.02	631.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,409.95

329.92	1,011.25	1,123.60	-614.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,849.95

392F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	225.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225.90

392G	NEWLY ELIGIBLE FEMA L
392H	NEWLY ELIGIBLE M&F
4
392J	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	-423.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-423.69

912.30	3,364.87	0.00	-2,166.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,110.78

0.00	151.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151.15

SUBTOTAL:

12,589,736.31

10,547,340.43     11,038,637.59     10,090,648.59     10,775,089.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,041,452.84

30,234.40	23,291.43	35,223.57	48,082.27	72,649.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,481.45	
30,234.40	23,291.43	35,223.57	48,082.27	72,649.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209,481.45	

9939	BIRTH SUPP PAYMENT N
SUBTOTAL:

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

15,750.99	11,410.21	1,972.17	2,099.53	1,479.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,712.11

2,852,910.73	1,969,093.03	2,008,972.85	2,080,455.42	2,090,276.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,001,708.58

4414	SOBRA 100-133% MALE	1,102,921.39	938,252.77	987,329.79	1,052,852.22	1,061,123.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,142,479.74

4415	SOBRA 100-133% FEM AL
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

1,582,957.43	1,403,586.79	1,451,664.27	1,560,929.24	1,566,904.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,566,042.52

210.49	292.85	326.38	0.00	125.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	954.79

145,537.73	98,551.70	107,654.69	79,201.83	41,152.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	472,098.48

441D	SOBRA 100-133% MALE	179,041.42	93,546.34	91,139.52	64,152.03	46,016.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	473,895.48

441E	SOBRA 100-133% FEM AL

208,772.31	106,487.44	116,156.60	64,786.53	53,899.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	550,102.14

SUBTOTAL:

6,088,102.49

4,621,221.13	4,765,216.27	4,904,476.80	4,860,977.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,239,993.84

S
SUBTOTAL:

9944	BIRTH SUPP PAYMENT	35,479.33	29,417.65	23,549.95	24,394.66	18,450.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,292.44	
	35,479.33	29,417.65	23,549.95	24,394.66	18,450.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	131,292.44	

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

8,839.74	8,852.79	8,743.39	9,457.02	9,986.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00

45,879.74	
601,116.00	
3,020.51	
1,256.75	
10,618.86	
404.88	
41,901.42	

119,472.32	119,099.24	116,798.57	123,527.44	122,218.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,473.25	1,134.89	0.00	0.00	412.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	413.89	0.00	489.82	353.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00

448.89	3,855.31	1,234.94	515.43	4,564.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00

88.11	271.08	0.00	0.00	45.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8,119.40	8,190.07	8,139.76	8,681.81	8,770.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

4618	CC PATIENT FEMALE 4
5
461G	CC PATIENT FEMALE 2
1
461H	CC PATIENT FEMALE 4
5

7,425.15	7,949.01	7,949.01	8,007.55	8,549.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,879.89

1,050.37	37.03	557.03	292.94	19.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,957.06

724.76	0.00	0.00	688.88	431.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,844.81

SUBTOTAL:

147,641.99

149,803.31	143,422.70	151,660.89	155,351.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	747,879.92

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

111.47	111.47	111.47	110.58	110.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	555.57

1,244,519.95	1,265,826.16	1,272,816.33	1,278,006.88	1,284,932.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,346,102.30

6,724.26	10,834.42	3,136.00	9,247.26	3,859.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,801.62

177,605.31	180,687.48	192,244.62	209,764.35	204,164.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	964,465.79

18,701.90	17,782.48	34,798.68	47,955.65	20,041.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139,280.27

142,004.63	141,706.42	140,001.72	142,784.20	145,814.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	712,311.02

1,299.02	2,799.55	1,846.22	643.95	242.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,830.84

SUBTOTAL:

1,590,966.54

1,619,747.98	1,644,955.04	1,688,512.87	1,659,164.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,203,347.41

423,481,294.76	407,890,297.52	414,472,740.09	425,754,664.25	424,880,980.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,096,479,977.38	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 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	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00

1006	TANF 21-44 MALE WITH	104.67	108.97	90.78	99.76	90.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	494.98

1007	TANF 21-44 FEMALE WI	235.10	247.82	246.95	266.50	248.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,245.03

1008	TANF 45-64 M & F WIT	172.61	179.92	177.12	193.04	178.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	901.03

1009	TANF 65+ M & F WITH	55.09	52.15	54.06	62.15	56.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	280.26

100F	TANF 21-44 MALE WITH	8.20	0.35	5.19	2.14	2.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.87

100G	TANF 21-44 FEMALE WI	19.62	13.93	4.30	16.20	10.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.57

100H	TANF 44-64 M & F WIT	22.13	6.12	4.86	11.03	2.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.26

100J	TANF 65+ M & F WITH	3.89	0.67	9.92	1.74	0.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.85

1011	TANF <1 M & F NON-ME	15,270.56	15,218.68	15,485.73	15,370.64	15,096.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,442.51

1012	TANF 01-05 M & F NON	84,569.28	85,094.13	85,234.78	85,225.74	83,403.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	423,527.29

1013	TANF 06-13 M & F NON	132,621.53	133,901.83	135,264.08	135,892.47	133,564.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	671,243.91

1014	TANF 14-20 MALE NON-	25,621.38	25,952.43	26,217.60	26,576.69	26,494.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	130,862.48

1015	TANF 14-20 FEMALE N O

30,629.14	30,783.95	31,085.66	31,343.98	30,920.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	154,763.20

1016	TANF 21-44 MALE NON-	22,587.19	22,942.22	23,303.89	23,398.68	23,078.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115,310.39

1017	TANF 21-44 FEMALE N O

89,032.05	90,674.39	91,953.04	92,646.92	91,092.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	455,399.35

1018	TANF 45-64 M & F NON	18,333.22	18,688.62	18,990.56	19,101.68	19,141.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94,255.82

1019	TANF 65+ M & F NON-M	51.35	56.59	59.22	57.85	55.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	280.30

101A	TANF < 1 M & F NON-M	356.79	359.28	339.08	374.07	322.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,751.94

101B	TANF 01-05 M & F NON	3,295.48	2,935.40	2,446.17	2,718.44	2,597.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,992.53

101C	TANF 06-13 M & F NON	3,920.74	3,536.48	2,980.96	3,028.44	2,877.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,344.17

101D	TANF 14-20 MALE NON-	836.55	839.23	645.56	683.76	616.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,621.74

101E	TANF 14-20 FEMALE N O

1,255.72	1,019.24	859.65	913.15	729.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,776.91

101F	TANF 21-44 MALE NON-	3,415.15	1,238.51	1,085.00	1,059.05	999.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,797.30

101G	TANF 21-44 FEMALE N O

7,513.72	3,505.15	3,166.60	3,023.66	3,096.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,305.59

101H	TANF 44-64 M & F NON	3,472.14	936.34	917.73	556.31	696.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,579.03

101J	TANF 65+ N & F NON-M	25.59	3.01	6.26	-0.85	2.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36.86

1026	TANF 21-44 MALE WITH	1.00	2.00	3.63	6.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.63

1027	TANF 21-44 FEMALE WI	10.00	9.00	11.20	20.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67.20

1028	TANF 45-64 M & F WIT	5.00	6.77	9.00	8.00	13.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.76

1029	TANF 65+ M & F WITH	2.00	2.00	3.96	3.90	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.86

102F	TANF 21-44 MALE WITH	0.00	0.00	0.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.36

102J	TANF 65+ M & F WITH	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03

2100	SSI AGED WITH MEDIC A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDIC
AR

4,370.68	4,347.93	4,360.25	4,520.65	4,374.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,973.99

902.84	381.78	183.85	232.94	184.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,886.38

6,138.76	6,358.34	6,368.22	6,402.03	6,386.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,653.43

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014

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

211Z	SSI AGED NON-MEDIC AR

1,881.26	947.08	682.35	432.93	480.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,424.23

2120	SSI AGED WITH QMB	21,139.27	21,618.35	21,892.09	22,140.06	22,014.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,803.84

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	230.59	152.26	158.11	294.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,271.46

4,292.08	4,262.41	4,279.85	5,055.96	4,337.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,227.91

659.56	304.25	203.76	241.91	174.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,583.64

58,085.69	58,087.88	58,057.39	58,012.43	57,866.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	290,109.48

3,034.88	1,839.55	1,379.74	1,040.61	1,100.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,395.26

25,240.50	25,243.76	25,480.32	25,656.46	25,367.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,988.67

97.75	112.63	39.47	40.20	26.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	316.62

2300	SSI BLIND WITH MEDIC	32.48	33.00	30.00	31.45	30.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	157.13

230Z	SSI BLIND WITH MEDIC	1.51	0.00	0.00	2.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.05

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

427.53	426.89	427.03	425.87	424.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,132.05

9.31	5.91	15.12	21.47	9.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61.07

2320	SSI BLIND WITH QMB	204.14	203.00	205.98	207.99	206.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,027.55

4301	SOBRA CHILD <1 M & F	1.00	1.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.80

4302	SOBRA CHILD 01-05 M	1.51	3.06	-0.41	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.16

4303	SOBRA CHILD 06-13 M	1.00	1.45	0.00	0.00	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.38

4304	SOBRA CHILD 14-20 MA	0.00	2.00	0.00	0.96	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.96

4305	SOBRA CHILD 14-20 FE	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

430A	SOBRA CHILD < 1 M &	0.00	0.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.19

430B	SOBRA CHILD 01-05 M	5.48	9.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.40

430C	SOBRA CHILD 06-13 M	0.00	8.54	0.00	0.00	5.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.60

430D	SOBRA CHILD 14-20 MA	0.00	2.00	0.00	1.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.03

4311	SOBRA CHILD <1 M & F	32,941.40	32,869.17	33,321.28	33,290.96	32,832.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165,254.96

4312	SOBRA CHILD 01-05 M	99,019.99	100,577.33	101,362.18	102,197.44	100,684.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	503,841.25

4313	SOBRA CHILD 06-13 M	122,544.94	124,976.78	127,084.81	128,918.53	127,812.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	631,337.22

4314	SOBRA CHILD 14-20 MA	31,558.09	32,213.12	32,709.48	33,015.85	32,605.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162,101.97

4315	SOBRA CHILD 14-20 FE	31,209.97	31,927.15	32,288.25	32,670.19	32,213.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160,309.26

431A	SOBRA CHILD < 1 M &	1,170.89	705.34	799.14	697.40	803.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,176.35

431B	SOBRA CHILD 01-05 M	10,635.96	5,366.79	4,896.50	4,697.42	4,625.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,221.90

431C	SOBRA CHILD 6-13 M& F

11,649.29	5,833.52	4,949.60	4,555.10	4,305.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,293.08

431D	SOBRA CHILD 14-20 MA	3,814.47	1,796.34	1,462.95	1,370.65	1,324.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,768.72

431E	SOBRA CHILD 14-20 FE	3,680.89	1,770.66	1,604.02	1,393.59	1,351.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,800.48

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M

50.81	50.91	49.36	50.40	57.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.21

4.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

2.15	12.05	0.63	3.44	6.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.53

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT

0.00	0.00	1.00	2.51	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.51

3,195.16	3,227.04	3,261.98	3,154.18	3,059.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,897.40

11,094.84	11,080.86	10,947.08	10,863.14	10,515.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,501.06

51.43	43.50	44.09	42.44	44.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225.50

0.00	0.00	0.00	1.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.48

491.51	473.50	375.36	358.09	348.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,047.38

1,552.87	1,313.22	1,290.34	1,270.11	1,214.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,641.52

8.54	1.48	13.89	5.54	4.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.37

5.99	5.87	7.00	6.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.86

0.00	2.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.12

-2.03	-16.00	-16.00	0.00	-3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-37.03

SUBTOTAL:

935,093.91

916,984.24	920,878.14	925,857.20	912,526.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,611,340.39

5,297.00	
48.00	
168.00	
9,089.00	
14,602.00	

E

00

9910	TANF & SOBRA CHILDR	1,113.00	1,048.00	1,120.00	1,041.00	975.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	10.00	7.00	15.00	11.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	43.00	27.00	32.00	37.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	1,908.00	1,791.00	1,960.00	1,919.00	1,511.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,074.00	2,873.00	3,127.00	3,008.00	2,520.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

3100	TRANSPLANT OPTION
1
310Z	TRANSPLANT OPTION
1
3200	TRANSPLANT OPTION
2
320Z	TRANSPLANT OPTION
2

0.00	0.00	1.19	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.19

0.00	0.00	1.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.79

0.00	0.00	0.00	0.00	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.93

0.00	0.00	0.00	0.00	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.06

SUBTOTAL:

0.00

0.00	2.98	2.00	3.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.97

2.00	
3,930.63	
8,555.74	
12,594.35	
3,976.66	
143.82	
295.48	
374.27	
231.07	
201.68	
4,375.52	
13,575.99	
6,789.41	

1105	TANF EXPANDED 14-20	1.00	1.00	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	772.52	774.22	819.75	780.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	1,727.78	1,730.43	1,724.50	1,719.69	1,653.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	2,418.15	2,437.95	2,494.83	2,737.15	2,506.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1109	TANF EXPANDED 65+ M&

761.60	777.87	791.55	833.44	812.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110F	TANF EXPANDED 21-44	23.58	38.84	27.73	31.86	21.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110G	TANF EXPANDED 21-44	53.63	61.63	67.18	50.56	62.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110H	TANF EXPANDED 45-64	95.35	86.77	42.99	94.96	54.20	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	60.96	17.40	46.48	50.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00

41.95	37.93	39.85	37.30	44.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	844.18	871.07	883.13	894.21	882.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	2,726.58	2,736.37	2,697.06	2,737.33	2,678.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	1,344.20	1,354.93	1,368.03	1,370.14	1,352.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014

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

1115	TANF EXPANDED 14-20	2,712.20	2,747.34	2,714.84	2,752.79	2,633.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,560.88

1116	TANF EXPANDED 21-44	27,812.41	28,482.07	28,774.90	28,967.43	28,320.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,357.75

1117	TANF EXPANDED 21-44	58,482.54	59,776.19	60,790.23	61,688.83	60,828.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	301,566.63

1118	TANF EXPANDED 45-64	19,991.08	20,609.06	21,007.91	21,306.26	21,166.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104,080.98

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

45.63	52.61	51.87	65.37	47.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	262.64

2.76	2.05	4.16	3.65	4.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.77

111B	TANF EXPANDED 01-05	33.43	30.88	21.06	47.31	17.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	150.54

111C	TANF EXPANDED 06-13	91.68	94.89	55.35	127.43	70.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	439.61

111D	TANF EXPANDED 14-20	70.38	72.62	60.15	66.99	52.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	322.35

111E	TANF EXPANDED 14-20	198.05	148.93	89.81	112.12	100.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	649.00

111F	TANF EXPANDED 21-44	4,073.04	1,889.76	1,432.91	1,346.16	1,216.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,958.47

111G	TANF EXPANDED 21-44	7,379.68	3,428.17	2,588.24	2,559.07	2,338.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,294.13

111H	TANF EXPANDED 45-64	4,005.87	1,290.55	984.27	987.05	969.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,236.95

111J	TANF EXPANDED 65+ M&

21.28	17.18	6.02	21.46	1.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67.77

1126	TANF EXPANDED 21-44	32.93	39.75	49.68	57.63	63.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	242.99

1127	TANF EXPANDED 21-44	64.65	71.62	84.08	91.83	107.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419.46

1128	TANF EXPANDED 45-64	125.92	136.01	165.35	197.80	199.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	824.52

1129	TANF EXPANDED 65+ M&

49.26	60.61	71.83	81.99	88.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	352.61

112F	TANF EXPANDED 21-44	0.64	7.02	6.29	8.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.29

112G	TANF EXPANDED 21-44	23.31	4.89	0.89	4.77	-4.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.40

112H	TANF EXPANDED 45-64	23.98	40.04	8.20	13.58	5.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91.45

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	11.34	0.16	0.00	10.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.04

581.54	565.94	599.57	644.56	580.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,971.96

491.82	374.01	631.37	528.24	448.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,473.72

1,309.52	1,264.48	1,238.89	1,345.57	1,294.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,452.92

347.68	242.29	309.35	378.83	239.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,518.02

21,506.00	21,646.70	21,762.56	22,334.80	22,474.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,724.09

487.45	464.59	370.63	421.41	475.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,219.39

3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00

5.00	3.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00

603.87	594.65	641.21	908.50	647.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,395.88

395.75	352.07	238.17	313.99	201.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,501.43

1,730.47	1,749.03	1,699.19	1,627.72	1,424.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,231.05

315.29	156.53	172.63	100.03	81.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	825.52

9,091.72	9,232.20	9,509.32	9,853.08	10,007.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,693.48

113.19	110.35	107.80	89.28	112.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	532.77

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	173,132.87	166,740.69	167,182.36	170,430.74	167,128.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	844,615.08		

9911	SB PAYMENT FOR TAN F
9922	SB PAYMENT FOR SSI
E
9923	SB PAYMENT FOR SSI
E

72.00	68.00	88.00	89.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

377.00	
6.00	
1.00	
384.00	

1.00	0.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

73.00

69.00	90.00	91.00	61.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00

3308	AHC CARE M&F 45-64
W
330H	AHC CARE M&F 45-64
W

0.00	0.00	0.00	-3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-3.00

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

3318	AHC CARE M&F 45-64 N	0.00	-1.00	0.00	-0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.93

331D	AHC CARE MALE 14-20	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

331E	AHC CARE FEMALE 14-
2

0.00	0.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00

331F	AHC CARE MALE 21-44	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

331G	AHC CARE FEMALE 21-
4

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

331H	AHC CARE M&F 45-64 N	0.00	1.00	0.00	-0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.94

3329	AHC CARE M&F 65+ W/	0.00	0.00	0.00	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.00

SUBTOTAL:

0.00

0.00	15.00	-1.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.01

3609	AHC CARE/MI M&F 65+	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

3614	AHC CARE/MI MALE 14-	-6.73	1.00	1.00	1.00	-0.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4.43

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.67

3617	AHC CARE/MI FEMALE
2

0.96	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.96

3618	AHC CARE/MI M&F 45-6	1.00	-1.00	1.00	-2.00	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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

361E	AHC CARE/MI FEMALE
1

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

361F	AHC CARE/MI MALE 21-	2.00	-0.81	12.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.19

361G	AHC CARE/MI FEMALE
2

0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

361H	AHC CARE/MI M&F 45-6	0.00	2.00	16.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.00

SUBTOTAL:

5.23

4.19	42.00	15.00	0.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67.39

3506	ADULT 40-100% MALE
2
3507	ADULT 40-100% FEMAL
E

59.62	55.45	52.54	-13.67	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

207.94	
116.90	
1,312.58	
229.19	
36.19	
21.31	
159.77	
94.22	

35.66	35.11	33.74	-25.90	38.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	348.51	359.02	342.35	-64.30	327.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	76.14	78.50	37.92	-50.28	86.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350F	ADULT 40-100% MALE
2
350G	ADULT 40-100% FEMAL
E

26.33	4.28	4.88	0.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

11.30	12.88	3.19	-6.62	0.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350H	ADULT 40-100% M&F 45	65.04	48.30	46.74	-21.77	21.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350J	ADULT 40-100% M&F 65	34.02	15.47	19.99	12.68	12.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014

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

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

1,984.67	2,065.04	2,058.68	2,083.06	2,115.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,306.75

2,614.51	2,670.67	2,726.85	2,782.47	2,848.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,642.99

12,714.59	13,533.02	14,111.15	14,618.12	14,939.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,916.61

12,070.40	12,868.07	13,361.73	13,869.29	14,171.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,341.16

3518	ADULT 40-100% M&F 45	27,169.50	28,434.27	29,364.98	29,773.29	30,657.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,399.29

3519	ADULT 40-100% M&F 65	14.04	14.83	36.32	259.58	15.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	340.05

351D	ADULT 40-100% MALE
1
351E	ADULT 40-100% FEMAL
E
351F	ADULT 40-100% MALE
2
351G	ADULT 40-100% FEMAL
E

313.78	181.67	171.50	150.11	121.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	938.82

403.56	228.94	285.63	198.12	215.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,331.31

2,859.91	2,031.13	1,773.86	1,159.39	1,266.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,090.34

2,581.00	1,703.20	1,578.56	1,004.56	1,199.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,067.15

351H	ADULT 40-100% M&F 45	7,211.46	3,371.85	3,091.21	1,894.23	1,782.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,351.71

351J	ADULT 40-100% M&F 65	108.10	25.19	47.66	42.37	35.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.01

3526	ADULT 40-100% MALE
2
3527	ADULT 40-100% FEMAL
E

1.93	3.00	3.00	-2.67	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.26

6.45	7.00	2.40	-4.31	2.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.94

3528	ADULT 40-100% M&F 45	26.71	29.59	24.32	-22.81	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81.81

3529	ADULT 40-100% M&F 65	6.00	15.00	6.00	-2.01	8.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.72

352F	ADULT 40-100% MALE
2
352G	ADULT 40-100% FEMAL
E

1.06	0.00	0.00	-2.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.44

0.00	0.00	0.00	-1.68	0.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.08

352H	ADULT 40-100% M&F 45	12.24	1.38	3.23	-3.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.87

352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	-0.74	15.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.52

3704	ADULT <40% EXP MAL E
3705	ADULT <40% EXP FEM
AL
3706	ADULT <40% EXP MAL
E
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
370F	ADULT <40% EXP MAL
E
370G	ADULT <40% EXP FEM
AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4

1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

1.93	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.93

103.25	111.71	84.84	-54.92	97.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	342.57

48.48	48.94	35.43	-13.67	42.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	161.28

283.95	338.46	268.52	-23.74	322.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,189.28

56.31	44.45	21.90	-12.92	22.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132.30

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

14.26	15.04	9.01	7.43	4.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50.09

21.77	4.58	4.07	-5.93	1.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.71

42.46	16.69	26.64	3.98	25.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115.75

12.45	1.54	9.10	-2.86	3.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.66

11,007.76	11,025.46	11,264.02	11,571.49	11,500.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,369.06

9,706.11	9,741.20	10,012.97	10,282.00	10,282.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,024.92

48,059.07	50,383.36	52,664.76	54,392.55	55,689.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	261,189.63

30,195.28	31,546.27	32,673.10	33,708.32	34,395.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162,518.25

63,522.48	65,959.10	67,857.20	69,267.69	70,625.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	337,232.22

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014

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

3719	ADULT <40% EXP M&F
6
371D	ADULT <40% EXP MAL
E
371E	ADULT <40% EXP FEM
AL
371F	ADULT <40% EXP MAL
E
371G	ADULT <40% EXP FEM
AL
371H	ADULT <40% EXP M&F
4
371J	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6
372F	ADULT <40% EXP MAL
E
372G	ADULT <40% EXP FEM
AL
372H	ADULT <40% EXP M&F
4
372J	ADULT <40% EXP M&F
6

44.36	54.24	72.42	140.60	59.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	370.88

1,088.95	744.05	996.81	659.46	547.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,036.68

1,021.43	690.50	796.72	637.59	474.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,620.92

6,765.74	4,743.82	4,863.04	3,660.33	4,547.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,580.50

4,743.81	2,946.56	2,646.68	2,192.59	2,859.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,388.84

9,643.66	5,153.80	5,223.51	3,460.30	4,176.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,657.78

66.80	27.72	19.23	12.58	28.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	155.05

3.54	4.47	6.56	-4.39	4.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.94

1.54	4.80	8.00	-1.88	3.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.59

10.28	10.22	20.13	-8.43	15.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47.74

0.00	1.00	0.00	1.96	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.96

0.00	2.19	1.43	-0.16	0.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.69

0.00	0.00	0.00	0.87	0.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.47

3.70	6.75	0.26	-5.27	4.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.24

0.00	0.00	0.00	1.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.03

SUBTOTAL:

257,226.96

251,422.78	258,778.78	257,494.33	265,705.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,290,627.91

A

5.00	
126.99	
49.81	
1,150.56	
288.94	
58.48	
17.16	
247.99	
88.52	
3,237.16	
3,538.68	
31,046.27	
29,105.06	
72,663.97	
89.03	
540.23	

SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	17.00	15.00	18.00	25.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.00	
9937	BIRTH SUPP PAYMENT	36.00	54.00	71.00	64.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289.00	
	53.00	69.00	89.00	89.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	381.00	

3905	NEWLY ELIGIBLE FEMA L

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

3906	NEWLY ELIGIBLE MALE	62.36	50.69	9.18	-5.36	10.12	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	25.00	2.23	-17.92	3.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00

583.32	464.17	124.90	-125.92	104.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00

71.12	106.14	55.47	11.21	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390F	NEWLY ELIGIBLE MALE	42.44	7.00	2.79	-5.61	11.86	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	8.76	-1.05	0.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00

131.86	92.81	26.55	-40.06	36.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00

35.81	29.02	9.48	4.21	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	622.70	615.18	650.41	647.14	701.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

704.17	681.10	715.71	700.19	737.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	5,431.26	5,826.97	6,365.18	6,550.14	6,872.72	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	5,501.50	5,946.45	6,133.41	6,472.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00

13,011.73	13,984.51	14,881.85	15,160.60	15,625.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00

12.97	16.28	21.99	23.89	13.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391D	NEWLY ELIGIBLE MALE	139.88	114.69	172.17	38.05	75.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014

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

391E	NEWLY ELIGIBLE FEMA L

161.43	76.72	179.62	67.18	81.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	566.35

391F	NEWLY ELIGIBLE MALE	2,612.58	1,545.82	1,766.22	707.43	738.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,370.74

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

3,026.68	1,519.30	1,615.35	644.99	889.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,695.55

8,327.51	3,561.78	3,359.60	1,613.97	1,716.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,579.37

68.94	33.73	31.96	17.08	9.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160.81

3926	NEWLY ELIGIBLE MALE	1.00	1.00	0.00	-0.87	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.13

3927	NEWLY ELIGIBLE FEMA L
3928	NEWLY ELIGIBLE M&F
4
3929	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	-4.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4.73

6.28	12.94	6.70	-20.66	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.26

1.00	3.45	4.00	-2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.45

392F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.87

392G	NEWLY ELIGIBLE FEMA L
392H	NEWLY ELIGIBLE M&F
4
392J	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	-1.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.25

2.70	10.49	0.00	-7.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.91

0.00	0.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.54

SUBTOTAL:

40,155.12

34,280.83	35,956.57	32,092.65	34,158.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	176,643.85

5.00	4.00	6.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.00	
5.00	4.00	6.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.00	

9939	BIRTH SUPP PAYMENT N
SUBTOTAL:

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

128.25	116.83	18.70	19.00	12.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295.59

18,951.90	17,885.34	18,069.72	18,014.10	17,992.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	90,913.61

4414	SOBRA 100-133% MALE	6,066.89	5,979.56	6,241.71	6,390.34	6,422.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,100.56

4415	SOBRA 100-133% FEM AL
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

5,923.23	5,777.63	5,977.89	6,132.81	6,154.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,966.54

3.70	5.16	7.30	0.00	2.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.22

2,589.88	1,731.20	1,897.57	1,248.03	705.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,172.32

441D	SOBRA 100-133% MALE	1,092.57	565.99	560.30	363.00	282.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,863.87

441E	SOBRA 100-133% FEM AL

1,079.50	551.61	600.34	322.06	278.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,831.63

SUBTOTAL:

35,835.92

32,613.32	33,373.53	32,489.34	31,850.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166,162.34

S
SUBTOTAL:

9944	BIRTH SUPP PAYMENT	6.00	5.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00	
	6.00	5.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.00	

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

38.00	37.90	37.32	38.47	40.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00

192.25	
1,406.83	
7.92	
6.02	
23.75	
1.01	
130.08	

288.12	281.92	279.22	281.82	275.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3.78	3.24	0.00	0.00	0.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	2.08	0.00	2.51	1.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1.32	7.91	3.09	1.14	10.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.18	0.73	0.00	0.00	0.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00

25.51	25.80	25.39	26.48	26.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending November 30, 2014

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

4618	CC PATIENT FEMALE 4
5
461G	CC PATIENT FEMALE 2
1
461H	CC PATIENT FEMALE 4
5

18.73	20.00	20.00	19.44	20.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98.90

5.48	0.19	2.59	1.51	0.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.87

2.32	0.00	0.00	1.54	1.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.12

SUBTOTAL:

383.44

379.77	367.61	372.91	378.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,881.75

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

1,318.39	1,324.42	1,354.33	1,396.27	1,406.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,800.23

70.71	116.78	35.90	106.49	41.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	371.51

176.19	177.36	190.82	202.81	198.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	945.85

38.70	38.74	74.53	112.44	43.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	307.68

175.01	179.64	188.72	193.91	191.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	928.41

16.33	32.61	19.26	6.60	2.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77.46

SUBTOTAL:

1,796.33

1,870.55	1,864.56	2,019.52	1,885.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,436.14

TOTAL:	1,446,840.78	1,407,316.37	1,421,777.53	1,423,971.70	1,416,314.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,116,220.83		

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	9,640.51	10,016.56	9,640.51	9,748.96	10,125.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,171.55

1010	TANF NON-MEDICARE	2,119,642.85	2,113,999.86	2,104,519.62	2,123,081.73	2,126,882.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,588,126.08

1020	TANF WITH QMB	6,677.94	6,677.94	6,677.94	3,345.48	3,345.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,724.78

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

30,836,613.84    34,570,502.80     30,935,967.12     31,372,866.59     35,239,337.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162,955,287.85

615,597.94	729,576.72	688,405.76	664,286.50	596,267.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,294,134.76

2,604,038.91	2,783,598.60	2,545,373.27	2,558,167.28	2,784,981.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,276,159.93

19,614.65	14,978.98	7,769.14	36,248.05	12,459.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91,070.79

2120	SSI AGED WITH QMB	17,350,133.73    19,808,558.29     17,876,596.10     18,248,083.92     20,489,387.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	93,772,759.79

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	8,676.88	5,467.70	10,321.54	11,974.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,329.35

13,837,679.72    14,827,724.89     13,765,759.22     14,043,931.24     15,112,189.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71,587,284.60

82,279.18	102,250.19	81,722.03	121,624.38	71,380.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	459,256.27

84,294,536.39    85,893,699.47     85,286,548.21     85,469,641.29     87,030,964.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427,975,390.02

31,789.29	35,099.30	26,766.85	38,234.27	29,582.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	161,472.44

19,966,282.88    21,012,877.23     20,270,819.28     20,408,639.93     21,400,723.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,059,343.10

1,541.29	7,803.55	0.00	1,703.71	6,352.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,400.94

2300	SSI BLIND WITH MEDIC	69,541.93	72,181.18	69,541.93	72,926.26	70,082.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	354,273.99

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

478,057.14	491,679.66	490,075.21	481,841.47	485,749.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,427,403.33

0.00	3,251.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,251.25

2320	SSI BLIND WITH QMB	126,705.55	125,345.33	117,181.83	121,490.14	121,496.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	612,219.71

SUBTOTAL:

172,463,262.81

182,618,498.68   174,288,831.72   175,786,182.74   185,603,284.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	890,760,060.53

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

67,556.86	73,398.32	64,735.65	65,903.92	71,492.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00

343,087.19	
519,894.35	
4,927.88	
63,844.92	
931,754.34	

101,819.57	107,175.95	99,858.26	100,146.55	110,894.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,309.31	0.00	0.00	0.00	1,618.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00

16,243.89	17,081.70	9,942.35	9,932.26	10,644.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

188,929.63

197,655.97	174,536.26	175,982.73	194,649.75	0.00	0.00	0.00	0.00	0.00	0.00

0.00

TOTAL:

172,652,192.44

182,816,154.65   174,463,367.98   175,962,165.47   185,797,934.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	891,691,814.87

LONG TERM CARE MEMBER MONTHS

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00

1010	TANF NON-MEDICARE	633.10	629.83	627.45	631.62	631.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,153.62

1020	TANF WITH QMB	2.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

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

11,510.64	11,449.32	11,525.89	11,554.03	11,529.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,569.07

680.99	812.44	766.78	736.17	639.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,635.53

604.41	604.39	593.07	596.85	602.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,000.94

22.69	16.62	8.62	39.07	13.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100.49

2120	SSI AGED WITH QMB	6,956.11	7,115.15	7,150.50	7,188.17	7,202.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,612.45

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	9.92	5.94	11.10	12.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.00

4,675.34	4,642.31	4,647.27	4,695.10	4,693.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,353.66

91.28	112.25	91.86	124.95	76.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	496.85

24,410.73	24,526.37	24,664.11	24,715.17	24,817.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	123,133.46

34.40	38.90	29.82	40.98	31.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	175.65

6,545.92	6,594.62	6,636.45	6,644.30	6,660.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,081.49

1.70	8.83	0.00	1.83	6.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.29

2300	SSI BLIND WITH MEDIC	22.00	22.00	22.00	23.00	21.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110.38

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

137.93	139.38	140.73	138.77	138.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	695.17

0.00	3.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.61

2320	SSI BLIND WITH QMB	42.00	40.38	38.92	40.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	200.30

SUBTOTAL:

56,388.68

56,771.32	56,954.41	57,185.11	57,119.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	284,418.96

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

22.00	22.00	21.00	21.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

107.00	
116.18	
5.80	
24.00	
252.98	

23.32	23.00	23.00	23.00	23.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3.67	0.00	0.00	0.00	2.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00

6.00	6.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

54.99

51.00	48.00	48.00	50.99	0.00	0.00	0.00	0.00	0.00	0.00

0.00

TOTAL:	56,443.67	56,822.32	57,002.41	57,233.11	57,170.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	284,671.94		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	74.40	74.40	37.20	37.14	37.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	260.28

1010	TANF NON-MEDICARE	10,900,567.20    11,013,841.20     11,139,465.60     11,141,702.88     10,882,837.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,078,413.96

2120	SSI AGED WITH QMB	0.00	0.00	37.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37.20

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 M
ED
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

37.20	37.20	74.40	74.28	74.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	297.36

434,533.20	432,375.60	431,743.20	427,889.94	427,295.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,153,837.64

297.60	297.60	297.60	297.12	297.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,487.04

1,450.80	1,450.80	1,450.80	1,522.74	1,597.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,472.16

74.40	148.80	74.40	37.14	74.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	409.02

10,572,984.00    10,832,528.40     10,994,385.60     11,087,552.76     10,926,662.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,414,113.04

12,648.00	12,536.40	12,871.20	12,107.64	12,590.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	62,753.70

SUBTOTAL:

21,922,666.80

22,293,290.40     22,580,437.20     22,671,221.64     22,251,465.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111,719,081.40

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

198,090.00	197,941.20	199,243.20	198,884.70	194,502.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	988,661.28

74.40	74.40	74.40	74.28	74.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	371.76

SUBTOTAL:

198,164.40

198,015.60	199,317.60	198,958.98	194,576.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	989,033.04

4410	SOBRA 100-133% FOR	1,017,829.20	1,035,387.60	1,038,438.00	1,047,459.42	1,051,470.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,017,829.20	1,035,387.60	1,038,438.00	1,047,459.42	1,051,470.54	0.00	0.00	0.00	0.00	0.00	0.00	0.	

5,190,584.76
F
00	5,190,584.76

TOTAL:

23,138,660.40

23,526,693.60     23,818,192.80     23,917,640.04     23,497,512.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	117,898,699.20

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00

1010	TANF NON-MEDICARE	293,026.00	296,071.00	299,448.00	299,992.00	293,022.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,481,559.00

2120	SSI AGED WITH QMB	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

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 M
ED
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

1.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

11,681.00	11,623.00	11,606.00	11,521.00	11,505.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,936.00

8.00	8.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40.00

39.00	39.00	39.00	41.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	201.00

2.00	4.00	2.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00

284,220.00	291,197.00	295,548.00	298,534.00	294,202.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,463,701.00

340.00	337.00	346.00	326.00	339.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,688.00

SUBTOTAL:

589,319.00

599,282.00	607,001.00	610,426.00	599,124.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,005,152.00

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

5,325.00	5,321.00	5,356.00	5,355.00	5,237.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,594.00

2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00

SUBTOTAL:

5,327.00

5,323.00	5,358.00	5,357.00	5,239.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,604.00

4410	SOBRA 100-133% FOR	27,361.00	27,833.00	27,915.00	28,203.00	28,311.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	27,361.00	27,833.00	27,915.00	28,203.00	28,311.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

139,623.00
F
00	139,623.00

TOTAL:	622,007.00	632,438.00	640,274.00	643,986.00	632,674.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,171,379.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	17,922.18	18,687.54	17,954.07	19,266.56	19,266.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	93,096.91

1010	TANF NON-MEDICARE	4,703,200.98	4,819,025.46	4,903,661.52	5,241,488.00	5,143,696.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,811,072.60

1020	TANF WITH QMB	510.24	574.02	733.47	1,017.60	1,288.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,124.29

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

146,311.32	148,129.05	149,468.43	160,339.84	159,424.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	763,672.64

188,884.47	199,790.85	201,863.70	216,782.72	216,240.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,023,561.74

2120	SSI AGED WITH QMB	716,823.42	733,820.79	744,950.40	796,509.44	795,763.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,787,867.25

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

146,279.43	147,491.25	147,618.81	157,626.24	158,372.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	757,388.21

1,335,648.87	1,334,086.26	1,336,860.69	1,418,839.68	1,416,329.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,841,765.10

798,079.14	797,983.47	804,457.14	856,378.24	853,121.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,110,019.91

2300	SSI BLIND WITH MEDIC	1,148.04	1,179.93	1,084.26	1,221.12	1,255.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,888.39

2310	SSI BLIND NON-MEDIC A

13,648.92	13,585.14	13,553.25	14,382.08	14,314.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,483.63

2320	SSI BLIND WITH QMB	7,908.72	7,749.27	7,813.05	8,378.24	8,310.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,159.68

4300	SOBRA CHILD WITH M ED
4310	SOBRA CHILD NON-ME
DI
4320	SOBRA CHILD WITH Q
MB
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

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

619,718.37	636,269.28	643,029.96	678,230.40	656,250.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,233,498.25

0.00	0.00	0.00	33.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.92

1,626.39	1,530.72	1,498.83	1,594.24	1,763.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,014.02

437,658.36	440,432.79	440,847.36	460,565.76	447,133.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,226,637.71

159.45	127.56	191.34	169.60	271.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	919.31

SUBTOTAL:

9,135,528.30

9,300,495.27	9,415,586.28     10,032,823.68	9,892,801.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,777,235.45

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	179,572.59	181,932.45	195,752.32	191,749.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	927,527.34

3,547,634.94	3,668,179.14	3,746,182.08	4,025,116.80	3,952,697.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,939,810.56

8,291.40	9,343.77	11,703.63	12,991.36	15,196.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,526.32

16,837.92	17,667.06	16,774.14	16,654.72	18,079.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	86,013.20

40,277.07	38,842.02	37,693.98	41,992.96	42,433.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	201,239.95

693,639.39	696,796.50	703,429.62	761,470.08	774,054.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,629,389.99

95.67	95.67	63.78	67.84	67.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	390.80

159.45	95.67	95.67	67.84	67.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	486.47

13,840.26	15,083.97	15,402.87	16,790.40	17,638.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	78,755.90

40,946.76	41,871.57	40,532.19	41,144.96	37,719.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	202,214.52

257,447.97	257,958.21	266,887.41	291,101.44	298,055.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,371,450.07

SUBTOTAL:

4,797,691.05

4,925,506.17	5,020,697.82	5,403,150.72	5,347,759.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,494,805.12

FO
SUBTOTAL:

3610	AHC CARE EXPANDED	127.56	127.56	95.67	101.76	33.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		486.47	
	127.56	127.56	95.67	101.76	33.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	486.47	

3500	ADULT 40-100% FOR FI	16,327.68	16,678.47	14,701.29	16,383.36	17,299.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	1,775,730.87	1,901,409.36	1,984,132.02	2,183,600.00	2,224,473.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

81,390.00

10,069,345.85

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending November 30, 2014

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

3520	ADULT 40-100% FOR FI	1,275.60	1,753.95	1,211.82	1,221.12	1,322.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,785.37

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

15,083.97	16,391.46	12,532.77	14,042.88	15,128.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,179.40

5,540,791.83	5,808,859.17	6,030,909.24	6,600,764.16	6,696,622.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,677,946.48

446.46	542.13	892.92	949.76	983.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,814.95

SUBTOTAL:

7,349,656.41

7,745,634.54	8,044,380.06	8,816,961.28	8,955,829.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,912,462.05

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

23,215.92	20,441.49	5,867.76	5,054.08	5,121.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,701.17

753,847.71	842,916.48	896,396.01	1,006,202.88	1,039,953.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,539,316.36

223.23	414.57	382.68	135.68	101.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,257.92

SUBTOTAL:

777,286.86

863,772.54	902,646.45	1,011,392.64	1,045,176.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,600,275.45

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	62,918.97	72,964.32	81,383.28	96,264.96	96,502.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		410,033.93	
	62,918.97	72,964.32	81,383.28	96,264.96	96,502.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	410,033.93	

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

10,236.69	10,109.13	10,204.80	10,718.72	10,684.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,954.14

1,466.94	1,466.94	1,435.05	1,492.48	1,560.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,421.73

SUBTOTAL:

11,703.63

11,576.07	11,639.85	12,211.20	12,245.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,375.87

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

31.89	31.89	31.89	33.92	33.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	163.51

27,393.51	27,265.95	28,382.10	30,765.44	31,545.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,352.60

4,655.94	4,751.61	5,070.51	5,596.80	5,698.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,773.42

3,890.58	4,081.92	4,368.93	4,748.80	4,748.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,839.03

SUBTOTAL:

35,971.92

36,131.37	37,853.43	41,144.96	42,026.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	193,128.56

22,170,884.70	22,956,207.84	23,514,282.84	25,414,051.20	25,392,376.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119,447,802.90	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	562.00	586.00	563.00	568.00	568.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,847.00

1010	TANF NON-MEDICARE	147,482.00	151,114.00	153,768.00	154,525.00	151,642.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	758,531.00

1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,347.00

5,923.00	6,265.00	6,330.00	6,391.00	6,375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,284.00

2120	SSI AGED WITH QMB	22,478.00	23,011.00	23,360.00	23,482.00	23,460.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115,791.00

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

4,587.00	4,625.00	4,629.00	4,647.00	4,669.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,157.00

41,883.00	41,834.00	41,921.00	41,829.00	41,755.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209,222.00

25,026.00	25,023.00	25,226.00	25,247.00	25,151.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125,673.00

2300	SSI BLIND WITH MEDIC	36.00	37.00	34.00	36.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	180.00

2310	SSI BLIND NON-MEDIC A

428.00	426.00	425.00	424.00	422.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,125.00

2320	SSI BLIND WITH QMB	248.00	243.00	245.00	247.00	245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,228.00

4300	SOBRA CHILD WITH M ED
4310	SOBRA CHILD NON-ME
DI
4320	SOBRA CHILD WITH Q
MB
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

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

19,433.00	19,952.00	20,164.00	19,995.00	19,347.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,891.00

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

51.00	48.00	47.00	47.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	245.00

13,724.00	13,811.00	13,824.00	13,578.00	13,182.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,119.00

5.00	4.00	6.00	5.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.00

SUBTOTAL:

286,470.00

291,643.00	295,252.00	295,779.00	291,651.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,460,795.00

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	5,631.00	5,705.00	5,771.00	5,653.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,358.00

111,246.00	115,026.00	117,472.00	118,665.00	116,530.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	578,939.00

260.00	293.00	367.00	383.00	448.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,751.00

528.00	554.00	526.00	491.00	533.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,632.00

1,263.00	1,218.00	1,182.00	1,238.00	1,251.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,152.00

21,751.00	21,850.00	22,058.00	22,449.00	22,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,928.00

3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00

5.00	3.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00

434.00	473.00	483.00	495.00	520.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,405.00

1,284.00	1,313.00	1,271.00	1,213.00	1,112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,193.00

8,073.00	8,089.00	8,369.00	8,582.00	8,787.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,900.00

SUBTOTAL:

150,445.00

154,453.00	157,438.00	159,291.00	157,658.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	779,285.00

FO
SUBTOTAL:

3610	AHC CARE EXPANDED	4.00	4.00	3.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00	
	4.00	4.00	3.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00	

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	55,683.00	59,624.00	62,218.00	64,375.00	65,580.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,489.00

307,480.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending November 30, 2014

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

3520	ADULT 40-100% FOR FI	40.00	55.00	38.00	36.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	208.00

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

473.00	514.00	393.00	414.00	446.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,240.00

173,747.00	182,153.00	189,116.00	194,598.00	197,424.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	937,038.00

14.00	17.00	28.00	28.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116.00

SUBTOTAL:

230,469.00

242,886.00	252,254.00	259,934.00	264,028.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,249,571.00

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

728.00	641.00	184.00	149.00	151.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,853.00

23,639.00	26,432.00	28,109.00	29,664.00	30,659.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138,503.00

7.00	13.00	12.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39.00

SUBTOTAL:

24,374.00

27,086.00	28,305.00	29,817.00	30,813.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140,395.00

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,496.00	
	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,496.00	

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

321.00	317.00	320.00	316.00	315.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,589.00

46.00	46.00	45.00	44.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227.00

SUBTOTAL:

367.00

363.00	365.00	360.00	361.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,816.00

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

1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

859.00	855.00	890.00	907.00	930.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,441.00

146.00	149.00	159.00	165.00	168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	787.00

122.00	128.00	137.00	140.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	667.00

SUBTOTAL:

1,128.00

1,133.00	1,187.00	1,213.00	1,239.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,900.00

TOTAL:	695,230.00	719,856.00	737,356.00	749,235.00	748,596.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,650,273.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	26,194.82	27,313.46	26,241.43	25,065.84	25,065.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	129,881.39

1010	TANF NON-MEDICARE	6,874,136.02	7,043,423.54	7,167,126.48	6,819,188.25	6,691,961.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,595,835.75

1020	TANF WITH QMB	745.76	838.98	1,072.03	1,323.90	1,676.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,657.61

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

213,846.68	216,503.45	218,461.07	208,602.51	207,411.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,064,824.71

276,071.03	292,011.65	295,041.30	282,034.83	281,328.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,426,487.56

2120	SSI AGED WITH QMB	1,047,699.58	1,072,542.71	1,088,809.60	1,036,260.66	1,035,289.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,280,602.35

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

213,800.07	215,571.25	215,757.69	205,072.11	206,042.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,056,244.09

1,952,166.63	1,949,882.74	1,953,937.81	1,845,913.77	1,842,648.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,544,549.10

1,166,461.86	1,166,322.03	1,175,783.86	1,114,150.11	1,109,913.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,732,631.49

2300	SSI BLIND WITH MEDIC	1,677.96	1,724.57	1,584.74	1,588.68	1,632.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,208.76

2310	SSI BLIND NON-MEDIC A

19,949.08	19,855.86	19,809.25	18,711.12	18,622.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,948.17

2320	SSI BLIND WITH QMB	11,559.28	11,326.23	11,419.45	10,900.11	10,811.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,016.92

4300	SOBRA CHILD WITH M ED
4310	SOBRA CHILD NON-ME
DI
4320	SOBRA CHILD WITH Q
MB
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

0.00	46.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.61

905,772.13	929,962.72	939,844.04	882,379.35	853,783.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,511,741.35

0.00	0.00	0.00	44.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44.13

2,377.11	2,237.28	2,190.67	2,074.11	2,294.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,173.93

639,675.64	643,730.71	644,336.64	599,197.14	581,721.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,108,661.79

233.05	186.44	279.66	220.65	353.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,272.84

SUBTOTAL:

13,352,366.70

13,593,480.23     13,761,695.72     13,052,727.27     12,870,558.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,630,828.55

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	262,460.91	265,910.05	254,674.23	249,466.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,293,434.86

5,185,176.06	5,361,361.86	5,475,369.92	5,236,686.45	5,142,468.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,401,063.19

12,118.60	13,656.73	17,105.87	16,901.79	19,770.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,553.23

24,610.08	25,821.94	24,516.86	21,667.83	23,521.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	120,138.00

58,868.43	56,770.98	55,093.02	54,632.94	55,206.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	280,572.00

1,013,814.11	1,018,428.50	1,028,123.38	990,674.37	1,007,046.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,058,086.96

139.83	139.83	93.22	88.26	88.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	549.40

233.05	139.83	139.83	88.26	88.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	689.23

20,228.74	22,046.53	22,512.63	21,844.35	22,947.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,579.85

59,847.24	61,198.93	59,241.31	53,529.69	49,072.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	282,889.73

376,282.53	377,028.29	390,079.09	378,723.66	387,770.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,909,883.88

SUBTOTAL:

7,012,241.45

7,199,054.33	7,338,185.18	7,029,511.83	6,957,447.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,536,440.33

FO
SUBTOTAL:

3610	AHC CARE EXPANDED	186.44	186.44	139.83	132.39	44.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		689.23	
	186.44	186.44	139.83	132.39	44.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	689.23	

3500	ADULT 40-100% FOR FI	23,864.32	24,377.03	21,487.21	21,314.79	22,506.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	2,595,384.63	2,779,074.64	2,899,980.98	2,840,868.75	2,894,045.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

113,549.65

14,009,354.40

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending November 30, 2014

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

3520	ADULT 40-100% FOR FI	1,864.40	2,563.55	1,771.18	1,588.68	1,721.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,508.88

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

22,046.53	23,957.54	18,317.73	18,269.82	19,681.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	102,273.60

8,098,347.67	8,490,151.33	8,814,696.76	8,587,609.74	8,712,321.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,703,126.62

652.54	792.37	1,305.08	1,235.64	1,279.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,265.40

SUBTOTAL:

10,742,160.09

11,320,916.46     11,757,558.94     11,470,887.42     11,651,555.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,943,078.55

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

33,932.08	29,877.01	8,576.24	6,575.37	6,663.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,624.33

1,101,813.79	1,231,995.52	1,310,160.49	1,309,072.32	1,352,981.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,306,023.79

326.27	605.93	559.32	176.52	132.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,800.43

SUBTOTAL:

1,136,072.14

1,262,478.46	1,319,296.05	1,315,824.21	1,359,777.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,393,448.55

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	91,961.53	106,643.68	118,948.72	125,240.94	125,549.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		568,344.72	
	91,961.53	106,643.68	118,948.72	125,240.94	125,549.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	568,344.72	

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

14,961.81	14,775.37	14,915.20	13,945.08	13,900.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,498.41

2,144.06	2,144.06	2,097.45	1,941.72	2,029.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,357.27

SUBTOTAL:

17,105.87

16,919.43	17,012.65	15,886.80	15,930.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82,855.68

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

46.61	46.61	46.61	44.13	44.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	228.09

40,037.99	39,851.55	41,482.90	40,025.91	41,040.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	202,439.25

6,805.06	6,944.89	7,410.99	7,281.45	7,413.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,856.23

5,686.42	5,966.08	6,385.57	6,178.20	6,178.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,394.47

SUBTOTAL:

52,576.08

52,809.13	55,326.07	53,529.69	54,677.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	268,918.04

32,404,670.30	33,552,488.16	34,368,163.16	33,063,740.55	33,035,541.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166,424,603.65	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	562.00	586.00	563.00	568.00	568.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,847.00

1010	TANF NON-MEDICARE	147,482.00	151,114.00	153,768.00	154,525.00	151,642.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	758,531.00

1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,347.00

5,923.00	6,265.00	6,330.00	6,391.00	6,375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,284.00

2120	SSI AGED WITH QMB	22,478.00	23,011.00	23,360.00	23,482.00	23,460.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115,791.00

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

4,587.00	4,625.00	4,629.00	4,647.00	4,669.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,157.00

41,883.00	41,834.00	41,921.00	41,829.00	41,755.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209,222.00

25,026.00	25,023.00	25,226.00	25,247.00	25,151.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125,673.00

2300	SSI BLIND WITH MEDIC	36.00	37.00	34.00	36.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	180.00

2310	SSI BLIND NON-MEDIC A

428.00	426.00	425.00	424.00	422.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,125.00

2320	SSI BLIND WITH QMB	248.00	243.00	245.00	247.00	245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,228.00

4300	SOBRA CHILD WITH M ED
4310	SOBRA CHILD NON-ME
DI
4320	SOBRA CHILD WITH Q
MB
5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

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

19,433.00	19,952.00	20,164.00	19,995.00	19,347.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,891.00

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

51.00	48.00	47.00	47.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	245.00

13,724.00	13,811.00	13,824.00	13,578.00	13,182.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,119.00

5.00	4.00	6.00	5.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.00

SUBTOTAL:

286,470.00

291,643.00	295,252.00	295,779.00	291,651.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,460,795.00

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	5,631.00	5,705.00	5,771.00	5,653.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,358.00

111,246.00	115,026.00	117,472.00	118,665.00	116,530.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	578,939.00

260.00	293.00	367.00	383.00	448.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,751.00

528.00	554.00	526.00	491.00	533.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,632.00

1,263.00	1,218.00	1,182.00	1,238.00	1,251.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,152.00

21,751.00	21,850.00	22,058.00	22,449.00	22,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,928.00

3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00

5.00	3.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00

434.00	473.00	483.00	495.00	520.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,405.00

1,284.00	1,313.00	1,271.00	1,213.00	1,112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,193.00

8,073.00	8,089.00	8,369.00	8,582.00	8,787.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,900.00

SUBTOTAL:

150,445.00

154,453.00	157,438.00	159,291.00	157,658.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	779,285.00

FO
SUBTOTAL:

3610	AHC CARE EXPANDED	4.00	4.00	3.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00	
	4.00	4.00	3.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00	

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	55,683.00	59,624.00	62,218.00	64,375.00	65,580.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,489.00

307,480.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending November 30, 2014

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

3520	ADULT 40-100% FOR FI	40.00	55.00	38.00	36.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	208.00

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

473.00	514.00	393.00	414.00	446.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,240.00

173,747.00	182,153.00	189,116.00	194,598.00	197,424.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	937,038.00

14.00	17.00	28.00	28.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116.00

SUBTOTAL:

230,469.00

242,886.00	252,254.00	259,934.00	264,028.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,249,571.00

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

728.00	641.00	184.00	149.00	151.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,853.00

23,639.00	26,432.00	28,109.00	29,664.00	30,659.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138,503.00

7.00	13.00	12.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39.00

SUBTOTAL:

24,374.00

27,086.00	28,305.00	29,817.00	30,813.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140,395.00

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,496.00	
	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,496.00	

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

321.00	317.00	320.00	316.00	315.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,589.00

46.00	46.00	45.00	44.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227.00

SUBTOTAL:

367.00

363.00	365.00	360.00	361.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,816.00

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

1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

859.00	855.00	890.00	907.00	930.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,441.00

146.00	149.00	159.00	165.00	168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	787.00

122.00	128.00	137.00	140.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	667.00

SUBTOTAL:

1,128.00

1,133.00	1,187.00	1,213.00	1,239.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,900.00

TOTAL:	695,230.00	719,856.00	737,356.00	749,235.00	748,596.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,650,273.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending November 30, 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	2,024,777.95	1,904,080.88	1,484,152.78	1,407,449.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,909,536.12

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	407,211.61	407,211.61	317,900.72	327,142.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,863,293.54

1,128.01	1,128.01	1,128.01	924.13	924.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,232.29

14,048,236.54    14,167,805.60     14,499,440.54     12,119,964.95     12,211,453.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,046,901.45

18,048.16	21,432.19	18,048.16	13,861.95	12,937.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,328.28

SUBTOTAL:

16,560,314.81

16,622,355.36     16,829,909.20     13,936,804.53     13,959,907.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77,909,291.68

15,792.14	15,792.14	18,048.16	17,558.47	26,799.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,990.68	
15,792.14	15,792.14	18,048.16	17,558.47	26,799.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	93,990.68	

4410	SOBRA 100-133% FOR F
SUBTOTAL:

16,576,106.95	16,638,147.50	16,847,957.36	13,954,363.00	13,986,707.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	78,003,282.36	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending November 30, 2014

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

1010	TANF NON-MEDICARE	1,852.00	1,795.00	1,688.00	1,606.00	1,523.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,464.00

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	361.00	361.00	344.00	354.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,778.00

1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

12,454.00	12,560.00	12,854.00	13,115.00	13,214.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,197.00

16.00	19.00	16.00	15.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80.00

SUBTOTAL:

14,681.00

14,736.00	14,920.00	15,081.00	15,106.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,524.00

14.00	14.00	16.00	19.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.00	
14.00	14.00	16.00	19.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92.00	

4410	SOBRA 100-133% FOR F
SUBTOTAL:

TOTAL:	14,695.00	14,750.00	14,936.00	15,100.00	15,135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,616.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	0.00	478.75	478.75	502.99	502.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,963.48

1010	TANF NON-MEDICARE	0.00	123,517.50	122,560.00	128,262.45	128,262.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	502,602.40

1011	TANF <1 M & F NON-ME	0.00	12,975.87	13,933.37	18,298.97	17,379.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	62,587.26

1012	TANF 01-05 M & F NON	0.00	61,123.78	60,251.07	65,067.82	62,983.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	249,425.84

1013	TANF 06-13 M & F NON	0.00	63,038.78	61,602.53	67,655.46	65,901.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	258,198.45

1014	TANF 14-20 MALE NON-	0.00	13,170.26	13,170.26	13,513.88	14,850.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,705.13

1015	TANF 14-20 FEMALE N O
2110	SSI AGED NON-MEDIC
AR
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

0.00	16,885.48	17,279.44	16,604.51	17,941.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,710.79

0.00	393.96	393.96	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,621.78

0.00	3,266.46	3,745.21	5,446.83	7,961.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,420.28

0.00	2,861,956.87	2,859,338.74	3,012,217.32	3,020,265.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,753,778.09

0.00	16,980.63	17,065.42	15,003.64	16,009.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,059.31

2300	SSI BLIND WITH MEDIC	0.00	957.50	957.50	1,005.98	1,005.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,926.96

2310	SSI BLIND NON-MEDIC A

0.00	26,919.60	26,525.64	28,484.94	28,068.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,998.19

4311	SOBRA CHILD <1 M & F	0.00	16,357.11	16,187.53	20,827.29	20,827.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,199.22

4312	SOBRA CHILD 01-05 M	0.00	94,547.40	94,377.82	93,422.44	87,744.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	370,091.83

4313	SOBRA CHILD 06-13 M	0.00	75,058.24	83,730.54	90,119.58	92,303.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	341,212.02

4314	SOBRA CHILD 14-20 MA	0.00	19,284.41	20,466.29	22,408.95	19,735.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,894.90

4315	SOBRA CHILD 14-20 FE	0.00	23,957.13	24,435.88	24,003.98	24,090.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,487.03

5015	SOBRA PREG 14-20 FE M

0.00	1,351.46	872.71	919.92	919.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,064.01

SUBTOTAL:

0.00

3,432,221.19	3,437,372.66	3,624,183.88	3,627,169.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,120,946.97

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	393.96	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	1,575.84	1,181.88	1,250.79	833.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	787.92	393.96	416.93	833.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	2,757.72	1,575.84	1,667.72	2,084.65	0.00	0.00	0.00	0.00	0.00	0.00	0.	

416.93	
393.96	
4,842.37	
2,432.67	
8,085.93	

00

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL

0.00	393.96	393.96	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,621.78

0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	416.93

0.00	6,697.32	5,909.40	6,253.95	6,670.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,531.55

0.00	3,939.60	4,727.52	4,586.23	3,752.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,005.72

0.00	393.96	393.96	0.00	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,204.85

0.00	787.92	787.92	833.86	833.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,243.56

SUBTOTAL:

0.00

12,212.76	12,212.76	12,090.97	12,507.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,024.39

4413	SOBRA 100-133% M&F	0.00	3,939.60	3,939.60	4,169.30	4,169.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	1,181.88	1,181.88	1,667.72	2,170.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM	0.00	1,181.88	1,181.88	1,667.72	1,250.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,217.80
6
6,202.19

5,282.27
AL

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	6,303.36	6,303.36	7,504.74	7,590.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,702.26		

0.00	3,453,495.03	3,457,464.62	3,645,447.31	3,649,352.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,205,759.55	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

1010	TANF NON-MEDICARE	0.00	258.00	256.00	255.00	255.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,024.00

1011	TANF <1 M & F NON-ME	0.00	31.00	33.00	41.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144.00

1012	TANF 01-05 M & F NON	0.00	153.00	151.00	154.00	149.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	607.00

1013	TANF 06-13 M & F NON	0.00	157.00	154.00	160.00	156.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	627.00

1014	TANF 14-20 MALE NON-	0.00	33.00	33.00	32.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133.00

1015	TANF 14-20 FEMALE N O
2110	SSI AGED NON-MEDIC
AR
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

0.00	42.00	43.00	39.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166.00

0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

0.00	7.00	8.00	11.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00

0.00	6,066.00	6,060.00	6,074.00	6,090.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,290.00

0.00	36.00	36.00	30.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	134.00

2300	SSI BLIND WITH MEDIC	0.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

2310	SSI BLIND NON-MEDIC A

0.00	58.00	57.00	58.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	230.00

4311	SOBRA CHILD <1 M & F	0.00	37.00	37.00	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	164.00

4312	SOBRA CHILD 01-05 M	0.00	209.00	209.00	196.00	183.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	797.00

4313	SOBRA CHILD 06-13 M	0.00	169.00	188.00	192.00	196.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	745.00

4314	SOBRA CHILD 14-20 MA	0.00	44.00	47.00	49.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	183.00

4315	SOBRA CHILD 14-20 FE	0.00	55.00	56.00	52.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.00

5015	SOBRA PREG 14-20 FE M

0.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00

SUBTOTAL:

0.00

7,362.00	7,374.00	7,394.00	7,396.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,526.00

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	1.00	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	4.00	3.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	2.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	7.00	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

1.00	
1.00	
12.00	
6.00	
20.00	

00

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL

0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

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

0.00	17.00	15.00	15.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63.00

0.00	10.00	12.00	11.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00

0.00	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00

0.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

SUBTOTAL:

0.00

31.00	31.00	29.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121.00

4413	SOBRA 100-133% M&F	0.00	10.00	10.00	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	3.00	3.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM	0.00	3.00	3.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

40.00
6
15.00

13.00
AL

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	16.00	16.00	18.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68.00		

SUBTOTAL:

TOTAL:	0.00	7,416.00	7,425.00	7,445.00	7,449.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,735.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 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	7,574.57	5,945.37	12,215.07	7,565.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,176.62

1007	TANF 21-44 FEMALE WI	23,137.76	17,832.63	43,923.29	20,080.22	22,545.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127,519.84

1008	TANF 45-64 M & F WIT	23,169.55	9,761.50	10,844.20	14,232.62	6,557.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,565.35

1009	TANF 65+ M & F WITH	3,332.06	859.77	638.60	2,223.59	1,402.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,456.48

1011	TANF <1 M & F NON-ME	2,087,574.20	1,747,347.06	1,942,486.85	1,532,652.73	1,607,745.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,917,806.65

1012	TANF 01-05 M & F NON	2,916,068.11	2,453,516.86	2,830,145.55	2,769,718.79	2,538,016.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,507,465.49

1013	TANF 06-13 M & F NON	4,199,876.85	4,048,602.09	4,349,822.83	3,829,981.46	4,401,477.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,829,760.73

1014	TANF 14-20 MALE NON-	1,022,564.58	882,263.46	830,955.05	729,314.57	796,704.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,261,802.06

1015	TANF 14-20 FEMALE N O

1,309,250.39	1,446,163.44	1,498,820.46	1,170,576.47	1,365,734.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,790,545.05

1016	TANF 21-44 MALE NON-	1,650,221.45	1,536,024.42	1,693,197.31	1,499,220.25	1,489,932.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,868,595.83

1017	TANF 21-44 FEMALE N O

7,591,183.72	6,988,273.68	8,108,895.86	6,885,385.11	6,669,153.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,242,891.45

1018	TANF 45-64 M & F NON	2,302,643.98	2,022,171.49	2,016,262.14	2,023,276.44	1,877,922.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,242,276.13

1019	TANF 65+ M & F NON-M	3,798.00	5,899.99	3,421.07	4,575.21	3,131.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,825.41

1027	TANF 21-44 FEMALE WI	4,573.78	2,736.00	0.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,651.78

1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	4,002.06	3,093.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,095.44

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

112,069.05	103,882.05	140,484.93	100,297.57	77,397.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	534,130.77

179,464.34	152,722.12	161,825.86	180,615.64	163,448.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	838,076.64

2120	SSI AGED WITH QMB	504,498.36	451,023.64	458,040.53	525,035.77	405,416.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,344,015.03

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

423,542.79	375,979.18	320,212.46	334,111.62	206,083.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,659,929.78

9,192,572.30	8,115,791.88	8,638,107.12	8,116,472.87	7,615,207.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,678,152.16

1,557,854.20	1,144,568.81	1,176,467.90	1,432,747.51	1,018,249.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,329,888.00

2300	SSI BLIND WITH MEDIC	2,028.97	1,798.82	712.93	779.03	1,792.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,112.66

2310	SSI BLIND NON-MEDIC A

119,577.24	87,006.17	112,595.00	124,841.37	81,261.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	525,281.56

2320	SSI BLIND WITH QMB	22,834.90	18,680.13	11,066.96	14,435.28	15,566.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82,583.70

4311	SOBRA CHILD <1 M & F	2,402,981.11	1,558,312.98	1,911,948.26	2,273,287.52	1,907,354.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,053,884.72

4312	SOBRA CHILD 01-05 M	1,602,715.67	1,261,601.00	1,558,882.36	1,496,678.77	1,261,873.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,181,751.11

4313	SOBRA CHILD 06-13 M	2,128,396.32	1,877,894.61	2,046,562.67	1,834,901.69	1,872,656.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,760,412.02

4314	SOBRA CHILD 14-20 MA	931,900.37	820,506.24	855,134.37	647,871.48	790,168.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,045,581.04

4315	SOBRA CHILD 14-20 FE	1,397,957.59	958,099.85	992,718.92	866,292.47	1,081,265.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,296,334.09

4325	SOBRA CHILD 14-20 FE	0.00	0.00	90.66	359.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	449.90

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	632.45	32.95	448.60	146.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,206.19

485,491.24	423,602.92	427,141.69	320,730.37	359,622.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,016,588.55

1,579,257.75	1,309,225.62	1,576,807.86	1,308,394.70	1,188,511.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,962,197.55

-16,663.69	3,520.34	3,457.60	2,564.54	2,644.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4,476.74

2,970.00	330.00	0.00	990.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,290.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	45,790,665.31	39,834,205.77	43,727,649.61	40,079,652.63	38,839,649.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	208,271,823.04		

1106	TANF EXPANDED 21-44	27,367.94	12,614.40	10,427.70	24,113.60	23,226.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,750.62

1107	TANF EXPANDED 21-44	44,839.69	28,542.92	25,156.80	38,488.24	24,965.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	161,993.02

1108	TANF EXPANDED 45-64	101,282.81	76,431.82	88,146.44	95,565.29	69,054.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	430,480.71

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

28,221.65	29,488.63	32,284.70	33,881.19	20,115.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143,991.98

390.77	148.71	0.00	0.00	830.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,369.56

1112	TANF EXPANDED 01-05	13,437.17	10,204.60	16,836.91	8,288.80	9,240.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,007.61

1113	TANF EXPANDED 06-13	57,770.47	48,403.09	59,938.89	59,164.05	62,574.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	287,850.98

1114	TANF EXPANDED 14-20	24,761.78	17,015.17	21,300.11	19,559.85	23,327.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105,964.40

1115	TANF EXPANDED 14-20	57,511.45	71,816.30	60,997.19	47,691.85	56,330.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	294,347.37

1116	TANF EXPANDED 21-44	796,257.60	738,761.31	908,020.34	729,904.03	703,394.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,876,337.86

1117	TANF EXPANDED 21-44	1,959,110.73	1,856,820.56	2,095,500.02	1,742,999.87	1,654,522.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,308,953.42

1118	TANF EXPANDED 45-64	1,137,517.50	1,100,214.21	1,195,375.35	1,180,613.31	1,146,585.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,760,306.01

1119	TANF EXPANDED 65+ M&

2,554.51	4,344.81	1,345.01	12,070.16	2,076.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,390.80

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	77.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77.42

1127	TANF EXPANDED 21-44	151.39	8.27	94.46	110.11	120.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	484.60

1128	TANF EXPANDED 45-64	9,482.43	4,293.81	9,336.06	14,285.20	3,361.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,759.38

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	4,920.53	2,598.09	5,133.75	5,915.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,201.17

21,197.10	14,263.07	31,200.01	36,552.07	23,674.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,886.43

147,386.35	121,937.93	114,828.74	75,978.09	76,263.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	536,394.91

470,852.93	408,920.65	374,872.37	511,594.90	380,311.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,146,552.26

-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	11,817.76	9,192.27	10,627.71	10,689.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,458.46

107,386.52	106,898.65	76,899.90	89,852.33	79,337.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	460,375.00

231,908.23	184,557.12	168,972.41	224,275.77	164,347.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	974,061.10

SUBTOTAL:

5,257,823.19

4,852,424.32	5,303,323.77	4,960,750.17	4,540,343.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,914,665.07

3309	AHC CARE M&F 65+ W/	0.00	60.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60.62

3316	AHC CARE MALE 21-44	4,102.58	1,676.76	-552.04	687.90	68.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,983.37

3317	AHC CARE FEMALE 21-
4

793.70	1,980.00	-1,001.17	0.00	-10.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,762.28

3318	AHC CARE M&F 45-64 N	11,478.24	20,380.93	3,310.82	1,464.51	100.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,735.35

3328	AHC CARE M&F 45-64
W

0.00	-13.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13.75

SUBTOTAL:

16,374.52

24,084.56	1,757.61	2,152.41	158.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,527.87

3400	MED ELIGIBILITY W/ M	-23.88	-86.21	0.00	-117.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	-121.13	-588.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3607	AHC CARE/MI FEMALE	41.99	0.00	3.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-227.53

-709.13

45.74
2

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

3608	AHC CARE/MI M&F 45-6	2,501.53	2,942.28	624.97	0.00	39.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,107.85

3614	AHC CARE/MI MALE 14-	10,196.42	1,507.30	568.22	2,751.49	27.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,051.18

3615	AHC CARE/MI FEMALE
1

7,211.81	1,363.64	773.45	2,378.64	429.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,157.38

3616	AHC CARE/MI MALE 21-	20,576.90	24,442.36	15,689.92	16,319.52	2,550.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,578.75

3617	AHC CARE/MI FEMALE
2

-6,005.41	61,825.29	935.30	15,317.50	2,067.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,140.63

3618	AHC CARE/MI M&F 45-6	103,003.33	130,002.99	4,642.03	26,880.13	-8,878.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255,650.37

3619	AHC CARE/MI M&F 65+	0.00	2,292.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,292.95

SUBTOTAL:

137,502.69

224,169.47	22,649.64	63,529.84	-3,763.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	444,088.19

3506	ADULT 40-100% MALE
2
3507	ADULT 40-100% FEMAL
E

684.00	3,580.48	1,303.73	3,103.25	3,193.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,864.99

0.00	0.00	342.00	0.00	-342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	22,526.34	37,003.34	25,465.59	13,348.52	29,850.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	128,194.61

3509	ADULT 40-100% M&F 65	7,038.51	3,738.82	2,054.88	94.34	-53.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,873.53

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

12,687.18	16,373.68	22,458.35	8,580.44	8,918.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,017.72

32,086.25	36,991.08	45,390.22	98,253.80	32,669.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	245,391.15

305,234.79	351,770.07	576,346.80	465,211.13	437,893.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,136,456.04

436,287.52	386,457.94	478,010.90	423,309.93	426,762.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,150,828.41

3518	ADULT 40-100% M&F 45	1,438,811.14	1,490,006.65	1,641,262.40	1,385,433.91	1,357,913.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,313,427.41

3519	ADULT 40-100% M&F 65	-990.00	0.00	4,234.40	1,631.55	684.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,559.95

3528	ADULT 40-100% M&F 45	33.73	0.00	129.06	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	222.19

3529	ADULT 40-100% M&F 65	192.12	71.86	424.98	0.00	93.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	782.13

3706	ADULT <40% EXP MAL E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

1,792.92	1,968.09	902.92	316.42	110.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,091.06

2,767.07	1,278.08	-370.33	3,691.15	918.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,284.43

42,387.39	19,031.85	18,960.72	46,284.65	13,203.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139,868.31

3,535.49	168.39	1,548.60	1,648.72	1,389.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,290.76

347,633.63	347,324.94	317,071.70	269,612.77	314,440.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,596,083.64

438,080.79	431,929.74	423,714.83	416,138.04	313,484.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,023,347.98

6,263,512.29	5,519,096.64	5,963,654.37	5,617,859.72	5,103,187.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,467,310.43

3,575,464.37	3,382,124.05	3,905,064.56	3,334,687.58	3,112,141.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,309,481.85

7,929,765.21	6,957,856.36	8,103,595.28	7,102,447.58	7,155,297.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,248,961.97

3,910.92	3,664.70	41,258.90	8,231.44	11,930.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,996.53

0.00	15.75	0.00	0.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	357.75

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

0.00	1,026.00	2,681.16	7,969.67	241.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,918.73

SUBTOTAL:

20,863,498.73

18,991,478.51     21,575,506.02     19,207,914.01     18,324,271.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,962,668.64

3906	NEWLY ELIGIBLE MALE	282.87	244.78	3,954.66	845.41	701.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,029.63

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

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

836.82	0.00	1,756.31	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,935.13

36,628.12	26,922.19	16,205.75	17,898.74	3,618.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,272.94

735.29	4,495.57	6,089.30	2,028.30	2,167.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,516.08

3914	NEWLY ELIGIBLE MALE	4,432.09	7,350.77	4,425.47	2,808.00	1,742.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,758.49

3915	NEWLY ELIGIBLE FEMA L

8,684.59	8,570.78	11,952.24	18,573.34	12,779.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,560.93

3916	NEWLY ELIGIBLE MALE	190,656.56	140,972.52	172,124.15	179,726.97	158,777.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	842,257.32

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

152,717.83	182,054.27	259,830.54	161,208.72	156,299.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	912,111.18

668,831.27	599,382.33	855,754.73	702,966.02	618,574.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,445,508.86

1,429.82	731.49	342.00	342.00	684.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,529.31

0.00	0.00	1,828.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,828.80

SUBTOTAL:

1,065,235.26

970,724.70	1,334,263.95	1,086,739.50	955,345.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,412,308.67

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

4,977.56	2,394.00	1,717.57	1,368.00	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,483.13

235,987.47	238,080.25	286,276.53	229,804.63	264,183.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,254,332.76

4414	SOBRA 100-133% MALE	85,340.26	87,080.59	94,321.88	83,076.40	84,875.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	434,695.12

4415	SOBRA 100-133% FEM AL

113,390.65	105,222.91	136,439.88	96,722.72	157,919.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	609,695.67

SUBTOTAL:

439,695.94

432,777.75	518,755.86	410,971.75	508,005.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,310,206.68

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

0.00	2,688.00	342.00	0.00	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,056.00

40,445.07	20,543.90	18,293.18	13,540.70	26,903.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119,726.69

2,736.00	0.00	469.34	442.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,647.51

SUBTOTAL:

43,181.07

23,231.90	19,104.52	13,982.87	27,929.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127,430.20

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

3,947.35	5,987.91	4,342.90	1,505.21	2,846.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,630.35

2,758.57	2,394.00	2,736.00	2,775.74	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,690.31

266.39	131.57	188.92	230.40	600.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,417.47

SUBTOTAL:

6,972.31

8,513.48	7,267.82	4,511.35	4,473.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,738.13

73,620,949.02	65,361,610.46	72,510,278.80	65,830,204.53	63,196,413.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	340,519,456.49	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending November 30, 2014

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

1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	312.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	312.04

1013	TANF 06-13 M & F NON	0.00	0.00	324.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	324.98

1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	234.70	236.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	471.67

1015	TANF 14-20 FEMALE N O

4,556.11	2,141.99	9,981.62	5,621.37	4,798.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,099.70

1016	TANF 21-44 MALE NON-	2,387.41	9,567.79	17,302.15	13,267.56	35,827.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	78,352.68

1017	TANF 21-44 FEMALE N O

4,275.74	56,487.23	53,988.90	128,188.32	57,311.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	300,251.32

1018	TANF 45-64 M & F NON	624.62	13,353.85	27,439.42	40,475.30	7,025.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,918.94

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

922.64	226.91	3,074.97	4,272.30	2,918.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,414.91

3,789.39	1,046.16	4,455.25	5,266.94	3,072.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,630.53

2120	SSI AGED WITH QMB	0.00	0.00	43.35	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.60

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

0.00	36.29	1,193.01	3,296.07	1,930.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,455.77

4,511.70	7,150.54	20,268.15	15,221.00	9,243.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,394.53

0.00	0.00	60.89	35.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96.54

4311	SOBRA CHILD <1 M & F	15,885.00	10,600.80	28,405.64	12,784.46	21,118.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,794.49

4312	SOBRA CHILD 01-05 M	2,904.79	7,758.18	15,385.96	12,507.49	16,211.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,768.35

4313	SOBRA CHILD 06-13 M	555.73	16,453.57	21,123.59	8,585.74	9,363.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,082.60

4314	SOBRA CHILD 14-20 MA	617.95	3,921.06	15,040.43	9,192.10	37,618.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,390.18

4315	SOBRA CHILD 14-20 FE	381.31	4,618.73	9,526.84	11,858.83	42,202.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,588.51

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

1,449.77	842.30	13,180.05	7,897.65	6,334.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,704.05

10,432.36	23,430.15	28,335.79	14,201.19	26,830.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,230.35

SUBTOTAL:

53,294.52

157,635.55	269,130.99	293,245.96	282,045.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,055,352.74

1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	1.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.85

1109	TANF EXPANDED 65+ M&

0.00	0.00	0.00	0.00	634.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	634.57

1115	TANF EXPANDED 14-20	0.00	0.00	5,776.18	9.61	70.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,855.91

1116	TANF EXPANDED 21-44	275.40	10,001.59	4,198.14	5,442.76	12,230.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,148.70

1117	TANF EXPANDED 21-44	2,783.56	10,043.43	84,042.94	12,470.25	16,085.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125,425.38

1118	TANF EXPANDED 45-64	179.28	1,406.71	3,613.34	1,796.85	5,400.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,396.37

2400	SSI AGED EXPANDED WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

21.47	5,168.71	2,839.31	9,171.19	7,188.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,389.58

0.00	0.00	0.00	0.00	549.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	549.49

73.59	17.48	29.02	715.75	860.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,696.67

285.27	275.92	826.59	5,724.38	747.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,860.06

0.00	985.61	2,246.18	2,538.65	2,363.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,133.61

11.55	0.00	136.55	8.67	826.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	983.24

SUBTOTAL:

3,630.12

27,899.45	103,708.25	37,878.11	46,959.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220,075.43

3508	ADULT 40-100% M&F 45	0.00	0.00	451.74	365.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

817.49

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending November 30, 2014

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

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

171.21	3,225.92	147.79	144.57	774.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,464.41

0.00	439.63	3,768.03	1,871.01	11,838.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,917.47

247.60	2,157.04	12,408.98	7,765.36	20,089.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,668.43

1,176.50	5,293.82	12,225.76	5,188.29	13,161.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,046.31

3518	ADULT 40-100% M&F 45	8,542.82	41,548.55	34,573.67	29,729.55	26,645.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	141,040.35

3714	ADULT <40% EXP MAL E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4

0.00	1,327.29	1,482.68	10,022.27	7,462.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,294.90

376.67	4,178.34	3,217.57	14,484.38	9,919.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,176.09

6,067.34	85,317.95	190,168.66	239,964.51	242,409.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	763,927.80

2,907.86	29,170.77	55,381.77	123,684.49	99,596.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	310,741.28

28,847.18	115,592.61	182,495.36	255,086.77	332,583.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	914,605.07

SUBTOTAL:

48,337.18

288,251.92	496,322.01	688,306.95	764,481.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,285,699.60

3908	NEWLY ELIGIBLE M&F
4

0.00	0.00	0.00	0.00	69.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69.43

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	659.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	659.08

3915	NEWLY ELIGIBLE FEMA L

0.00	887.29	164.59	0.00	6,134.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,186.08

3916	NEWLY ELIGIBLE MALE	2,219.12	5,544.41	9,292.86	24,648.69	7,777.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,482.56

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

3,257.75	6,212.67	23,034.92	50,690.42	17,726.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100,922.64

3,025.43	23,641.19	61,731.84	40,358.62	28,980.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	157,737.55

SUBTOTAL:

8,502.30

36,285.56	94,224.21	115,697.73	61,347.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	316,057.34

4413	SOBRA 100-133% M&F
6

2,402.45	3,556.80	758.88	1,511.11	4,010.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,240.06

4414	SOBRA 100-133% MALE	1,368.00	0.00	115.26	4,802.82	3,639.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,925.39

4415	SOBRA 100-133% FEM AL

0.00	1,932.86	2,685.30	0.00	500.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,118.60

SUBTOTAL:

3,770.45

5,489.66	3,559.44	6,313.93	8,150.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,284.05

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M

217.38	148.32	34.58	47.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	447.61

0.00	326.52	0.00	58.14	204.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	589.09

SUBTOTAL:

217.38

474.84	34.58	105.47	204.43	0.00	0.00	0.00	0.00	0.00	0.00

0.00	1,036.70

TOTAL:	117,751.95	516,036.98	966,979.48	1,141,548.15	1,163,189.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,905,505.86		

IT
SUBTOTAL:

FAMILY PLANNING SERVICES

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	1,058.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,058.21		
	0.00	1,058.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,058.21		

0.00	1,058.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,058.21	

TOTAL:

FEDERAL EMERGENCY SERVICES

For The Period Ending November 30, 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	774.92	79.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,674.69

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	12,210.84	95,310.93	12,118.26	4,864.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	134,745.29

1013	TANF 06-13 M & F NON	23,681.01	72,450.81	63,270.15	42,352.50	19,243.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220,998.33

1014	TANF 14-20 MALE NON-	101,456.98	83,053.44	96,673.15	84,992.05	89,208.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	455,383.72

1015	TANF 14-20 FEMALE N O

700,203.94	477,647.74	511,723.03	353,435.39	535,270.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,578,280.73

1016	TANF 21-44 MALE NON-	131,895.09	136,642.01	151,856.35	134,645.69	127,636.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	682,675.56

1017	TANF 21-44 FEMALE N O

3,848,448.61	3,256,861.93	3,757,938.70	2,245,500.27	3,240,269.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,349,018.61

1018	TANF 45-64 M & F NON	287,422.21	185,243.32	179,004.97	198,478.01	181,931.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,032,080.00

1019	TANF 65+ M & F NON-M	1,367.38	50.36	3,006.83	0.00	-161.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,263.48

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

8,124.92	3,462.59	4,105.19	2,493.51	120.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,306.37

686,565.89	486,327.79	526,332.11	560,946.82	537,125.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,797,298.32

28,071.60	29,258.47	34,565.50	45,650.11	17,524.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	155,070.14

811,372.82	739,101.65	783,464.79	843,599.64	701,699.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,879,238.22

2,582.38	0.00	107.59	-341.29	5.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,354.32

SUBTOTAL:

6,645,181.08

5,482,310.95	6,208,134.21	4,523,950.45	5,454,737.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,314,314.61

1106	TANF EXPANDED 21-44	1,613.67	653.56	4,201.04	932.00	6,011.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,411.68

1107	TANF EXPANDED 21-44	81.76	74.69	768.84	1,261.10	610.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,797.33

1108	TANF EXPANDED 45-64	1,746.90	240.92	1,203.84	0.00	826.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,018.18

1113	TANF EXPANDED 06-13	0.00	5.83	5.83	370.29	228.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	610.06

1114	TANF EXPANDED 14-20	34.97	2,450.74	93.40	72.00	5,093.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,744.11

1115	TANF EXPANDED 14-20	11,771.70	25,932.07	7,814.64	9,083.11	10,651.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,253.30

1116	TANF EXPANDED 21-44	358,572.55	390,495.13	377,975.49	320,628.22	336,243.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,783,914.67

1117	TANF EXPANDED 21-44	758,042.25	533,723.61	653,487.41	502,738.23	544,247.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,992,238.68

1118	TANF EXPANDED 45-64	283,242.10	270,641.84	259,763.19	165,989.07	242,889.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,222,525.82

1119	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

214.96	7.57	2,777.49	1,386.84	1,163.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,550.13

0.00	72.72	0.00	672.78	204.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	949.93

0.00	0.00	0.00	823.73	10,080.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,904.01

0.00	0.00	0.00	3,206.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,206.17

2,523.41	-12.00	0.00	9,480.23	4,291.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,283.08

SUBTOTAL:

1,417,844.27

1,224,286.68	1,308,091.17	1,016,643.77	1,162,541.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,129,407.15

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

1,415.88	1,411.95	0.00	-1,562.84	-142.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,122.22	
-7,395.28	
26,731.13	
8,994.63	

2,289.04	578.80	0.00	-10,263.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

89,472.61	22,341.03	-2,887.03	-68,913.35	-13,282.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00

14,241.72	16,722.07	0.00	-17,419.95	-4,549.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00

FEDERAL EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

3518	ADULT 40-100% M&F 45	105,362.43	111,303.89	-865.58	-207,554.32	-34,663.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-26,417.53

3707	ADULT <40% EXP FEM AL
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6

777.07	47.95	0.00	0.00	-95.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	729.12

11,927.67	105,433.15	-536.88	-44,480.41	-2,343.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,999.99

10,875.16	21,482.86	0.00	-14,142.67	-14,558.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,656.40

331,193.61	259,868.44	-2,536.72	-383,740.56	-44,770.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160,014.35

54,689.87	132,072.18	-12,698.30	-115,825.12	-56,903.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,334.73

516,687.58	466,084.08	-18,915.90	-824,729.77	-71,025.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,100.88

1,353.93	3,879.07	0.00	-6,171.01	-459.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,397.03

SUBTOTAL:

1,140,286.57

1,141,225.47	-38,440.41	-1,694,803.12	-242,794.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	305,473.61

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

0.00	0.00	749.65	0.00	-47.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	701.70

0.00	0.00	0.00	21.42	693.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	715.13

3914	NEWLY ELIGIBLE MALE	270.58	862.62	64,766.14	58,834.17	51,644.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	176,377.56

3915	NEWLY ELIGIBLE FEMA L

700.41	7.57	2,697.89	32,902.85	29,592.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,901.30

3916	NEWLY ELIGIBLE MALE	68,081.76	19,874.30	250,395.78	840,040.37	363,819.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,542,211.80

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3927	NEWLY ELIGIBLE FEMA
L

19,080.23	35,620.91	121,474.29	390,053.08	186,749.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	752,977.76

46,459.07	34,571.04	819,625.84	1,521,424.01	640,984.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,063,064.10

0.00	0.00	2,058.48	33,555.09	9,020.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,634.45

0.00	0.00	0.00	730.36	228.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	958.45

SUBTOTAL:

134,592.05

90,936.44	1,261,768.07	2,877,561.35	1,282,684.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,647,542.25

TOTAL:	9,337,903.97	7,938,759.54	8,739,553.04	6,723,352.45	7,657,168.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,396,737.62		

FEDERAL ESP CHRONIC SERVICES

For The Period Ending November 30, 2014

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

2100	SSI AGED WITH MEDIC A

0.00	0.00	0.00	865.99	-865.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	865.99	-865.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3918	NEWLY ELIGIBLE M&F
4

0.00	0.00	0.00	2,971.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,971.56

SUBTOTAL:

0.00

0.00	0.00	2,971.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,971.56

0.00	0.00	0.00	3,837.55	-865.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,971.56	

TOTAL:

QMB - FEE FOR SERVICE

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	227,508.42	323,661.58	198,990.91	336,157.76	204,441.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,290,759.95		
	227,508.42	323,661.58	198,990.91	336,157.76	204,441.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,290,759.95		

SUBTOTAL:

TOTAL:	227,508.42	323,661.58	198,990.91	336,157.76	204,441.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,290,759.95		

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending November 30, 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-MEDIC
AR

1,750.41	0.00	7,007.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,758.07

44,497.58	8,807.48	14,389.41	100,947.49	9,925.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178,567.13

73,301.36	82,631.11	79,441.64	159,588.26	151,232.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	546,195.32

2120	SSI AGED WITH QMB	13,915.92	7,995.79	8,126.46	75,732.32	2,333.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,103.89

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
5017	SOBRA PREG 21-44 FE
M

4,073.14	0.00	519.72	388.90	9.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,991.37

0.00	1,038.51	808.37	14,554.04	2,640.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,041.58

1,975.23	16,840.57	8,486.35	5,052.05	6,307.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,661.30

SUBTOTAL:

139,513.64

117,313.46	118,779.61	356,263.06	172,448.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	904,318.66

SUBTOTAL:

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	-59,680.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-59,680.05	
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		0.00	
	0.00	0.00	0.00	-59,680.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-59,680.05	

3516	ADULT 40-100% MALE
2

0.00	174.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	174.96

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 MAL E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3714	ADULT <40% EXP MAL
E
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4

17,224.61	10,190.95	16,468.17	9,132.98	3,439.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,456.43

236.17	116.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	352.31

28,660.93	43,321.56	11,908.91	-426.94	1,269.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,733.56

821.12	634.83	374.49	721.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,551.72

239,576.63	251,224.77	186,647.70	203,044.50	79,944.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	960,437.70

6,841.48	3,338.30	14,739.60	22,819.43	2,293.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,032.53

193,944.21	209,147.18	241,670.75	448,656.73	194,257.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,287,676.35

SUBTOTAL:

487,477.64

518,148.69	471,809.62	683,947.98	281,204.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,442,588.05

4
SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	0.00	0.00	21,268.71	5,903.84	68,757.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,930.49	
3918	NEWLY ELIGIBLE M&F	0.00	0.00	1,987.81	-428.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,559.70	
	0.00	0.00	23,256.52	5,475.73	68,757.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,490.19	

626,991.28	635,462.15	613,845.75	986,006.72	522,410.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,384,716.85	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2200	SSI DISABLED WITH M	0.00	0.00	5,262.44	177.08	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,446.52		
	0.00	0.00	5,262.44	177.08	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,446.52		

E
SUBTOTAL:

TOTAL:	0.00	0.00	5,262.44	177.08	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,446.52		

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending November 30, 2014

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

1016	TANF 21-44 MALE NON-	0.00	0.00	1,290.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,290.19

1017	TANF 21-44 FEMALE N O

0.00	0.00	351.85	1,661.98	813.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,827.20

1018	TANF 45-64 M & F NON	0.00	0.00	435.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	435.39

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

3,365.09	0.00	417.09	744.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,526.39

0.00	0.00	4,190.71	2,375.47	7,477.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,043.46

0.00	0.00	0.00	88.36	218.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	306.63

4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	607.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	607.93

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

235.45	0.00	0.00	2,561.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,797.39

1,433.60	2,561.94	4,466.26	1,855.40	6,284.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,601.54

SUBTOTAL:

5,034.14

2,561.94	11,151.49	9,287.36	15,401.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,436.12

E
SUBTOTAL:

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	590.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590.17	
2620	SSI DISABLED EXPAND	0.00	0.00	0.00	1,490.40	571.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,061.52	
	0.00	0.00	0.00	1,490.40	1,161.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,651.69	

3515	ADULT 40-100% FEMAL E
3517	ADULT 40-100% FEMAL
E

0.00	0.00	0.00	0.00	3,536.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,536.84

0.00	429.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	429.04

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	385.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	385.28

3716	ADULT <40% EXP MAL E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4

8,220.27	3,894.04	23,019.10	13,678.57	31,422.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,234.77

4,470.06	0.00	69.43	2,092.40	2,806.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,437.96

398.58	2,007.44	560.46	4,482.41	29,462.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,911.87

SUBTOTAL:

13,088.91

6,330.52	23,648.99	20,638.66	67,228.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	130,935.76

18,123.05	8,892.46	34,800.48	31,416.42	83,791.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	177,023.57	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending November 30, 2014

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

1017	TANF 21-44 FEMALE N O
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
5017	SOBRA PREG 21-44 FE
M

443.20	0.00	0.00	0.00	1,999.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,443.09

0.00	0.00	1,359.40	160.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,520.27

0.00	2,281.13	549.96	170.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,001.86

259.64	0.00	694.56	421.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,376.10

6,591.20	3,917.51	1,120.00	0.00	4,754.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,383.52

SUBTOTAL:

7,294.04

6,198.64	3,723.92	753.54	6,754.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,724.84

E
SUBTOTAL:

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	1,471.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,471.06	
2610	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	1,958.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,958.42	
	0.00	0.00	0.00	0.00	3,429.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,429.48	

3716	ADULT <40% EXP MAL E
3718	ADULT <40% EXP M&F
4

2,763.39	17,422.92	0.00	0.00	860.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,046.60

1,679.53	17,584.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,263.67

SUBTOTAL:

4,442.92

35,007.06	0.00	0.00	860.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,310.27

TOTAL:	11,736.96	41,205.70	3,723.92	753.54	11,044.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,464.59		

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending November 30, 2014

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

1016	TANF 21-44 MALE NON-	0.00	0.00	98.99	0.00	204.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	303.42

1017	TANF 21-44 FEMALE N O

0.00	147.09	15,987.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,134.37

2120	SSI AGED WITH QMB	0.00	0.00	2,062.13	245.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,308.00

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

1,230.46	1,900.89	219.54	234.94	369.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,955.54

0.00	0.00	0.00	0.00	3,335.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,335.39

SUBTOTAL:

1,230.46

2,047.98	18,367.94	480.81	3,909.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,036.72

2,451.81	8,946.30	2,253.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,651.35	
2,451.81	8,946.30	2,253.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,651.35	

2600	SSI DISABLED EXPAND E
SUBTOTAL:

3516	ADULT 40-100% MALE
2
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4

0.00	0.00	0.00	1,593.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,593.96

69,885.82	4,424.13	2,585.73	22,219.69	3,665.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	102,780.53

416.43	377.59	585.05	327.95	3,373.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,080.43

10,106.81	34,737.21	3,139.28	9,368.47	166.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,518.66

SUBTOTAL:

80,409.06

39,538.93	6,310.06	33,510.07	7,205.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166,973.58

84,091.33	50,533.21	26,931.24	33,990.88	11,114.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206,661.65	

TOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEM	0.00	0.00	277.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277.25		
	0.00	0.00	277.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	277.25		

AL
SUBTOTAL:

TOTAL:	0.00	0.00	277.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	277.25		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD

For The Period Ending November 30, 2014

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

1010	TANF NON-MEDICARE	696.00	1,368.00	1,710.00	1,757.96	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,873.96

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

2,949,233.74	2,553,248.28	2,547,707.72	2,744,556.33	2,405,191.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,199,937.89

257,831.11	199,089.40	169,264.15	223,213.39	181,007.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,030,405.27

2120	SSI AGED WITH QMB	3,395,534.81	2,960,815.42	2,998,487.63	3,477,031.72	3,074,729.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,906,598.87

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

523,308.04	521,024.91	487,724.77	554,282.95	462,207.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,548,548.19

2,765,516.29	2,446,767.02	2,597,908.87	2,501,535.56	2,407,162.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,718,889.96

753,716.70	682,052.47	662,908.96	785,228.13	684,943.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,568,849.36

2300	SSI BLIND WITH MEDIC	406.36	101.07	204.74	-96.39	265.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	881.13

2310	SSI BLIND NON-MEDIC A

19,566.98	22,981.57	20,585.98	14,407.35	22,039.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,581.27

2320	SSI BLIND WITH QMB	8,634.19	8,670.31	5,363.33	10,825.38	7,786.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,279.58

SUBTOTAL:

10,674,444.22

9,396,118.45	9,491,866.15     10,312,742.38	9,245,674.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,120,845.48

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

0.00	4,587.51	2,336.85	2,296.32	2,122.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,343.24

2,742.24	2,647.68	2,966.82	2,957.30	3,061.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,375.24

SUBTOTAL:

2,742.24

7,235.19	5,303.67	5,253.62	5,183.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,718.48

10,677,186.46	9,403,353.64	9,497,169.82	10,317,996.00	9,250,858.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,146,563.96	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending November 30, 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-MEDIC
AR

10,604.85	6,556.27	4,904.83	21,431.27	21,860.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,357.46

0.00	3,762.00	679.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,441.61

2120	SSI AGED WITH QMB	0.00	335.71	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	385.71

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

909.00	1,038.77	2,561.60	-47.66	257.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,718.71

14,258.99	13,715.98	2,327.42	9,892.81	28,252.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,447.43

424.41	420.94	525.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,370.35

0.00	0.00	0.00	169.45	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	219.45

SUBTOTAL:

26,197.25

25,829.67	11,048.46	31,445.87	50,419.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144,940.72

TOTAL:	26,197.25	25,829.67	11,048.46	31,445.87	50,419.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144,940.72		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending November 30, 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	40,248.60	26,108.83	43,435.77	53,191.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	242,253.69

1013	TANF 06-13 M & F NON	146,919.93	53,520.17	48,821.09	111,064.06	119,940.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	480,265.46

1014	TANF 14-20 MALE NON-	9,642.30	4,300.62	5,068.51	9,775.48	12,866.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,653.04

1015	TANF 14-20 FEMALE N O
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

5,937.29	1,659.32	2,048.84	3,615.92	5,239.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,501.12

285,353.96	141,414.07	121,637.11	157,813.34	213,277.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	919,495.97

-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	132.43	0.00	18.93	63.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	413.63

2310	SSI BLIND NON-MEDIC A

1,150.83	776.30	790.05	1,583.20	1,457.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,758.30

4305	SOBRA CHILD 14-20 FE	125.02	0.00	0.00	0.00	7.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132.99

4312	SOBRA CHILD 01-05 M	85,612.86	51,376.50	33,585.46	58,256.39	67,044.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295,876.15

4313	SOBRA CHILD 06-13 M	125,563.85	40,259.17	40,961.40	104,479.42	103,459.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	414,723.28

4314	SOBRA CHILD 14-20 MA	8,367.62	3,051.25	3,874.19	6,993.04	9,561.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,847.37

4315	SOBRA CHILD 14-20 FE	4,600.75	1,396.66	1,644.07	4,087.51	4,202.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,931.73

5015	SOBRA PREG 14-20 FE M

0.00	0.00	102.54	0.00	82.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	184.74

1112	TANF EXPANDED 01-05	579.40	170.25	323.23	716.42	325.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,115.17	
1113	TANF EXPANDED 06-13	2,647.22	1,130.45	1,072.47	2,889.46	2,761.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,501.48	
1114	TANF EXPANDED 14-20	454.98	239.78	28.68	176.36	302.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,202.59	
1115	TANF EXPANDED 14-20	332.61	217.88	0.00	123.15	178.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852.02	
2610	SSI DISABLED EXPAND	305.53	64.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370.06	
	4,319.74	1,822.89	1,424.38	3,905.39	3,568.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,041.32	

SUBTOTAL:

752,725.57

338,135.09	284,642.09	501,123.06	590,395.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,467,020.86

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
3515	ADULT 40-100% FEMAL
E
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL

155.62	48.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	204.52

53.60	0.00	0.00	0.00	17.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.88

476.23	94.36	149.28	281.22	863.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,865.06

271.22	13.06	39.15	258.50	195.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	777.18

SUBTOTAL:

956.67

156.32	188.43	539.72	1,076.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,917.64

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

35.71	0.00	0.00	177.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	213.26

18,746.09	7,134.23	6,336.04	15,638.70	15,231.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,086.09

4414	SOBRA 100-133% MALE	1,596.05	456.57	462.77	1,508.43	1,650.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,674.13

4415	SOBRA 100-133% FEM AL

1,702.55	3,076.73	516.64	348.60	897.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,541.80

SUBTOTAL:

22,080.40

10,667.53	7,315.45	17,673.28	17,778.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,515.28

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	780,070.90	350,781.83	293,570.35	523,241.45	612,819.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,560,483.62		

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending November 30, 2014

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

1010	TANF NON-MEDICARE	47,470.63	21,432.22	18,846.93	27,265.06	38,488.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	153,503.39

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	2,144.04	684.80	346.92	1,036.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,624.67

1,478,954.03	694,004.94	538,459.10	721,921.58	996,957.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,430,297.24

4,777.36	3,124.80	1,162.93	1,707.31	2,323.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,096.30

10,115.61	3,200.88	2,535.87	6,084.02	9,657.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,593.61

SUBTOTAL:

1,542,730.01

723,906.88	561,689.63	757,324.89	1,048,463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,634,115.21

TOTAL:	1,542,730.01	723,906.88	561,689.63	757,324.89	1,048,463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,634,115.21		

ACUTE REINSURANCE

For The Period Ending November 30, 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	98,805.90	1,008,665.00	511,635.03	1,293,922.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,530,829.73

1012	TANF 01-05 M & F NON	226,432.73	113,704.79	95,070.99	178,087.61	74,184.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	687,480.77

1013	TANF 06-13 M & F NON	127,284.33	42,661.83	170,521.34	85,151.97	239,975.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	665,595.02

1014	TANF 14-20 MALE NON-	108,649.47	-4,443.77	374,095.78	-5,681.49	38,532.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	511,152.75

1015	TANF 14-20 FEMALE N O

26,416.78	8,394.13	58,355.61	59,133.80	34,497.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	186,798.12

1016	TANF 21-44 MALE NON-	132,385.08	173,376.31	292,747.33	64,996.50	173,255.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	836,761.11

1017	TANF 21-44 FEMALE N O

341,065.51	201,857.67	210,936.57	253,326.86	186,635.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,193,822.33

1018	TANF 45-64 M & F NON	201,160.52	184,914.30	290,339.30	109,588.10	128,202.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	914,204.93

1019	TANF 65+ M & F NON-M	1,093.03	0.00	-13,476.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-12,383.32

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

-11,064.51	20,679.74	9,511.66	1,576.15	24,489.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,192.17

128,077.73	94,236.33	91,762.23	118,229.74	226,009.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	658,315.74

20,315.85	-10,671.36	54,805.16	6,873.58	27,635.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,958.77

5,320,586.01	3,420,318.63	5,707,039.79	2,816,813.74	2,906,532.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,171,290.19

2,687.38	-11,640.56	0.00	1,357.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7,595.25

4311	SOBRA CHILD <1 M & F	786,856.39	349,782.11	1,099,621.16	1,111,859.28	2,623,130.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,971,249.12

4312	SOBRA CHILD 01-05 M	42,898.59	31,960.46	446,875.71	273,059.72	368,592.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,163,387.04

4313	SOBRA CHILD 06-13 M	342,577.75	67,788.19	560,809.73	148,080.44	221,081.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,340,337.75

4314	SOBRA CHILD 14-20 MA	1,333,911.20	92,018.33	-344,711.91	451,855.92	1,981,996.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,515,069.90

4315	SOBRA CHILD 14-20 FE	190,628.79	20,582.43	116,774.64	75,863.10	25,241.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	429,090.66

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

-5,501.24	7,852.13	37,376.93	6,376.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,104.13

35,660.75	7,458.14	102,096.78	3,037.03	24,380.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	172,633.64

SUBTOTAL:

9,969,923.69

4,909,635.73     10,369,217.45	6,271,221.32     10,598,297.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,118,295.30

1
SUBTOTAL:

3100	TRANSPLANT OPTION	0.00	-4.00	85.99	-6.06	-79.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3.70	
	0.00	-4.00	85.99	-6.06	-79.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-3.70	

20,704.86	
158.98	
101,280.11	
17,303.13	
7,336.15	
862,628.30	
477,696.12	
386,078.61	
-9,938.86	
8,664.75	
137,827.83	

1106	TANF EXPANDED 21-44	5,783.54	13,350.95	542.92	133.36	894.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	1,873.11	0.00	-1,714.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	72.82	61,789.30	6,983.13	274.92	32,159.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1115	TANF EXPANDED 14-20	0.00	0.00	5,936.61	1,399.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	157,110.28	82,741.38	455,063.66	88,476.06	79,236.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	93,886.49	109,876.31	96,015.23	64,363.24	113,554.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	76,199.68	14,785.12	174,735.48	44,869.25	75,489.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO

0.00	0.00	0.00	-9,938.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8,461.10	0.00	124.35	10.98	68.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00

10,343.80	38,833.17	48,929.18	16,878.16	22,843.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE REINSURANCE

For The Period Ending November 30, 2014

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

2600	SSI DISABLED EXPAND E
2610	SSI DISABLED EXPAND
E

6,615.59	41.18	259.67	-43.69	660.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,533.74

33,618.83	26,765.25	35,130.20	64,258.30	57,942.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	217,715.30

SUBTOTAL:

411,268.37

348,182.66	822,006.30	270,681.26	382,850.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,234,989.02

3314	AHC CARE MALE 14-20	0.00	0.00	0.00	-11.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11.62

3316	AHC CARE MALE 21-44	824.99	0.00	0.00	476.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,301.40

3317	AHC CARE FEMALE 21-
4

2,554.20	1,630.00	-1,699.92	3,631.25	23,289.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,404.95

3318	AHC CARE M&F 45-64 N	11,680.93	9,959.46	8,678.19	2,269.60	2,017.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,605.20

SUBTOTAL:

15,060.12

11,589.46	6,978.27	6,365.64	25,306.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,299.93

3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	-6,845.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-6,845.12

3614	AHC CARE/MI MALE 14-	284.63	19,818.72	0.00	11,716.84	5,773.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,594.00

3615	AHC CARE/MI FEMALE
1

0.00	0.00	-14,175.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-14,175.29

3616	AHC CARE/MI MALE 21-	35,449.75	5,486.62	11,138.39	3,366.22	-45,704.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,736.71

3617	AHC CARE/MI FEMALE
2

2,346.33	149.94	2,110.32	-3,857.24	2,459.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,208.91

3618	AHC CARE/MI M&F 45-6	92,677.00	81,721.95	44,330.54	19,060.38	135,891.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	373,681.03

SUBTOTAL:

130,757.71

107,177.23	43,403.96	30,286.20	91,575.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	403,200.24

3508	ADULT 40-100% M&F 45	0.00	1,491.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,491.78

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	185.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	185.27

3514	ADULT 40-100% MALE
1
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

151,764.97	87.21	121,941.25	219.47	110,342.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	384,355.65

110,085.04	28,336.63	12,796.30	50,169.11	99,573.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	300,960.89

14,191.06	42,194.34	5,249.57	4,955.67	2,150.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,740.87

3518	ADULT 40-100% M&F 45	124,182.25	80,115.17	153,287.28	155,636.54	242,864.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	756,085.97

3706	ADULT <40% EXP MAL E
3708	ADULT <40% EXP M&F
4
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4

0.00	321.77	2,973.17	2,209.46	2,081.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,585.63

0.00	0.00	1,239.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,239.45

60,063.28	970.09	86,261.30	67,956.06	23,765.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	239,015.90

28,863.68	9,089.82	0.00	3,832.02	1,785.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,570.77

527,880.83	612,804.86	986,924.78	428,531.24	470,042.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,026,183.87

203,328.99	-85,250.98	39,308.70	113,882.18	151,084.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	422,353.77

547,533.52	560,814.97	721,102.11	723,238.79	847,355.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,400,044.76

1,443.90	
-5.01	
56,933.76	
15,685.95	
278,225.97	

SUBTOTAL:

1,767,893.62

1,250,975.66	2,131,083.91	1,550,815.81	1,951,045.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,651,814.58

3908	NEWLY ELIGIBLE M&F
4

0.00	0.00	0.00	0.00	1,443.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	0.00	0.00	6.06	0.00	-11.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	0.00	0.00	14,764.01	-13,290.27	55,460.02	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

0.00	0.00	6,908.43	8,777.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

22,286.86	20,209.37	79,895.32	96,867.66	58,966.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	22,286.86	20,209.37	101,573.82	92,354.91	115,859.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	352,284.57		

4413	SOBRA 100-133% M&F
6

14,312.67	8,754.46	24,795.69	6,159.74	38,014.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4414	SOBRA 100-133% MALE	65.18	19,810.58	102,761.85	37,400.05	51,462.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4415	SOBRA 100-133% FEM AL

0.00	-7,529.00	17,232.86	18,975.57	5,920.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

14,377.85

21,036.04	144,790.40	62,535.36	95,396.90	0.00	0.00	0.00	0.00	0.00	0.00

0.00

92,036.59	
211,499.73	
34,600.23	
338,136.55	

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	0.00	0.00	0.00	6,209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,209.80

10,313.98	4,032.69	22,493.05	16,045.91	-7,955.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,930.34

0.00	0.00	2,131.29	9,032.07	-736.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,426.42

6,115.12	-6,057.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.47

SUBTOTAL:

16,429.10

-2,024.96	24,624.34	25,077.98	-2,482.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,624.03

M
SUBTOTAL:

8710	SSI DISABLED FREEDO	2,558.36	99,193.33	35,512.47	-10,364.78	16,562.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,462.08	
	2,558.36	99,193.33	35,512.47	-10,364.78	16,562.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143,462.08	

12,350,555.68	6,765,970.52	13,679,276.91	8,298,967.64	13,274,331.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,369,102.60	

TOTAL:

LONG TERM CARE REINSURANCE

For The Period Ending November 30, 2014

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

1010	TANF NON-MEDICARE	770.44	1,211.99	2,146.75	3,891.39	1,497.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,518.15

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

444,766.14	302,713.80	603,255.00	438,652.82	415,507.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,204,895.43

94,778.89	68,228.22	239,845.11	302,132.92	162,138.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	867,124.07

542,384.64	745,227.77	1,060,996.47	700,811.88	851,980.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,901,401.18

2,252,785.70	2,463,223.47	3,374,452.37	3,279,509.10	3,025,825.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,395,795.85

16,178.78	10,868.82	46,055.83	13,881.85	24,909.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111,895.25

SUBTOTAL:

3,351,664.59

3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,490,629.93

TOTAL:	3,351,664.59	3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,490,629.93		

ACUTE SMIB

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	64,841.20	63,789.20	57,855.80	64,149.80	64,198.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314,834.80

1010	TANF NON-MEDICARE	314.70	314.70	314.70	209.80	209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,363.70

1020	TANF WITH QMB	1,993.10	1,888.20	1,783.30	3,671.50	4,300.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,637.00

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

233,087.80	189,316.60	73,485.90	77,472.10	70,338.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	643,701.30

400,566.10	392,011.30	395,473.00	394,528.90	402,711.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,985,290.40

2120	SSI AGED WITH QMB	2,312,587.30	2,407,498.90	2,459,471.60	2,484,936.70	2,477,338.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,141,833.30

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

431,726.00	393,804.40	196,687.50	205,227.90	198,475.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,425,921.60

325,924.30	328,756.60	332,702.80	334,897.50	332,533.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,654,814.20

2,938,167.40	2,948,060.50	2,962,742.20	2,977,216.20	2,936,899.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,763,085.50

2300	SSI BLIND WITH MEDIC	2,307.80	2,098.00	209.80	209.80	629.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,454.80

2310	SSI BLIND NON-MEDIC A

3,356.80	3,461.70	3,356.80	3,356.80	3,776.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,308.50

2320	SSI BLIND WITH QMB	26,329.90	26,130.10	26,434.80	23,517.60	26,329.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	128,742.30

4300	SOBRA CHILD WITH M ED
4310	SOBRA CHILD NON-ME
DI
5000	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

0.00	0.00	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314.70

0.00	0.00	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.90

0.00	104.90	2,307.80	3,147.00	2,412.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,972.40

314.70	419.60	524.50	1,573.50	629.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,461.70

8000	SMIB ONLY NOT ELIGIB	142,941.40	138,959.60	0.00	0.00	-209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	281,691.20

8020	QMB ONLY	451,354.50	444,411.20	440,537.90	446,707.80	471,183.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,254,195.00

8040	SLMB	2,943,067.40	2,935,466.10	3,034,675.20	3,194,386.00	3,319,052.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,426,647.30

8888	SMIB ONLY NOT ELIGIB	10,545.90	53,013.10	-122,308.40	-7,552.80	-13,010.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-79,312.70

9999	SMIB ONLY NOT ELIGIB	104,243.20	279,672.30	-49,755.80	165,466.10	243,117.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	742,743.30

SUBTOTAL:

10,393,669.50

10,609,177.00	9,816,709.20     10,373,227.10     10,541,022.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,733,805.20

9910	TANF & SOBRA CHILDR	0.00	-209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	0.00	-104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

-209.80
E
-104.90

00	-314.70

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
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

839.20	1,388.40	598,877.80	613,200.10	634,134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,848,439.50	
1,049.00	
127,033.90	
265,699.30	
5,559.70	
12,173,239.70	
1,678.40	
104,915.00	
209.80	
5,186,036.10	

0.00	0.00	314.70	419.60	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	38,708.10	45,002.10	43,323.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00

106,596.20	97,002.30	18,986.90	25,385.80	17,728.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,468.60	1,153.90	1,153.90	629.40	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,329,792.40	2,507,887.80	2,428,160.60	2,436,748.60	2,470,650.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00

524.50	419.60	314.70	209.80	209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00

49,093.20	56,031.60	-209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

951,712.70	1,111,220.00	1,014,433.70	1,044,837.50	1,063,832.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9900	HOSP. KICK PAYMENT	8,811.60	11,853.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,665.30	
	8,811.60	11,853.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,665.30	

SUBTOTAL:

ACUTE SMIB

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	3,440,131.70	3,775,208.50	4,100,740.60	4,166,432.90	4,231,346.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,713,860.40		

A
SUBTOTAL:

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	419.60	475.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		895.10	
3520	ADULT 40-100% FOR FI	3,042.10	4,300.90	4,825.40	3,776.40	4,091.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,035.90	
3700	ADULT <40% EXP FOR F	0.00	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.70	
3720	AHC CARE EXPANDED	1,049.00	1,153.90	2,517.60	3,671.50	2,727.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,119.40	
	4,510.70	6,245.00		7,343.00	7,447.90	6,818.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,365.10	

3900	NEWLY ELIGIBLE FOR F
3920	NEWLY ELIGIBLE FOR
F

0.00	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.90

1,258.80	734.30	1,678.40	1,783.30	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,608.70

SUBTOTAL:

1,258.80

839.20	1,678.40	1,783.30	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,713.60

8700	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

1,049.00	1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,098.00

16,154.60	17,833.00	19,931.00	20,140.80	19,511.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	93,570.80

SUBTOTAL:

17,203.60

18,882.00	19,931.00	20,140.80	19,511.40	0.00	0.00	0.00	0.00	0.00	0.00

0.00	95,668.80

TOTAL:

13,865,585.90

14,421,890.70     13,946,402.20     14,569,032.00     14,799,852.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71,602,763.70

ACUTE HIB

For The Period Ending November 30, 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-MEDIC
AR

-5,222.40	1,704.00	426.00	-426.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-3,518.40

-7,299.40	5,613.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,686.40

2120	SSI AGED WITH QMB	138,085.50	183,470.40	180,831.60	183,415.80	188,884.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	874,687.50

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	81,575.40	79,871.40	85,989.00	81,256.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	351,452.20

2320	SSI BLIND WITH QMB	426.00	426.00	426.00	426.00	426.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,130.00

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	5,046.60	3,918.60	2,734.20	3,090.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,698.20

9999	SMIB ONLY NOT ELIGIB	-89,633.40	-5,389.20	-6,432.00	-2,187.00	1,043.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-102,598.20

2420	SSI AGED EXPANDED	2,805.80	1,938.00	1,938.00	1,938.00	3,216.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,835.80	
	2,805.80	1,938.00	1,938.00	1,938.00	3,216.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,835.80	

SUBTOTAL:

58,791.90

272,446.20	259,041.60	269,952.00	274,700.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,134,932.10

WI
SUBTOTAL:

TOTAL:	61,597.70	274,384.20	260,979.60	271,890.00	277,916.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,146,767.90		

SUBTOTAL:	0

Q1

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	1,614,709.50	1,575,256.30	2,047,309.70	1,885,145.90	1,927,080.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,049,501.40		
9999	SMIB ONLY NOT ELIGIB	12,692.90	46,532.10	-64,720.20	944.10	1,573.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,977.60		
	1,627,402.40	1,621,788.40		1,982,589.5		1,886,090.00	1,928,653.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,046,523.80		

1,627,402.40	1,621,788.40	1,982,589.50	1,886,090.00	1,928,653.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,046,523.80	

TOTAL:

LTC SMIB

For The Period Ending November 30, 2014

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

1000	TANF WITH MEDICARE	209.80	209.80	209.80	209.80	209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,049.00

1020	TANF WITH QMB	209.80	209.80	209.80	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	839.20

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

888,555.70	873,534.60	857,715.10	861,295.50	876,233.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,357,334.30

152,419.70	154,098.10	154,307.90	156,615.70	156,091.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	773,532.60

2120	SSI AGED WITH QMB	701,571.20	723,659.60	742,796.90	743,761.00	748,566.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,660,355.10

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

332,642.90	322,652.70	317,112.70	316,378.40	317,742.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,606,528.80

15,525.20	15,839.90	16,574.20	17,098.70	16,469.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,507.30

663,338.30	680,244.30	688,514.30	693,444.60	693,969.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,419,510.60

2300	SSI BLIND WITH MEDIC	1,049.00	839.20	839.20	839.20	1,258.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,825.40

2310	SSI BLIND NON-MEDIC A

209.80	314.70	314.70	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,468.60

2320	SSI BLIND WITH QMB	4,300.90	4,300.90	4,300.90	4,196.00	4,196.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,294.70

8720	SSI DISABLED FREEDO	524.50	524.50	419.60	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,098.00	
	524.50	524.50	419.60	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,098.00	

SUBTOTAL:

2,760,032.30

2,775,903.60	2,782,895.50	2,794,258.50	2,815,155.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,928,245.60

M
SUBTOTAL:

TOTAL:	2,760,556.80	2,776,428.10	2,783,315.10	2,794,573.20	2,815,470.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,930,343.60		

LTC HIB

For The Period Ending November 30, 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-MEDIC
AR

-5,106.60	0.00	0.00	426.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4,680.60

-6,887.80	5,613.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,274.80

2120	SSI AGED WITH QMB	148,322.10	262,344.00	258,760.20	266,282.40	261,745.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,197,453.90

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

-1,539.40	0.00	426.00	-852.00	426.00	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	7,956.00	7,338.60	12,054.60	10,350.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,831.50

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

275,913.00	266,524.80	277,911.00	272,521.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,214,438.90

121,568.30	275,913.00	266,524.80	277,911.00	272,521.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,214,438.90	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 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	1,509.02	1,093.31	1,184.10	1,281.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,510.04

1007	TANF 21-44 FEMALE WI	7,891.55	4,440.10	37,095.67	5,204.05	11,335.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,967.19

1008	TANF 45-64 M & F WIT	688.07	4,551.70	6,186.60	7,407.18	3,733.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,566.89

1009	TANF 65+ M & F WITH	2,777.42	692.23	471.06	1,233.62	976.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,150.43

1011	TANF <1 M & F NON-ME	1,237,866.75	932,978.33	1,131,834.80	1,000,946.76	872,460.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,176,086.83

1012	TANF 01-05 M & F NON	2,340,612.57	1,919,266.49	2,243,633.53	2,186,511.59	1,967,573.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,657,597.43

1013	TANF 06-13 M & F NON	3,637,963.98	3,594,181.03	3,683,496.59	3,156,471.07	3,734,480.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,806,593.44

1014	TANF 14-20 MALE NON-	789,166.76	666,853.53	701,533.91	576,596.64	650,572.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,384,723.31

1015	TANF 14-20 FEMALE N O

1,078,108.85	1,185,943.41	1,229,700.53	872,114.99	1,098,823.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,464,691.39

1016	TANF 21-44 MALE NON-	1,173,513.39	1,086,941.76	1,266,018.20	1,075,586.46	994,203.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,596,263.71

1017	TANF 21-44 FEMALE N O

5,649,472.39	5,271,845.29	6,148,673.71	5,106,675.27	4,919,859.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,096,525.99

1018	TANF 45-64 M & F NON	1,634,097.28	1,426,990.58	1,590,708.15	1,355,560.84	1,389,361.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,396,718.83

1019	TANF 65+ M & F NON-M	3,798.00	3,834.76	3,253.05	4,446.00	3,131.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,462.95

1027	TANF 21-44 FEMALE WI	4,120.76	2,736.00	0.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,198.76

1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	1,376.01	1,276.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,652.97

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

55,280.06	61,807.18	52,962.78	58,259.92	35,963.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	264,273.46

122,058.59	95,993.44	111,925.93	121,536.53	82,043.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	533,558.30

2120	SSI AGED WITH QMB	240,326.58	230,567.57	231,158.40	261,929.02	195,589.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,159,571.45

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

141,948.53	159,969.16	144,932.50	155,742.39	92,640.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	695,232.68

5,600,784.07	4,878,415.73	5,361,312.61	4,421,143.38	4,225,871.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,487,527.16

505,684.41	462,707.23	465,266.11	509,682.34	379,838.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,323,178.99

2300	SSI BLIND WITH MEDIC	732.05	1,083.49	134.57	670.80	1,194.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,815.89

2310	SSI BLIND NON-MEDIC A

58,811.72	53,564.21	70,414.36	74,538.56	53,470.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	310,799.27

2320	SSI BLIND WITH QMB	6,877.81	7,105.79	5,428.99	6,812.69	6,272.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,497.80

4311	SOBRA CHILD <1 M & F	1,346,693.34	1,056,011.50	1,229,599.65	994,222.35	993,599.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,620,126.46

4312	SOBRA CHILD 01-05 M	1,349,383.33	1,055,252.28	1,317,175.42	1,230,654.57	1,005,835.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,958,301.55

4313	SOBRA CHILD 06-13 M	1,906,239.87	1,676,932.51	1,758,654.05	1,553,964.50	1,578,357.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,474,147.96

4314	SOBRA CHILD 14-20 MA	819,236.05	706,030.79	717,542.51	535,873.37	620,642.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,399,325.28

4315	SOBRA CHILD 14-20 FE	1,262,134.73	805,629.49	853,710.30	695,968.72	960,135.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,577,578.39

4325	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

158.10	59.40	571.42	179.57	146.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,114.83

327,656.19	297,669.00	310,183.13	221,676.68	249,107.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,406,292.46

1,091,567.67	946,301.56	1,169,090.06	986,816.43	812,410.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,006,185.77

-18,468.00	3,071.60	3,420.00	2,475.20	1,072.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-8,428.61

2,970.00	330.00	0.00	990.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,290.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	32,382,594.67	28,601,266.16	31,847,181.90	27,184,793.60	26,943,262.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,959,099.25		

1106	TANF EXPANDED 21-44	6,408.48	4,488.35	5,192.83	7,061.09	6,710.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,861.05

1107	TANF EXPANDED 21-44	13,495.32	12,706.18	10,880.70	10,508.67	8,592.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,182.90

1108	TANF EXPANDED 45-64	30,378.85	28,533.23	34,497.12	29,931.18	22,272.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,612.87

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

19,280.09	19,116.75	18,240.76	17,222.69	11,053.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,914.04

342.00	0.00	0.00	0.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	684.00

1112	TANF EXPANDED 01-05	9,006.00	8,938.95	11,623.85	5,501.17	6,653.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,723.55

1113	TANF EXPANDED 06-13	51,575.17	42,983.60	52,423.69	50,487.63	57,785.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255,255.13

1114	TANF EXPANDED 14-20	22,170.63	16,255.50	17,324.79	18,051.36	18,982.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92,785.16

1115	TANF EXPANDED 14-20	47,309.83	42,419.66	54,623.86	31,881.60	46,287.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	222,522.00

1116	TANF EXPANDED 21-44	591,969.39	562,199.70	684,810.63	500,868.98	492,500.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,832,348.79

1117	TANF EXPANDED 21-44	1,556,828.28	1,471,553.46	1,730,161.36	1,372,816.73	1,320,720.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,452,080.80

1118	TANF EXPANDED 45-64	886,655.00	786,372.06	880,244.74	764,652.74	796,223.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,114,148.31

1119	TANF EXPANDED 65+ M&

342.00	684.00	1,026.00	2,394.00	1,098.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,544.14

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	77.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77.42

1127	TANF EXPANDED 21-44	151.39	8.27	94.46	110.11	120.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	484.60

1128	TANF EXPANDED 45-64	3,030.80	783.84	3,283.40	3,586.48	2,660.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,344.91

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	1,787.21	1,215.52	2,075.30	1,251.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,388.69

12,551.22	7,567.69	11,266.27	27,257.02	13,480.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,122.75

47,919.09	48,564.00	54,031.56	45,796.97	42,956.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	239,268.27

205,652.65	186,044.63	175,582.01	231,675.45	161,533.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	960,487.88

-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	2,210.05	3,730.20	4,895.87	5,234.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,618.88

70,066.79	61,883.80	57,114.09	58,998.22	50,285.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	298,348.34

85,071.68	74,095.59	69,290.34	83,409.55	61,957.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	373,824.57

SUBTOTAL:

3,668,481.80

3,379,196.52	3,876,658.18	3,269,182.81	3,128,779.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,322,299.05

3309	AHC CARE M&F 65+ W/	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3316	AHC CARE MALE 21-44	3,984.00	1,650.00	-552.04	687.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,769.86

3317	AHC CARE FEMALE 21-
4

2,002.28	1,980.00	-948.00	0.00	-10.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,024.03

3318	AHC CARE M&F 45-64 N	11,059.15	20,372.17	3,434.97	1,336.45	100.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,303.59

3328	AHC CARE M&F 45-64
W

0.00	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:

17,045.43

24,002.17	1,934.93	2,024.35	90.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,097.48

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	
3410	MED ELIGIBILITY NON-	0.00	0.00	-588.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3607	AHC CARE/MI FEMALE	41.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

-588.00

41.99
2

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

3608	AHC CARE/MI M&F 45-6	0.00	2,890.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,890.64

3614	AHC CARE/MI MALE 14-	9,988.67	1,507.30	-141.25	2,718.80	27.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,101.27

3615	AHC CARE/MI FEMALE
1

6,338.94	1,363.64	688.74	341.22	429.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,162.38

3616	AHC CARE/MI MALE 21-	11,700.14	22,355.93	3,742.25	14,955.13	1,966.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,720.35

3617	AHC CARE/MI FEMALE
2

-10,085.42	14,975.79	1,345.49	2,594.02	2,174.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,004.33

3618	AHC CARE/MI M&F 45-6	102,440.36	47,844.90	2,478.30	26,770.49	-8,989.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	170,544.93

3619	AHC CARE/MI 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

SUBTOTAL:

120,424.68

90,938.20	7,525.53	47,379.66	-4,390.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	261,877.89

3506	ADULT 40-100% MALE
2
3507	ADULT 40-100% FEMAL
E

684.00	2,736.00	0.00	1,368.00	435.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,223.98

0.00	0.00	342.00	0.00	-342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	9,119.57	7,599.64	17,255.92	6,807.55	5,202.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,985.43

3509	ADULT 40-100% M&F 65	4,900.96	3,425.25	1,759.86	24.59	-138.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,972.44

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

11,956.88	15,259.04	11,015.99	6,091.76	5,163.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,487.33

30,135.72	25,033.04	38,775.33	28,669.44	27,488.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	150,101.80

214,543.22	272,200.59	396,809.12	243,752.03	248,328.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,375,633.86

353,269.80	308,087.27	365,630.82	332,449.95	338,773.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,698,211.40

3518	ADULT 40-100% M&F 45	1,126,897.64	1,079,018.25	1,262,645.73	946,557.46	966,075.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,381,194.86

3519	ADULT 40-100% M&F 65	-990.00	0.00	2,394.00	1,368.00	684.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,456.00

3528	ADULT 40-100% M&F 45	23.40	0.00	129.06	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	211.86

3529	ADULT 40-100% M&F 65	192.12	71.86	424.98	0.00	93.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	782.13

3706	ADULT <40% EXP MAL E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

1,792.92	1,968.09	297.17	182.40	627.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,868.25

1,067.23	420.38	-251.10	1,380.33	741.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,358.80

14,748.72	7,103.33	9,806.11	6,948.85	3,447.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,054.78

3,515.98	93.07	1,056.57	879.12	1,071.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,616.55

239,581.44	231,188.42	205,950.10	196,940.37	253,893.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,127,553.70

359,309.33	351,228.87	363,914.24	341,840.78	251,734.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,668,027.76

3,847,800.35	3,546,062.74	4,041,892.63	3,442,949.46	3,052,156.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,930,861.95

2,702,957.26	2,499,001.62	2,930,369.65	2,323,636.33	2,219,259.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,675,224.69

5,364,337.66	4,940,915.69	5,614,113.55	4,577,348.60	4,831,791.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,328,506.73

2,748.00	1,368.00	39,287.82	1,710.00	5,814.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,927.82

0.00	15.75	0.00	0.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	357.75

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

0.00	1,026.00	0.00	569.61	193.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,789.56

SUBTOTAL:

14,288,592.20

13,293,822.90     15,303,619.55     12,461,534.03     12,212,840.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,560,409.43

3906	NEWLY ELIGIBLE MALE	0.00	203.20	1,275.39	828.81	701.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,009.31

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

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

696.00	0.00	1,710.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,748.00

15,345.28	11,628.43	8,100.42	10,133.07	1,752.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,959.25

735.29	3,671.34	5,409.63	1,978.28	869.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,664.24

3914	NEWLY ELIGIBLE MALE	4,167.88	7,302.00	4,425.47	2,808.00	1,488.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,191.35

3915	NEWLY ELIGIBLE FEMA L

6,849.61	5,130.00	5,153.95	16,192.56	9,918.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,244.12

3916	NEWLY ELIGIBLE MALE	163,852.24	96,121.50	114,419.26	136,067.12	99,557.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	610,017.70

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

130,991.21	153,945.73	161,583.42	119,051.66	120,153.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	685,725.85

497,280.63	460,771.54	605,755.88	482,433.85	408,590.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,454,832.01

1,368.00	684.00	342.00	342.00	684.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,420.00

0.00	0.00	1,828.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,828.80

SUBTOTAL:

821,286.14

739,457.74	910,004.22	770,177.35	643,715.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,884,640.63

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

4,638.00	2,394.00	1,710.00	1,368.00	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,136.00

220,130.89	222,012.81	266,413.75	194,465.10	218,511.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,121,533.65

4414	SOBRA 100-133% MALE	72,117.92	76,274.16	82,444.14	73,759.67	76,608.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	381,204.53

4415	SOBRA 100-133% FEM AL

96,355.37	96,932.98	126,797.45	85,782.45	115,138.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	521,006.74

SUBTOTAL:

393,242.18

397,613.95	477,365.34	355,375.22	411,284.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,034,880.92

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1

0.00	2,688.00	342.00	0.00	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,056.00

32,045.00	11,844.27	17,920.12	9,400.87	6,805.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	78,015.30

2,736.00	0.00	342.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,420.00

SUBTOTAL:

34,781.00

14,532.27	18,604.12	9,742.87	7,831.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,491.30

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

1,454.42	423.99	3,462.33	95.70	1,337.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,773.88

2,736.00	2,394.00	2,736.00	2,394.00	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,286.00

256.13	68.12	137.78	69.66	559.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,090.87

SUBTOTAL:

4,446.55

2,886.11	6,336.11	2,559.36	2,922.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,150.75

TOTAL:	51,730,894.65	46,543,716.02	52,449,229.88	44,102,769.25	43,346,336.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	238,172,946.70		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 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	5,509.22	4,738.73	9,532.59	4,948.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,240.18

1007	TANF 21-44 FEMALE WI	15,246.21	13,392.53	6,751.56	14,675.65	9,577.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,643.71

1008	TANF 45-64 M & F WIT	4,700.46	1,563.84	2,961.12	3,335.97	1,094.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,656.32

1009	TANF 65+ M & F WITH	554.64	167.54	167.54	989.97	404.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,284.63

1011	TANF <1 M & F NON-ME	732,298.41	755,161.45	702,747.44	425,059.42	508,751.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,124,017.91

1012	TANF 01-05 M & F NON	531,443.83	479,890.34	537,804.59	527,849.95	491,968.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,568,957.30

1013	TANF 06-13 M & F NON	506,765.09	421,076.98	618,501.33	631,612.73	635,945.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,813,901.84

1014	TANF 14-20 MALE NON-	215,330.10	202,961.83	122,006.47	131,859.01	138,434.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	810,591.71

1015	TANF 14-20 FEMALE N O

209,694.11	211,625.01	232,455.11	265,468.10	249,410.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,168,652.61

1016	TANF 21-44 MALE NON-	445,479.43	357,175.48	371,805.96	385,447.27	373,782.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,933,690.26

1017	TANF 21-44 FEMALE N O

1,705,492.72	1,509,894.24	1,723,446.12	1,620,639.40	1,375,277.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,934,749.66

1018	TANF 45-64 M & F NON	635,145.79	572,301.18	372,748.14	531,665.84	436,040.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,547,901.91

1019	TANF 65+ M & F NON-M	0.00	1,192.98	168.02	129.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,490.21

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

1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	1,898.77	48.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,946.79

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

52,744.87	38,379.36	63,306.89	38,592.69	38,601.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	231,625.11

35,489.62	32,547.24	28,257.86	33,757.70	62,370.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	192,423.30

2120	SSI AGED WITH QMB	242,074.39	213,448.56	215,432.79	251,120.09	199,731.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,121,807.82

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

266,485.96	172,649.08	166,477.74	168,126.72	107,342.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	881,081.61

3,163,355.90	2,743,716.75	2,913,378.24	3,184,896.21	2,948,173.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,953,520.50

1,005,134.11	652,376.80	671,203.10	879,517.48	604,374.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,812,605.52

2300	SSI BLIND WITH MEDIC	1,296.92	715.33	578.36	108.23	597.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,296.77

2310	SSI BLIND NON-MEDIC A

59,530.65	29,246.29	32,265.52	41,267.97	24,024.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	186,335.04

2320	SSI BLIND WITH QMB	15,673.05	11,384.27	5,603.15	7,539.34	7,929.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,129.62

4311	SOBRA CHILD <1 M & F	980,037.24	310,735.71	613,881.86	590,179.30	786,237.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,281,071.98

4312	SOBRA CHILD 01-05 M	201,675.08	181,056.35	215,879.69	244,914.68	206,873.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,050,399.43

4313	SOBRA CHILD 06-13 M	183,132.69	165,135.66	233,840.47	255,298.13	259,773.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,097,180.00

4314	SOBRA CHILD 14-20 MA	100,507.75	88,002.42	83,325.00	101,286.62	131,567.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	504,689.68

4315	SOBRA CHILD 14-20 FE	122,461.08	134,721.79	118,638.74	142,115.11	102,471.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	620,408.20

4325	SOBRA CHILD 14-20 FE	0.00	0.00	90.66	351.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	441.71

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	573.05	-538.47	269.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	333.12

139,377.14	102,991.33	94,124.61	75,488.88	92,219.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	504,201.44

432,998.83	322,833.36	357,939.48	266,537.43	275,999.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,656,308.95

1,755.04	448.74	37.60	89.34	1,571.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,902.60

0.00	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-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	12,024,874.74	9,732,874.71	10,510,025.42	10,831,619.88	10,075,545.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53,174,940.46		

1106	TANF EXPANDED 21-44	20,739.17	8,100.82	5,105.04	16,969.98	16,315.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,230.92

1107	TANF EXPANDED 21-44	29,774.01	15,342.27	11,557.24	27,241.00	15,808.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,723.30

1108	TANF EXPANDED 45-64	68,920.08	45,889.75	52,345.68	63,765.68	44,053.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	274,974.83

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

7,438.23	9,025.57	11,942.73	14,963.64	7,844.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,215.01

48.77	99.94	0.00	0.00	488.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	636.79

1112	TANF EXPANDED 01-05	4,152.37	748.37	5,140.86	2,399.27	2,463.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,904.04

1113	TANF EXPANDED 06-13	6,195.30	5,396.23	5,514.09	8,387.09	4,731.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,223.96

1114	TANF EXPANDED 14-20	1,476.39	759.67	2,431.97	793.98	4,046.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,508.69

1115	TANF EXPANDED 14-20	8,362.55	3,636.28	5,678.74	11,722.66	9,565.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,965.31

1116	TANF EXPANDED 21-44	160,136.01	138,780.95	155,648.92	181,818.28	166,653.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	803,037.27

1117	TANF EXPANDED 21-44	325,927.10	311,091.45	313,484.04	303,205.38	282,787.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,536,495.54

1118	TANF EXPANDED 45-64	213,882.58	282,231.58	291,882.45	403,598.03	308,839.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,500,434.06

1119	TANF EXPANDED 65+ M&

2,212.51	3,660.81	319.01	9,424.88	978.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,595.38

1126	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

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	3,509.97	6,052.66	10,639.52	182.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,780.62

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	3,133.32	1,382.57	3,058.45	4,663.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,718.03

7,771.38	3,949.84	19,571.19	6,356.10	9,431.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,080.47

97,330.44	71,054.90	28,493.77	28,675.55	24,511.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	250,066.28

251,590.15	212,198.30	189,287.96	257,492.94	202,736.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,113,305.76

0.00	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	6,530.52	5,282.47	4,928.44	5,127.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,137.90

37,110.66	44,135.71	18,879.29	30,701.48	24,963.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	155,790.42

140,475.36	103,873.91	91,251.84	130,395.87	96,370.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	562,367.79

SUBTOTAL:

1,399,688.11

1,273,150.16	1,221,252.52	1,516,538.22	1,232,563.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,643,192.37

3309	AHC CARE M&F 65+ W/	0.00	60.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60.62

3316	AHC CARE MALE 21-44	118.58	26.76	0.00	0.00	68.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	213.51

3317	AHC CARE FEMALE 21-
4

-1,208.58	0.00	-53.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,261.75

3318	AHC CARE M&F 45-64 N	419.09	8.76	-124.15	128.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	431.76

3328	AHC CARE M&F 45-64
W

0.00	-13.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13.75

SUBTOTAL:

-670.91

82.39	-177.32	128.06	68.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-569.61

3400	MED ELIGIBILITY W/ M	-23.88	-86.21	0.00	-117.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	-121.13	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	0.00	0.00	3.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-227.53

-121.13

3.75
2

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 2014

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

3608	AHC CARE/MI M&F 45-6	2,261.53	112.60	624.97	0.00	51.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,050.57

3614	AHC CARE/MI MALE 14-	207.75	0.00	709.47	32.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	949.91

3615	AHC CARE/MI FEMALE
1

872.87	0.00	84.71	2,037.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,995.00

3616	AHC CARE/MI MALE 21-	5,204.61	2,086.43	11,947.67	1,364.39	583.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,186.25

3617	AHC CARE/MI FEMALE
2

3,444.53	22,145.25	-410.19	2,422.82	-106.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,495.91

3618	AHC CARE/MI M&F 45-6	903.34	18,611.19	-266.03	755.16	111.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,114.67

3619	AHC CARE/MI 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

SUBTOTAL:

12,870.75

42,748.13	12,694.35	6,495.04	639.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,447.40

3506	ADULT 40-100% MALE
2
3507	ADULT 40-100% FEMAL
E

0.00	844.48	47.95	1,648.42	2,757.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,298.40

0.00	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	29,375.02	8,209.67	6,333.09	24,409.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,733.67

3509	ADULT 40-100% M&F 65	2,137.55	313.57	295.02	69.75	85.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,901.09

3514	ADULT 40-100% MALE
1
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

299.88	76.69	10,062.27	2,334.06	3,113.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,886.37

1,481.60	6,383.38	6,313.09	10,036.45	4,665.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,880.27

68,950.30	58,982.36	145,718.92	166,430.07	89,814.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	529,896.21

48,033.43	59,177.22	71,542.32	75,673.56	70,564.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	324,990.75

3518	ADULT 40-100% M&F 45	247,350.24	297,795.27	264,081.84	326,383.33	331,389.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,467,000.63

3519	ADULT 40-100% M&F 65	0.00	0.00	1,840.40	263.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,103.95

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 MAL E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

0.00	0.00	706.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	706.88

1,699.84	857.70	202.77	2,310.82	176.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,247.63

25,187.13	9,795.84	8,317.14	34,199.09	8,292.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,791.52

19.51	59.79	399.85	769.60	317.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,566.50

96,519.59	99,948.03	73,933.94	60,810.15	54,671.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	385,883.30

70,257.57	72,084.69	50,645.92	61,101.00	55,344.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	309,433.30

2,056,952.53	1,717,512.69	1,635,655.49	1,942,921.88	1,764,448.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,117,490.95

763,329.78	694,754.25	852,786.42	872,179.85	771,277.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,954,327.85

2,272,604.78	1,714,216.40	2,195,997.31	2,260,024.67	2,159,280.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,602,123.20

1,162.92	2,296.70	1,971.08	6,521.44	6,116.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,068.71

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	2,562.03	5,966.87	47.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,576.85

SUBTOTAL:

5,669,460.82

4,764,474.08	5,331,290.31	5,835,977.65	5,346,772.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,947,975.43

3906	NEWLY ELIGIBLE MALE	57.76	41.58	2,679.27	16.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,795.21

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 2014

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

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

140.82	0.00	46.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	187.13

20,470.96	14,484.59	7,064.47	7,393.77	1,680.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,094.57

0.00	824.23	603.22	0.00	1,297.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,725.37

3914	NEWLY ELIGIBLE MALE	264.21	48.77	0.00	0.00	48.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	361.85

3915	NEWLY ELIGIBLE FEMA L

1,257.16	3,440.78	6,661.64	2,380.78	2,672.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,413.07

3916	NEWLY ELIGIBLE MALE	15,313.98	25,583.75	54,954.73	33,336.11	40,173.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	169,361.73

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

15,483.34	24,987.66	67,374.92	31,854.35	20,317.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160,018.08

112,833.00	101,863.69	155,676.62	183,213.83	130,258.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	683,845.82

61.82	47.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109.31

0.00	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:

165,883.05

171,322.54	295,061.18	258,195.44	196,449.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,086,912.14

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

255.50	0.00	7.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	263.07

14,205.19	14,325.32	18,387.82	24,979.21	36,364.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,261.87

4414	SOBRA 100-133% MALE	6,204.87	7,600.45	11,674.28	8,788.49	8,007.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,275.36

4415	SOBRA 100-133% FEM AL

15,855.01	8,205.55	8,660.55	9,568.56	32,813.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,103.15

SUBTOTAL:

36,520.57

30,131.32	38,730.22	43,336.26	77,185.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225,903.45

4517	BC PATIENT FEMALE 2
1
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

5,769.75	6,234.29	251.86	1,499.08	9,441.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,196.40

0.00	0.00	127.34	100.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	227.51

SUBTOTAL:

5,769.75

6,234.29	379.20	1,599.25	9,441.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,423.91

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

2,168.55	5,501.70	880.57	1,409.51	1,509.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,469.87

22.57	0.00	0.00	381.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	404.31

10.26	26.01	32.42	0.00	41.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109.70

SUBTOTAL:

2,201.38

5,527.71	912.99	1,791.25	1,550.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,983.88

19,316,598.26	16,026,545.33	17,410,168.87	18,495,681.05	16,940,215.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,189,209.43	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 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

1028	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

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

4325	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:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 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		

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

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

1126	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

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

3309	AHC CARE M&F 65+ W/	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	0.00

3317	AHC CARE FEMALE 21-
4

0.00	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	0.00

3328	AHC CARE M&F 45-64
W

0.00	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

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	
3410	MED ELIGIBILITY 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	
3607	AHC CARE/MI FEMALE	0.00	0.00	0.00	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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

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	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	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	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	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	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	0.00

3619	AHC CARE/MI 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

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

3506	ADULT 40-100% MALE
2
3507	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

0.00	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
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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 MAL E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

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
3928	NEWLY ELIGIBLE M&F
4

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

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% 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

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

4517	BC PATIENT FEMALE 2
1
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

0.00	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:	0.00	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 - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 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	316.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	316.80

1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	21.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.42

1011	TANF <1 M & F NON-ME	32,641.98	541.56	2,292.08	1,081.20	3,965.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,522.17

1012	TANF 01-05 M & F NON	9,726.79	10,879.71	10,704.08	29,229.00	5,323.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,862.59

1013	TANF 06-13 M & F NON	10,337.38	2,119.92	5,671.19	7,216.60	3,894.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,239.95

1014	TANF 14-20 MALE NON-	2,637.34	782.94	303.02	437.44	453.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,614.00

1015	TANF 14-20 FEMALE N O

9,633.77	10,933.80	18,126.06	14,115.94	6,604.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,413.81

1016	TANF 21-44 MALE NON-	-210.03	1,528.38	2,803.51	3,725.36	13,026.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,873.74

1017	TANF 21-44 FEMALE N O

25,840.81	12,347.84	13,803.03	13,332.08	23,928.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,252.55

1018	TANF 45-64 M & F NON	5,304.56	11,222.82	24,739.97	10,571.09	4,180.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,019.29

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

1028	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

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

637.35	193.42	1,743.48	-72.49	2,408.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,910.37

18,494.71	22,036.44	13,385.43	24,808.71	11,022.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,747.65

2120	SSI AGED WITH QMB	2,170.55	-2,697.32	219.69	106.83	2,442.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,242.42

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

1,445.44	827.70	195.47	2,076.72	3,265.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,811.13

105,053.82	209,122.34	14,233.08	27,623.51	41,144.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	397,177.29

2,636.06	979.86	2,151.99	2,424.99	2,291.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,484.41

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	57,230.54	20,360.21	9,731.03	49,225.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144,652.34

4312	SOBRA CHILD 01-05 M	16,415.77	14,505.47	9,347.09	10,961.16	10,489.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,718.56

4313	SOBRA CHILD 06-13 M	8,910.38	15,869.21	40,306.43	6,741.09	3,265.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,092.12

4314	SOBRA CHILD 14-20 MA	3,167.94	14,900.22	4,753.71	1,882.40	27,838.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,542.87

4315	SOBRA CHILD 14-20 FE	7,512.52	8,420.80	1,209.35	2,403.18	12,599.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,144.98

4325	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

355.24	6,402.33	543.66	4,185.11	1,979.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,466.12

8,677.15	1,983.35	8,295.19	11,055.70	14,341.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,352.59

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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 - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	279,494.58	400,131.33	195,187.72	183,953.45	243,712.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,302,479.17		

1106	TANF EXPANDED 21-44	100.87	0.00	51.03	34.58	1.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	188.19

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	9.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.77

1108	TANF EXPANDED 45-64	556.81	778.47	121.83	27.05	48.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,532.18

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	48.77	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	278.80	517.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	796.08

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	1,543.35	0.00	297.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,956.04

1115	TANF EXPANDED 14-20	1,795.17	675.99	18.36	46.44	478.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,014.41

1116	TANF EXPANDED 21-44	8,190.51	8,056.75	2,683.69	7,220.52	14,719.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,871.18

1117	TANF EXPANDED 21-44	18,106.82	9,214.66	10,448.05	2,162.79	6,352.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,284.93

1118	TANF EXPANDED 45-64	12,066.69	7,108.61	8,473.65	2,086.26	460.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,196.08

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

1126	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

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	519.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	519.37

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	2,681.23	65.99	2,450.62	228.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,506.42

0.00	1,192.03	0.00	1,323.58	898.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,414.30

1,266.08	1,879.33	-20.58	613.30	3,749.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,487.94

0.00	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	1,442.53	26.49	170.03	81.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,942.09

0.00	0.00	364.40	0.00	3,604.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,968.59

504.00	504.00	0.00	151.88	1,131.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,291.09

SUBTOTAL:

44,281.56

34,099.65	23,776.26	16,287.05	32,582.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151,027.43

3309	AHC CARE M&F 65+ W/	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	0.00

3317	AHC CARE FEMALE 21-
4

0.00	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	0.00

3328	AHC CARE M&F 45-64
W

0.00	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

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	
3410	MED ELIGIBILITY 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	
3607	AHC CARE/MI FEMALE	0.00	0.00	0.00	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

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

3608	AHC CARE/MI M&F 45-6	0.00	-60.96	0.00	0.00	-12.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-73.36

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	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	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	2,085.47

3617	AHC CARE/MI FEMALE
2

581.91	24,704.25	0.00	10,300.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,586.82

3618	AHC CARE/MI M&F 45-6	-2,340.05	61,957.41	2,429.76	-1,672.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,374.97

3619	AHC CARE/MI M&F 65+	0.00	2,292.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,292.95

SUBTOTAL:

327.33

88,893.65	2,429.76	8,628.51	-12.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100,266.85

3506	ADULT 40-100% MALE
2
3507	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

0.00	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	28.68	0.00	207.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	236.56

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
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

0.00	1,037.95	1,111.41	154.62	640.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,944.92

468.93	4,952.17	301.80	0.00	426.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,149.81

11,090.38	8,180.30	12,187.52	8,047.54	47,784.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,290.63

11,245.70	3,906.95	14,416.97	8,265.10	5,315.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,150.44

3518	ADULT 40-100% M&F 45	34,728.21	77,548.47	48,293.72	68,043.28	15,995.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	244,608.88

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 MAL E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

0.00	0.00	-101.13	134.02	-516.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-484.07

0.00	0.00	-352.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-352.31

0.00	-72.49	0.00	2,629.57	1,220.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,778.06

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,032.24	5,562.92	16,066.16	20.67	2,194.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,876.39

3,136.03	1,842.31	1,286.62	2,814.13	1,954.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,033.37

81,484.42	56,813.62	41,056.81	57,543.56	55,410.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	292,308.85

15,464.69	7,575.62	11,004.31	18,345.03	15,707.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,097.55

68,101.26	119,344.07	112,828.42	120,940.44	53,059.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	474,274.05

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

286,720.57	258,100.30	287,145.84	199,194.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,258,913.13

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

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014

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

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	23.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.52

0.00	0.00	76.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.45

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	136.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	714.47

3916	NEWLY ELIGIBLE MALE	10,823.55	13,258.37	707.31	803.73	16,715.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,308.41

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

169.41	212.50	2,051.45	5,094.89	9,685.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,213.64

45,902.49	23,614.63	57,874.92	12,240.95	1,212.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140,845.36

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

37,109.02	60,846.78	18,139.57	27,613.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	201,406.85

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	286.93	175.46	86.90	461.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,156.89

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% FEM AL

798.96	84.38	662.74	231.12	54.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,831.73

SUBTOTAL:

944.67

371.31	838.20	318.02	516.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,988.62

4517	BC PATIENT FEMALE 2
1
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	63.08	0.00	5,650.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,713.51

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

SUBTOTAL:

0.00

0.00	63.08	0.00	5,650.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,713.51

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

610,498.27	847,325.53	541,242.10	514,472.44	509,257.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,022,795.56	

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	20,749.45	33,935.21	14,028.32	27,958.67	25,170.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,842.47		
	20,749.45	33,935.21		14,028.3		27,958.67	25,170.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121,842.47		

IT

SUBTOTAL:	2

TOTAL:	20,749.45	33,935.21	14,028.32	27,958.67	25,170.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121,842.47		

IT

SUBTOTAL:	0

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		0.0		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	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:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	206,280.04	288,775.58	184,962.59	308,199.09	179,270.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,167,487.76		
	206,280.04	288,775.58		184,962.5		308,199.09	179,270.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,167,487.76		

IT

SUBTOTAL:	9

TOTAL:	206,280.04	288,775.58	184,962.59	308,199.09	179,270.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,167,487.76		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 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	556.33	113.33	1,498.38	1,334.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,426.40

1007	TANF 21-44 FEMALE WI	0.00	0.00	76.06	200.52	1,632.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,908.94

1008	TANF 45-64 M & F WIT	17,781.02	3,645.96	1,696.48	3,172.67	1,729.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,025.34

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	58,665.72	105,612.53	105,565.35	77,646.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	432,257.23

1012	TANF 01-05 M & F NON	34,284.92	43,480.32	38,003.35	26,128.25	36,235.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178,131.95

1013	TANF 06-13 M & F NON	44,810.40	31,224.16	42,153.72	34,681.06	27,156.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	180,025.50

1014	TANF 14-20 MALE NON-	15,430.38	11,665.16	7,111.65	20,421.48	7,244.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,873.04

1015	TANF 14-20 FEMALE N O

11,813.66	37,661.22	18,538.76	18,877.44	10,896.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,787.24

1016	TANF 21-44 MALE NON-	31,438.66	90,378.80	52,569.64	34,461.16	108,919.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	317,768.12

1017	TANF 21-44 FEMALE N O

210,377.80	194,186.31	222,973.00	144,738.36	350,087.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,122,363.25

1018	TANF 45-64 M & F NON	28,096.35	11,656.91	28,065.88	125,478.67	48,338.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	241,636.10

1019	TANF 65+ M & F NON-M	0.00	872.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	872.25

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

1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	727.28	1,768.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,495.68

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

3,406.77	3,502.09	22,471.78	3,517.45	423.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,321.83

3,421.42	2,145.00	8,256.64	512.70	8,011.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,347.39

2120	SSI AGED WITH QMB	19,926.84	9,704.83	11,229.65	11,879.83	7,652.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,393.34

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

13,662.86	42,533.24	8,606.75	8,165.79	2,835.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,804.36

304,798.51	274,300.06	347,966.26	367,239.77	297,453.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,591,758.28

44,399.62	28,504.92	37,846.70	41,122.70	31,745.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	183,619.08

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	4,195.67	9,915.12	9,034.84	3,766.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,147.25

2320	SSI BLIND WITH QMB	284.04	190.07	34.82	83.25	1,364.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,956.28

4311	SOBRA CHILD <1 M & F	68,145.48	122,295.23	44,411.54	51,135.66	70,020.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	356,008.76

4312	SOBRA CHILD 01-05 M	35,241.49	10,786.90	16,480.16	10,148.36	38,674.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111,331.57

4313	SOBRA CHILD 06-13 M	30,113.38	19,957.23	13,761.72	18,897.97	31,261.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	113,991.94

4314	SOBRA CHILD 14-20 MA	8,988.63	11,572.81	49,513.15	8,829.09	10,119.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,023.21

4315	SOBRA CHILD 14-20 FE	5,849.26	9,327.77	19,160.53	25,805.46	6,059.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,202.52

4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	8.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.19

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	16,540.26	22,290.29	19,379.70	16,315.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92,628.53

46,014.10	38,107.35	41,483.13	43,985.14	85,760.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255,350.24

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:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	1,085,121.32	1,077,656.57	1,170,342.64	1,135,696.52	1,284,454.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,753,271.32		

1106	TANF EXPANDED 21-44	119.42	25.23	78.80	47.95	199.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	470.46

1107	TANF EXPANDED 21-44	1,570.36	494.47	2,718.86	738.57	554.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,077.05

1108	TANF EXPANDED 45-64	1,427.07	1,230.37	1,181.81	1,841.38	2,680.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,360.83

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

1,503.33	1,346.31	2,101.21	1,694.86	1,217.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,862.93

0.00	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	72.20	388.36	123.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	583.94

1113	TANF EXPANDED 06-13	0.00	23.26	2,001.11	289.33	58.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,371.89

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	714.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	714.51

1115	TANF EXPANDED 14-20	43.90	25,084.37	676.23	4,041.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,845.65

1116	TANF EXPANDED 21-44	35,961.69	29,723.91	64,877.10	39,996.25	29,521.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	200,080.62

1117	TANF EXPANDED 21-44	58,248.53	64,960.99	41,406.57	64,814.97	44,661.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	274,092.15

1118	TANF EXPANDED 45-64	24,913.23	24,501.96	14,774.51	10,276.28	36,244.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,710.56

1119	TANF EXPANDED 65+ M&

0.00	0.00	0.00	251.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	251.28

1126	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

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	59.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	114.48

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	64.31	296.56	488.33	532.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,176.79

2,136.82	1,127.00	32,303.41	181.99	7,896.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,646.06

12,344.05	8,798.39	10,022.98	21,813.21	12,292.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,270.68

0.00	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	1,634.66	153.11	633.37	245.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,759.59

209.07	879.14	542.12	152.63	484.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,267.65

5,857.19	6,083.62	8,430.23	10,318.47	4,888.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,577.65

SUBTOTAL:

145,371.72

165,977.99	181,636.81	158,742.09	141,600.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	793,329.22

3309	AHC CARE M&F 65+ W/	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	0.00

3317	AHC CARE FEMALE 21-
4

0.00	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	0.00

3328	AHC CARE M&F 45-64
W

0.00	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

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	
3410	MED ELIGIBILITY 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	
3607	AHC CARE/MI FEMALE	0.00	0.00	0.00	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

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 2014

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

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	240.00

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	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	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	1,586.68

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	53.57

3618	AHC CARE/MI M&F 45-6	1,999.68	1,589.49	0.00	1,026.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,615.80

3619	AHC CARE/MI 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

SUBTOTAL:

3,879.93

1,589.49

0.00	1,026.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,496.05

3506	ADULT 40-100% MALE
2
3507	ADULT 40-100% FEMAL
E

0.00	0.00	1,255.78	86.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,342.61

0.00	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	238.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	238.95

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
3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE
2
3517	ADULT 40-100% FEMAL
E

430.42	0.00	268.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	699.10

0.00	622.49	0.00	59,547.91	88.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,259.27

10,650.89	12,406.82	21,631.24	46,981.49	51,964.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143,635.34

23,738.59	15,286.50	26,420.79	6,921.32	12,108.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,475.82

3518	ADULT 40-100% M&F 45	29,835.05	35,644.66	66,241.11	44,449.84	44,452.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220,623.04

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 MAL E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MAL
E
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	30.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30.31

2,451.54	2,205.17	837.47	2,507.14	242.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,243.95

0.00	15.53	92.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107.71

9,500.36	10,625.57	21,121.50	11,841.58	3,681.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,770.25

5,377.86	6,773.87	7,868.05	10,382.13	4,451.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,853.55

277,274.99	198,707.59	245,049.44	174,444.82	231,171.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,126,648.68

85,369.64	98,701.56	110,904.18	120,526.37	105,896.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	521,397.76

224,721.51	183,380.20	180,656.00	144,133.87	101,728.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	834,619.99

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	119.13	1,433.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,552.32

SUBTOTAL:

669,350.85

564,369.96	682,495.86	623,256.49	556,025.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,095,498.65

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

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending November 30, 2014

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

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	785.65	1,040.86	371.90	185.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,970.60

0.00	0.00	0.00	50.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50.02

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	205.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	205.29

3915	NEWLY ELIGIBLE FEMA L

0.00	0.00	0.00	0.00	189.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	189.27

3916	NEWLY ELIGIBLE MALE	666.79	6,008.90	2,042.85	9,520.01	2,330.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,569.48

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

6,073.87	2,908.38	28,820.75	5,207.82	6,142.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,153.61

12,815.15	13,132.47	36,447.31	25,077.39	78,513.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165,985.67

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

22,835.40	68,351.77	40,227.14	87,566.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	239,349.05

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	1,455.19	1,299.50	10,273.42	8,846.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,380.35

4414	SOBRA 100-133% MALE	7,017.47	3,205.98	203.46	528.24	260.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,215.23

4415	SOBRA 100-133% FEM AL

381.31	0.00	319.14	1,140.59	9,913.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,754.05

SUBTOTAL:

8,988.52

4,661.17	1,822.10	11,942.25	19,019.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,433.69

4517	BC PATIENT FEMALE 2
1
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

2,630.32	2,465.34	58.12	2,640.75	5,006.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,801.48

0.00	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

2,465.34	58.12	2,640.75	5,006.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,801.48

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

324.38	62.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	386.60

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	37.44	18.72	160.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216.90

SUBTOTAL:

324.38

99.66	18.72	160.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	603.50

1,936,034.84	1,839,655.58	2,104,726.02	1,973,692.61	2,093,673.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,947,782.96	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER

For The Period Ending November 30, 2014

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

1010	TANF NON-MEDICARE	696.00	1,368.00	1,710.00	1,757.96	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,873.96

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDIC
AR

182,999.78	206,203.74	177,774.65	192,246.43	141,311.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	900,535.89

69,456.96	25,781.96	23,642.14	45,010.52	21,237.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	185,129.47

2120	SSI AGED WITH QMB	194,238.72	171,693.51	188,023.41	210,964.33	149,565.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	914,485.02

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

45,131.68	36,659.49	44,022.63	49,795.83	32,822.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	208,431.98

893,176.80	795,148.70	804,113.36	726,804.46	660,524.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,879,767.34

75,691.55	64,844.94	78,301.76	97,280.92	63,449.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	379,568.17

2300	SSI BLIND WITH MEDIC	0.00	80.33	204.74	-96.39	265.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	454.03

2310	SSI BLIND NON-MEDIC A

9,875.35	16,860.00	11,977.29	7,137.09	10,464.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,314.27

2320	SSI BLIND WITH QMB	144.17	131.13	248.54	758.75	457.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,739.83

SUBTOTAL:

1,471,411.01

1,318,771.80	1,330,018.52	1,331,659.90	1,080,438.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,532,299.96

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

0.00	43.89	51.65	121.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216.98

0.00	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

43.89	51.65	121.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216.98

TOTAL:	1,471,411.01	1,318,815.69	1,330,070.17	1,331,781.34	1,080,438.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,532,516.94		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending November 30, 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-MEDIC
AR

2,664,791.67	2,286,017.04	2,299,939.18	2,502,189.39	2,230,289.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,983,227.24

179,461.32	166,339.47	142,936.57	138,988.15	157,154.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	784,880.49

2120	SSI AGED WITH QMB	3,181,633.79	2,768,875.56	2,793,166.53	3,244,702.74	2,912,111.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,900,490.58

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

466,608.06	464,804.54	438,058.71	500,388.76	427,476.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,297,336.55

1,779,146.34	1,594,652.73	1,743,036.88	1,697,019.69	1,672,951.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,486,807.51

668,132.19	607,853.55	577,938.21	677,284.14	613,119.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,144,327.82

2300	SSI BLIND WITH MEDIC	379.43	20.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	400.17

2310	SSI BLIND NON-MEDIC A

9,691.63	6,114.88	7,549.04	7,270.26	11,574.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,200.66

2320	SSI BLIND WITH QMB	8,442.00	8,076.27	4,987.34	10,018.61	7,281.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,805.33

SUBTOTAL:

8,958,286.43

7,902,754.78	8,007,612.46	8,777,861.74	8,031,960.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,678,476.35

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

0.00	4,543.62	2,285.20	2,174.88	2,122.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,126.26

2,742.24	2,647.68	2,966.82	2,957.30	3,061.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,375.24

SUBTOTAL:

2,742.24

7,191.30	5,252.02	5,132.18	5,183.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,501.50

8,961,028.67	7,909,946.08	8,012,864.48	8,782,993.92	8,037,144.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,703,977.85	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending November 30, 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-MEDIC
AR

46,355.76	35,342.62	62,560.09	36,171.51	18,075.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	198,505.83

8,709.42	6,954.55	2,685.44	39,124.80	247.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,722.13

2120	SSI AGED WITH QMB	1,098.73	24.23	571.16	751.60	76.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,522.21

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

4,865.65	14,348.75	3,854.67	2,379.84	-342.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,106.07

28,693.95	27,064.64	25,095.06	37,137.90	10,069.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	128,060.77

2,249.80	1,733.79	2,228.64	353.86	4,127.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,693.68

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

85,468.58	96,995.06	115,919.51	32,254.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	422,610.69

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

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:	91,973.31	85,468.58	96,995.06	115,919.51	32,254.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	422,610.69		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV

For The Period Ending November 30, 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-MEDIC
AR

55,086.53	25,684.88	7,433.80	13,949.00	15,514.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	117,668.93

203.41	13.42	0.00	89.92	2,366.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,673.18

2120	SSI AGED WITH QMB	18,563.57	20,222.12	16,726.53	20,613.05	12,975.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,101.06

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

6,702.65	5,212.13	1,788.76	1,718.52	2,251.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,673.59

64,499.20	29,900.95	25,663.57	40,573.51	63,617.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	224,254.34

7,643.16	7,620.19	4,440.35	10,309.21	4,246.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,259.69

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	6.69	1,059.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,066.34

2320	SSI BLIND WITH QMB	48.02	462.91	127.45	48.02	48.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	734.42

SUBTOTAL:

152,773.47

89,123.29	57,240.11	87,301.23	101,020.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487,458.48

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

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

152,773.47	89,123.29	57,240.11	87,301.23	101,020.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487,458.48	

TOTAL:

KidsCare - CAPITATION AMOUNTS

For The Period Ending November 30, 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	4,734.91	4,529.87	4,251.11	3,344.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,384.66

6012	KIDS 1-5 M & F NON-M	3,921.57	2,756.23	2,851.52	2,435.47	1,913.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,878.76

6013	KIDS 6-13 M & F NON-	129,970.36	125,163.63	123,163.41	125,050.70	123,469.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	626,817.49

6014	KIDS 14-19 MALE NON-	69,288.89	68,444.73	69,540.30	73,816.22	72,411.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	353,501.60

6015	KIDS 14-19 FEMALE NO	110,216.77	112,119.60	111,831.80	118,788.21	118,988.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	571,945.33

9960	KIDSCARE KICK PAYM EN

0.00	6,046.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,046.14

SUBTOTAL:

317,921.81

319,265.24	311,916.90	324,341.71	320,128.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,593,573.98

TOTAL:	317,921.81	319,265.24	311,916.90	324,341.71	320,128.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,593,573.98		

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending November 30, 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	10.45	10.00	9.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.45

6012	KIDS 1-5 M & F NON-M	38.83	26.67	28.00	23.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	134.50

6013	KIDS 6-13 M & F NON-	1,047.73	1,020.93	1,001.01	984.05	956.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,010.54

6014	KIDS 14-19 MALE NON-	406.52	407.06	414.19	419.20	417.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,063.97

6015	KIDS 14-19 FEMALE NO	440.63	448.54	447.83	452.69	453.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,242.69

9960	KIDSCARE KICK PAYM EN

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

SUBTOTAL:

1,943.71

1,914.65	1,901.03	1,887.94	1,851.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,499.15

1,943.71	1,914.65	1,901.03	1,887.94	1,851.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,499.15	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending November 30, 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	409.20	409.20	371.40	297.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,896.12

6012	KIDS 1-5 M & F NON-M	1,488.00	1,190.40	1,078.80	891.36	705.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,354.22

6013	KIDS 6-13 M & F NON-	38,650.80	37,869.60	36,976.80	36,248.64	35,357.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	185,103.12

6014	KIDS 14-19 MALE NON-	15,387.26	15,555.32	15,807.19	15,809.34	15,758.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	78,317.33

6015	KIDS 14-19 FEMALE NO	17,426.93	17,678.80	17,772.90	17,525.61	17,618.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,022.91

SUBTOTAL:

73,362.19

72,703.32	72,044.89	70,846.35	69,736.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	358,693.70

TOTAL:	73,362.19	72,703.32	72,044.89	70,846.35	69,736.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	358,693.70		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending November 30, 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	11.00	11.00	10.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.00

6012	KIDS 1-5 M & F NON-M	40.00	32.00	29.00	24.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144.00

6013	KIDS 6-13 M & F NON-	1,039.00	1,018.00	994.00	976.00	952.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,979.00

6014	KIDS 14-19 MALE NON-	402.00	405.00	410.00	414.00	413.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,044.00

6015	KIDS 14-19 FEMALE NO	450.00	455.00	455.00	454.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,269.00

SUBTOTAL:

1,942.00

1,921.00	1,899.00	1,878.00	1,847.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,487.00

TOTAL:

1,942.00

1,921.00	1,899.00	1,878.00	1,847.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,487.00

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending November 30, 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	0.00	393.96	393.96	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,204.85		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		416.93		
	0.00	393.96		393.9		416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,621.78		

SUBTOTAL:	6

TOTAL:	0.00	393.96	393.96	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,621.78		

SUBTOTAL:	0

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending November 30, 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	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
	0.00	1.00		1.0		1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00		

0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	

TOTAL:

KidsCare - FEE FOR SERVICE

For The Period Ending November 30, 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	-5.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	512.79

6012	KIDS 1-5 M & F NON-M	5,220.12	5,339.07	686.68	716.05	38.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,000.25

6013	KIDS 6-13 M & F NON-	5,620.16	8,092.01	1,382.10	804.49	2,599.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,498.47

6014	KIDS 14-19 MALE NON-	1,847.16	1,367.27	5,093.48	1,279.55	804.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,392.04

6015	KIDS 14-19 FEMALE NO	6,826.40	349.49	512.47	967.25	538.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,194.37

SUBTOTAL:

20,032.56

15,147.84	7,668.80	3,767.34	3,981.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,597.92

TOTAL:	20,032.56	15,147.84	7,668.80	3,767.34	3,981.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,597.92		

SUBTOTAL:			0		
TOTAL:	-99,947.16	14,868.46	81,729.60	563.56	27,046.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,261.01	

KidsCare - REINSURANCE

For The Period Ending November 30, 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	3,536.95	-3,508.50	999.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-162,780.37		
6013	KIDS 6-13 M & F NON-	35,860.62	11,331.51	30,472.34	-358.55	84.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,390.02		
6014	KIDS 14-19 MALE NON-	28,000.15	0.00	54,765.76	-77.00	26,962.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,651.36		
	-99,947.16	14,868.46		81,729.6		563.56	27,046.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,261.01		

110007 DES-DD - CAP MEMBER MONTHS

For The Period Ending November 30, 2014		
RATE CODE	DESCRIPTION	JULY	AUGUST     SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
		
1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1010	TANF NON-MEDICARE	618.38	616.83	616.45	620.62	620.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,092.90		
1020	TANF WITH QMB	2.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2100	SSI AGED WITH MEDICA	146.99	145.63	148.00	147.00	146.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		733.95		
2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
2120	SSI AGED WITH QMB	236.79	237.09	241.99	240.01	240.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,195.88		
2200	SSI DISABLED WITH ME	1,737.61	1,747.31	1,738.54	1,777.91	1,778.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,780.13		
220Z	SSI DISABLED WITH ME	0.00	0.00	0.00	3.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.73		
2210	SSI DISABLED NON-MED	20,351.11	20,460.87	20,577.35	20,616.28	20,717.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,723.60		
221Z	SSI DISABLED NON-MED	0.00	0.00	0.00	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06		
2220	SSI DISABLED WITH QM	3,823.28	3,835.07	3,863.93	3,862.06	3,863.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,248.11		
2300	SSI BLIND WITH MEDIC	15.00	15.00	15.00	15.00	13.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.38		
2310	SSI BLIND NON-MEDICA	112.93	113.00	113.73	114.00	115.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		569.02		
2320	SSI BLIND WITH QMB	29.00	28.00	26.93	28.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.93		
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.00		
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
8720	SSI DISABLED FREEDOM	3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
	27,092.09	27,219.80

27,219.80	27,361.92

27,361.92	27,443.67

27,443.67	27,542.21	0.00

0.00	0.00

0.00	0.00

0.00	0.00	0.00

0.00	0.00

0.00	0.00

0.00	136,659.69		
	27,092.09				27,542.21				0.00				136,659.69		

SUBTOTAL: TOTAL:

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending November 30, 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	377,975.63
91,563,188.35	376,641.36
82,730,279.25	377,090.04
83,774,273.60	376,452.78
93,279,309.59	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	1,886,960.01
433,179,385.69	
	82,211,135.10
90,441,057.34	91,941,163.98
90,874,990.67	83,106,920.61
91,356,447.37	84,151,363.64
91,810,801.83	93,655,762.37
92,142,171.96	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
0.00	435,066,345.70
456,625,469.17	
	90,441,057.34	90,874,990.67	91,356,447.37	91,810,801.83	92,142,171.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	456,625,469.17	
TOTAL LTC - CAP	172,652,192.44	182,816,154.65	174,463,367.98	175,962,165.47	185,797,934.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	891,691,814.87	

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	9,403,353.64
0.00	9,497,169.82
0.00	10,317,996.00
0.00	9,250,858.04
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	49,146,563.96
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	0.00	
TOTAL LTC - FFS	10,677,186.46	9,403,353.64	9,497,169.82	10,317,996.00	9,250,858.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,146,563.96	

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	3,372,978.62
218,495.45	4,928,777.99
397,973.54	4,472,011.06
266,868.90	4,152,641.85
329,217.93	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	20,030,560.07
1,460,069.86	
	247,514.04	218,495.45	397,973.54	266,868.90	329,217.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,460,069.86	
TOTAL LTC - REIN	3,351,664.59	3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,490,629.93	

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	3,052,341.10	3,049,839.90	3,072,484.20	3,087,992.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,144,782.50	

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.

116

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending November 30, 2014

010115	CRS FULLY INTEGRATED PLAN - CAP	14,351,926.69	12,696,255.55	12,817,520.60	13,313,962.00	13,275,823.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,455,487.97	
010145	CRS ACUTE SEMI INTEGRATED - CAP	140,282.17	106,532.24	121,467.59	113,733.94	117,439.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	599,455.69	
999125	CRS SEMI INTEGRATED PLAN - CAP	0.00	3,003,198.75	3,005,592.50	3,164,310.09	3,177,387.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,350,489.17	
999135	CRS ONLY PLAN - CAP	0.00	450,296.28	451,872.12	481,137.22	471,964.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,855,270.38	
	14,492,208.86	16,256,282.82	16,396,452.81	17,073,143.25	17,042,615.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,260,703.21	

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

TOTAL

Wednesday, December 17, 2014

999155	CRS REINSURANCE ONLY	2,324,970.00	490,042.82	1,745,299.36	450,149.05	1,230,087.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,240,548.61	
	2,324,970.00	490,042.82	1,745,299.36	450,149.05	1,230,087.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,240,548.61	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC CAP	52,459.25	49,207.44	49,167.91	51,977.51	52,127.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	254,939.95	
999135	CRS ONLY PLAN - KC CAP	0.00	393.96	393.96	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,621.78	
	52,459.25	49,601.40	49,561.87	52,394.44	52,544.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	256,561.73	

Subtotal

Subtotal

16,869,638.11	16,795,927.04	18,191,314.04	17,575,686.74	18,325,247.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,757,813.55	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending November 30, 2014

010115	CRS FULLY INTEGRATED PLAN - MM	19,358.09	17,125.68	17,289.14	17,094.47	17,044.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,911.90	
010145	CRS ACUTE SEMI INTEGRATED - MM	213.57	162.16	184.98	164.14	169.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	894.37	
999125	CRS SEMI INTEGRATED PLAN - MM	0.00	6,273.00	6,278.00	6,291.00	6,317.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,159.00	
999135	CRS ONLY PLAN - MM	0.00	1,143.00	1,147.00	1,154.00	1,132.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,576.00	
	19,571.66	24,703.84	24,899.12	24,703.61	24,663.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	118,541.27	

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

TOTAL

Wednesday, December 17, 2014

010115	CRS FULLY INTEGRATED PLAN - KC MM	70.77	66.38	66.38	66.69	67.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	337.22	
999135	CRS ONLY PLAN - KC MM	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	
	70.77	67.38	67.38	67.69	68.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	341.22	

Subtotal

Subtotal

19,642.43	24,771.22	24,966.50	24,771.30	24,731.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	118,882.49	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending November 30, 2014

078999	MERCY MARICOPA INTEGRATED - CAP	41,786,965.61	42,950,978.28	43,354,678.66	43,620,639.57	44,539,840.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216,253,102.45	
	41,786,965.61	42,950,978.28	43,354,678.66	43,620,639.57	44,539,840.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216,253,102.45	

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

TOTAL

Wednesday, December 17, 2014

Subtotal

41,786,965.61	42,950,978.28	43,354,678.66	43,620,639.57	44,539,840.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216,253,102.45	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending November 30, 2014

078999	MERCY MARICOPA INTEGRATED - MM	17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,569.08	
	17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,569.08	

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

TOTAL

Wednesday, December 17, 2014

Subtotal

17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,569.08	

GRAND TOTAL