Douglas A. Ducey, Governor
Thomas J. Betlach, Director

January 26, 2015

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

The Honorable David M. Gowan Sr., Speaker
Arizona House of Representatives
1700 West Washington
Phoenix, AZ 85007

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

Dear President Biggs and Speaker Gowan:

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 December 31, 2014.

Status Summary – In December, AHCCCS submitted a FY 2016 budget revision to the Governor’s Office of Strategic Planning and Budgeting.   Based on that revision and administrative adjustment activity through December, AHCCCS is currently forecasting a FY
2015 Total Fund shortfall of $286.6 million.  The total fund shortfall is comprised of a Federal Expenditure Authority shortfall of $263.2 million; a Hospital Assessment Expenditure Authority shortfall of $67.5 million; a CHIP fund shortfall of $1.3 million; and a General Fund surplus of
$45.4 million.  The estimated General Fund surplus reflects the Executive Recommendation of shifting up to $15.0 million to the Arizona Department of Health Services in FY 2015 for potential shortfalls.

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 settlement of claims related to the ACA primary care physician rate increase two year eligibility period.
•	Implementation of the hospital presumptive eligibility program.
•	Ongoing implementation of the first ACA health insurer fee payment. The ACA includes a nationwide $8.0 billion fee on the health insurance industry beginning in 2014. In order to maintain actuarially sound capitation rates, AHCCCS must reimburse the health plans for this fee.   The estimated statewide impact for FY 2015 is $70 million Total Fund ($20.9 million State Match).
•	Potential Agency audit liabilities, which are detailed in the ASR.

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

The Honorable Andy Biggs
The Honorable David M. Gowan, Sr. January 26, 2015
Page 2

The Hospital Assessment shortfall of $67.5 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 only $39.0 million.   AHCCCS is evaluating the potential need for an increase to the assessment which would take place in the final quarter of FY 2015.

The $286.6 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 – December 2014 enrollment is 1,636,484 members, a 6,957 member increase over the prior month.  Enrollment for January 2015 decreased to 1,635,539 members, a
945 member decrease.  Major January changes by eligibility category include: 1931 for Families and Children - decrease of 20,359; SOBRA Children – increase of 8,928; Transitional Medical Assistance –  increase of  620;  Supplemental Security Income –  increase of  865;  Prop  204
Restoration - increase of 2,459; Adult Expansion - increase of 3,779; and Emergency Services - increase of 2,506.

Tobacco Funds  Revenue Update  – Tobacco tax collections through December 2014 are $1.9 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
Jeffery Tegen at (602) 417-4705. Sincerely,

Thomas J. Betlach
Director

Enclosure

cc:       The Honorable Douglas A. Ducey, Governor
The Honorable Don Shooter, Chairman, Senate Appropriations Committee
The Honorable Justin Olson, Chairman, House Appropriations Committee
The Honorable Nancy Barto, Chairman, Senate Health and Human Services Committee
The Honorable Heather Carter, Chairman, House Health 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 December 31, 2014

Prepared by: Division of Business and Finance

Appropriation	Status	Report
Table	of	Contents

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

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

CASELOAD AND EXPENDITURES BY RATE CODE………………………………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 December 31, 2014
SUMMARY OF APPROPRIATED EXPENDITURES

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

APPROPRIATIONS:

ADMINISTRATION

AHCCCS Operating Lump Sum	$	81,923,000		$	40,961,100		$	37,554,676		$	3,406,424		$	81,923,000		$	-	
AHCCCS Prop 204 Administration	6,863,900		3,431,900		3,564,860		(132,960)		6,863,900		-	
DES Eligibility	54,874,500		27,436,900		27,600,103		(163,203)		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		19,179,500		8,466,401		10,713,099		38,358,700		-	
TOTAL ADMINISTRATION	182,020,100		91,009,400		77,186,040		13,823,360		182,020,100		-	

Traditional Medicaid Services	3,791,084,500		1,778,684,300	1,649,580,845	129,103,455	3,791,084,500		-	
Proposition 204 Services	2,050,717,900		972,237,100	1,136,356,484	(164,119,384)	2,050,717,900		-	
ACA Adult Expansion	227,369,700		95,785,000	68,353,014	27,431,986	227,369,700		-	
Children's Rehabilitative Services	196,042,400		96,302,100	105,022,339	(8,720,239)	196,042,400		-	
KidsCare Services	6,223,000		4,227,100	3,136,731	1,090,369	6,223,000		-	
ALTCS Services	1,344,569,500		657,927,500	641,004,746	16,922,754	1,344,569,500		-	
Disproportionate Share Payments	13,487,100		-	-	-	13,487,100		-	
Rural Hospitals	22,650,000		5,708,500	5,245,950	462,550	22,650,000		-	
Voluntary Political Subdivision Programs	313,041,900		228,351,489	228,351,489	-	313,041,900		-	
TOTAL PROGRAMMATIC	7,965,186,000	3,839,223,089	3,837,051,598	2,171,491	7,965,186,000	-

TOTAL EXPENDITURES

$	8,147,206,100

$    3,930,232,489

$   3,914,237,638

$	15,994,851

$  8,147,206,100	$	-

ARIZONA  HEALTH  CARE  COST  CONTAINMENT   SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending December 31, 2014
APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

STATE - GENERAL FUND

Administrative Expenditures

$ 	52,984,500 	$

26,492,100 	$

24,408,185

2,083,915 	$

52,984,500 	$ 	-

Proposition 204 - Administrative Expenditures 	19,658,700 	9,829,700 	6,417,788 	3,411,912 	19,658,700 	-

Programmatic Expenditures
Traditional Medicaid Services 		 858,358,000 	 410,847,700 	 401,291,847 	    9,555,853 	   858,358,000 	   - Proposition 204 Services 	102,000,000 	79,323,900 	85,518,849 	(6,194,949) 	102,000,000 	- Children's Rehabilitative Services 		62,248,100 	31,172,700 	34,547,505 	(3,374,805) 	  62,248,100 	- KidsCare Services 		  1,257,200 		   876,700 		753,228 	    123,472 		1,257,200 	- ALTCS Services 	167,797,400 	82,930,400 	83,898,692 	   (968,292) 	167,797,400 	- DSH and Rural Hospitals 		10,099,300 		1,821,400 	  1,654,573 	    166,827 	  10,099,300 	- TOTAL GF EXPENDITURES 	1,274,403,200 	 643,294,600 	 638,490,666 	    4,803,934 	1,274,403,200 	   -

FEDERAL

Administrative Expenditures 	83,696,900 	41,848,100 	40,688,814 	1,159,286 	83,696,900 	- Proposition 204 - Administrative Expenditures 	22,179,500 	11,089,400 		4,767,374 	6,322,026 	22,179,500 	-

Programmatic Expenditures
Traditional Medicaid Services 	   2,575,804,300 	1,188,835,800 	1,074,903,771 		 113,932,029 	   2,575,804,300 	   - Proposition 204 Services 	1,587,663,200 	761,458,400 	909,408,871 	(147,950,471) 	1,587,663,200 	- ACA Adult Expansion 	   227,369,700 	  95,785,000 	  68,353,014 		27,431,986 	   227,369,700 	- Children's Rehabilitative Services 	   133,794,300 	  65,129,400 	  70,474,834 		 (5,345,434) 	   133,794,300 	- KidsCare Services 		  4,595,800 		3,159,800 	    2,040,420 		  1,119,380 		4,595,800 	- ALTCS Services and Nursing Facility Assessment 	   895,343,500 	437,715,600 	419,579,648 		18,135,952 	   895,343,500 	- DSH and Rural Hospitals 		26,037,800 		3,887,100 	    3,591,377 		     295,723 	     26,037,800 	- Voluntary Political Subdivision Programs - See Note 5 	   213,394,800 	164,519,418 	164,519,418 			- 	   213,394,800 	- TOTAL FEDERAL EXPENDITURES 	   5,769,879,800 	2,773,428,018 	2,758,327,540 		   15,100,478 	   5,769,879,800 	   -

COUNTY

Administrative Expenditures Proposition 204 - BNCF 	3,384,400 	1,692,300 	846,100 	846,200 	3,384,400 	- Programmatic Expenditures
Traditional Medicaid Services Acute Care 		  50,199,900 		25,099,800 	     25,099,800 		- 		50,199,900 	   - ALTCS Services 	245,196,200 	121,193,800 	113,603,945 	7,589,855 	245,196,200 	- TOTAL COUNTY EXPENDITURES 		298,780,500 	   147,985,900 	   139,549,845 	   8,436,055 	   298,780,500 	   -

Programmatic Expenditures

TOBACCO FUNDS

Traditional Medicaid Services Acute Care - Medically Needy 		   34,178,800 		 17,628,800 	   16,841,396 		787,404 		34,178,800 	   - Proposition 204 Services - Emergency Health Services 		18,202,400 		9,440,200 	  7,969,050 	1,471,150 	  18,202,400 	- Proposition 204 Services - Proposition 204 Protection 		38,225,000 	19,715,800 	16,735,005 	2,980,795 	  38,225,000 	- Proposition 204 Services - ATLSF 	100,000,000 			- 		- 		     - 	100,000,000 	- TOTAL TOBACCO EXPENDITURES 		 190,606,200 		 46,784,800 	   41,545,451 	   5,239,349 	   190,606,200 	   -

Administrative Expenditures

OTHER

Prescription Drug Rebate Program                                                                                                                116,100                                           57,800                                           57,780                                                  20                                          116,100                                                  - Programmatic Expenditures
Acute Care - Prescription Drug Rebate Program State Match 		   73,756,400 		 36,878,100 	     36,878,200 				(100) 		 73,756,400 	   - Acute Care - Prescription Drug Rebate Program Federal Authority 	198,561,200 	  99,280,800 	  94,174,955 		 5,105,845 	198,561,200 	- Long Term Care - Prescription Drug Rebate Program State Match 		  5,162,500 		2,579,300 	    2,581,250 			(1,950) 		5,162,500 	- Long Term Care - Prescription Drug Rebate Program Federal Authority 		13,898,100 		6,943,900 	  11,118,480 		(4,174,580) 	  13,898,100 	- Proposition 204 Services - Hospital Assessment 	204,627,300 	102,298,800 	116,724,710 	(14,425,910) 	204,627,300 	- Traditional Medicaid Services - TPL 		     194,700 		     97,200 		369,793 		   (272,593) 		   194,700 	- ALTCS Services - TPL 				- 			- 		433,902 		   (433,902) 			- 	- ALTCS Services - Nursing Facility Assessment 		17,171,800 		6,564,500 	    9,788,829 		(3,224,329) 	  17,171,800 	- KidsCare Services Premiums 		     370,000 		   190,600 		343,084 		   (152,484) 		   370,000 	- Freedom to Work Premiums 			31,200 		     16,100 		  21,084 			(4,984) 		     31,200 	- Voluntary Political Subdivision Programs - See Note 5 		99,647,100 	  63,832,071 	  63,832,071 			     - 	  99,647,100 	- TOTAL OTHER  EXPENDITURES		 613,536,400 	   318,739,171 	   336,324,137 		 (17,584,965) 	   613,536,400 	   -

TOTAL

Administrative Expenditures                                                                                                                       182,020,100                                    91,009,400                                    77,186,040                                    13,823,360                                   182,020,100                                                  - Acute Care                                                                                                                                               6,620,616,500                               3,181,295,589                               3,196,046,852                                   (14,751,263)                              6,620,616,500                                                  - Long Term Care                                                                                                                                       1,344,569,500                                  657,927,500                                  641,004,746                                    16,922,754                                1,344,569,500                                                  -

TOTAL EXPENDITURES

$ 	8,147,206,100

$ 	3,930,232,489

$ 	3,914,237,638 	$

15,994,851

$ 	8,147,206,100 	$ 	-

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

BUDGET 	BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	983,689,900		$	470,333,900		$	461,902,109	
Proposition 204 Services & Administrative	121,658,700		89,153,600		91,877,581	
KidsCare Services	1,257,200		876,700		753,228	
ALTCS Services	167,797,400		82,930,400		83,898,692	
TOTAL	1,274,403,200		643,294,600		638,431,609	

FEDERAL:
Acute & Administrative	4,869,940,500		2,332,552,618		2,776,950,908	
KidsCare Services	4,595,800		3,159,800		4,504,899	
ALTCS Services	895,343,500		437,715,600		424,791,116	
TOTAL	5,769,879,800		2,773,428,018		3,206,246,923	

COUNTY:
Acute & Administrative	53,584,300		26,792,100		28,475,381	
ALTCS Services	245,196,200		121,193,800		122,598,108	
TOTAL	298,780,500		147,985,900		151,073,489	

TOBACCO FUNDS:
Traditional Medicaid Services	34,178,800		17,628,800		16,841,396	
Proposition 204 Services	156,427,400		29,156,000		24,704,055	
TOTAL	190,606,200		46,784,800		41,545,451	

OTHER:
Administrative	116,100		57,800		57,780	
Acute Care - Prescription Drug Rebate Program	272,317,600		136,158,900		131,053,155	
Long Term Care - Prescription Drug Rebate Program	19,060,600		9,523,200		13,699,730	
Hospital Assessment	204,627,300		102,298,800		116,657,204	
ALTCS - Nursing Facility Assessment	17,171,800		6,564,500		7,869,289	
Acute TPL - Note 1	194,700		97,200		369,793	
LTC TPL - Note 1	-		-		433,902	
KidsCare TPL - Note 1	-		-		727	
Member Premiums - CHIP	370,000		190,600		353,237	
Member Premiums - Freedom to Work	31,200		16,100		21,084	
Voluntary Political Subdivision - State Match	99,647,100		63,832,071		46,128,829	
TOTAL	613,536,400		318,739,171		316,644,729	

TOTAL REVENUE

$	8,147,206,100

$	3,930,232,489

$	4,353,942,200

Appropriation Status Report

Footnotes

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

Note 1:	Third Party Liability Collections: Gross Collections:	December 2014		December 2013		July 1, 2014
December 31, 2014		July 1, 2013
December 31, 2013	
	Acute	$ 	404,240		$ 	337,933		$ 	2,871,484		$ 	4,630,546	
	LTC	262,934		295,123		1,841,439		2,067,245	
	KidsCare	291		5,426		3,703		9,081	
	Total TPL Collections	$ 	667,465		$ 	638,482		$ 	4,716,626		$ 	6,706,872	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$ 	42,889		$ 	49,458		$ 	369,793		$ 	501,366	
LTC	64,054		70,255		433,902		504,081	
KidsCare	59		1,019		727		1,762	
Total Expenditure Offsets	$ 	107,002		$ 	120,732		$ 	804,422		$ 	1,007,209	

FY 15 Total
Note 2:    Authorized Positions 	1,032.2
Actual Positions as of December 31, 2014 	930.4

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2014	

$    2,106,203	
	Revenues	4,048,516	
	Transfers-In	73,625	
	Total Revenues	4,122,141	
	
Expenditures	
3,500,273	
	Transfers-out	247,500	
	Total Expenditures	3,747,773	

Ending Balance December 31, 2014

$    2,480,571

Of the $2,480,571 ending balance, $1,518,172 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through February 2015.

Note 4:

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

Schedule of Outstanding Liabilities
As of December 31, 2014

Description	Amount

Type

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

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

Deferral - Extrapolated Error for Adults with Medicare	-	CMS Region IX Financial Review

38,864,844

The adjustment to correct expenditures and return the federal share for the CMS Adults with Medicare has been processed as part of the CMS-64 federal expenditure report. Ongoing adjustments will be processed as necessary.

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

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of  December 31, 2014
Expenditures

State Match 	Federal 	Total

DSH Voluntary

$ 	1,093,784 	$

2,314,688 	$

3,408,472

GME Voluntary 	37,915,682 	76,434,561 	114,350,243
Safety Net Care Pool 	24,822,606 	85,770,168 	110,592,773

Total Voluntary Political Subdivision Program Expenditures

$ 	63,832,071 	$

164,519,418 	$

228,351,489

Note 6:

The following is a summary of $280,266,266 Total Fund ($63,030,964 General Fund) administrative adjustment transactions processed through December 2014 that either pay for or transfer expenditures with dates of service prior to June 30, 2014.

FY 2014 YTD December 31, 2014

General	Expenditure	ALTCS	Total	
Fund	Authority Fund	Fund	Fund	

Traditional Medicaid Services	$ 	48,705,506	$ 	146,870,672	$ 	- 	$ 	195,576,178	
Proposition 204 Services	1,967,001	46,999,659	- 	48,966,660	
ACA Adult Expansion	-	14,796,579	- 	14,796,579	
KidsCare - Children Services	484,185	951,055	- 	1,435,240	
Children's Rehabilitative Services	9,330,610	1,395,363	- 	10,725,973	
Long Term Care 	- 	- 	8,765,637 	8,765,637

Total

$ 	60,487,302 	$

211,013,328 	$

8,765,637 	$

280,266,267

The adjustment to correct expenditures and return the federal share for the CMS Adults with Medicare deferral has been processed as part of the CMS-64 federal expenditure report.  Ongoing adjustments will be processed as necessary.

-

-

Appropriation Status Report

Caseload	and	Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending December 31, 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	272,935,387	0	0	0	0	0	0	1,495,855,856	
CAPITATION - LTC	172,652,192	182,816,155	174,463,368	175,962,165	185,797,934	178,739,886	0	0	0	0	0	0	1,070,431,700	
MENTAL HEALTH - CHILD	22,940,496	23,328,678	23,618,875	23,718,681	23,302,936	25,767,800	0	0	0	0	0	0	142,677,466	
MENTAL HEALTH - ADULT	9,246,123	9,421,167	9,546,463	10,182,445	10,043,576	12,526,900	0	0	0	0	0	0	60,966,673	
MENTAL HEALTH - GENERAL	13,514,010	13,769,852	13,952,983	13,247,385	13,066,716	14,463,438	0	0	0	0	0	0	82,014,385	
MENTAL HEALTH - CMDP	16,576,107	16,638,148	16,847,957	13,954,363	13,986,708	15,535,784	0	0	0	0	0	0	93,539,067	
CHILDREN'S REHAB SERVICES	0	3,438,525	3,443,676	3,631,689	3,634,760	3,639,274	0	0	0	0	0	0	17,787,923	
FEE FOR SERVICE - ACUTE	46,280,515	40,298,729	44,272,778	40,509,119	39,380,058	44,268,466	0	0	0	0	0	0	255,009,664	
FFS - PRIOR QUARTER COVERAGE	57,282	163,600	272,725	299,665	290,401	278,750	0	0	0	0	0	0	1,362,423	
EMERGENCY SERVICES - FEDERAL	6,645,181	5,482,311	6,208,134	4,523,950	5,454,738	4,624,812	0	0	0	0	0	0	32,939,126	
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	578,833	0	0	0	0	0	0	3,121,369	
QMB - FEE FOR SERVICE	227,508	323,662	198,991	336,158	204,441	226,551	0	0	0	0	0	0	1,517,311	
INPATIENT INMATES FFS	139,514	117,313	118,780	356,263	172,449	110,017	0	0	0	0	0	0	1,014,336	
PIMA COUNTY INMATES FFS	7,294	6,199	3,724	754	6,755	8,059	0	0	0	0	0	0	32,784	
MARICOPA CTY INMATES FFS	5,034	2,562	11,151	9,287	15,401	35,253	0	0	0	0	0	0	78,689	
COCONINO COUNTY INMATES FFS	0	0	5,262	177	7	2,623	0	0	0	0	0	0	8,069	
PINAL COUNTY INMATES FFS	1,230	2,048	18,368	481	3,910	338	0	0	0	0	0	0	26,374	
FEE FOR SERVICE - LTC	10,677,186	9,403,354	9,497,170	10,317,996	9,250,858	10,622,159	0	0	0	0	0	0	59,768,723	
LFFS - PRIOR QUARTER COVERAGE	26,197	25,830	11,048	31,446	50,419	30,113	0	0	0	0	0	0	175,054	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,542,730	723,907	561,690	757,325	1,048,464	994,287	0	0	0	0	0	0	5,628,403	
REINSURANCE - ACUTE	10,003,289	5,027,836	10,574,231	6,348,464	10,707,695	6,925,180	0	0	0	0	0	0	49,586,695	
REINSURANCE - LTC	3,351,665	3,591,474	5,326,752	4,738,880	4,481,860	3,996,174	0	0	0	0	0	0	25,486,804	
SMIB - ACUTE	10,410,873	10,627,744	9,836,640	10,393,368	10,560,534	10,287,385	0	0	0	0	0	0	62,116,545	
HIB - ACUTE	58,792	272,446	259,042	269,952	274,700	262,747	0	0	0	0	0	0	1,397,679	
Q1	1,627,402	1,621,788	1,982,590	1,886,090	1,928,654	1,776,799	0	0	0	0	0	0	10,823,323	
SMIB - LTC	2,760,557	2,776,428	2,783,315	2,794,573	2,815,470	2,852,859	0	0	0	0	0	0	16,783,202	
HIB - LTC	121,568	275,913	266,525	277,911	272,522	280,297	0	0	0	0	0	0	1,494,736	
	574,967,964	569,698,114	576,142,462	575,954,762	583,111,966	611,770,171	0	0	0	0	0	0	3,491,645,439	

TITLE XIX PROP 204

CAPITATION - ACUTE	165,540,913	158,127,081	161,630,611	164,729,420	168,280,548	179,258,376	0	0	0	0	0	0	997,566,949	
MENTAL HEALTH - CHILD	198,164	198,016	199,318	198,959	194,576	224,014	0	0	0	0	0	0	1,213,047	
MENTAL HEALTH - ADULT	12,147,475	12,671,268	13,065,174	14,220,214	14,303,623	16,310,998	0	0	0	0	0	0	82,718,752	
MENTAL HEALTH - GENERAL	17,754,588	18,520,157	19,095,884	18,500,532	18,609,047	19,869,025	0	0	0	0	0	0	112,349,233	
MENTAL HEALTH - CMDP	0	0	0	0	0	1,035	0	0	0	0	0	0	1,035	
CHILDREN'S REHAB SERVICES	0	14,970	13,789	13,759	14,593	16,260	0	0	0	0	0	0	73,371	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending December 31, 2014

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

TOTAL

SUBTOTAL

FEE FOR SERVICE - ACUTE	26,275,199	24,092,157	26,903,237	24,234,346	22,861,010	26,100,136	0	0	0	0	0	0	150,466,085	
FFS - PRIOR QUARTER COVERAGE	51,967	316,151	600,030	726,185	811,441	1,006,665	0	0	0	0	0	0	3,512,440	
EMERGENCY SERVICES - FEDERAL	2,558,131	2,365,512	1,269,651	-678,159	919,746	744,391	0	0	0	0	0	0	7,179,272	
FFS MEDICAID IN PUBLIC SCHOOLS	5,265	1,979	1,613	4,445	4,645	4,671	0	0	0	0	0	0	22,619	
INPATIENT INMATES FFS	487,478	518,149	471,810	624,268	281,204	565,945	0	0	0	0	0	0	2,948,853	
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	5,657	0	0	0	0	0	0	186,282	
PIMA COUNTY INMATES FFS	4,443	35,007	0	0	4,290	1,085	0	0	0	0	0	0	44,824	
MARICOPA CTY INMATES FFS	13,089	6,331	23,649	22,129	68,390	127,897	0	0	0	0	0	0	261,484	
REINSURANCE - ACUTE	2,324,980	1,717,925	3,003,472	1,858,149	2,450,778	2,129,311	0	0	0	0	0	0	13,484,615	
SMIB - ACUTE	3,453,454	3,793,307	4,108,084	4,173,881	4,238,165	4,273,910	0	0	0	0	0	0	24,040,801	
HIB - ACUTE	2,806	1,938	1,938	1,938	3,216	2,364	0	0	0	0	0	0	14,200	
	230,900,813	222,428,433	230,397,099	228,663,575	233,052,479	250,641,739	0	0	0	0	0	0	1,396,084,138	

TITLE XIX ACA ADULT EXPANSION

SUBTOTAL

TOTAL TITLE XIX

CAPITATION - ACUTE	12,619,971	10,570,632	11,073,861	10,138,731	10,847,740	13,231,183	0	0	0	0	0	0	68,482,117	
MENTAL HEALTH - ADULT	777,287	863,773	902,646	1,011,393	1,045,177	1,097,210	0	0	0	0	0	0	5,697,486	
MENTAL HEALTH - GENERAL	1,136,072	1,262,478	1,319,296	1,315,824	1,359,778	1,427,473	0	0	0	0	0	0	7,820,922	
FEE FOR SERVICE - ACUTE	1,065,235	970,725	1,334,264	1,086,740	955,345	1,273,064	0	0	0	0	0	0	6,685,372	
FFS - PRIOR QUARTER COVERAGE	8,502	36,286	94,224	115,698	61,348	91,140	0	0	0	0	0	0	407,197	
EMERGENCY SERVICES - FEDERAL	134,592	90,936	1,261,768	2,877,561	1,282,684	1,768,797	0	0	0	0	0	0	7,416,339	
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	10,062	0	0	0	0	0	0	107,553	
REINSURANCE - ACUTE	22,287	20,209	101,574	92,355	115,860	104,882	0	0	0	0	0	0	457,167	
SMIB - ACUTE	1,259	839	1,678	1,783	1,154	210	0	0	0	0	0	0	6,923	
	15,765,205	13,815,878	16,112,569	16,648,532	15,737,843	19,004,021	0	0	0	0	0	0	97,084,047	
	821,633,982	805,942,426	822,652,130	821,266,869	831,902,288	881,415,930	0	0	0	0	0	0	4,984,813,624	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	317,922	319,265	311,917	324,342	320,128	1,129,266	0	0	0	0	0	0	2,722,840	
KidsCare - FEE FOR SERVICE	20,033	15,148	7,669	3,767	3,981	2,965	0	0	0	0	0	0	53,563	
KidsCare - MENTAL HEALTH	73,362	72,703	72,045	70,846	69,737	203,812	0	0	0	0	0	0	562,506	
KidsCare - REINSURANCE	-99,947	14,868	81,730	564	27,047	29,953	0	0	0	0	0	0	54,214	
KidsCare - CHILD REHAB SERVICES	0	394	394	417	417	417	0	0	0	0	0	0	2,039	

311,369	422,379	473,754	399,936	421,310	1,366,413	0	0	0	0	0	0	3,395,162	

TOTAL TITLE XXI

821,945,351	806,364,804	823,125,884	821,666,805	832,323,598	882,782,343	0	0	0	0	0	0	4,988,208,786	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

1003	TANF 06-13 M & F WIT	217.11	217.11	104.87	110.47	110.47	151.32	0.00	0.00	0.00	0.00	0.00	0.00	911.35

1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	23.39	0.00	0.00	0.00	0.00	0.00	0.00	23.39

1005	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	82.58	0.00	0.00	0.00	0.00	0.00	0.00	82.58

1006	TANF 21-44 MALE WITH	28,781.97	29,606.16	22,489.87	24,204.78	20,700.80	23,496.98	0.00	0.00	0.00	0.00	0.00	0.00	149,280.56

1007	TANF 21-44 FEMALE WI	114,269.17	118,106.00	119,978.28	129,844.18	125,121.31	128,805.54	0.00	0.00	0.00	0.00	0.00	0.00	736,124.48

1008	TANF 45-64 M & F WIT	84,108.25	89,927.78	94,307.26	104,102.12	95,198.49	109,261.01	0.00	0.00	0.00	0.00	0.00	0.00	576,904.91

1009	TANF 65+ M & F WITH	21,484.01	20,398.00	20,925.41	25,007.51	23,095.30	25,448.03	0.00	0.00	0.00	0.00	0.00	0.00	136,358.26

100F	TANF 21-44 MALE WITH	1,342.88	55.35	872.59	351.90	484.51	91.99	0.00	0.00	0.00	0.00	0.00	0.00	3,199.22

100G	TANF 21-44 FEMALE WI	3,762.11	2,684.84	841.74	3,224.55	2,067.90	1,975.62	0.00	0.00	0.00	0.00	0.00	0.00	14,556.76

100H	TANF 44-64 M & F WIT	8,995.65	2,560.05	2,390.16	4,872.53	1,031.45	4,766.01	0.00	0.00	0.00	0.00	0.00	0.00	24,615.85

100J	TANF 65+ M & F WITH	1,372.61	214.32	3,333.60	667.70	289.40	42.63	0.00	0.00	0.00	0.00	0.00	0.00	5,920.26

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	8,139,637.10	0.00	0.00	0.00	0.00	0.00	0.00	43,591,892.96

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     10,696,546.77	0.00	0.00	0.00	0.00	0.00	0.00	58,620,745.63

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     17,068,421.58	0.00	0.00	0.00	0.00	0.00	0.00	92,921,519.39

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	4,891,421.52	0.00	0.00	0.00	0.00	0.00	0.00	26,182,144.75

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	8,713,698.20	0.00	0.00	0.00	0.00	0.00	0.00	46,966,572.92

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	4,085,889.42	0.00	0.00	0.00	0.00	0.00	0.00	22,237,990.11

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     25,474,341.38	0.00	0.00	0.00	0.00	0.00	0.00	138,461,136.24

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	8,879,132.98	0.00	0.00	0.00	0.00	0.00	0.00	47,505,207.14

1019	TANF 65+ M & F NON-M	21,729.03	24,032.79	24,944.73	23,717.54	22,795.35	24,831.47	0.00	0.00	0.00	0.00	0.00	0.00	142,050.91

101A	TANF < 1 M & F NON-M	376,288.07	381,373.40	359,779.22	411,453.00	357,013.84	355,822.80	0.00	0.00	0.00	0.00	0.00	0.00	2,241,730.33

101B	TANF 01-05 M & F NON	187,236.57	166,174.01	139,408.00	157,915.78	152,952.58	121,253.09	0.00	0.00	0.00	0.00	0.00	0.00	924,940.03

101C	TANF 06-13 M & F NON	223,211.63	202,174.91	168,521.24	174,604.46	172,316.84	148,996.59	0.00	0.00	0.00	0.00	0.00	0.00	1,089,825.67

101D	TANF 14-20 MALE NON-	138,442.93	139,162.10	106,459.42	113,930.58	103,773.99	97,699.81	0.00	0.00	0.00	0.00	0.00	0.00	699,468.83

101E	TANF 14-20 FEMALE N O

244,533.70	199,126.82	167,992.36	179,404.63	145,439.74	158,923.86	0.00	0.00	0.00	0.00	0.00	0.00	1,095,421.11

101F	TANF 21-44 MALE NON-	562,829.25	205,145.88	181,413.75	176,459.37	166,735.25	198,925.55	0.00	0.00	0.00	0.00	0.00	0.00	1,491,509.05

101G	TANF 21-44 FEMALE N O

1,456,806.28	679,825.09	617,006.12	595,290.09	617,304.89	642,692.14	0.00	0.00	0.00	0.00	0.00	0.00	4,608,924.61

101H	TANF 44-64 M & F NON	1,442,455.59	387,196.22	379,269.30	234,508.79	291,425.12	368,314.87	0.00	0.00	0.00	0.00	0.00	0.00	3,103,169.89

101J	TANF 65+ N & F NON-M	10,089.16	1,333.72	2,057.69	-382.34	1,307.46	1,027.19	0.00	0.00	0.00	0.00	0.00	0.00	15,432.88

1026	TANF 21-44 MALE WITH	165.98	324.87	567.02	909.50	3,283.99	3,312.14	0.00	0.00	0.00	0.00	0.00	0.00	8,563.50

1027	TANF 21-44 FEMALE WI	6,723.14	6,476.82	9,589.29	13,371.10	12,641.42	13,003.80	0.00	0.00	0.00	0.00	0.00	0.00	61,805.57

1028	TANF 45-64 M & F WIT	2,004.87	2,570.40	3,427.81	5,168.81	7,807.07	9,109.34	0.00	0.00	0.00	0.00	0.00	0.00	30,088.30

1029	TANF 65+ M & F WITH	727.32	729.10	1,511.49	1,532.34	1,165.27	2,233.09	0.00	0.00	0.00	0.00	0.00	0.00	7,898.61

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

102G	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	25.40	0.00	0.00	0.00	0.00	0.00	0.00	25.40

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

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

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

682,116.95	665,548.05	675,360.22	689,644.65	673,487.78	742,109.30	0.00	0.00	0.00	0.00	0.00	0.00	4,128,266.95

84,778.64	36,520.03	17,286.95	22,552.34	15,938.88	94,972.48	0.00	0.00	0.00	0.00	0.00	0.00	272,049.32

4,592,127.22	4,730,015.83	4,736,543.75	5,044,668.40	5,053,970.65	5,485,285.88	0.00	0.00	0.00	0.00	0.00	0.00	29,642,611.73

906,703.14	450,324.83	325,452.91	211,742.26	239,796.29	172,207.74	0.00	0.00	0.00	0.00	0.00	0.00	2,306,227.17

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	4,046,842.68	0.00	0.00	0.00	0.00	0.00	0.00	22,657,672.88

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	30,588.73	0.00	0.00	0.00	0.00	0.00	0.00	147,336.47

1,620,418.47	1,652,777.49	1,640,988.05	1,802,103.68	1,697,117.89	1,744,994.02	0.00	0.00	0.00	0.00	0.00	0.00	10,158,399.60

61,688.36	27,741.11	18,277.11	21,663.06	16,726.53	18,077.93	0.00	0.00	0.00	0.00	0.00	0.00	164,174.10

54,178,004.81    54,186,330.75     54,140,342.06     55,990,760.45     55,929,755.60     61,257,214.32	0.00	0.00	0.00	0.00	0.00	0.00	335,682,407.99

1,411,266.35	841,644.53	641,017.98	508,757.42	536,770.16	538,267.57	0.00	0.00	0.00	0.00	0.00	0.00	4,477,724.01

10,511,923.37    10,469,394.95     10,565,310.14     10,536,986.13     10,466,175.09     10,889,639.28	0.00	0.00	0.00	0.00	0.00	0.00	63,439,428.96

8,859.10	9,858.59	3,731.42	3,377.54	2,464.59	4,679.13	0.00	0.00	0.00	0.00	0.00	0.00	32,970.37

2300	SSI BLIND WITH MEDIC	8,180.98	8,297.65	5,559.30	5,860.72	5,008.60	5,188.92	0.00	0.00	0.00	0.00	0.00	0.00	38,096.17

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	396,678.85	0.00	0.00	0.00	0.00	0.00	0.00	2,094,354.89

4,907.37	3,051.36	7,642.71	11,145.34	4,120.11	763.03	0.00	0.00	0.00	0.00	0.00	0.00	31,629.92

2320	SSI BLIND WITH QMB	38,091.63	39,048.80	39,534.51	39,685.51	39,537.65	45,087.87	0.00	0.00	0.00	0.00	0.00	0.00	240,985.97

232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	3.24	0.00	0.00	0.00	0.00	0.00	0.00	3.24

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	287.62	0.00	0.00	0.00	0.00	0.00	0.00	2,252.51

4303	SOBRA CHILD 06-13 M	104.88	148.65	0.00	0.00	103.11	220.89	0.00	0.00	0.00	0.00	0.00	0.00	577.53

4304	SOBRA CHILD 14-20 MA	0.00	285.74	0.00	147.65	160.15	160.15	0.00	0.00	0.00	0.00	0.00	0.00	753.69

4305	SOBRA CHILD 14-20 FE	741.22	741.22	741.22	779.16	779.16	941.34	0.00	0.00	0.00	0.00	0.00	0.00	4,723.32

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	184.43	0.00	0.00	0.00	0.00	0.00	0.00	1,119.07

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     17,747,460.47	0.00	0.00	0.00	0.00	0.00	0.00	94,213,045.06

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     13,728,911.92	0.00	0.00	0.00	0.00	0.00	0.00	73,597,764.39

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     17,425,626.67	0.00	0.00	0.00	0.00	0.00	0.00	92,134,786.46

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	6,170,452.81	0.00	0.00	0.00	0.00	0.00	0.00	32,907,273.02

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	9,149,184.88	0.00	0.00	0.00	0.00	0.00	0.00	48,917,589.74

431A	SOBRA CHILD < 1 M &	1,214,271.08	737,223.55	823,890.18	739,897.03	859,180.49	1,077,641.26	0.00	0.00	0.00	0.00	0.00	0.00	5,452,103.59

431B	SOBRA CHILD 01-05 M	627,471.65	335,309.44	312,814.81	290,423.29	293,264.58	399,627.23	0.00	0.00	0.00	0.00	0.00	0.00	2,258,911.00

431C	SOBRA CHILD 6-13 M& F

674,986.02	367,543.08	325,950.59	299,186.74	278,592.82	405,278.63	0.00	0.00	0.00	0.00	0.00	0.00	2,351,537.88

431D	SOBRA CHILD 14-20 MA	640,855.23	305,564.40	248,468.19	238,815.69	227,875.88	306,525.73	0.00	0.00	0.00	0.00	0.00	0.00	1,968,105.12

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

431E	SOBRA CHILD 14-20 FE	720,865.32	353,182.53	322,197.87	282,684.42	275,464.52	393,459.48	0.00	0.00	0.00	0.00	0.00	0.00	2,347,854.14

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
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
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT

21,833.03	22,940.47	24,900.15	25,248.13	31,205.32	32,605.08	0.00	0.00	0.00	0.00	0.00	0.00	158,732.18

1,697.44	1,259.47	1,259.47	1,318.07	1,318.07	1,318.07	0.00	0.00	0.00	0.00	0.00	0.00	8,170.59

411.89	2,270.17	121.17	666.48	1,221.73	164.35	0.00	0.00	0.00	0.00	0.00	0.00	4,855.79

0.00	0.00	228.55	394.56	326.07	602.60	0.00	0.00	0.00	0.00	0.00	0.00	1,551.78

746,510.58	755,732.48	766,591.83	774,695.29	762,603.21	851,151.71	0.00	0.00	0.00	0.00	0.00	0.00	4,657,285.10

2,581,731.79	2,593,995.79	2,553,661.22	2,670,239.86	2,604,827.47	2,922,688.23	0.00	0.00	0.00	0.00	0.00	0.00	15,927,144.36

20,379.89	17,127.95	17,296.31	17,117.25	17,657.98	18,456.91	0.00	0.00	0.00	0.00	0.00	0.00	108,036.29

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	70,706.57	0.00	0.00	0.00	0.00	0.00	0.00	471,838.37

302,251.20	254,788.69	250,382.55	248,879.06	241,477.63	291,679.91	0.00	0.00	0.00	0.00	0.00	0.00	1,589,459.04

3,747.04	650.37	4,050.44	1,776.35	1,800.60	4,253.52	0.00	0.00	0.00	0.00	0.00	0.00	16,278.32

4,767.49	3,535.74	3,779.29	3,550.08	6,644.36	9,643.35	0.00	0.00	0.00	0.00	0.00	0.00	31,920.31

0.00	0.00	0.00	0.00	0.00	371.28	0.00	0.00	0.00	0.00	0.00	0.00	371.28

0.00	407.18	0.00	0.00	0.00	28.47	0.00	0.00	0.00	0.00	0.00	0.00	435.65

-25.48	-222.08	-215.19	0.00	-39.27	-12.50	0.00	0.00	0.00	0.00	0.00	0.00	-514.52

SUBTOTAL:

219,325,258.77

215,820,558.09   216,718,395.63   225,832,636.97   223,739,145.50   246,871,627.22	0.00	0.00	0.00	0.00	0.00	0.00	1,348,307,622.18

E

SUBTOTAL:

9910	TANF & SOBRA CHILDR	6,571,134.40	6,179,708.87	6,623,616.05	6,325,435.24	5,921,355.59	7,121,844.89	0.00	0.00	0.00	0.00	0.00	0.00		38,743,095.04	
9920	SSI W/MEDICARE KICK	59,951.62	40,761.17	88,298.65	65,641.81	30,491.21	67,549.67	0.00	0.00	0.00	0.00	0.00	0.00		352,694.13	
9921	SSI W/O MEDICARE KIC	255,183.61	158,774.68	186,447.87	224,873.16	176,012.13	248,259.08	0.00	0.00	0.00	0.00	0.00	0.00		1,249,550.53	
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	11,395,806.09	0.00	0.00	0.00	0.00	0.00	0.00		65,649,932.52	
	18,132,961.47	16,951,836.97	18,472,678.41	18,284,798.22	15,319,537.42	18,833,459.73	0.00	0.00	0.00	0.00	0.00	0.00	105,995,272.22	

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	33.00	0.00	0.00	0.00	0.00	0.00	0.00	118.80

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	16.50	0.00	0.00	0.00	0.00	0.00	0.00	31.90

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

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	246,381.40	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	866,890.56	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	1,379,463.88	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	307,783.65	314,163.72	319,878.40	350,014.76	342,232.35	374,736.47	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	2,994.74	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	17,349.53	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	42,481.02	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

0.00

0.00	49.50	33.00	66.00	49.50	0.00	0.00	0.00	0.00	0.00	0.00	198.00

483.38	
1,370,827.56	
4,949,342.28	
7,686,289.57	
2,008,809.35	
26,820.84	
75,094.14	
194,643.26	

M&

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

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	10,994.29	0.00	0.00	0.00	0.00	0.00	0.00	98,659.32

19,671.67	17,536.46	18,187.21	18,144.58	21,475.98	22,319.90	0.00	0.00	0.00	0.00	0.00	0.00	117,335.80

1112	TANF EXPANDED 01-05	92,317.79	94,334.79	94,771.51	100,017.96	101,580.36	114,539.89	0.00	0.00	0.00	0.00	0.00	0.00	597,562.30

1113	TANF EXPANDED 06-13	306,399.70	307,071.24	301,164.82	322,580.64	316,982.77	371,085.11	0.00	0.00	0.00	0.00	0.00	0.00	1,925,284.28

1114	TANF EXPANDED 14-20	210,348.15	214,471.08	216,431.16	227,941.59	225,312.00	252,669.28	0.00	0.00	0.00	0.00	0.00	0.00	1,347,173.26

1115	TANF EXPANDED 14-20	643,300.84	649,418.38	646,818.69	682,783.70	652,895.58	727,011.16	0.00	0.00	0.00	0.00	0.00	0.00	4,002,228.35

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	4,810,571.61	0.00	0.00	0.00	0.00	0.00	0.00	26,410,000.29

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     16,423,849.65	0.00	0.00	0.00	0.00	0.00	0.00	88,732,433.43

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	9,503,863.31	0.00	0.00	0.00	0.00	0.00	0.00	51,218,920.43

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	25,048.05	0.00	0.00	0.00	0.00	0.00	0.00	128,169.38

3,069.23	2,215.08	4,340.03	4,089.78	4,743.47	1,619.09	0.00	0.00	0.00	0.00	0.00	0.00	20,076.68

111B	TANF EXPANDED 01-05	1,901.09	1,697.03	1,174.41	2,744.56	1,035.70	1,064.37	0.00	0.00	0.00	0.00	0.00	0.00	9,617.16

111C	TANF EXPANDED 06-13	5,213.11	5,167.03	3,167.11	7,318.93	4,226.15	2,855.50	0.00	0.00	0.00	0.00	0.00	0.00	27,947.83

111D	TANF EXPANDED 14-20	11,719.65	11,908.96	9,975.30	11,162.66	8,442.84	8,171.62	0.00	0.00	0.00	0.00	0.00	0.00	61,381.03

111E	TANF EXPANDED 14-20	38,981.20	28,821.18	17,611.10	22,052.24	19,825.52	26,310.43	0.00	0.00	0.00	0.00	0.00	0.00	153,601.67

111F	TANF EXPANDED 21-44	670,244.78	312,184.10	235,633.03	223,770.09	203,735.32	274,205.85	0.00	0.00	0.00	0.00	0.00	0.00	1,919,773.17

111G	TANF EXPANDED 21-44	1,430,871.86	666,063.85	503,599.59	501,095.66	467,003.56	584,423.58	0.00	0.00	0.00	0.00	0.00	0.00	4,153,058.10

111H	TANF EXPANDED 45-64	1,626,074.12	515,761.49	396,398.89	399,312.44	400,134.17	478,315.39	0.00	0.00	0.00	0.00	0.00	0.00	3,815,996.50

111J	TANF EXPANDED 65+ M&

8,192.11	5,842.05	2,447.64	10,469.17	714.38	19,869.92	0.00	0.00	0.00	0.00	0.00	0.00	47,535.27

1126	TANF EXPANDED 21-44	13,124.22	16,899.08	21,161.04	24,738.82	23,241.40	20,364.89	0.00	0.00	0.00	0.00	0.00	0.00	119,529.45

1127	TANF EXPANDED 21-44	28,106.94	29,980.28	31,155.61	34,168.88	48,526.23	58,487.47	0.00	0.00	0.00	0.00	0.00	0.00	230,425.41

1128	TANF EXPANDED 45-64	65,711.50	74,359.91	89,279.62	100,211.86	107,212.97	129,077.59	0.00	0.00	0.00	0.00	0.00	0.00	565,853.45

1129	TANF EXPANDED 65+ M&

20,594.42	25,749.49	30,073.08	35,123.44	38,148.36	44,486.30	0.00	0.00	0.00	0.00	0.00	0.00	194,175.09

112F	TANF EXPANDED 21-44	104.01	1,379.49	1,028.72	1,618.17	0.00	213.95	0.00	0.00	0.00	0.00	0.00	0.00	4,344.34

112G	TANF EXPANDED 21-44	4,554.37	932.81	169.53	913.80	-849.09	310.57	0.00	0.00	0.00	0.00	0.00	0.00	6,031.99

112H	TANF EXPANDED 45-64	10,330.63	14,843.52	3,145.66	5,317.31	1,623.70	346.53	0.00	0.00	0.00	0.00	0.00	0.00	35,607.35

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

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	120,729.32	0.00	0.00	0.00	0.00	0.00	0.00	724,381.19

44,875.33	35,043.96	57,888.79	48,623.03	40,920.35	143,235.82	0.00	0.00	0.00	0.00	0.00	0.00	370,587.28

996,608.43	969,583.79	952,406.57	1,083,088.18	1,051,233.85	1,154,858.19	0.00	0.00	0.00	0.00	0.00	0.00	6,207,779.01

167,945.16	118,708.69	148,067.44	181,653.43	119,651.49	122,357.52	0.00	0.00	0.00	0.00	0.00	0.00	858,383.73

4,944,165.87	4,948,750.29	4,920,506.37	4,992,810.54	4,934,065.67	5,304,683.35	0.00	0.00	0.00	0.00	0.00	0.00	30,044,982.09

44,737.03	42,857.94	33,476.24	38,538.79	43,511.73	66,024.88	0.00	0.00	0.00	0.00	0.00	0.00	269,146.61

2,055.56	2,055.56	1,374.99	1,431.39	1,431.39	1,431.39	0.00	0.00	0.00	0.00	0.00	0.00	9,780.28

693.76	329.64	329.64	248.57	248.57	447.51	0.00	0.00	0.00	0.00	0.00	0.00	2,297.69

336,773.78	334,318.28	334,763.54	370,682.01	322,978.24	323,304.70	0.00	0.00	0.00	0.00	0.00	0.00	2,022,820.55

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

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

37,212.73	33,070.90	21,806.80	27,527.25	17,907.77	42,098.04	0.00	0.00	0.00	0.00	0.00	0.00	179,623.49

2,136,559.39	2,124,308.69	2,046,689.85	1,924,487.10	1,680,665.59	1,663,702.19	0.00	0.00	0.00	0.00	0.00	0.00	11,576,412.81

148,355.71	70,917.72	82,751.94	45,675.28	40,247.44	128,530.07	0.00	0.00	0.00	0.00	0.00	0.00	516,478.16

4,542,694.09	4,650,545.08	4,820,226.36	4,950,694.96	5,072,447.13	5,325,363.55	0.00	0.00	0.00	0.00	0.00	0.00	29,361,971.17

10,508.92	9,697.93	9,674.68	7,947.47	9,878.98	10,355.98	0.00	0.00	0.00	0.00	0.00	0.00	58,063.96

SUBTOTAL:

47,192,060.43

45,561,816.56     45,681,882.77     47,838,621.40     46,954,797.80     51,249,495.41	0.00	0.00	0.00	0.00	0.00	0.00	284,478,674.37

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	655,950.94	0.00	0.00	0.00	0.00	0.00	0.00	2,915,488.08

6,120.18	0.00	11,960.62	12,580.34	6,160.56	5,972.38	0.00	0.00	0.00	0.00	0.00	0.00	42,794.08

0.00	5,731.51	0.00	0.00	0.00	6,081.33	0.00	0.00	0.00	0.00	0.00	0.00	11,812.84

SUBTOTAL:

434,621.43

407,401.49	534,566.71	555,878.42	369,622.30	668,004.65	0.00	0.00	0.00	0.00	0.00	0.00	2,970,095.00

3306	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	470.90	0.00	0.00	0.00	0.00	0.00	0.00	470.90

3307	AHC CARE FEMALE 21-
4
3308	AHC CARE M&F 45-64
W

0.00	0.00	0.00	0.00	0.00	171.28	0.00	0.00	0.00	0.00	0.00	0.00	171.28

0.00	0.00	0.00	-1,341.18	0.00	1,016.83	0.00	0.00	0.00	0.00	0.00	0.00	-324.35

3309	AHC CARE M&F 65+ W/	0.00	0.00	0.00	0.00	0.00	594.35	0.00	0.00	0.00	0.00	0.00	0.00	594.35

330H	AHC CARE M&F 45-64
W

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

3314	AHC CARE MALE 14-20	0.00	0.00	0.00	0.00	0.00	43,070.58	0.00	0.00	0.00	0.00	0.00	0.00	43,070.58

3315	AHC CARE FEMALE 14-
2

0.00	0.00	0.00	0.00	0.00	56,217.92	0.00	0.00	0.00	0.00	0.00	0.00	56,217.92

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	115,240.01	0.00	0.00	0.00	0.00	0.00	0.00	115,240.01

3317	AHC CARE FEMALE 21-
4

0.00	0.00	0.00	0.00	0.00	125,025.82	0.00	0.00	0.00	0.00	0.00	0.00	125,025.82

3318	AHC CARE M&F 45-64 N	0.00	-425.41	0.00	-335.03	0.00	405,575.09	0.00	0.00	0.00	0.00	0.00	0.00	404,814.65

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

3326	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	470.50	0.00	0.00	0.00	0.00	0.00	0.00	470.50

3327	AHC CARE FEMALE 21-
4
3328	AHC CARE M&F 45-64
W

0.00	0.00	0.00	0.00	0.00	62.84	0.00	0.00	0.00	0.00	0.00	0.00	62.84

0.00	0.00	0.00	0.00	0.00	726.42	0.00	0.00	0.00	0.00	0.00	0.00	726.42

3329	AHC CARE M&F 65+ W/	0.00	0.00	0.00	-404.14	0.00	286.42	0.00	0.00	0.00	0.00	0.00	0.00	-117.72

3606	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	453.95	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	86.31	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	663.88	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3611	AHC CARE/MI M&F < 1	0.00	0.00	0.00	0.00	0.00	72.67	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

0.00

258.15	11,019.45	193.87	0.00	748,928.96	0.00	0.00	0.00	0.00	0.00	0.00	760,400.43

453.95	
86.31	
663.88	
801.40	
72.67	

2

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

3614	AHC CARE/MI MALE 14-	-2,598.60	400.70	400.70	390.16	-237.97	282,022.47	0.00	0.00	0.00	0.00	0.00	0.00	280,377.46

3615	AHC CARE/MI FEMALE
1

0.00	0.00	0.00	0.00	0.00	265,100.06	0.00	0.00	0.00	0.00	0.00	0.00	265,100.06

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	227.15	435,960.72	0.00	0.00	0.00	0.00	0.00	0.00	436,187.87

3617	AHC CARE/MI FEMALE
2

389.72	759.41	401.27	416.26	416.26	342,688.05	0.00	0.00	0.00	0.00	0.00	0.00	345,070.97

3618	AHC CARE/MI M&F 45-6	461.59	-389.23	461.59	-736.40	0.00	915,745.51	0.00	0.00	0.00	0.00	0.00	0.00	915,543.06

3619	AHC CARE/MI M&F 65+	0.00	0.00	0.00	0.00	0.00	71.09	0.00	0.00	0.00	0.00	0.00	0.00	71.09

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

3628	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	135.49	0.00	0.00	0.00	0.00	0.00	0.00	135.49

SUBTOTAL:

5,457.46

2,850.90	29,041.16	9,757.70	405.44	2,243,000.20	0.00	0.00	0.00	0.00	0.00	0.00	2,290,512.86

157,335.32	
106,954.09	
794,290.00	
126,932.37	
25,171.86	
19,606.58	
119,247.95	
63,350.37	
5,183,075.46	
6,941,181.33	
35,620,913.79	
34,068,248.94	
73,245,439.24	
148,135.68	
744,971.04	
1,117,737.06	
7,032,822.17	
6,239,251.23	
13,211,183.12	
215,484.16	
11,776.12	
13,274.85	

3506	ADULT 40-100% MALE 2	33,464.06	34,621.07	27,069.30	-1,570.91	32,195.17	31,556.63	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

16,601.36	20,427.03	20,973.32	-5,640.58	27,471.78	27,121.18	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	165,114.32	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	30,340.95	0.00	0.00	0.00	0.00	0.00	0.00

350F	ADULT 40-100% MALE 2	16,508.10	3,026.60	3,425.67	871.12	0.00	1,340.37	0.00	0.00	0.00	0.00	0.00	0.00

350G	ADULT 40-100% FEMAL E

7,648.32	8,772.26	2,144.63	-4,813.18	389.49	5,465.06	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	14,606.96	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

3514	ADULT 40-100% MALE 1	819,832.68	842,828.88	840,953.28	876,800.15	893,590.25	909,070.22	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

1,084,483.92	1,096,915.46	1,118,914.49	1,178,156.71	1,209,908.66	1,252,802.09	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	5,172,698.34	5,528,748.17	5,767,825.62	6,142,511.46	6,309,689.79	6,699,440.41	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

4,973,808.19	5,313,599.25	5,519,892.97	5,890,072.39	6,020,533.74	6,350,342.40	0.00	0.00	0.00	0.00	0.00	0.00

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     13,297,207.13	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	5,684.54	6,036.37	14,886.80	103,787.27	6,287.25	11,453.45	0.00	0.00	0.00	0.00	0.00	0.00

351D	ADULT 40-100% MALE 1	203,430.24	118,278.59	111,979.61	102,431.85	86,409.79	122,440.96	0.00	0.00	0.00	0.00	0.00	0.00

351E	ADULT 40-100% FEMAL E

270,798.34	157,446.11	188,301.23	129,680.95	143,841.01	227,669.42	0.00	0.00	0.00	0.00	0.00	0.00

351F	ADULT 40-100% MALE 2	1,898,001.29	1,359,172.37	1,160,997.99	765,475.81	840,442.78	1,008,731.93	0.00	0.00	0.00	0.00	0.00	0.00

351G	ADULT 40-100% FEMAL E

1,700,470.56	1,138,581.49	1,048,087.89	670,281.19	793,715.62	888,114.48	0.00	0.00	0.00	0.00	0.00	0.00

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	1,623,668.07	0.00	0.00	0.00	0.00	0.00	0.00

351J	ADULT 40-100% M&F 65	73,691.23	17,095.07	33,084.44	25,538.43	23,653.31	42,421.68	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	840.56	1,183.72	1,278.98	982.13	4,190.25	3,300.48	0.00	0.00	0.00	0.00	0.00	0.00

3527	ADULT 40-100% FEMAL E

4,533.45	4,844.31	1,758.24	-127.71	1,012.33	1,254.23	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

3528	ADULT 40-100% M&F 45	10,351.94	12,732.82	9,529.39	-8,931.52	9,835.04	10,734.16	0.00	0.00	0.00	0.00	0.00	0.00	44,251.83

3529	ADULT 40-100% M&F 65	2,418.24	5,799.29	2,157.44	-888.39	3,354.67	5,592.65	0.00	0.00	0.00	0.00	0.00	0.00	18,433.90

352F	ADULT 40-100% MALE 2	727.05	0.00	0.00	-1,658.69	0.00	682.99	0.00	0.00	0.00	0.00	0.00	0.00	-248.65

352G	ADULT 40-100% FEMAL E

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	2,595.29	0.00	0.00	0.00	0.00	0.00	0.00	10,659.10

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 MALE	358.14	358.14	767.56	372.61	0.00	431.69	0.00	0.00	0.00	0.00	0.00	0.00	2,288.14

3705	ADULT <40% EXP FEM AL

863.92	891.67	891.67	924.53	924.53	924.53	0.00	0.00	0.00	0.00	0.00	0.00	5,420.85

3706	ADULT <40% EXP MALE	66,342.05	90,906.49	64,804.70	11,629.81	85,235.20	82,474.29	0.00	0.00	0.00	0.00	0.00	0.00	401,392.54

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

27,895.47	28,762.05	25,344.58	5,617.72	34,819.31	32,594.15	0.00	0.00	0.00	0.00	0.00	0.00	155,033.28

151,258.01	181,061.18	141,318.22	19,911.72	170,772.89	195,886.26	0.00	0.00	0.00	0.00	0.00	0.00	860,208.28

21,725.98	17,546.12	8,954.75	-5,051.05	8,994.94	7,277.56	0.00	0.00	0.00	0.00	0.00	0.00	59,448.30

370D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	1,396.83	0.00	0.00	0.00	0.00	0.00	0.00	1,396.83

370E	ADULT <40% EXP FEM AL

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

370F	ADULT <40% EXP MALE	9,711.72	8,915.14	7,256.19	4,079.50	3,031.09	22,002.44	0.00	0.00	0.00	0.00	0.00	0.00	54,996.08

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

14,796.79	2,816.57	2,643.56	-3,666.11	847.71	8,159.37	0.00	0.00	0.00	0.00	0.00	0.00	25,597.89

27,786.44	11,083.34	18,874.57	2,755.54	17,182.08	5,431.93	0.00	0.00	0.00	0.00	0.00	0.00	83,113.90

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

3714	ADULT <40% EXP MALE	4,660,701.72	4,609,307.78	4,699,719.76	4,983,993.27	4,967,501.61	4,920,258.73	0.00	0.00	0.00	0.00	0.00	0.00	28,841,482.87

3715	ADULT <40% EXP FEM AL

4,120,603.82	4,068,860.79	4,176,043.28	4,436,003.45	4,455,880.48	4,450,900.35	0.00	0.00	0.00	0.00	0.00	0.00	25,708,292.17

3716	ADULT <40% EXP MALE    20,467,726.18    21,642,151.29     22,652,596.64     24,114,702.02     24,867,544.52     25,650,195.34	0.00	0.00	0.00	0.00	0.00	0.00	139,394,915.99

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

13,101,290.86    13,787,135.05     14,316,548.26     15,186,356.28     15,607,747.20     16,014,494.76	0.00	0.00	0.00	0.00	0.00	0.00	88,013,572.41

26,828,359.99    27,999,678.77     28,886,381.41     30,342,374.67     31,102,100.31     31,842,005.33	0.00	0.00	0.00	0.00	0.00	0.00	177,000,900.48

17,618.55	21,642.08	28,214.43	57,106.51	24,073.57	28,449.88	0.00	0.00	0.00	0.00	0.00	0.00	177,105.02

371D	ADULT <40% EXP MALE	718,104.76	492,931.75	652,804.50	440,084.96	362,409.37	386,701.52	0.00	0.00	0.00	0.00	0.00	0.00	3,053,036.86

371E	ADULT <40% EXP FEM AL

677,187.15	455,966.63	525,225.14	423,286.82	321,422.52	352,510.21	0.00	0.00	0.00	0.00	0.00	0.00	2,755,598.47

371F	ADULT <40% EXP MALE	4,492,505.58	3,143,839.58	3,233,348.06	2,433,416.79	3,018,935.25	2,875,754.38	0.00	0.00	0.00	0.00	0.00	0.00	19,197,799.64

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

3,159,846.04	1,948,048.39	1,745,769.58	1,455,033.81	1,885,867.58	1,719,887.70	0.00	0.00	0.00	0.00	0.00	0.00	11,914,453.10

6,497,274.23	3,447,635.99	3,511,604.06	2,317,267.87	2,806,468.09	2,460,469.11	0.00	0.00	0.00	0.00	0.00	0.00	21,040,719.35

46,866.80	16,446.84	12,678.13	9,267.39	17,007.87	9,056.62	0.00	0.00	0.00	0.00	0.00	0.00	111,323.65

3724	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	478.45	0.00	0.00	0.00	0.00	0.00	0.00	478.45

3726	ADULT <40% EXP MALE	4,479.71	7,147.16	6,661.04	-10,771.62	2,016.19	9,471.35	0.00	0.00	0.00	0.00	0.00	0.00	19,003.83

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

1,735.34	5,609.88	7,359.90	1,302.88	3,335.96	6,098.67	0.00	0.00	0.00	0.00	0.00	0.00	25,442.63

4,216.78	4,186.26	13,184.14	-141.68	8,772.34	11,593.08	0.00	0.00	0.00	0.00	0.00	0.00	41,810.92

0.00	408.64	0.00	886.78	813.50	446.08	0.00	0.00	0.00	0.00	0.00	0.00	2,555.00

372F	ADULT <40% EXP MALE	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

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

372G	ADULT <40% EXP FEM AL
372H	ADULT <40% EXP M&F
4
372J	ADULT <40% EXP M&F
6

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	820.36	0.00	0.00	0.00	0.00	0.00	0.00	8,868.60

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   123,829,238.48	0.00	0.00	0.00	0.00	0.00	0.00	704,263,405.28

9935	BIRTH SUPP PAYMENT A
9937	BIRTH SUPP PAYMENT
A

98,220.75	87,414.00	107,601.65	153,761.10	103,593.59	147,194.59	0.00	0.00	0.00	0.00	0.00	0.00	697,785.68

213,395.97	322,263.74	418,907.69	390,616.39	388,378.41	372,513.28	0.00	0.00	0.00	0.00	0.00	0.00	2,106,075.48

1,515.27	
69,358.39	
39,264.05	
464,210.46	
98,474.46	
19,491.70	
5,113.47	
91,818.63	
32,180.50	
1,245,547.82	
1,383,154.42	
11,927,579.42	
11,248,480.94	
27,424,728.68	
32,883.75	
228,955.53	
272,713.86	
3,062,601.28	
3,233,442.95	
7,201,067.33	
68,938.42	
521.71	
-1,421.61	
3,309.89	
1,849.95	
225.90	
-423.69	
2,110.78	

SUBTOTAL:

311,616.72

409,677.74	526,509.34	544,377.49	491,972.00	519,707.87	0.00	0.00	0.00	0.00	0.00

0.00	2,803,861.16

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	2,746.88	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	733.46	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	29,263.34	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	10,430.39	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	237.91	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	13,979.61	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	2,949.29	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	245,697.26	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	270,109.45	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	2,435,714.27	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	2,314,584.82	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	5,242,431.92	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	6,308.39	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	51,766.66	0.00	0.00	0.00	0.00	0.00	0.00

391E	NEWLY ELIGIBLE FEMA L

55,613.58	25,265.46	58,955.65	22,327.63	27,362.99	83,188.55	0.00	0.00	0.00	0.00	0.00	0.00

391F	NEWLY ELIGIBLE MALE	857,867.49	510,673.93	582,071.35	235,075.81	247,439.04	629,473.66	0.00	0.00	0.00	0.00	0.00	0.00

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	699,529.06	0.00	0.00	0.00	0.00	0.00	0.00

2,753,614.91	1,167,503.66	1,110,174.16	543,175.68	566,920.39	1,059,678.53	0.00	0.00	0.00	0.00	0.00	0.00

22,569.38	10,407.41	10,604.84	5,326.54	3,361.07	16,669.18	0.00	0.00	0.00	0.00	0.00	0.00

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

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

1,894.48	3,803.61	1,958.94	-5,879.02	631.94	899.94	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

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

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

392J	NEWLY ELIGIBLE M&F
6

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     13,116,392.57	0.00	0.00	0.00	0.00	0.00	0.00	68,157,845.41

9939	BIRTH SUPP PAYMENT N

30,234.40	23,291.43	35,223.57	48,082.27	72,649.78	114,790.06	0.00	0.00	0.00	0.00	0.00	0.00	324,271.51

SUBTOTAL:

30,234.40

23,291.43	35,223.57	48,082.27	72,649.78	114,790.06	0.00	0.00	0.00	0.00	0.00	0.00	324,271.51

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	735.66	0.00	0.00	0.00	0.00	0.00	0.00	33,447.77

2,852,910.73	1,969,093.03	2,008,972.85	2,080,455.42	2,090,276.55	2,127,245.37	0.00	0.00	0.00	0.00	0.00	0.00	13,128,953.95

4414	SOBRA 100-133% MALE	1,102,921.39	938,252.77	987,329.79	1,052,852.22	1,061,123.57	1,101,170.63	0.00	0.00	0.00	0.00	0.00	0.00	6,243,650.37

4415	SOBRA 100-133% FEMA L
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	1,629,020.26	0.00	0.00	0.00	0.00	0.00	0.00	9,195,062.78

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	167,995.88	0.00	0.00	0.00	0.00	0.00	0.00	640,094.36

441D	SOBRA 100-133% MALE	179,041.42	93,546.34	91,139.52	64,152.03	46,016.17	133,391.72	0.00	0.00	0.00	0.00	0.00	0.00	607,287.20

441E	SOBRA 100-133% FEMA L

208,772.31	106,487.44	116,156.60	64,786.53	53,899.26	153,332.08	0.00	0.00	0.00	0.00	0.00	0.00	703,434.22

SUBTOTAL:

6,088,102.49

4,621,221.13	4,765,216.27	4,904,476.80	4,860,977.15	5,312,891.60	0.00	0.00	0.00	0.00	0.00	0.00	30,552,885.44

9944	BIRTH SUPP PAYMENT	35,479.33	29,417.65	23,549.95	24,394.66	18,450.85	36,240.96	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	35,479.33	29,417.65	23,549.95	24,394.66	18,450.85	36,240.96	0.00	0.00	0.00	0.00	0.00	0.	

167,533.40
S
00	167,533.40

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

8,839.74	8,852.79	8,743.39	9,457.02	9,986.80	10,958.60	0.00	0.00	0.00	0.00	0.00	0.00

56,838.34	
732,124.94	
4,283.35	
1,256.75	
12,746.06	
451.21	
51,788.19	
49,491.84	
2,739.81	
1,859.55	
913,580.04	

119,472.32	119,099.24	116,798.57	123,527.44	122,218.43	131,008.94	0.00	0.00	0.00	0.00	0.00	0.00

1,473.25	1,134.89	0.00	0.00	412.37	1,262.84	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	2,127.20	0.00	0.00	0.00	0.00	0.00	0.00

88.11	271.08	0.00	0.00	45.69	46.33	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	9,886.77	0.00	0.00	0.00	0.00	0.00	0.00

7,425.15	7,949.01	7,949.01	8,007.55	8,549.17	9,611.95	0.00	0.00	0.00	0.00	0.00	0.00

1,050.37	37.03	557.03	292.94	19.69	782.75	0.00	0.00	0.00	0.00	0.00	0.00

724.76	0.00	0.00	688.88	431.17	14.74	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

147,641.99

149,803.31	143,422.70	151,660.89	155,351.03	165,700.12	0.00	0.00	0.00	0.00	0.00

0.00

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	110.58	0.00	0.00	0.00	0.00	0.00	0.00

666.15	
7,661,633.20	
45,381.93	
1,179,419.79	
161,407.91	
863,425.34	
6,830.84	

1,244,519.95	1,265,826.16	1,272,816.33	1,278,006.88	1,284,932.98	1,315,530.90	0.00	0.00	0.00	0.00	0.00	0.00

6,724.26	10,834.42	3,136.00	9,247.26	3,859.68	11,580.31	0.00	0.00	0.00	0.00	0.00	0.00

177,605.31	180,687.48	192,244.62	209,764.35	204,164.03	214,954.00	0.00	0.00	0.00	0.00	0.00	0.00

18,701.90	17,782.48	34,798.68	47,955.65	20,041.56	22,127.64	0.00	0.00	0.00	0.00	0.00	0.00

142,004.63	141,706.42	140,001.72	142,784.20	145,814.05	151,114.32	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	1,590,966.54	1,619,747.98	1,644,955.04	1,688,512.87	1,659,164.98	1,715,417.75	0.00	0.00	0.00	0.00	0.00	0.00	9,918,765.16		

423,481,294.76	407,890,297.52	414,472,740.09	425,754,664.25	424,880,980.76	465,424,945.08	0.00	0.00	0.00	0.00	0.00	0.00	2,561,904,922.46	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

1003	TANF 06-13 M & F WIT	2.00	2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

1004	TANF 14-20 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

1005	TANF 14-20 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

1006	TANF 21-44 MALE WITH	104.67	108.97	90.78	99.76	90.80	98.41	0.00	0.00	0.00	0.00	0.00	0.00	593.39

1007	TANF 21-44 FEMALE WI	235.10	247.82	246.95	266.50	248.66	253.58	0.00	0.00	0.00	0.00	0.00	0.00	1,498.61

1008	TANF 45-64 M & F WIT	172.61	179.92	177.12	193.04	178.34	195.87	0.00	0.00	0.00	0.00	0.00	0.00	1,096.90

1009	TANF 65+ M & F WITH	55.09	52.15	54.06	62.15	56.81	58.87	0.00	0.00	0.00	0.00	0.00	0.00	339.13

100F	TANF 21-44 MALE WITH	8.20	0.35	5.19	2.14	2.99	0.57	0.00	0.00	0.00	0.00	0.00	0.00	19.44

100G	TANF 21-44 FEMALE WI	19.62	13.93	4.30	16.20	10.52	9.74	0.00	0.00	0.00	0.00	0.00	0.00	74.31

100H	TANF 44-64 M & F WIT	22.13	6.12	4.86	11.03	2.12	13.95	0.00	0.00	0.00	0.00	0.00	0.00	60.21

100J	TANF 65+ M & F WITH	3.89	0.67	9.92	1.74	0.63	0.12	0.00	0.00	0.00	0.00	0.00	0.00	16.97

1011	TANF <1 M & F NON-ME	15,270.56	15,218.68	15,485.73	15,370.64	15,096.90	15,235.19	0.00	0.00	0.00	0.00	0.00	0.00	91,677.70

1012	TANF 01-05 M & F NON	84,569.28	85,094.13	85,234.78	85,225.74	83,403.36	82,033.27	0.00	0.00	0.00	0.00	0.00	0.00	505,560.56

1013	TANF 06-13 M & F NON	132,621.53	133,901.83	135,264.08	135,892.47	133,564.00	131,836.18	0.00	0.00	0.00	0.00	0.00	0.00	803,080.09

1014	TANF 14-20 MALE NON-	25,621.38	25,952.43	26,217.60	26,576.69	26,494.38	26,383.40	0.00	0.00	0.00	0.00	0.00	0.00	157,245.88

1015	TANF 14-20 FEMALE N O

30,629.14	30,783.95	31,085.66	31,343.98	30,920.47	30,883.22	0.00	0.00	0.00	0.00	0.00	0.00	185,646.42

1016	TANF 21-44 MALE NON-	22,587.19	22,942.22	23,303.89	23,398.68	23,078.41	23,095.12	0.00	0.00	0.00	0.00	0.00	0.00	138,405.51

1017	TANF 21-44 FEMALE N O

89,032.05	90,674.39	91,953.04	92,646.92	91,092.95	90,673.87	0.00	0.00	0.00	0.00	0.00	0.00	546,073.22

1018	TANF 45-64 M & F NON	18,333.22	18,688.62	18,990.56	19,101.68	19,141.74	19,343.41	0.00	0.00	0.00	0.00	0.00	0.00	113,599.23

1019	TANF 65+ M & F NON-M	51.35	56.59	59.22	57.85	55.29	57.35	0.00	0.00	0.00	0.00	0.00	0.00	337.65

101A	TANF < 1 M & F NON-M	356.79	359.28	339.08	374.07	322.72	319.43	0.00	0.00	0.00	0.00	0.00	0.00	2,071.37

101B	TANF 01-05 M & F NON	3,295.48	2,935.40	2,446.17	2,718.44	2,597.04	2,028.39	0.00	0.00	0.00	0.00	0.00	0.00	16,020.92

101C	TANF 06-13 M & F NON	3,920.74	3,536.48	2,980.96	3,028.44	2,877.55	2,481.35	0.00	0.00	0.00	0.00	0.00	0.00	18,825.52

101D	TANF 14-20 MALE NON-	836.55	839.23	645.56	683.76	616.64	584.87	0.00	0.00	0.00	0.00	0.00	0.00	4,206.61

101E	TANF 14-20 FEMALE N O

1,255.72	1,019.24	859.65	913.15	729.15	792.01	0.00	0.00	0.00	0.00	0.00	0.00	5,568.92

101F	TANF 21-44 MALE NON-	3,415.15	1,238.51	1,085.00	1,059.05	999.59	1,179.68	0.00	0.00	0.00	0.00	0.00	0.00	8,976.98

101G	TANF 21-44 FEMALE N O

7,513.72	3,505.15	3,166.60	3,023.66	3,096.46	3,215.72	0.00	0.00	0.00	0.00	0.00	0.00	23,521.31

101H	TANF 44-64 M & F NON	3,472.14	936.34	917.73	556.31	696.51	863.89	0.00	0.00	0.00	0.00	0.00	0.00	7,442.92

101J	TANF 65+ N & F NON-M	25.59	3.01	6.26	-0.85	2.85	2.60	0.00	0.00	0.00	0.00	0.00	0.00	39.46

1026	TANF 21-44 MALE WITH	1.00	2.00	3.63	6.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	26.63

1027	TANF 21-44 FEMALE WI	10.00	9.00	11.20	20.00	17.00	17.87	0.00	0.00	0.00	0.00	0.00	0.00	85.07

1028	TANF 45-64 M & F WIT	5.00	6.77	9.00	8.00	13.99	16.00	0.00	0.00	0.00	0.00	0.00	0.00	58.76

1029	TANF 65+ M & F WITH	2.00	2.00	3.96	3.90	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	20.86

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

102G	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.12

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

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

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

4,370.68	4,347.93	4,360.25	4,520.65	4,374.48	4,436.34	0.00	0.00	0.00	0.00	0.00	0.00	26,410.33

902.84	381.78	183.85	232.94	184.97	1,080.72	0.00	0.00	0.00	0.00	0.00	0.00	2,967.10

6,138.76	6,358.34	6,368.22	6,402.03	6,386.08	6,413.44	0.00	0.00	0.00	0.00	0.00	0.00	38,066.87

1,881.26	947.08	682.35	432.93	480.61	330.10	0.00	0.00	0.00	0.00	0.00	0.00	4,754.33

2120	SSI AGED WITH QMB	21,139.27	21,618.35	21,892.09	22,140.06	22,014.07	21,996.96	0.00	0.00	0.00	0.00	0.00	0.00	130,800.80

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	338.55	0.00	0.00	0.00	0.00	0.00	0.00	1,610.01

4,292.08	4,262.41	4,279.85	5,055.96	4,337.61	4,374.52	0.00	0.00	0.00	0.00	0.00	0.00	26,602.43

659.56	304.25	203.76	241.91	174.16	192.23	0.00	0.00	0.00	0.00	0.00	0.00	1,775.87

58,085.69	58,087.88	58,057.39	58,012.43	57,866.09	57,675.63	0.00	0.00	0.00	0.00	0.00	0.00	347,785.11

3,034.88	1,839.55	1,379.74	1,040.61	1,100.48	1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	9,444.26

25,240.50	25,243.76	25,480.32	25,656.46	25,367.63	25,314.67	0.00	0.00	0.00	0.00	0.00	0.00	152,303.34

97.75	112.63	39.47	40.20	26.57	52.19	0.00	0.00	0.00	0.00	0.00	0.00	368.81

2300	SSI BLIND WITH MEDIC	32.48	33.00	30.00	31.45	30.20	30.00	0.00	0.00	0.00	0.00	0.00	0.00	187.13

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	433.17	0.00	0.00	0.00	0.00	0.00	0.00	2,565.22

9.31	5.91	15.12	21.47	9.26	1.34	0.00	0.00	0.00	0.00	0.00	0.00	62.41

2320	SSI BLIND WITH QMB	204.14	203.00	205.98	207.99	206.44	208.06	0.00	0.00	0.00	0.00	0.00	0.00	1,235.61

232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.03

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	2.87	0.00	0.00	0.00	0.00	0.00	0.00	9.03

4303	SOBRA CHILD 06-13 M	1.00	1.45	0.00	0.00	0.93	2.00	0.00	0.00	0.00	0.00	0.00	0.00	5.38

4304	SOBRA CHILD 14-20 MA	0.00	2.00	0.00	0.96	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	4.96

4305	SOBRA CHILD 14-20 FE	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

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	3.12	0.00	0.00	0.00	0.00	0.00	0.00	18.52

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	33,230.55	0.00	0.00	0.00	0.00	0.00	0.00	198,485.51

4312	SOBRA CHILD 01-05 M	99,019.99	100,577.33	101,362.18	102,197.44	100,684.31	101,706.69	0.00	0.00	0.00	0.00	0.00	0.00	605,547.94

4313	SOBRA CHILD 06-13 M	122,544.94	124,976.78	127,084.81	128,918.53	127,812.16	129,429.49	0.00	0.00	0.00	0.00	0.00	0.00	760,766.71

4314	SOBRA CHILD 14-20 MA	31,558.09	32,213.12	32,709.48	33,015.85	32,605.43	32,893.51	0.00	0.00	0.00	0.00	0.00	0.00	194,995.48

4315	SOBRA CHILD 14-20 FE	31,209.97	31,927.15	32,288.25	32,670.19	32,213.70	32,555.14	0.00	0.00	0.00	0.00	0.00	0.00	192,864.40

431A	SOBRA CHILD < 1 M &	1,170.89	705.34	799.14	697.40	803.58	986.82	0.00	0.00	0.00	0.00	0.00	0.00	5,163.17

431B	SOBRA CHILD 01-05 M	10,635.96	5,366.79	4,896.50	4,697.42	4,625.23	6,243.97	0.00	0.00	0.00	0.00	0.00	0.00	36,465.87

431C	SOBRA CHILD 6-13 M& F

11,649.29	5,833.52	4,949.60	4,555.10	4,305.57	6,266.07	0.00	0.00	0.00	0.00	0.00	0.00	37,559.15

431D	SOBRA CHILD 14-20 MA	3,814.47	1,796.34	1,462.95	1,370.65	1,324.31	1,762.63	0.00	0.00	0.00	0.00	0.00	0.00	11,531.35

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

431E	SOBRA CHILD 14-20 FE	3,680.89	1,770.66	1,604.02	1,393.59	1,351.32	1,943.80	0.00	0.00	0.00	0.00	0.00	0.00	11,744.28

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
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
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT

50.81	50.91	49.36	50.40	57.73	58.08	0.00	0.00	0.00	0.00	0.00	0.00	317.29

4.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	19.00

2.15	12.05	0.63	3.44	6.26	0.83	0.00	0.00	0.00	0.00	0.00	0.00	25.36

0.00	0.00	1.00	2.51	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	8.51

3,195.16	3,227.04	3,261.98	3,154.18	3,059.04	2,981.71	0.00	0.00	0.00	0.00	0.00	0.00	18,879.11

11,094.84	11,080.86	10,947.08	10,863.14	10,515.14	10,589.52	0.00	0.00	0.00	0.00	0.00	0.00	65,090.58

51.43	43.50	44.09	42.44	44.04	44.37	0.00	0.00	0.00	0.00	0.00	0.00	269.87

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	353.73	0.00	0.00	0.00	0.00	0.00	0.00	2,401.11

1,552.87	1,313.22	1,290.34	1,270.11	1,214.98	1,465.33	0.00	0.00	0.00	0.00	0.00	0.00	8,106.85

8.54	1.48	13.89	5.54	4.92	9.60	0.00	0.00	0.00	0.00	0.00	0.00	43.97

5.99	5.87	7.00	6.00	10.00	12.83	0.00	0.00	0.00	0.00	0.00	0.00	47.69

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

0.00	2.12	0.00	0.00	0.00	0.16	0.00	0.00	0.00	0.00	0.00	0.00	2.28

-2.03	-16.00	-16.00	0.00	-3.00	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	-38.03

SUBTOTAL:

935,093.91

916,984.24	920,878.14	925,857.20	912,526.90	918,165.82	0.00	0.00	0.00	0.00	0.00	0.00	5,529,506.21

E

SUBTOTAL:

9910	TANF & SOBRA CHILDR	1,113.00	1,048.00	1,120.00	1,041.00	975.00	1,170.00	0.00	0.00	0.00	0.00	0.00	0.00		6,467.00	
9920	SSI W/MEDICARE KICK	10.00	7.00	15.00	11.00	5.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00		59.00	
9921	SSI W/O MEDICARE KIC	43.00	27.00	32.00	37.00	29.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00		209.00	
9950	S.O.B.R.A. KICK PAYM	1,908.00	1,791.00	1,960.00	1,919.00	1,511.00	1,869.00	0.00	0.00	0.00	0.00	0.00	0.00		10,958.00	
	3,074.00	2,873.00	3,127.00	3,008.00	2,520.00	3,091.00	0.00	0.00	0.00	0.00	0.00	0.00	17,693.00	

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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	7.19

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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.93

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

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	775.95	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	1,643.01	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	2,493.30	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	761.60	777.87	791.55	833.44	812.20	823.25	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	18.36	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	84.60	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	100.96	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

0.00

0.00	2.98	2.00	3.99	3.00	0.00	0.00	0.00	0.00	0.00	0.00	11.97

2.00	
4,706.58	
10,198.75	
15,087.65	
4,799.91	
162.18	
380.08	
475.23	

M&

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

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

55.56	60.96	17.40	46.48	50.67	26.93	0.00	0.00	0.00	0.00	0.00	0.00	258.00

41.95	37.93	39.85	37.30	44.65	42.17	0.00	0.00	0.00	0.00	0.00	0.00	243.85

1112	TANF EXPANDED 01-05	844.18	871.07	883.13	894.21	882.93	879.67	0.00	0.00	0.00	0.00	0.00	0.00	5,255.19

1113	TANF EXPANDED 06-13	2,726.58	2,736.37	2,697.06	2,737.33	2,678.65	2,694.50	0.00	0.00	0.00	0.00	0.00	0.00	16,270.49

1114	TANF EXPANDED 14-20	1,344.20	1,354.93	1,368.03	1,370.14	1,352.11	1,336.78	0.00	0.00	0.00	0.00	0.00	0.00	8,126.19

1115	TANF EXPANDED 14-20	2,712.20	2,747.34	2,714.84	2,752.79	2,633.71	2,598.55	0.00	0.00	0.00	0.00	0.00	0.00	16,159.43

1116	TANF EXPANDED 21-44	27,812.41	28,482.07	28,774.90	28,967.43	28,320.94	28,164.60	0.00	0.00	0.00	0.00	0.00	0.00	170,522.35

1117	TANF EXPANDED 21-44	58,482.54	59,776.19	60,790.23	61,688.83	60,828.84	60,681.52	0.00	0.00	0.00	0.00	0.00	0.00	362,248.15

1118	TANF EXPANDED 45-64	19,991.08	20,609.06	21,007.91	21,306.26	21,166.67	21,298.77	0.00	0.00	0.00	0.00	0.00	0.00	125,379.75

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

45.63	52.61	51.87	65.37	47.16	57.27	0.00	0.00	0.00	0.00	0.00	0.00	319.91

2.76	2.05	4.16	3.65	4.15	1.80	0.00	0.00	0.00	0.00	0.00	0.00	18.57

111B	TANF EXPANDED 01-05	33.43	30.88	21.06	47.31	17.86	17.05	0.00	0.00	0.00	0.00	0.00	0.00	167.59

111C	TANF EXPANDED 06-13	91.68	94.89	55.35	127.43	70.26	47.33	0.00	0.00	0.00	0.00	0.00	0.00	486.94

111D	TANF EXPANDED 14-20	70.38	72.62	60.15	66.99	52.21	49.75	0.00	0.00	0.00	0.00	0.00	0.00	372.10

111E	TANF EXPANDED 14-20	198.05	148.93	89.81	112.12	100.09	131.19	0.00	0.00	0.00	0.00	0.00	0.00	780.19

111F	TANF EXPANDED 21-44	4,073.04	1,889.76	1,432.91	1,346.16	1,216.60	1,635.62	0.00	0.00	0.00	0.00	0.00	0.00	11,594.09

111G	TANF EXPANDED 21-44	7,379.68	3,428.17	2,588.24	2,559.07	2,338.97	2,945.37	0.00	0.00	0.00	0.00	0.00	0.00	21,239.50

111H	TANF EXPANDED 45-64	4,005.87	1,290.55	984.27	987.05	969.21	1,136.25	0.00	0.00	0.00	0.00	0.00	0.00	9,373.20

111J	TANF EXPANDED 65+ M&

21.28	17.18	6.02	21.46	1.83	45.57	0.00	0.00	0.00	0.00	0.00	0.00	113.34

1126	TANF EXPANDED 21-44	32.93	39.75	49.68	57.63	63.00	70.93	0.00	0.00	0.00	0.00	0.00	0.00	313.92

1127	TANF EXPANDED 21-44	64.65	71.62	84.08	91.83	107.28	128.30	0.00	0.00	0.00	0.00	0.00	0.00	547.76

1128	TANF EXPANDED 45-64	125.92	136.01	165.35	197.80	199.44	230.97	0.00	0.00	0.00	0.00	0.00	0.00	1,055.49

1129	TANF EXPANDED 65+ M&

49.26	60.61	71.83	81.99	88.92	99.99	0.00	0.00	0.00	0.00	0.00	0.00	452.60

112F	TANF EXPANDED 21-44	0.64	7.02	6.29	8.34	0.00	1.06	0.00	0.00	0.00	0.00	0.00	0.00	23.35

112G	TANF EXPANDED 21-44	23.31	4.89	0.89	4.77	-4.46	1.66	0.00	0.00	0.00	0.00	0.00	0.00	31.06

112H	TANF EXPANDED 45-64	23.98	40.04	8.20	13.58	5.65	0.95	0.00	0.00	0.00	0.00	0.00	0.00	92.40

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

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	657.07	0.00	0.00	0.00	0.00	0.00	0.00	3,629.03

491.82	374.01	631.37	528.24	448.28	1,561.33	0.00	0.00	0.00	0.00	0.00	0.00	4,035.05

1,309.52	1,264.48	1,238.89	1,345.57	1,294.46	1,296.54	0.00	0.00	0.00	0.00	0.00	0.00	7,749.46

347.68	242.29	309.35	378.83	239.87	233.89	0.00	0.00	0.00	0.00	0.00	0.00	1,751.91

21,506.00	21,646.70	21,762.56	22,334.80	22,474.03	22,879.08	0.00	0.00	0.00	0.00	0.00	0.00	132,603.17

487.45	464.59	370.63	421.41	475.31	710.65	0.00	0.00	0.00	0.00	0.00	0.00	2,930.04

3.00	3.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00

5.00	3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	17.00

603.87	594.65	641.21	908.50	647.65	681.67	0.00	0.00	0.00	0.00	0.00	0.00	4,077.55

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

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

395.75	352.07	238.17	313.99	201.45	440.52	0.00	0.00	0.00	0.00	0.00	0.00	1,941.95

1,730.47	1,749.03	1,699.19	1,627.72	1,424.64	1,305.20	0.00	0.00	0.00	0.00	0.00	0.00	9,536.25

315.29	156.53	172.63	100.03	81.04	266.85	0.00	0.00	0.00	0.00	0.00	0.00	1,092.37

9,091.72	9,232.20	9,509.32	9,853.08	10,007.16	10,302.67	0.00	0.00	0.00	0.00	0.00	0.00	57,996.15

113.19	110.35	107.80	89.28	112.15	113.00	0.00	0.00	0.00	0.00	0.00	0.00	645.77

SUBTOTAL:

173,132.87

166,740.69	167,182.36	170,430.74	167,128.42	170,716.45	0.00	0.00	0.00	0.00	0.00	0.00	1,015,331.53

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	108.00	0.00	0.00	0.00	0.00	0.00	0.00	485.00

1.00	0.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00

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

SUBTOTAL:

73.00

69.00	90.00	91.00	61.00	110.00	0.00	0.00	0.00	0.00	0.00	0.00	494.00

3306	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

3307	AHC CARE FEMALE 21-
4
3308	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

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

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

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

3314	AHC CARE MALE 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

3315	AHC CARE FEMALE 14-
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

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	-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

3326	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

3327	AHC CARE FEMALE 21-
4
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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3606	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	
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	
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	
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	
3611	AHC CARE/MI M&F < 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	

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

0.00	
0.00	
0.00	
2.00	
0.00	

2

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

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

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	0.67	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	6.96

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

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

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

3628	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

SUBTOTAL:

5.23

4.19

42.00	15.00	0.97	1.00	0.00	0.00	0.00	0.00	0.00	0.00	68.39

262.78	
154.67	
1,676.70	
305.19	
38.05	
29.31	
182.44	
94.22	
12,456.11	
16,585.79	
85,730.61	
81,248.03	
177,029.72	
369.28	
1,118.15	
1,668.87	
10,604.83	
9,388.70	
19,799.38	
324.73	
13.26	
16.94	

3506	ADULT 40-100% MALE 2	59.62	55.45	52.54	-13.67	54.00	54.84	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

35.66	35.11	33.74	-25.90	38.29	37.77	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	364.12	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	76.00	0.00	0.00	0.00	0.00	0.00	0.00

350F	ADULT 40-100% MALE 2	26.33	4.28	4.88	0.70	0.00	1.86	0.00	0.00	0.00	0.00	0.00	0.00

350G	ADULT 40-100% FEMAL E

11.30	12.88	3.19	-6.62	0.56	8.00	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	22.67	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

3514	ADULT 40-100% MALE 1	1,984.67	2,065.04	2,058.68	2,083.06	2,115.30	2,149.36	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

2,614.51	2,670.67	2,726.85	2,782.47	2,848.49	2,942.80	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	12,714.59	13,533.02	14,111.15	14,618.12	14,939.73	15,814.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

12,070.40	12,868.07	13,361.73	13,869.29	14,171.67	14,906.87	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	27,169.50	28,434.27	29,364.98	29,773.29	30,657.25	31,630.43	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	14.04	14.83	36.32	259.58	15.28	29.23	0.00	0.00	0.00	0.00	0.00	0.00

351D	ADULT 40-100% MALE 1	313.78	181.67	171.50	150.11	121.76	179.33	0.00	0.00	0.00	0.00	0.00	0.00

351E	ADULT 40-100% FEMAL E

403.56	228.94	285.63	198.12	215.06	337.56	0.00	0.00	0.00	0.00	0.00	0.00

351F	ADULT 40-100% MALE 2	2,859.91	2,031.13	1,773.86	1,159.39	1,266.05	1,514.49	0.00	0.00	0.00	0.00	0.00	0.00

351G	ADULT 40-100% FEMAL E

2,581.00	1,703.20	1,578.56	1,004.56	1,199.83	1,321.55	0.00	0.00	0.00	0.00	0.00	0.00

351H	ADULT 40-100% M&F 45	7,211.46	3,371.85	3,091.21	1,894.23	1,782.96	2,447.67	0.00	0.00	0.00	0.00	0.00	0.00

351J	ADULT 40-100% M&F 65	108.10	25.19	47.66	42.37	35.69	65.72	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	1.93	3.00	3.00	-2.67	5.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00

3527	ADULT 40-100% FEMAL E

6.45	7.00	2.40	-4.31	2.40	3.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

3528	ADULT 40-100% M&F 45	26.71	29.59	24.32	-22.81	24.00	26.08	0.00	0.00	0.00	0.00	0.00	0.00	107.89

3529	ADULT 40-100% M&F 65	6.00	15.00	6.00	-2.01	8.73	15.00	0.00	0.00	0.00	0.00	0.00	0.00	48.72

352F	ADULT 40-100% MALE 2	1.06	0.00	0.00	-2.50	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	-0.44

352G	ADULT 40-100% FEMAL E

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	3.88	0.00	0.00	0.00	0.00	0.00	0.00	16.75

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

3705	ADULT <40% EXP FEM AL

1.93	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	11.93

3706	ADULT <40% EXP MALE	103.25	111.71	84.84	-54.92	97.69	100.71	0.00	0.00	0.00	0.00	0.00	0.00	443.28

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

48.48	48.94	35.43	-13.67	42.10	42.98	0.00	0.00	0.00	0.00	0.00	0.00	204.26

283.95	338.46	268.52	-23.74	322.09	351.54	0.00	0.00	0.00	0.00	0.00	0.00	1,540.82

56.31	44.45	21.90	-12.92	22.56	18.00	0.00	0.00	0.00	0.00	0.00	0.00	150.30

370D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	2.03	0.00	0.00	0.00	0.00	0.00	0.00	2.03

370E	ADULT <40% EXP FEM AL

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

370F	ADULT <40% EXP MALE	14.26	15.04	9.01	7.43	4.35	32.34	0.00	0.00	0.00	0.00	0.00	0.00	82.43

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

21.77	4.58	4.07	-5.93	1.22	10.07	0.00	0.00	0.00	0.00	0.00	0.00	35.78

42.46	16.69	26.64	3.98	25.98	8.31	0.00	0.00	0.00	0.00	0.00	0.00	124.06

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

3714	ADULT <40% EXP MALE	11,007.76	11,025.46	11,264.02	11,571.49	11,500.33	11,358.20	0.00	0.00	0.00	0.00	0.00	0.00	67,727.26

3715	ADULT <40% EXP FEM AL

9,706.11	9,741.20	10,012.97	10,282.00	10,282.64	10,283.46	0.00	0.00	0.00	0.00	0.00	0.00	60,308.38

3716	ADULT <40% EXP MALE	48,059.07	50,383.36	52,664.76	54,392.55	55,689.89	57,229.69	0.00	0.00	0.00	0.00	0.00	0.00	318,419.32

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

30,195.28	31,546.27	32,673.10	33,708.32	34,395.28	35,190.31	0.00	0.00	0.00	0.00	0.00	0.00	197,708.56

63,522.48	65,959.10	67,857.20	69,267.69	70,625.75	71,982.73	0.00	0.00	0.00	0.00	0.00	0.00	409,214.95

44.36	54.24	72.42	140.60	59.26	69.99	0.00	0.00	0.00	0.00	0.00	0.00	440.87

371D	ADULT <40% EXP MALE	1,088.95	744.05	996.81	659.46	547.41	567.99	0.00	0.00	0.00	0.00	0.00	0.00	4,604.67

371E	ADULT <40% EXP FEM AL

1,021.43	690.50	796.72	637.59	474.68	533.67	0.00	0.00	0.00	0.00	0.00	0.00	4,154.59

371F	ADULT <40% EXP MALE	6,765.74	4,743.82	4,863.04	3,660.33	4,547.57	4,312.08	0.00	0.00	0.00	0.00	0.00	0.00	28,892.58

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

4,743.81	2,946.56	2,646.68	2,192.59	2,859.20	2,563.81	0.00	0.00	0.00	0.00	0.00	0.00	17,952.65

9,643.66	5,153.80	5,223.51	3,460.30	4,176.51	3,658.61	0.00	0.00	0.00	0.00	0.00	0.00	31,316.39

66.80	27.72	19.23	12.58	28.72	14.02	0.00	0.00	0.00	0.00	0.00	0.00	169.07

3724	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

3726	ADULT <40% EXP MALE	3.54	4.47	6.56	-4.39	4.76	8.41	0.00	0.00	0.00	0.00	0.00	0.00	23.35

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

1.54	4.80	8.00	-1.88	3.13	5.00	0.00	0.00	0.00	0.00	0.00	0.00	20.59

10.28	10.22	20.13	-8.43	15.54	16.12	0.00	0.00	0.00	0.00	0.00	0.00	63.86

0.00	1.00	0.00	1.96	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	5.96

372F	ADULT <40% EXP MALE	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

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

372G	ADULT <40% EXP FEM AL
372H	ADULT <40% EXP M&F
4
372J	ADULT <40% EXP M&F
6

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	1.19	0.00	0.00	0.00	0.00	0.00	0.00	11.43

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	272,322.45	0.00	0.00	0.00	0.00	0.00	0.00	1,562,950.36

9935	BIRTH SUPP PAYMENT A
9937	BIRTH SUPP PAYMENT
A

17.00	15.00	18.00	25.00	17.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	116.00

36.00	54.00	71.00	64.00	64.00	61.00	0.00	0.00	0.00	0.00	0.00	0.00	350.00

5.00	
135.99	
52.12	
1,222.71	
323.83	
58.48	
17.83	
294.14	
97.26	
4,002.98	
4,371.54	
38,775.06	
36,466.14	
89,441.99	
109.50	
696.44	
813.50	
9,286.88	
9,819.61	
21,776.62	
210.32	
2.13	
-4.73	
10.26	
6.45	
0.87	
-1.25	
5.91	

SUBTOTAL:

53.00

69.00	89.00	89.00	81.00	85.00	0.00	0.00	0.00	0.00	0.00

0.00	466.00

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	9.00	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	2.31	0.00	0.00	0.00	0.00	0.00	0.00

583.32	464.17	124.90	-125.92	104.09	72.15	0.00	0.00	0.00	0.00	0.00	0.00

71.12	106.14	55.47	11.21	45.00	34.89	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	0.67	0.00	0.00	0.00	0.00	0.00	0.00

131.86	92.81	26.55	-40.06	36.83	46.15	0.00	0.00	0.00	0.00	0.00	0.00

35.81	29.02	9.48	4.21	10.00	8.74	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	765.82	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	832.86	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	7,728.79	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	7,361.08	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	16,778.02	0.00	0.00	0.00	0.00	0.00	0.00

12.97	16.28	21.99	23.89	13.90	20.47	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	156.21	0.00	0.00	0.00	0.00	0.00	0.00

391E	NEWLY ELIGIBLE FEMA L

161.43	76.72	179.62	67.18	81.40	247.15	0.00	0.00	0.00	0.00	0.00	0.00

391F	NEWLY ELIGIBLE MALE	2,612.58	1,545.82	1,766.22	707.43	738.69	1,916.14	0.00	0.00	0.00	0.00	0.00	0.00

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	2,124.06	0.00	0.00	0.00	0.00	0.00	0.00

8,327.51	3,561.78	3,359.60	1,613.97	1,716.51	3,197.25	0.00	0.00	0.00	0.00	0.00	0.00

68.94	33.73	31.96	17.08	9.10	49.51	0.00	0.00	0.00	0.00	0.00	0.00

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

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

6.28	12.94	6.70	-20.66	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

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

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014

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

392J	NEWLY ELIGIBLE M&F
6

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	41,354.27	0.00	0.00	0.00	0.00	0.00	0.00	217,998.12

9939	BIRTH SUPP PAYMENT N

5.00	4.00	6.00	8.00	12.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	54.00

SUBTOTAL:

5.00

4.00	6.00	8.00	12.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	54.00

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

128.25	116.83	18.70	19.00	12.81	7.00	0.00	0.00	0.00	0.00	0.00	0.00	302.59

18,951.90	17,885.34	18,069.72	18,014.10	17,992.55	18,409.69	0.00	0.00	0.00	0.00	0.00	0.00	109,323.30

4414	SOBRA 100-133% MALE	6,066.89	5,979.56	6,241.71	6,390.34	6,422.06	6,692.56	0.00	0.00	0.00	0.00	0.00	0.00	37,793.12

4415	SOBRA 100-133% FEMA L
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	6,421.65	0.00	0.00	0.00	0.00	0.00	0.00	36,388.19

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	2,583.54	0.00	0.00	0.00	0.00	0.00	0.00	10,755.86

441D	SOBRA 100-133% MALE	1,092.57	565.99	560.30	363.00	282.01	801.31	0.00	0.00	0.00	0.00	0.00	0.00	3,665.18

441E	SOBRA 100-133% FEMA L

1,079.50	551.61	600.34	322.06	278.12	780.92	0.00	0.00	0.00	0.00	0.00	0.00	3,612.55

SUBTOTAL:

35,835.92

32,613.32	33,373.53	32,489.34	31,850.23	35,696.67	0.00	0.00	0.00	0.00	0.00	0.00	201,859.01

9944	BIRTH SUPP PAYMENT	6.00	5.00	4.00	4.00	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6.00	5.00	4.00	4.00	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.	

28.00
S
00	28.00

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

38.00	37.90	37.32	38.47	40.56	41.00	0.00	0.00	0.00	0.00	0.00	0.00

233.25	
1,678.60	
10.81	
6.02	
28.65	
1.10	
158.04	
119.86	
13.90	
5.15	
2,255.38	

288.12	281.92	279.22	281.82	275.75	271.77	0.00	0.00	0.00	0.00	0.00	0.00

3.78	3.24	0.00	0.00	0.90	2.89	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	4.90	0.00	0.00	0.00	0.00	0.00	0.00

0.18	0.73	0.00	0.00	0.10	0.09	0.00	0.00	0.00	0.00	0.00	0.00

25.51	25.80	25.39	26.48	26.90	27.96	0.00	0.00	0.00	0.00	0.00	0.00

18.73	20.00	20.00	19.44	20.73	20.96	0.00	0.00	0.00	0.00	0.00	0.00

5.48	0.19	2.59	1.51	0.10	4.03	0.00	0.00	0.00	0.00	0.00	0.00

2.32	0.00	0.00	1.54	1.26	0.03	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

383.44

379.77	367.61	372.91	378.02	373.63	0.00	0.00	0.00	0.00	0.00

0.00

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	1.00	0.00	0.00	0.00	0.00	0.00	0.00

6.00	
8,231.57	
497.46	
1,145.48	
356.49	
1,123.31	
77.46	

1,318.39	1,324.42	1,354.33	1,396.27	1,406.82	1,431.34	0.00	0.00	0.00	0.00	0.00	0.00

70.71	116.78	35.90	106.49	41.63	125.95	0.00	0.00	0.00	0.00	0.00	0.00

176.19	177.36	190.82	202.81	198.67	199.63	0.00	0.00	0.00	0.00	0.00	0.00

38.70	38.74	74.53	112.44	43.27	48.81	0.00	0.00	0.00	0.00	0.00	0.00

175.01	179.64	188.72	193.91	191.13	194.90	0.00	0.00	0.00	0.00	0.00	0.00

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

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	1,796.33	1,870.55	1,864.56	2,019.52	1,885.18	2,001.63	0.00	0.00	0.00	0.00	0.00	0.00	11,437.77		

SUBTOTAL:

TOTAL:	1,446,840.78	1,407,316.37	1,421,777.53	1,423,971.70	1,416,314.45	1,443,945.92	0.00	0.00	0.00	0.00	0.00	0.00	8,560,166.75		

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending December 31, 2014

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

1000	TANF WITH MEDICARE	9,640.51	10,016.56	9,640.51	9,748.96	10,125.01	9,793.15	0.00	0.00	0.00	0.00	0.00	0.00	58,964.70

1010	TANF NON-MEDICARE	2,119,642.85	2,113,999.86	2,104,519.62	2,123,081.73	2,126,882.02	2,151,205.15	0.00	0.00	0.00	0.00	0.00	0.00	12,739,331.23

101Z	TANF ALTCS NON-MED IC

0.00	0.00	0.00	0.00	0.00	1,510.86	0.00	0.00	0.00	0.00	0.00	0.00	1,510.86

1020	TANF WITH QMB	6,677.94	6,677.94	6,677.94	3,345.48	3,345.48	3,478.05	0.00	0.00	0.00	0.00	0.00	0.00	30,202.83

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

30,836,613.84    34,570,502.80     30,935,967.12     31,372,866.59     35,239,337.50     31,439,888.23	0.00	0.00	0.00	0.00	0.00	0.00	194,395,176.08

615,597.94	729,576.72	688,405.76	664,286.50	596,267.84	699,202.36	0.00	0.00	0.00	0.00	0.00	0.00	3,993,337.12

2,604,038.91	2,783,598.60	2,545,373.27	2,558,167.28	2,784,981.87	2,580,196.66	0.00	0.00	0.00	0.00	0.00	0.00	15,856,356.59

19,614.65	14,978.98	7,769.14	36,248.05	12,459.97	16,602.08	0.00	0.00	0.00	0.00	0.00	0.00	107,672.87

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     18,426,198.14	0.00	0.00	0.00	0.00	0.00	0.00	112,198,957.93

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	26,197.41	0.00	0.00	0.00	0.00	0.00	0.00	75,526.76

13,837,679.72    14,827,724.89     13,765,759.22     14,043,931.24     15,112,189.53     14,262,064.99	0.00	0.00	0.00	0.00	0.00	0.00	85,849,349.59

82,279.18	102,250.19	81,722.03	121,624.38	71,380.49	73,502.98	0.00	0.00	0.00	0.00	0.00	0.00	532,759.25

84,294,536.39    85,893,699.47     85,286,548.21     85,469,641.29     87,030,964.66     87,465,381.22	0.00	0.00	0.00	0.00	0.00	0.00	515,440,771.24

31,789.29	35,099.30	26,766.85	38,234.27	29,582.73	30,504.56	0.00	0.00	0.00	0.00	0.00	0.00	191,977.00

19,966,282.88    21,012,877.23     20,270,819.28     20,408,639.93     21,400,723.78     20,677,775.08	0.00	0.00	0.00	0.00	0.00	0.00	123,737,118.18

1,541.29	7,803.55	0.00	1,703.71	6,352.39	2,596.92	0.00	0.00	0.00	0.00	0.00	0.00	19,997.86

2300	SSI BLIND WITH MEDIC	69,541.93	72,181.18	69,541.93	72,926.26	70,082.69	76,807.55	0.00	0.00	0.00	0.00	0.00	0.00	431,081.54

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	485,422.02	0.00	0.00	0.00	0.00	0.00	0.00	2,912,825.35

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	118,939.74	0.00	0.00	0.00	0.00	0.00	0.00	731,159.45

SUBTOTAL:

172,463,262.81

182,618,498.68   174,288,831.72   175,786,182.74   185,603,284.58   178,547,267.15	0.00	0.00	0.00	0.00	0.00	0.00	1,069,307,327.68

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

67,556.86	73,398.32	64,735.65	65,903.92	71,492.44	69,307.88	0.00	0.00	0.00	0.00	0.00	0.00

412,395.07	
5,543.95	
624,549.64	
4,927.88	
76,956.20	
1,124,372.74	

0.00	0.00	0.00	0.00	0.00	5,543.95	0.00	0.00	0.00	0.00	0.00	0.00

101,819.57	107,175.95	99,858.26	100,146.55	110,894.02	104,655.29	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	13,111.28	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	192,618.40	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   178,739,885.55	0.00	0.00	0.00	0.00	0.00	0.00	1,070,431,700.42

LONG TERM CARE MEMBER MONTHS

For The Period Ending December 31, 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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	18.00

1010	TANF NON-MEDICARE	633.10	629.83	627.45	631.62	631.62	631.96	0.00	0.00	0.00	0.00	0.00	0.00	3,785.58

101Z	TANF ALTCS NON-MED IC

0.00	0.00	0.00	0.00	0.00	0.45	0.00	0.00	0.00	0.00	0.00	0.00	0.45

1020	TANF WITH QMB	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00

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

11,510.64	11,449.32	11,525.89	11,554.03	11,529.19	11,528.39	0.00	0.00	0.00	0.00	0.00	0.00	69,097.46

680.99	812.44	766.78	736.17	639.15	744.01	0.00	0.00	0.00	0.00	0.00	0.00	4,379.54

604.41	604.39	593.07	596.85	602.22	588.71	0.00	0.00	0.00	0.00	0.00	0.00	3,589.65

22.69	16.62	8.62	39.07	13.49	18.23	0.00	0.00	0.00	0.00	0.00	0.00	118.72

2120	SSI AGED WITH QMB	6,956.11	7,115.15	7,150.50	7,188.17	7,202.52	7,217.66	0.00	0.00	0.00	0.00	0.00	0.00	42,830.11

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

14.44	9.92	5.94	11.10	12.60	27.46	0.00	0.00	0.00	0.00	0.00	0.00	81.46

4,675.34	4,642.31	4,647.27	4,695.10	4,693.64	4,718.73	0.00	0.00	0.00	0.00	0.00	0.00	28,072.39

91.28	112.25	91.86	124.95	76.51	80.55	0.00	0.00	0.00	0.00	0.00	0.00	577.40

24,410.73	24,526.37	24,664.11	24,715.17	24,817.08	24,998.38	0.00	0.00	0.00	0.00	0.00	0.00	148,131.84

34.40	38.90	29.82	40.98	31.55	32.11	0.00	0.00	0.00	0.00	0.00	0.00	207.76

6,545.92	6,594.62	6,636.45	6,644.30	6,660.20	6,667.85	0.00	0.00	0.00	0.00	0.00	0.00	39,749.34

1.70	8.83	0.00	1.83	6.93	2.70	0.00	0.00	0.00	0.00	0.00	0.00	21.99

2300	SSI BLIND WITH MEDIC	22.00	22.00	22.00	23.00	21.38	24.00	0.00	0.00	0.00	0.00	0.00	0.00	134.38

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

137.93	139.38	140.73	138.77	138.36	139.61	0.00	0.00	0.00	0.00	0.00	0.00	834.78

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	39.00	0.00	0.00	0.00	0.00	0.00	0.00	239.30

SUBTOTAL:

56,388.68

56,771.32	56,954.41	57,185.11	57,119.44	57,463.80	0.00	0.00	0.00	0.00	0.00	0.00	341,882.76

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

22.00	22.00	21.00	21.00	21.00	22.03	0.00	0.00	0.00	0.00	0.00	0.00

129.03	
5.96	
140.18	
5.80	
29.00	
309.97	

0.00	0.00	0.00	0.00	0.00	5.96	0.00	0.00	0.00	0.00	0.00	0.00

23.32	23.00	23.00	23.00	23.86	24.00	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	5.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

54.99

51.00	48.00	48.00	50.99	56.99	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	57,520.79	0.00	0.00	0.00	0.00	0.00	0.00	342,192.73		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending December 31, 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	45.82	0.00	0.00	0.00	0.00	0.00	0.00	306.10

1010	TANF NON-MEDICARE	10,900,567.20    11,013,841.20     11,139,465.60     11,141,702.88     10,882,837.08     12,007,477.28	0.00	0.00	0.00	0.00	0.00	0.00	67,085,891.24

2110	SSI AGED NON-MEDICA R

0.00	0.00	0.00	0.00	0.00	37.14	0.00	0.00	0.00	0.00	0.00	0.00	37.14

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 ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

37.20	37.20	74.40	74.28	74.28	124.44	0.00	0.00	0.00	0.00	0.00	0.00	421.80

434,533.20	432,375.60	431,743.20	427,889.94	427,295.70	492,219.36	0.00	0.00	0.00	0.00	0.00	0.00	2,646,057.00

297.60	297.60	297.60	297.12	297.12	329.42	0.00	0.00	0.00	0.00	0.00	0.00	1,816.46

1,450.80	1,450.80	1,450.80	1,522.74	1,597.02	2,075.42	0.00	0.00	0.00	0.00	0.00	0.00	9,547.58

74.40	148.80	74.40	37.14	74.28	194.38	0.00	0.00	0.00	0.00	0.00	0.00	603.40

10,572,984.00    10,832,528.40     10,994,385.60     11,087,552.76     10,926,662.28     12,207,323.60	0.00	0.00	0.00	0.00	0.00	0.00	66,621,436.64

12,648.00	12,536.40	12,871.20	12,107.64	12,590.46	13,745.16	0.00	0.00	0.00	0.00	0.00	0.00	76,498.86

SUBTOTAL:

21,922,666.80

22,293,290.40     22,580,437.20     22,671,221.64     22,251,465.36     24,723,572.02	0.00	0.00	0.00	0.00	0.00	0.00	136,442,653.42

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	223,914.02	0.00	0.00	0.00	0.00	0.00	0.00	1,212,575.30

74.40	74.40	74.40	74.28	74.28	95.98	0.00	0.00	0.00	0.00	0.00	0.00	467.74

SUBTOTAL:

198,164.40

198,015.60	199,317.60	198,958.98	194,576.46	224,010.00	0.00	0.00	0.00	0.00	0.00

0.00	1,213,043.04

0.00	0.00	0.00	0.00	0.00	4.34	0.00	0.00	0.00	0.00	0.00	0.00		4.34	
0.00	0.00	0.00	0.00	0.00	4.34	0.00	0.00	0.00	0.00	0.00	0.00	4.34	

3610	AHC CARE EXPANDED FO
SUBTOTAL:

F
SUBTOTAL:

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	1,044,228.24	0.00	0.00	0.00	0.00	0.00	0.00		6,234,813.00	
	1,017,829.20	1,035,387.60	1,038,438.00	1,047,459.42	1,051,470.54	1,044,228.24	0.00	0.00	0.00	0.00	0.00	0.00	6,234,813.00	

23,138,660.40	23,526,693.60	23,818,192.80	23,917,640.04	23,497,512.36	25,991,814.60	0.00	0.00	0.00	0.00	0.00	0.00	143,890,513.80	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending December 31, 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

1010	TANF NON-MEDICARE	293,026.00	296,071.00	299,448.00	299,992.00	293,022.00	290,265.00	0.00	0.00	0.00	0.00	0.00	0.00	1,771,824.00

2110	SSI AGED NON-MEDICA R

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

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 ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

1.00	1.00	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00

11,681.00	11,623.00	11,606.00	11,521.00	11,505.00	11,468.00	0.00	0.00	0.00	0.00	0.00	0.00	69,404.00

8.00	8.00	8.00	8.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	47.00

39.00	39.00	39.00	41.00	43.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	248.00

2.00	4.00	2.00	1.00	2.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

284,220.00	291,197.00	295,548.00	298,534.00	294,202.00	295,682.00	0.00	0.00	0.00	0.00	0.00	0.00	1,759,383.00

340.00	337.00	346.00	326.00	339.00	314.00	0.00	0.00	0.00	0.00	0.00	0.00	2,002.00

SUBTOTAL:

589,319.00

599,282.00	607,001.00	610,426.00	599,124.00	597,793.00	0.00	0.00	0.00	0.00	0.00	0.00	3,602,945.00

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	5,253.00	0.00	0.00	0.00	0.00	0.00	0.00	31,847.00

2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00

SUBTOTAL:

5,327.00

5,323.00	5,358.00	5,357.00	5,239.00	5,255.00	0.00	0.00	0.00	0.00	0.00

0.00	31,859.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3610	AHC CARE EXPANDED FO

4410	SOBRA 100-133% FOR	27,361.00	27,833.00	27,915.00	28,203.00	28,311.00	28,116.00	0.00	0.00	0.00	0.00	0.00	0.00		167,739.00	
	27,361.00	27,833.00	27,915.00	28,203.00	28,311.00	28,116.00	0.00	0.00	0.00	0.00	0.00	0.00	167,739.00	

SUBTOTAL:

F
SUBTOTAL:

TOTAL:	622,007.00	632,438.00	640,274.00	643,986.00	632,674.00	631,164.00	0.00	0.00	0.00	0.00	0.00	0.00	3,802,543.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending December 31, 2014

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

1000	TANF WITH MEDICARE	17,922.18	18,687.54	17,954.07	19,266.56	19,266.56	25,209.60	0.00	0.00	0.00	0.00	0.00	0.00	118,306.51

1010	TANF NON-MEDICARE	4,703,200.98	4,819,025.46	4,903,661.52	5,241,488.00	5,143,696.64	6,358,562.25	0.00	0.00	0.00	0.00	0.00	0.00	31,169,634.85

1020	TANF WITH QMB	510.24	574.02	733.47	1,017.60	1,288.96	1,664.68	0.00	0.00	0.00	0.00	0.00	0.00	5,788.97

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

146,311.32	148,129.05	149,468.43	160,339.84	159,424.00	195,009.65	0.00	0.00	0.00	0.00	0.00	0.00	958,682.29

188,884.47	199,790.85	201,863.70	216,782.72	216,240.00	261,801.81	0.00	0.00	0.00	0.00	0.00	0.00	1,285,363.55

2120	SSI AGED WITH QMB	716,823.42	733,820.79	744,950.40	796,509.44	795,763.20	970,638.02	0.00	0.00	0.00	0.00	0.00	0.00	4,758,505.27

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	196,697.50	0.00	0.00	0.00	0.00	0.00	0.00	954,085.71

1,335,648.87	1,334,086.26	1,336,860.69	1,418,839.68	1,416,329.60	1,832,767.44	0.00	0.00	0.00	0.00	0.00	0.00	8,674,532.54

798,079.14	797,983.47	804,457.14	856,378.24	853,121.92	1,103,769.36	0.00	0.00	0.00	0.00	0.00	0.00	5,213,789.27

2300	SSI BLIND WITH MEDIC	1,148.04	1,179.93	1,084.26	1,221.12	1,255.04	1,478.90	0.00	0.00	0.00	0.00	0.00	0.00	7,367.29

2310	SSI BLIND NON-MEDIC A

13,648.92	13,585.14	13,553.25	14,382.08	14,314.24	18,099.52	0.00	0.00	0.00	0.00	0.00	0.00	87,583.15

2320	SSI BLIND WITH QMB	7,908.72	7,749.27	7,813.05	8,378.24	8,310.40	10,599.10	0.00	0.00	0.00	0.00	0.00	0.00	50,758.78

4300	SOBRA CHILD WITH ME D
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	8.61	0.00	0.00	0.00	0.00	0.00	0.00	40.50

619,718.37	636,269.28	643,029.96	678,230.40	656,250.24	803,551.09	0.00	0.00	0.00	0.00	0.00	0.00	4,037,049.34

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	2,245.48	0.00	0.00	0.00	0.00	0.00	0.00	10,259.50

437,658.36	440,432.79	440,847.36	460,565.76	447,133.44	568,437.81	0.00	0.00	0.00	0.00	0.00	0.00	2,795,075.52

159.45	127.56	191.34	169.60	271.36	373.64	0.00	0.00	0.00	0.00	0.00	0.00	1,292.95

SUBTOTAL:

9,135,528.30

9,300,495.27	9,415,586.28     10,032,823.68	9,892,801.92     12,350,914.46	0.00	0.00	0.00	0.00	0.00	0.00	60,128,149.91

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	238,286.23	0.00	0.00	0.00	0.00	0.00	0.00	1,165,813.57

3,547,634.94	3,668,179.14	3,746,182.08	4,025,116.80	3,952,697.60	4,803,079.35	0.00	0.00	0.00	0.00	0.00	0.00	23,742,889.91

8,291.40	9,343.77	11,703.63	12,991.36	15,196.16	20,148.88	0.00	0.00	0.00	0.00	0.00	0.00	77,675.20

16,837.92	17,667.06	16,774.14	16,654.72	18,079.36	20,578.86	0.00	0.00	0.00	0.00	0.00	0.00	106,592.06

40,277.07	38,842.02	37,693.98	41,992.96	42,433.92	52,177.32	0.00	0.00	0.00	0.00	0.00	0.00	253,417.27

693,639.39	696,796.50	703,429.62	761,470.08	774,054.40	976,119.63	0.00	0.00	0.00	0.00	0.00	0.00	4,605,509.62

95.67	95.67	63.78	67.84	67.84	67.84	0.00	0.00	0.00	0.00	0.00	0.00	458.64

159.45	95.67	95.67	67.84	67.84	188.38	0.00	0.00	0.00	0.00	0.00	0.00	674.85

13,840.26	15,083.97	15,402.87	16,790.40	17,638.40	20,672.53	0.00	0.00	0.00	0.00	0.00	0.00	99,428.43

40,946.76	41,871.57	40,532.19	41,144.96	37,719.04	53,933.34	0.00	0.00	0.00	0.00	0.00	0.00	256,147.86

257,447.97	257,958.21	266,887.41	291,101.44	298,055.04	387,310.65	0.00	0.00	0.00	0.00	0.00	0.00	1,758,760.72

SUBTOTAL:

4,797,691.05

4,925,506.17	5,020,697.82	5,403,150.72	5,347,759.36	6,572,563.01	0.00	0.00	0.00	0.00	0.00	0.00	32,067,368.13

3300	AHC CARE EXPANDED FO
3310	AHC CARE EXPANDED
FO
3320	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	361.62	0.00	0.00	0.00	0.00	0.00	0.00	361.62

0.00	0.00	0.00	0.00	0.00	141,927.24	0.00	0.00	0.00	0.00	0.00	0.00	141,927.24

0.00	0.00	0.00	0.00	0.00	275.52	0.00	0.00	0.00	0.00	0.00	0.00	275.52

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	142,564.38	0.00	0.00	0.00	0.00	0.00	0.00	142,564.38

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending December 31, 2014

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

3600	AHC CARE EXPANDED FO
3610	AHC CARE EXPANDED
FO
3620	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	232.47	0.00	0.00	0.00	0.00	0.00	0.00	232.47

127.56	127.56	95.67	101.76	33.92	475,211.21	0.00	0.00	0.00	0.00	0.00	0.00	475,697.68

0.00	0.00	0.00	0.00	0.00	17.22	0.00	0.00	0.00	0.00	0.00	0.00	17.22

SUBTOTAL:

127.56

127.56

95.67	101.76	33.92	475,460.90	0.00	0.00	0.00	0.00	0.00	0.00	475,947.37

3500	ADULT 40-100% FOR FI	16,327.68	16,678.47	14,701.29	16,383.36	17,299.20	18,825.60	0.00	0.00	0.00	0.00	0.00	0.00	100,215.60

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	2,301,234.56	0.00	0.00	0.00	0.00	0.00	0.00	12,370,580.41

3520	ADULT 40-100% FOR FI	1,275.60	1,753.95	1,211.82	1,221.12	1,322.88	1,356.80	0.00	0.00	0.00	0.00	0.00	0.00	8,142.17

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	16,213.76	0.00	0.00	0.00	0.00	0.00	0.00	89,393.16

5,540,791.83	5,808,859.17	6,030,909.24	6,600,764.16	6,696,622.08	6,781,829.12	0.00	0.00	0.00	0.00	0.00	0.00	37,459,775.60

446.46	542.13	892.92	949.76	983.68	949.76	0.00	0.00	0.00	0.00	0.00	0.00	4,764.71

SUBTOTAL:

7,349,656.41

7,745,634.54	8,044,380.06	8,816,961.28	8,955,829.76	9,120,409.60	0.00	0.00	0.00	0.00	0.00	0.00	50,032,871.65

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	3,697.28	0.00	0.00	0.00	0.00	0.00	0.00	63,398.45

753,847.71	842,916.48	896,396.01	1,006,202.88	1,039,953.28	1,093,411.20	0.00	0.00	0.00	0.00	0.00	0.00	5,632,727.56

223.23	414.57	382.68	135.68	101.76	101.76	0.00	0.00	0.00	0.00	0.00	0.00	1,359.68

SUBTOTAL:

777,286.86

863,772.54	902,646.45	1,011,392.64	1,045,176.96	1,097,210.24	0.00	0.00	0.00	0.00	0.00	0.00	5,697,485.69

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	62,918.97	72,964.32	81,383.28	96,264.96	96,502.40	104,541.44	0.00	0.00	0.00	0.00	0.00	0.00		514,575.37	
	62,918.97	72,964.32	81,383.28	96,264.96	96,502.40	104,541.44	0.00	0.00	0.00	0.00	0.00	0.00	514,575.37	

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	13,202.56	0.00	0.00	0.00	0.00	0.00	0.00	65,156.70

1,466.94	1,466.94	1,435.05	1,492.48	1,560.32	2,050.57	0.00	0.00	0.00	0.00	0.00	0.00	9,472.30

SUBTOTAL:

11,703.63

11,576.07	11,639.85	12,211.20	12,245.12	15,253.13	0.00	0.00	0.00	0.00	0.00	0.00	74,629.00

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	33.92	0.00	0.00	0.00	0.00	0.00	0.00

197.43	
187,879.36	
33,191.90	
28,050.49	
249,319.18	

27,393.51	27,265.95	28,382.10	30,765.44	31,545.60	42,526.76	0.00	0.00	0.00	0.00	0.00	0.00

4,655.94	4,751.61	5,070.51	5,596.80	5,698.56	7,418.48	0.00	0.00	0.00	0.00	0.00	0.00

3,890.58	4,081.92	4,368.93	4,748.80	4,748.80	6,211.46	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

35,971.92

36,131.37	37,853.43	41,144.96	42,026.88	56,190.62	0.00	0.00	0.00	0.00	0.00

0.00

TOTAL:

22,170,884.70

22,956,207.84     23,514,282.84     25,414,051.20     25,392,376.32     29,935,107.78	0.00	0.00	0.00	0.00	0.00	0.00	149,382,910.68

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending December 31, 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	597.00	0.00	0.00	0.00	0.00	0.00	0.00	3,444.00

1010	TANF NON-MEDICARE	147,482.00	151,114.00	153,768.00	154,525.00	151,642.00	151,404.00	0.00	0.00	0.00	0.00	0.00	0.00	909,935.00

1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	169.00

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

4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	4,699.00	0.00	0.00	0.00	0.00	0.00	0.00	28,046.00

5,923.00	6,265.00	6,330.00	6,391.00	6,375.00	6,396.00	0.00	0.00	0.00	0.00	0.00	0.00	37,680.00

2120	SSI AGED WITH QMB	22,478.00	23,011.00	23,360.00	23,482.00	23,460.00	23,449.00	0.00	0.00	0.00	0.00	0.00	0.00	139,240.00

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	4,715.00	0.00	0.00	0.00	0.00	0.00	0.00	27,872.00

41,883.00	41,834.00	41,921.00	41,829.00	41,755.00	41,643.00	0.00	0.00	0.00	0.00	0.00	0.00	250,865.00

25,026.00	25,023.00	25,226.00	25,247.00	25,151.00	25,098.00	0.00	0.00	0.00	0.00	0.00	0.00	150,771.00

2300	SSI BLIND WITH MEDIC	36.00	37.00	34.00	36.00	37.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	217.00

2310	SSI BLIND NON-MEDIC A

428.00	426.00	425.00	424.00	422.00	428.00	0.00	0.00	0.00	0.00	0.00	0.00	2,553.00

2320	SSI BLIND WITH QMB	248.00	243.00	245.00	247.00	245.00	248.00	0.00	0.00	0.00	0.00	0.00	0.00	1,476.00

4300	SOBRA CHILD WITH ME D
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	19,163.00	0.00	0.00	0.00	0.00	0.00	0.00	118,054.00

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	53.00	0.00	0.00	0.00	0.00	0.00	0.00	298.00

13,724.00	13,811.00	13,824.00	13,578.00	13,182.00	12,987.00	0.00	0.00	0.00	0.00	0.00	0.00	81,106.00

5.00	4.00	6.00	5.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	38.00

SUBTOTAL:

286,470.00

291,643.00	295,252.00	295,779.00	291,651.00	290,971.00	0.00	0.00	0.00	0.00	0.00	0.00	1,751,766.00

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	5,621.00	0.00	0.00	0.00	0.00	0.00	0.00	33,979.00

111,246.00	115,026.00	117,472.00	118,665.00	116,530.00	115,938.00	0.00	0.00	0.00	0.00	0.00	0.00	694,877.00

260.00	293.00	367.00	383.00	448.00	527.00	0.00	0.00	0.00	0.00	0.00	0.00	2,278.00

528.00	554.00	526.00	491.00	533.00	528.00	0.00	0.00	0.00	0.00	0.00	0.00	3,160.00

1,263.00	1,218.00	1,182.00	1,238.00	1,251.00	1,257.00	0.00	0.00	0.00	0.00	0.00	0.00	7,409.00

21,751.00	21,850.00	22,058.00	22,449.00	22,820.00	23,256.00	0.00	0.00	0.00	0.00	0.00	0.00	134,184.00

3.00	3.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00

5.00	3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	17.00

434.00	473.00	483.00	495.00	520.00	530.00	0.00	0.00	0.00	0.00	0.00	0.00	2,935.00

1,284.00	1,313.00	1,271.00	1,213.00	1,112.00	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	7,219.00

8,073.00	8,089.00	8,369.00	8,582.00	8,787.00	9,027.00	0.00	0.00	0.00	0.00	0.00	0.00	50,927.00

SUBTOTAL:

150,445.00

154,453.00	157,438.00	159,291.00	157,658.00	157,714.00	0.00	0.00	0.00	0.00	0.00	0.00	936,999.00

3300	AHC CARE EXPANDED FO
3310	AHC CARE EXPANDED
FO
3320	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending December 31, 2014

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

3600	AHC CARE EXPANDED FO
3610	AHC CARE EXPANDED
FO
3620	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4.00	4.00	3.00	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

4.00

4.00

3.00	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	555.00	0.00	0.00	0.00	0.00	0.00	0.00	3,044.00

3510	ADULT 40-100% FOR FI	55,683.00	59,624.00	62,218.00	64,375.00	65,580.00	67,843.00	0.00	0.00	0.00	0.00	0.00	0.00	375,323.00

3520	ADULT 40-100% FOR FI	40.00	55.00	38.00	36.00	39.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	248.00

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	478.00	0.00	0.00	0.00	0.00	0.00	0.00	2,718.00

173,747.00	182,153.00	189,116.00	194,598.00	197,424.00	199,936.00	0.00	0.00	0.00	0.00	0.00	0.00	1,136,974.00

14.00	17.00	28.00	28.00	29.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	144.00

SUBTOTAL:

230,469.00

242,886.00	252,254.00	259,934.00	264,028.00	268,880.00	0.00	0.00	0.00	0.00	0.00	0.00	1,518,451.00

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	109.00	0.00	0.00	0.00	0.00	0.00	0.00	1,962.00

23,639.00	26,432.00	28,109.00	29,664.00	30,659.00	32,235.00	0.00	0.00	0.00	0.00	0.00	0.00	170,738.00

7.00	13.00	12.00	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00

SUBTOTAL:

24,374.00

27,086.00	28,305.00	29,817.00	30,813.00	32,347.00	0.00	0.00	0.00	0.00	0.00	0.00	172,742.00

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	0.00	0.00	0.00	0.00	0.00	0.00		15,578.00	
	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	0.00	0.00	0.00	0.00	0.00	0.00	15,578.00	

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

321.00	317.00	320.00	316.00	315.00	308.00	0.00	0.00	0.00	0.00	0.00	0.00	1,897.00

46.00	46.00	45.00	44.00	46.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	274.00

SUBTOTAL:

367.00

363.00	365.00	360.00	361.00	355.00	0.00	0.00	0.00	0.00	0.00	0.00	2,171.00

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	1.00	0.00	0.00	0.00	0.00	0.00	0.00

6.00	
5,381.00	
959.00	
809.00	
7,155.00	

859.00	855.00	890.00	907.00	930.00	940.00	0.00	0.00	0.00	0.00	0.00	0.00

146.00	149.00	159.00	165.00	168.00	172.00	0.00	0.00	0.00	0.00	0.00	0.00

122.00	128.00	137.00	140.00	140.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,128.00

1,133.00	1,187.00	1,213.00	1,239.00	1,255.00	0.00	0.00	0.00	0.00	0.00

0.00

TOTAL:	695,230.00	719,856.00	737,356.00	749,235.00	748,596.00	754,605.00	0.00	0.00	0.00	0.00	0.00	0.00	4,404,878.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending December 31, 2014

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

1000	TANF WITH MEDICARE	26,194.82	27,313.46	26,241.43	25,065.84	25,065.84	29,156.49	0.00	0.00	0.00	0.00	0.00	0.00	159,037.88

1010	TANF NON-MEDICARE	6,874,136.02	7,043,423.54	7,167,126.48	6,819,188.25	6,691,961.46	7,374,599.08	0.00	0.00	0.00	0.00	0.00	0.00	41,970,434.83

1020	TANF WITH QMB	745.76	838.98	1,072.03	1,323.90	1,676.94	2,039.32	0.00	0.00	0.00	0.00	0.00	0.00	7,696.93

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

213,846.68	216,503.45	218,461.07	208,602.51	207,411.00	227,555.43	0.00	0.00	0.00	0.00	0.00	0.00	1,292,380.14

276,071.03	292,011.65	295,041.30	282,034.83	281,328.75	307,675.40	0.00	0.00	0.00	0.00	0.00	0.00	1,734,162.96

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	1,134,131.89	0.00	0.00	0.00	0.00	0.00	0.00	6,414,734.24

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	228,910.55	0.00	0.00	0.00	0.00	0.00	0.00	1,285,154.64

1,952,166.63	1,949,882.74	1,953,937.81	1,845,913.77	1,842,648.15	2,075,888.63	0.00	0.00	0.00	0.00	0.00	0.00	11,620,437.73

1,166,461.86	1,166,322.03	1,175,783.86	1,114,150.11	1,109,913.63	1,250,656.34	0.00	0.00	0.00	0.00	0.00	0.00	6,983,287.83

2300	SSI BLIND WITH MEDIC	1,677.96	1,724.57	1,584.74	1,588.68	1,632.81	1,759.69	0.00	0.00	0.00	0.00	0.00	0.00	9,968.45

2310	SSI BLIND NON-MEDIC A

19,949.08	19,855.86	19,809.25	18,711.12	18,622.86	20,917.72	0.00	0.00	0.00	0.00	0.00	0.00	117,865.89

2320	SSI BLIND WITH QMB	11,559.28	11,326.23	11,419.45	10,900.11	10,811.85	12,183.76	0.00	0.00	0.00	0.00	0.00	0.00	68,200.68

4300	SOBRA CHILD WITH ME D
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	4.88	0.00	0.00	0.00	0.00	0.00	0.00	51.49

905,772.13	929,962.72	939,844.04	882,379.35	853,783.11	932,688.23	0.00	0.00	0.00	0.00	0.00	0.00	5,444,429.58

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	2,592.65	0.00	0.00	0.00	0.00	0.00	0.00	13,766.58

639,675.64	643,730.71	644,336.64	599,197.14	581,721.66	645,618.47	0.00	0.00	0.00	0.00	0.00	0.00	3,754,280.26

233.05	186.44	279.66	220.65	353.04	460.82	0.00	0.00	0.00	0.00	0.00	0.00	1,733.66

SUBTOTAL:

13,352,366.70

13,593,480.23     13,761,695.72     13,052,727.27     12,870,558.63     14,246,839.35	0.00	0.00	0.00	0.00	0.00	0.00	80,877,667.90

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	275,046.01	0.00	0.00	0.00	0.00	0.00	0.00	1,568,480.87

5,185,176.06	5,361,361.86	5,475,369.92	5,236,686.45	5,142,468.90	5,609,707.06	0.00	0.00	0.00	0.00	0.00	0.00	32,010,770.25

12,118.60	13,656.73	17,105.87	16,901.79	19,770.24	24,544.83	0.00	0.00	0.00	0.00	0.00	0.00	104,098.06

24,610.08	25,821.94	24,516.86	21,667.83	23,521.29	24,813.44	0.00	0.00	0.00	0.00	0.00	0.00	144,951.44

58,868.43	56,770.98	55,093.02	54,632.94	55,206.63	60,878.45	0.00	0.00	0.00	0.00	0.00	0.00	341,450.45

1,013,814.11	1,018,428.50	1,028,123.38	990,674.37	1,007,046.60	1,132,432.16	0.00	0.00	0.00	0.00	0.00	0.00	6,190,519.12

139.83	139.83	93.22	88.26	88.26	88.26	0.00	0.00	0.00	0.00	0.00	0.00	637.66

233.05	139.83	139.83	88.26	88.26	156.58	0.00	0.00	0.00	0.00	0.00	0.00	845.81

20,228.74	22,046.53	22,512.63	21,844.35	22,947.60	24,916.34	0.00	0.00	0.00	0.00	0.00	0.00	134,496.19

59,847.24	61,198.93	59,241.31	53,529.69	49,072.56	56,120.74	0.00	0.00	0.00	0.00	0.00	0.00	339,010.47

376,282.53	377,028.29	390,079.09	378,723.66	387,770.31	444,335.99	0.00	0.00	0.00	0.00	0.00	0.00	2,354,219.87

SUBTOTAL:

7,012,241.45

7,199,054.33	7,338,185.18	7,029,511.83	6,957,447.54	7,653,039.86	0.00	0.00	0.00	0.00	0.00	0.00	43,189,480.19

3300	AHC CARE EXPANDED FO
3310	AHC CARE EXPANDED
FO
3320	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	204.96	0.00	0.00	0.00	0.00	0.00	0.00	204.96

0.00	0.00	0.00	0.00	0.00	80,441.92	0.00	0.00	0.00	0.00	0.00	0.00	80,441.92

0.00	0.00	0.00	0.00	0.00	156.16	0.00	0.00	0.00	0.00	0.00	0.00	156.16

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	80,803.04	0.00	0.00	0.00	0.00	0.00	0.00	80,803.04

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending December 31, 2014

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

3600	AHC CARE EXPANDED FO
3610	AHC CARE EXPANDED
FO
3620	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	131.76	0.00	0.00	0.00	0.00	0.00	0.00	131.76

186.44	186.44	139.83	132.39	44.13	269,366.45	0.00	0.00	0.00	0.00	0.00	0.00	270,055.68

0.00	0.00	0.00	0.00	0.00	9.76	0.00	0.00	0.00	0.00	0.00	0.00	9.76

SUBTOTAL:

186.44

186.44	139.83	132.39	44.13	269,507.97	0.00	0.00	0.00	0.00	0.00	0.00	270,197.20

3500	ADULT 40-100% FOR FI	23,864.32	24,377.03	21,487.21	21,314.79	22,506.30	24,492.15	0.00	0.00	0.00	0.00	0.00	0.00	138,041.80

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	2,993,911.59	0.00	0.00	0.00	0.00	0.00	0.00	17,003,265.99

3520	ADULT 40-100% FOR FI	1,864.40	2,563.55	1,771.18	1,588.68	1,721.07	1,765.20	0.00	0.00	0.00	0.00	0.00	0.00	11,274.08

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	21,094.14	0.00	0.00	0.00	0.00	0.00	0.00	123,367.74

8,098,347.67	8,490,151.33	8,814,696.76	8,587,609.74	8,712,321.12	8,823,175.68	0.00	0.00	0.00	0.00	0.00	0.00	51,526,302.30

652.54	792.37	1,305.08	1,235.64	1,279.77	1,235.64	0.00	0.00	0.00	0.00	0.00	0.00	6,501.04

SUBTOTAL:

10,742,160.09

11,320,916.46     11,757,558.94     11,470,887.42     11,651,555.64     11,865,674.40	0.00	0.00	0.00	0.00	0.00	0.00	68,808,752.95

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	4,810.17	0.00	0.00	0.00	0.00	0.00	0.00	90,434.50

1,101,813.79	1,231,995.52	1,310,160.49	1,309,072.32	1,352,981.67	1,422,530.55	0.00	0.00	0.00	0.00	0.00	0.00	7,728,554.34

326.27	605.93	559.32	176.52	132.39	132.39	0.00	0.00	0.00	0.00	0.00	0.00	1,932.82

SUBTOTAL:

1,136,072.14

1,262,478.46	1,319,296.05	1,315,824.21	1,359,777.69	1,427,473.11	0.00	0.00	0.00	0.00	0.00	0.00	7,820,921.66

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	91,961.53	106,643.68	118,948.72	125,240.94	125,549.85	136,008.66	0.00	0.00	0.00	0.00	0.00	0.00		704,353.38	
	91,961.53	106,643.68	118,948.72	125,240.94	125,549.85	136,008.66	0.00	0.00	0.00	0.00	0.00	0.00	704,353.38	

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	15,153.64	0.00	0.00	0.00	0.00	0.00	0.00	87,652.05

2,144.06	2,144.06	2,097.45	1,941.72	2,029.98	2,332.75	0.00	0.00	0.00	0.00	0.00	0.00	12,690.02

SUBTOTAL:

17,105.87

16,919.43	17,012.65	15,886.80	15,930.93	17,486.39	0.00	0.00	0.00	0.00	0.00	0.00	100,342.07

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	44.13	0.00	0.00	0.00	0.00	0.00	0.00

272.22	
249,953.13	
44,344.51	
37,451.49	
332,021.35	

40,037.99	39,851.55	41,482.90	40,025.91	41,040.90	47,513.88	0.00	0.00	0.00	0.00	0.00	0.00

6,805.06	6,944.89	7,410.99	7,281.45	7,413.84	8,488.28	0.00	0.00	0.00	0.00	0.00	0.00

5,686.42	5,966.08	6,385.57	6,178.20	6,178.20	7,057.02	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

52,576.08

52,809.13	55,326.07	53,529.69	54,677.07	63,103.31	0.00	0.00	0.00	0.00	0.00

0.00

TOTAL:

32,404,670.30

33,552,488.16     34,368,163.16     33,063,740.55     33,035,541.48     35,759,936.09	0.00	0.00	0.00	0.00	0.00	0.00	202,184,539.74

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending December 31, 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	597.00	0.00	0.00	0.00	0.00	0.00	0.00	3,444.00

1010	TANF NON-MEDICARE	147,482.00	151,114.00	153,768.00	154,525.00	151,642.00	151,404.00	0.00	0.00	0.00	0.00	0.00	0.00	909,935.00

1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	169.00

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

4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	4,699.00	0.00	0.00	0.00	0.00	0.00	0.00	28,046.00

5,923.00	6,265.00	6,330.00	6,391.00	6,375.00	6,396.00	0.00	0.00	0.00	0.00	0.00	0.00	37,680.00

2120	SSI AGED WITH QMB	22,478.00	23,011.00	23,360.00	23,482.00	23,460.00	23,449.00	0.00	0.00	0.00	0.00	0.00	0.00	139,240.00

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	4,715.00	0.00	0.00	0.00	0.00	0.00	0.00	27,872.00

41,883.00	41,834.00	41,921.00	41,829.00	41,755.00	41,643.00	0.00	0.00	0.00	0.00	0.00	0.00	250,865.00

25,026.00	25,023.00	25,226.00	25,247.00	25,151.00	25,098.00	0.00	0.00	0.00	0.00	0.00	0.00	150,771.00

2300	SSI BLIND WITH MEDIC	36.00	37.00	34.00	36.00	37.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	217.00

2310	SSI BLIND NON-MEDIC A

428.00	426.00	425.00	424.00	422.00	428.00	0.00	0.00	0.00	0.00	0.00	0.00	2,553.00

2320	SSI BLIND WITH QMB	248.00	243.00	245.00	247.00	245.00	248.00	0.00	0.00	0.00	0.00	0.00	0.00	1,476.00

4300	SOBRA CHILD WITH ME D
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	19,163.00	0.00	0.00	0.00	0.00	0.00	0.00	118,054.00

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	53.00	0.00	0.00	0.00	0.00	0.00	0.00	298.00

13,724.00	13,811.00	13,824.00	13,578.00	13,182.00	12,987.00	0.00	0.00	0.00	0.00	0.00	0.00	81,106.00

5.00	4.00	6.00	5.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	38.00

SUBTOTAL:

286,470.00

291,643.00	295,252.00	295,779.00	291,651.00	290,971.00	0.00	0.00	0.00	0.00	0.00	0.00	1,751,766.00

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	5,621.00	0.00	0.00	0.00	0.00	0.00	0.00	33,979.00

111,246.00	115,026.00	117,472.00	118,665.00	116,530.00	115,938.00	0.00	0.00	0.00	0.00	0.00	0.00	694,877.00

260.00	293.00	367.00	383.00	448.00	527.00	0.00	0.00	0.00	0.00	0.00	0.00	2,278.00

528.00	554.00	526.00	491.00	533.00	528.00	0.00	0.00	0.00	0.00	0.00	0.00	3,160.00

1,263.00	1,218.00	1,182.00	1,238.00	1,251.00	1,257.00	0.00	0.00	0.00	0.00	0.00	0.00	7,409.00

21,751.00	21,850.00	22,058.00	22,449.00	22,820.00	23,256.00	0.00	0.00	0.00	0.00	0.00	0.00	134,184.00

3.00	3.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00

5.00	3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	17.00

434.00	473.00	483.00	495.00	520.00	530.00	0.00	0.00	0.00	0.00	0.00	0.00	2,935.00

1,284.00	1,313.00	1,271.00	1,213.00	1,112.00	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	7,219.00

8,073.00	8,089.00	8,369.00	8,582.00	8,787.00	9,027.00	0.00	0.00	0.00	0.00	0.00	0.00	50,927.00

SUBTOTAL:

150,445.00

154,453.00	157,438.00	159,291.00	157,658.00	157,714.00	0.00	0.00	0.00	0.00	0.00	0.00	936,999.00

3300	AHC CARE EXPANDED FO
3310	AHC CARE EXPANDED
FO
3320	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending December 31, 2014

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

3600	AHC CARE EXPANDED FO
3610	AHC CARE EXPANDED
FO
3620	AHC CARE EXPANDED
FO

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4.00	4.00	3.00	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

4.00

4.00

3.00	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	555.00	0.00	0.00	0.00	0.00	0.00	0.00	3,044.00

3510	ADULT 40-100% FOR FI	55,683.00	59,624.00	62,218.00	64,375.00	65,580.00	67,843.00	0.00	0.00	0.00	0.00	0.00	0.00	375,323.00

3520	ADULT 40-100% FOR FI	40.00	55.00	38.00	36.00	39.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	248.00

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	478.00	0.00	0.00	0.00	0.00	0.00	0.00	2,718.00

173,747.00	182,153.00	189,116.00	194,598.00	197,424.00	199,936.00	0.00	0.00	0.00	0.00	0.00	0.00	1,136,974.00

14.00	17.00	28.00	28.00	29.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	144.00

SUBTOTAL:

230,469.00

242,886.00	252,254.00	259,934.00	264,028.00	268,880.00	0.00	0.00	0.00	0.00	0.00	0.00	1,518,451.00

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	109.00	0.00	0.00	0.00	0.00	0.00	0.00	1,962.00

23,639.00	26,432.00	28,109.00	29,664.00	30,659.00	32,235.00	0.00	0.00	0.00	0.00	0.00	0.00	170,738.00

7.00	13.00	12.00	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00

SUBTOTAL:

24,374.00

27,086.00	28,305.00	29,817.00	30,813.00	32,347.00	0.00	0.00	0.00	0.00	0.00	0.00	172,742.00

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	0.00	0.00	0.00	0.00	0.00	0.00		15,578.00	
	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	0.00	0.00	0.00	0.00	0.00	0.00	15,578.00	

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

321.00	317.00	320.00	316.00	315.00	308.00	0.00	0.00	0.00	0.00	0.00	0.00	1,897.00

46.00	46.00	45.00	44.00	46.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	274.00

SUBTOTAL:

367.00

363.00	365.00	360.00	361.00	355.00	0.00	0.00	0.00	0.00	0.00	0.00	2,171.00

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	1.00	0.00	0.00	0.00	0.00	0.00	0.00

6.00	
5,381.00	
959.00	
809.00	
7,155.00	

859.00	855.00	890.00	907.00	930.00	940.00	0.00	0.00	0.00	0.00	0.00	0.00

146.00	149.00	159.00	165.00	168.00	172.00	0.00	0.00	0.00	0.00	0.00	0.00

122.00	128.00	137.00	140.00	140.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,128.00

1,133.00	1,187.00	1,213.00	1,239.00	1,255.00	0.00	0.00	0.00	0.00	0.00

0.00

TOTAL:	695,230.00	719,856.00	737,356.00	749,235.00	748,596.00	754,605.00	0.00	0.00	0.00	0.00	0.00	0.00	4,404,878.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending December 31, 2014

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

1010	TANF NON-MEDICARE	2,089,074.52	2,024,777.95	1,904,080.88	1,484,152.78	1,407,449.99	1,648,065.33	0.00	0.00	0.00	0.00	0.00	0.00	10,557,601.45

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	355,792.33	0.00	0.00	0.00	0.00	0.00	0.00	2,219,085.87

1,128.01	1,128.01	1,128.01	924.13	924.13	1,255.63	0.00	0.00	0.00	0.00	0.00	0.00	6,487.92

14,048,236.54    14,167,805.60     14,499,440.54     12,119,964.95     12,211,453.82     13,479,411.81	0.00	0.00	0.00	0.00	0.00	0.00	80,526,313.26

18,048.16	21,432.19	18,048.16	13,861.95	12,937.82	21,687.08	0.00	0.00	0.00	0.00	0.00	0.00	106,015.36

SUBTOTAL:

16,560,314.81

16,622,355.36     16,829,909.20     13,936,804.53     13,959,907.78     15,506,212.18	0.00	0.00	0.00	0.00	0.00	0.00	93,415,503.86

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	924.13	0.00	0.00	0.00	0.00	0.00	0.00	924.13

0.00	0.00	0.00	0.00	0.00	110.50	0.00	0.00	0.00	0.00	0.00	0.00	110.50

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	1,034.63	0.00	0.00	0.00	0.00	0.00	0.00	1,034.63

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	15,792.14	15,792.14	18,048.16	17,558.47	26,799.77	29,572.16	0.00	0.00	0.00	0.00	0.00	0.00		123,562.84	
	15,792.14	15,792.14	18,048.16	17,558.47	26,799.77	29,572.16	0.00	0.00	0.00	0.00	0.00	0.00	123,562.84	

16,576,106.95	16,638,147.50	16,847,957.36	13,954,363.00	13,986,707.55	15,536,818.97	0.00	0.00	0.00	0.00	0.00	0.00	93,540,101.33	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending December 31, 2014

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

1010	TANF NON-MEDICARE	1,852.00	1,795.00	1,688.00	1,606.00	1,523.00	1,395.00	0.00	0.00	0.00	0.00	0.00	0.00	9,859.00

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	341.00	0.00	0.00	0.00	0.00	0.00	0.00	2,119.00

1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

12,454.00	12,560.00	12,854.00	13,115.00	13,214.00	13,395.00	0.00	0.00	0.00	0.00	0.00	0.00	77,592.00

16.00	19.00	16.00	15.00	14.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	100.00

SUBTOTAL:

14,681.00

14,736.00	14,920.00	15,081.00	15,106.00	15,152.00	0.00	0.00	0.00	0.00	0.00	0.00	89,676.00

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	1.00	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	0.00	0.00	0.00

4410	SOBRA 100-133% FOR	14.00	14.00	16.00	19.00	29.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00		124.00	
	14.00	14.00	16.00	19.00	29.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	124.00	

SUBTOTAL:

0.00

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

F
SUBTOTAL:

TOTAL:	14,695.00	14,750.00	14,936.00	15,100.00	15,135.00	15,185.00	0.00	0.00	0.00	0.00	0.00	0.00	89,801.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending December 31, 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	502.99	0.00	0.00	0.00	0.00	0.00	0.00	2,466.47

1010	TANF NON-MEDICARE	0.00	123,517.50	122,560.00	128,262.45	128,262.45	129,268.43	0.00	0.00	0.00	0.00	0.00	0.00	631,870.83

1011	TANF <1 M & F NON-ME	0.00	12,975.87	13,933.37	18,298.97	17,379.05	18,298.97	0.00	0.00	0.00	0.00	0.00	0.00	80,886.23

1012	TANF 01-05 M & F NON	0.00	61,123.78	60,251.07	65,067.82	62,983.17	63,227.98	0.00	0.00	0.00	0.00	0.00	0.00	312,653.82

1013	TANF 06-13 M & F NON	0.00	63,038.78	61,602.53	67,655.46	65,901.68	64,736.95	0.00	0.00	0.00	0.00	0.00	0.00	322,935.40

1014	TANF 14-20 MALE NON-	0.00	13,170.26	13,170.26	13,513.88	14,850.73	16,101.52	0.00	0.00	0.00	0.00	0.00	0.00	70,806.65

1015	TANF 14-20 FEMALE N O

0.00	16,885.48	17,279.44	16,604.51	17,941.36	18,775.22	0.00	0.00	0.00	0.00	0.00	0.00	87,486.01

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	0.00	0.00	416.93

1017	TANF 21-44 FEMALE N O
2110	SSI AGED NON-MEDICA
R
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	416.93	0.00	0.00	0.00	0.00	0.00	0.00	416.93

0.00	393.96	393.96	416.93	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	2,038.71

0.00	3,266.46	3,745.21	5,446.83	7,961.78	6,955.80	0.00	0.00	0.00	0.00	0.00	0.00	27,376.08

0.00	2,861,956.87	2,859,338.74	3,012,217.32	3,020,265.16	3,016,989.04	0.00	0.00	0.00	0.00	0.00	0.00	14,770,767.13

0.00	16,980.63	17,065.42	15,003.64	16,009.62	18,021.58	0.00	0.00	0.00	0.00	0.00	0.00	83,080.89

2300	SSI BLIND WITH MEDIC	0.00	957.50	957.50	1,005.98	1,005.98	1,005.98	0.00	0.00	0.00	0.00	0.00	0.00	4,932.94

2310	SSI BLIND NON-MEDIC A

0.00	26,919.60	26,525.64	28,484.94	28,068.01	29,490.92	0.00	0.00	0.00	0.00	0.00	0.00	139,489.11

4311	SOBRA CHILD <1 M & F	0.00	16,357.11	16,187.53	20,827.29	20,827.29	20,165.55	0.00	0.00	0.00	0.00	0.00	0.00	94,364.77

4312	SOBRA CHILD 01-05 M	0.00	94,547.40	94,377.82	93,422.44	87,744.17	92,012.90	0.00	0.00	0.00	0.00	0.00	0.00	462,104.73

4313	SOBRA CHILD 06-13 M	0.00	75,058.24	83,730.54	90,119.58	92,303.66	88,954.85	0.00	0.00	0.00	0.00	0.00	0.00	430,166.87

4314	SOBRA CHILD 14-20 MA	0.00	19,284.41	20,466.29	22,408.95	19,735.25	19,907.37	0.00	0.00	0.00	0.00	0.00	0.00	101,802.27

4315	SOBRA CHILD 14-20 FE	0.00	23,957.13	24,435.88	24,003.98	24,090.04	25,096.02	0.00	0.00	0.00	0.00	0.00	0.00	121,583.05

5015	SOBRA PREG 14-20 FE M

0.00	1,351.46	872.71	919.92	919.92	919.92	0.00	0.00	0.00	0.00	0.00	0.00	4,983.93

SUBTOTAL:

0.00

3,432,221.19	3,437,372.66	3,624,183.88	3,627,169.24	3,631,682.78	0.00	0.00	0.00	0.00	0.00	0.00	17,752,629.75

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	416.93	416.93	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	416.93	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	833.86	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	833.86	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	2,501.58	0.00	0.00	0.00	0.00	0.00	0.	

833.86	
810.89	
5,676.23	
3,266.53	
10,587.51	

00

3514	ADULT 40-100% MALE 1	0.00	393.96	393.96	416.93	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	2,038.71

3515	ADULT 40-100% FEMAL E

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

3714	ADULT <40% EXP MALE	0.00	6,697.32	5,909.40	6,253.95	6,670.88	7,504.74	0.00	0.00	0.00	0.00	0.00	0.00	33,036.29

3715	ADULT <40% EXP FEM AL

0.00	3,939.60	4,727.52	4,586.23	3,752.37	4,586.23	0.00	0.00	0.00	0.00	0.00	0.00	21,591.95

3716	ADULT <40% EXP MALE	0.00	393.96	393.96	0.00	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	1,621.78

3717	ADULT <40% EXP FEM AL

0.00	787.92	787.92	833.86	833.86	833.86	0.00	0.00	0.00	0.00	0.00	0.00	4,077.42

SUBTOTAL:

0.00

12,212.76	12,212.76	12,090.97	12,507.90	13,758.69	0.00	0.00	0.00	0.00	0.00	0.00	62,783.08

4413	SOBRA 100-133% M&F
6

0.00	3,939.60	3,939.60	4,169.30	4,169.30	4,169.30	0.00	0.00	0.00	0.00	0.00	0.00	20,387.10

L
SUBTOTAL:	6

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4414	SOBRA 100-133% MALE	0.00	1,181.88	1,181.88	1,667.72	2,170.71	2,170.71	0.00	0.00	0.00	0.00	0.00	0.00		8,372.90		
4415	SOBRA 100-133% FEMA	0.00	1,181.88	1,181.88	1,667.72	1,250.79	1,250.79	0.00	0.00	0.00	0.00	0.00	0.00		6,533.06		
	0.00	6,303.36		6,303.3		7,504.74	7,590.80	7,590.80	0.00	0.00	0.00	0.00	0.00	0.00	35,293.06		

0.00	3,453,495.03	3,457,464.62	3,645,447.31	3,649,352.59	3,655,533.85	0.00	0.00	0.00	0.00	0.00	0.00	17,861,293.40	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending December 31, 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

1010	TANF NON-MEDICARE	0.00	258.00	256.00	255.00	255.00	257.00	0.00	0.00	0.00	0.00	0.00	0.00	1,281.00

1011	TANF <1 M & F NON-ME	0.00	31.00	33.00	41.00	39.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	185.00

1012	TANF 01-05 M & F NON	0.00	153.00	151.00	154.00	149.00	150.00	0.00	0.00	0.00	0.00	0.00	0.00	757.00

1013	TANF 06-13 M & F NON	0.00	157.00	154.00	160.00	156.00	153.00	0.00	0.00	0.00	0.00	0.00	0.00	780.00

1014	TANF 14-20 MALE NON-	0.00	33.00	33.00	32.00	35.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	171.00

1015	TANF 14-20 FEMALE N O

0.00	42.00	43.00	39.00	42.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	210.00

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

1017	TANF 21-44 FEMALE N O
2110	SSI AGED NON-MEDICA
R
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

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

0.00	7.00	8.00	11.00	16.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	56.00

0.00	6,066.00	6,060.00	6,074.00	6,090.00	6,084.00	0.00	0.00	0.00	0.00	0.00	0.00	30,374.00

0.00	36.00	36.00	30.00	32.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	170.00

2300	SSI BLIND WITH MEDIC	0.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00

2310	SSI BLIND NON-MEDIC A

0.00	58.00	57.00	58.00	57.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	290.00

4311	SOBRA CHILD <1 M & F	0.00	37.00	37.00	45.00	45.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	207.00

4312	SOBRA CHILD 01-05 M	0.00	209.00	209.00	196.00	183.00	192.00	0.00	0.00	0.00	0.00	0.00	0.00	989.00

4313	SOBRA CHILD 06-13 M	0.00	169.00	188.00	192.00	196.00	189.00	0.00	0.00	0.00	0.00	0.00	0.00	934.00

4314	SOBRA CHILD 14-20 MA	0.00	44.00	47.00	49.00	43.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	226.00

4315	SOBRA CHILD 14-20 FE	0.00	55.00	56.00	52.00	52.00	54.00	0.00	0.00	0.00	0.00	0.00	0.00	269.00

5015	SOBRA PREG 14-20 FE M

0.00	3.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00

SUBTOTAL:

0.00

7,362.00	7,374.00	7,394.00	7,396.00	7,406.00	0.00	0.00	0.00	0.00	0.00	0.00	36,932.00

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	1.00	1.00	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	1.00	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	2.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	7.00	4.00	4.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.	

2.00	
2.00	
14.00	
8.00	
26.00	

00

3514	ADULT 40-100% MALE 1	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

3515	ADULT 40-100% FEMAL E

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

3714	ADULT <40% EXP MALE	0.00	17.00	15.00	15.00	16.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	81.00

3715	ADULT <40% EXP FEM AL

0.00	10.00	12.00	11.00	9.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	53.00

3716	ADULT <40% EXP MALE	0.00	1.00	1.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

3717	ADULT <40% EXP FEM AL

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

SUBTOTAL:

0.00

31.00	31.00	29.00	30.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	154.00

4413	SOBRA 100-133% M&F
6

0.00	10.00	10.00	10.00	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	50.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4414	SOBRA 100-133% MALE	0.00	3.00	3.00	4.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
4415	SOBRA 100-133% FEMA	0.00	3.00	3.00	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
	0.00	16.00		16.0		18.00	18.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	86.00		

L
SUBTOTAL:	0

TOTAL:	0.00	7,416.00	7,425.00	7,445.00	7,449.00	7,463.00	0.00	0.00	0.00	0.00	0.00	0.00	37,198.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2014

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

1006	TANF 21-44 MALE WITH	21,876.52	7,574.57	5,945.37	12,215.07	7,565.09	9,755.64	0.00	0.00	0.00	0.00	0.00	0.00	64,932.26

1007	TANF 21-44 FEMALE WI	23,137.76	17,832.63	43,923.29	20,080.22	22,545.94	14,940.01	0.00	0.00	0.00	0.00	0.00	0.00	142,459.85

1008	TANF 45-64 M & F WIT	23,169.55	9,761.50	10,844.20	14,232.62	6,557.48	3,005.89	0.00	0.00	0.00	0.00	0.00	0.00	67,571.24

1009	TANF 65+ M & F WITH	3,332.06	859.77	638.60	2,223.59	1,402.46	1,700.77	0.00	0.00	0.00	0.00	0.00	0.00	10,157.25

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	1,949,460.76	0.00	0.00	0.00	0.00	0.00	0.00	10,867,267.41

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	2,719,473.15	0.00	0.00	0.00	0.00	0.00	0.00	16,226,938.64

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	4,369,799.58	0.00	0.00	0.00	0.00	0.00	0.00	25,199,560.31

1014	TANF 14-20 MALE NON-	1,022,564.58	882,263.46	830,955.05	729,314.57	796,704.40	922,510.81	0.00	0.00	0.00	0.00	0.00	0.00	5,184,312.87

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	1,296,602.23	0.00	0.00	0.00	0.00	0.00	0.00	8,087,147.28

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	1,504,568.33	0.00	0.00	0.00	0.00	0.00	0.00	9,373,164.16

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	7,538,982.52	0.00	0.00	0.00	0.00	0.00	0.00	43,781,873.97

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	2,145,509.05	0.00	0.00	0.00	0.00	0.00	0.00	12,387,785.18

1019	TANF 65+ M & F NON-M	3,798.00	5,899.99	3,421.07	4,575.21	3,131.14	6,765.82	0.00	0.00	0.00	0.00	0.00	0.00	27,591.23

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	3,602.33	0.00	0.00	0.00	0.00	0.00	0.00	10,697.77

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

112,069.05	103,882.05	140,484.93	100,297.57	77,397.17	103,109.29	0.00	0.00	0.00	0.00	0.00	0.00	637,240.06

179,464.34	152,722.12	161,825.86	180,615.64	163,448.68	230,859.65	0.00	0.00	0.00	0.00	0.00	0.00	1,068,936.29

2120	SSI AGED WITH QMB	504,498.36	451,023.64	458,040.53	525,035.77	405,416.73	525,150.24	0.00	0.00	0.00	0.00	0.00	0.00	2,869,165.27

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	441,710.57	0.00	0.00	0.00	0.00	0.00	0.00	2,101,640.35

9,192,572.30	8,115,791.88	8,638,107.12	8,116,472.87	7,615,207.99	8,735,597.68	0.00	0.00	0.00	0.00	0.00	0.00	50,413,749.84

1,557,854.20	1,144,568.81	1,176,467.90	1,432,747.51	1,018,249.58	1,449,274.39	0.00	0.00	0.00	0.00	0.00	0.00	7,779,162.39

2300	SSI BLIND WITH MEDIC	2,028.97	1,798.82	712.93	779.03	1,792.91	2,233.24	0.00	0.00	0.00	0.00	0.00	0.00	9,345.90

2310	SSI BLIND NON-MEDIC A

119,577.24	87,006.17	112,595.00	124,841.37	81,261.78	134,625.27	0.00	0.00	0.00	0.00	0.00	0.00	659,906.83

2320	SSI BLIND WITH QMB	22,834.90	18,680.13	11,066.96	14,435.28	15,566.43	17,746.70	0.00	0.00	0.00	0.00	0.00	0.00	100,330.40

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	2,071,849.28	0.00	0.00	0.00	0.00	0.00	0.00	12,125,734.00

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	1,520,562.75	0.00	0.00	0.00	0.00	0.00	0.00	8,702,313.86

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	2,009,460.22	0.00	0.00	0.00	0.00	0.00	0.00	11,769,872.24

4314	SOBRA CHILD 14-20 MA	931,900.37	820,506.24	855,134.37	647,871.48	790,168.58	957,728.71	0.00	0.00	0.00	0.00	0.00	0.00	5,003,309.75

4315	SOBRA CHILD 14-20 FE	1,397,957.59	958,099.85	992,718.92	866,292.47	1,081,265.26	1,151,447.28	0.00	0.00	0.00	0.00	0.00	0.00	6,447,781.37

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	1,899.64	0.00	0.00	0.00	0.00	0.00	0.00	5,105.83

485,491.24	423,602.92	427,141.69	320,730.37	359,622.33	356,962.43	0.00	0.00	0.00	0.00	0.00	0.00	2,373,550.98

1,579,257.75	1,309,225.62	1,576,807.86	1,308,394.70	1,188,511.62	1,456,348.89	0.00	0.00	0.00	0.00	0.00	0.00	8,418,546.44

-16,663.69	3,520.34	3,457.60	2,564.54	2,644.47	1,594.61	0.00	0.00	0.00	0.00	0.00	0.00	-2,882.13

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 December 31, 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	43,654,837.73	0.00	0.00	0.00	0.00	0.00	0.00	251,926,660.77		

1106	TANF EXPANDED 21-44	27,367.94	12,614.40	10,427.70	24,113.60	23,226.98	31,363.67	0.00	0.00	0.00	0.00	0.00	0.00	129,114.29

1107	TANF EXPANDED 21-44	44,839.69	28,542.92	25,156.80	38,488.24	24,965.37	45,986.73	0.00	0.00	0.00	0.00	0.00	0.00	207,979.75

1108	TANF EXPANDED 45-64	101,282.81	76,431.82	88,146.44	95,565.29	69,054.35	114,865.77	0.00	0.00	0.00	0.00	0.00	0.00	545,346.48

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	23,180.75	0.00	0.00	0.00	0.00	0.00	0.00	167,172.73

390.77	148.71	0.00	0.00	830.08	342.00	0.00	0.00	0.00	0.00	0.00	0.00	1,711.56

1112	TANF EXPANDED 01-05	13,437.17	10,204.60	16,836.91	8,288.80	9,240.13	9,917.31	0.00	0.00	0.00	0.00	0.00	0.00	67,924.92

1113	TANF EXPANDED 06-13	57,770.47	48,403.09	59,938.89	59,164.05	62,574.48	58,490.38	0.00	0.00	0.00	0.00	0.00	0.00	346,341.36

1114	TANF EXPANDED 14-20	24,761.78	17,015.17	21,300.11	19,559.85	23,327.49	25,498.74	0.00	0.00	0.00	0.00	0.00	0.00	131,463.14

1115	TANF EXPANDED 14-20	57,511.45	71,816.30	60,997.19	47,691.85	56,330.58	51,051.81	0.00	0.00	0.00	0.00	0.00	0.00	345,399.18

1116	TANF EXPANDED 21-44	796,257.60	738,761.31	908,020.34	729,904.03	703,394.58	874,936.78	0.00	0.00	0.00	0.00	0.00	0.00	4,751,274.64

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	1,875,151.82	0.00	0.00	0.00	0.00	0.00	0.00	11,184,105.24

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	1,361,694.59	0.00	0.00	0.00	0.00	0.00	0.00	7,122,000.60

1119	TANF EXPANDED 65+ M&

2,554.51	4,344.81	1,345.01	12,070.16	2,076.31	5,155.06	0.00	0.00	0.00	0.00	0.00	0.00	27,545.86

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	8.72	0.00	0.00	0.00	0.00	0.00	0.00	493.32

1128	TANF EXPANDED 45-64	9,482.43	4,293.81	9,336.06	14,285.20	3,361.88	9,472.80	0.00	0.00	0.00	0.00	0.00	0.00	50,232.18

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	2,467.29	0.00	0.00	0.00	0.00	0.00	0.00	26,668.46

21,197.10	14,263.07	31,200.01	36,552.07	23,674.18	26,863.52	0.00	0.00	0.00	0.00	0.00	0.00	153,749.95

147,386.35	121,937.93	114,828.74	75,978.09	76,263.80	75,346.32	0.00	0.00	0.00	0.00	0.00	0.00	611,741.23

470,852.93	408,920.65	374,872.37	511,594.90	380,311.41	457,177.15	0.00	0.00	0.00	0.00	0.00	0.00	2,603,729.41

-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	16,690.93	0.00	0.00	0.00	0.00	0.00	0.00	72,149.39

107,386.52	106,898.65	76,899.90	89,852.33	79,337.60	124,985.71	0.00	0.00	0.00	0.00	0.00	0.00	585,360.71

231,908.23	184,557.12	168,972.41	224,275.77	164,347.57	231,635.24	0.00	0.00	0.00	0.00	0.00	0.00	1,205,696.34

SUBTOTAL:

5,257,823.19

4,852,424.32	5,303,323.77	4,960,750.17	4,540,343.62	5,422,283.09	0.00	0.00	0.00	0.00	0.00	0.00	30,336,948.16

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	-616.71	0.00	0.00	0.00	0.00	0.00	0.00	5,366.66

3317	AHC CARE FEMALE 21-
4

793.70	1,980.00	-1,001.17	0.00	-10.25	-663.15	0.00	0.00	0.00	0.00	0.00	0.00	1,099.13

3318	AHC CARE M&F 45-64 N	11,478.24	20,380.93	3,310.82	1,464.51	100.85	650.05	0.00	0.00	0.00	0.00	0.00	0.00	37,385.40

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	-629.81	0.00	0.00	0.00	0.00	0.00	0.00	43,898.06

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	-1,377.33	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

-2,086.46

45.74
2

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 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	376.14	0.00	0.00	0.00	0.00	0.00	0.00	15,427.32

3615	AHC CARE/MI FEMALE
1

7,211.81	1,363.64	773.45	2,378.64	429.84	83.02	0.00	0.00	0.00	0.00	0.00	0.00	12,240.40

3616	AHC CARE/MI MALE 21-	20,576.90	24,442.36	15,689.92	16,319.52	2,550.05	32,295.32	0.00	0.00	0.00	0.00	0.00	0.00	111,874.07

3617	AHC CARE/MI FEMALE
2

-6,005.41	61,825.29	935.30	15,317.50	2,067.95	-937.02	0.00	0.00	0.00	0.00	0.00	0.00	73,203.61

3618	AHC CARE/MI M&F 45-6	103,003.33	130,002.99	4,642.03	26,880.13	-8,878.11	1,847.46	0.00	0.00	0.00	0.00	0.00	0.00	257,497.83

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	32,287.59	0.00	0.00	0.00	0.00	0.00	0.00	476,375.78

3506	ADULT 40-100% MALE 2	684.00	3,580.48	1,303.73	3,103.25	3,193.53	1,838.90	0.00	0.00	0.00	0.00	0.00	0.00	13,703.89

3507	ADULT 40-100% FEMAL E

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	14,220.83	0.00	0.00	0.00	0.00	0.00	0.00	142,415.44

3509	ADULT 40-100% M&F 65	7,038.51	3,738.82	2,054.88	94.34	-53.02	2,462.77	0.00	0.00	0.00	0.00	0.00	0.00	15,336.30

3514	ADULT 40-100% MALE 1	12,687.18	16,373.68	22,458.35	8,580.44	8,918.07	20,901.71	0.00	0.00	0.00	0.00	0.00	0.00	89,919.43

3515	ADULT 40-100% FEMAL E

32,086.25	36,991.08	45,390.22	98,253.80	32,669.80	31,839.90	0.00	0.00	0.00	0.00	0.00	0.00	277,231.05

3516	ADULT 40-100% MALE 2	305,234.79	351,770.07	576,346.80	465,211.13	437,893.25	398,521.83	0.00	0.00	0.00	0.00	0.00	0.00	2,534,977.87

3517	ADULT 40-100% FEMAL E

436,287.52	386,457.94	478,010.90	423,309.93	426,762.12	494,193.60	0.00	0.00	0.00	0.00	0.00	0.00	2,645,022.01

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	1,672,378.22	0.00	0.00	0.00	0.00	0.00	0.00	8,985,805.63

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	935.15	0.00	0.00	0.00	0.00	0.00	0.00	1,157.34

3529	ADULT 40-100% M&F 65	192.12	71.86	424.98	0.00	93.17	57.11	0.00	0.00	0.00	0.00	0.00	0.00	839.24

3706	ADULT <40% EXP MALE	1,792.92	1,968.09	902.92	316.42	110.71	2,629.57	0.00	0.00	0.00	0.00	0.00	0.00	7,720.63

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

2,767.07	1,278.08	-370.33	3,691.15	918.46	6,145.09	0.00	0.00	0.00	0.00	0.00	0.00	14,429.52

42,387.39	19,031.85	18,960.72	46,284.65	13,203.70	16,691.36	0.00	0.00	0.00	0.00	0.00	0.00	156,559.67

3,535.49	168.39	1,548.60	1,648.72	1,389.56	684.26	0.00	0.00	0.00	0.00	0.00	0.00	8,975.02

3714	ADULT <40% EXP MALE	347,633.63	347,324.94	317,071.70	269,612.77	314,440.60	359,189.97	0.00	0.00	0.00	0.00	0.00	0.00	1,955,273.61

3715	ADULT <40% EXP FEM AL

438,080.79	431,929.74	423,714.83	416,138.04	313,484.58	395,707.36	0.00	0.00	0.00	0.00	0.00	0.00	2,419,055.34

3716	ADULT <40% EXP MALE	6,263,512.29	5,519,096.64	5,963,654.37	5,617,859.72	5,103,187.41	5,865,815.73	0.00	0.00	0.00	0.00	0.00	0.00	34,333,126.16

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

3,575,464.37	3,382,124.05	3,905,064.56	3,334,687.58	3,112,141.29	3,454,030.29	0.00	0.00	0.00	0.00	0.00	0.00	20,763,512.14

7,929,765.21	6,957,856.36	8,103,595.28	7,102,447.58	7,155,297.54	7,897,153.90	0.00	0.00	0.00	0.00	0.00	0.00	45,146,115.87

3,910.92	3,664.70	41,258.90	8,231.44	11,930.57	8,451.44	0.00	0.00	0.00	0.00	0.00	0.00	77,447.97

3726	ADULT <40% EXP MALE	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

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

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	2,345.84	0.00	0.00	0.00	0.00	0.00	0.00	14,264.57

SUBTOTAL:

20,863,498.73

18,991,478.51     21,575,506.02     19,207,914.01     18,324,271.37     20,646,194.83	0.00	0.00	0.00	0.00	0.00	0.00	119,608,863.47

3906	NEWLY ELIGIBLE MALE	282.87	244.78	3,954.66	845.41	701.91	236.40	0.00	0.00	0.00	0.00	0.00	0.00	

6,266.03

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 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	2,485.02	0.00	0.00	0.00	0.00	0.00	0.00	5,420.15

36,628.12	26,922.19	16,205.75	17,898.74	3,618.14	12,067.32	0.00	0.00	0.00	0.00	0.00	0.00	113,340.26

735.29	4,495.57	6,089.30	2,028.30	2,167.62	342.00	0.00	0.00	0.00	0.00	0.00	0.00	15,858.08

3914	NEWLY ELIGIBLE MALE	4,432.09	7,350.77	4,425.47	2,808.00	1,742.16	2,107.98	0.00	0.00	0.00	0.00	0.00	0.00	22,866.47

3915	NEWLY ELIGIBLE FEMA L

8,684.59	8,570.78	11,952.24	18,573.34	12,779.98	12,708.05	0.00	0.00	0.00	0.00	0.00	0.00	73,268.98

3916	NEWLY ELIGIBLE MALE	190,656.56	140,972.52	172,124.15	179,726.97	158,777.12	227,695.34	0.00	0.00	0.00	0.00	0.00	0.00	1,069,952.66

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	232,362.08	0.00	0.00	0.00	0.00	0.00	0.00	1,144,473.26

668,831.27	599,382.33	855,754.73	702,966.02	618,574.51	782,636.29	0.00	0.00	0.00	0.00	0.00	0.00	4,228,145.15

1,429.82	731.49	342.00	342.00	684.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	3,871.31

0.00	0.00	1,828.80	0.00	0.00	81.04	0.00	0.00	0.00	0.00	0.00	0.00	1,909.84

SUBTOTAL:

1,065,235.26

970,724.70	1,334,263.95	1,086,739.50	955,345.26	1,273,063.52	0.00	0.00	0.00	0.00	0.00	0.00	6,685,372.19

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	342.00	0.00	0.00	0.00	0.00	0.00	0.00	11,825.13

235,987.47	238,080.25	286,276.53	229,804.63	264,183.88	304,736.60	0.00	0.00	0.00	0.00	0.00	0.00	1,559,069.36

4414	SOBRA 100-133% MALE	85,340.26	87,080.59	94,321.88	83,076.40	84,875.99	136,385.23	0.00	0.00	0.00	0.00	0.00	0.00	571,080.35

4415	SOBRA 100-133% FEMA L

113,390.65	105,222.91	136,439.88	96,722.72	157,919.51	127,832.08	0.00	0.00	0.00	0.00	0.00	0.00	737,527.75

SUBTOTAL:

439,695.94

432,777.75	518,755.86	410,971.75	508,005.38	569,295.91	0.00	0.00	0.00	0.00	0.00	0.00	2,879,502.59

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	5,195.38	0.00	0.00	0.00	0.00	0.00	0.00	9,251.38

40,445.07	20,543.90	18,293.18	13,540.70	26,903.84	32,443.64	0.00	0.00	0.00	0.00	0.00	0.00	152,170.33

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	37,639.02	0.00	0.00	0.00	0.00	0.00	0.00	165,069.22

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	2,695.31	0.00	0.00	0.00	0.00	0.00	0.00	21,325.66

2,758.57	2,394.00	2,736.00	2,775.74	1,026.00	3,684.21	0.00	0.00	0.00	0.00	0.00	0.00	15,374.52

266.39	131.57	188.92	230.40	600.19	313.77	0.00	0.00	0.00	0.00	0.00	0.00	1,731.24

SUBTOTAL:

6,972.31

8,513.48	7,267.82	4,511.35	4,473.17	6,693.29	0.00	0.00	0.00	0.00	0.00	0.00	38,431.42

73,620,949.02	65,361,610.46	72,510,278.80	65,830,204.53	63,196,413.68	71,641,665.17	0.00	0.00	0.00	0.00	0.00	0.00	412,161,121.66	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending December 31, 2014

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

1011	TANF <1 M & F NON-ME	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	48.77	0.00	0.00	0.00	0.00	0.00	0.00	520.44

1015	TANF 14-20 FEMALE N O

4,556.11	2,141.99	9,981.62	5,621.37	4,798.61	1,890.72	0.00	0.00	0.00	0.00	0.00	0.00	28,990.42

1016	TANF 21-44 MALE NON-	2,387.41	9,567.79	17,302.15	13,267.56	35,827.77	20,290.01	0.00	0.00	0.00	0.00	0.00	0.00	98,642.69

1017	TANF 21-44 FEMALE N O

4,275.74	56,487.23	53,988.90	128,188.32	57,311.13	75,132.29	0.00	0.00	0.00	0.00	0.00	0.00	375,383.61

1018	TANF 45-64 M & F NON	624.62	13,353.85	27,439.42	40,475.30	7,025.75	13,426.28	0.00	0.00	0.00	0.00	0.00	0.00	102,345.22

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

922.64	226.91	3,074.97	4,272.30	2,918.09	5,445.46	0.00	0.00	0.00	0.00	0.00	0.00	16,860.37

3,789.39	1,046.16	4,455.25	5,266.94	3,072.79	6,876.52	0.00	0.00	0.00	0.00	0.00	0.00	24,507.05

2120	SSI AGED WITH QMB	0.00	0.00	43.35	27.25	0.00	402.08	0.00	0.00	0.00	0.00	0.00	0.00	472.68

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	3,154.15	0.00	0.00	0.00	0.00	0.00	0.00	9,609.92

4,511.70	7,150.54	20,268.15	15,221.00	9,243.14	31,138.01	0.00	0.00	0.00	0.00	0.00	0.00	87,532.54

0.00	0.00	60.89	35.65	0.00	5.28	0.00	0.00	0.00	0.00	0.00	0.00	101.82

4311	SOBRA CHILD <1 M & F	15,885.00	10,600.80	28,405.64	12,784.46	21,118.59	22,160.24	0.00	0.00	0.00	0.00	0.00	0.00	110,954.73

4312	SOBRA CHILD 01-05 M	2,904.79	7,758.18	15,385.96	12,507.49	16,211.93	17,380.55	0.00	0.00	0.00	0.00	0.00	0.00	72,148.90

4313	SOBRA CHILD 06-13 M	555.73	16,453.57	21,123.59	8,585.74	9,363.97	7,859.27	0.00	0.00	0.00	0.00	0.00	0.00	63,941.87

4314	SOBRA CHILD 14-20 MA	617.95	3,921.06	15,040.43	9,192.10	37,618.64	5,635.75	0.00	0.00	0.00	0.00	0.00	0.00	72,025.93

4315	SOBRA CHILD 14-20 FE	381.31	4,618.73	9,526.84	11,858.83	42,202.80	20,233.43	0.00	0.00	0.00	0.00	0.00	0.00	88,821.94

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

0.00	0.00	0.00	0.00	0.00	448.06	0.00	0.00	0.00	0.00	0.00	0.00	448.06

1,449.77	842.30	13,180.05	7,897.65	6,334.28	10,134.33	0.00	0.00	0.00	0.00	0.00	0.00	39,838.38

10,432.36	23,430.15	28,335.79	14,201.19	26,830.86	33,564.95	0.00	0.00	0.00	0.00	0.00	0.00	136,795.30

0.00	0.00	0.00	0.00	0.00	1,671.81	0.00	0.00	0.00	0.00	0.00	0.00	1,671.81

SUBTOTAL:

53,294.52

157,635.55	269,130.99	293,245.96	282,045.72	276,897.96	0.00	0.00	0.00	0.00	0.00	0.00	1,332,250.70

1.85	
1,084.91	
6,442.07	
50,727.51	
153,077.56	
17,868.48	
29,984.76	
4,706.71	
2,148.09	
13,440.97	
9,080.14	
1,062.20	

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

1109	TANF EXPANDED 65+ M&

0.00	0.00	0.00	0.00	634.57	450.34	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	0.00	5,776.18	9.61	70.12	586.16	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	275.40	10,001.59	4,198.14	5,442.76	12,230.81	18,578.81	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	2,783.56	10,043.43	84,042.94	12,470.25	16,085.20	27,652.18	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	179.28	1,406.71	3,613.34	1,796.85	5,400.19	5,472.11	0.00	0.00	0.00	0.00	0.00	0.00

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	5,595.18	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	549.49	4,157.22	0.00	0.00	0.00	0.00	0.00	0.00

73.59	17.48	29.02	715.75	860.83	451.42	0.00	0.00	0.00	0.00	0.00	0.00

285.27	275.92	826.59	5,724.38	747.90	5,580.91	0.00	0.00	0.00	0.00	0.00	0.00

0.00	985.61	2,246.18	2,538.65	2,363.17	946.53	0.00	0.00	0.00	0.00	0.00	0.00

11.55	0.00	136.55	8.67	826.47	78.96	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	3,630.12	27,899.45	103,708.25	37,878.11	46,959.50	69,549.82	0.00	0.00	0.00	0.00	0.00	0.00	289,625.25		

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

3514	ADULT 40-100% MALE 1	171.21	3,225.92	147.79	144.57	774.92	3,726.75	0.00	0.00	0.00	0.00	0.00	0.00	8,191.16

3515	ADULT 40-100% FEMAL E

0.00	439.63	3,768.03	1,871.01	11,838.80	1,390.18	0.00	0.00	0.00	0.00	0.00	0.00	19,307.65

3516	ADULT 40-100% MALE 2	247.60	2,157.04	12,408.98	7,765.36	20,089.45	11,926.07	0.00	0.00	0.00	0.00	0.00	0.00	54,594.50

3517	ADULT 40-100% FEMAL E

1,176.50	5,293.82	12,225.76	5,188.29	13,161.94	14,278.15	0.00	0.00	0.00	0.00	0.00	0.00	51,324.46

3518	ADULT 40-100% M&F 45	8,542.82	41,548.55	34,573.67	29,729.55	26,645.76	76,842.48	0.00	0.00	0.00	0.00	0.00	0.00	217,882.83

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	93.40	0.00	0.00	0.00	0.00	0.00	0.00	93.40

3714	ADULT <40% EXP MALE	0.00	1,327.29	1,482.68	10,022.27	7,462.66	6,584.44	0.00	0.00	0.00	0.00	0.00	0.00	26,879.34

3715	ADULT <40% EXP FEM AL

376.67	4,178.34	3,217.57	14,484.38	9,919.13	11,695.72	0.00	0.00	0.00	0.00	0.00	0.00	43,871.81

3716	ADULT <40% EXP MALE	6,067.34	85,317.95	190,168.66	239,964.51	242,409.34	353,486.46	0.00	0.00	0.00	0.00	0.00	0.00	1,117,414.26

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

2,907.86	29,170.77	55,381.77	123,684.49	99,596.39	116,908.79	0.00	0.00	0.00	0.00	0.00	0.00	427,650.07

28,847.18	115,592.61	182,495.36	255,086.77	332,583.15	340,182.67	0.00	0.00	0.00	0.00	0.00	0.00	1,254,787.74

SUBTOTAL:

48,337.18

288,251.92	496,322.01	688,306.95	764,481.54	937,115.11	0.00	0.00	0.00	0.00	0.00	0.00	3,222,814.71

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

0.00	0.00	0.00	0.00	0.00	1,148.98	0.00	0.00	0.00	0.00	0.00	0.00	1,148.98

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	1,208.21	0.00	0.00	0.00	0.00	0.00	0.00	1,867.29

3915	NEWLY ELIGIBLE FEMA L

0.00	887.29	164.59	0.00	6,134.20	2,882.87	0.00	0.00	0.00	0.00	0.00	0.00	10,068.95

3916	NEWLY ELIGIBLE MALE	2,219.12	5,544.41	9,292.86	24,648.69	7,777.48	24,322.11	0.00	0.00	0.00	0.00	0.00	0.00	73,804.67

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	16,133.68	0.00	0.00	0.00	0.00	0.00	0.00	117,056.32

3,025.43	23,641.19	61,731.84	40,358.62	28,980.47	45,443.97	0.00	0.00	0.00	0.00	0.00	0.00	203,181.52

SUBTOTAL:

8,502.30

36,285.56	94,224.21	115,697.73	61,347.54	91,139.82	0.00	0.00	0.00	0.00	0.00	0.00	407,197.16

4413	SOBRA 100-133% M&F
6

2,402.45	3,556.80	758.88	1,511.11	4,010.82	372.96	0.00	0.00	0.00	0.00	0.00	0.00	12,613.02

4414	SOBRA 100-133% MALE	1,368.00	0.00	115.26	4,802.82	3,639.31	513.21	0.00	0.00	0.00	0.00	0.00	0.00	10,438.60

4415	SOBRA 100-133% FEMA L

0.00	1,932.86	2,685.30	0.00	500.44	747.39	0.00	0.00	0.00	0.00	0.00	0.00	5,865.99

SUBTOTAL:

3,770.45

5,489.66	3,559.44	6,313.93	8,150.57	1,633.56	0.00	0.00	0.00	0.00	0.00	0.00	28,917.61

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M

217.38	148.32	34.58	47.33	0.00	218.10	0.00	0.00	0.00	0.00	0.00	0.00	665.71

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	218.10	0.00	0.00	0.00	0.00	0.00	0.00	1,254.80

TOTAL:	117,751.95	516,036.98	966,979.48	1,141,548.15	1,163,189.30	1,376,554.37	0.00	0.00	0.00	0.00	0.00	0.00	5,282,060.23		

IT
SUBTOTAL:

FAMILY PLANNING SERVICES

For The Period Ending December 31, 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 December 31, 2014

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

1006	TANF 21-44 MALE WITH	2,820.28	0.00	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	1,254.92	0.00	0.00	0.00	0.00	0.00	0.00	136,000.21

1013	TANF 06-13 M & F NON	23,681.01	72,450.81	63,270.15	42,352.50	19,243.86	29,306.20	0.00	0.00	0.00	0.00	0.00	0.00	250,304.53

1014	TANF 14-20 MALE NON-	101,456.98	83,053.44	96,673.15	84,992.05	89,208.10	92,977.76	0.00	0.00	0.00	0.00	0.00	0.00	548,361.48

1015	TANF 14-20 FEMALE N O

700,203.94	477,647.74	511,723.03	353,435.39	535,270.63	218,169.65	0.00	0.00	0.00	0.00	0.00	0.00	2,796,450.38

1016	TANF 21-44 MALE NON-	131,895.09	136,642.01	151,856.35	134,645.69	127,636.42	91,096.33	0.00	0.00	0.00	0.00	0.00	0.00	773,771.89

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	2,783,659.69	0.00	0.00	0.00	0.00	0.00	0.00	19,132,678.30

1018	TANF 45-64 M & F NON	287,422.21	185,243.32	179,004.97	198,478.01	181,931.49	121,415.08	0.00	0.00	0.00	0.00	0.00	0.00	1,153,495.08

1019	TANF 65+ M & F NON-M	1,367.38	50.36	3,006.83	0.00	-161.09	692.33	0.00	0.00	0.00	0.00	0.00	0.00	4,955.81

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

8,124.92	3,462.59	4,105.19	2,493.51	120.16	4,717.93	0.00	0.00	0.00	0.00	0.00	0.00	23,024.30

686,565.89	486,327.79	526,332.11	560,946.82	537,125.71	526,717.30	0.00	0.00	0.00	0.00	0.00	0.00	3,324,015.62

28,071.60	29,258.47	34,565.50	45,650.11	17,524.46	25,593.27	0.00	0.00	0.00	0.00	0.00	0.00	180,663.41

811,372.82	739,101.65	783,464.79	843,599.64	701,699.32	729,302.07	0.00	0.00	0.00	0.00	0.00	0.00	4,608,540.29

0.00	0.00	0.00	0.00	0.00	47.95	0.00	0.00	0.00	0.00	0.00	0.00	47.95

2,582.38	0.00	107.59	-341.29	5.64	-138.79	0.00	0.00	0.00	0.00	0.00	0.00	2,215.53

SUBTOTAL:

6,645,181.08

5,482,310.95	6,208,134.21	4,523,950.45	5,454,737.92	4,624,811.69	0.00	0.00	0.00	0.00	0.00	0.00	32,939,126.30

1106	TANF EXPANDED 21-44	1,613.67	653.56	4,201.04	932.00	6,011.41	4,346.63	0.00	0.00	0.00	0.00	0.00	0.00	17,758.31

1107	TANF EXPANDED 21-44	81.76	74.69	768.84	1,261.10	610.94	1,300.30	0.00	0.00	0.00	0.00	0.00	0.00	4,097.63

1108	TANF EXPANDED 45-64	1,746.90	240.92	1,203.84	0.00	826.52	1,221.91	0.00	0.00	0.00	0.00	0.00	0.00	5,240.09

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	547.20	0.00	0.00	0.00	0.00	0.00	0.00	8,291.31

1115	TANF EXPANDED 14-20	11,771.70	25,932.07	7,814.64	9,083.11	10,651.78	13,124.73	0.00	0.00	0.00	0.00	0.00	0.00	78,378.03

1116	TANF EXPANDED 21-44	358,572.55	390,495.13	377,975.49	320,628.22	336,243.28	391,983.27	0.00	0.00	0.00	0.00	0.00	0.00	2,175,897.94

1117	TANF EXPANDED 21-44	758,042.25	533,723.61	653,487.41	502,738.23	544,247.18	511,021.63	0.00	0.00	0.00	0.00	0.00	0.00	3,503,260.31

1118	TANF EXPANDED 45-64	283,242.10	270,641.84	259,763.19	165,989.07	242,889.62	239,410.69	0.00	0.00	0.00	0.00	0.00	0.00	1,461,936.51

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	5,059.60	0.00	0.00	0.00	0.00	0.00	0.00	10,609.73

0.00	72.72	0.00	672.78	204.43	798.70	0.00	0.00	0.00	0.00	0.00	0.00	1,748.63

0.00	0.00	0.00	823.73	10,080.28	4,664.21	0.00	0.00	0.00	0.00	0.00	0.00	15,568.22

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	7,852.30	0.00	0.00	0.00	0.00	0.00	0.00	24,135.38

SUBTOTAL:

1,417,844.27

1,224,286.68	1,308,091.17	1,016,643.77	1,162,541.26	1,181,331.17	0.00	0.00	0.00	0.00	0.00	0.00	7,310,738.32

3514	ADULT 40-100% MALE 1	1,415.88	1,411.95	0.00	-1,562.84	-142.77	-93.40	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	2,289.04	578.80	0.00	-10,263.12	0.00	-683.25	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	89,472.61	22,341.03	-2,887.03	-68,913.35	-13,282.13	-7,310.29	0.00	0.00	0.00	0.00	0.00	0.00	

1,028.82

-8,078.53
E
19,420.84

FEDERAL EMERGENCY SERVICES

For The Period Ending December 31, 2014

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

3517	ADULT 40-100% FEMAL E

14,241.72	16,722.07	0.00	-17,419.95	-4,549.21	-8,769.93	0.00	0.00	0.00	0.00	0.00	0.00	224.70

3518	ADULT 40-100% M&F 45	105,362.43	111,303.89	-865.58	-207,554.32	-34,663.95	-57,332.76	0.00	0.00	0.00	0.00	0.00	0.00	-83,750.29

3707	ADULT <40% EXP FEM AL

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

3714	ADULT <40% EXP MALE	11,927.67	105,433.15	-536.88	-44,480.41	-2,343.54	-74,466.08	0.00	0.00	0.00	0.00	0.00	0.00	-4,466.09

3715	ADULT <40% EXP FEM AL

10,875.16	21,482.86	0.00	-14,142.67	-14,558.95	-13,216.50	0.00	0.00	0.00	0.00	0.00	0.00	-9,560.10

3716	ADULT <40% EXP MALE	331,193.61	259,868.44	-2,536.72	-383,740.56	-44,770.42	-125,417.31	0.00	0.00	0.00	0.00	0.00	0.00	34,597.04

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

54,689.87	132,072.18	-12,698.30	-115,825.12	-56,903.90	-24,554.58	0.00	0.00	0.00	0.00	0.00	0.00	-23,219.85

516,687.58	466,084.08	-18,915.90	-824,729.77	-71,025.11	-124,302.94	0.00	0.00	0.00	0.00	0.00	0.00	-56,202.06

1,353.93	3,879.07	0.00	-6,171.01	-459.02	-793.05	0.00	0.00	0.00	0.00	0.00	0.00	-2,190.08

SUBTOTAL:

1,140,286.57

1,141,225.47	-38,440.41	-1,694,803.12	-242,794.90	-436,940.09	0.00	0.00	0.00	0.00	0.00	0.00	-131,466.48

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	752.34	0.00	0.00	0.00	0.00	0.00	0.00	1,467.47

3914	NEWLY ELIGIBLE MALE	270.58	862.62	64,766.14	58,834.17	51,644.05	88,086.88	0.00	0.00	0.00	0.00	0.00	0.00	264,464.44

3915	NEWLY ELIGIBLE FEMA L

700.41	7.57	2,697.89	32,902.85	29,592.58	27,009.85	0.00	0.00	0.00	0.00	0.00	0.00	92,911.15

3916	NEWLY ELIGIBLE MALE	68,081.76	19,874.30	250,395.78	840,040.37	363,819.59	454,948.85	0.00	0.00	0.00	0.00	0.00	0.00	1,997,160.65

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	174,831.75	0.00	0.00	0.00	0.00	0.00	0.00	927,809.51

46,459.07	34,571.04	819,625.84	1,521,424.01	640,984.14	1,015,084.30	0.00	0.00	0.00	0.00	0.00	0.00	4,078,148.40

0.00	0.00	2,058.48	33,555.09	9,020.88	8,034.89	0.00	0.00	0.00	0.00	0.00	0.00	52,669.34

0.00	0.00	0.00	730.36	228.09	47.95	0.00	0.00	0.00	0.00	0.00	0.00	1,006.40

SUBTOTAL:

134,592.05

90,936.44	1,261,768.07	2,877,561.35	1,282,684.34	1,768,796.81	0.00	0.00	0.00	0.00	0.00	0.00	7,416,339.06

TOTAL:	9,337,903.97	7,938,759.54	8,739,553.04	6,723,352.45	7,657,168.62	7,137,999.58	0.00	0.00	0.00	0.00	0.00	0.00	47,534,737.20		

FEDERAL ESP CHRONIC SERVICES

For The Period Ending December 31, 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 December 31, 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	226,551.24	0.00	0.00	0.00	0.00	0.00	0.00		1,517,311.19		
	227,508.42	323,661.58	198,990.91	336,157.76	204,441.28	226,551.24	0.00	0.00	0.00	0.00	0.00	0.00	1,517,311.19		

SUBTOTAL:

TOTAL:	227,508.42	323,661.58	198,990.91	336,157.76	204,441.28	226,551.24	0.00	0.00	0.00	0.00	0.00	0.00	1,517,311.19		

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending December 31, 2014

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

1017	TANF 21-44 FEMALE N O
2100	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R

1,750.41	0.00	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	48,431.00	0.00	0.00	0.00	0.00	0.00	0.00	226,998.13

73,301.36	82,631.11	79,441.64	159,588.26	151,232.95	36,892.25	0.00	0.00	0.00	0.00	0.00	0.00	583,087.57

2120	SSI AGED WITH QMB	13,915.92	7,995.79	8,126.46	75,732.32	2,333.40	2,031.15	0.00	0.00	0.00	0.00	0.00	0.00	110,135.04

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	636.26	0.00	0.00	0.00	0.00	0.00	0.00	5,627.63

0.00	1,038.51	808.37	14,554.04	2,640.66	16,172.13	0.00	0.00	0.00	0.00	0.00	0.00	35,213.71

1,975.23	16,840.57	8,486.35	5,052.05	6,307.10	5,854.20	0.00	0.00	0.00	0.00	0.00	0.00	44,515.50

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	764.04	0.00	0.00	0.00	0.00	0.00	0.00		764.04	
	0.00	0.00	0.00	0.00	0.00	764.04	0.00	0.00	0.00	0.00	0.00	0.00	764.04	

SUBTOTAL:

139,513.64

117,313.46	118,779.61	356,263.06	172,448.89	110,016.99	0.00	0.00	0.00	0.00	0.00	0.00	1,014,335.65

SUBTOTAL:

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 MALE	17,224.61	10,190.95	16,468.17	9,132.98	3,439.72	2,236.30	0.00	0.00	0.00	0.00	0.00	0.00	58,692.73

3707	ADULT <40% EXP FEM AL
3708	ADULT <40% EXP M&F
4

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	7,305.58	0.00	0.00	0.00	0.00	0.00	0.00	92,039.14

3714	ADULT <40% EXP MALE	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

3716	ADULT <40% EXP MALE	239,576.63	251,224.77	186,647.70	203,044.50	79,944.10	302,120.33	0.00	0.00	0.00	0.00	0.00	0.00	1,262,558.03

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

6,841.48	3,338.30	14,739.60	22,819.43	2,293.72	21,464.58	0.00	0.00	0.00	0.00	0.00	0.00	71,497.11

193,944.21	209,147.18	241,670.75	448,656.73	194,257.48	232,053.95	0.00	0.00	0.00	0.00	0.00	0.00	1,519,730.30

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	2,736.73	0.00	0.00	0.00	0.00	0.00	0.00		2,736.73	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	21,268.71	5,903.84	68,757.94	6,597.41	0.00	0.00	0.00	0.00	0.00	0.00		102,527.90	
3918	NEWLY ELIGIBLE M&F	0.00	0.00	1,987.81	-428.11	0.00	728.20	0.00	0.00	0.00	0.00	0.00	0.00		2,287.90	
	0.00	0.00	23,256.52	5,475.73	68,757.94	10,062.34	0.00	0.00	0.00	0.00	0.00	0.00	107,552.53	

SUBTOTAL:

487,477.64

518,148.69	471,809.62	683,947.98	281,204.12	565,180.74	0.00	0.00	0.00	0.00	0.00	0.00	3,007,768.79

4
SUBTOTAL:

626,991.28	635,462.15	613,845.75	986,006.72	522,410.95	686,024.11	0.00	0.00	0.00	0.00	0.00	0.00	4,070,740.96	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 2014

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

2200	SSI DISABLED WITH M E
5017	SOBRA PREG 21-44 FE
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	0.00	0.00	0.00	2,622.96	0.00	0.00	0.00	0.00	0.00	0.00	2,622.96

SUBTOTAL:

0.00

0.00	5,262.44	177.08	7.00	2,622.96	0.00	0.00	0.00	0.00	0.00	0.00	8,069.48

TOTAL:	0.00	0.00	5,262.44	177.08	7.00	2,622.96	0.00	0.00	0.00	0.00	0.00	0.00	8,069.48		

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 2014

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

1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	2,040.23	0.00	0.00	0.00	0.00	0.00	0.00	2,040.23

1016	TANF 21-44 MALE NON-	0.00	0.00	1,290.19	0.00	0.00	250.64	0.00	0.00	0.00	0.00	0.00	0.00	1,540.83

1017	TANF 21-44 FEMALE N O

0.00	0.00	351.85	1,661.98	813.37	32.27	0.00	0.00	0.00	0.00	0.00	0.00	2,859.47

1018	TANF 45-64 M & F NON	0.00	0.00	435.39	0.00	0.00	2,019.88	0.00	0.00	0.00	0.00	0.00	0.00	2,455.27

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	21,506.83	0.00	0.00	0.00	0.00	0.00	0.00	35,550.29

0.00	0.00	0.00	88.36	218.27	30.96	0.00	0.00	0.00	0.00	0.00	0.00	337.59

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	9,372.17	0.00	0.00	0.00	0.00	0.00	0.00	25,973.71

SUBTOTAL:

5,034.14

2,561.94	11,151.49	9,287.36	15,401.19	35,252.98	0.00	0.00	0.00	0.00	0.00	0.00	78,689.10

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	2,471.90	0.00	0.00	0.00	0.00	0.00	0.00		4,533.42	
	0.00	0.00	0.00	1,490.40	1,161.29	2,471.90	0.00	0.00	0.00	0.00	0.00	0.00	5,123.59	

3515	ADULT 40-100% FEMAL E
3517	ADULT 40-100% FEMAL
E

0.00	0.00	0.00	0.00	3,536.84	79.49	0.00	0.00	0.00	0.00	0.00	0.00	3,616.33

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 MALE	8,220.27	3,894.04	23,019.10	13,678.57	31,422.79	86,232.82	0.00	0.00	0.00	0.00	0.00	0.00	166,467.59

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

4,470.06	0.00	69.43	2,092.40	2,806.07	19,138.49	0.00	0.00	0.00	0.00	0.00	0.00	28,576.45

398.58	2,007.44	560.46	4,482.41	29,462.98	19,974.03	0.00	0.00	0.00	0.00	0.00	0.00	56,885.90

SUBTOTAL:

13,088.91

6,330.52	23,648.99	20,638.66	67,228.68	125,424.83	0.00	0.00	0.00	0.00	0.00	0.00	256,360.59

18,123.05	8,892.46	34,800.48	31,416.42	83,791.16	163,149.71	0.00	0.00	0.00	0.00	0.00	0.00	340,173.28	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 2014

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

1017	TANF 21-44 FEMALE N O
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

443.20	0.00	0.00	0.00	1,999.89	3,098.74	0.00	0.00	0.00	0.00	0.00	0.00	5,541.83

0.00	0.00	1,359.40	160.87	0.00	1,593.72	0.00	0.00	0.00	0.00	0.00	0.00	3,113.99

0.00	2,281.13	549.96	170.77	0.00	176.90	0.00	0.00	0.00	0.00	0.00	0.00	3,178.76

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

4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	2,109.21	0.00	0.00	0.00	0.00	0.00	0.00	2,109.21

5017	SOBRA PREG 21-44 FE M

6,591.20	3,917.51	1,120.00	0.00	4,754.81	1,080.75	0.00	0.00	0.00	0.00	0.00	0.00	17,464.27

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	969.97	0.00	0.00	0.00	0.00	0.00	0.00		2,928.39	
	0.00	0.00	0.00	0.00	3,429.48	969.97	0.00	0.00	0.00	0.00	0.00	0.00	4,399.45	

SUBTOTAL:

7,294.04

6,198.64	3,723.92	753.54	6,754.70	8,059.32	0.00	0.00	0.00	0.00	0.00	0.00	32,784.16

E

3716	ADULT <40% EXP MALE	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	
3718	ADULT <40% EXP M&F	1,679.53	17,584.14	0.00	0.00	0.00	114.76	0.00	0.00	0.00	0.00	0.00	0.00		19,378.43	
	4,442.92	35,007.06		0.00	0.00	860.29	114.76	0.00	0.00	0.00	0.00	0.00	0.00	40,425.03	

SUBTOTAL:

4
SUBTOTAL:

TOTAL:	11,736.96	41,205.70	3,723.92	753.54	11,044.47	9,144.05	0.00	0.00	0.00	0.00	0.00	0.00	77,608.64		

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 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	327.95	0.00	0.00	0.00	0.00	0.00	0.00	631.37

1017	TANF 21-44 FEMALE N O

0.00	147.09	15,987.28	0.00	0.00	9.61	0.00	0.00	0.00	0.00	0.00	0.00	16,143.98

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	337.56	0.00	0.00	0.00	0.00	0.00	0.00	26,374.28

2400	SSI AGED EXPANDED WI
2600	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	3,093.20	0.00	0.00	0.00	0.00	0.00	0.00	3,093.20

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

SUBTOTAL:

2,451.81

8,946.30	2,253.24	0.00	0.00	3,093.20	0.00	0.00	0.00	0.00	0.00	0.00	16,744.55

3516	ADULT 40-100% MALE 2	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

3716	ADULT <40% EXP MALE	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

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

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	2,563.48	0.00	0.00	0.00	0.00	0.00	0.00	60,082.14

SUBTOTAL:

80,409.06

39,538.93	6,310.06	33,510.07	7,205.46	2,563.48	0.00	0.00	0.00	0.00	0.00	0.00	169,537.06

TOTAL:

84,091.33

50,533.21	26,931.24	33,990.88	11,114.99	5,994.24	0.00	0.00	0.00	0.00	0.00	0.00	212,655.89

YAVAPAI COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 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 December 31, 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	684.00	0.00	0.00	0.00	0.00	0.00	0.00	6,557.96

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

2,949,233.74	2,553,248.28	2,547,707.72	2,744,556.33	2,405,191.82	2,784,284.23	0.00	0.00	0.00	0.00	0.00	0.00	15,984,222.12

257,831.11	199,089.40	169,264.15	223,213.39	181,007.22	225,151.12	0.00	0.00	0.00	0.00	0.00	0.00	1,255,556.39

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	3,344,808.16	0.00	0.00	0.00	0.00	0.00	0.00	19,251,407.03

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	564,753.44	0.00	0.00	0.00	0.00	0.00	0.00	3,113,301.63

2,765,516.29	2,446,767.02	2,597,908.87	2,501,535.56	2,407,162.22	2,908,436.23	0.00	0.00	0.00	0.00	0.00	0.00	15,627,326.19

753,716.70	682,052.47	662,908.96	785,228.13	684,943.10	764,049.01	0.00	0.00	0.00	0.00	0.00	0.00	4,332,898.37

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	20,409.60	0.00	0.00	0.00	0.00	0.00	0.00	119,990.87

2320	SSI BLIND WITH QMB	8,634.19	8,670.31	5,363.33	10,825.38	7,786.37	6,206.17	0.00	0.00	0.00	0.00	0.00	0.00	47,485.75

SUBTOTAL:

10,674,444.22

9,396,118.45	9,491,866.15     10,312,742.38	9,245,674.28     10,618,781.96	0.00	0.00	0.00	0.00	0.00	0.00	59,739,627.44

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	3,376.80	0.00	0.00	0.00	0.00	0.00	0.00	17,752.04

SUBTOTAL:

2,742.24

7,235.19	5,303.67	5,253.62	5,183.76	3,376.80	0.00	0.00	0.00	0.00	0.00	0.00	29,095.28

10,677,186.46	9,403,353.64	9,497,169.82	10,317,996.00	9,250,858.04	10,622,158.76	0.00	0.00	0.00	0.00	0.00	0.00	59,768,722.72	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending December 31, 2014

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

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

10,604.85	6,556.27	4,904.83	21,431.27	21,860.24	23,681.17	0.00	0.00	0.00	0.00	0.00	0.00	89,038.63

0.00	3,762.00	679.61	0.00	0.00	2,533.71	0.00	0.00	0.00	0.00	0.00	0.00	6,975.32

2120	SSI AGED WITH QMB	0.00	335.71	50.00	0.00	0.00	391.05	0.00	0.00	0.00	0.00	0.00	0.00	776.76

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	552.69	0.00	0.00	0.00	0.00	0.00	0.00	5,271.40

14,258.99	13,715.98	2,327.42	9,892.81	28,252.23	2,844.75	0.00	0.00	0.00	0.00	0.00	0.00	71,292.18

424.41	420.94	525.00	0.00	0.00	110.00	0.00	0.00	0.00	0.00	0.00	0.00	1,480.35

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	30,113.37	0.00	0.00	0.00	0.00	0.00	0.00	175,054.09

TOTAL:	26,197.25	25,829.67	11,048.46	31,445.87	50,419.47	30,113.37	0.00	0.00	0.00	0.00	0.00	0.00	175,054.09		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending December 31, 2014

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

1012	TANF 01-05 M & F NON	79,268.59	40,248.60	26,108.83	43,435.77	53,191.90	52,544.62	0.00	0.00	0.00	0.00	0.00	0.00	294,798.31

1013	TANF 06-13 M & F NON	146,919.93	53,520.17	48,821.09	111,064.06	119,940.21	115,171.73	0.00	0.00	0.00	0.00	0.00	0.00	595,437.19

1014	TANF 14-20 MALE NON-	9,642.30	4,300.62	5,068.51	9,775.48	12,866.13	9,766.78	0.00	0.00	0.00	0.00	0.00	0.00	51,419.82

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	3,650.77	0.00	0.00	0.00	0.00	0.00	0.00	22,151.89

285,353.96	141,414.07	121,637.11	157,813.34	213,277.49	206,317.70	0.00	0.00	0.00	0.00	0.00	0.00	1,125,813.67

-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	303.69	0.00	0.00	0.00	0.00	0.00	0.00	717.32

2310	SSI BLIND NON-MEDIC A

1,150.83	776.30	790.05	1,583.20	1,457.92	1,381.84	0.00	0.00	0.00	0.00	0.00	0.00	7,140.14

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	61,691.24	0.00	0.00	0.00	0.00	0.00	0.00	357,567.39

4313	SOBRA CHILD 06-13 M	125,563.85	40,259.17	40,961.40	104,479.42	103,459.44	100,930.99	0.00	0.00	0.00	0.00	0.00	0.00	515,654.27

4314	SOBRA CHILD 14-20 MA	8,367.62	3,051.25	3,874.19	6,993.04	9,561.27	7,347.82	0.00	0.00	0.00	0.00	0.00	0.00	39,195.19

4315	SOBRA CHILD 14-20 FE	4,600.75	1,396.66	1,644.07	4,087.51	4,202.74	4,302.21	0.00	0.00	0.00	0.00	0.00	0.00	20,233.94

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	625.38	0.00	0.00	0.00	0.00	0.00	0.00		2,740.55	
1113	TANF EXPANDED 06-13	2,647.22	1,130.45	1,072.47	2,889.46	2,761.88	3,345.11	0.00	0.00	0.00	0.00	0.00	0.00		13,846.59	
1114	TANF EXPANDED 14-20	454.98	239.78	28.68	176.36	302.79	298.73	0.00	0.00	0.00	0.00	0.00	0.00		1,501.32	
1115	TANF EXPANDED 14-20	332.61	217.88	0.00	123.15	178.38	47.48	0.00	0.00	0.00	0.00	0.00	0.00		899.50	
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	4,316.70	0.00	0.00	0.00	0.00	0.00	0.00	19,358.02	

SUBTOTAL:

752,725.57

338,135.09	284,642.09	501,123.06	590,395.05	563,409.39	0.00	0.00	0.00	0.00	0.00	0.00	3,030,430.25

E
SUBTOTAL:

SUBTOTAL:

3314	AHC CARE MALE 14-20	-11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11.48	
	-11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11.48	

3514	ADULT 40-100% MALE 1	155.62	48.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	204.52

3515	ADULT 40-100% FEMAL E

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

3714	ADULT <40% EXP MALE	476.23	94.36	149.28	281.22	863.97	184.08	0.00	0.00	0.00	0.00	0.00	0.00	2,049.14

3715	ADULT <40% EXP FEM AL

271.22	13.06	39.15	258.50	195.25	170.26	0.00	0.00	0.00	0.00	0.00	0.00	947.44

SUBTOTAL:

956.67

156.32	188.43	539.72	1,076.50	354.34	0.00	0.00	0.00	0.00	0.00	0.00	3,271.98

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	12,082.98	0.00	0.00	0.00	0.00	0.00	0.00	75,169.07

4414	SOBRA 100-133% MALE	1,596.05	456.57	462.77	1,508.43	1,650.31	1,127.89	0.00	0.00	0.00	0.00	0.00	0.00	6,802.02

4415	SOBRA 100-133% FEMA L

1,702.55	3,076.73	516.64	348.60	897.28	2,212.92	0.00	0.00	0.00	0.00	0.00	0.00	8,754.72

SUBTOTAL:

22,080.40

10,667.53	7,315.45	17,673.28	17,778.62	15,423.79	0.00	0.00	0.00	0.00	0.00	0.00	90,939.07

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending December 31, 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	583,504.22	0.00	0.00	0.00	0.00	0.00	0.00	3,143,987.84		

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending December 31, 2014

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

1010	TANF NON-MEDICARE	47,470.63	21,432.22	18,846.93	27,265.06	38,488.55	31,282.82	0.00	0.00	0.00	0.00	0.00	0.00	184,786.21

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	1,490.74	0.00	0.00	0.00	0.00	0.00	0.00	7,115.41

1,478,954.03	694,004.94	538,459.10	721,921.58	996,957.59	956,672.26	0.00	0.00	0.00	0.00	0.00	0.00	5,386,969.50

4,777.36	3,124.80	1,162.93	1,707.31	2,323.90	1,567.20	0.00	0.00	0.00	0.00	0.00	0.00	14,663.50

10,115.61	3,200.88	2,535.87	6,084.02	9,657.23	3,274.40	0.00	0.00	0.00	0.00	0.00	0.00	34,868.01

SUBTOTAL:

1,542,730.01

723,906.88	561,689.63	757,324.89	1,048,463.80	994,287.42	0.00	0.00	0.00	0.00	0.00	0.00	5,628,402.63

TOTAL:	1,542,730.01	723,906.88	561,689.63	757,324.89	1,048,463.80	994,287.42	0.00	0.00	0.00	0.00	0.00	0.00	5,628,402.63		

ACUTE REINSURANCE

For The Period Ending December 31, 2014

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

1011	TANF <1 M & F NON-ME	617,801.55	98,805.90	1,008,665.00	511,635.03	1,293,922.25	494,806.29	0.00	0.00	0.00	0.00	0.00	0.00	4,025,636.02

1012	TANF 01-05 M & F NON	226,432.73	113,704.79	95,070.99	178,087.61	74,184.65	82,489.27	0.00	0.00	0.00	0.00	0.00	0.00	769,970.04

1013	TANF 06-13 M & F NON	127,284.33	42,661.83	170,521.34	85,151.97	239,975.55	98,234.21	0.00	0.00	0.00	0.00	0.00	0.00	763,829.23

1014	TANF 14-20 MALE NON-	108,649.47	-4,443.77	374,095.78	-5,681.49	38,532.76	6,541.63	0.00	0.00	0.00	0.00	0.00	0.00	517,694.38

1015	TANF 14-20 FEMALE N O

26,416.78	8,394.13	58,355.61	59,133.80	34,497.80	7,715.35	0.00	0.00	0.00	0.00	0.00	0.00	194,513.47

1016	TANF 21-44 MALE NON-	132,385.08	173,376.31	292,747.33	64,996.50	173,255.89	281,541.76	0.00	0.00	0.00	0.00	0.00	0.00	1,118,302.87

1017	TANF 21-44 FEMALE N O

341,065.51	201,857.67	210,936.57	253,326.86	186,635.72	261,566.05	0.00	0.00	0.00	0.00	0.00	0.00	1,455,388.38

1018	TANF 45-64 M & F NON	201,160.52	184,914.30	290,339.30	109,588.10	128,202.71	86,285.02	0.00	0.00	0.00	0.00	0.00	0.00	1,000,489.95

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-MEDICA
R
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	27,219.93	0.00	0.00	0.00	0.00	0.00	0.00	72,412.10

128,077.73	94,236.33	91,762.23	118,229.74	226,009.71	18,714.07	0.00	0.00	0.00	0.00	0.00	0.00	677,029.81

20,315.85	-10,671.36	54,805.16	6,873.58	27,635.54	1,367.03	0.00	0.00	0.00	0.00	0.00	0.00	100,325.80

5,320,586.01	3,420,318.63	5,707,039.79	2,816,813.74	2,906,532.02	4,191,007.69	0.00	0.00	0.00	0.00	0.00	0.00	24,362,297.88

2,687.38	-11,640.56	0.00	1,357.93	0.00	440.17	0.00	0.00	0.00	0.00	0.00	0.00	-7,155.08

4311	SOBRA CHILD <1 M & F	786,856.39	349,782.11	1,099,621.16	1,111,859.28	2,623,130.18	755,102.86	0.00	0.00	0.00	0.00	0.00	0.00	6,726,351.98

4312	SOBRA CHILD 01-05 M	42,898.59	31,960.46	446,875.71	273,059.72	368,592.56	192,282.66	0.00	0.00	0.00	0.00	0.00	0.00	1,355,669.70

4313	SOBRA CHILD 06-13 M	342,577.75	67,788.19	560,809.73	148,080.44	221,081.64	-46,918.23	0.00	0.00	0.00	0.00	0.00	0.00	1,293,419.52

4314	SOBRA CHILD 14-20 MA	1,333,911.20	92,018.33	-344,711.91	451,855.92	1,981,996.36	132,278.85	0.00	0.00	0.00	0.00	0.00	0.00	3,647,348.75

4315	SOBRA CHILD 14-20 FE	190,628.79	20,582.43	116,774.64	75,863.10	25,241.70	129,725.31	0.00	0.00	0.00	0.00	0.00	0.00	558,815.97

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	12,487.96	0.00	0.00	0.00	0.00	0.00	0.00	58,592.09

35,660.75	7,458.14	102,096.78	3,037.03	24,380.94	23,590.53	0.00	0.00	0.00	0.00	0.00	0.00	196,224.17

SUBTOTAL:

9,969,923.69

4,909,635.73     10,369,217.45	6,271,221.32     10,598,297.11	6,756,478.41	0.00	0.00	0.00	0.00	0.00	0.00	48,874,773.71

1
SUBTOTAL:

3100	TRANSPLANT OPTION	0.00	-4.00	85.99	-6.06	-79.63	79.04	0.00	0.00	0.00	0.00	0.00	0.00		75.34	
	0.00	-4.00	85.99	-6.06	-79.63	79.04	0.00	0.00	0.00	0.00	0.00	0.00	75.34	

21,024.76	
158.98	
117,729.94	
17,303.13	
7,213.83	
1,014,445.90	
484,959.76	
454,336.37	
-9,938.86	
9,124.52	
206,519.88	

1106	TANF EXPANDED 21-44	5,783.54	13,350.95	542.92	133.36	894.09	319.90	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	16,449.83	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	-122.32	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	151,817.60	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	7,263.64	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	68,257.76	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	459.77	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	68,692.05	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE REINSURANCE

For The Period Ending December 31, 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	288.03	0.00	0.00	0.00	0.00	0.00	0.00	7,821.77

33,618.83	26,765.25	35,130.20	64,258.30	57,942.72	10,140.23	0.00	0.00	0.00	0.00	0.00	0.00	227,855.53

SUBTOTAL:

411,268.37

348,182.66	822,006.30	270,681.26	382,850.43	323,566.49	0.00	0.00	0.00	0.00	0.00	0.00	2,558,555.51

3308	AHC CARE M&F 45-64
W

0.00	0.00	0.00	0.00	0.00	-43,838.30	0.00	0.00	0.00	0.00	0.00	0.00	-43,838.30

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	2,976.23	0.00	0.00	0.00	0.00	0.00	0.00	37,581.43

SUBTOTAL:

15,060.12

11,589.46	6,978.27	6,365.64	25,306.44	-40,862.07	0.00	0.00	0.00	0.00	0.00	0.00	24,437.86

-6,845.12	
37,594.00	
-14,175.29	
13,515.04	
3,267.43	
421,296.65	
454,652.71	

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

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

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

3616	AHC CARE/MI MALE 21-	35,449.75	5,486.62	11,138.39	3,366.22	-45,704.27	3,778.33	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

2,346.33	149.94	2,110.32	-3,857.24	2,459.56	58.52	0.00	0.00	0.00	0.00	0.00	0.00

3618	AHC CARE/MI M&F 45-6	92,677.00	81,721.95	44,330.54	19,060.38	135,891.16	47,615.62	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

130,757.71

107,177.23	43,403.96	30,286.20	91,575.14	51,452.47	0.00	0.00	0.00	0.00	0.00

0.00

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	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

3516	ADULT 40-100% MALE 2	110,085.04	28,336.63	12,796.30	50,169.11	99,573.81	224,907.71	0.00	0.00	0.00	0.00	0.00	0.00	525,868.60

3517	ADULT 40-100% FEMAL E

14,191.06	42,194.34	5,249.57	4,955.67	2,150.23	13,596.97	0.00	0.00	0.00	0.00	0.00	0.00	82,337.84

3518	ADULT 40-100% M&F 45	124,182.25	80,115.17	153,287.28	155,636.54	242,864.73	225,507.29	0.00	0.00	0.00	0.00	0.00	0.00	981,593.26

3706	ADULT <40% EXP MALE	0.00	321.77	2,973.17	2,209.46	2,081.23	5,059.04	0.00	0.00	0.00	0.00	0.00	0.00	12,644.67

3708	ADULT <40% EXP M&F
4

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

3714	ADULT <40% EXP MALE	60,063.28	970.09	86,261.30	67,956.06	23,765.17	76,106.60	0.00	0.00	0.00	0.00	0.00	0.00	315,122.50

3715	ADULT <40% EXP FEM AL

28,863.68	9,089.82	0.00	3,832.02	1,785.25	1,489.93	0.00	0.00	0.00	0.00	0.00	0.00	45,060.70

3716	ADULT <40% EXP MALE	527,880.83	612,804.86	986,924.78	428,531.24	470,042.16	478,072.08	0.00	0.00	0.00	0.00	0.00	0.00	3,504,255.95

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

203,328.99	-85,250.98	39,308.70	113,882.18	151,084.88	49,542.39	0.00	0.00	0.00	0.00	0.00	0.00	471,896.16

547,533.52	560,814.97	721,102.11	723,238.79	847,355.37	710,375.64	0.00	0.00	0.00	0.00	0.00	0.00	4,110,420.40

0.00	0.00	0.00	0.00	0.00	10,496.54	0.00	0.00	0.00	0.00	0.00	0.00	10,496.54

SUBTOTAL:

1,767,893.62

1,250,975.66	2,131,083.91	1,550,815.81	1,951,045.58	1,795,154.19	0.00	0.00	0.00	0.00	0.00	0.00	10,446,968.77

3908	NEWLY ELIGIBLE M&F	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	
3915	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	8,654.38	0.00	0.00	0.00	0.00	0.00	0.00	

1,443.90
4
-5.01

8,654.38
L

ACUTE REINSURANCE

For The Period Ending December 31, 2014

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

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	56,933.76

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	15,685.95

22,286.86	20,209.37	79,895.32	96,867.66	58,966.76	96,227.90	0.00	0.00	0.00	0.00	0.00	0.00	374,453.87

SUBTOTAL:

22,286.86

20,209.37	101,573.82	92,354.91	115,859.61	104,882.28	0.00	0.00	0.00	0.00	0.00	0.00	457,166.85

4413	SOBRA 100-133% M&F
6

14,312.67	8,754.46	24,795.69	6,159.74	38,014.03	3,443.62	0.00	0.00	0.00	0.00	0.00	0.00	95,480.21

4414	SOBRA 100-133% MALE	65.18	19,810.58	102,761.85	37,400.05	51,462.07	52,674.99	0.00	0.00	0.00	0.00	0.00	0.00	264,174.72

4415	SOBRA 100-133% FEMA L

0.00	-7,529.00	17,232.86	18,975.57	5,920.80	18,710.25	0.00	0.00	0.00	0.00	0.00	0.00	53,310.48

SUBTOTAL:

14,377.85

21,036.04	144,790.40	62,535.36	95,396.90	74,828.86	0.00	0.00	0.00	0.00	0.00	0.00	412,965.41

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	29,895.59	0.00	0.00	0.00	0.00	0.00	0.00	74,825.93

0.00	0.00	2,131.29	9,032.07	-736.94	2,553.51	0.00	0.00	0.00	0.00	0.00	0.00	12,979.93

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	32,449.10	0.00	0.00	0.00	0.00	0.00	0.00	94,073.13

8710	SSI DISABLED FREEDO	2,558.36	99,193.33	35,512.47	-10,364.78	16,562.70	61,345.08	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,558.36	99,193.33	35,512.47	-10,364.78	16,562.70	61,345.08	0.00	0.00	0.00	0.00	0.00	0.	

204,807.16

	00	204,807.16	
12,350,555.68	6,765,970.52	13,679,276.91	8,298,967.64	13,274,331.85	9,159,373.85	0.00	0.00	0.00	0.00	0.00	0.00	63,528,476.45	

M

TOTAL:

LONG TERM CARE REINSURANCE

For The Period Ending December 31, 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	3,699.30	0.00	0.00	0.00	0.00	0.00	0.00	13,217.45

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

444,766.14	302,713.80	603,255.00	438,652.82	415,507.67	409,138.80	0.00	0.00	0.00	0.00	0.00	0.00	2,614,034.23

94,778.89	68,228.22	239,845.11	302,132.92	162,138.93	30,008.81	0.00	0.00	0.00	0.00	0.00	0.00	897,132.88

542,384.64	745,227.77	1,060,996.47	700,811.88	851,980.42	768,131.50	0.00	0.00	0.00	0.00	0.00	0.00	4,669,532.68

2,252,785.70	2,463,223.47	3,374,452.37	3,279,509.10	3,025,825.21	2,777,342.31	0.00	0.00	0.00	0.00	0.00	0.00	17,173,138.16

16,178.78	10,868.82	46,055.83	13,881.85	24,909.97	7,853.23	0.00	0.00	0.00	0.00	0.00	0.00	119,748.48

SUBTOTAL:

3,351,664.59

3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	3,996,173.95	0.00	0.00	0.00	0.00	0.00	0.00	25,486,803.88

TOTAL:	3,351,664.59	3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	3,996,173.95	0.00	0.00	0.00	0.00	0.00	0.00	25,486,803.88		

ACUTE SMIB

For The Period Ending December 31, 2014

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

1000	TANF WITH MEDICARE	64,841.20	63,789.20	57,855.80	64,149.80	64,198.80	61,576.30	0.00	0.00	0.00	0.00	0.00	0.00	376,411.10

1010	TANF NON-MEDICARE	314.70	314.70	314.70	209.80	209.80	2,098.00	0.00	0.00	0.00	0.00	0.00	0.00	3,461.70

1020	TANF WITH QMB	1,993.10	1,888.20	1,783.30	3,671.50	4,300.90	4,930.30	0.00	0.00	0.00	0.00	0.00	0.00	18,567.30

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

233,087.80	189,316.60	73,485.90	77,472.10	70,338.90	66,341.40	0.00	0.00	0.00	0.00	0.00	0.00	710,042.70

400,566.10	392,011.30	395,473.00	394,528.90	402,711.10	429,939.30	0.00	0.00	0.00	0.00	0.00	0.00	2,415,229.70

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	2,479,041.10	0.00	0.00	0.00	0.00	0.00	0.00	14,620,874.40

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	200,463.90	0.00	0.00	0.00	0.00	0.00	0.00	1,626,385.50

325,924.30	328,756.60	332,702.80	334,897.50	332,533.00	435,540.40	0.00	0.00	0.00	0.00	0.00	0.00	2,090,354.60

2,938,167.40	2,948,060.50	2,962,742.20	2,977,216.20	2,936,899.20	2,934,259.70	0.00	0.00	0.00	0.00	0.00	0.00	17,697,345.20

2300	SSI BLIND WITH MEDIC	2,307.80	2,098.00	209.80	209.80	629.40	419.60	0.00	0.00	0.00	0.00	0.00	0.00	5,874.40

2310	SSI BLIND NON-MEDIC A

3,356.80	3,461.70	3,356.80	3,356.80	3,776.40	3,881.30	0.00	0.00	0.00	0.00	0.00	0.00	21,189.80

2320	SSI BLIND WITH QMB	26,329.90	26,130.10	26,434.80	23,517.60	26,329.90	26,539.70	0.00	0.00	0.00	0.00	0.00	0.00	155,282.00

4300	SOBRA CHILD WITH ME D
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	104.90	0.00	0.00	0.00	0.00	0.00	0.00	419.60

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	3,566.60	0.00	0.00	0.00	0.00	0.00	0.00	11,539.00

314.70	419.60	524.50	1,573.50	629.40	1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	4,510.70

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	459,943.30	0.00	0.00	0.00	0.00	0.00	0.00	2,714,138.30

8040	SLMB	2,943,067.40	2,935,466.10	3,034,675.20	3,194,386.00	3,319,052.60	3,234,150.70	0.00	0.00	0.00	0.00	0.00	0.00	18,660,798.00

8888	SMIB ONLY NOT ELIGIB	10,545.90	53,013.10	-122,308.40	-7,552.80	-13,010.50	-14,790.90	0.00	0.00	0.00	0.00	0.00	0.00	-94,103.60

9999	SMIB ONLY NOT ELIGIB	104,243.20	279,672.30	-49,755.80	165,466.10	243,117.50	-62,544.30	0.00	0.00	0.00	0.00	0.00	0.00	680,199.00

SUBTOTAL:

10,393,669.50

10,609,177.00	9,816,709.20     10,373,227.10     10,541,022.40     10,266,510.30	0.00	0.00	0.00	0.00	0.00	0.00	62,000,315.50

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	590,013.20	0.00	0.00	0.00	0.00	0.00	0.00

2,438,452.70	
1,363.70	
180,847.60	
282,798.00	
7,867.50	
14,683,251.00	
1,888.20	
105,229.70	
209.80	
6,277,889.70	

0.00	0.00	314.70	419.60	314.70	314.70	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	53,813.70	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	17,098.70	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	2,307.80	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	2,510,011.30	0.00	0.00	0.00	0.00	0.00	0.00

524.50	419.60	314.70	209.80	209.80	209.80	0.00	0.00	0.00	0.00	0.00	0.00

49,093.20	56,031.60	-209.80	0.00	0.00	314.70	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	1,091,853.60	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

ACUTE SMIB

For The Period Ending December 31, 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	4,265,937.50	0.00	0.00	0.00	0.00	0.00	0.00	23,979,797.90		

A
SUBTOTAL:

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	

3500	ADULT 40-100% FOR FI	419.60	475.50	0.00	0.00	0.00	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	2,049.00

3520	ADULT 40-100% FOR FI	3,042.10	4,300.90	4,825.40	3,776.40	4,091.10	4,720.50	0.00	0.00	0.00	0.00	0.00	0.00	24,756.40

3700	ADULT <40% EXP FOR F
3720	AHC CARE EXPANDED
FO

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

1,049.00	1,153.90	2,517.60	3,671.50	2,727.40	2,098.00	0.00	0.00	0.00	0.00	0.00	0.00	13,217.40

SUBTOTAL:

4,510.70

6,245.00	7,343.00	7,447.90	6,818.50	7,972.40	0.00	0.00	0.00	0.00	0.00	0.00	40,337.50

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	209.80	0.00	0.00	0.00	0.00	0.00	0.00	6,818.50

SUBTOTAL:

1,258.80

839.20	1,678.40	1,783.30	1,153.90	209.80	0.00	0.00	0.00	0.00	0.00	0.00	6,923.40

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	20,875.10	0.00	0.00	0.00	0.00	0.00	0.00	114,445.90

SUBTOTAL:

17,203.60

18,882.00	19,931.00	20,140.80	19,511.40	20,875.10	0.00	0.00	0.00	0.00	0.00

0.00	116,543.90

TOTAL:

13,865,585.90

14,421,890.70     13,946,402.20     14,569,032.00     14,799,852.90     14,561,505.10	0.00	0.00	0.00	0.00	0.00	0.00	86,164,268.80

ACUTE HIB

For The Period Ending December 31, 2014

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

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

-5,222.40	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	176,824.20	0.00	0.00	0.00	0.00	0.00	0.00	1,051,511.70

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	91,522.80	0.00	0.00	0.00	0.00	0.00	0.00	442,975.00

2320	SSI BLIND WITH QMB	426.00	426.00	426.00	426.00	426.00	426.00	0.00	0.00	0.00	0.00	0.00	0.00	2,556.00

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	3,090.00	0.00	0.00	0.00	0.00	0.00	0.00	19,788.20

9999	SMIB ONLY NOT ELIGIB	-89,633.40	-5,389.20	-6,432.00	-2,187.00	1,043.40	-9,115.80	0.00	0.00	0.00	0.00	0.00	0.00	-111,714.00

2420	SSI AGED EXPANDED	2,805.80	1,938.00	1,938.00	1,938.00	3,216.00	2,364.00	0.00	0.00	0.00	0.00	0.00	0.00		14,199.80	
	2,805.80	1,938.00	1,938.00	1,938.00	3,216.00	2,364.00	0.00	0.00	0.00	0.00	0.00	0.00	14,199.80	

SUBTOTAL:

58,791.90

272,446.20	259,041.60	269,952.00	274,700.40	262,747.20	0.00	0.00	0.00	0.00	0.00	0.00	1,397,679.30

WI
SUBTOTAL:

TOTAL:	61,597.70	274,384.20	260,979.60	271,890.00	277,916.40	265,111.20	0.00	0.00	0.00	0.00	0.00	0.00	1,411,879.10		

SUBTOTAL:	0

Q1

For The Period Ending December 31, 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	1,760,539.80	0.00	0.00	0.00	0.00	0.00	0.00		10,810,041.20		
9999	SMIB ONLY NOT ELIGIB	12,692.90	46,532.10	-64,720.20	944.10	1,573.50	16,259.50	0.00	0.00	0.00	0.00	0.00	0.00		13,281.90		
	1,627,402.40	1,621,788.40		1,982,589.5		1,886,090.00	1,928,653.50	1,776,799.30	0.00	0.00	0.00	0.00	0.00	0.00	10,823,323.10		

1,627,402.40	1,621,788.40	1,982,589.50	1,886,090.00	1,928,653.50	1,776,799.30	0.00	0.00	0.00	0.00	0.00	0.00	10,823,323.10	

TOTAL:

LTC SMIB

For The Period Ending December 31, 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	209.80	0.00	0.00	0.00	0.00	0.00	0.00	1,258.80

1020	TANF WITH QMB	209.80	209.80	209.80	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	944.10

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

888,555.70	873,534.60	857,715.10	861,295.50	876,233.40	856,197.50	0.00	0.00	0.00	0.00	0.00	0.00	5,213,531.80

152,419.70	154,098.10	154,307.90	156,615.70	156,091.20	182,838.10	0.00	0.00	0.00	0.00	0.00	0.00	956,370.70

2120	SSI AGED WITH QMB	701,571.20	723,659.60	742,796.90	743,761.00	748,566.40	754,650.60	0.00	0.00	0.00	0.00	0.00	0.00	4,415,005.70

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	326,084.70	0.00	0.00	0.00	0.00	0.00	0.00	1,932,613.50

15,525.20	15,839.90	16,574.20	17,098.70	16,469.30	31,770.50	0.00	0.00	0.00	0.00	0.00	0.00	113,277.80

663,338.30	680,244.30	688,514.30	693,444.60	693,969.10	695,128.00	0.00	0.00	0.00	0.00	0.00	0.00	4,114,638.60

2300	SSI BLIND WITH MEDIC	1,049.00	839.20	839.20	839.20	1,258.80	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	5,979.30

2310	SSI BLIND NON-MEDIC A

209.80	314.70	314.70	314.70	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00	1,783.30

2320	SSI BLIND WITH QMB	4,300.90	4,300.90	4,300.90	4,196.00	4,196.00	4,091.10	0.00	0.00	0.00	0.00	0.00	0.00	25,385.80

8720	SSI DISABLED FREEDO	524.50	524.50	419.60	314.70	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00		2,412.70	
	524.50	524.50	419.60	314.70	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00	2,412.70	

SUBTOTAL:

2,760,032.30

2,775,903.60	2,782,895.50	2,794,258.50	2,815,155.70	2,852,543.80	0.00	0.00	0.00	0.00	0.00	0.00	16,780,789.40

M
SUBTOTAL:

TOTAL:	2,760,556.80	2,776,428.10	2,783,315.10	2,794,573.20	2,815,470.40	2,852,858.50	0.00	0.00	0.00	0.00	0.00	0.00	16,783,202.10		

LTC HIB

For The Period Ending December 31, 2014

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

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

-5,106.60	0.00	0.00	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	267,816.60	0.00	0.00	0.00	0.00	0.00	0.00	1,465,270.50

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	-426.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,965.40

-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	12,906.60	0.00	0.00	0.00	0.00	0.00	0.00	46,738.10

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	280,297.20	0.00	0.00	0.00	0.00	0.00	0.00	1,494,736.10

121,568.30	275,913.00	266,524.80	277,911.00	272,521.80	280,297.20	0.00	0.00	0.00	0.00	0.00	0.00	1,494,736.10	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2014

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

1006	TANF 21-44 MALE WITH	2,441.80	1,509.02	1,093.31	1,184.10	1,281.81	701.63	0.00	0.00	0.00	0.00	0.00	0.00	8,211.67

1007	TANF 21-44 FEMALE WI	7,891.55	4,440.10	37,095.67	5,204.05	11,335.82	2,581.58	0.00	0.00	0.00	0.00	0.00	0.00	68,548.77

1008	TANF 45-64 M & F WIT	688.07	4,551.70	6,186.60	7,407.18	3,733.34	312.18	0.00	0.00	0.00	0.00	0.00	0.00	22,879.07

1009	TANF 65+ M & F WITH	2,777.42	692.23	471.06	1,233.62	976.10	307.15	0.00	0.00	0.00	0.00	0.00	0.00	6,457.58

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	1,040,253.94	0.00	0.00	0.00	0.00	0.00	0.00	6,216,340.77

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	2,095,454.64	0.00	0.00	0.00	0.00	0.00	0.00	12,753,052.07

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	3,573,556.51	0.00	0.00	0.00	0.00	0.00	0.00	21,380,149.95

1014	TANF 14-20 MALE NON-	789,166.76	666,853.53	701,533.91	576,596.64	650,572.47	767,365.89	0.00	0.00	0.00	0.00	0.00	0.00	4,152,089.20

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	996,854.30	0.00	0.00	0.00	0.00	0.00	0.00	6,461,545.69

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	943,429.18	0.00	0.00	0.00	0.00	0.00	0.00	6,539,692.89

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	5,379,156.95	0.00	0.00	0.00	0.00	0.00	0.00	32,475,682.94

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	1,446,118.07	0.00	0.00	0.00	0.00	0.00	0.00	8,842,836.90

1019	TANF 65+ M & F NON-M	3,798.00	3,834.76	3,253.05	4,446.00	3,131.14	6,498.00	0.00	0.00	0.00	0.00	0.00	0.00	24,960.95

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	2,448.44	0.00	0.00	0.00	0.00	0.00	0.00	5,101.41

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

55,280.06	61,807.18	52,962.78	58,259.92	35,963.52	59,958.11	0.00	0.00	0.00	0.00	0.00	0.00	324,231.57

122,058.59	95,993.44	111,925.93	121,536.53	82,043.81	86,766.66	0.00	0.00	0.00	0.00	0.00	0.00	620,324.96

2120	SSI AGED WITH QMB	240,326.58	230,567.57	231,158.40	261,929.02	195,589.88	219,414.41	0.00	0.00	0.00	0.00	0.00	0.00	1,378,985.86

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	143,291.60	0.00	0.00	0.00	0.00	0.00	0.00	838,524.28

5,600,784.07	4,878,415.73	5,361,312.61	4,421,143.38	4,225,871.37	4,693,928.62	0.00	0.00	0.00	0.00	0.00	0.00	29,181,455.78

505,684.41	462,707.23	465,266.11	509,682.34	379,838.90	421,292.32	0.00	0.00	0.00	0.00	0.00	0.00	2,744,471.31

2300	SSI BLIND WITH MEDIC	732.05	1,083.49	134.57	670.80	1,194.98	875.15	0.00	0.00	0.00	0.00	0.00	0.00	4,691.04

2310	SSI BLIND NON-MEDIC A

58,811.72	53,564.21	70,414.36	74,538.56	53,470.42	69,424.73	0.00	0.00	0.00	0.00	0.00	0.00	380,224.00

2320	SSI BLIND WITH QMB	6,877.81	7,105.79	5,428.99	6,812.69	6,272.52	8,344.86	0.00	0.00	0.00	0.00	0.00	0.00	40,842.66

4311	SOBRA CHILD <1 M & F	1,346,693.34	1,056,011.50	1,229,599.65	994,222.35	993,599.62	1,161,516.56	0.00	0.00	0.00	0.00	0.00	0.00	6,781,643.02

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	1,219,630.28	0.00	0.00	0.00	0.00	0.00	0.00	7,177,931.83

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	1,642,132.15	0.00	0.00	0.00	0.00	0.00	0.00	10,116,280.11

4314	SOBRA CHILD 14-20 MA	819,236.05	706,030.79	717,542.51	535,873.37	620,642.56	716,514.91	0.00	0.00	0.00	0.00	0.00	0.00	4,115,840.19

4315	SOBRA CHILD 14-20 FE	1,262,134.73	805,629.49	853,710.30	695,968.72	960,135.15	929,888.07	0.00	0.00	0.00	0.00	0.00	0.00	5,507,466.46

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	1,431.61	0.00	0.00	0.00	0.00	0.00	0.00	2,546.44

327,656.19	297,669.00	310,183.13	221,676.68	249,107.46	261,990.76	0.00	0.00	0.00	0.00	0.00	0.00	1,668,283.22

1,091,567.67	946,301.56	1,169,090.06	986,816.43	812,410.05	1,029,774.56	0.00	0.00	0.00	0.00	0.00	0.00	6,035,960.33

-18,468.00	3,071.60	3,420.00	2,475.20	1,072.59	1,594.61	0.00	0.00	0.00	0.00	0.00	0.00	-6,834.00

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 December 31, 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	28,922,808.43	0.00	0.00	0.00	0.00	0.00	0.00	175,881,907.68		

1106	TANF EXPANDED 21-44	6,408.48	4,488.35	5,192.83	7,061.09	6,710.30	5,496.78	0.00	0.00	0.00	0.00	0.00	0.00	35,357.83

1107	TANF EXPANDED 21-44	13,495.32	12,706.18	10,880.70	10,508.67	8,592.03	12,279.11	0.00	0.00	0.00	0.00	0.00	0.00	68,462.01

1108	TANF EXPANDED 45-64	30,378.85	28,533.23	34,497.12	29,931.18	22,272.49	27,607.53	0.00	0.00	0.00	0.00	0.00	0.00	173,220.40

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	15,431.13	0.00	0.00	0.00	0.00	0.00	0.00	100,345.17

342.00	0.00	0.00	0.00	342.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	1,026.00

1112	TANF EXPANDED 01-05	9,006.00	8,938.95	11,623.85	5,501.17	6,653.58	5,484.79	0.00	0.00	0.00	0.00	0.00	0.00	47,208.34

1113	TANF EXPANDED 06-13	51,575.17	42,983.60	52,423.69	50,487.63	57,785.04	47,271.00	0.00	0.00	0.00	0.00	0.00	0.00	302,526.13

1114	TANF EXPANDED 14-20	22,170.63	16,255.50	17,324.79	18,051.36	18,982.88	22,351.06	0.00	0.00	0.00	0.00	0.00	0.00	115,136.22

1115	TANF EXPANDED 14-20	47,309.83	42,419.66	54,623.86	31,881.60	46,287.05	42,037.66	0.00	0.00	0.00	0.00	0.00	0.00	264,559.66

1116	TANF EXPANDED 21-44	591,969.39	562,199.70	684,810.63	500,868.98	492,500.09	560,038.93	0.00	0.00	0.00	0.00	0.00	0.00	3,392,387.72

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	1,460,130.17	0.00	0.00	0.00	0.00	0.00	0.00	8,912,210.97

1118	TANF EXPANDED 45-64	886,655.00	786,372.06	880,244.74	764,652.74	796,223.77	892,362.93	0.00	0.00	0.00	0.00	0.00	0.00	5,006,511.24

1119	TANF EXPANDED 65+ M&

342.00	684.00	1,026.00	2,394.00	1,098.14	2,684.77	0.00	0.00	0.00	0.00	0.00	0.00	8,228.91

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	8.72	0.00	0.00	0.00	0.00	0.00	0.00	493.32

1128	TANF EXPANDED 45-64	3,030.80	783.84	3,283.40	3,586.48	2,660.39	3,064.79	0.00	0.00	0.00	0.00	0.00	0.00	16,409.70

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	1,458.13	0.00	0.00	0.00	0.00	0.00	0.00	8,846.82

12,551.22	7,567.69	11,266.27	27,257.02	13,480.55	15,042.13	0.00	0.00	0.00	0.00	0.00	0.00	87,164.88

47,919.09	48,564.00	54,031.56	45,796.97	42,956.65	40,428.58	0.00	0.00	0.00	0.00	0.00	0.00	279,696.85

205,652.65	186,044.63	175,582.01	231,675.45	161,533.14	187,518.19	0.00	0.00	0.00	0.00	0.00	0.00	1,148,006.07

-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	5,439.89	0.00	0.00	0.00	0.00	0.00	0.00	29,058.77

70,066.79	61,883.80	57,114.09	58,998.22	50,285.44	89,316.44	0.00	0.00	0.00	0.00	0.00	0.00	387,664.78

85,071.68	74,095.59	69,290.34	83,409.55	61,957.41	79,231.76	0.00	0.00	0.00	0.00	0.00	0.00	453,056.33

SUBTOTAL:

3,668,481.80

3,379,196.52	3,876,658.18	3,269,182.81	3,128,779.74	3,515,026.49	0.00	0.00	0.00	0.00	0.00	0.00	20,837,325.54

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	44.07	0.00	0.00	0.00	0.00	0.00	0.00	3,068.10

3318	AHC CARE M&F 45-64 N	11,059.15	20,372.17	3,434.97	1,336.45	100.85	650.05	0.00	0.00	0.00	0.00	0.00	0.00	36,953.64

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	694.12	0.00	0.00	0.00	0.00	0.00	0.00	45,791.60

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 December 31, 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	376.14	0.00	0.00	0.00	0.00	0.00	0.00	14,477.41

3615	AHC CARE/MI FEMALE
1

6,338.94	1,363.64	688.74	341.22	429.84	83.02	0.00	0.00	0.00	0.00	0.00	0.00	9,245.40

3616	AHC CARE/MI MALE 21-	11,700.14	22,355.93	3,742.25	14,955.13	1,966.90	2,403.35	0.00	0.00	0.00	0.00	0.00	0.00	57,123.70

3617	AHC CARE/MI FEMALE
2

-10,085.42	14,975.79	1,345.49	2,594.02	2,174.45	1,908.06	0.00	0.00	0.00	0.00	0.00	0.00	12,912.39

3618	AHC CARE/MI M&F 45-6	102,440.36	47,844.90	2,478.30	26,770.49	-8,989.12	4,841.39	0.00	0.00	0.00	0.00	0.00	0.00	175,386.32

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	9,611.96	0.00	0.00	0.00	0.00	0.00	0.00	271,489.85

3506	ADULT 40-100% MALE 2	684.00	2,736.00	0.00	1,368.00	435.98	59.40	0.00	0.00	0.00	0.00	0.00	0.00	5,283.38

3507	ADULT 40-100% FEMAL E

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	6,903.21	0.00	0.00	0.00	0.00	0.00	0.00	52,888.64

3509	ADULT 40-100% M&F 65	4,900.96	3,425.25	1,759.86	24.59	-138.22	1,898.97	0.00	0.00	0.00	0.00	0.00	0.00	11,871.41

3514	ADULT 40-100% MALE 1	11,956.88	15,259.04	11,015.99	6,091.76	5,163.66	7,591.36	0.00	0.00	0.00	0.00	0.00	0.00	57,078.69

3515	ADULT 40-100% FEMAL E

30,135.72	25,033.04	38,775.33	28,669.44	27,488.27	23,746.53	0.00	0.00	0.00	0.00	0.00	0.00	173,848.33

3516	ADULT 40-100% MALE 2	214,543.22	272,200.59	396,809.12	243,752.03	248,328.90	272,105.94	0.00	0.00	0.00	0.00	0.00	0.00	1,647,739.80

3517	ADULT 40-100% FEMAL E

353,269.80	308,087.27	365,630.82	332,449.95	338,773.56	368,657.12	0.00	0.00	0.00	0.00	0.00	0.00	2,066,868.52

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	1,110,055.58	0.00	0.00	0.00	0.00	0.00	0.00	6,491,250.44

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	-59.40	0.00	0.00	0.00	0.00	0.00	0.00	152.46

3529	ADULT 40-100% M&F 65	192.12	71.86	424.98	0.00	93.17	57.11	0.00	0.00	0.00	0.00	0.00	0.00	839.24

3706	ADULT <40% EXP MALE	1,792.92	1,968.09	297.17	182.40	627.67	192.00	0.00	0.00	0.00	0.00	0.00	0.00	5,060.25

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

1,067.23	420.38	-251.10	1,380.33	741.96	1,349.39	0.00	0.00	0.00	0.00	0.00	0.00	4,708.19

14,748.72	7,103.33	9,806.11	6,948.85	3,447.77	5,941.34	0.00	0.00	0.00	0.00	0.00	0.00	47,996.12

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

3714	ADULT <40% EXP MALE	239,581.44	231,188.42	205,950.10	196,940.37	253,893.37	214,249.35	0.00	0.00	0.00	0.00	0.00	0.00	1,341,803.05

3715	ADULT <40% EXP FEM AL

359,309.33	351,228.87	363,914.24	341,840.78	251,734.54	295,640.31	0.00	0.00	0.00	0.00	0.00	0.00	1,963,668.07

3716	ADULT <40% EXP MALE	3,847,800.35	3,546,062.74	4,041,892.63	3,442,949.46	3,052,156.77	3,352,667.69	0.00	0.00	0.00	0.00	0.00	0.00	21,283,529.64

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

2,702,957.26	2,499,001.62	2,930,369.65	2,323,636.33	2,219,259.83	2,273,036.74	0.00	0.00	0.00	0.00	0.00	0.00	14,948,261.43

5,364,337.66	4,940,915.69	5,614,113.55	4,577,348.60	4,831,791.23	4,906,661.89	0.00	0.00	0.00	0.00	0.00	0.00	30,235,168.62

2,748.00	1,368.00	39,287.82	1,710.00	5,814.00	4,350.29	0.00	0.00	0.00	0.00	0.00	0.00	55,278.11

3726	ADULT <40% EXP MALE	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

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	1,026.00	0.00	569.61	193.95	342.00	0.00	0.00	0.00	0.00	0.00	0.00	2,131.56

SUBTOTAL:

14,288,592.20

13,293,822.90     15,303,619.55     12,461,534.03     12,212,840.75     12,845,446.82	0.00	0.00	0.00	0.00	0.00	0.00	80,405,856.25

3906	NEWLY ELIGIBLE MALE	0.00	203.20	1,275.39	828.81	701.91	236.40	0.00	0.00	0.00	0.00	0.00	0.00	

3,245.71

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 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	2,394.00	0.00	0.00	0.00	0.00	0.00	0.00	5,142.00

15,345.28	11,628.43	8,100.42	10,133.07	1,752.05	4,453.59	0.00	0.00	0.00	0.00	0.00	0.00	51,412.84

735.29	3,671.34	5,409.63	1,978.28	869.70	342.00	0.00	0.00	0.00	0.00	0.00	0.00	13,006.24

3914	NEWLY ELIGIBLE MALE	4,167.88	7,302.00	4,425.47	2,808.00	1,488.00	2,100.00	0.00	0.00	0.00	0.00	0.00	0.00	22,291.35

3915	NEWLY ELIGIBLE FEMA L

6,849.61	5,130.00	5,153.95	16,192.56	9,918.00	8,892.00	0.00	0.00	0.00	0.00	0.00	0.00	52,136.12

3916	NEWLY ELIGIBLE MALE	163,852.24	96,121.50	114,419.26	136,067.12	99,557.58	147,259.86	0.00	0.00	0.00	0.00	0.00	0.00	757,277.56

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	182,779.87	0.00	0.00	0.00	0.00	0.00	0.00	868,505.72

497,280.63	460,771.54	605,755.88	482,433.85	408,590.11	510,683.87	0.00	0.00	0.00	0.00	0.00	0.00	2,965,515.88

1,368.00	684.00	342.00	342.00	684.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	3,762.00

0.00	0.00	1,828.80	0.00	0.00	81.04	0.00	0.00	0.00	0.00	0.00	0.00	1,909.84

SUBTOTAL:

821,286.14

739,457.74	910,004.22	770,177.35	643,715.18	859,564.63	0.00	0.00	0.00	0.00	0.00	0.00	4,744,205.26

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	342.00	0.00	0.00	0.00	0.00	0.00	0.00	11,478.00

220,130.89	222,012.81	266,413.75	194,465.10	218,511.10	269,032.43	0.00	0.00	0.00	0.00	0.00	0.00	1,390,566.08

4414	SOBRA 100-133% MALE	72,117.92	76,274.16	82,444.14	73,759.67	76,608.64	119,426.62	0.00	0.00	0.00	0.00	0.00	0.00	500,631.15

4415	SOBRA 100-133% FEMA L

96,355.37	96,932.98	126,797.45	85,782.45	115,138.49	95,705.82	0.00	0.00	0.00	0.00	0.00	0.00	616,712.56

SUBTOTAL:

393,242.18

397,613.95	477,365.34	355,375.22	411,284.23	484,506.87	0.00	0.00	0.00	0.00	0.00	0.00	2,519,387.79

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	5,195.38	0.00	0.00	0.00	0.00	0.00	0.00	9,251.38

32,045.00	11,844.27	17,920.12	9,400.87	6,805.04	4,847.40	0.00	0.00	0.00	0.00	0.00	0.00	82,862.70

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	10,042.78	0.00	0.00	0.00	0.00	0.00	0.00	95,534.08

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	1,055.50	0.00	0.00	0.00	0.00	0.00	0.00	7,829.38

2,736.00	2,394.00	2,736.00	2,394.00	1,026.00	3,420.00	0.00	0.00	0.00	0.00	0.00	0.00	14,706.00

256.13	68.12	137.78	69.66	559.18	188.46	0.00	0.00	0.00	0.00	0.00	0.00	1,279.33

SUBTOTAL:

4,446.55

2,886.11	6,336.11	2,559.36	2,922.62	4,663.96	0.00	0.00	0.00	0.00	0.00	0.00	23,814.71

TOTAL:	51,730,894.65	46,543,716.02	52,449,229.88	44,102,769.25	43,346,336.90	46,652,366.06	0.00	0.00	0.00	0.00	0.00	0.00	284,825,312.76		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending December 31, 2014

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

1006	TANF 21-44 MALE WITH	18,511.10	5,509.22	4,738.73	9,532.59	4,948.54	7,607.61	0.00	0.00	0.00	0.00	0.00	0.00	50,847.79

1007	TANF 21-44 FEMALE WI	15,246.21	13,392.53	6,751.56	14,675.65	9,577.76	11,336.80	0.00	0.00	0.00	0.00	0.00	0.00	70,980.51

1008	TANF 45-64 M & F WIT	4,700.46	1,563.84	2,961.12	3,335.97	1,094.93	2,165.61	0.00	0.00	0.00	0.00	0.00	0.00	15,821.93

1009	TANF 65+ M & F WITH	554.64	167.54	167.54	989.97	404.94	1,330.92	0.00	0.00	0.00	0.00	0.00	0.00	3,615.55

1011	TANF <1 M & F NON-ME	732,298.41	755,161.45	702,747.44	425,059.42	508,751.19	850,197.43	0.00	0.00	0.00	0.00	0.00	0.00	3,974,215.34

1012	TANF 01-05 M & F NON	531,443.83	479,890.34	537,804.59	527,849.95	491,968.59	558,596.32	0.00	0.00	0.00	0.00	0.00	0.00	3,127,553.62

1013	TANF 06-13 M & F NON	506,765.09	421,076.98	618,501.33	631,612.73	635,945.71	770,569.09	0.00	0.00	0.00	0.00	0.00	0.00	3,584,470.93

1014	TANF 14-20 MALE NON-	215,330.10	202,961.83	122,006.47	131,859.01	138,434.30	149,689.00	0.00	0.00	0.00	0.00	0.00	0.00	960,280.71

1015	TANF 14-20 FEMALE N O

209,694.11	211,625.01	232,455.11	265,468.10	249,410.28	272,321.91	0.00	0.00	0.00	0.00	0.00	0.00	1,440,974.52

1016	TANF 21-44 MALE NON-	445,479.43	357,175.48	371,805.96	385,447.27	373,782.12	534,280.58	0.00	0.00	0.00	0.00	0.00	0.00	2,467,970.84

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	1,886,014.05	0.00	0.00	0.00	0.00	0.00	0.00	9,820,763.71

1018	TANF 45-64 M & F NON	635,145.79	572,301.18	372,748.14	531,665.84	436,040.96	645,487.24	0.00	0.00	0.00	0.00	0.00	0.00	3,193,389.15

1019	TANF 65+ M & F NON-M	0.00	1,192.98	168.02	129.21	0.00	267.82	0.00	0.00	0.00	0.00	0.00	0.00	1,758.03

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	1,153.89	0.00	0.00	0.00	0.00	0.00	0.00	3,100.68

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

52,744.87	38,379.36	63,306.89	38,592.69	38,601.30	41,184.93	0.00	0.00	0.00	0.00	0.00	0.00	272,810.04

35,489.62	32,547.24	28,257.86	33,757.70	62,370.88	91,648.46	0.00	0.00	0.00	0.00	0.00	0.00	284,071.76

2120	SSI AGED WITH QMB	242,074.39	213,448.56	215,432.79	251,120.09	199,731.99	296,487.60	0.00	0.00	0.00	0.00	0.00	0.00	1,418,295.42

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	208,194.12	0.00	0.00	0.00	0.00	0.00	0.00	1,089,275.73

3,163,355.90	2,743,716.75	2,913,378.24	3,184,896.21	2,948,173.40	3,422,126.69	0.00	0.00	0.00	0.00	0.00	0.00	18,375,647.19

1,005,134.11	652,376.80	671,203.10	879,517.48	604,374.03	971,973.67	0.00	0.00	0.00	0.00	0.00	0.00	4,784,579.19

2300	SSI BLIND WITH MEDIC	1,296.92	715.33	578.36	108.23	597.93	1,358.09	0.00	0.00	0.00	0.00	0.00	0.00	4,654.86

2310	SSI BLIND NON-MEDIC A

59,530.65	29,246.29	32,265.52	41,267.97	24,024.61	47,182.28	0.00	0.00	0.00	0.00	0.00	0.00	233,517.32

2320	SSI BLIND WITH QMB	15,673.05	11,384.27	5,603.15	7,539.34	7,929.81	7,979.93	0.00	0.00	0.00	0.00	0.00	0.00	56,109.55

4311	SOBRA CHILD <1 M & F	980,037.24	310,735.71	613,881.86	590,179.30	786,237.87	817,256.11	0.00	0.00	0.00	0.00	0.00	0.00	4,098,328.09

4312	SOBRA CHILD 01-05 M	201,675.08	181,056.35	215,879.69	244,914.68	206,873.63	264,302.95	0.00	0.00	0.00	0.00	0.00	0.00	1,314,702.38

4313	SOBRA CHILD 06-13 M	183,132.69	165,135.66	233,840.47	255,298.13	259,773.05	336,593.81	0.00	0.00	0.00	0.00	0.00	0.00	1,433,773.81

4314	SOBRA CHILD 14-20 MA	100,507.75	88,002.42	83,325.00	101,286.62	131,567.89	224,273.14	0.00	0.00	0.00	0.00	0.00	0.00	728,962.82

4315	SOBRA CHILD 14-20 FE	122,461.08	134,721.79	118,638.74	142,115.11	102,471.48	188,434.83	0.00	0.00	0.00	0.00	0.00	0.00	808,843.03

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	468.03	0.00	0.00	0.00	0.00	0.00	0.00	801.15

139,377.14	102,991.33	94,124.61	75,488.88	92,219.48	72,357.05	0.00	0.00	0.00	0.00	0.00	0.00	576,558.49

432,998.83	322,833.36	357,939.48	266,537.43	275,999.85	346,819.94	0.00	0.00	0.00	0.00	0.00	0.00	2,003,128.89

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 December 31, 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	13,029,659.90	0.00	0.00	0.00	0.00	0.00	0.00	66,204,600.36		

1106	TANF EXPANDED 21-44	20,739.17	8,100.82	5,105.04	16,969.98	16,315.91	25,654.78	0.00	0.00	0.00	0.00	0.00	0.00	92,885.70

1107	TANF EXPANDED 21-44	29,774.01	15,342.27	11,557.24	27,241.00	15,808.78	31,606.96	0.00	0.00	0.00	0.00	0.00	0.00	131,330.26

1108	TANF EXPANDED 45-64	68,920.08	45,889.75	52,345.68	63,765.68	44,053.64	83,548.49	0.00	0.00	0.00	0.00	0.00	0.00	358,523.32

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	7,355.78	0.00	0.00	0.00	0.00	0.00	0.00	58,570.79

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	3,860.05	0.00	0.00	0.00	0.00	0.00	0.00	18,764.09

1113	TANF EXPANDED 06-13	6,195.30	5,396.23	5,514.09	8,387.09	4,731.25	11,193.70	0.00	0.00	0.00	0.00	0.00	0.00	41,417.66

1114	TANF EXPANDED 14-20	1,476.39	759.67	2,431.97	793.98	4,046.68	3,130.26	0.00	0.00	0.00	0.00	0.00	0.00	12,638.95

1115	TANF EXPANDED 14-20	8,362.55	3,636.28	5,678.74	11,722.66	9,565.08	8,621.41	0.00	0.00	0.00	0.00	0.00	0.00	47,586.72

1116	TANF EXPANDED 21-44	160,136.01	138,780.95	155,648.92	181,818.28	166,653.11	251,575.84	0.00	0.00	0.00	0.00	0.00	0.00	1,054,613.11

1117	TANF EXPANDED 21-44	325,927.10	311,091.45	313,484.04	303,205.38	282,787.57	356,435.46	0.00	0.00	0.00	0.00	0.00	0.00	1,892,931.00

1118	TANF EXPANDED 45-64	213,882.58	282,231.58	291,882.45	403,598.03	308,839.42	406,130.11	0.00	0.00	0.00	0.00	0.00	0.00	1,906,564.17

1119	TANF EXPANDED 65+ M&

2,212.51	3,660.81	319.01	9,424.88	978.17	2,470.29	0.00	0.00	0.00	0.00	0.00	0.00	19,065.67

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	6,566.34	0.00	0.00	0.00	0.00	0.00	0.00	33,346.96

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	1,009.16	0.00	0.00	0.00	0.00	0.00	0.00	17,727.19

7,771.38	3,949.84	19,571.19	6,356.10	9,431.96	8,764.17	0.00	0.00	0.00	0.00	0.00	0.00	55,844.64

97,330.44	71,054.90	28,493.77	28,675.55	24,511.62	30,078.51	0.00	0.00	0.00	0.00	0.00	0.00	280,144.79

251,590.15	212,198.30	189,287.96	257,492.94	202,736.41	251,513.82	0.00	0.00	0.00	0.00	0.00	0.00	1,364,819.58

0.00	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	10,453.85	0.00	0.00	0.00	0.00	0.00	0.00	37,591.75

37,110.66	44,135.71	18,879.29	30,701.48	24,963.28	34,062.73	0.00	0.00	0.00	0.00	0.00	0.00	189,853.15

140,475.36	103,873.91	91,251.84	130,395.87	96,370.81	142,403.88	0.00	0.00	0.00	0.00	0.00	0.00	704,771.67

SUBTOTAL:

1,399,688.11

1,273,150.16	1,221,252.52	1,516,538.22	1,232,563.36	1,676,435.59	0.00	0.00	0.00	0.00	0.00	0.00	8,319,627.96

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	-707.22	0.00	0.00	0.00	0.00	0.00	0.00	-1,968.97

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	-707.22	0.00	0.00	0.00	0.00	0.00	0.00	-1,276.83

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	-748.03	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

-869.16

3.75
2

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending December 31, 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	29,891.97	0.00	0.00	0.00	0.00	0.00	0.00	51,078.22

3617	AHC CARE/MI FEMALE
2

3,444.53	22,145.25	-410.19	2,422.82	-106.50	-2,845.08	0.00	0.00	0.00	0.00	0.00	0.00	24,650.83

3618	AHC CARE/MI M&F 45-6	903.34	18,611.19	-266.03	755.16	111.01	-2,993.93	0.00	0.00	0.00	0.00	0.00	0.00	17,120.74

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	23,304.93	0.00	0.00	0.00	0.00	0.00	0.00	98,752.33

3506	ADULT 40-100% MALE 2	0.00	844.48	47.95	1,648.42	2,757.55	1,748.00	0.00	0.00	0.00	0.00	0.00	0.00	7,046.40

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

3508	ADULT 40-100% M&F 45	13,406.77	29,375.02	8,209.67	6,333.09	24,409.12	7,057.38	0.00	0.00	0.00	0.00	0.00	0.00	88,791.05

3509	ADULT 40-100% M&F 65	2,137.55	313.57	295.02	69.75	85.20	563.80	0.00	0.00	0.00	0.00	0.00	0.00	3,464.89

3514	ADULT 40-100% MALE 1	299.88	76.69	10,062.27	2,334.06	3,113.47	11,571.62	0.00	0.00	0.00	0.00	0.00	0.00	27,457.99

3515	ADULT 40-100% FEMAL E

1,481.60	6,383.38	6,313.09	10,036.45	4,665.75	6,673.90	0.00	0.00	0.00	0.00	0.00	0.00	35,554.17

3516	ADULT 40-100% MALE 2	68,950.30	58,982.36	145,718.92	166,430.07	89,814.56	87,042.44	0.00	0.00	0.00	0.00	0.00	0.00	616,938.65

3517	ADULT 40-100% FEMAL E

48,033.43	59,177.22	71,542.32	75,673.56	70,564.22	104,667.64	0.00	0.00	0.00	0.00	0.00	0.00	429,658.39

3518	ADULT 40-100% M&F 45	247,350.24	297,795.27	264,081.84	326,383.33	331,389.95	475,008.28	0.00	0.00	0.00	0.00	0.00	0.00	1,942,008.91

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	994.55	0.00	0.00	0.00	0.00	0.00	0.00	1,004.88

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

3706	ADULT <40% EXP MALE	0.00	0.00	706.88	0.00	0.00	2,437.57	0.00	0.00	0.00	0.00	0.00	0.00	3,144.45

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

1,699.84	857.70	202.77	2,310.82	176.50	4,795.70	0.00	0.00	0.00	0.00	0.00	0.00	10,043.33

25,187.13	9,795.84	8,317.14	34,199.09	8,292.32	10,892.19	0.00	0.00	0.00	0.00	0.00	0.00	96,683.71

19.51	59.79	399.85	769.60	317.75	328.51	0.00	0.00	0.00	0.00	0.00	0.00	1,895.01

3714	ADULT <40% EXP MALE	96,519.59	99,948.03	73,933.94	60,810.15	54,671.59	94,256.37	0.00	0.00	0.00	0.00	0.00	0.00	480,139.67

3715	ADULT <40% EXP FEM AL

70,257.57	72,084.69	50,645.92	61,101.00	55,344.12	89,415.91	0.00	0.00	0.00	0.00	0.00	0.00	398,849.21

3716	ADULT <40% EXP MALE	2,056,952.53	1,717,512.69	1,635,655.49	1,942,921.88	1,764,448.36	2,192,772.90	0.00	0.00	0.00	0.00	0.00	0.00	11,310,263.85

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

763,329.78	694,754.25	852,786.42	872,179.85	771,277.55	1,138,319.38	0.00	0.00	0.00	0.00	0.00	0.00	5,092,647.23

2,272,604.78	1,714,216.40	2,195,997.31	2,260,024.67	2,159,280.04	2,731,933.74	0.00	0.00	0.00	0.00	0.00	0.00	13,334,056.94

1,162.92	2,296.70	1,971.08	6,521.44	6,116.57	4,101.15	0.00	0.00	0.00	0.00	0.00	0.00	22,169.86

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

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

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	2,003.84	0.00	0.00	0.00	0.00	0.00	0.00	10,580.69

SUBTOTAL:

5,669,460.82

4,764,474.08	5,331,290.31	5,835,977.65	5,346,772.57	6,966,584.87	0.00	0.00	0.00	0.00	0.00	0.00	33,914,560.30

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 December 31, 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	91.02	0.00	0.00	0.00	0.00	0.00	0.00	278.15

20,470.96	14,484.59	7,064.47	7,393.77	1,680.78	5,096.67	0.00	0.00	0.00	0.00	0.00	0.00	56,191.24

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	7.98	0.00	0.00	0.00	0.00	0.00	0.00	369.83

3915	NEWLY ELIGIBLE FEMA L

1,257.16	3,440.78	6,661.64	2,380.78	2,672.71	3,816.05	0.00	0.00	0.00	0.00	0.00	0.00	20,229.12

3916	NEWLY ELIGIBLE MALE	15,313.98	25,583.75	54,954.73	33,336.11	40,173.16	61,938.90	0.00	0.00	0.00	0.00	0.00	0.00	231,300.63

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	34,921.96	0.00	0.00	0.00	0.00	0.00	0.00	194,940.04

112,833.00	101,863.69	155,676.62	183,213.83	130,258.68	239,047.46	0.00	0.00	0.00	0.00	0.00	0.00	922,893.28

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	344,920.04	0.00	0.00	0.00	0.00	0.00	0.00	1,431,832.18

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	32,560.15	0.00	0.00	0.00	0.00	0.00	0.00	140,822.02

4414	SOBRA 100-133% MALE	6,204.87	7,600.45	11,674.28	8,788.49	8,007.27	15,799.06	0.00	0.00	0.00	0.00	0.00	0.00	58,074.42

4415	SOBRA 100-133% FEMA L

15,855.01	8,205.55	8,660.55	9,568.56	32,813.48	28,423.23	0.00	0.00	0.00	0.00	0.00	0.00	103,526.38

SUBTOTAL:

36,520.57

30,131.32	38,730.22	43,336.26	77,185.08	76,782.44	0.00	0.00	0.00	0.00	0.00	0.00	302,685.89

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	20,348.27	0.00	0.00	0.00	0.00	0.00	0.00	43,544.67

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	20,348.27	0.00	0.00	0.00	0.00	0.00	0.00	43,772.18

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	1,639.81	0.00	0.00	0.00	0.00	0.00	0.00	13,109.68

22.57	0.00	0.00	381.74	0.00	174.86	0.00	0.00	0.00	0.00	0.00	0.00	579.17

10.26	26.01	32.42	0.00	41.01	125.31	0.00	0.00	0.00	0.00	0.00	0.00	235.01

SUBTOTAL:

2,201.38

5,527.71	912.99	1,791.25	1,550.55	1,939.98	0.00	0.00	0.00	0.00	0.00	0.00	13,923.86

19,316,598.26	16,026,545.33	17,410,168.87	18,495,681.05	16,940,215.92	22,139,268.80	0.00	0.00	0.00	0.00	0.00	0.00	110,328,478.23	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2014

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

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

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

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

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

1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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-MEDICA
R

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

2310	SSI BLIND NON-MEDIC A

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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 December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

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 December 31, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL 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

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

3515	ADULT 40-100% FEMAL E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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 December 31, 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% FEMA L

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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 December 31, 2014

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

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

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

1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	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	62.70	0.00	0.00	0.00	0.00	0.00	0.00	84.12

1011	TANF <1 M & F NON-ME	32,641.98	541.56	2,292.08	1,081.20	3,965.35	15,581.06	0.00	0.00	0.00	0.00	0.00	0.00	56,103.23

1012	TANF 01-05 M & F NON	9,726.79	10,879.71	10,704.08	29,229.00	5,323.01	32,395.18	0.00	0.00	0.00	0.00	0.00	0.00	98,257.77

1013	TANF 06-13 M & F NON	10,337.38	2,119.92	5,671.19	7,216.60	3,894.86	3,231.92	0.00	0.00	0.00	0.00	0.00	0.00	32,471.87

1014	TANF 14-20 MALE NON-	2,637.34	782.94	303.02	437.44	453.26	2,663.94	0.00	0.00	0.00	0.00	0.00	0.00	7,277.94

1015	TANF 14-20 FEMALE N O

9,633.77	10,933.80	18,126.06	14,115.94	6,604.24	6,400.38	0.00	0.00	0.00	0.00	0.00	0.00	65,814.19

1016	TANF 21-44 MALE NON-	-210.03	1,528.38	2,803.51	3,725.36	13,026.52	3,548.64	0.00	0.00	0.00	0.00	0.00	0.00	24,422.38

1017	TANF 21-44 FEMALE N O

25,840.81	12,347.84	13,803.03	13,332.08	23,928.79	43,160.08	0.00	0.00	0.00	0.00	0.00	0.00	132,412.63

1018	TANF 45-64 M & F NON	5,304.56	11,222.82	24,739.97	10,571.09	4,180.85	3,011.04	0.00	0.00	0.00	0.00	0.00	0.00	59,030.33

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-MEDICA
R

637.35	193.42	1,743.48	-72.49	2,408.61	193.66	0.00	0.00	0.00	0.00	0.00	0.00	5,104.03

18,494.71	22,036.44	13,385.43	24,808.71	11,022.36	27,393.53	0.00	0.00	0.00	0.00	0.00	0.00	117,141.18

2120	SSI AGED WITH QMB	2,170.55	-2,697.32	219.69	106.83	2,442.67	-237.53	0.00	0.00	0.00	0.00	0.00	0.00	2,004.89

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	496.16	0.00	0.00	0.00	0.00	0.00	0.00	8,307.29

105,053.82	209,122.34	14,233.08	27,623.51	41,144.54	124,521.23	0.00	0.00	0.00	0.00	0.00	0.00	521,698.52

2,636.06	979.86	2,151.99	2,424.99	2,291.51	4,084.45	0.00	0.00	0.00	0.00	0.00	0.00	14,568.86

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	12,273.85	0.00	0.00	0.00	0.00	0.00	0.00	156,926.19

4312	SOBRA CHILD 01-05 M	16,415.77	14,505.47	9,347.09	10,961.16	10,489.07	21,762.07	0.00	0.00	0.00	0.00	0.00	0.00	83,480.63

4313	SOBRA CHILD 06-13 M	8,910.38	15,869.21	40,306.43	6,741.09	3,265.01	5,619.73	0.00	0.00	0.00	0.00	0.00	0.00	80,711.85

4314	SOBRA CHILD 14-20 MA	3,167.94	14,900.22	4,753.71	1,882.40	27,838.60	5,260.76	0.00	0.00	0.00	0.00	0.00	0.00	57,803.63

4315	SOBRA CHILD 14-20 FE	7,512.52	8,420.80	1,209.35	2,403.18	12,599.13	8,227.55	0.00	0.00	0.00	0.00	0.00	0.00	40,372.53

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	2,453.44	0.00	0.00	0.00	0.00	0.00	0.00	15,919.56

8,677.15	1,983.35	8,295.19	11,055.70	14,341.20	6,590.59	0.00	0.00	0.00	0.00	0.00	0.00	50,943.18

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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 December 31, 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	328,694.43	0.00	0.00	0.00	0.00	0.00	0.00	1,631,173.60		

1106	TANF EXPANDED 21-44	100.87	0.00	51.03	34.58	1.71	57.07	0.00	0.00	0.00	0.00	0.00	0.00	245.26

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	1,829.93	0.00	0.00	0.00	0.00	0.00	0.00	3,362.11

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	47.05	0.00	0.00	0.00	0.00	0.00	0.00	843.13

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	17.42	0.00	0.00	0.00	0.00	0.00	0.00	2,973.46

1115	TANF EXPANDED 14-20	1,795.17	675.99	18.36	46.44	478.45	105.17	0.00	0.00	0.00	0.00	0.00	0.00	3,119.58

1116	TANF EXPANDED 21-44	8,190.51	8,056.75	2,683.69	7,220.52	14,719.71	14,535.28	0.00	0.00	0.00	0.00	0.00	0.00	55,406.46

1117	TANF EXPANDED 21-44	18,106.82	9,214.66	10,448.05	2,162.79	6,352.61	7,298.26	0.00	0.00	0.00	0.00	0.00	0.00	53,583.19

1118	TANF EXPANDED 45-64	12,066.69	7,108.61	8,473.65	2,086.26	460.87	5,755.51	0.00	0.00	0.00	0.00	0.00	0.00	35,951.59

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	-158.33	0.00	0.00	0.00	0.00	0.00	0.00	361.04

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	2,882.84	0.00	0.00	0.00	0.00	0.00	0.00	8,389.26

0.00	1,192.03	0.00	1,323.58	898.69	107.68	0.00	0.00	0.00	0.00	0.00	0.00	3,521.98

1,266.08	1,879.33	-20.58	613.30	3,749.81	1,859.92	0.00	0.00	0.00	0.00	0.00	0.00	9,347.86

0.00	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	21.80	0.00	0.00	0.00	0.00	0.00	0.00	1,963.89

0.00	0.00	364.40	0.00	3,604.19	-84.18	0.00	0.00	0.00	0.00	0.00	0.00	3,884.41

504.00	504.00	0.00	151.88	1,131.21	302.92	0.00	0.00	0.00	0.00	0.00	0.00	2,594.01

SUBTOTAL:

44,281.56

34,099.65	23,776.26	16,287.05	32,582.91	34,578.34	0.00	0.00	0.00	0.00	0.00	0.00	185,605.77

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	-616.71	0.00	0.00	0.00	0.00	0.00	0.00	-616.71

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	-616.71	0.00	0.00	0.00	0.00	0.00	0.00	-616.71

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	-629.30	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

-629.30

0.00
2

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 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	-629.30	0.00	0.00	0.00	0.00	0.00	0.00	99,637.55

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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	0.00	1,037.95	1,111.41	154.62	640.94	1,401.60	0.00	0.00	0.00	0.00	0.00	0.00	4,346.52

3515	ADULT 40-100% FEMAL E

468.93	4,952.17	301.80	0.00	426.91	586.91	0.00	0.00	0.00	0.00	0.00	0.00	6,736.72

3516	ADULT 40-100% MALE 2	11,090.38	8,180.30	12,187.52	8,047.54	47,784.89	24,877.47	0.00	0.00	0.00	0.00	0.00	0.00	112,168.10

3517	ADULT 40-100% FEMAL E

11,245.70	3,906.95	14,416.97	8,265.10	5,315.72	7,064.14	0.00	0.00	0.00	0.00	0.00	0.00	50,214.58

3518	ADULT 40-100% M&F 45	34,728.21	77,548.47	48,293.72	68,043.28	15,995.20	51,021.42	0.00	0.00	0.00	0.00	0.00	0.00	295,630.30

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

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

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

3706	ADULT <40% EXP MALE	0.00	0.00	-101.13	134.02	-516.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-484.07

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

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	-171.35	0.00	0.00	0.00	0.00	0.00	0.00	3,606.71

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

3714	ADULT <40% EXP MALE	2,032.24	5,562.92	16,066.16	20.67	2,194.40	10,833.05	0.00	0.00	0.00	0.00	0.00	0.00	36,709.44

3715	ADULT <40% EXP FEM AL

3,136.03	1,842.31	1,286.62	2,814.13	1,954.28	1,812.42	0.00	0.00	0.00	0.00	0.00	0.00	12,845.79

3716	ADULT <40% EXP MALE	81,484.42	56,813.62	41,056.81	57,543.56	55,410.44	121,662.05	0.00	0.00	0.00	0.00	0.00	0.00	413,970.90

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

15,464.69	7,575.62	11,004.31	18,345.03	15,707.90	25,521.33	0.00	0.00	0.00	0.00	0.00	0.00	93,618.88

68,101.26	119,344.07	112,828.42	120,940.44	53,059.86	61,079.88	0.00	0.00	0.00	0.00	0.00	0.00	535,353.93

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

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

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

SUBTOTAL:

227,751.86

286,720.57	258,100.30	287,145.84	199,194.56	305,688.92	0.00	0.00	0.00	0.00	0.00	0.00	1,564,602.05

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 December 31, 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	6,353.47	0.00	0.00	0.00	0.00	0.00	0.00	48,661.88

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	12,406.06	0.00	0.00	0.00	0.00	0.00	0.00	29,619.70

45,902.49	23,614.63	57,874.92	12,240.95	1,212.37	15,337.49	0.00	0.00	0.00	0.00	0.00	0.00	156,182.85

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	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	34,097.02	0.00	0.00	0.00	0.00	0.00	0.00	235,503.87

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	139.55	0.00	0.00	0.00	0.00	0.00	0.00	1,296.44

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4415	SOBRA 100-133% FEMA L

798.96	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	139.55	0.00	0.00	0.00	0.00	0.00	0.00	3,128.17

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	4,681.60	0.00	0.00	0.00	0.00	0.00	0.00	10,395.11

0.00	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	4,681.60	0.00	0.00	0.00	0.00	0.00	0.00	10,395.11

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	706,633.85	0.00	0.00	0.00	0.00	0.00	0.00	3,729,429.41	

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 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	15,406.80	0.00	0.00	0.00	0.00	0.00	0.00		137,249.27		
	20,749.45	33,935.21		14,028.3		27,958.67	25,170.82	15,406.80	0.00	0.00	0.00	0.00	0.00	0.00	137,249.27		

IT

SUBTOTAL:	2

TOTAL:	20,749.45	33,935.21	14,028.32	27,958.67	25,170.82	15,406.80	0.00	0.00	0.00	0.00	0.00	0.00	137,249.27		

IT

SUBTOTAL:	0

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending December 31, 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 December 31, 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	211,109.78	0.00	0.00	0.00	0.00	0.00	0.00		1,378,597.54		
	206,280.04	288,775.58		184,962.5		308,199.09	179,270.46	211,109.78	0.00	0.00	0.00	0.00	0.00	0.00	1,378,597.54		

IT

SUBTOTAL:	9

TOTAL:	206,280.04	288,775.58	184,962.59	308,199.09	179,270.46	211,109.78	0.00	0.00	0.00	0.00	0.00	0.00	1,378,597.54		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending December 31, 2014

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

1006	TANF 21-44 MALE WITH	923.62	556.33	113.33	1,498.38	1,334.74	1,446.40	0.00	0.00	0.00	0.00	0.00	0.00	5,872.80

1007	TANF 21-44 FEMALE WI	0.00	0.00	76.06	200.52	1,632.36	1,021.63	0.00	0.00	0.00	0.00	0.00	0.00	2,930.57

1008	TANF 45-64 M & F WIT	17,781.02	3,645.96	1,696.48	3,172.67	1,729.21	528.10	0.00	0.00	0.00	0.00	0.00	0.00	28,553.44

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	43,428.33	0.00	0.00	0.00	0.00	0.00	0.00	475,685.56

1012	TANF 01-05 M & F NON	34,284.92	43,480.32	38,003.35	26,128.25	36,235.11	33,027.01	0.00	0.00	0.00	0.00	0.00	0.00	211,158.96

1013	TANF 06-13 M & F NON	44,810.40	31,224.16	42,153.72	34,681.06	27,156.16	22,442.06	0.00	0.00	0.00	0.00	0.00	0.00	202,467.56

1014	TANF 14-20 MALE NON-	15,430.38	11,665.16	7,111.65	20,421.48	7,244.37	2,791.98	0.00	0.00	0.00	0.00	0.00	0.00	64,665.02

1015	TANF 14-20 FEMALE N O

11,813.66	37,661.22	18,538.76	18,877.44	10,896.16	21,025.64	0.00	0.00	0.00	0.00	0.00	0.00	118,812.88

1016	TANF 21-44 MALE NON-	31,438.66	90,378.80	52,569.64	34,461.16	108,919.86	23,309.93	0.00	0.00	0.00	0.00	0.00	0.00	341,078.05

1017	TANF 21-44 FEMALE N O

210,377.80	194,186.31	222,973.00	144,738.36	350,087.78	230,651.44	0.00	0.00	0.00	0.00	0.00	0.00	1,353,014.69

1018	TANF 45-64 M & F NON	28,096.35	11,656.91	28,065.88	125,478.67	48,338.29	50,892.70	0.00	0.00	0.00	0.00	0.00	0.00	292,528.80

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-MEDICA
R

3,406.77	3,502.09	22,471.78	3,517.45	423.74	1,772.59	0.00	0.00	0.00	0.00	0.00	0.00	35,094.42

3,421.42	2,145.00	8,256.64	512.70	8,011.63	25,051.00	0.00	0.00	0.00	0.00	0.00	0.00	47,398.39

2120	SSI AGED WITH QMB	19,926.84	9,704.83	11,229.65	11,879.83	7,652.19	9,485.76	0.00	0.00	0.00	0.00	0.00	0.00	69,879.10

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	7,637.69	0.00	0.00	0.00	0.00	0.00	0.00	83,442.05

304,798.51	274,300.06	347,966.26	367,239.77	297,453.68	425,900.14	0.00	0.00	0.00	0.00	0.00	0.00	2,017,658.42

44,399.62	28,504.92	37,846.70	41,122.70	31,745.14	51,923.95	0.00	0.00	0.00	0.00	0.00	0.00	235,543.03

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	18,018.26	0.00	0.00	0.00	0.00	0.00	0.00	46,165.51

2320	SSI BLIND WITH QMB	284.04	190.07	34.82	83.25	1,364.10	1,421.91	0.00	0.00	0.00	0.00	0.00	0.00	3,378.19

4311	SOBRA CHILD <1 M & F	68,145.48	122,295.23	44,411.54	51,135.66	70,020.85	80,802.76	0.00	0.00	0.00	0.00	0.00	0.00	436,811.52

4312	SOBRA CHILD 01-05 M	35,241.49	10,786.90	16,480.16	10,148.36	38,674.66	14,867.45	0.00	0.00	0.00	0.00	0.00	0.00	126,199.02

4313	SOBRA CHILD 06-13 M	30,113.38	19,957.23	13,761.72	18,897.97	31,261.64	25,114.53	0.00	0.00	0.00	0.00	0.00	0.00	139,106.47

4314	SOBRA CHILD 14-20 MA	8,988.63	11,572.81	49,513.15	8,829.09	10,119.53	11,679.90	0.00	0.00	0.00	0.00	0.00	0.00	100,703.11

4315	SOBRA CHILD 14-20 FE	5,849.26	9,327.77	19,160.53	25,805.46	6,059.50	24,896.83	0.00	0.00	0.00	0.00	0.00	0.00	91,099.35

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	20,161.18	0.00	0.00	0.00	0.00	0.00	0.00	112,789.71

46,014.10	38,107.35	41,483.13	43,985.14	85,760.52	73,163.80	0.00	0.00	0.00	0.00	0.00	0.00	328,514.04

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 December 31, 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	1,222,462.97	0.00	0.00	0.00	0.00	0.00	0.00	6,975,734.29		

1106	TANF EXPANDED 21-44	119.42	25.23	78.80	47.95	199.06	155.04	0.00	0.00	0.00	0.00	0.00	0.00	625.50

1107	TANF EXPANDED 21-44	1,570.36	494.47	2,718.86	738.57	554.79	2,100.66	0.00	0.00	0.00	0.00	0.00	0.00	8,177.71

1108	TANF EXPANDED 45-64	1,427.07	1,230.37	1,181.81	1,841.38	2,680.20	1,879.82	0.00	0.00	0.00	0.00	0.00	0.00	10,240.65

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	393.84	0.00	0.00	0.00	0.00	0.00	0.00	8,256.77

0.00	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	525.42	0.00	0.00	0.00	0.00	0.00	0.00	1,109.36

1113	TANF EXPANDED 06-13	0.00	23.26	2,001.11	289.33	58.19	25.68	0.00	0.00	0.00	0.00	0.00	0.00	2,397.57

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	287.57	0.00	0.00	0.00	0.00	0.00	0.00	30,133.22

1116	TANF EXPANDED 21-44	35,961.69	29,723.91	64,877.10	39,996.25	29,521.67	48,786.73	0.00	0.00	0.00	0.00	0.00	0.00	248,867.35

1117	TANF EXPANDED 21-44	58,248.53	64,960.99	41,406.57	64,814.97	44,661.09	51,287.93	0.00	0.00	0.00	0.00	0.00	0.00	325,380.08

1118	TANF EXPANDED 45-64	24,913.23	24,501.96	14,774.51	10,276.28	36,244.58	57,446.04	0.00	0.00	0.00	0.00	0.00	0.00	168,156.60

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	174.38	0.00	0.00	0.00	0.00	0.00	0.00	2,351.17

2,136.82	1,127.00	32,303.41	181.99	7,896.84	4,731.55	0.00	0.00	0.00	0.00	0.00	0.00	48,377.61

12,344.05	8,798.39	10,022.98	21,813.21	12,292.05	16,285.22	0.00	0.00	0.00	0.00	0.00	0.00	81,555.90

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

92.70	1,634.66	153.11	633.37	245.75	775.39	0.00	0.00	0.00	0.00	0.00	0.00	3,534.98

209.07	879.14	542.12	152.63	484.69	1,690.72	0.00	0.00	0.00	0.00	0.00	0.00	3,958.37

5,857.19	6,083.62	8,430.23	10,318.47	4,888.14	9,696.68	0.00	0.00	0.00	0.00	0.00	0.00	45,274.33

SUBTOTAL:

145,371.72

165,977.99	181,636.81	158,742.09	141,600.61	196,242.67	0.00	0.00	0.00	0.00	0.00	0.00	989,571.89

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 December 31, 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	0.00	0.00	1,255.78	86.83	0.00	31.50	0.00	0.00	0.00	0.00	0.00	0.00	1,374.11

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

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	238.95	260.24	0.00	0.00	0.00	0.00	0.00	0.00	499.19

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

3514	ADULT 40-100% MALE 1	430.42	0.00	268.68	0.00	0.00	337.13	0.00	0.00	0.00	0.00	0.00	0.00	1,036.23

3515	ADULT 40-100% FEMAL E

0.00	622.49	0.00	59,547.91	88.87	832.56	0.00	0.00	0.00	0.00	0.00	0.00	61,091.83

3516	ADULT 40-100% MALE 2	10,650.89	12,406.82	21,631.24	46,981.49	51,964.90	14,495.98	0.00	0.00	0.00	0.00	0.00	0.00	158,131.32

3517	ADULT 40-100% FEMAL E

23,738.59	15,286.50	26,420.79	6,921.32	12,108.62	13,804.70	0.00	0.00	0.00	0.00	0.00	0.00	98,280.52

3518	ADULT 40-100% M&F 45	29,835.05	35,644.66	66,241.11	44,449.84	44,452.38	36,292.94	0.00	0.00	0.00	0.00	0.00	0.00	256,915.98

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

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

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

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

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

0.00	0.00	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	29.18	0.00	0.00	0.00	0.00	0.00	0.00	8,273.13

0.00	15.53	92.18	0.00	0.00	355.75	0.00	0.00	0.00	0.00	0.00	0.00	463.46

3714	ADULT <40% EXP MALE	9,500.36	10,625.57	21,121.50	11,841.58	3,681.24	39,851.20	0.00	0.00	0.00	0.00	0.00	0.00	96,621.45

3715	ADULT <40% EXP FEM AL

5,377.86	6,773.87	7,868.05	10,382.13	4,451.64	8,838.72	0.00	0.00	0.00	0.00	0.00	0.00	43,692.27

3716	ADULT <40% EXP MALE	277,274.99	198,707.59	245,049.44	174,444.82	231,171.84	198,713.09	0.00	0.00	0.00	0.00	0.00	0.00	1,325,361.77

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

85,369.64	98,701.56	110,904.18	120,526.37	105,896.01	99,243.84	0.00	0.00	0.00	0.00	0.00	0.00	620,641.60

224,721.51	183,380.20	180,656.00	144,133.87	101,728.41	197,478.39	0.00	0.00	0.00	0.00	0.00	0.00	1,032,098.38

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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	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	610,565.22	0.00	0.00	0.00	0.00	0.00	0.00	3,706,063.87

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 December 31, 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	2,517.06	0.00	0.00	0.00	0.00	0.00	0.00	5,487.66

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	12,143.11	0.00	0.00	0.00	0.00	0.00	0.00	32,712.59

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	2,254.19	0.00	0.00	0.00	0.00	0.00	0.00	51,407.80

12,815.15	13,132.47	36,447.31	25,077.39	78,513.35	17,567.47	0.00	0.00	0.00	0.00	0.00	0.00	183,553.14

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

0.00	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	34,481.83	0.00	0.00	0.00	0.00	0.00	0.00	273,830.88

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	3,004.47	0.00	0.00	0.00	0.00	0.00	0.00	26,384.82

4414	SOBRA 100-133% MALE	7,017.47	3,205.98	203.46	528.24	260.08	1,159.55	0.00	0.00	0.00	0.00	0.00	0.00	12,374.78

4415	SOBRA 100-133% FEMA L

381.31	0.00	319.14	1,140.59	9,913.01	3,703.03	0.00	0.00	0.00	0.00	0.00	0.00	15,457.08

SUBTOTAL:

8,988.52

4,661.17	1,822.10	11,942.25	19,019.65	7,867.05	0.00	0.00	0.00	0.00	0.00	0.00	54,300.74

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	2,566.37	0.00	0.00	0.00	0.00	0.00	0.00	15,367.85

0.00	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	2,566.37	0.00	0.00	0.00	0.00	0.00	0.00	15,367.85

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	89.35	0.00	0.00	0.00	0.00	0.00	0.00	89.35

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	89.35	0.00	0.00	0.00	0.00	0.00	0.00	692.85

1,936,034.84	1,839,655.58	2,104,726.02	1,973,692.61	2,093,673.91	2,074,275.46	0.00	0.00	0.00	0.00	0.00	0.00	12,022,058.42	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER

For The Period Ending December 31, 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	684.00	0.00	0.00	0.00	0.00	0.00	0.00	6,557.96

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

182,999.78	206,203.74	177,774.65	192,246.43	141,311.29	189,450.03	0.00	0.00	0.00	0.00	0.00	0.00	1,089,985.92

69,456.96	25,781.96	23,642.14	45,010.52	21,237.89	49,688.78	0.00	0.00	0.00	0.00	0.00	0.00	234,818.25

2120	SSI AGED WITH QMB	194,238.72	171,693.51	188,023.41	210,964.33	149,565.05	176,178.38	0.00	0.00	0.00	0.00	0.00	0.00	1,090,663.40

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	35,765.73	0.00	0.00	0.00	0.00	0.00	0.00	244,197.71

893,176.80	795,148.70	804,113.36	726,804.46	660,524.02	780,792.25	0.00	0.00	0.00	0.00	0.00	0.00	4,660,559.59

75,691.55	64,844.94	78,301.76	97,280.92	63,449.00	77,800.76	0.00	0.00	0.00	0.00	0.00	0.00	457,368.93

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	8,935.89	0.00	0.00	0.00	0.00	0.00	0.00	65,250.16

2320	SSI BLIND WITH QMB	144.17	131.13	248.54	758.75	457.24	1,165.03	0.00	0.00	0.00	0.00	0.00	0.00	2,904.86

SUBTOTAL:

1,471,411.01

1,318,771.80	1,330,018.52	1,331,659.90	1,080,438.73	1,320,460.85	0.00	0.00	0.00	0.00	0.00	0.00	7,852,760.81

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	1,320,460.85	0.00	0.00	0.00	0.00	0.00	0.00	7,852,977.79		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending December 31, 2014

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

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

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

2,664,791.67	2,286,017.04	2,299,939.18	2,502,189.39	2,230,289.96	2,506,926.63	0.00	0.00	0.00	0.00	0.00	0.00	14,490,153.87

179,461.32	166,339.47	142,936.57	138,988.15	157,154.98	155,955.08	0.00	0.00	0.00	0.00	0.00	0.00	940,835.57

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	3,150,517.68	0.00	0.00	0.00	0.00	0.00	0.00	18,051,008.26

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	524,802.68	0.00	0.00	0.00	0.00	0.00	0.00	2,822,139.23

1,779,146.34	1,594,652.73	1,743,036.88	1,697,019.69	1,672,951.87	2,048,985.48	0.00	0.00	0.00	0.00	0.00	0.00	10,535,792.99

668,132.19	607,853.55	577,938.21	677,284.14	613,119.73	679,406.95	0.00	0.00	0.00	0.00	0.00	0.00	3,823,734.77

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	10,740.90	0.00	0.00	0.00	0.00	0.00	0.00	52,941.56

2320	SSI BLIND WITH QMB	8,442.00	8,076.27	4,987.34	10,018.61	7,281.11	4,993.12	0.00	0.00	0.00	0.00	0.00	0.00	43,798.45

SUBTOTAL:

8,958,286.43

7,902,754.78	8,007,612.46	8,777,861.74	8,031,960.94	9,082,328.52	0.00	0.00	0.00	0.00	0.00	0.00	50,760,804.87

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	3,376.80	0.00	0.00	0.00	0.00	0.00	0.00	17,752.04

SUBTOTAL:

2,742.24

7,191.30	5,252.02	5,132.18	5,183.76	3,376.80	0.00	0.00	0.00	0.00	0.00	0.00	28,878.30

8,961,028.67	7,909,946.08	8,012,864.48	8,782,993.92	8,037,144.70	9,085,705.32	0.00	0.00	0.00	0.00	0.00	0.00	50,789,683.17	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2014

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

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

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

46,355.76	35,342.62	62,560.09	36,171.51	18,075.85	52,064.05	0.00	0.00	0.00	0.00	0.00	0.00	250,569.88

8,709.42	6,954.55	2,685.44	39,124.80	247.92	14,408.00	0.00	0.00	0.00	0.00	0.00	0.00	72,130.13

2120	SSI AGED WITH QMB	1,098.73	24.23	571.16	751.60	76.49	4,648.31	0.00	0.00	0.00	0.00	0.00	0.00	7,170.52

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	1,804.64	0.00	0.00	0.00	0.00	0.00	0.00	26,910.71

28,693.95	27,064.64	25,095.06	37,137.90	10,069.22	36,168.46	0.00	0.00	0.00	0.00	0.00	0.00	164,229.23

2,249.80	1,733.79	2,228.64	353.86	4,127.59	905.92	0.00	0.00	0.00	0.00	0.00	0.00	11,599.60

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	109,999.38	0.00	0.00	0.00	0.00	0.00	0.00	532,610.07

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	109,999.38	0.00	0.00	0.00	0.00	0.00	0.00	532,610.07		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV

For The Period Ending December 31, 2014

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

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

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

55,086.53	25,684.88	7,433.80	13,949.00	15,514.72	35,843.52	0.00	0.00	0.00	0.00	0.00	0.00	153,512.45

203.41	13.42	0.00	89.92	2,366.43	5,099.26	0.00	0.00	0.00	0.00	0.00	0.00	7,772.44

2120	SSI AGED WITH QMB	18,563.57	20,222.12	16,726.53	20,613.05	12,975.79	13,463.79	0.00	0.00	0.00	0.00	0.00	0.00	102,564.85

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	2,380.39	0.00	0.00	0.00	0.00	0.00	0.00	20,053.98

64,499.20	29,900.95	25,663.57	40,573.51	63,617.11	42,490.04	0.00	0.00	0.00	0.00	0.00	0.00	266,744.38

7,643.16	7,620.19	4,440.35	10,309.21	4,246.78	5,935.38	0.00	0.00	0.00	0.00	0.00	0.00	40,195.07

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	732.81	0.00	0.00	0.00	0.00	0.00	0.00	1,799.15

2320	SSI BLIND WITH QMB	48.02	462.91	127.45	48.02	48.02	48.02	0.00	0.00	0.00	0.00	0.00	0.00	782.44

SUBTOTAL:

152,773.47

89,123.29	57,240.11	87,301.23	101,020.38	105,993.21	0.00	0.00	0.00	0.00	0.00	0.00	593,451.69

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

152,773.47	89,123.29	57,240.11	87,301.23	101,020.38	105,993.21	0.00	0.00	0.00	0.00	0.00	0.00	593,451.69	

TOTAL:

KidsCare - CAPITATION AMOUNTS

For The Period Ending December 31, 2014

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

6011	KIDS <1M&F NON MEDI C

4,524.22	4,734.91	4,529.87	4,251.11	3,344.55	26,299.99	0.00	0.00	0.00	0.00	0.00	0.00	47,684.65

6012	KIDS 1-5 M & F NON-M	3,921.57	2,756.23	2,851.52	2,435.47	1,913.97	126,341.41	0.00	0.00	0.00	0.00	0.00	0.00	140,220.17

6013	KIDS 6-13 M & F NON-	129,970.36	125,163.63	123,163.41	125,050.70	123,469.39	456,109.13	0.00	0.00	0.00	0.00	0.00	0.00	1,082,926.62

6014	KIDS 14-19 MALE NON-	69,288.89	68,444.73	69,540.30	73,816.22	72,411.46	204,535.12	0.00	0.00	0.00	0.00	0.00	0.00	558,036.72

6015	KIDS 14-19 FEMALE NO	110,216.77	112,119.60	111,831.80	118,788.21	118,988.95	309,764.55	0.00	0.00	0.00	0.00	0.00	0.00	881,709.88

9960	KIDSCARE KICK PAYME N

0.00	6,046.14	0.00	0.00	0.00	6,216.14	0.00	0.00	0.00	0.00	0.00	0.00	12,262.28

SUBTOTAL:

317,921.81

319,265.24	311,916.90	324,341.71	320,128.32	1,129,266.34	0.00	0.00	0.00	0.00	0.00	0.00	2,722,840.32

TOTAL:	317,921.81	319,265.24	311,916.90	324,341.71	320,128.32	1,129,266.34	0.00	0.00	0.00	0.00	0.00	0.00	2,722,840.32		

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending December 31, 2014

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

6011	KIDS <1M&F NON MEDI C

10.00	10.45	10.00	9.00	7.00	6.41	0.00	0.00	0.00	0.00	0.00	0.00	52.86

6012	KIDS 1-5 M & F NON-M	38.83	26.67	28.00	23.00	18.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	148.50

6013	KIDS 6-13 M & F NON-	1,047.73	1,020.93	1,001.01	984.05	956.82	936.50	0.00	0.00	0.00	0.00	0.00	0.00	5,947.04

6014	KIDS 14-19 MALE NON-	406.52	407.06	414.19	419.20	417.00	421.24	0.00	0.00	0.00	0.00	0.00	0.00	2,485.21

6015	KIDS 14-19 FEMALE NO	440.63	448.54	447.83	452.69	453.00	456.52	0.00	0.00	0.00	0.00	0.00	0.00	2,699.21

9960	KIDSCARE KICK PAYME N

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

SUBTOTAL:

1,943.71

1,914.65	1,901.03	1,887.94	1,851.82	1,835.67	0.00	0.00	0.00	0.00	0.00	0.00	11,334.82

1,943.71	1,914.65	1,901.03	1,887.94	1,851.82	1,835.67	0.00	0.00	0.00	0.00	0.00	0.00	11,334.82	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending December 31, 2014

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

6011	KIDS <1M&F NON MEDI C

409.20	409.20	409.20	371.40	297.12	1,381.26	0.00	0.00	0.00	0.00	0.00	0.00	3,277.38

6012	KIDS 1-5 M & F NON-M	1,488.00	1,190.40	1,078.80	891.36	705.66	26,429.12	0.00	0.00	0.00	0.00	0.00	0.00	31,783.34

6013	KIDS 6-13 M & F NON-	38,650.80	37,869.60	36,976.80	36,248.64	35,357.28	103,855.26	0.00	0.00	0.00	0.00	0.00	0.00	288,958.38

6014	KIDS 14-19 MALE NON-	15,387.26	15,555.32	15,807.19	15,809.34	15,758.22	35,406.12	0.00	0.00	0.00	0.00	0.00	0.00	113,723.45

6015	KIDS 14-19 FEMALE NO	17,426.93	17,678.80	17,772.90	17,525.61	17,618.67	36,740.15	0.00	0.00	0.00	0.00	0.00	0.00	124,763.06

SUBTOTAL:

73,362.19

72,703.32	72,044.89	70,846.35	69,736.95	203,811.91	0.00	0.00	0.00	0.00	0.00	0.00	562,505.61

TOTAL:	73,362.19	72,703.32	72,044.89	70,846.35	69,736.95	203,811.91	0.00	0.00	0.00	0.00	0.00	0.00	562,505.61		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending December 31, 2014

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

6011	KIDS <1M&F NON MEDI C

11.00	11.00	11.00	10.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	58.00

6012	KIDS 1-5 M & F NON-M	40.00	32.00	29.00	24.00	19.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	158.00

6013	KIDS 6-13 M & F NON-	1,039.00	1,018.00	994.00	976.00	952.00	937.00	0.00	0.00	0.00	0.00	0.00	0.00	5,916.00

6014	KIDS 14-19 MALE NON-	402.00	405.00	410.00	414.00	413.00	416.00	0.00	0.00	0.00	0.00	0.00	0.00	2,460.00

6015	KIDS 14-19 FEMALE NO	450.00	455.00	455.00	454.00	455.00	459.00	0.00	0.00	0.00	0.00	0.00	0.00	2,728.00

SUBTOTAL:

1,942.00

1,921.00	1,899.00	1,878.00	1,847.00	1,833.00	0.00	0.00	0.00	0.00	0.00	0.00	11,320.00

TOTAL:

1,942.00

1,921.00	1,899.00	1,878.00	1,847.00	1,833.00	0.00	0.00	0.00	0.00	0.00	0.00	11,320.00

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	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	416.93	0.00	0.00	0.00	0.00	0.00	0.00		833.86		
	0.00	393.96		393.9		416.93	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	2,038.71		

SUBTOTAL:	6

TOTAL:	0.00	393.96	393.96	416.93	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	2,038.71		

SUBTOTAL:	0

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
	0.00	1.00		1.0		1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00		

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

TOTAL:

KidsCare - FEE FOR SERVICE

For The Period Ending December 31, 2014

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

6011	KIDS <1M&F NON MEDI C

518.72	0.00	-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	1,050.09	0.00	0.00	0.00	0.00	0.00	0.00	19,548.56

6014	KIDS 14-19 MALE NON-	1,847.16	1,367.27	5,093.48	1,279.55	804.58	1,224.83	0.00	0.00	0.00	0.00	0.00	0.00	11,616.87

6015	KIDS 14-19 FEMALE NO	6,826.40	349.49	512.47	967.25	538.76	690.08	0.00	0.00	0.00	0.00	0.00	0.00	9,884.45

SUBTOTAL:

20,032.56

15,147.84	7,668.80	3,767.34	3,981.38	2,965.00	0.00	0.00	0.00	0.00	0.00	0.00	53,562.92

TOTAL:	20,032.56	15,147.84	7,668.80	3,767.34	3,981.38	2,965.00	0.00	0.00	0.00	0.00	0.00	0.00	53,562.92		

SUBTOTAL:			0		
TOTAL:	-99,947.16	14,868.46	81,729.60	563.56	27,046.55	29,952.95	0.00	0.00	0.00	0.00	0.00	0.00	54,213.96	

KidsCare - REINSURANCE

For The Period Ending December 31, 2014	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	-163,807.93	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	29,570.11	0.00	0.00	0.00	0.00	0.00	0.00		106,960.13		
6014	KIDS 14-19 MALE NON-	28,000.15	0.00	54,765.76	-77.00	26,962.45	382.84	0.00	0.00	0.00	0.00	0.00	0.00		110,034.20		
	-99,947.16	14,868.46		81,729.6		563.56	27,046.55	29,952.95	0.00	0.00	0.00	0.00	0.00	0.00	54,213.96		

110007 DES-DD - CAP MEMBER MONTHS

For The Period Ending December 31, 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	2.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1010	TANF NON-MEDICARE	618.38	616.83	616.45	620.62	620.62	620.96	0.00	0.00	0.00	0.00	0.00	0.00		3,713.86		
101Z	TANF ALTCS NON-MEDIC	0.00	0.00	0.00	0.00	0.00	0.45	0.00	0.00	0.00	0.00	0.00	0.00		0.45		
1020	TANF WITH QMB	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
2100	SSI AGED WITH MEDICA	146.99	145.63	148.00	147.00	146.33	150.00	0.00	0.00	0.00	0.00	0.00	0.00		883.95		
2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
2120	SSI AGED WITH QMB	236.79	237.09	241.99	240.01	240.00	243.77	0.00	0.00	0.00	0.00	0.00	0.00		1,439.65		
2200	SSI DISABLED WITH ME	1,737.61	1,747.31	1,738.54	1,777.91	1,778.76	1,796.54	0.00	0.00	0.00	0.00	0.00	0.00		10,576.67		
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	20,869.76	0.00	0.00	0.00	0.00	0.00	0.00		123,593.36		
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	3,876.25	0.00	0.00	0.00	0.00	0.00	0.00		23,124.36		
2300	SSI BLIND WITH MEDIC	15.00	15.00	15.00	15.00	13.38	16.00	0.00	0.00	0.00	0.00	0.00	0.00		89.38		
2310	SSI BLIND NON-MEDICA	112.93	113.00	113.73	114.00	115.36	118.00	0.00	0.00	0.00	0.00	0.00	0.00		687.02		
2320	SSI BLIND WITH QMB	29.00	28.00	26.93	28.00	27.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00		163.93		
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
8720	SSI DISABLED FREEDOM	3.00	3.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
	27,092.09	27,219.80	27,361.92	27,443.67	27,542.21	27,735.73	0.00	0.00	0.00	0.00	0.00	0.00	164,395.42		
	27,092.09	27,219.80	27,361.92	27,443.67	27,542.21	27,735.73	0.00	0.00	0.00	0.00	0.00	0.00	164,395.42		

SUBTOTAL: TOTAL:

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending December 31, 2014

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL EPD
TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	378,800.20
81,832,334.90	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	372,298.89
84,421,747.15	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	2,259,258.90
517,601,132.84	
	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	84,794,046.04
93,945,839.51	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	519,860,391.74
550,571,308.68	
	90,441,057.34	90,874,990.67	91,356,447.37	91,810,801.83	92,142,171.96	93,945,839.51	0.00	0.00	0.00	0.00	0.00	0.00	550,571,308.68	
TOTAL LTC - CAP	172,652,192.44	182,816,154.65	174,463,367.98	175,962,165.47	185,797,934.33	178,739,885.55	0.00	0.00	0.00	0.00	0.00	0.00	1,070,431,700.42	

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	10,622,158.76
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	59,768,722.72
0.00	
	0.00	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	10,622,158.76	0.00	0.00	0.00	0.00	0.00	0.00	59,768,722.72	

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	3,769,357.44
226,816.51	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	23,799,917.51
1,686,886.37	
	247,514.04	218,495.45	397,973.54	266,868.90	329,217.93	226,816.51	0.00	0.00	0.00	0.00	0.00	0.00	1,686,886.37	
TOTAL LTC - REIN	3,351,664.59	3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	3,996,173.95	0.00	0.00	0.00	0.00	0.00	0.00	25,486,803.88	

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	3,133,155.70	0.00	0.00	0.00	0.00	0.00	0.00	18,277,938.20	

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.

118

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending December 31, 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	15,068,983.78	0.00	0.00	0.00	0.00	0.00	0.00	81,524,471.75	
010145	CRS ACUTE SEMI INTEGRATED - CAP	140,282.17	106,532.24	121,467.59	113,733.94	117,439.75	133,572.59	0.00	0.00	0.00	0.00	0.00	0.00	733,028.28	
999125	CRS SEMI INTEGRATED PLAN - CAP	0.00	3,003,198.75	3,005,592.50	3,164,310.09	3,177,387.83	3,179,399.79	0.00	0.00	0.00	0.00	0.00	0.00	15,529,888.96	
999135	CRS ONLY PLAN - CAP	0.00	450,296.28	451,872.12	481,137.22	471,964.76	476,134.06	0.00	0.00	0.00	0.00	0.00	0.00	2,331,404.44	
	14,492,208.86	16,256,282.82	16,396,452.81	17,073,143.25	17,042,615.47	18,858,090.22	0.00	0.00	0.00	0.00	0.00	0.00	100,118,793.43	

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

TOTAL

Thursday, January 15, 2015

999155	CRS REINSURANCE ONLY	2,324,970.00	490,042.82	1,745,299.36	450,149.05	1,230,087.38	532,316.45	0.00	0.00	0.00	0.00	0.00	0.00	6,772,865.06	
	2,324,970.00	490,042.82	1,745,299.36	450,149.05	1,230,087.38	532,316.45	0.00	0.00	0.00	0.00	0.00	0.00	6,772,865.06	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC CAP	52,459.25	49,207.44	49,167.91	51,977.51	52,127.84	161,303.67	0.00	0.00	0.00	0.00	0.00	0.00	416,243.62	
010145	CRS ACUTE SEMI INTEGRATED - KC CAP	0.00	0.00	0.00	0.00	0.00	1,108.66	0.00	0.00	0.00	0.00	0.00	0.00	1,108.66	
999135	CRS ONLY PLAN - KC CAP	0.00	393.96	393.96	416.93	416.93	416.93	0.00	0.00	0.00	0.00	0.00	0.00	2,038.71	
	52,459.25	49,601.40	49,561.87	52,394.44	52,544.77	162,829.26	0.00	0.00	0.00	0.00	0.00	0.00	419,390.99	

Subtotal

Subtotal

16,869,638.11	16,795,927.04	18,191,314.04	17,575,686.74	18,325,247.62	19,553,235.93	0.00	0.00	0.00	0.00	0.00	0.00	107,311,049.48	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending December 31, 2014

010115	CRS FULLY INTEGRATED PLAN - MM	19,358.09	17,125.68	17,289.14	17,094.47	17,044.52	16,953.90	0.00	0.00	0.00	0.00	0.00	0.00	104,865.80	
010145	CRS ACUTE SEMI INTEGRATED - MM	213.57	162.16	184.98	164.14	169.52	171.53	0.00	0.00	0.00	0.00	0.00	0.00	1,065.90	
999125	CRS SEMI INTEGRATED PLAN - MM	0.00	6,273.00	6,278.00	6,291.00	6,317.00	6,321.00	0.00	0.00	0.00	0.00	0.00	0.00	31,480.00	
999135	CRS ONLY PLAN - MM	0.00	1,143.00	1,147.00	1,154.00	1,132.00	1,142.00	0.00	0.00	0.00	0.00	0.00	0.00	5,718.00	
	19,571.66	24,703.84	24,899.12	24,703.61	24,663.04	24,588.43	0.00	0.00	0.00	0.00	0.00	0.00	143,129.70	

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

TOTAL

Thursday, January 15, 2015

010115	CRS FULLY INTEGRATED PLAN - KC MM	70.77	66.38	66.38	66.69	67.00	64.70	0.00	0.00	0.00	0.00	0.00	0.00	401.92	
010145	CRS ACUTE SEMI INTEGRATED - KC MM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
999135	CRS ONLY PLAN - KC MM	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
	70.77	67.38	67.38	67.69	68.00	65.70	0.00	0.00	0.00	0.00	0.00	0.00	406.92	

Subtotal

Subtotal

19,642.43	24,771.22	24,966.50	24,771.30	24,731.04	24,654.13	0.00	0.00	0.00	0.00	0.00	0.00	143,536.62	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending December 31, 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	45,058,011.01	0.00	0.00	0.00	0.00	0.00	0.00	261,311,113.46	
	41,786,965.61	42,950,978.28	43,354,678.66	43,620,639.57	44,539,840.33	45,058,011.01	0.00	0.00	0.00	0.00	0.00	0.00	261,311,113.46	

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

TOTAL

Thursday, January 15, 2015

Subtotal

41,786,965.61	42,950,978.28	43,354,678.66	43,620,639.57	44,539,840.33	45,058,011.01	0.00	0.00	0.00	0.00	0.00	0.00	261,311,113.46	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending December 31, 2014

078999	MERCY MARICOPA INTEGRATED - MM	17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	18,785.29	0.00	0.00	0.00	0.00	0.00	0.00	108,354.37	
	17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	18,785.29	0.00	0.00	0.00	0.00	0.00	0.00	108,354.37	

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

TOTAL

Thursday, January 15, 2015

Subtotal

17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	18,785.29	0.00	0.00	0.00	0.00	0.00	0.00	108,354.37	

GRAND TOTAL