May 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

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

SUBJECT: FY 2015 Appropriation Status Report for the Period Ended April 30, 2015

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 April 30, 2015.

Status Summary – Laws 2015, Chapter 8, included the following FY 2015 appropriation adjustments:

Section 113 - General Fund reduction of $48,520,500  Section 113 - Expenditure Authority increase of 268,809,500
Section 114 – Potential General Fund transfer to ADHS of up to $10,000,000

Based on these appropriation adjustments, AHCCCS is projecting a potential surplus of $155.0 million Total Fund ($42.5 million General fund and $112.5 million Federal Expenditure Authority). These projections are subject to variability based on a number of factors as itemized below.

There are several issues this fiscal year that have the potential to affect the final actual expenditures. They include:
Continued volatility in caseload growth and prior period expenditures. As described in the enrollment update on the following page, there continues to be inconsistent growth in the AHCCCS caseloads which will likely have a significant impact on the final 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

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. May 26, 2015
Page 2

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.

Enrollment Update – April 2015 enrollment is 1,660,163 members, a 23,720 member increase over the prior month. Enrollment for May 2015 increased to 1,680,606 members, a 20,443 member increase. The substantial growth in the last three months eclipsed the prior four month period (from November through February) where enrollment declined by 19,463.

Major May changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 13,165; Supplemental Security Income – decrease of 822; Prop 204 Restoration - decrease of 356; Adult Expansion - increase of 4,212; Medicare Cost Sharing – increase of 1,540; and Emergency Services - increase of 2,598.

Tobacco Funds Revenue Update – Tobacco tax collections through April 2015 are $6.0 million more than the AHCCCS monthly projected flows. In April, AHCCCS received $99,974,970 in Tobacco Litigation Settlement funding which is slightly lower than the FY15 appropriation of
$100,000,000. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2015 appropriations. Surplus tobacco funding would positively impact the projected General Fund surplus and potentially result in a Hospital Assessment surplus.

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
Bret Cloninger, Asst. Director, Governor’s Office of Strategic Planning and Budgeting Bill Greeney, Asst. Director, Governor’s Office of Strategic Planning and Budgeting Richard Stavneak, Director, Joint Legislative Budget Committee

Appropriation Status Report
(ASR)

Fiscal Year 2015

Through April 30, 2015

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 April 30, 2015
SUMMARY OF APPROPRIATED EXPENDITURES

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

AHCCCS Operating Lump Sum	$	90,574,400		$	74,765,600		$	65,155,428		$	9,610,172		$	90,574,400		$	-	
AHCCCS Prop 204 Administration	6,863,900		5,777,200		5,849,920		(72,720)		6,863,900		-	
DES Eligibility	54,874,500		46,267,800		50,793,508		(4,525,708)		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		32,356,800		21,357,537		10,999,263		38,358,700		-	
TOTAL ADMINISTRATION	190,671,500		159,167,400		143,156,392		16,011,008		190,671,500		-	

APPROPRIATIONS: ADMINISTRATION

Traditional Medicaid Services	3,676,212,600		2,981,671,100		2,797,555,544		184,115,556		3,521,212,600		155,000,000	
Proposition 204 Services	2,353,937,900		1,926,602,000		1,884,886,889		41,715,111		2,353,937,900		-	
ACA Adult Expansion	227,369,700		179,843,900		150,906,588		28,937,312		227,369,700		-	
Children's Rehabilitative Services	214,042,400		177,574,100		177,625,929		(51,829)		214,042,400		-	
KidsCare Services	7,512,500		6,753,200		5,526,898		1,226,302		7,512,500		-	
ALTCS Services	1,348,569,500		1,114,301,100		1,063,495,178		50,805,922		1,348,569,500		-	
Disproportionate Share Payments	13,487,100	-	-	-	13,487,100	-	
Rural Hospitals	22,650,000		17,404,100		17,404,050		50		22,650,000		-	
Voluntary Political Subdivision Programs	324,060,600		302,104,300		302,104,273		27		324,060,600		-	
TOTAL PROGRAMMATIC	8,187,842,300	6,706,253,800	6,399,505,350	306,748,450	8,032,842,300	155,000,000

TOTAL EXPENDITURES

$	8,378,513,800

$    6,865,421,200

$   6,542,661,743

$	322,759,457

$  8,223,513,800

$   155,000,000

Administrative Expenditures Proposition 204 - BNCF Programmatic Expenditures
Traditional Medicaid Services Acute Care	3,384,400

50,199,900		2,855,000

41,833,000		2,538,300

41,833,000		316,700

-		3,384,400

50,199,900		-

-	
ALTCS Services	245,196,200		203,977,300		190,873,786		13,103,514		245,196,200		-	
TOTAL COUNTY EXPENDITURES	298,780,500		248,665,300		235,245,086		13,420,214		298,780,500		-	
	TOBACCO FUNDS											
Programmatic Expenditures
Traditional Medicaid Services Acute Care - Medically Needy	
34,178,800		
28,421,200		
31,423,416		
(3,002,216)		
34,178,800		
-	
Proposition 204 Services - Emergency Health Services	18,202,400		15,157,000		16,036,172		(879,172)		18,202,400		-	
Proposition 204 Services - Proposition 204 Protection	38,225,000		31,785,800		33,675,960		(1,890,160)		38,225,000		-	
Proposition 204 Services - ATLSF	100,000,000		100,000,000		99,974,970		25,030		100,000,000		-	
TOTAL TOBACCO EXPENDITURES	190,606,200		175,364,000		181,110,518		(5,746,518)		190,606,200		-	
	OTHER											
Administrative Expenditures
Prescription Drug Rebate Program	
116,100		
96,600		
113,098		
(16,498)		
116,100		
-	
Acute Care - Prescription Drug Rebate Program State Match	73,756,400		61,463,600		61,463,667		(67)		73,756,400		-	
Acute Care - Prescription Drug Rebate Program Federal Authority	198,561,200		165,468,000		158,666,051		6,801,949		198,561,200		-	
Long Term Care - Prescription Drug Rebate Program State Match	5,162,500		4,294,800		4,302,083		(7,283)		5,162,500		-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	17,898,100		14,889,900		15,761,324		(871,424)		17,898,100		-	
Proposition 204 Services - Hospital Assessment	270,442,100		153,448,200		175,075,921		(21,627,721)		270,442,100		-	
Traditional Medicaid Services - TPL	194,700		64,900		597,747		(532,847)		194,700		-	
ALTCS Services - TPL	-		-		651,216		(651,216)		-		-	
ALTCS Services - Nursing Facility Assessment	17,171,800		11,868,100		14,132,919		(2,264,819)		17,171,800		-	
KidsCare Services Premiums	370,000		311,600		561,028		(249,428)		370,000		-	
Freedom to Work Premiums	31,200		26,900		38,826		(11,926)		31,200		-	
Voluntary Political Subdivision Programs - See Note 5	104,721,600		99,665,700		99,665,700		(0)		104,721,600		-	
TOTAL OTHER EXPENDITURES	688,425,700		511,598,300		531,029,580		(19,431,280)		688,425,700		-	
	TOTAL											

Administrative Expenditures	
190,671,500		
159,167,400		
143,156,392		
16,011,008		
190,671,500		
-	
Acute Care	6,839,272,800		5,591,952,700		5,336,010,172		255,942,528		6,684,272,800		155,000,000	
Long Term Care	1,348,569,500		1,114,301,100		1,063,495,178		50,805,922		1,348,569,500		-	
TOTAL EXPENDITURES	$	8,378,513,800		$	6,865,421,200		$	6,542,661,743		$	322,759,457		$	8,223,513,800		$	155,000,000	

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

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

Administrative Expenditures	$	55,488,700		$	46,329,200		$	43,710,024		2,619,176		$	55,488,700		$	-	
Proposition 204 - Administrative Expenditures	19,658,700		16,580,400		9,018,051		7,562,349		19,658,700		-	
Programmatic Expenditures Traditional Medicaid Services	
749,633,300		
601,651,000		
673,749,910		
(72,098,910)		
707,133,300		
42,500,000	
Proposition 204 Services	159,700,000		180,988,200		23,156,635		157,831,565		159,700,000		-	
Children's Rehabilitative Services	62,248,100		51,846,600		56,707,996		(4,861,396)		62,248,100		-	
KidsCare Services	1,257,200		1,139,000		946,041		192,959		1,257,200		-	
ALTCS Services	167,797,400		139,577,600		139,831,161		(253,561)		167,797,400		-	
DSH and Rural Hospitals	10,099,300		5,489,300		4,981,668		507,632		10,099,300		-	
TOTAL GF EXPENDITURES	1,225,882,700		1,043,601,300		952,101,485		91,499,815		1,183,382,700		42,500,000	

Administrative Expenditures	89,844,100		74,607,600		72,125,814		2,481,786		89,844,100		-	
Proposition 204 - Administrative Expenditures	22,179,500		18,698,600		15,651,106		3,047,494		22,179,500		-	
Programmatic Expenditures Traditional Medicaid Services	
2,569,657,100		
2,082,742,500		
1,829,782,927		
252,959,573		
2,457,157,100		
112,500,000	
Proposition 204 Services	1,767,368,400		1,445,222,800		1,536,967,231		(91,744,431)		1,767,368,400		-	
ACA Adult Expansion	227,369,700		179,843,900		150,906,588		28,937,312		227,369,700		-	
Children's Rehabilitative Services	151,794,300		125,727,500		120,917,934		4,809,566		151,794,300		-	
KidsCare Services	5,885,300		5,302,600		4,019,829		1,282,771		5,885,300		-	
ALTCS Services and Nursing Facility Assessment	895,343,500		739,693,400		697,942,689		41,750,711		895,343,500		-	
DSH and Rural Hospitals	26,037,800		11,914,800		12,422,382		(507,582)		26,037,800		-	
Voluntary Political Subdivision Programs - See Note 5	219,339,000		202,438,600		202,438,573		27		219,339,000		-	
TOTAL FEDERAL EXPENDITURES	5,974,818,700		4,886,192,300		4,643,175,074		243,017,226		5,862,318,700		112,500,000	

Programmatic Expenditures

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

BUDGET	BUDGET
YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	877,469,400		$	705,316,100		$	779,149,597	
Proposition 204 Services & Administrative	179,358,700		197,568,600		31,940,875	
KidsCare Services	1,257,200		1,139,000		946,041	
ALTCS Services	 	167,797,400 			 	139,577,600 			 	139,831,161 		
TOTAL	1,225,882,700		1,043,601,300		951,867,674	

FEDERAL:
Acute & Administrative	5,073,589,900		4,141,196,300		4,480,647,739	
KidsCare Services	5,885,300		5,302,600		5,723,856	
ALTCS Services	 	895,343,500 			 	739,693,400 			 	704,448,931 		
TOTAL	5,974,818,700		4,886,192,300		5,190,820,526	

COUNTY:
Acute & Administrative	53,584,300		44,688,000		44,927,601	
ALTCS Services	 	245,196,200 			 	203,977,300 			 	204,330,180 		
TOTAL	298,780,500		248,665,300		249,257,781	

TOBACCO FUNDS:
Traditional Medicaid Services	34,178,800		28,421,200		31,423,416	
Proposition 204 Services	 	156,427,400 			 	146,942,800 			 	149,687,102 		
TOTAL	190,606,200		175,364,000		181,110,518	

OTHER:
Administrative	116,100		96,600		113,098	
Acute Care - Prescription Drug Rebate Program	272,317,600		226,931,600		220,129,718	
Long Term Care - Prescription Drug Rebate Program	23,060,600		19,184,700		20,063,407	
Hospital Assessment	270,442,100		153,448,200		177,193,840	
ALTCS - Nursing Facility Assessment	17,171,800		11,868,100		13,242,390	
Acute TPL - Note 1	194,700		64,900		597,747	
LTC TPL - Note 1	-		-		651,216	
KidsCare TPL - Note 1	-		-		5,657	
Member Premiums - CHIP	370,000		311,600		555,337	
Member Premiums - Freedom to Work	31,200		26,900		38,826	
Voluntary Political Subdivision - State Match	 	104,721,600 			 	99,665,700 			 	65,528,887 		
TOTAL	688,425,700		511,598,300		498,120,123	

TOTAL REVENUE

$	8,378,513,800

$	6,865,421,200

$	7,071,176,622

Appropriation Status Report

Footnotes

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

Note 1:	Third Party Liability Collections: Gross Collections:	April 2015		April 2014		July 1, 2014
April 30, 2015		July 1, 2013
April 30, 2014	
	Acute	$	382,026		$	356,269		$	4,360,210		$	6,632,403	
	LTC	166,384		149,817		2,789,398		3,139,598	
	KidsCare	18,282		-		35,304		12,723	
	Total TPL Collections	$	566,692		$	506,086		$	7,184,912		$	9,784,724	

Acute	$	53,004		$	23,704		$	597,747		$	748,402	
LTC	39,082		36,911		651,216		759,198	
KidsCare	2,588		-		5,657		2,331	
Total Expenditure Offsets	$	94,674		$	60,615		$	1,254,620		$	1,509,931	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:

FY 15 Total

Note 2:	Authorized Positions	1,032.2	
	Actual Positions as of April 30, 2015	932.4	

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2014	

$	2,092,063	
	Revenues	5,885,527	
	Transfers-In	 	220,875 		
	Total Revenues	 	6,106,402 		
	Expenditures	5,690,570	
	Transfers-out	 	742,500 		
	Total Expenditures	 	6,433,070 		

Ending Balance April 30, 2015

$	1,765,395

Of the $1,765,395 ending balance, $940,672 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through May 2015.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of April 30, 2015

Description	Amount

Type

School Based Claiming Medicaid Administrative Costs	18,941,355	HHS-OIG & AHCCCS Self Reported School Based Claiming Direct Services Costs	19,923,489	HHS-OIG
38,864,844

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 April 30, 2015

Note 5:	Summary of Voluntary Political Subdivision Contribution Expenditures.			
As of April 30, 2015 Expenditures		
		State Match		Federal		Total	
	
DSH Voluntary	
$	6,364,970		
$	12,402,437		
$	18,767,407	
	GME Voluntary	52,044,553		104,265,968		156,310,521	
	Safety Net Care Pool	41,256,177		85,770,168		127,026,344	
	Total Voluntary Political Subdivision Program Expenditures	$	99,665,700		$	202,438,573		$	302,104,273	

Note 6:

The following is a summary of $280,266,267 Total Fund ($60,487,302 General Fund) administrative adjustment transactions processed through January 2015 that either pay for or transfer expenditures with dates of service prior to June 30, 2014.

FY 2014 YTD April 30, 2015

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

-

-

Appropriation Status Report

Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending April 30, 2015

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	248,076,844	245,643,693	251,496,624	256,388,717	0	0	2,497,461,735	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	7,850,160	0	0	7,850,160	
CAPITATION - LTC	172,652,192	182,816,155	174,463,368	175,962,165	185,797,934	178,739,886	177,003,567	189,959,040	178,633,505	180,448,535	0	0	1,796,476,347	
MENTAL HEALTH - CHILD	22,940,496	23,328,678	23,618,875	23,718,681	23,302,936	25,767,800	23,006,113	22,648,826	22,760,283	23,232,636	0	0	234,325,325	
MENTAL HEALTH - ADULT	9,246,123	9,421,167	9,546,463	10,182,445	10,043,576	12,526,900	9,967,053	9,902,944	9,896,397	9,928,543	0	0	100,661,611	
MENTAL HEALTH - GENERAL	13,514,010	13,769,852	13,952,983	13,247,385	13,066,716	14,463,438	12,967,159	12,883,754	12,875,236	13,355,595	0	0	134,096,129	
MENTAL HEALTH - CMDP	16,576,107	16,638,148	16,847,957	13,954,363	13,986,708	15,535,784	14,120,706	14,298,139	14,470,028	14,686,502	0	0	151,114,442	
CHILDREN'S REHAB SERVICES	0	3,438,525	3,443,676	3,631,689	3,634,760	3,639,274	3,644,158	3,649,976	3,659,116	3,672,740	0	0	32,413,913	
FEE FOR SERVICE - ACUTE	46,280,515	40,298,729	44,272,778	40,509,119	39,380,058	44,268,466	35,455,277	37,912,817	50,501,722	42,758,843	0	0	421,638,324	
FFS - PRIOR QUARTER COVERAGE	57,282	163,600	272,725	299,665	290,401	278,750	370,730	373,960	575,418	492,498	0	0	3,175,030	
EMERGENCY SERVICES - FEDERAL	6,645,181	5,482,311	6,208,134	4,523,950	5,454,738	4,624,812	5,290,703	4,129,951	5,597,483	5,455,594	0	0	53,412,859	
FEDERAL ESP CHRONIC SERVICES	0	0	0	866	-866	0	0	0	605	0	0	0	605	
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	553,068	737,457	1,119,981	751,301	0	0	6,283,176	
QMB - FEE FOR SERVICE	227,508	323,662	198,991	336,158	204,441	226,551	333,888	319,484	386,291	229,557	0	0	2,786,531	
INPATIENT INMATES FFS	139,514	117,313	118,780	356,263	172,449	110,017	120,196	83,623	169,533	139,618	0	0	1,527,305	
PINAL COUNTY INMATES FFS	1,230	2,048	18,368	481	3,910	338	501	0	0	3,325	0	0	30,200	
COCONINO COUNTY INMATES FFS	0	0	5,262	177	7	2,623	0	0	0	850	0	0	8,919	
PIMA COUNTY INMATES FFS	7,294	6,199	3,724	754	6,755	8,059	16,606	11,069	32,319	2,343	0	0	95,122	
MARICOPA CTY INMATES FFS	5,034	2,562	11,151	9,287	15,401	35,253	41,392	5,385	105,634	20,277	0	0	251,377	
FEE FOR SERVICE - LTC	10,677,186	9,403,354	9,497,170	10,317,996	9,250,858	10,622,159	9,119,365	8,926,784	11,928,249	9,754,009	0	0	99,497,130	
LFFS - PRIOR QUARTER COVERAGE	26,197	25,830	11,048	31,446	50,419	30,113	28,027	69,020	21,983	78,849	0	0	372,934	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,542,730	723,907	561,690	757,325	1,048,464	994,287	917,735	1,108,421	1,826,798	1,216,903	0	0	10,698,260	
REINSURANCE - ACUTE	10,003,289	5,027,836	10,574,231	6,348,464	10,707,695	6,925,180	5,704,923	11,384,335	4,501,881	3,996,386	0	0	75,174,220	
REINSURANCE - LTC	3,351,665	3,591,474	5,326,752	4,738,880	4,481,860	3,996,174	1,922,482	3,304,801	1,949,942	2,289,621	0	0	34,953,650	
SMIB - ACUTE	10,410,873	10,627,744	9,836,640	10,393,368	10,560,534	10,287,385	10,447,551	10,498,162	10,392,557	10,452,792	0	0	103,907,607	
HIB - ACUTE	58,792	272,446	259,042	269,952	274,700	262,747	255,222	258,386	251,753	268,049	0	0	2,431,089	
Q1	1,627,402	1,621,788	1,982,590	1,886,090	1,928,654	1,776,799	1,785,949	1,776,198	1,780,100	1,664,529	0	0	17,830,099	
SMIB - LTC	2,760,557	2,776,428	2,783,315	2,794,573	2,815,470	2,852,859	2,842,007	2,817,134	2,817,930	2,844,980	0	0	28,105,254	
HIB - LTC	121,568	275,913	266,525	277,911	272,522	280,297	241,486	265,225	262,505	274,530	0	0	2,538,482	
	574,967,964	569,698,114	576,142,462	575,954,762	583,111,966	611,770,171	564,232,709	582,968,587	588,013,876	592,258,280	0	0	5,819,118,891	

TITLE XIX PROP 204

CAPITATION - ACUTE	165,540,913	158,127,081	161,630,611	164,729,420	168,280,548	179,258,376	175,030,332	174,525,533	186,164,369	177,711,851	0	0	1,710,999,035	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	1,874,488	0	0	1,874,488	
MENTAL HEALTH - CHILD	198,164	198,016	199,318	198,959	194,576	224,014	184,586	181,243	169,581	149,374	0	0	1,897,832	
MENTAL HEALTH - ADULT	12,147,475	12,671,268	13,065,174	14,220,214	14,303,623	16,310,998	14,498,867	14,375,635	14,603,544	14,860,891	0	0	141,057,688	
MENTAL HEALTH - GENERAL	17,754,588	18,520,157	19,095,884	18,500,532	18,609,047	19,869,025	18,863,060	18,702,735	18,999,245	19,990,450	0	0	188,904,723	
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	15,843	16,677	15,009	13,759	0	0	134,660	
FEE FOR SERVICE - ACUTE	26,275,199	24,092,157	26,903,237	24,234,346	22,861,010	26,100,136	21,916,904	23,704,584	30,331,747	26,789,479	0	0	253,208,800	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending April 30, 2015

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

TOTAL

SUBTOTAL

FFS - PRIOR QUARTER COVERAGE	51,967	316,151	600,030	726,185	811,441	1,006,665	911,248	818,623	1,366,083	982,334	0	0	7,590,728	
EMERGENCY SERVICES - FEDERAL	2,558,131	2,365,512	1,269,651	-678,159	919,746	744,391	-22,359	699,009	1,194,759	1,820,527	0	0	10,871,208	
FFS MEDICAID IN PUBLIC SCHOOLS	5,265	1,979	1,613	4,445	4,645	4,671	5,794	5,469	9,050	6,917	0	0	49,848	
INPATIENT INMATES FFS	487,478	518,149	471,810	624,268	281,204	565,945	412,164	451,128	555,192	666,639	0	0	5,033,976	
MARICOPA CTY INMATES FFS	13,089	6,331	23,649	22,129	68,390	127,897	124,307	35,197	124,829	149,724	0	0	695,540	
YAVAPAI COUNTY INMATES FFS	0	0	277	0	0	0	0	0	0	1,876	0	0	2,154	
PINAL COUNTY INMATES FFS	82,861	48,485	8,563	33,510	7,205	5,657	11,005	16,319	4,420	6,102	0	0	224,127	
PIMA COUNTY INMATES FFS	4,443	35,007	0	0	4,290	1,085	4,955	7,213	10,453	7,743	0	0	75,188	
COCONINO COUNTY INMATES FFS	0	0	0	0	0	0	7,649	105	758	10,077	0	0	18,588	
COCHISE COUNTY INMATES FFS	0	0	0	0	0	0	0	0	2,020	0	0	0	2,020	
REINSURANCE - ACUTE	2,324,980	1,717,925	3,003,472	1,858,149	2,450,778	2,129,311	958,126	2,995,317	2,318,824	2,023,868	0	0	21,780,750	
SMIB - ACUTE	3,453,454	3,793,307	4,108,084	4,173,881	4,238,165	4,273,910	4,245,599	4,332,285	4,372,687	4,604,219	0	0	41,595,592	
HIB - ACUTE	2,806	1,938	1,938	1,938	3,216	2,364	2,057	4,739	3,073	4,416	0	0	28,485	
	230,900,813	222,428,433	230,397,099	228,663,575	233,052,479	250,641,739	237,170,135	240,871,811	260,245,644	251,674,736	0	0	2,386,046,465	

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	14,776,685	15,335,158	19,881,757	18,756,539	0	0	137,232,255	
MENTAL HEALTH - ADULT	777,287	863,773	902,646	1,011,393	1,045,177	1,097,210	1,223,732	1,256,668	1,411,886	1,719,820	0	0	11,309,591	
MENTAL HEALTH - GENERAL	1,136,072	1,262,478	1,319,296	1,315,824	1,359,778	1,427,473	1,592,078	1,634,928	1,836,867	2,313,453	0	0	15,198,248	
FEE FOR SERVICE - ACUTE	1,065,235	970,725	1,334,264	1,086,740	955,345	1,273,064	1,015,740	1,444,487	1,722,843	1,652,692	0	0	12,521,135	
FFS - PRIOR QUARTER COVERAGE	8,502	36,286	94,224	115,698	61,348	91,140	77,015	89,383	239,521	110,103	0	0	923,218	
EMERGENCY SERVICES - FEDERAL	134,592	90,936	1,261,768	2,877,561	1,282,684	1,768,797	2,259,139	1,229,394	2,243,844	1,635,459	0	0	14,784,174	
FEDERAL ESP CHRONIC SERVICES	0	0	0	2,972	0	0	0	0	0	0	0	0	2,972	
FFS MEDICAID IN PUBLIC SCHOOLS	0	0	0	0	0	0	0	0	271	75	0	0	346	
INPATIENT INMATES FFS	0	0	23,257	5,476	68,758	10,062	9,605	15,688	45,488	19,305	0	0	197,639	
REINSURANCE - ACUTE	22,287	20,209	101,574	92,355	115,860	104,882	7,119	175,771	201,343	118,744	0	0	960,144	
SMIB - ACUTE	1,259	839	1,678	1,783	1,154	210	210	210	210	315	0	0	7,868	
	15,765,205	13,815,878	16,112,569	16,648,532	15,737,843	19,004,021	20,961,323	21,181,687	27,584,029	26,326,503	0	0	193,137,588	
	821,633,982	805,942,426	822,652,130	821,266,869	831,902,288	881,415,930	822,364,167	845,022,085	875,843,550	870,259,518	0	0	8,398,302,944	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	317,922	319,265	311,917	324,342	320,128	1,129,266	313,734	285,769	278,713	231,269	0	0	3,832,325	
KidsCare - FEE FOR SERVICE	20,033	15,148	7,669	3,767	3,981	2,965	1,407	-2,332	2,073	3,293	0	0	58,005	
KidsCare - MENTAL HEALTH	73,362	72,703	72,045	70,846	69,737	203,812	68,407	60,835	59,696	47,887	0	0	799,331	
KidsCare - REINSURANCE	-99,947	14,868	81,730	564	27,047	29,953	29,608	43,441	27,826	81,707	0	0	236,795	
KidsCare - TRANSPLANT REIN	0	0	0	0	0	0	0	0	76,204	0	0	0	76,204	
KidsCare - CHILD REHAB SERVICES	0	394	394	417	417	417	417	417	417	417	0	0	3,706	

311,369	422,379	473,754	399,936	421,310	1,366,413	413,574	388,129	444,929	364,573	0	0	5,006,367	

TOTAL TITLE XXI

821,945,351	806,364,804	823,125,884	821,666,805	832,323,598	882,782,343	822,777,741	845,410,214	876,288,479	870,624,091	0	0	8,403,309,310	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
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	110.47	110.47	110.47	113.17	0.00	0.00		1,355.93		
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	19,589.59	20,193.49	22,499.04	31,294.01	0.00	0.00		242,856.69		
1007	TANF 21-44 FEMALE WI	114,269.17	118,106.00	119,978.28	129,844.18	125,121.31	128,805.54	118,311.49	103,504.40	96,825.55	116,305.01	0.00	0.00		1,171,070.93		
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	103,426.38	95,332.90	96,543.75	119,255.09	0.00	0.00		991,463.03		
1009	TANF 65+ M & F WITH	21,484.01	20,398.00	20,925.41	25,007.51	23,095.30	25,448.03	26,535.40	27,804.90	29,804.51	35,988.16	0.00	0.00		256,491.23		
100F	TANF 21-44 MALE WITH	1,342.88	55.35	872.59	351.90	484.51	91.99	440.60	273.83	1,267.09	5,847.63	0.00	0.00		11,028.37		
100G	TANF 21-44 FEMALE WI	3,762.11	2,684.84	841.74	3,224.55	2,067.90	1,975.62	1,160.63	2,467.26	5,803.76	9,115.63	0.00	0.00		33,104.04		
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	7,706.24	8,786.78	33,722.99	0.00	0.00		74,831.86		
100J	TANF 65+ M & F WITH	1,372.61	214.32	3,333.60	667.70	289.40	42.63	1,065.61	1,945.61	5,119.93	8,644.96	0.00	0.00		22,696.37		
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	7,053,954.14	6,913,342.86	6,829,373.29	7,065,481.25	0.00	0.00		71,454,044.50		
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	9,106,025.88	8,725,624.44	7,927,864.61	7,383,212.27	0.00	0.00		91,763,472.83		
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	14,774,171.99     14,237,029.26	12,979,534.26	12,153,410.71	0.00	0.00		147,065,665.61		
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	4,320,303.20	4,211,551.13	3,901,382.90	3,607,045.23	0.00	0.00		42,222,427.21		
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	7,678,612.70	7,510,393.88	7,020,972.66	6,579,565.45	0.00	0.00		75,756,117.61		
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	3,688,668.17	3,674,890.74	3,697,333.89	3,933,165.96	0.00	0.00		37,232,048.87		
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	22,726,861.34     22,392,239.30	22,271,197.48	22,691,242.40	0.00	0.00		228,542,676.76		
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	8,078,367.51	7,990,822.10	8,037,118.83	8,357,264.73	0.00	0.00		79,968,780.31		
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	24,109.18	24,097.00	27,968.73	31,552.78	0.00	0.00		249,778.60		
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	332,157.53	254,920.07	248,993.92	373,036.16	0.00	0.00		3,450,838.01		
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	135,567.26	106,872.09	76,978.70	51,925.62	0.00	0.00		1,296,283.70		
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	159,266.32	132,615.48	94,734.59	64,215.46	0.00	0.00		1,540,657.52		
101D	TANF 14-20 MALE NON-	138,442.93	139,162.10	106,459.42	113,930.58	103,773.99	97,699.81	99,668.35	77,931.68	68,832.45	48,551.44	0.00	0.00		994,452.75		
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	161,516.23	151,338.65	127,824.93	98,920.37	0.00	0.00		1,635,021.29		
101F	TANF 21-44 MALE NON-	562,829.25	205,145.88	181,413.75	176,459.37	166,735.25	198,925.55	252,413.27	278,574.19	396,087.40	409,115.51	0.00	0.00		2,827,699.42		
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	788,127.13	819,882.93	1,016,442.65	998,229.46	0.00	0.00		8,231,606.78		
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	381,951.32	423,258.58	623,565.12	689,929.40	0.00	0.00		5,221,874.31		
101J	TANF 65+ N & F NON-M	10,089.16	1,333.72	2,057.69	-382.34	1,307.46	1,027.19	4,535.89	2,970.17	9,150.25	5,935.68	0.00	0.00		38,024.87		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	523.51	0.00	0.00		523.51		
1022	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	102.99	0.00	0.00		102.99		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	234.49	255.98	0.00	0.00	0.00		490.47		
1026	TANF 21-44 MALE WITH	165.98	324.87	567.02	909.50	3,283.99	3,312.14	5,786.25	5,946.40	4,430.10	6,622.14	0.00	0.00		31,348.39		
1027	TANF 21-44 FEMALE WI	6,723.14	6,476.82	9,589.29	13,371.10	12,641.42	13,003.80	10,961.21	13,407.82	13,809.38	18,376.31	0.00	0.00		118,360.29		
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	10,174.87	11,424.30	16,917.33	22,328.79	0.00	0.00		90,933.59		
1029	TANF 65+ M & F WITH	727.32	729.10	1,511.49	1,532.34	1,165.27	2,233.09	2,341.26	2,362.38	4,701.70	7,780.87	0.00	0.00		25,084.82		

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	0.00	0.00	59.87	0.00	0.00	0.00	0.00	0.00	21.29	60.27	0.00	0.00		141.43		
102G	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	25.40	0.00	526.22	25.40	738.78	0.00	0.00		1,315.80		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103.18	6,638.48	0.00	0.00		6,741.66		
102J	TANF 65+ M & F WITH	0.00	0.00	10.55	0.00	0.00	0.00	0.00	0.00	0.00	760.56	0.00	0.00		771.11		
2100	SSI AGED WITH MEDIC A	682,116.95	665,548.05	675,360.22	689,644.65	673,487.78	742,109.30	697,314.27	675,877.96	662,354.14	685,638.26	0.00	0.00		6,849,451.58		
210Z	SSI AGED WITH MEDIC A	84,778.64	36,520.03	17,286.95	22,552.34	15,938.88	94,972.48	6,898.17	11,821.01	40,216.62	34,611.74	0.00	0.00		365,596.86		
2110	SSI AGED NON-MEDIC AR	4,592,127.22	4,730,015.83	4,736,543.75	5,044,668.40	5,053,970.65	5,485,285.88	5,048,161.00	5,121,272.49	5,160,765.34	5,015,063.36	0.00	0.00		49,987,873.92		
211Z	SSI AGED NON-MEDIC AR	906,703.14	450,324.83	325,452.91	211,742.26	239,796.29	172,207.74	190,432.10	209,176.26	259,050.40	147,615.08	0.00	0.00		3,112,501.01		
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	3,741,269.38	3,702,376.81	3,608,935.96	3,705,124.61	0.00	0.00		37,415,379.64		
212Z	SSI AGED WITH QMB P P	39,895.21	21,261.96	14,694.28	14,818.73	26,077.56	30,588.73	5,865.99	5,526.77	5,748.70	5,291.10	0.00	0.00		169,769.03		
2200	SSI DISABLED WITH M E	1,620,418.47	1,652,777.49	1,640,988.05	1,802,103.68	1,697,117.89	1,744,994.02	1,776,340.14	1,762,701.47	1,529,722.78	1,514,381.59	0.00	0.00		16,741,545.58		
220Z	SSI DISABLED WITH M E	61,688.36	27,741.11	18,277.11	21,663.06	16,726.53	18,077.93	14,007.94	15,880.25	27,048.14	18,602.76	0.00	0.00		239,713.19		
2210	SSI DISABLED NON-ME D	54,178,004.81	54,186,330.75	54,140,342.06	55,990,760.45	55,929,755.60	61,257,214.32	55,750,910.59     55,770,583.88	55,723,522.68	56,053,501.91	0.00	0.00		558,980,927.05		
221Z	SSI DISABLED NON-ME D	1,411,266.35	841,644.53	641,017.98	508,757.42	536,770.16	538,267.57	578,895.88	706,840.27	667,997.30	582,994.29	0.00	0.00		7,014,451.75		
2220	SSI DISABLED WITH Q M	10,511,923.37	10,469,394.95	10,565,310.14	10,536,986.13	10,466,175.09	10,889,639.28	10,964,732.30     10,893,242.14	10,983,204.78	11,344,369.81	0.00	0.00		107,624,977.99		
222Z	SSI DISABLED WITH Q M	8,859.10	9,858.59	3,731.42	3,377.54	2,464.59	4,679.13	4,560.00	2,617.41	4,214.96	4,253.53	0.00	0.00		48,616.27		
2300	SSI BLIND WITH MEDIC	8,180.98	8,297.65	5,559.30	5,860.72	5,008.60	5,188.92	4,724.69	4,724.69	4,383.08	4,705.02	0.00	0.00		56,633.65		
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	333,362.58	333,314.84	333,723.66	349,198.67	348,076.29	396,678.85	359,577.60	356,439.13	358,271.38	368,368.53	0.00	0.00		3,537,011.53		
231Z	SSI BLIND NON-MEDIC A	4,907.37	3,051.36	7,642.71	11,145.34	4,120.11	763.03	1,206.33	3,685.61	8,452.39	4,237.57	0.00	0.00		49,211.82		
2320	SSI BLIND WITH QMB	38,091.63	39,048.80	39,534.51	39,685.51	39,537.65	45,087.87	44,178.40	44,318.91	44,388.60	47,590.97	0.00	0.00		421,462.85		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	3.24	0.00	0.00	0.00	3.84	0.00	0.00		7.08		
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	238.65	209.85	306.07	369.18	0.00	0.00		3,376.26		
4303	SOBRA CHILD 06-13 M	104.88	148.65	0.00	0.00	103.11	220.89	220.89	256.40	486.57	227.07	0.00	0.00		1,768.46		
4304	SOBRA CHILD 14-20 MA	0.00	285.74	0.00	147.65	160.15	160.15	160.15	160.15	264.10	162.24	0.00	0.00		1,500.33		
4305	SOBRA CHILD 14-20 FE	741.22	741.22	741.22	779.16	779.16	941.34	779.16	779.16	779.16	789.59	0.00	0.00		7,850.39		
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	99.94	0.00	125.96	45.27	0.00	0.00		1,390.24		
430C	SOBRA CHILD 06-13 M	0.00	517.86	0.00	0.00	291.95	0.00	0.00	102.28	267.72	0.00	0.00	0.00		1,179.81		
430D	SOBRA CHILD 14-20 MA	0.00	299.78	0.00	168.61	0.00	0.00	0.00	0.00	207.56	0.00	0.00	0.00		675.95		
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	15,752,207.40     15,795,480.05	16,507,005.00	18,127,218.11	0.00	0.00		160,394,955.62		
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	12,506,744.33     12,682,005.00	13,762,870.98	15,684,678.38	0.00	0.00		128,234,063.08		
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	15,843,453.44     16,117,961.70	17,331,452.66	19,649,143.09	0.00	0.00		161,076,797.35		
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	5,628,602.43	5,736,429.98	6,124,484.34	6,761,838.83	0.00	0.00		57,158,628.60		
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	8,342,404.08	8,460,210.36	9,142,245.51	10,129,984.44	0.00	0.00		84,992,434.13		

9910	TANF & SOBRA CHILDR E	6,571,134.40	6,179,708.87	6,623,616.05	6,325,435.24	5,921,355.59	7,121,844.89	6,027,669.23	4,910,877.04	5,265,275.46	4,227,424.89	0.00	0.00		59,174,341.66	
9920	SSI W/MEDICARE KICK	59,951.62	40,761.17	88,298.65	65,641.81	30,491.21	67,549.67	48,963.02	78,653.93	43,112.74	49,169.73	0.00	0.00		572,593.55	
9921	SSI W/O MEDICARE KI C	255,183.61	158,774.68	186,447.87	224,873.16	176,012.13	248,259.08	159,436.87	206,214.76	194,995.13	152,100.37	0.00	0.00		1,962,297.66	
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	10,497,875.29	9,682,295.41	10,918,931.44	10,570,951.68	0.00	0.00		107,319,986.34	
	18,132,961.47	16,951,836.97	18,472,678.41	18,284,798.22	15,319,537.42	18,833,459.73	16,733,944.41	14,878,041.14	16,422,314.77	14,999,646.67	0.00	0.00	169,029,219.21	

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	1,196,371.23	1,608,881.80	2,140,144.67	1,315,929.75	0.00	0.00		11,713,431.04		
431B	SOBRA CHILD 01-05 M	627,471.65	335,309.44	312,814.81	290,423.29	293,264.58	399,627.23	470,468.02	598,901.90	796,562.28	506,304.13	0.00	0.00		4,631,147.33		
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	450,292.77	554,094.72	754,837.15	608,440.48	0.00	0.00		4,719,203.00		
431D	SOBRA CHILD 14-20 MA	640,855.23	305,564.40	248,468.19	238,815.69	227,875.88	306,525.73	358,631.20	411,700.90	558,380.09	425,712.49	0.00	0.00		3,722,529.80		
431E	SOBRA CHILD 14-20 FE	720,865.32	353,182.53	322,197.87	282,684.42	275,464.52	393,459.48	434,409.61	491,106.27	669,964.32	517,252.21	0.00	0.00		4,460,586.55		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89.29	383.47	113.90	0.00	0.00		586.66		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	398.98	1,126.48	0.00	0.00		1,525.46		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142.18	0.00	0.00		142.18		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	475.40	1,001.16	250.64	0.00	0.00		1,727.20		
432B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.86	0.00	0.00	0.00		7.86		
432C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.58	0.00	0.00	0.00		23.58		
432E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.12	0.00	0.00	0.00	0.00		28.12		
5007	SOBRA PREG 21-44 FE M	21,833.03	22,940.47	24,900.15	25,248.13	31,205.32	32,605.08	33,298.06	34,969.56	35,082.99	35,372.44	0.00	0.00		297,455.23		
5008	SOBRA PREG 45-64 FE M	1,697.44	1,259.47	1,259.47	1,318.07	1,318.07	1,318.07	1,791.04	873.80	1,189.09	450.45	0.00	0.00		12,474.97		
500G	SOBRA PREG 21-44 FE M	411.89	2,270.17	121.17	666.48	1,221.73	164.35	38.11	2,906.54	557.43	233.92	0.00	0.00		8,591.79		
500H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	442.21	0.00	3,732.28	0.00	0.00	0.00		4,174.49		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	228.55	394.56	326.07	602.60	565.48	514.33	589.29	609.71	0.00	0.00		3,830.59		
5015	SOBRA PREG 14-20 FE M	746,510.58	755,732.48	766,591.83	774,695.29	762,603.21	851,151.71	719,035.87	731,194.18	791,366.63	871,277.37	0.00	0.00		7,770,159.15		
5017	SOBRA PREG 21-44 FE M	2,581,731.79	2,593,995.79	2,553,661.22	2,670,239.86	2,604,827.47	2,922,688.23	2,595,592.98	2,733,046.53	3,022,579.02	3,437,401.80	0.00	0.00		27,715,764.69		
5018	SOBRA PREG 45-64 FE M	20,379.89	17,127.95	17,296.31	17,117.25	17,657.98	18,456.91	20,202.80	18,776.67	21,562.98	23,201.30	0.00	0.00		191,780.04		
501C	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	66.92	0.00	0.00	0.00	102.28	0.00	0.00	0.00	0.00		169.20		
501E	SOBRA PREG 14-20 FE M	95,588.48	92,529.29	72,717.87	71,213.97	69,082.19	70,706.57	68,426.33	102,065.02	109,959.78	94,624.73	0.00	0.00		846,914.23		
501G	SOBRA PREG 21-44 FE M	302,251.20	254,788.69	250,382.55	248,879.06	241,477.63	291,679.91	297,672.21	367,628.76	412,663.18	380,663.01	0.00	0.00		3,048,086.20		
501H	SOBRA PREG 45-64 FE M	3,747.04	650.37	4,050.44	1,776.35	1,800.60	4,253.52	2,346.92	288.71	7,609.72	4,625.97	0.00	0.00		31,149.64		
5027	SOBRA PREG 21-44 FE M	4,767.49	3,535.74	3,779.29	3,550.08	6,644.36	9,643.35	4,778.30	4,541.84	6,464.72	944.14	0.00	0.00		48,649.31		
5028	SOBRA PREG 45-64 FE M	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		
502G	SOBRA PREG 21-44 FE M	0.00	407.18	0.00	0.00	0.00	28.47	0.00	14.06	0.00	0.00	0.00	0.00		449.71		
5510	SOBRA FPS FEMALE W IT	-25.48	-222.08	-215.19	0.00	-39.27	-12.50	-59.42	-37.50	-117.42	0.00	0.00	0.00		-728.86		
	219,325,258.77	215,820,558.09	216,718,395.63	225,832,636.97	223,739,145.50	246,871,627.22	223,984,470.14	223,964,438.43	226,956,098.03	233,081,506.50	0.00	0.00	2,256,294,135.28		

SUBTOTAL:

3100	TRANSPLANT OPTION 1	0.00	0.00	19.80	33.00	33.00	33.00	33.00	33.00	33.00	33.00	0.00	0.00	

250.80

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
310Z	TRANSPLANT OPTION 1	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		
3200	TRANSPLANT OPTION 2	0.00	0.00	0.00	0.00	15.40	16.50	16.50	16.50	16.50	0.00	0.00	0.00		81.40		
320Z	TRANSPLANT OPTION 2	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		
	0.00	0.00	49.50	33.00	66.00	49.50	49.50	49.50	49.50	33.00	0.00	0.00	379.50		

483.38	
2,273,557.72	
8,154,813.18	
12,918,092.44	
3,431,620.10	
48,976.14	
118,789.21	
383,474.54	
198,558.76	
189,249.88	
948,020.97	
3,035,666.32	
2,144,636.33	
6,399,191.31	
43,768,883.12	
148,906,423.36	
87,426,284.12	
266,429.46	
26,654.67	
13,338.98	
39,745.46	
94,811.92	
243,580.04	
3,134,665.62	
6,721,717.04	
6,103,727.73	
122,500.87	
259.91	
310,178.28	
798,910.09	
1,345,763.83	

SUBTOTAL:

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	219,685.73	217,387.87	231,011.33	234,645.23	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	808,385.51	778,286.22	814,201.12	804,598.05	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	1,293,741.12	1,267,810.63	1,314,072.76	1,356,178.36	0.00	0.00	
1109	TANF EXPANDED 65+
M&	307,783.65	314,163.72	319,878.40	350,014.76	342,232.35	374,736.47	348,386.38	347,332.84	364,068.12	363,023.41	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	4,410.51	5,103.24	9,678.43	2,963.12	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	14,167.40	11,423.22	15,030.24	3,074.21	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	37,233.30	56,367.25	79,773.51	15,457.22	0.00	0.00	
110J	TANF EXPANDED 65+
M&	22,286.04	20,455.08	7,163.10	17,804.09	19,956.72	10,994.29	12,428.07	32,764.40	47,249.41	7,457.56	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	19,671.67	17,536.46	18,187.21	18,144.58	21,475.98	22,319.90	18,093.70	18,011.47	19,958.81	15,850.10	0.00	0.00	
1112	TANF EXPANDED 01-05	92,317.79	94,334.79	94,771.51	100,017.96	101,580.36	114,539.89	95,526.01	92,414.40	86,354.60	76,163.66	0.00	0.00	
1113	TANF EXPANDED 06-13	306,399.70	307,071.24	301,164.82	322,580.64	316,982.77	371,085.11	296,501.64	289,869.13	272,683.64	251,327.63	0.00	0.00	
1114	TANF EXPANDED 14-20	210,348.15	214,471.08	216,431.16	227,941.59	225,312.00	252,669.28	210,745.23	204,220.84	197,623.44	184,873.56	0.00	0.00	
1115	TANF EXPANDED 14-20	643,300.84	649,418.38	646,818.69	682,783.70	652,895.58	727,011.16	624,520.55	602,938.25	597,372.34	572,131.82	0.00	0.00	
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	4,320,729.29	4,262,636.60	4,354,231.29	4,421,285.65	0.00	0.00	
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	14,875,279.69     14,740,558.48	15,111,335.45	15,446,816.31	0.00	0.00	
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	8,748,848.31	8,815,189.90	9,177,105.02	9,466,220.46	0.00	0.00	
1119	TANF EXPANDED 65+
M&	17,823.07	20,468.09	20,106.66	25,686.73	19,036.78	25,048.05	25,859.77	31,872.92	38,243.75	42,283.64	0.00	0.00	
111A	TANF EXPANDED <1 M
&F	3,069.23	2,215.08	4,340.03	4,089.78	4,743.47	1,619.09	2,810.14	1,247.50	2,520.35	0.00	0.00	0.00	
111B	TANF EXPANDED 01-05	1,901.09	1,697.03	1,174.41	2,744.56	1,035.70	1,064.37	1,492.12	1,512.40	491.13	226.17	0.00	0.00	
111C	TANF EXPANDED 06-13	5,213.11	5,167.03	3,167.11	7,318.93	4,226.15	2,855.50	4,750.82	3,354.96	2,651.62	1,040.23	0.00	0.00	
111D	TANF EXPANDED 14-20	11,719.65	11,908.96	9,975.30	11,162.66	8,442.84	8,171.62	10,500.04	12,326.34	7,257.03	3,347.48	0.00	0.00	
111E	TANF EXPANDED 14-20	38,981.20	28,821.18	17,611.10	22,052.24	19,825.52	26,310.43	25,722.07	27,164.03	31,768.17	5,324.10	0.00	0.00	
111F	TANF EXPANDED 21-44	670,244.78	312,184.10	235,633.03	223,770.09	203,735.32	274,205.85	297,882.69	350,494.31	493,352.31	73,163.14	0.00	0.00	
111G	TANF EXPANDED 21-44	1,430,871.86	666,063.85	503,599.59	501,095.66	467,003.56	584,423.58	702,719.26	735,417.52	970,569.74	159,952.42	0.00	0.00	
111H	TANF EXPANDED 45-64	1,626,074.12	515,761.49	396,398.89	399,312.44	400,134.17	478,315.39	609,025.30	705,033.78	861,311.81	112,360.34	0.00	0.00	
111J	TANF EXPANDED 65+
M&	8,192.11	5,842.05	2,447.64	10,469.17	714.38	19,869.92	18,958.39	18,978.21	35,771.69	1,257.31	0.00	0.00	
1125	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.91	0.00	0.00	
1126	TANF EXPANDED 21-44	13,124.22	16,899.08	21,161.04	24,738.82	23,241.40	20,364.89	23,779.77	32,228.05	58,238.25	76,402.76	0.00	0.00	
1127	TANF EXPANDED 21-44	28,106.94	29,980.28	31,155.61	34,168.88	48,526.23	58,487.47	77,727.25	110,194.33	173,098.83	207,464.27	0.00	0.00	
1128	TANF EXPANDED 45-64	65,711.50	74,359.91	89,279.62	100,211.86	107,212.97	129,077.59	141,536.41	159,175.48	224,620.27	254,578.22	0.00	0.00	

9911	SB PAYMENT FOR TAN F	428,501.25	401,669.98	522,606.09	543,298.08	363,461.74	655,950.94	522,754.26	477,576.06	469,749.99	652,597.11	0.00	0.00		5,038,165.50	
9922	SB PAYMENT FOR SSI E	6,120.18	0.00	11,960.62	12,580.34	6,160.56	5,972.38	5,743.01	6,290.17	17,500.38	24,383.27	0.00	0.00		96,710.91	
9923	SB PAYMENT FOR SSI E	0.00	5,731.51	0.00	0.00	0.00	6,081.33	0.00	11,440.46	0.00	6,216.14	0.00	0.00		29,469.44	
	434,621.43	407,401.49	534,566.71	555,878.42	369,622.30	668,004.65	528,497.27	495,306.69	487,250.37	683,196.52	0.00	0.00	5,164,345.85	

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1129	TANF EXPANDED 65+
M&	20,594.42	25,749.49	30,073.08	35,123.44	38,148.36	44,486.30	44,067.67	49,824.92	68,474.71	85,707.88	0.00	0.00		442,250.27		
112F	TANF EXPANDED 21-44	104.01	1,379.49	1,028.72	1,618.17	0.00	213.95	0.00	23.57	84.13	0.00	0.00	0.00		4,452.04		
112G	TANF EXPANDED 21-44	4,554.37	932.81	169.53	913.80	-849.09	310.57	297.68	273.44	254.06	59.14	0.00	0.00		6,916.31		
112H	TANF EXPANDED 45-64	10,330.63	14,843.52	3,145.66	5,317.31	1,623.70	346.53	1,564.34	195.84	4,307.39	652.16	0.00	0.00		42,327.08		
112J	TANF EXPANDED 65+
M&	13,364.24	4,278.10	73.05	0.00	3,219.25	0.00	221.10	874.67	2,536.15	0.00	0.00	0.00		24,566.56		
2400	SSI AGED EXPANDED WI	124,966.70	108,716.83	115,454.14	130,698.88	123,815.32	120,729.32	133,173.69	112,332.32	134,946.43	126,707.16	0.00	0.00		1,231,540.79		
240Z	SSI AGED EXPANDED WI	44,875.33	35,043.96	57,888.79	48,623.03	40,920.35	143,235.82	51,655.32	71,642.94	99,415.13	36,969.27	0.00	0.00		630,269.94		
2410	SSI AGED EXPANDED NO	996,608.43	969,583.79	952,406.57	1,083,088.18	1,051,233.85	1,154,858.19	1,026,627.31	1,027,819.03	1,077,204.32	1,090,328.65	0.00	0.00		10,429,758.32		
241Z	SSI AGED EXPANDED NO	167,945.16	118,708.69	148,067.44	181,653.43	119,651.49	122,357.52	83,657.32	97,873.86	94,025.97	33,688.15	0.00	0.00		1,167,629.03		
2420	SSI AGED EXPANDED WI	4,944,165.87	4,948,750.29	4,920,506.37	4,992,810.54	4,934,065.67	5,304,683.35	4,922,812.19	4,936,268.42	4,879,331.24	4,983,362.34	0.00	0.00		49,766,756.28		
242Z	SSI AGED EXPANDED WI	44,737.03	42,857.94	33,476.24	38,538.79	43,511.73	66,024.88	20,582.01	19,922.17	19,706.37	12,262.55	0.00	0.00		341,619.71		
2510	SSI BLIND EXPANDED N	2,055.56	2,055.56	1,374.99	1,431.39	1,431.39	1,431.39	1,431.39	1,431.39	1,431.39	1,458.65	0.00	0.00		15,533.10		
2520	SSI BLIND EXPANDED W	693.76	329.64	329.64	248.57	248.57	447.51	248.57	248.57	248.57	124.99	0.00	0.00		3,168.39		
2600	SSI DISABLED EXPAND E	336,773.78	334,318.28	334,763.54	370,682.01	322,978.24	323,304.70	307,772.72	259,621.36	210,078.54	176,650.95	0.00	0.00		2,976,944.12		
260Z	SSI DISABLED EXPAND E	37,212.73	33,070.90	21,806.80	27,527.25	17,907.77	42,098.04	33,425.35	45,847.52	52,582.22	31,169.70	0.00	0.00		342,648.28		
2610	SSI DISABLED EXPAND E	2,136,559.39	2,124,308.69	2,046,689.85	1,924,487.10	1,680,665.59	1,663,702.19	1,464,131.93	1,470,296.27	1,732,459.74	2,044,023.47	0.00	0.00		18,287,324.22		
261Z	SSI DISABLED EXPAND E	148,355.71	70,917.72	82,751.94	45,675.28	40,247.44	128,530.07	98,650.95	183,711.10	180,485.79	28,212.99	0.00	0.00		1,007,538.99		
2620	SSI DISABLED EXPAND E	4,542,694.09	4,650,545.08	4,820,226.36	4,950,694.96	5,072,447.13	5,325,363.55	4,855,224.78	5,032,661.60	5,305,878.26	5,735,613.67	0.00	0.00		50,291,349.48		
262Z	SSI DISABLED EXPAND E	10,508.92	9,697.93	9,674.68	7,947.47	9,878.98	10,355.98	11,285.50	7,332.83	12,144.22	5,732.35	0.00	0.00		94,558.86		
	47,192,060.43	45,561,816.56	45,681,882.77	47,838,621.40	46,954,797.80	51,249,495.41	46,928,276.29	47,249,516.39	49,467,239.09	48,552,450.41	0.00	0.00	476,676,156.55		

470.90	
171.28	
-324.35	
594.35	
2,308.38	
43,070.58	
56,217.92	
115,240.01	
125,025.82	
404,814.65	
697.08	

SUBTOTAL:

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	
3307	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	171.28	0.00	0.00	0.00	0.00	0.00	0.00	
3308	AHC CARE M&F 45-64 W	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	
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	
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	
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	
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	
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	
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	
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	
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	

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
331E	AHC CARE FEMALE 14- 2	0.00	0.00	6,631.50	0.00	0.00	0.00	0.00	0.00	529.46	0.00	0.00	0.00		7,160.96		
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	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		
3328	AHC CARE M&F 45-64 W	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		
	0.00	258.15	11,019.45	193.87	0.00	748,928.96	0.00	0.00	529.46	0.00	0.00	0.00	760,929.89		

SUBTOTAL:

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 2	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	
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	
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	
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	
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	
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	-466.86	0.00	0.00	0.00	
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	
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	
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	
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	-683.56	0.00	0.00	0.00	
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	
361H	AHC CARE/MI M&F 45-6	0.00	1,737.54	11,895.88	2,734.24	0.00	0.00	1,367.12	0.00	0.00	-2,050.68	0.00	0.00	
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	
SUBTOTAL:	5,457.46	2,850.90	29,041.16	9,757.70	405.44	2,243,000.20	1,367.12	0.00	-1,150.42	-2,050.68	0.00	0.	

453.95	
86.31	
663.88	
801.40	
72.67	
280,377.46	
265,100.06	
436,187.87	
345,070.97	
915,076.20	
71.09	
11,416.42	
1,447.03	
14,567.44	
1,466.54	
15,684.10	
135.49	
2,288,678.88	

219,951.96	
162,435.32	
1,091,942.15	
244,956.30	
43,539.35	
47,570.23	
204,467.76	
99,327.12	

00

3506	ADULT 40-100% MALE
2	33,464.06	34,621.07	27,069.30	-1,570.91	32,195.17	31,556.63	24,271.07	15,798.97	12,994.94	9,551.66	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	16,968.35	16,619.08	12,487.54	9,406.26	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	122,372.34	75,631.67	56,182.32	43,465.82	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	24,186.42	27,560.95	36,095.49	30,181.07	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	429.92	418.63	8,029.65	9,489.29	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	5,299.95	7,891.97	14,634.35	137.38	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	15,190.32	981.91	62,566.69	6,480.89	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	8,697.55	9,861.94	17,417.26	0.00	0.00	

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE
1	819,832.68	842,828.88	840,953.28	876,800.15	893,590.25	909,070.22	920,893.56	915,049.76	1,015,613.82	1,113,747.01	0.00	0.00		9,148,379.61		
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	1,271,151.18	1,268,683.68	1,355,258.04	1,447,650.99	0.00	0.00		12,283,925.22		
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	6,840,841.96	6,879,578.08	7,211,184.27	7,457,385.01	0.00	0.00		64,009,903.11		
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	6,467,561.52	6,440,179.97	6,623,951.45	6,756,400.38	0.00	0.00		60,356,342.26		
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	13,360,717.41     13,558,680.03	14,123,284.94	14,763,617.68	0.00	0.00		129,051,739.30		
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	11,010.74	9,187.94	11,414.11	11,335.55	0.00	0.00		191,084.02		
351D	ADULT 40-100% MALE
1	203,430.24	118,278.59	111,979.61	102,431.85	86,409.79	122,440.96	136,814.90	197,825.50	277,057.93	137,845.91	0.00	0.00		1,494,515.28		
351E	ADULT 40-100% FEMAL E	270,798.34	157,446.11	188,301.23	129,680.95	143,841.01	227,669.42	221,542.26	235,843.41	372,575.49	172,038.46	0.00	0.00		2,119,736.68		
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	1,399,854.54	1,065,112.19	1,717,114.11	767,315.32	0.00	0.00		11,982,218.33		
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	1,018,624.73	868,991.14	1,378,062.10	520,024.02	0.00	0.00		10,024,953.22		
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	2,186,465.13	1,944,720.60	2,857,256.24	1,321,511.97	0.00	0.00		21,521,137.06		
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	28,302.73	25,308.58	71,629.82	3,622.47	0.00	0.00		344,347.76		
3526	ADULT 40-100% MALE
2	840.56	1,183.72	1,278.98	982.13	4,190.25	3,300.48	3,724.24	4,182.10	3,768.72	1,256.44	0.00	0.00		24,707.62		
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	419.06	2,624.70	0.00	0.00		16,318.61		
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	7,043.99	6,087.93	8,413.46	12,324.10	0.00	0.00		78,121.31		
3529	ADULT 40-100% M&F 65	2,418.24	5,799.29	2,157.44	-888.39	3,354.67	5,592.65	3,728.28	5,442.02	6,593.82	4,953.04	0.00	0.00		39,151.06		
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	9,437.99	687.33	1,030.32	0.00	0.00		21,814.74		
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	-644.57	10,415.21	0.00	0.00	279.36	961.43	4,307.02	0.00	0.00		15,318.45		
3704	ADULT <40% EXP MAL E	358.14	358.14	767.56	372.61	0.00	431.69	446.08	446.08	0.00	0.00	0.00	0.00		3,180.30		
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 MAL E	66,342.05	90,906.49	64,804.70	11,629.81	85,235.20	82,474.29	54,597.00	55,899.55	41,417.96	30,565.44	0.00	0.00		583,872.49		
3707	ADULT <40% EXP FEM AL	27,895.47	28,762.05	25,344.58	5,617.72	34,819.31	32,594.15	20,407.53	11,316.34	12,719.90	8,261.40	0.00	0.00		207,738.45		
3708	ADULT <40% EXP M&F 4	151,258.01	181,061.18	141,318.22	19,911.72	170,772.89	195,886.26	117,274.29	85,028.54	75,683.16	62,820.03	0.00	0.00		1,201,014.30		
3709	ADULT <40% EXP M&F 6	21,725.98	17,546.12	8,954.75	-5,051.05	8,994.94	7,277.56	6,010.39	7,329.05	9,024.81	7,199.58	0.00	0.00		89,012.13		
370D	ADULT <40% EXP MAL E	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 MAL E	9,711.72	8,915.14	7,256.19	4,079.50	3,031.09	22,002.44	4,687.43	4,543.85	5,106.44	2,001.85	0.00	0.00		71,335.65		
370G	ADULT <40% EXP FEM AL	14,796.79	2,816.57	2,643.56	-3,666.11	847.71	8,159.37	-624.29	3,346.17	7,448.24	52.08	0.00	0.00		35,820.09		
370H	ADULT <40% EXP M&F 4	27,786.44	11,083.34	18,874.57	2,755.54	17,182.08	5,431.93	21,760.07	19,435.89	48,132.69	1,985.82	0.00	0.00		174,428.37		
370J	ADULT <40% EXP M&F 6	8,590.58	1,057.53	5,885.27	-3,132.01	2,174.37	0.00	0.00	0.00	11,102.81	2,628.65	0.00	0.00		28,307.20		
3714	ADULT <40% EXP MAL E	4,660,701.72	4,609,307.78	4,699,719.76	4,983,993.27	4,967,501.61	4,920,258.73	4,892,866.81	4,749,896.92	4,724,125.48	4,565,041.47	0.00	0.00		47,773,413.55		
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	4,364,766.00	4,231,683.00	4,167,367.42	4,013,236.42	0.00	0.00		42,485,345.01		
3716	ADULT <40% EXP MAL E	20,467,726.18	21,642,151.29	22,652,596.64	24,114,702.02	24,867,544.52	25,650,195.34	26,115,755.85     25,450,749.34	26,484,548.11	26,899,254.30	0.00	0.00		244,345,223.59		
3717	ADULT <40% EXP FEM AL	13,101,290.86	13,787,135.05	14,316,548.26	15,186,356.28	15,607,747.20	16,014,494.76	16,156,133.04     15,844,503.83	16,283,869.41	16,443,871.07	0.00	0.00		152,741,949.76		

9935	BIRTH SUPP PAYMENT A	98,220.75	87,414.00	107,601.65	153,761.10	103,593.59	147,194.59	172,540.00	165,236.52	166,589.06	145,724.49	0.00	0.00		1,347,875.75	
9937	BIRTH SUPP PAYMENT A	213,395.97	322,263.74	418,907.69	390,616.39	388,378.41	372,513.28	423,438.28	404,490.87	420,883.14	412,243.20	0.00	0.00		3,767,130.97	
	311,616.72	409,677.74	526,509.34	544,377.49	491,972.00	519,707.87	595,978.28	569,727.39	587,472.20	557,967.69	0.00	0.00	5,115,006.72	

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3718	ADULT <40% EXP M&F 4	26,828,359.99	27,999,678.77	28,886,381.41	30,342,374.67	31,102,100.31	31,842,005.33	32,044,519.72     31,691,131.94	32,589,228.65	33,054,402.36	0.00	0.00		306,380,183.15		
3719	ADULT <40% EXP M&F 6	17,618.55	21,642.08	28,214.43	57,106.51	24,073.57	28,449.88	29,483.09	30,823.99	33,702.10	35,029.81	0.00	0.00		306,144.01		
371D	ADULT <40% EXP MAL E	718,104.76	492,931.75	652,804.50	440,084.96	362,409.37	386,701.52	534,902.41	486,054.45	709,457.84	448,863.52	0.00	0.00		5,232,315.08		
371E	ADULT <40% EXP FEM AL	677,187.15	455,966.63	525,225.14	423,286.82	321,422.52	352,510.21	408,264.74	414,717.36	603,968.00	436,308.58	0.00	0.00		4,618,857.15		
371F	ADULT <40% EXP MAL E	4,492,505.58	3,143,839.58	3,233,348.06	2,433,416.79	3,018,935.25	2,875,754.38	3,318,420.97	3,905,872.55	5,052,282.29	3,006,799.32	0.00	0.00		34,481,174.77		
371G	ADULT <40% EXP FEM AL	3,159,846.04	1,948,048.39	1,745,769.58	1,455,033.81	1,885,867.58	1,719,887.70	1,832,113.18	2,065,982.02	2,799,049.40	1,792,463.94	0.00	0.00		20,404,061.64		
371H	ADULT <40% EXP M&F 4	6,497,274.23	3,447,635.99	3,511,604.06	2,317,267.87	2,806,468.09	2,460,469.11	2,926,409.28	3,527,539.43	4,691,459.90	2,451,846.60	0.00	0.00		34,637,974.56		
371J	ADULT <40% EXP M&F 6	46,866.80	16,446.84	12,678.13	9,267.39	17,007.87	9,056.62	25,505.27	18,864.23	8,097.30	12,786.20	0.00	0.00		176,576.65		
3724	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	478.45	0.00	0.00	0.00	1,941.11	0.00	0.00		2,419.56		
3725	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	444.28	956.90	0.00	0.00	0.00		1,401.18		
3726	ADULT <40% EXP MAL E	4,479.71	7,147.16	6,661.04	-10,771.62	2,016.19	9,471.35	4,084.14	3,011.18	3,485.15	2,951.47	0.00	0.00		32,535.77		
3727	ADULT <40% EXP FEM AL	1,735.34	5,609.88	7,359.90	1,302.88	3,335.96	6,098.67	902.21	3,322.80	2,234.88	2,810.98	0.00	0.00		34,713.50		
3728	ADULT <40% EXP M&F 4	4,216.78	4,186.26	13,184.14	-141.68	8,772.34	11,593.08	8,174.28	9,354.63	5,534.04	11,096.24	0.00	0.00		75,970.11		
3729	ADULT <40% EXP M&F 6	0.00	408.64	0.00	886.78	813.50	446.08	0.00	757.92	1,113.93	811.50	0.00	0.00		5,238.35		
372E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.10	0.00	0.00	0.00	0.00		49.10		
372F	ADULT <40% EXP MAL E	0.00	1,191.11	963.60	-89.39	160.38	0.00	464.05	0.00	484.74	0.00	0.00	0.00		3,174.49		
372G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	736.84	412.40	0.00	0.00	0.00	1,177.49	137.38	0.00	0.00		2,464.11		
372H	ADULT <40% EXP M&F 4	2,534.24	3,919.74	140.02	-2,674.87	4,129.11	820.36	1,894.06	687.33	2,150.68	0.00	0.00	0.00		13,600.67		
372J	ADULT <40% EXP M&F 6	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		
	117,597,157.42	111,745,075.69	114,847,592.00	115,780,591.10	120,463,750.59	123,829,238.48	126,976,213.14	126,210,982.78	135,623,028.78	127,920,287.14	0.00	0.00	1,220,993,917.12		

1,515.27	
99,311.20	
47,842.04	
542,937.41	
135,316.49	
47,458.46	
11,018.63	
171,843.75	
70,148.46	
2,579,942.97	
2,912,606.11	
24,637,656.62	

SUBTOTAL:

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	4,916.29	3,365.72	10,380.28	11,290.52	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	26,377.26	15,963.72	563.90	-5,494.61	1,120.32	733.46	1,561.76	1,267.60	1,713.60	4,035.03	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	230,110.61	166,419.22	43,827.86	-47,085.20	41,674.63	29,263.34	19,880.22	12,620.88	19,027.96	27,197.89	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	23,148.00	31,406.89	16,258.53	3,892.58	13,338.07	10,430.39	8,217.11	8,556.96	11,768.18	8,299.78	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	14,499.62	2,357.06	922.36	-1,824.98	3,537.64	0.00	3,332.17	4,208.40	18,735.20	1,690.99	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	2,569.58	0.00	2,416.36	-154.91	44.53	237.91	3,272.84	0.00	2,632.32	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	42,268.26	29,329.86	8,224.62	-13,824.53	11,840.81	13,979.61	4,541.32	17,320.75	47,548.45	10,614.60	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	12,169.94	9,110.02	3,334.84	1,236.00	3,380.41	2,949.29	6,578.93	2,288.76	4,258.74	24,841.53	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	292,208.55	299,371.90	346,863.02	395,951.68	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	318,101.86	334,381.04	408,595.13	468,373.66	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	2,695,761.76	2,731,239.07	3,341,107.00	3,941,969.37	0.00	0.00	

9939	BIRTH SUPP PAYMENT N	30,234.40	23,291.43	35,223.57	48,082.27	72,649.78	114,790.06	140,418.87	98,846.90	170,019.86	189,194.25	0.00	0.00		922,751.39	
	30,234.40	23,291.43	35,223.57	48,082.27	72,649.78	114,790.06	140,418.87	98,846.90	170,019.86	189,194.25	0.00	0.00	922,751.39	

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3917	NEWLY ELIGIBLE FEMA L	1,523,387.26	1,659,829.76	1,794,161.03	1,917,666.25	2,038,851.82	2,314,584.82	2,581,102.44	2,757,362.30	3,540,349.92	4,476,696.66	0.00	0.00		24,603,992.26		
3918	NEWLY ELIGIBLE M&F 4	3,915,892.06	4,196,713.89	4,477,443.72	4,721,147.87	4,871,099.22	5,242,431.92	5,666,112.70	5,787,959.51	6,533,219.71	7,196,090.16	0.00	0.00		52,608,110.76		
3919	NEWLY ELIGIBLE M&F 6	3,917.22	4,915.93	6,153.79	7,352.95	4,235.47	6,308.39	5,971.35	9,803.82	13,474.07	13,670.70	0.00	0.00		75,803.69		
391D	NEWLY ELIGIBLE MALE	46,326.46	37,457.78	56,245.94	12,760.03	24,398.66	51,766.66	46,265.40	68,346.23	132,812.69	31,051.77	0.00	0.00		507,431.62		
391E	NEWLY ELIGIBLE FEMA L	55,613.58	25,265.46	58,955.65	22,327.63	27,362.99	83,188.55	77,142.75	74,083.98	117,580.30	51,446.21	0.00	0.00		592,967.10		
391F	NEWLY ELIGIBLE MALE	857,867.49	510,673.93	582,071.35	235,075.81	247,439.04	629,473.66	764,473.42	760,265.13	1,334,297.15	501,558.83	0.00	0.00		6,423,195.81		
391G	NEWLY ELIGIBLE FEMA L	994,884.35	500,397.47	530,077.84	215,322.26	293,231.97	699,529.06	805,085.73	922,152.47	1,574,488.21	618,205.45	0.00	0.00		7,153,374.81		
391H	NEWLY ELIGIBLE M&F 4	2,753,614.91	1,167,503.66	1,110,174.16	543,175.68	566,920.39	1,059,678.53	1,306,445.99	1,413,165.68	2,206,503.15	764,006.01	0.00	0.00		12,891,188.16		
391J	NEWLY ELIGIBLE M&F 6	22,569.38	10,407.41	10,604.84	5,326.54	3,361.07	16,669.18	24,977.08	27,655.36	44,069.27	14,892.37	0.00	0.00		180,532.50		
3926	NEWLY ELIGIBLE MALE	252.25	252.25	0.00	-298.76	315.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521.71		
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	-1,421.61	0.00	0.00	0.00	0.00	362.83	665.52	0.00	0.00		-393.26		
3928	NEWLY ELIGIBLE M&F 4	1,894.48	3,803.61	1,958.94	-5,879.02	631.94	899.94	315.97	895.55	315.97	1,828.59	0.00	0.00		6,665.97		
3929	NEWLY ELIGIBLE M&F 6	329.92	1,011.25	1,123.60	-614.82	0.00	0.00	0.00	0.00	250.47	851.89	0.00	0.00		2,952.31		
392F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	225.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.90		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	-423.69	0.00	0.00	0.00	0.00	1,383.24	0.00	0.00	0.00		959.55		
392H	NEWLY ELIGIBLE M&F 4	912.30	3,364.87	0.00	-2,166.39	0.00	0.00	0.00	0.00	0.00	342.46	0.00	0.00		2,453.24		
392J	NEWLY ELIGIBLE M&F 6	0.00	151.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,773.04	0.00	0.00		1,924.19		
	12,589,736.31	10,547,340.43	11,038,637.59	10,090,648.59	10,775,089.92	13,116,392.57	14,636,265.64	15,236,311.11	19,711,736.86	18,567,344.71	0.00	0.00	136,309,503.73		

4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	492.63	503.61	0.00	0.00		996.24	
4412	SOBRA 100-133% M&F
1	15,750.99	11,410.21	1,972.17	2,099.53	1,479.21	735.66	424.36	212.93	110.42	227.80	0.00	0.00		34,423.28	
4413	SOBRA 100-133% M&F
6	2,852,910.73	1,969,093.03	2,008,972.85	2,080,455.42	2,090,276.55	2,127,245.37	2,210,738.47	1,968,994.33	2,404,419.25	2,986,705.53	0.00	0.00		22,699,811.53	
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	1,152,021.17	998,992.65	1,169,071.07	1,336,922.64	0.00	0.00		10,900,657.90	
4415	SOBRA 100-133% FEM AL	1,582,957.43	1,403,586.79	1,451,664.27	1,560,929.24	1,566,904.79	1,629,020.26	1,709,569.32	1,459,438.04	1,691,999.44	1,946,987.92	0.00	0.00		16,003,057.50	
441B	SOBRA 100-133% M&F
1	210.49	292.85	326.38	0.00	125.07	0.00	0.00	0.00	0.00	60.93	0.00	0.00		1,015.72	
441C	SOBRA 100-133% M&F
6	145,537.73	98,551.70	107,654.69	79,201.83	41,152.53	167,995.88	143,471.78	193,613.23	325,844.06	27,388.32	0.00	0.00		1,330,411.75	
441D	SOBRA 100-133% MALE	179,041.42	93,546.34	91,139.52	64,152.03	46,016.17	133,391.72	109,185.74	170,721.03	300,567.53	31,847.52	0.00	0.00		1,219,609.02	
441E	SOBRA 100-133% FEM AL	208,772.31	106,487.44	116,156.60	64,786.53	53,899.26	153,332.08	145,838.11	168,548.73	351,080.42	22,855.88	0.00	0.00		1,391,757.36	
	6,088,102.49	4,621,221.13	4,765,216.27	4,904,476.80	4,860,977.15	5,312,891.60	5,471,248.95	4,960,520.94	6,243,584.82	6,353,500.15	0.00	0.00	53,581,740.30	

SUBTOTAL:

9944	BIRTH SUPP PAYMENT S	35,479.33	29,417.65	23,549.95	24,394.66	18,450.85	36,240.96	49,466.37	30,303.50	30,222.39	30,266.24	0.00	0.00		307,791.90	
	35,479.33	29,417.65	23,549.95	24,394.66	18,450.85	36,240.96	49,466.37	30,303.50	30,222.39	30,266.24	0.00	0.00	307,791.90	

SUBTOTAL:

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	8,839.74	8,852.79	8,743.39	9,457.02	9,986.80	10,958.60	9,584.51	8,323.18	7,754.80	7,967.09	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	119,472.32	119,099.24	116,798.57	123,527.44	122,218.43	131,008.94	120,893.29	114,428.94	114,800.98	116,641.62	0.00	0.00	

90,467.92

1,198,889.77

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4519	BC PATIENT FEMALE 6 5	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		4,283.35		
451G	BC PATIENT FEMALE 2 1	0.00	413.89	0.00	489.82	353.04	0.00	31.78	0.00	0.00	0.00	0.00	0.00		1,288.53		
451H	BC PATIENT FEMALE 4 5	448.89	3,855.31	1,234.94	515.43	4,564.29	2,127.20	4,277.06	3,728.15	680.13	427.06	0.00	0.00		21,858.46		
451J	BC PATIENT FEMALE 6 5	88.11	271.08	0.00	0.00	45.69	46.33	0.00	0.00	0.00	0.00	0.00	0.00		451.21		
4617	CC PATIENT FEMALE 2 1	8,119.40	8,190.07	8,139.76	8,681.81	8,770.38	9,886.77	8,350.08	8,122.42	8,293.64	5,980.18	0.00	0.00		82,534.51		
4618	CC PATIENT FEMALE 4 5	7,425.15	7,949.01	7,949.01	8,007.55	8,549.17	9,611.95	7,799.71	7,799.71	7,799.71	8,487.08	0.00	0.00		81,378.05		
461G	CC PATIENT FEMALE 2 1	1,050.37	37.03	557.03	292.94	19.69	782.75	0.00	351.57	0.00	0.00	0.00	0.00		3,091.38		
461H	CC PATIENT FEMALE 4 5	724.76	0.00	0.00	688.88	431.17	14.74	0.00	0.00	0.00	0.00	0.00	0.00		1,859.55		
	147,641.99	149,803.31	143,422.70	151,660.89	155,351.03	165,700.12	150,936.43	142,753.97	139,329.26	139,503.03	0.00	0.00	1,486,102.73		

8600	SSI BLIND FREEDOM/W O	111.47	111.47	111.47	110.58	110.58	110.58	110.58	110.58	110.58	119.15	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,244,519.95	1,265,826.16	1,272,816.33	1,278,006.88	1,284,932.98	1,315,530.90	1,309,037.72	1,312,495.58	1,333,524.48	1,334,987.93	0.00	0.00	
870Z	SSI DISABLED FREEDO M	6,724.26	10,834.42	3,136.00	9,247.26	3,859.68	11,580.31	3,732.97	1,182.25	5,007.97	11,559.18	0.00	0.00	
8710	SSI DISABLED FREEDO M	177,605.31	180,687.48	192,244.62	209,764.35	204,164.03	214,954.00	204,228.62	205,958.59	207,602.93	227,233.40	0.00	0.00	
871Z	SSI DISABLED FREEDO M	18,701.90	17,782.48	34,798.68	47,955.65	20,041.56	22,127.64	22,454.78	5,170.83	17,476.79	51,374.13	0.00	0.00	
8720	SSI DISABLED FREEDO M	142,004.63	141,706.42	140,001.72	142,784.20	145,814.05	151,114.32	146,638.64	141,962.30	141,302.94	158,912.26	0.00	0.00	
872Z	SSI DISABLED FREEDO M	1,299.02	2,799.55	1,846.22	643.95	242.10	0.00	524.78	705.63	0.00	74.89	0.00	0.00	
SUBTOTAL:	1,590,966.54	1,619,747.98	1,644,955.04	1,688,512.87	1,659,164.98	1,715,417.75	1,686,728.09	1,667,585.76	1,705,025.69	1,784,260.94	0.00	0.	

1,117.04	
12,951,678.91	
66,864.30	
2,024,443.33	
257,884.44	
1,452,241.48	
8,136.14	
16,762,365.64	

00

423,481,294.76	407,890,297.52	414,472,740.09	425,754,664.25	424,880,980.76	465,424,945.08	437,883,860.50	435,504,384.50	457,542,750.66	452,857,106.57	0.00	0.00	4,345,693,024.69	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
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	1.00	1.00	1.00	1.00	0.00	0.00		12.00		
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	98.04	94.07	90.05	105.12	0.00	0.00		980.67		
1007	TANF 21-44 FEMALE WI	235.10	247.82	246.95	266.50	248.66	253.58	240.60	211.04	209.75	232.31	0.00	0.00		2,392.31		
1008	TANF 45-64 M & F WIT	172.61	179.92	177.12	193.04	178.34	195.87	205.61	190.14	184.84	233.72	0.00	0.00		1,911.21		
1009	TANF 65+ M & F WITH	55.09	52.15	54.06	62.15	56.81	58.87	65.89	69.67	74.78	86.86	0.00	0.00		636.33		
100F	TANF 21-44 MALE WITH	8.20	0.35	5.19	2.14	2.99	0.57	2.52	1.74	7.06	35.15	0.00	0.00		65.91		
100G	TANF 21-44 FEMALE WI	19.62	13.93	4.30	16.20	10.52	9.74	5.82	12.91	29.22	44.95	0.00	0.00		167.21		
100H	TANF 44-64 M & F WIT	22.13	6.12	4.86	11.03	2.12	13.95	0.00	18.45	21.04	81.19	0.00	0.00		180.89		
100J	TANF 65+ M & F WITH	3.89	0.67	9.92	1.74	0.63	0.12	2.09	5.30	15.16	23.59	0.00	0.00		63.11		
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	14,814.54	14,501.74	14,298.90	14,053.08	0.00	0.00		149,345.96		
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	78,772.69	75,590.14	68,731.89	60,074.26	0.00	0.00		788,729.54		
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	127,305.54	122,654.70	111,943.51	98,359.17	0.00	0.00		1,263,343.01		
1014	TANF 14-20 MALE NON-	25,621.38	25,952.43	26,217.60	26,576.69	26,494.38	26,383.40	25,782.93	25,075.51	23,290.53	20,835.74	0.00	0.00		252,230.59		
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	30,190.27	29,454.64	27,518.35	24,999.92	0.00	0.00		297,809.60		
1016	TANF 21-44 MALE NON-	22,587.19	22,942.22	23,303.89	23,398.68	23,078.41	23,095.12	22,753.66	22,578.28	22,711.86	23,299.52	0.00	0.00		229,748.83		
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	88,856.16	87,399.98	86,649.83	85,504.06	0.00	0.00		894,483.25		
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	19,200.80	18,975.89	19,054.19	19,313.73	0.00	0.00		190,143.84		
1019	TANF 65+ M & F NON-M	51.35	56.59	59.22	57.85	55.29	57.35	58.67	58.48	67.52	74.95	0.00	0.00		597.27		
101A	TANF < 1 M & F NON-M	356.79	359.28	339.08	374.07	322.72	319.43	298.98	228.16	225.30	333.79	0.00	0.00		3,157.60		
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	2,266.14	1,781.62	1,268.46	850.68	0.00	0.00		22,187.82		
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	2,667.34	2,199.62	1,560.53	1,054.15	0.00	0.00		26,307.16		
101D	TANF 14-20 MALE NON-	836.55	839.23	645.56	683.76	616.64	584.87	596.52	469.89	411.35	291.95	0.00	0.00		5,976.32		
101E	TANF 14-20 FEMALE N O	1,255.72	1,019.24	859.65	913.15	729.15	792.01	814.70	754.94	640.18	496.43	0.00	0.00		8,275.17		
101F	TANF 21-44 MALE NON-	3,415.15	1,238.51	1,085.00	1,059.05	999.59	1,179.68	1,516.75	1,670.06	2,376.30	2,448.07	0.00	0.00		16,988.16		
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	3,951.70	4,093.36	5,092.38	4,980.48	0.00	0.00		41,639.23		
101H	TANF 44-64 M & F NON	3,472.14	936.34	917.73	556.31	696.51	863.89	905.14	994.36	1,446.90	1,662.99	0.00	0.00		12,452.31		
101J	TANF 65+ N & F NON-M	25.59	3.01	6.26	-0.85	2.85	2.60	10.78	6.48	23.28	17.14	0.00	0.00		97.14		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		1.00		
1022	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		1.00		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00		2.00		
1026	TANF 21-44 MALE WITH	1.00	2.00	3.63	6.00	7.00	7.00	9.00	10.00	14.87	27.59	0.00	0.00		88.09		
1027	TANF 21-44 FEMALE WI	10.00	9.00	11.20	20.00	17.00	17.87	19.00	29.31	30.87	43.65	0.00	0.00		207.90		
1028	TANF 45-64 M & F WIT	5.00	6.77	9.00	8.00	13.99	16.00	15.00	18.00	26.77	39.06	0.00	0.00		157.59		
1029	TANF 65+ M & F WITH	2.00	2.00	3.96	3.90	3.00	6.00	6.00	6.00	12.00	18.62	0.00	0.00		63.48		

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	0.00	0.00	0.36	0.00	0.00	0.00	0.00	0.00	0.12	0.36	0.00	0.00		0.84		
102G	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.12	0.00	2.66	0.12	3.71	0.00	0.00		6.61		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.22	14.92	0.00	0.00		15.14		
102J	TANF 65+ M & F WITH	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	2.36	0.00	0.00		2.39		
2100	SSI AGED WITH MEDIC A	4,370.68	4,347.93	4,360.25	4,520.65	4,374.48	4,436.34	4,491.10	4,409.73	4,274.38	4,214.40	0.00	0.00		43,799.94		
210Z	SSI AGED WITH MEDIC A	902.84	381.78	183.85	232.94	184.97	1,080.72	75.10	133.16	426.34	372.24	0.00	0.00		3,973.94		
2110	SSI AGED NON-MEDIC AR	6,138.76	6,358.34	6,368.22	6,402.03	6,386.08	6,413.44	6,365.24	6,457.17	6,505.72	6,234.73	0.00	0.00		63,629.73		
211Z	SSI AGED NON-MEDIC AR	1,881.26	947.08	682.35	432.93	480.61	330.10	370.96	410.79	494.70	283.55	0.00	0.00		6,314.33		
2120	SSI AGED WITH QMB	21,139.27	21,618.35	21,892.09	22,140.06	22,014.07	21,996.96	22,071.85	21,878.54	21,493.13	20,978.09	0.00	0.00		217,222.41		
212Z	SSI AGED WITH QMB P P	435.63	230.59	152.26	158.11	294.87	338.55	61.21	58.83	62.08	54.62	0.00	0.00		1,846.75		
2200	SSI DISABLED WITH M E	4,292.08	4,262.41	4,279.85	5,055.96	4,337.61	4,374.52	4,485.13	4,427.44	3,965.82	3,832.34	0.00	0.00		43,313.16		
220Z	SSI DISABLED WITH M E	659.56	304.25	203.76	241.91	174.16	192.23	158.08	184.17	289.73	213.35	0.00	0.00		2,621.20		
2210	SSI DISABLED NON-ME D	58,085.69	58,087.88	58,057.39	58,012.43	57,866.09	57,675.63	57,658.07	57,716.63	57,817.95	57,781.99	0.00	0.00		578,759.75		
221Z	SSI DISABLED NON-ME D	3,034.88	1,839.55	1,379.74	1,040.61	1,100.48	1,049.00	1,179.85	1,423.34	1,329.06	1,159.66	0.00	0.00		14,536.17		
2220	SSI DISABLED WITH Q M	25,240.50	25,243.76	25,480.32	25,656.46	25,367.63	25,314.67	26,030.77	25,955.32	26,159.10	26,235.26	0.00	0.00		256,683.79		
222Z	SSI DISABLED WITH Q M	97.75	112.63	39.47	40.20	26.57	52.19	49.65	30.69	43.89	44.54	0.00	0.00		537.58		
2300	SSI BLIND WITH MEDIC	32.48	33.00	30.00	31.45	30.20	30.00	28.00	28.00	29.28	27.69	0.00	0.00		300.10		
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	427.53	426.89	427.03	425.87	424.73	433.17	439.50	437.55	440.07	445.85	0.00	0.00		4,328.19		
231Z	SSI BLIND NON-MEDIC A	9.31	5.91	15.12	21.47	9.26	1.34	2.18	6.73	18.30	7.46	0.00	0.00		97.08		
2320	SSI BLIND WITH QMB	204.14	203.00	205.98	207.99	206.44	208.06	208.85	209.99	209.96	213.68	0.00	0.00		2,078.09		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00	0.00	0.03	0.00	0.00		0.06		
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	2.32	2.00	2.96	3.30	0.00	0.00		19.61		
4303	SOBRA CHILD 06-13 M	1.00	1.45	0.00	0.00	0.93	2.00	2.00	2.32	4.44	2.00	0.00	0.00		16.14		
4304	SOBRA CHILD 14-20 MA	0.00	2.00	0.00	0.96	1.00	1.00	1.00	1.00	1.74	1.00	0.00	0.00		9.70		
4305	SOBRA CHILD 14-20 FE	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
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	1.67	0.00	2.03	0.70	0.00	0.00		22.92		
430C	SOBRA CHILD 06-13 M	0.00	8.54	0.00	0.00	5.06	0.00	0.00	1.67	4.38	0.00	0.00	0.00		19.65		
430D	SOBRA CHILD 14-20 MA	0.00	2.00	0.00	1.03	0.00	0.00	0.00	0.00	1.25	0.00	0.00	0.00		4.28		
4311	SOBRA CHILD <1 M & F	32,941.40	32,869.17	33,321.28	33,290.96	32,832.15	33,230.55	33,028.61	33,088.94	34,534.37	36,032.79	0.00	0.00		335,170.22		
4312	SOBRA CHILD 01-05 M	99,019.99	100,577.33	101,362.18	102,197.44	100,684.31	101,706.69	102,462.62	103,615.09	113,065.85	122,034.67	0.00	0.00		1,046,726.17		
4313	SOBRA CHILD 06-13 M	122,544.94	124,976.78	127,084.81	128,918.53	127,812.16	129,429.49	130,246.21	132,253.36	142,315.91	153,010.19	0.00	0.00		1,318,592.38		
4314	SOBRA CHILD 14-20 MA	31,558.09	32,213.12	32,709.48	33,015.85	32,605.43	32,893.51	33,015.92	33,667.23	36,017.03	38,593.79	0.00	0.00		336,289.45		
4315	SOBRA CHILD 14-20 FE	31,209.97	31,927.15	32,288.25	32,670.19	32,213.70	32,555.14	32,767.26	33,247.28	35,940.36	38,597.49	0.00	0.00		333,416.79		

9910	TANF & SOBRA CHILDR E	1,113.00	1,048.00	1,120.00	1,041.00	975.00	1,170.00	990.00	807.00	867.00	694.00	0.00	0.00		9,825.00	
9920	SSI W/MEDICARE KICK	10.00	7.00	15.00	11.00	5.00	11.00	8.00	13.00	7.00	8.00	0.00	0.00		95.00	
9921	SSI W/O MEDICARE KI C	43.00	27.00	32.00	37.00	29.00	41.00	26.00	34.00	32.00	25.00	0.00	0.00		326.00	
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	1,728.00	1,591.00	1,793.00	1,739.00	0.00	0.00		17,809.00	
	3,074.00	2,873.00	3,127.00	3,008.00	2,520.00	3,091.00	2,752.00	2,445.00	2,699.00	2,466.00	0.00	0.00	28,055.00	

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431A	SOBRA CHILD < 1 M &	1,170.89	705.34	799.14	697.40	803.58	986.82	1,085.47	1,466.38	1,925.07	1,203.72	0.00	0.00		10,843.81		
431B	SOBRA CHILD 01-05 M	10,635.96	5,366.79	4,896.50	4,697.42	4,625.23	6,243.97	7,351.76	9,642.43	12,671.14	7,822.23	0.00	0.00		73,953.43		
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	7,085.91	8,607.57	12,015.16	9,467.68	0.00	0.00		74,735.47		
431D	SOBRA CHILD 14-20 MA	3,814.47	1,796.34	1,462.95	1,370.65	1,324.31	1,762.63	2,037.88	2,396.39	3,272.08	2,462.47	0.00	0.00		21,700.17		
431E	SOBRA CHILD 14-20 FE	3,680.89	1,770.66	1,604.02	1,393.59	1,351.32	1,943.80	2,108.30	2,381.00	3,316.35	2,490.40	0.00	0.00		22,040.33		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.87	1.00	0.00	0.00		5.87		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.61	10.00	0.00	0.00		13.61		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		1.00		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.85	4.00	1.00	0.00	0.00		6.85		
432B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.12	0.00	0.00	0.00		0.12		
432C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.38	0.00	0.00	0.00		0.38		
432E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.14	0.00	0.00	0.00	0.00		0.14		
5007	SOBRA PREG 21-44 FE M	50.81	50.91	49.36	50.40	57.73	58.08	56.76	58.77	55.15	52.26	0.00	0.00		540.23		
5008	SOBRA PREG 45-64 FE M	4.00	3.00	3.00	3.00	3.00	3.00	4.03	2.00	2.70	1.00	0.00	0.00		28.73		
500G	SOBRA PREG 21-44 FE M	2.15	12.05	0.63	3.44	6.26	0.83	0.19	14.75	2.82	0.93	0.00	0.00		44.05		
500H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.96	0.00	8.29	0.00	0.00	0.00		9.25		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	1.00	2.51	2.00	3.00	3.00	2.32	3.00	3.00	0.00	0.00		19.83		
5015	SOBRA PREG 14-20 FE M	3,195.16	3,227.04	3,261.98	3,154.18	3,059.04	2,981.71	2,878.45	2,909.90	3,117.67	3,361.66	0.00	0.00		31,146.79		
5017	SOBRA PREG 21-44 FE M	11,094.84	11,080.86	10,947.08	10,863.14	10,515.14	10,589.52	10,538.08	11,029.53	12,185.41	13,409.46	0.00	0.00		112,253.06		
5018	SOBRA PREG 45-64 FE M	51.43	43.50	44.09	42.44	44.04	44.37	49.63	45.99	53.27	55.78	0.00	0.00		474.54		
501C	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	1.48	0.00	0.00	0.00	1.67	0.00	0.00	0.00	0.00		3.15		
501E	SOBRA PREG 14-20 FE M	491.51	473.50	375.36	358.09	348.92	353.73	340.74	510.03	548.95	473.75	0.00	0.00		4,274.58		
501G	SOBRA PREG 21-44 FE M	1,552.87	1,313.22	1,290.34	1,270.11	1,214.98	1,465.33	1,495.18	1,841.87	2,075.49	1,893.12	0.00	0.00		15,412.51		
501H	SOBRA PREG 45-64 FE M	8.54	1.48	13.89	5.54	4.92	9.60	6.35	0.99	23.70	10.18	0.00	0.00		85.19		
5027	SOBRA PREG 21-44 FE M	5.99	5.87	7.00	6.00	10.00	12.83	11.00	9.92	9.00	4.00	0.00	0.00		81.61		
5028	SOBRA PREG 45-64 FE 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		
502G	SOBRA PREG 21-44 FE M	0.00	2.12	0.00	0.00	0.00	0.16	0.00	0.07	0.00	0.00	0.00	0.00		2.35		
5510	SOBRA FPS FEMALE W IT	-2.03	-16.00	-16.00	0.00	-3.00	-1.00	-4.00	-3.00	-9.00	0.00	0.00	0.00		-54.03		
	935,093.91	916,984.24	920,878.14	925,857.20	912,526.90	918,165.82	911,687.72	909,728.68	924,769.19	912,747.32	0.00	0.00	9,188,439.12		

SUBTOTAL:

3100	TRANSPLANT OPTION 1	0.00	0.00	1.19	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	

15.19

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
310Z	TRANSPLANT OPTION 1	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		
3200	TRANSPLANT OPTION 2	0.00	0.00	0.00	0.00	0.93	1.00	1.00	1.00	1.00	0.00	0.00	0.00		4.93		
320Z	TRANSPLANT OPTION 2	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		
	0.00	0.00	2.98	2.00	3.99	3.00	3.00	3.00	3.00	2.00	0.00	0.00	22.97		

2.00	
7,714.54	
16,589.15	
25,218.90	
8,141.05	
296.23	
597.64	
918.36	
509.78	
389.86	
8,243.58	
25,566.80	
12,931.68	
25,698.27	
280,888.32	
603,506.21	
212,642.00	
657.68	
24.21	
227.73	
687.14	
573.86	
1,229.79	
18,877.57	
34,128.01	
14,875.23	
300.35	
1.00	
817.60	
1,628.87	
2,436.53	

SUBTOTAL:

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	754.55	731.03	762.47	759.91	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	1,626.34	1,580.74	1,609.64	1,573.68	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	2,525.53	2,481.86	2,566.05	2,557.81	0.00	0.00	
1109	TANF EXPANDED 65+
M&	761.60	777.87	791.55	833.44	812.20	823.25	824.70	821.41	858.61	836.42	0.00	0.00	
110F	TANF EXPANDED 21-44	23.58	38.84	27.73	31.86	21.81	18.36	26.81	30.96	58.22	18.06	0.00	0.00	
110G	TANF EXPANDED 21-44	53.63	61.63	67.18	50.56	62.48	84.60	69.85	57.10	76.10	14.51	0.00	0.00	
110H	TANF EXPANDED 45-64	95.35	86.77	42.99	94.96	54.20	100.96	87.25	137.09	186.91	31.88	0.00	0.00	
110J	TANF EXPANDED 65+
M&	55.56	60.96	17.40	46.48	50.67	26.93	29.71	81.81	123.71	16.55	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	41.95	37.93	39.85	37.30	44.65	42.17	37.27	36.88	40.86	31.00	0.00	0.00	
1112	TANF EXPANDED 01-05	844.18	871.07	883.13	894.21	882.93	879.67	835.00	797.58	738.65	617.16	0.00	0.00	
1113	TANF EXPANDED 06-13	2,726.58	2,736.37	2,697.06	2,737.33	2,678.65	2,694.50	2,515.75	2,482.81	2,291.40	2,006.35	0.00	0.00	
1114	TANF EXPANDED 14-20	1,344.20	1,354.93	1,368.03	1,370.14	1,352.11	1,336.78	1,269.60	1,244.37	1,202.19	1,089.33	0.00	0.00	
1115	TANF EXPANDED 14-20	2,712.20	2,747.34	2,714.84	2,752.79	2,633.71	2,598.55	2,509.76	2,422.25	2,386.71	2,220.12	0.00	0.00	
1116	TANF EXPANDED 21-44	27,812.41	28,482.07	28,774.90	28,967.43	28,320.94	28,164.60	27,698.26	27,347.73	27,925.94	27,394.04	0.00	0.00	
1117	TANF EXPANDED 21-44	58,482.54	59,776.19	60,790.23	61,688.83	60,828.84	60,681.52	60,169.33	59,598.66	61,054.23	60,435.84	0.00	0.00	
1118	TANF EXPANDED 45-64	19,991.08	20,609.06	21,007.91	21,306.26	21,166.67	21,298.77	21,267.19	21,409.40	22,266.59	22,319.07	0.00	0.00	
1119	TANF EXPANDED 65+
M&	45.63	52.61	51.87	65.37	47.16	57.27	63.52	78.61	94.44	101.20	0.00	0.00	
111A	TANF EXPANDED <1 M
&F	2.76	2.05	4.16	3.65	4.15	1.80	2.44	1.09	2.11	0.00	0.00	0.00	
111B	TANF EXPANDED 01-05	33.43	30.88	21.06	47.31	17.86	17.05	24.34	23.92	8.20	3.68	0.00	0.00	
111C	TANF EXPANDED 06-13	91.68	94.89	55.35	127.43	70.26	47.33	81.87	55.81	45.27	17.25	0.00	0.00	
111D	TANF EXPANDED 14-20	70.38	72.62	60.15	66.99	52.21	49.75	63.67	74.26	43.62	20.21	0.00	0.00	
111E	TANF EXPANDED 14-20	198.05	148.93	89.81	112.12	100.09	131.19	129.70	135.64	158.23	26.03	0.00	0.00	
111F	TANF EXPANDED 21-44	4,073.04	1,889.76	1,432.91	1,346.16	1,216.60	1,635.62	1,781.74	2,105.44	2,957.42	438.88	0.00	0.00	
111G	TANF EXPANDED 21-44	7,379.68	3,428.17	2,588.24	2,559.07	2,338.97	2,945.37	3,528.29	3,689.07	4,867.58	803.57	0.00	0.00	
111H	TANF EXPANDED 45-64	4,005.87	1,290.55	984.27	987.05	969.21	1,136.25	1,459.88	1,689.60	2,094.44	258.11	0.00	0.00	
111J	TANF EXPANDED 65+
M&	21.28	17.18	6.02	21.46	1.83	45.57	45.37	49.00	88.84	3.80	0.00	0.00	
1125	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
1126	TANF EXPANDED 21-44	32.93	39.75	49.68	57.63	63.00	70.93	81.00	92.81	148.84	181.03	0.00	0.00	
1127	TANF EXPANDED 21-44	64.65	71.62	84.08	91.83	107.28	128.30	165.60	208.86	314.95	391.70	0.00	0.00	
1128	TANF EXPANDED 45-64	125.92	136.01	165.35	197.80	199.44	230.97	256.32	291.57	385.15	448.00	0.00	0.00	

9911	SB PAYMENT FOR TAN F	72.00	68.00	88.00	89.00	60.00	108.00	86.00	78.00	77.00	107.00	0.00	0.00		833.00	
9922	SB PAYMENT FOR SSI E	1.00	0.00	2.00	2.00	1.00	1.00	1.00	1.00	3.00	4.00	0.00	0.00		16.00	
9923	SB PAYMENT FOR SSI E	0.00	1.00	0.00	0.00	0.00	1.00	0.00	2.00	0.00	1.00	0.00	0.00		5.00	
	73.00	69.00	90.00	91.00	61.00	110.00	87.00	81.00	80.00	112.00	0.00	0.00	854.00	

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1129	TANF EXPANDED 65+
M&	49.26	60.61	71.83	81.99	88.92	99.99	103.46	117.20	164.24	195.00	0.00	0.00		1,032.50		
112F	TANF EXPANDED 21-44	0.64	7.02	6.29	8.34	0.00	1.06	0.00	0.14	0.51	0.00	0.00	0.00		24.00		
112G	TANF EXPANDED 21-44	23.31	4.89	0.89	4.77	-4.46	1.66	1.44	1.38	1.28	0.30	0.00	0.00		35.46		
112H	TANF EXPANDED 45-64	23.98	40.04	8.20	13.58	5.65	0.95	3.63	0.42	10.58	2.00	0.00	0.00		109.03		
112J	TANF EXPANDED 65+
M&	32.48	11.34	0.16	0.00	10.06	0.00	0.48	1.88	6.73	0.00	0.00	0.00		63.13		
2400	SSI AGED EXPANDED WI	581.54	565.94	599.57	644.56	580.35	657.07	731.43	709.85	781.59	673.17	0.00	0.00		6,525.07		
240Z	SSI AGED EXPANDED WI	491.82	374.01	631.37	528.24	448.28	1,561.33	573.80	778.71	1,078.04	402.82	0.00	0.00		6,868.42		
2410	SSI AGED EXPANDED NO	1,309.52	1,264.48	1,238.89	1,345.57	1,294.46	1,296.54	1,264.25	1,269.52	1,329.85	1,331.26	0.00	0.00		12,944.34		
241Z	SSI AGED EXPANDED NO	347.68	242.29	309.35	378.83	239.87	233.89	160.39	208.24	183.90	66.51	0.00	0.00		2,370.95		
2420	SSI AGED EXPANDED WI	21,506.00	21,646.70	21,762.56	22,334.80	22,474.03	22,879.08	22,866.34	23,122.52	23,483.32	23,492.60	0.00	0.00		225,567.95		
242Z	SSI AGED EXPANDED WI	487.45	464.59	370.63	421.41	475.31	710.65	225.05	225.31	210.17	134.52	0.00	0.00		3,725.09		
2510	SSI BLIND EXPANDED N	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00		22.00		
2520	SSI BLIND EXPANDED W	5.00	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00		24.00		
2600	SSI DISABLED EXPAND E	603.87	594.65	641.21	908.50	647.65	681.67	661.83	606.07	507.38	408.91	0.00	0.00		6,261.74		
260Z	SSI DISABLED EXPAND E	395.75	352.07	238.17	313.99	201.45	440.52	382.59	500.11	585.28	334.64	0.00	0.00		3,744.57		
2610	SSI DISABLED EXPAND E	1,730.47	1,749.03	1,699.19	1,627.72	1,424.64	1,305.20	1,348.13	1,459.01	1,845.38	2,171.20	0.00	0.00		16,359.97		
261Z	SSI DISABLED EXPAND E	315.29	156.53	172.63	100.03	81.04	266.85	208.46	363.57	361.30	57.70	0.00	0.00		2,083.40		
2620	SSI DISABLED EXPAND E	9,091.72	9,232.20	9,509.32	9,853.08	10,007.16	10,302.67	9,960.63	10,352.57	11,246.87	12,054.33	0.00	0.00		101,610.55		
262Z	SSI DISABLED EXPAND E	113.19	110.35	107.80	89.28	112.15	113.00	121.93	79.66	143.80	62.38	0.00	0.00		1,053.54		
	173,132.87	166,740.69	167,182.36	170,430.74	167,128.42	170,716.45	168,548.48	169,557.52	177,301.59	166,006.53	0.00	0.00	1,696,745.65		

0.00	
0.00	
-3.00	
0.00	
3.00	
0.00	
0.00	
0.00	
0.00	
-1.93	
1.00	

SUBTOTAL:

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	
3307	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	
3308	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	
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	
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	
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	
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	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 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	
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	
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	

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
331E	AHC CARE FEMALE 14- 2	0.00	0.00	9.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00		10.00		
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	0.00	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		
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		
	0.00	0.00	15.00	-1.99	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	14.01		

SUBTOTAL:

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 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3618	AHC CARE/MI M&F 45-6	1.00	-1.00	1.00	-2.00	0.00	0.00	0.00	0.00	-1.10	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	
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	
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	
361F	AHC CARE/MI MALE 21-	2.00	-0.81	12.00	9.00	0.00	0.00	0.00	0.00	-1.00	0.00	0.00	0.00	
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	
361H	AHC CARE/MI M&F 45-6	0.00	2.00	16.00	4.00	0.00	0.00	2.00	0.00	0.00	-3.00	0.00	0.00	
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	
SUBTOTAL:	5.23	4.19	42.00	15.00	0.97	1.00	2.00	0.00	-2.10	-3.00	0.00	0.	

0.00	
0.00	
0.00	
2.00	
0.00	
-4.43	
0.00	
0.67	
6.96	
-2.10	
0.00	
16.00	
2.00	
21.19	
2.00	
21.00	
0.00	
65.29	

374.16	
246.78	
2,356.99	
592.18	
61.49	
66.37	
304.37	
143.01	

00

3506	ADULT 40-100% MALE
2	59.62	55.45	52.54	-13.67	54.00	54.84	35.32	29.21	26.47	20.38	0.00	0.00	
3507	ADULT 40-100% FEMAL E	35.66	35.11	33.74	-25.90	38.29	37.77	26.38	25.43	23.50	16.80	0.00	0.00	
3508	ADULT 40-100% M&F 45	348.51	359.02	342.35	-64.30	327.00	364.12	283.28	174.00	125.02	97.99	0.00	0.00	
3509	ADULT 40-100% M&F 65	76.14	78.50	37.92	-50.28	86.91	76.00	58.89	67.69	88.30	72.11	0.00	0.00	
350F	ADULT 40-100% MALE
2	26.33	4.28	4.88	0.70	0.00	1.86	0.67	0.78	10.50	11.49	0.00	0.00	
350G	ADULT 40-100% FEMAL E	11.30	12.88	3.19	-6.62	0.56	8.00	6.61	10.53	19.72	0.20	0.00	0.00	
350H	ADULT 40-100% M&F 45	65.04	48.30	46.74	-21.77	21.46	22.67	23.70	1.42	87.94	8.87	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	11.27	13.67	23.85	0.00	0.00	

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE
1	1,984.67	2,065.04	2,058.68	2,083.06	2,115.30	2,149.36	2,162.92	2,154.19	2,389.28	2,564.92	0.00	0.00		21,727.42		
3515	ADULT 40-100% FEMAL E	2,614.51	2,670.67	2,726.85	2,782.47	2,848.49	2,942.80	2,965.60	2,955.20	3,146.17	3,300.52	0.00	0.00		28,953.28		
3516	ADULT 40-100% MALE
2	12,714.59	13,533.02	14,111.15	14,618.12	14,939.73	15,814.00	16,128.40	16,180.42	16,933.10	17,219.54	0.00	0.00		152,192.07		
3517	ADULT 40-100% FEMAL E	12,070.40	12,868.07	13,361.73	13,869.29	14,171.67	14,906.87	15,186.37	15,126.45	15,519.72	15,485.73	0.00	0.00		142,566.30		
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	31,702.10	32,204.26	33,512.34	34,336.75	0.00	0.00		308,785.17		
3519	ADULT 40-100% M&F 65	14.04	14.83	36.32	259.58	15.28	29.23	27.04	22.93	27.94	27.50	0.00	0.00		474.69		
351D	ADULT 40-100% MALE
1	313.78	181.67	171.50	150.11	121.76	179.33	200.82	295.31	416.62	208.10	0.00	0.00		2,239.00		
351E	ADULT 40-100% FEMAL E	403.56	228.94	285.63	198.12	215.06	337.56	326.43	358.44	552.21	258.05	0.00	0.00		3,164.00		
351F	ADULT 40-100% MALE
2	2,859.91	2,031.13	1,773.86	1,159.39	1,266.05	1,514.49	2,112.54	1,625.27	2,611.77	1,125.64	0.00	0.00		18,080.05		
351G	ADULT 40-100% FEMAL E	2,581.00	1,703.20	1,578.56	1,004.56	1,199.83	1,321.55	1,537.48	1,307.41	2,077.43	784.01	0.00	0.00		15,095.03		
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	3,285.30	2,921.78	4,270.74	1,982.32	0.00	0.00		32,259.52		
351J	ADULT 40-100% M&F 65	108.10	25.19	47.66	42.37	35.69	65.72	41.88	39.01	111.94	5.50	0.00	0.00		523.06		
3526	ADULT 40-100% MALE
2	1.93	3.00	3.00	-2.67	5.00	3.00	4.00	5.00	4.32	3.00	0.00	0.00		29.58		
3527	ADULT 40-100% FEMAL E	6.45	7.00	2.40	-4.31	2.40	3.00	0.00	0.00	1.00	1.93	0.00	0.00		19.87		
3528	ADULT 40-100% M&F 45	26.71	29.59	24.32	-22.81	24.00	26.08	17.00	14.63	19.99	22.31	0.00	0.00		181.82		
3529	ADULT 40-100% M&F 65	6.00	15.00	6.00	-2.01	8.73	15.00	9.00	13.53	16.25	12.42	0.00	0.00		99.92		
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	13.78	0.99	1.49	0.00	0.00		33.01		
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	-0.74	15.26	0.00	0.00	0.45	1.73	5.56	0.00	0.00		22.26		
3704	ADULT <40% EXP MAL E	1.00	1.00	2.00	1.00	0.00	0.96	1.00	1.00	0.00	0.00	0.00	0.00		7.96		
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 MAL E	103.25	111.71	84.84	-54.92	97.69	100.71	63.98	57.24	45.04	39.21	0.00	0.00		648.75		
3707	ADULT <40% EXP FEM AL	48.48	48.94	35.43	-13.67	42.10	42.98	19.30	12.74	14.33	8.96	0.00	0.00		259.59		
3708	ADULT <40% EXP M&F 4	283.95	338.46	268.52	-23.74	322.09	351.54	223.06	153.20	137.71	106.71	0.00	0.00		2,161.50		
3709	ADULT <40% EXP M&F 6	56.31	44.45	21.90	-12.92	22.56	18.00	15.00	19.00	22.28	17.23	0.00	0.00		223.81		
370D	ADULT <40% EXP MAL E	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 MAL E	14.26	15.04	9.01	7.43	4.35	32.34	6.85	6.95	7.70	3.00	0.00	0.00		106.93		
370G	ADULT <40% EXP FEM AL	21.77	4.58	4.07	-5.93	1.22	10.07	-0.80	4.23	11.02	0.06	0.00	0.00		50.29		
370H	ADULT <40% EXP M&F 4	42.46	16.69	26.64	3.98	25.98	8.31	34.19	27.72	72.00	2.88	0.00	0.00		260.85		
370J	ADULT <40% EXP M&F 6	12.45	1.54	9.10	-2.86	3.43	0.00	0.00	0.00	12.93	5.00	0.00	0.00		41.59		
3714	ADULT <40% EXP MAL E	11,007.76	11,025.46	11,264.02	11,571.49	11,500.33	11,358.20	11,245.94	10,866.24	10,773.50	10,264.28	0.00	0.00		110,877.22		
3715	ADULT <40% EXP FEM AL	9,706.11	9,741.20	10,012.97	10,282.00	10,282.64	10,283.46	10,064.07	9,731.87	9,578.29	9,061.37	0.00	0.00		98,743.98		
3716	ADULT <40% EXP MAL E	48,059.07	50,383.36	52,664.76	54,392.55	55,689.89	57,229.69	58,239.47	56,711.64	58,882.59	58,613.24	0.00	0.00		550,866.26		
3717	ADULT <40% EXP FEM AL	30,195.28	31,546.27	32,673.10	33,708.32	34,395.28	35,190.31	35,519.66	34,781.10	35,580.71	35,222.32	0.00	0.00		338,812.35		

9935	BIRTH SUPP PAYMENT A	17.00	15.00	18.00	25.00	17.00	24.00	28.00	27.00	27.00	24.00	0.00	0.00		222.00	
9937	BIRTH SUPP PAYMENT A	36.00	54.00	71.00	64.00	64.00	61.00	69.00	66.00	69.00	68.00	0.00	0.00		622.00	
	53.00	69.00	89.00	89.00	81.00	85.00	97.00	93.00	96.00	92.00	0.00	0.00	844.00	

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3718	ADULT <40% EXP M&F 4	63,522.48	65,959.10	67,857.20	69,267.69	70,625.75	71,982.73	72,244.61	71,173.39	73,137.64	72,692.45	0.00	0.00		698,463.04		
3719	ADULT <40% EXP M&F 6	44.36	54.24	72.42	140.60	59.26	69.99	67.23	70.15	77.21	79.63	0.00	0.00		735.09		
371D	ADULT <40% EXP MAL E	1,088.95	744.05	996.81	659.46	547.41	567.99	795.23	718.56	1,058.18	688.78	0.00	0.00		7,865.42		
371E	ADULT <40% EXP FEM AL	1,021.43	690.50	796.72	637.59	474.68	533.67	601.17	619.57	896.94	650.60	0.00	0.00		6,922.87		
371F	ADULT <40% EXP MAL E	6,765.74	4,743.82	4,863.04	3,660.33	4,547.57	4,312.08	4,960.27	5,840.37	7,545.47	4,506.62	0.00	0.00		51,745.31		
371G	ADULT <40% EXP FEM AL	4,743.81	2,946.56	2,646.68	2,192.59	2,859.20	2,563.81	2,727.44	3,111.78	4,196.22	2,662.17	0.00	0.00		30,650.26		
371H	ADULT <40% EXP M&F 4	9,643.66	5,153.80	5,223.51	3,460.30	4,176.51	3,658.61	4,360.32	5,246.64	6,986.73	3,644.87	0.00	0.00		51,554.95		
371J	ADULT <40% EXP M&F 6	66.80	27.72	19.23	12.58	28.72	14.02	41.72	29.80	14.48	22.36	0.00	0.00		277.43		
3724	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.80	0.00	0.00		1.80		
3725	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.92	2.00	0.00	0.00	0.00		2.92		
3726	ADULT <40% EXP MAL E	3.54	4.47	6.56	-4.39	4.76	8.41	4.92	7.00	8.18	7.00	0.00	0.00		50.45		
3727	ADULT <40% EXP FEM AL	1.54	4.80	8.00	-1.88	3.13	5.00	2.00	3.00	2.93	1.80	0.00	0.00		30.32		
3728	ADULT <40% EXP M&F 4	10.28	10.22	20.13	-8.43	15.54	16.12	10.18	13.00	8.86	15.99	0.00	0.00		111.89		
3729	ADULT <40% EXP M&F 6	0.00	1.00	0.00	1.96	2.00	1.00	0.00	2.00	3.00	2.00	0.00	0.00		12.96		
372E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.07	0.00	0.00	0.00	0.00		0.07		
372F	ADULT <40% EXP MAL E	0.00	2.19	1.43	-0.16	0.23	0.00	0.87	0.00	0.80	0.00	0.00	0.00		5.36		
372G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.87	0.60	0.00	0.00	0.00	1.51	0.20	0.00	0.00		3.18		
372H	ADULT <40% EXP M&F 4	3.70	6.75	0.26	-5.27	4.80	1.19	2.80	1.00	3.12	0.00	0.00	0.00		18.35		
372J	ADULT <40% EXP M&F 6	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		
	257,226.96	251,422.78	258,778.78	257,494.33	265,705.06	272,322.45	277,392.21	274,768.57	291,090.03	275,916.51	0.00	0.00	2,682,117.68		

5.00	
189.45	
73.19	
1,430.27	
443.26	
139.03	
37.10	
541.99	
210.60	
8,167.39	
9,045.61	
78,838.06	

SUBTOTAL:

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	9.08	10.63	18.20	15.55	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	36.64	25.00	2.23	-17.92	3.86	2.31	5.12	4.39	5.56	6.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	583.32	464.17	124.90	-125.92	104.09	72.15	51.92	34.84	56.58	64.22	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	71.12	106.14	55.47	11.21	45.00	34.89	27.36	27.54	37.86	26.67	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	42.44	7.00	2.79	-5.61	11.86	0.00	9.89	12.33	52.67	5.66	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	9.32	0.00	8.76	-1.05	0.13	0.67	11.86	0.00	7.41	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	131.86	92.81	26.55	-40.06	36.83	46.15	13.19	53.96	147.78	32.92	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	35.81	29.02	9.48	4.21	10.00	8.74	19.59	6.41	12.11	75.23	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	622.70	615.18	650.41	647.14	701.73	765.82	916.69	937.15	1,095.90	1,214.67	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	704.17	681.10	715.71	700.19	737.51	832.86	979.85	1,023.17	1,245.18	1,425.87	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	8,541.09	8,696.24	10,608.38	12,217.29	0.00	0.00	

9939	BIRTH SUPP PAYMENT N	5.00	4.00	6.00	8.00	12.00	19.00	23.00	16.00	28.00	31.00	0.00	0.00		152.00	
	5.00	4.00	6.00	8.00	12.00	19.00	23.00	16.00	28.00	31.00	0.00	0.00	152.00	

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3917	NEWLY ELIGIBLE FEMA L	5,051.42	5,501.50	5,946.45	6,133.41	6,472.28	7,361.08	8,222.68	8,758.33	11,220.75	13,888.93	0.00	0.00		78,556.83		
3918	NEWLY ELIGIBLE M&F 4	13,011.73	13,984.51	14,881.85	15,160.60	15,625.28	16,778.02	18,149.71	18,450.77	20,850.37	22,426.08	0.00	0.00		169,318.92		
3919	NEWLY ELIGIBLE M&F 6	12.97	16.28	21.99	23.89	13.90	20.47	19.89	32.63	45.09	44.92	0.00	0.00		252.03		
391D	NEWLY ELIGIBLE MALE	139.88	114.69	172.17	38.05	75.44	156.21	138.95	198.37	405.34	91.82	0.00	0.00		1,530.92		
391E	NEWLY ELIGIBLE FEMA L	161.43	76.72	179.62	67.18	81.40	247.15	225.40	228.59	352.43	154.96	0.00	0.00		1,774.88		
391F	NEWLY ELIGIBLE MALE	2,612.58	1,545.82	1,766.22	707.43	738.69	1,916.14	2,318.30	2,298.03	4,024.58	1,503.56	0.00	0.00		19,431.35		
391G	NEWLY ELIGIBLE FEMA L	3,026.68	1,519.30	1,615.35	644.99	889.23	2,124.06	2,425.64	2,780.33	4,726.49	1,846.48	0.00	0.00		21,598.55		
391H	NEWLY ELIGIBLE M&F 4	8,327.51	3,561.78	3,359.60	1,613.97	1,716.51	3,197.25	3,957.90	4,239.49	6,646.48	2,306.65	0.00	0.00		38,927.14		
391J	NEWLY ELIGIBLE M&F 6	68.94	33.73	31.96	17.08	9.10	49.51	75.02	87.26	139.28	46.79	0.00	0.00		558.67		
3926	NEWLY ELIGIBLE MALE	1.00	1.00	0.00	-0.87	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.13		
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	-4.73	0.00	0.00	0.00	0.00	1.09	2.00	0.00	0.00		-1.64		
3928	NEWLY ELIGIBLE M&F 4	6.28	12.94	6.70	-20.66	2.00	3.00	1.00	3.00	1.00	6.02	0.00	0.00		21.28		
3929	NEWLY ELIGIBLE M&F 6	1.00	3.45	4.00	-2.00	0.00	0.00	0.00	0.00	1.00	2.79	0.00	0.00		10.24		
392F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.87		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	-1.25	0.00	0.00	0.00	0.00	3.89	0.00	0.00	0.00		2.64		
392H	NEWLY ELIGIBLE M&F 4	2.70	10.49	0.00	-7.28	0.00	0.00	0.00	0.00	0.00	0.99	0.00	0.00		6.90		
392J	NEWLY ELIGIBLE M&F 6	0.00	0.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.19	0.00	0.00		5.73		
	40,155.12	34,280.83	35,956.57	32,092.65	34,158.68	41,354.27	46,120.13	47,883.46	61,705.42	57,411.26	0.00	0.00	431,118.39		

4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		2.00	
4412	SOBRA 100-133% M&F
1	128.25	116.83	18.70	19.00	12.81	7.00	4.00	2.00	1.00	2.00	0.00	0.00		311.59	
4413	SOBRA 100-133% M&F
6	18,951.90	17,885.34	18,069.72	18,014.10	17,992.55	18,409.69	19,186.42	16,986.98	20,754.23	24,244.36	0.00	0.00		190,495.29	
4414	SOBRA 100-133% MALE	6,066.89	5,979.56	6,241.71	6,390.34	6,422.06	6,692.56	7,016.27	6,060.66	7,084.69	7,859.59	0.00	0.00		65,814.33	
4415	SOBRA 100-133% FEM AL	5,923.23	5,777.63	5,977.89	6,132.81	6,154.98	6,421.65	6,727.70	5,713.39	6,663.54	7,443.66	0.00	0.00		62,936.48	
441B	SOBRA 100-133% M&F
1	3.70	5.16	7.30	0.00	2.06	0.00	0.00	0.00	0.00	1.00	0.00	0.00		19.22	
441C	SOBRA 100-133% M&F
6	2,589.88	1,731.20	1,897.57	1,248.03	705.64	2,583.54	2,442.21	3,275.64	5,479.79	460.17	0.00	0.00		22,413.67	
441D	SOBRA 100-133% MALE	1,092.57	565.99	560.30	363.00	282.01	801.31	664.83	1,021.60	1,809.71	192.85	0.00	0.00		7,354.17	
441E	SOBRA 100-133% FEM AL	1,079.50	551.61	600.34	322.06	278.12	780.92	738.21	841.57	1,768.89	112.93	0.00	0.00		7,074.15	
	35,835.92	32,613.32	33,373.53	32,489.34	31,850.23	35,696.67	36,779.64	33,901.84	43,562.85	40,317.56	0.00	0.00	356,420.90	

SUBTOTAL:

9944	BIRTH SUPP PAYMENT S	6.00	5.00	4.00	4.00	3.00	6.00	8.00	5.00	5.00	5.00	0.00	0.00		51.00	
	6.00	5.00	4.00	4.00	3.00	6.00	8.00	5.00	5.00	5.00	0.00	0.00	51.00	

SUBTOTAL:

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	38.00	37.90	37.32	38.47	40.56	41.00	38.87	34.00	32.00	32.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	288.12	281.92	279.22	281.82	275.75	271.77	270.15	263.48	264.29	261.06	0.00	0.00	

370.12

2,737.58

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4519	BC PATIENT FEMALE 6 5	3.78	3.24	0.00	0.00	0.90	2.89	0.00	0.00	0.00	0.00	0.00	0.00		10.81		
451G	BC PATIENT FEMALE 2 1	0.00	2.08	0.00	2.51	1.43	0.00	0.12	0.00	0.00	0.00	0.00	0.00		6.14		
451H	BC PATIENT FEMALE 4 5	1.32	7.91	3.09	1.14	10.29	4.90	9.39	7.49	1.50	0.93	0.00	0.00		47.96		
451J	BC PATIENT FEMALE 6 5	0.18	0.73	0.00	0.00	0.10	0.09	0.00	0.00	0.00	0.00	0.00	0.00		1.10		
4617	CC PATIENT FEMALE 2 1	25.51	25.80	25.39	26.48	26.90	27.96	25.25	24.21	25.00	14.61	0.00	0.00		247.11		
4618	CC PATIENT FEMALE 4 5	18.73	20.00	20.00	19.44	20.73	20.96	19.00	19.00	19.00	20.00	0.00	0.00		196.86		
461G	CC PATIENT FEMALE 2 1	5.48	0.19	2.59	1.51	0.10	4.03	0.00	1.78	0.00	0.00	0.00	0.00		15.68		
461H	CC PATIENT FEMALE 4 5	2.32	0.00	0.00	1.54	1.26	0.03	0.00	0.00	0.00	0.00	0.00	0.00		5.15		
	383.44	379.77	367.61	372.91	378.02	373.63	362.78	349.96	341.79	328.60	0.00	0.00	3,638.51		

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,318.39	1,324.42	1,354.33	1,396.27	1,406.82	1,431.34	1,450.69	1,444.55	1,443.90	1,449.51	0.00	0.00	
870Z	SSI DISABLED FREEDO M	70.71	116.78	35.90	106.49	41.63	125.95	39.69	12.10	51.18	128.33	0.00	0.00	
8710	SSI DISABLED FREEDO M	176.19	177.36	190.82	202.81	198.67	199.63	199.66	201.05	203.81	218.33	0.00	0.00	
871Z	SSI DISABLED FREEDO M	38.70	38.74	74.53	112.44	43.27	48.81	45.08	9.91	36.60	99.48	0.00	0.00	
8720	SSI DISABLED FREEDO M	175.01	179.64	188.72	193.91	191.13	194.90	196.66	195.66	190.96	198.65	0.00	0.00	
872Z	SSI DISABLED FREEDO M	16.33	32.61	19.26	6.60	2.66	0.00	5.32	7.89	0.00	1.23	0.00	0.00	
SUBTOTAL:	1,796.33	1,870.55	1,864.56	2,019.52	1,885.18	2,001.63	1,938.10	1,872.16	1,927.45	2,096.53	0.00	0.	

10.00	
14,020.22	
728.76	
1,968.33	
547.56	
1,905.24	
91.90	
19,272.01	

00

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	1,445,801.06	1,440,705.19	1,503,608.22	1,457,529.31	0.00	0.00	14,407,810.53		

9811	RURAL HOSP PMT TAC I	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,631.35	0.00	0.00		1,631.35	
9813	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94.14	0.00	0.00		94.14	
9815	RURAL HOSP PMT MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,744.46	0.00	0.00		1,744.46	
9817	RURAL HOSP PMT FMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,757,728.29	0.00	0.00		1,757,728.29	
9819	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,112.97	0.00	0.00		3,112.97	
9823	RURAL HOSP PMT FOR S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,152.97	0.00	0.00		110,152.97	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,874,464.18	0.00	0.00	1,874,464.18	

SUBTOTAL:

ACUTE CAPITATION RURAL HOSPITAL - AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9810	RURAL HOSP PMT TAC I	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,070,948.33	0.00	0.00		2,070,948.33		
9812	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,271.53	0.00	0.00		26,271.53		
9814	RURAL HOSP PMT MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,283.64	0.00	0.00		2,283.64		
9816	RURAL HOSP PMT FMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,837,278.84	0.00	0.00		3,837,278.84		
9818	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,553.79	0.00	0.00		4,553.79		
9821	RURAL HOSP PMT SSI W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,900,757.52	0.00	0.00		1,900,757.52		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,842,093.65	0.00	0.00	7,842,093.65		

SUBTOTAL:

9836	RURAL HOSP PMT FOR A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.01	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.01	0.00	0.	

24.01

9845	RURAL HOSP PMT FOR B	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,109.56	0.00	0.00		1,109.56	
9846	RURAL HOSP PMT FOR C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	852.96	0.00	0.00		852.96	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,962.52	0.00	0.00	1,962.52	

00	24.01

9887	RH PAYMENT FREEDO M T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,104.01	0.00	0.00		6,104.01	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,104.01	0.00	0.00	6,104.01	

SUBTOTAL:

SUBTOTAL:

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,724,648.37	0.00	0.00	9,724,648.37	

TOTAL:

9811	RURAL HOSP PMT TAC I	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.15	0.00	0.00		0.15	
9813	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00		0.03	
9815	RURAL HOSP PMT MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.36	0.00	0.00		0.36	
9817	RURAL HOSP PMT FMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	404.37	0.00	0.00		404.37	
9819	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.72	0.00	0.00		0.72	
9823	RURAL HOSP PMT FOR S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20.10	0.00	0.00		20.10	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	425.73	0.00	0.00	425.73	

SUBTOTAL:

ACUTE CAPITATION RURAL HOSPITAL - MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9810	RURAL HOSP PMT TAC I	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.61	0.00	0.00		215.61		
9812	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.91	0.00	0.00		2.91		
9814	RURAL HOSP PMT MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.57	0.00	0.00		0.57		
9816	RURAL HOSP PMT FMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	908.55	0.00	0.00		908.55		
9818	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.08	0.00	0.00		1.08		
9821	RURAL HOSP PMT SSI W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	362.88	0.00	0.00		362.88		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,491.60	0.00	0.00	1,491.60		

SUBTOTAL:

9836	RURAL HOSP PMT FOR A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.	

0.03

9845	RURAL HOSP PMT FOR B	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.24	0.00	0.00		0.24	
9846	RURAL HOSP PMT FOR C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.18	0.00	0.00		0.18	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.42	0.00	0.00	0.42	

00	0.03

9887	RH PAYMENT FREEDO M T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.11	0.00	0.00		1.11	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.11	0.00	0.00	1.11	

SUBTOTAL:

SUBTOTAL:

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,918.89	0.00	0.00	1,918.89		

8700	SSI DISABLED FREEDO M	67,556.86	73,398.32	64,735.65	65,903.92	71,492.44	69,307.88	65,903.92	76,007.71	66,142.28	69,851.71	0.00	0.00		690,300.69	
870Z	SSI DISABLED FREEDO M	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		5,543.95	
8710	SSI DISABLED FREEDO M	101,819.57	107,175.95	99,858.26	100,146.55	110,894.02	104,655.29	103,990.47	113,999.93	107,834.39	108,538.30	0.00	0.00		1,058,912.73	
871Z	SSI DISABLED FREEDO M	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		4,927.88	
8720	SSI DISABLED FREEDO M	16,243.89	17,081.70	9,942.35	9,932.26	10,644.72	13,111.28	12,990.26	13,706.56	16,335.74	16,447.41	0.00	0.00		136,436.17	
	188,929.63	197,655.97	174,536.26	175,982.73	194,649.75	192,618.40	182,884.65	203,714.20	190,312.41	194,837.42	0.00	0.00	1,896,121.42	

SUBTOTAL:

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending April 30, 2015	
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	9,748.96	10,250.32	9,748.96	9,811.94	0.00	0.00		98,524.88		
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	2,133,670.78	2,166,355.88	2,176,275.37	2,188,476.69	0.00	0.00		21,404,109.95		
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	3,345.48	3,345.48	3,345.48	3,358.43	0.00	0.00		43,597.70		
2100	SSI AGED WITH MEDIC A	30,836,613.84	34,570,502.80	30,935,967.12	31,372,866.59	35,239,337.50	31,439,888.23	31,000,379.57     36,305,791.08	31,172,446.91	31,549,981.07	0.00	0.00		324,423,774.71		
210Z	SSI AGED WITH MEDIC A	615,597.94	729,576.72	688,405.76	664,286.50	596,267.84	699,202.36	704,730.59	701,797.45	755,005.00	775,758.45	0.00	0.00		6,930,628.61		
2110	SSI AGED NON-MEDIC AR	2,604,038.91	2,783,598.60	2,545,373.27	2,558,167.28	2,784,981.87	2,580,196.66	2,615,461.39	2,864,020.92	2,662,363.65	2,775,624.13	0.00	0.00		26,773,826.68		
211Z	SSI AGED NON-MEDIC AR	19,614.65	14,978.98	7,769.14	36,248.05	12,459.97	16,602.08	8,973.34	7,598.24	27,295.06	38,831.12	0.00	0.00		190,370.63		
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	18,162,954.02     21,384,772.09	18,686,547.50	18,940,990.31	0.00	0.00		189,374,221.85		
212Z	SSI AGED WITH QMB P P	12,889.07	8,676.88	5,467.70	10,321.54	11,974.16	26,197.41	14,953.30	9,536.24	20,844.45	19,830.63	0.00	0.00		140,691.38		
2200	SSI DISABLED WITH M E	13,837,679.72	14,827,724.89	13,765,759.22	14,043,931.24	15,112,189.53	14,262,064.99	14,351,108.10     15,077,091.22	13,594,442.19	13,715,933.73	0.00	0.00		142,587,924.83		
220Z	SSI DISABLED WITH M E	82,279.18	102,250.19	81,722.03	121,624.38	71,380.49	73,502.98	71,208.17	54,465.79	87,812.71	102,751.66	0.00	0.00		848,997.58		
2210	SSI DISABLED NON-ME D	84,294,536.39	85,893,699.47	85,286,548.21	85,469,641.29	87,030,964.66	87,465,381.22	86,450,320.32     88,482,327.82	87,770,604.17	88,416,534.96	0.00	0.00		866,560,558.51		
221Z	SSI DISABLED NON-ME D	31,789.29	35,099.30	26,766.85	38,234.27	29,582.73	30,504.56	58,647.49	45,780.92	31,133.04	73,101.65	0.00	0.00		400,640.10		
2220	SSI DISABLED WITH Q M	19,966,282.88	21,012,877.23	20,270,819.28	20,408,639.93	21,400,723.78	20,677,775.08	20,563,327.74     21,971,743.41	20,796,389.35	21,006,260.36	0.00	0.00		208,074,839.04		
222Z	SSI DISABLED WITH Q M	1,541.29	7,803.55	0.00	1,703.71	6,352.39	2,596.92	0.00	2,635.57	348.11	36.09	0.00	0.00		23,017.63		
2300	SSI BLIND WITH MEDIC	69,541.93	72,181.18	69,541.93	72,926.26	70,082.69	76,807.55	79,855.32	73,463.50	69,580.78	66,973.79	0.00	0.00		720,954.93		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	1,895.47	0.00	0.00	0.00	0.00	0.00		1,895.47		
2310	SSI BLIND NON-MEDIC A	478,057.14	491,679.66	490,075.21	481,841.47	485,749.85	485,422.02	472,409.62	471,537.15	458,093.73	447,738.51	0.00	0.00		4,762,604.36		
231Z	SSI BLIND NON-MEDIC A	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	117,692.70	122,813.09	120,915.98	121,703.60	0.00	0.00		1,214,284.82		
	172,463,262.81	182,618,498.68	174,288,831.72	175,786,182.74	185,603,284.58	178,547,267.15	176,820,682.36	189,755,326.17	178,443,192.44	180,253,697.12	0.00	0.00	1,794,580,225.77		

SUBTOTAL:

172,652,192.44	182,816,154.65	174,463,367.98	175,962,165.47	185,797,934.33	178,739,885.55	177,003,567.01	189,959,040.37	178,633,504.85	180,448,534.54	0.00	0.00	1,796,476,347.19	

TOTAL:

8700	SSI DISABLED FREEDO M	22.00	22.00	21.00	21.00	21.00	22.03	21.00	22.00	21.00	22.00	0.00	0.00		215.03	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	5.96	0.00	0.00	0.00	0.00	0.00	0.00		5.96	
8710	SSI DISABLED FREEDO M	23.32	23.00	23.00	23.00	23.86	24.00	24.00	24.00	25.00	25.00	0.00	0.00		238.18	
871Z	SSI DISABLED FREEDO M	3.67	0.00	0.00	0.00	2.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.80	
8720	SSI DISABLED FREEDO M	6.00	6.00	4.00	4.00	4.00	5.00	5.00	5.00	6.00	6.00	0.00	0.00		51.00	
	54.99	51.00	48.00	48.00	50.99	56.99	50.00	51.00	52.00	53.00	0.00	0.00	515.97	

SUBTOTAL:

LONG TERM CARE MEMBER MONTHS

For The Period Ending April 30, 2015	
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	3.00	3.00	3.00	3.00	0.00	0.00		30.00		
1010	TANF NON-MEDICARE	633.10	629.83	627.45	631.62	631.62	631.96	634.79	642.33	646.68	647.80	0.00	0.00		6,357.18		
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	1.00	1.00	1.00	1.00	0.00	0.00		13.00		
2100	SSI AGED WITH MEDIC A	11,510.64	11,449.32	11,525.89	11,554.03	11,529.19	11,528.39	11,403.72	11,451.83	11,446.48	11,399.17	0.00	0.00		114,798.66		
210Z	SSI AGED WITH MEDIC A	680.99	812.44	766.78	736.17	639.15	744.01	740.52	732.75	785.92	804.54	0.00	0.00		7,443.27		
2110	SSI AGED NON-MEDIC AR	604.41	604.39	593.07	596.85	602.22	588.71	587.77	597.36	617.63	631.68	0.00	0.00		6,024.09		
211Z	SSI AGED NON-MEDIC AR	22.69	16.62	8.62	39.07	13.49	18.23	9.06	8.01	28.76	39.68	0.00	0.00		204.23		
2120	SSI AGED WITH QMB	6,956.11	7,115.15	7,150.50	7,188.17	7,202.52	7,217.66	7,142.05	7,279.00	7,343.74	7,337.16	0.00	0.00		71,932.06		
212Z	SSI AGED WITH QMB P P	14.44	9.92	5.94	11.10	12.60	27.46	16.06	10.52	21.54	21.46	0.00	0.00		151.04		
2200	SSI DISABLED WITH M E	4,675.34	4,642.31	4,647.27	4,695.10	4,693.64	4,718.73	4,782.06	4,588.55	4,527.88	4,528.34	0.00	0.00		46,499.22		
220Z	SSI DISABLED WITH M E	91.28	112.25	91.86	124.95	76.51	80.55	69.15	57.14	93.40	107.45	0.00	0.00		904.54		
2210	SSI DISABLED NON-ME D	24,410.73	24,526.37	24,664.11	24,715.17	24,817.08	24,998.38	25,013.73	25,145.39	25,424.51	25,471.92	0.00	0.00		249,187.39		
221Z	SSI DISABLED NON-ME D	34.40	38.90	29.82	40.98	31.55	32.11	60.95	47.93	32.75	57.52	0.00	0.00		406.91		
2220	SSI DISABLED WITH Q M	6,545.92	6,594.62	6,636.45	6,644.30	6,660.20	6,667.85	6,696.68	6,735.73	6,753.54	6,774.35	0.00	0.00		66,709.64		
222Z	SSI DISABLED WITH Q M	1.70	8.83	0.00	1.83	6.93	2.70	0.00	2.74	0.37	0.03	0.00	0.00		25.13		
2300	SSI BLIND WITH MEDIC	22.00	22.00	22.00	23.00	21.38	24.00	25.06	22.00	22.00	21.00	0.00	0.00		224.44		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	1.80	0.00	0.00	0.00	0.00	0.00		1.80		
2310	SSI BLIND NON-MEDIC A	137.93	139.38	140.73	138.77	138.36	139.61	137.93	134.92	134.16	131.00	0.00	0.00		1,372.79		
231Z	SSI BLIND NON-MEDIC A	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	39.00	39.00	40.00	40.00	0.00	0.00		397.30		
	56,388.68	56,771.32	56,954.41	57,185.11	57,119.44	57,463.80	57,364.33	57,499.20	57,923.36	58,017.10	0.00	0.00	572,686.75		

SUBTOTAL:

TOTAL:	56,443.67	56,822.32	57,002.41	57,233.11	57,170.43	57,520.79	57,414.33	57,550.20	57,975.36	58,070.10	0.00	0.00	573,202.72		

SUBTOTAL:

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending April 30, 2015	
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	37.14	37.14	37.14	37.55	0.00	0.00		455.07		
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	10,424,380.92     10,095,729.06	9,319,131.66	8,329,979.35	0.00	0.00		105,255,112.23		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37.14	0.00	112.65	0.00	0.00		149.79		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	37.14	37.14	37.14	37.14	37.55	0.00	0.00		186.11		
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	37.20	37.20	74.40	74.28	74.28	124.44	111.42	111.42	111.42	112.65	0.00	0.00		868.71		
2210	SSI DISABLED NON-ME D	434,533.20	432,375.60	431,743.20	427,889.94	427,295.70	492,219.36	426,404.34	425,253.00	426,627.18	433,664.95	0.00	0.00		4,358,006.47		
2220	SSI DISABLED WITH Q M	297.60	297.60	297.60	297.12	297.12	329.42	259.98	259.98	222.84	187.75	0.00	0.00		2,747.01		
2310	SSI BLIND NON-MEDIC A	1,450.80	1,450.80	1,450.80	1,522.74	1,597.02	2,075.42	1,671.30	1,671.30	1,522.74	1,539.55	0.00	0.00		15,952.47		
4300	SOBRA CHILD WITH M ED	74.40	148.80	74.40	37.14	74.28	194.38	148.56	148.56	185.70	187.75	0.00	0.00		1,273.97		
4310	SOBRA CHILD NON-ME DI	10,572,984.00	10,832,528.40	10,994,385.60	11,087,552.76	10,926,662.28	12,207,323.60	11,047,293.00     11,172,640.50	11,911,057.98	13,084,297.50	0.00	0.00		113,836,725.62		
4320	SOBRA CHILD WITH Q MB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37.14	297.12	638.35	0.00	0.00		972.61		
5010	SOBRA PREGNANT WO MAN	12,648.00	12,536.40	12,871.20	12,107.64	12,590.46	13,745.16	10,659.18	10,919.16	11,290.56	13,067.40	0.00	0.00		122,435.16		
	21,922,666.80	22,293,290.40	22,580,437.20	22,671,221.64	22,251,465.36	24,723,572.02	21,911,002.98	21,706,881.54	21,670,521.48	21,863,863.00	0.00	0.00	223,594,922.42		

1110	TANF EXPANDED FOR FI	198,090.00	197,941.20	199,243.20	198,884.70	194,502.18	223,914.02	184,511.52	181,168.92	169,506.96	149,336.35	0.00	0.00	
2610	SSI DISABLED EXPAND E	74.40	74.40	74.40	74.28	74.28	95.98	74.28	74.28	74.28	37.55	0.00	0.00	
SUBTOTAL:	198,164.40	198,015.60	199,317.60	198,958.98	194,576.46	224,010.00	184,585.80	181,243.20	169,581.24	149,373.90	0.00	0.	

1,897,099.05	
728.13	
1,897,827.18	

3610	AHC CARE EXPANDED FO	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	

00

4410	SOBRA 100-133% FOR F	1,017,829.20	1,035,387.60	1,038,438.00	1,047,459.42	1,051,470.54	1,044,228.24	1,095,110.04	941,944.68	1,089,761.88	1,368,772.60	0.00	0.00		10,730,402.20	
	1,017,829.20	1,035,387.60	1,038,438.00	1,047,459.42	1,051,470.54	1,044,228.24	1,095,110.04	941,944.68	1,089,761.88	1,368,772.60	0.00	0.00	10,730,402.20	

SUBTOTAL:

SUBTOTAL:

23,138,660.40	23,526,693.60	23,818,192.80	23,917,640.04	23,497,512.36	25,991,814.60	23,190,698.82	22,830,069.42	22,929,864.60	23,382,009.50	0.00	0.00	236,223,156.14	

TOTAL:

SUBTOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending April 30, 2015	
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	1.00	1.00	1.00	1.00	0.00	0.00		12.00		
1010	TANF NON-MEDICARE	293,026.00	296,071.00	299,448.00	299,992.00	293,022.00	290,265.00	280,678.00	271,829.00	250,919.00	221,837.00	0.00	0.00		2,797,087.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	3.00	0.00	0.00		4.00		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		5.00		
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	1.00	1.00	2.00	2.00	2.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00		23.00		
2210	SSI DISABLED NON-ME D	11,681.00	11,623.00	11,606.00	11,521.00	11,505.00	11,468.00	11,481.00	11,450.00	11,487.00	11,549.00	0.00	0.00		115,371.00		
2220	SSI DISABLED WITH Q M	8.00	8.00	8.00	8.00	8.00	7.00	7.00	7.00	6.00	5.00	0.00	0.00		72.00		
2310	SSI BLIND NON-MEDIC A	39.00	39.00	39.00	41.00	43.00	47.00	45.00	45.00	41.00	41.00	0.00	0.00		420.00		
4300	SOBRA CHILD WITH M ED	2.00	4.00	2.00	1.00	2.00	5.00	4.00	4.00	5.00	5.00	0.00	0.00		34.00		
4310	SOBRA CHILD NON-ME DI	284,220.00	291,197.00	295,548.00	298,534.00	294,202.00	295,682.00	297,450.00	300,825.00	320,707.00	348,450.00	0.00	0.00		3,026,815.00		
4320	SOBRA CHILD WITH Q MB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	8.00	17.00	0.00	0.00		26.00		
5010	SOBRA PREGNANT WO MAN	340.00	337.00	346.00	326.00	339.00	314.00	287.00	294.00	304.00	348.00	0.00	0.00		3,235.00		
	589,319.00	599,282.00	607,001.00	610,426.00	599,124.00	597,793.00	589,957.00	584,461.00	583,482.00	582,260.00	0.00	0.00	5,943,105.00		

1110	TANF EXPANDED FOR FI	5,325.00	5,321.00	5,356.00	5,355.00	5,237.00	5,253.00	4,968.00	4,878.00	4,564.00	3,977.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00	
SUBTOTAL:	5,327.00	5,323.00	5,358.00	5,357.00	5,239.00	5,255.00	4,970.00	4,880.00	4,566.00	3,978.00	0.00	0.	

50,234.00	
19.00	
50,253.00	

3610	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	

00

4410	SOBRA 100-133% FOR F	27,361.00	27,833.00	27,915.00	28,203.00	28,311.00	28,116.00	29,486.00	25,362.00	29,342.00	36,452.00	0.00	0.00		288,381.00	
	27,361.00	27,833.00	27,915.00	28,203.00	28,311.00	28,116.00	29,486.00	25,362.00	29,342.00	36,452.00	0.00	0.00	288,381.00	

SUBTOTAL:

SUBTOTAL:

TOTAL:	622,007.00	632,438.00	640,274.00	643,986.00	632,674.00	631,164.00	624,413.00	614,703.00	617,390.00	622,690.00	0.00	0.00	6,281,739.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending April 30, 2015	
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	20,691.20	19,130.88	18,147.20	18,057.10	0.00	0.00		194,332.89		
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	5,047,228.16	4,996,348.16	4,948,249.60	4,887,103.01	0.00	0.00		51,048,563.78		
1020	TANF WITH QMB	510.24	574.02	733.47	1,017.60	1,288.96	1,664.68	1,526.40	1,899.52	2,713.60	4,088.40	0.00	0.00		16,016.89		
2100	SSI AGED WITH MEDIC A	146,311.32	148,129.05	149,468.43	160,339.84	159,424.00	195,009.65	163,290.88	160,373.76	153,962.88	150,861.96	0.00	0.00		1,587,171.77		
2110	SSI AGED NON-MEDIC AR	188,884.47	199,790.85	201,863.70	216,782.72	216,240.00	261,801.81	215,832.96	219,767.68	220,513.92	214,402.51	0.00	0.00		2,155,880.62		
2120	SSI AGED WITH QMB	716,823.42	733,820.79	744,950.40	796,509.44	795,763.20	970,638.02	800,104.96	793,524.48	780,702.72	767,120.12	0.00	0.00		7,899,957.55		
2200	SSI DISABLED WITH M E	146,279.43	147,491.25	147,618.81	157,626.24	158,372.48	196,697.50	163,697.92	160,916.48	146,229.12	142,344.46	0.00	0.00		1,567,273.69		
2210	SSI DISABLED NON-ME D	1,335,648.87	1,334,086.26	1,336,860.69	1,418,839.68	1,416,329.60	1,832,767.44	1,409,986.56	1,412,801.92	1,419,178.88	1,427,737.42	0.00	0.00		14,344,237.32		
2220	SSI DISABLED WITH Q M	798,079.14	797,983.47	804,457.14	856,378.24	853,121.92	1,103,769.36	870,590.72	867,639.68	874,864.64	881,254.62	0.00	0.00		8,708,138.93		
2300	SSI BLIND WITH MEDIC	1,148.04	1,179.93	1,084.26	1,221.12	1,255.04	1,478.90	1,187.20	1,153.28	1,255.04	1,192.45	0.00	0.00		12,155.26		
2310	SSI BLIND NON-MEDIC A	13,648.92	13,585.14	13,553.25	14,382.08	14,314.24	18,099.52	14,755.20	14,823.04	14,823.04	15,127.08	0.00	0.00		147,111.51		
2320	SSI BLIND WITH QMB	7,908.72	7,749.27	7,813.05	8,378.24	8,310.40	10,599.10	8,344.32	8,310.40	8,310.40	8,415.29	0.00	0.00		84,139.19		
4300	SOBRA CHILD WITH M ED	0.00	31.89	0.00	0.00	0.00	8.61	33.92	33.92	33.92	34.07	0.00	0.00		176.33		
4310	SOBRA CHILD NON-ME DI	619,718.37	636,269.28	643,029.96	678,230.40	656,250.24	803,551.09	640,138.24	643,055.36	660,184.96	695,981.96	0.00	0.00		6,676,409.86		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	1,626.39	1,530.72	1,498.83	1,594.24	1,763.84	2,245.48	1,729.92	1,662.08	1,560.32	1,430.94	0.00	0.00		16,642.76		
5010	SOBRA PREGNANT WO MAN	437,658.36	440,432.79	440,847.36	460,565.76	447,133.44	568,437.81	437,093.12	455,409.92	488,753.28	537,352.04	0.00	0.00		4,713,683.88		
5020	SOBRA PREGNANT WO MAN	159.45	127.56	191.34	169.60	271.36	373.64	339.20	271.36	237.44	136.28	0.00	0.00		2,277.23		
	9,135,528.30	9,300,495.27	9,415,586.28	10,032,823.68	9,892,801.92	12,350,914.46	9,796,570.88	9,757,121.92	9,739,720.96	9,752,639.71	0.00	0.00	99,174,203.38		

1100	TANF EXPANDED FPR FI	178,520.22	179,572.59	181,932.45	195,752.32	191,749.76	238,286.23	189,714.56	186,695.68	190,460.80	192,120.73	0.00	0.00		1,924,805.34	
1110	TANF EXPANDED FOR FI	3,547,634.94	3,668,179.14	3,746,182.08	4,025,116.80	3,952,697.60	4,803,079.35	3,888,894.08	3,861,927.68	3,928,207.36	4,009,255.39	0.00	0.00		39,431,174.42	
1120	TANF EXPANDED FOR FI	8,291.40	9,343.77	11,703.63	12,991.36	15,196.16	20,148.88	20,046.72	23,099.52	32,902.40	40,407.02	0.00	0.00		194,130.86	
2400	SSI AGED EXPANDED WI	16,837.92	17,667.06	16,774.14	16,654.72	18,079.36	20,578.86	22,692.48	22,319.36	22,455.04	20,748.63	0.00	0.00		194,807.57	
2410	SSI AGED EXPANDED NO	40,277.07	38,842.02	37,693.98	41,992.96	42,433.92	52,177.32	42,060.80	42,298.24	44,197.76	45,824.15	0.00	0.00		427,798.22	
2420	SSI AGED EXPANDED WI	693,639.39	696,796.50	703,429.62	761,470.08	774,054.40	976,119.63	790,064.64	798,103.68	813,537.28	826,367.85	0.00	0.00		7,833,583.07	
2510	SSI BLIND EXPANDED N	95.67	95.67	63.78	67.84	67.84	67.84	67.84	67.84	67.84	68.14	0.00	0.00		730.30	
2520	SSI BLIND EXPANDED W	159.45	95.67	95.67	67.84	67.84	188.38	67.84	67.84	67.84	34.07	0.00	0.00		912.44	
2600	SSI DISABLED EXPAND E	13,840.26	15,083.97	15,402.87	16,790.40	17,638.40	20,672.53	17,502.72	16,417.28	11,363.20	9,675.88	0.00	0.00		154,387.51	
2610	SSI DISABLED EXPAND E	40,946.76	41,871.57	40,532.19	41,144.96	37,719.04	53,933.34	37,108.48	41,450.24	55,255.68	70,047.92	0.00	0.00		460,010.18	
2620	SSI DISABLED EXPAND E	257,447.97	257,958.21	266,887.41	291,101.44	298,055.04	387,310.65	298,631.68	310,503.68	338,826.88	369,148.45	0.00	0.00		3,075,871.41	
	4,797,691.05	4,925,506.17	5,020,697.82	5,403,150.72	5,347,759.36	6,572,563.01	5,306,851.84	5,302,951.04	5,437,342.08	5,583,698.23	0.00	0.00	53,698,211.32	

SUBTOTAL:

3300	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	
3310	AHC CARE EXPANDED FO	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	
3320	AHC CARE EXPANDED FO	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	
	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	

SUBTOTAL:

SUBTOTAL:

3500	ADULT 40-100% FOR FI	16,327.68	16,678.47	14,701.29	16,383.36	17,299.20	18,825.60	13,635.84	10,243.84	8,412.16	7,052.49	0.00	0.00		139,559.93	
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	2,325,385.60	2,358,423.68	2,395,023.36	2,513,854.95	0.00	0.00		21,963,268.00	
3520	ADULT 40-100% FOR FI	1,275.60	1,753.95	1,211.82	1,221.12	1,322.88	1,356.80	983.68	1,051.52	1,322.88	1,090.24	0.00	0.00		12,590.49	
3700	ADULT <40% EXP FOR F	15,083.97	16,391.46	12,532.77	14,042.88	15,128.32	16,213.76	9,870.72	7,530.24	6,784.00	5,280.85	0.00	0.00		118,858.97	
3710	AHC CARE EXPANDED FO	5,540,791.83	5,808,859.17	6,030,909.24	6,600,764.16	6,696,622.08	6,781,829.12	6,841,630.08	6,694,620.80	6,753,675.52	6,749,062.58	0.00	0.00		64,498,764.58	
3720	AHC CARE EXPANDED FO	446.46	542.13	892.92	949.76	983.68	949.76	508.80	814.08	983.68	851.75	0.00	0.00		7,923.02	
	7,349,656.41	7,745,634.54	8,044,380.06	8,816,961.28	8,955,829.76	9,120,409.60	9,192,014.72	9,072,684.16	9,166,201.60	9,277,192.86	0.00	0.00	86,740,964.99	

SUBTOTAL:

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3600	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		
3610	AHC CARE EXPANDED FO	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		
3620	AHC CARE EXPANDED FO	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		
	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		

3900	NEWLY ELIGIBLE FOR F	23,215.92	20,441.49	5,867.76	5,054.08	5,121.92	3,697.28	2,815.36	2,238.72	2,781.44	2,827.81	0.00	0.00		74,061.78	
3910	NEWLY ELIGIBLE FOR F	753,847.71	842,916.48	896,396.01	1,006,202.88	1,039,953.28	1,093,411.20	1,220,882.56	1,254,327.68	1,409,036.80	1,716,753.23	0.00	0.00		11,233,727.83	
3920	NEWLY ELIGIBLE FOR F	223.23	414.57	382.68	135.68	101.76	101.76	33.92	101.76	67.84	238.49	0.00	0.00		1,801.69	
	777,286.86	863,772.54	902,646.45	1,011,392.64	1,045,176.96	1,097,210.24	1,223,731.84	1,256,668.16	1,411,886.08	1,719,819.53	0.00	0.00	11,309,591.30	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	62,918.97	72,964.32	81,383.28	96,264.96	96,502.40	104,541.44	115,022.72	90,769.92	102,234.88	120,778.15	0.00	0.00		943,381.04	
	62,918.97	72,964.32	81,383.28	96,264.96	96,502.40	104,541.44	115,022.72	90,769.92	102,234.88	120,778.15	0.00	0.00	943,381.04	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	10,236.69	10,109.13	10,204.80	10,718.72	10,684.80	13,202.56	10,379.52	10,176.00	10,142.08	10,084.72	0.00	0.00		105,939.02	
4610	CC PATIENT FOR FINA N	1,466.94	1,466.94	1,435.05	1,492.48	1,560.32	2,050.57	1,560.32	1,492.48	1,526.40	1,430.94	0.00	0.00		15,482.44	
	11,703.63	11,576.07	11,639.85	12,211.20	12,245.12	15,253.13	11,939.84	11,668.48	11,668.48	11,515.66	0.00	0.00	121,421.46	

SUBTOTAL:

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	31.89	31.89	31.89	33.92	33.92	33.92	33.92	33.92	33.92	34.07	0.00	0.00	
8700	SSI DISABLED FREEDO M	27,393.51	27,265.95	28,382.10	30,765.44	31,545.60	42,526.76	32,868.48	32,631.04	32,122.24	32,570.92	0.00	0.00	
8710	SSI DISABLED FREEDO M	4,655.94	4,751.61	5,070.51	5,596.80	5,698.56	7,418.48	5,766.40	5,834.24	5,834.24	6,200.74	0.00	0.00	
8720	SSI DISABLED FREEDO M	3,890.58	4,081.92	4,368.93	4,748.80	4,748.80	6,211.46	4,850.56	4,884.48	4,782.72	4,803.87	0.00	0.00	
SUBTOTAL:	35,971.92	36,131.37	37,853.43	41,144.96	42,026.88	56,190.62	43,519.36	43,383.68	42,773.12	43,609.60	0.00	0.	

333.26	
318,072.04	
56,827.52	
47,372.12	
422,604.94	

00

22,170,884.70	22,956,207.84	23,514,282.84	25,414,051.20	25,392,376.32	29,935,107.78	25,689,651.20	25,535,247.36	25,911,827.20	26,509,253.74	0.00	0.00	253,028,890.18	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending April 30, 2015	
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	610.00	564.00	535.00	530.00	0.00	0.00		5,683.00		
1010	TANF NON-MEDICARE	147,482.00	151,114.00	153,768.00	154,525.00	151,642.00	151,404.00	148,798.00	147,298.00	145,880.00	143,443.00	0.00	0.00		1,495,354.00		
1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	44.00	45.00	56.00	80.00	120.00	0.00	0.00		470.00		
2100	SSI AGED WITH MEDIC A	4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	4,699.00	4,814.00	4,728.00	4,539.00	4,428.00	0.00	0.00		46,555.00		
2110	SSI AGED NON-MEDIC AR	5,923.00	6,265.00	6,330.00	6,391.00	6,375.00	6,396.00	6,363.00	6,479.00	6,501.00	6,293.00	0.00	0.00		63,316.00		
2120	SSI AGED WITH QMB	22,478.00	23,011.00	23,360.00	23,482.00	23,460.00	23,449.00	23,588.00	23,394.00	23,016.00	22,516.00	0.00	0.00		231,754.00		
2200	SSI DISABLED WITH M E	4,587.00	4,625.00	4,629.00	4,647.00	4,669.00	4,715.00	4,826.00	4,744.00	4,311.00	4,178.00	0.00	0.00		45,931.00		
2210	SSI DISABLED NON-ME D	41,883.00	41,834.00	41,921.00	41,829.00	41,755.00	41,643.00	41,568.00	41,651.00	41,839.00	41,906.00	0.00	0.00		417,829.00		
2220	SSI DISABLED WITH Q M	25,026.00	25,023.00	25,226.00	25,247.00	25,151.00	25,098.00	25,666.00	25,579.00	25,792.00	25,866.00	0.00	0.00		253,674.00		
2300	SSI BLIND WITH MEDIC	36.00	37.00	34.00	36.00	37.00	37.00	35.00	34.00	37.00	35.00	0.00	0.00		358.00		
2310	SSI BLIND NON-MEDIC A	428.00	426.00	425.00	424.00	422.00	428.00	435.00	437.00	437.00	444.00	0.00	0.00		4,306.00		
2320	SSI BLIND WITH QMB	248.00	243.00	245.00	247.00	245.00	248.00	246.00	245.00	245.00	247.00	0.00	0.00		2,459.00		
4300	SOBRA CHILD WITH M ED	0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00		5.00		
4310	SOBRA CHILD NON-ME DI	19,433.00	19,952.00	20,164.00	19,995.00	19,347.00	19,163.00	18,872.00	18,958.00	19,463.00	20,428.00	0.00	0.00		195,775.00		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	51.00	48.00	47.00	47.00	52.00	53.00	51.00	49.00	46.00	42.00	0.00	0.00		486.00		
5010	SOBRA PREGNANT WO MAN	13,724.00	13,811.00	13,824.00	13,578.00	13,182.00	12,987.00	12,886.00	13,426.00	14,409.00	15,772.00	0.00	0.00		137,599.00		
5020	SOBRA PREGNANT WO MAN	5.00	4.00	6.00	5.00	8.00	10.00	10.00	8.00	7.00	4.00	0.00	0.00		67.00		
	286,470.00	291,643.00	295,252.00	295,779.00	291,651.00	290,971.00	288,814.00	287,651.00	287,138.00	286,253.00	0.00	0.00	2,901,622.00		

1100	TANF EXPANDED FPR FI	5,598.00	5,631.00	5,705.00	5,771.00	5,653.00	5,621.00	5,593.00	5,504.00	5,615.00	5,639.00	0.00	0.00		56,330.00	
1110	TANF EXPANDED FOR FI	111,246.00	115,026.00	117,472.00	118,665.00	116,530.00	115,938.00	114,649.00	113,854.00	115,808.00	117,677.00	0.00	0.00		1,156,865.00	
1120	TANF EXPANDED FOR FI	260.00	293.00	367.00	383.00	448.00	527.00	591.00	681.00	970.00	1,186.00	0.00	0.00		5,706.00	
2400	SSI AGED EXPANDED WI	528.00	554.00	526.00	491.00	533.00	528.00	669.00	658.00	662.00	609.00	0.00	0.00		5,758.00	
2410	SSI AGED EXPANDED NO	1,263.00	1,218.00	1,182.00	1,238.00	1,251.00	1,257.00	1,240.00	1,247.00	1,303.00	1,345.00	0.00	0.00		12,544.00	
2420	SSI AGED EXPANDED WI	21,751.00	21,850.00	22,058.00	22,449.00	22,820.00	23,256.00	23,292.00	23,529.00	23,984.00	24,255.00	0.00	0.00		229,244.00	
2510	SSI BLIND EXPANDED N	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00		22.00	
2520	SSI BLIND EXPANDED W	5.00	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00		24.00	
2600	SSI DISABLED EXPAND E	434.00	473.00	483.00	495.00	520.00	530.00	516.00	484.00	335.00	284.00	0.00	0.00		4,554.00	
2610	SSI DISABLED EXPAND E	1,284.00	1,313.00	1,271.00	1,213.00	1,112.00	1,026.00	1,094.00	1,222.00	1,629.00	2,056.00	0.00	0.00		13,220.00	
2620	SSI DISABLED EXPAND E	8,073.00	8,089.00	8,369.00	8,582.00	8,787.00	9,027.00	8,804.00	9,154.00	9,989.00	10,835.00	0.00	0.00		89,709.00	
	150,445.00	154,453.00	157,438.00	159,291.00	157,658.00	157,714.00	156,452.00	156,337.00	160,299.00	163,889.00	0.00	0.00	1,573,976.00	

SUBTOTAL:

3300	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	
3310	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	
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	

SUBTOTAL:

SUBTOTAL:

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	555.00	402.00	302.00	248.00	207.00	0.00	0.00		4,203.00	
3510	ADULT 40-100% FOR FI	55,683.00	59,624.00	62,218.00	64,375.00	65,580.00	67,843.00	68,555.00	69,529.00	70,608.00	73,785.00	0.00	0.00		657,800.00	
3520	ADULT 40-100% FOR FI	40.00	55.00	38.00	36.00	39.00	40.00	29.00	31.00	39.00	32.00	0.00	0.00		379.00	
3700	ADULT <40% EXP FOR F	473.00	514.00	393.00	414.00	446.00	478.00	291.00	222.00	200.00	155.00	0.00	0.00		3,586.00	
3710	AHC CARE EXPANDED FO	173,747.00	182,153.00	189,116.00	194,598.00	197,424.00	199,936.00	201,699.00	197,365.00	199,106.00	198,094.00	0.00	0.00		1,933,238.00	
3720	AHC CARE EXPANDED FO	14.00	17.00	28.00	28.00	29.00	28.00	15.00	24.00	29.00	25.00	0.00	0.00		237.00	
	230,469.00	242,886.00	252,254.00	259,934.00	264,028.00	268,880.00	270,991.00	267,473.00	270,230.00	272,298.00	0.00	0.00	2,599,443.00	

SUBTOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3600	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		
3610	AHC CARE EXPANDED FO	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		
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		

3900	NEWLY ELIGIBLE FOR F	728.00	641.00	184.00	149.00	151.00	109.00	83.00	66.00	82.00	83.00	0.00	0.00		2,276.00	
3910	NEWLY ELIGIBLE FOR F	23,639.00	26,432.00	28,109.00	29,664.00	30,659.00	32,235.00	35,993.00	36,979.00	41,540.00	50,389.00	0.00	0.00		335,639.00	
3920	NEWLY ELIGIBLE FOR F	7.00	13.00	12.00	4.00	3.00	3.00	1.00	3.00	2.00	7.00	0.00	0.00		55.00	
	24,374.00	27,086.00	28,305.00	29,817.00	30,813.00	32,347.00	36,077.00	37,048.00	41,624.00	50,479.00	0.00	0.00	337,970.00	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	3,391.00	2,676.00	3,014.00	3,545.00	0.00	0.00		28,204.00	
	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	3,391.00	2,676.00	3,014.00	3,545.00	0.00	0.00	28,204.00	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	321.00	317.00	320.00	316.00	315.00	308.00	306.00	300.00	299.00	296.00	0.00	0.00		3,098.00	
4610	CC PATIENT FOR FINA N	46.00	46.00	45.00	44.00	46.00	47.00	46.00	44.00	45.00	42.00	0.00	0.00		451.00	
	367.00	363.00	365.00	360.00	361.00	355.00	352.00	344.00	344.00	338.00	0.00	0.00	3,549.00	

SUBTOTAL:

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	859.00	855.00	890.00	907.00	930.00	940.00	969.00	962.00	947.00	956.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	146.00	149.00	159.00	165.00	168.00	172.00	170.00	172.00	172.00	182.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	122.00	128.00	137.00	140.00	140.00	142.00	143.00	144.00	141.00	141.00	0.00	0.00	
SUBTOTAL:	1,128.00	1,133.00	1,187.00	1,213.00	1,239.00	1,255.00	1,283.00	1,279.00	1,261.00	1,280.00	0.00	0.	

10.00	
9,215.00	
1,655.00	
1,378.00	
12,258.00	

00

TOTAL:	695,230.00	719,856.00	737,356.00	749,235.00	748,596.00	754,605.00	757,360.00	752,808.00	763,910.00	778,082.00	0.00	0.00	7,457,038.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending April 30, 2015	
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	26,919.30	24,889.32	23,609.55	24,289.90	0.00	0.00		258,745.95		
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	6,566,455.74	6,500,260.74	6,437,684.40	6,573,992.69	0.00	0.00		68,048,828.40		
1020	TANF WITH QMB	745.76	838.98	1,072.03	1,323.90	1,676.94	2,039.32	1,985.85	2,471.28	3,530.40	5,499.60	0.00	0.00		21,184.06		
2100	SSI AGED WITH MEDIC A	213,846.68	216,503.45	218,461.07	208,602.51	207,411.00	227,555.43	212,441.82	208,646.64	200,306.07	202,935.24	0.00	0.00		2,116,709.91		
2110	SSI AGED NON-MEDIC AR	276,071.03	292,011.65	295,041.30	282,034.83	281,328.75	307,675.40	280,799.19	285,918.27	286,889.13	288,408.19	0.00	0.00		2,876,177.74		
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	1,040,938.44	1,032,377.22	1,015,696.08	1,031,908.28	0.00	0.00		10,535,654.26		
2200	SSI DISABLED WITH M E	213,800.07	215,571.25	215,757.69	205,072.11	206,042.97	228,910.55	212,971.38	209,352.72	190,244.43	191,477.74	0.00	0.00		2,089,200.91		
2210	SSI DISABLED NON-ME D	1,952,166.63	1,949,882.74	1,953,937.81	1,845,913.77	1,842,648.15	2,075,888.63	1,834,395.84	1,838,058.63	1,846,355.07	1,920,551.98	0.00	0.00		19,059,799.25		
2220	SSI DISABLED WITH Q M	1,166,461.86	1,166,322.03	1,175,783.86	1,114,150.11	1,109,913.63	1,250,656.34	1,132,640.58	1,128,801.27	1,138,200.96	1,185,438.78	0.00	0.00		11,568,369.42		
2300	SSI BLIND WITH MEDIC	1,677.96	1,724.57	1,584.74	1,588.68	1,632.81	1,759.69	1,544.55	1,500.42	1,632.81	1,604.05	0.00	0.00		16,250.28		
2310	SSI BLIND NON-MEDIC A	19,949.08	19,855.86	19,809.25	18,711.12	18,622.86	20,917.72	19,196.55	19,284.81	19,284.81	20,348.52	0.00	0.00		195,980.58		
2320	SSI BLIND WITH QMB	11,559.28	11,326.23	11,419.45	10,900.11	10,811.85	12,183.76	10,855.98	10,811.85	10,811.85	11,320.01	0.00	0.00		112,000.37		
4300	SOBRA CHILD WITH M ED	0.00	46.61	0.00	0.00	0.00	4.88	44.13	44.13	44.13	45.83	0.00	0.00		229.71		
4310	SOBRA CHILD NON-ME DI	905,772.13	929,962.72	939,844.04	882,379.35	853,783.11	932,688.23	832,821.36	836,616.54	858,902.19	936,215.24	0.00	0.00		8,908,984.91		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	2,377.11	2,237.28	2,190.67	2,074.11	2,294.76	2,592.65	2,250.63	2,162.37	2,029.98	1,924.86	0.00	0.00		22,134.42		
5010	SOBRA PREGNANT WO MAN	639,675.64	643,730.71	644,336.64	599,197.14	581,721.66	645,618.47	568,659.18	592,489.38	635,869.17	722,830.76	0.00	0.00		6,274,128.75		
5020	SOBRA PREGNANT WO MAN	233.05	186.44	279.66	220.65	353.04	460.82	441.30	353.04	308.91	183.32	0.00	0.00		3,020.23		
	13,352,366.70	13,593,480.23	13,761,695.72	13,052,727.27	12,870,558.63	14,246,839.35	12,745,361.82	12,694,038.63	12,671,399.94	13,118,974.99	0.00	0.00	132,107,443.28		

1100	TANF EXPANDED FPR FI	260,922.78	262,460.91	265,910.05	254,674.23	249,466.89	275,046.01	246,819.09	242,891.52	247,789.95	258,435.37	0.00	0.00		2,564,416.80	
1110	TANF EXPANDED FOR FI	5,185,176.06	5,361,361.86	5,475,369.92	5,236,686.45	5,142,468.90	5,609,707.06	5,059,460.37	5,024,377.02	5,110,607.04	5,393,136.91	0.00	0.00		52,598,351.59	
1120	TANF EXPANDED FOR FI	12,118.60	13,656.73	17,105.87	16,901.79	19,770.24	24,544.83	26,080.83	30,052.53	42,806.10	54,354.38	0.00	0.00		257,391.90	
2400	SSI AGED EXPANDED WI	24,610.08	25,821.94	24,516.86	21,667.83	23,521.29	24,813.44	29,522.97	29,037.54	29,214.06	27,910.47	0.00	0.00		260,636.48	
2410	SSI AGED EXPANDED NO	58,868.43	56,770.98	55,093.02	54,632.94	55,206.63	60,878.45	54,721.20	55,030.11	57,501.39	61,641.35	0.00	0.00		570,344.50	
2420	SSI AGED EXPANDED WI	1,013,814.11	1,018,428.50	1,028,123.38	990,674.37	1,007,046.60	1,132,432.16	1,027,875.96	1,038,334.77	1,058,413.92	1,111,606.65	0.00	0.00		10,426,750.42	
2510	SSI BLIND EXPANDED N	139.83	139.83	93.22	88.26	88.26	88.26	88.26	88.26	88.26	91.66	0.00	0.00		994.10	
2520	SSI BLIND EXPANDED W	233.05	139.83	139.83	88.26	88.26	156.58	88.26	88.26	88.26	45.83	0.00	0.00		1,156.42	
2600	SSI DISABLED EXPAND E	20,228.74	22,046.53	22,512.63	21,844.35	22,947.60	24,916.34	22,771.08	21,358.92	14,783.55	13,015.72	0.00	0.00		206,425.46	
2610	SSI DISABLED EXPAND E	59,847.24	61,198.93	59,241.31	53,529.69	49,072.56	56,120.74	48,278.22	53,926.86	71,887.77	94,226.48	0.00	0.00		607,329.80	
2620	SSI DISABLED EXPAND E	376,282.53	377,028.29	390,079.09	378,723.66	387,770.31	444,335.99	388,520.52	403,966.02	440,814.57	496,568.05	0.00	0.00		4,084,089.03	
	7,012,241.45	7,199,054.33	7,338,185.18	7,029,511.83	6,957,447.54	7,653,039.86	6,904,226.76	6,899,151.81	7,073,994.87	7,511,032.87	0.00	0.00	71,577,886.50	

SUBTOTAL:

3300	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	
3310	AHC CARE EXPANDED FO	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	
3320	AHC CARE EXPANDED FO	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	
	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	

SUBTOTAL:

SUBTOTAL:

3500	ADULT 40-100% FOR FI	23,864.32	24,377.03	21,487.21	21,314.79	22,506.30	24,492.15	17,740.26	13,327.26	10,944.24	9,486.81	0.00	0.00		189,540.37	
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	3,025,332.15	3,068,314.77	3,115,931.04	3,381,566.55	0.00	0.00		29,594,410.50	
3520	ADULT 40-100% FOR FI	1,864.40	2,563.55	1,771.18	1,588.68	1,721.07	1,765.20	1,279.77	1,368.03	1,721.07	1,466.56	0.00	0.00		17,109.51	
3700	ADULT <40% EXP FOR F	22,046.53	23,957.54	18,317.73	18,269.82	19,681.98	21,094.14	12,841.83	9,796.86	8,826.00	7,103.65	0.00	0.00		161,936.08	
3710	AHC CARE EXPANDED FO	8,098,347.67	8,490,151.33	8,814,696.76	8,587,609.74	8,712,321.12	8,823,175.68	8,900,976.87	8,709,717.45	8,786,547.78	9,078,648.02	0.00	0.00		87,002,192.42	
3720	AHC CARE EXPANDED FO	652.54	792.37	1,305.08	1,235.64	1,279.77	1,235.64	661.95	1,059.12	1,279.77	1,145.75	0.00	0.00		10,647.63	
	10,742,160.09	11,320,916.46	11,757,558.94	11,470,887.42	11,651,555.64	11,865,674.40	11,958,832.83	11,803,583.49	11,925,249.90	12,479,417.34	0.00	0.00	116,975,836.51	

SUBTOTAL:

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3600	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		
3610	AHC CARE EXPANDED FO	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		
3620	AHC CARE EXPANDED FO	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		
	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		

3900	NEWLY ELIGIBLE FOR F	33,932.08	29,877.01	8,576.24	6,575.37	6,663.63	4,810.17	3,662.79	2,912.58	3,618.66	3,803.89	0.00	0.00		104,432.42	
3910	NEWLY ELIGIBLE FOR F	1,101,813.79	1,231,995.52	1,310,160.49	1,309,072.32	1,352,981.67	1,422,530.55	1,588,371.09	1,631,883.27	1,833,160.20	2,309,327.87	0.00	0.00		15,091,296.77	
3920	NEWLY ELIGIBLE FOR F	326.27	605.93	559.32	176.52	132.39	132.39	44.13	132.39	88.26	320.81	0.00	0.00		2,518.41	
	1,136,072.14	1,262,478.46	1,319,296.05	1,315,824.21	1,359,777.69	1,427,473.11	1,592,078.01	1,634,928.24	1,836,867.12	2,313,452.57	0.00	0.00	15,198,247.60	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	91,961.53	106,643.68	118,948.72	125,240.94	125,549.85	136,008.66	149,644.83	118,091.88	133,007.82	162,467.35	0.00	0.00		1,267,565.26	
	91,961.53	106,643.68	118,948.72	125,240.94	125,549.85	136,008.66	149,644.83	118,091.88	133,007.82	162,467.35	0.00	0.00	1,267,565.26	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	14,961.81	14,775.37	14,915.20	13,945.08	13,900.95	15,153.64	13,503.78	13,239.00	13,194.87	13,565.68	0.00	0.00		141,155.38	
4610	CC PATIENT FOR FINA N	2,144.06	2,144.06	2,097.45	1,941.72	2,029.98	2,332.75	2,029.98	1,941.72	1,985.85	1,924.86	0.00	0.00		20,572.43	
	17,105.87	16,919.43	17,012.65	15,886.80	15,930.93	17,486.39	15,533.76	15,180.72	15,180.72	15,490.54	0.00	0.00	161,727.81	

SUBTOTAL:

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	46.61	46.61	46.61	44.13	44.13	44.13	44.13	44.13	44.13	45.83	0.00	0.00	
8700	SSI DISABLED FREEDO M	40,037.99	39,851.55	41,482.90	40,025.91	41,040.90	47,513.88	42,761.97	42,453.06	41,791.11	43,813.48	0.00	0.00	
8710	SSI DISABLED FREEDO M	6,805.06	6,944.89	7,410.99	7,281.45	7,413.84	8,488.28	7,502.10	7,590.36	7,590.36	8,341.06	0.00	0.00	
8720	SSI DISABLED FREEDO M	5,686.42	5,966.08	6,385.57	6,178.20	6,178.20	7,057.02	6,310.59	6,354.72	6,222.33	6,462.03	0.00	0.00	
SUBTOTAL:	52,576.08	52,809.13	55,326.07	53,529.69	54,677.07	63,103.31	56,618.79	56,442.27	55,647.93	58,662.40	0.00	0.	

450.44	
420,772.75	
75,368.39	
62,801.16	
559,392.74	

00

32,404,670.30	33,552,488.16	34,368,163.16	33,063,740.55	33,035,541.48	35,759,936.09	33,422,296.80	33,221,417.04	33,711,348.30	35,659,498.06	0.00	0.00	338,199,099.94	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending April 30, 2015	
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	610.00	564.00	535.00	530.00	0.00	0.00		5,683.00		
1010	TANF NON-MEDICARE	147,482.00	151,114.00	153,768.00	154,525.00	151,642.00	151,404.00	148,798.00	147,298.00	145,880.00	143,443.00	0.00	0.00		1,495,354.00		
1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	44.00	45.00	56.00	80.00	120.00	0.00	0.00		470.00		
2100	SSI AGED WITH MEDIC A	4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	4,699.00	4,814.00	4,728.00	4,539.00	4,428.00	0.00	0.00		46,555.00		
2110	SSI AGED NON-MEDIC AR	5,923.00	6,265.00	6,330.00	6,391.00	6,375.00	6,396.00	6,363.00	6,479.00	6,501.00	6,293.00	0.00	0.00		63,316.00		
2120	SSI AGED WITH QMB	22,478.00	23,011.00	23,360.00	23,482.00	23,460.00	23,449.00	23,588.00	23,394.00	23,016.00	22,516.00	0.00	0.00		231,754.00		
2200	SSI DISABLED WITH M E	4,587.00	4,625.00	4,629.00	4,647.00	4,669.00	4,715.00	4,826.00	4,744.00	4,311.00	4,178.00	0.00	0.00		45,931.00		
2210	SSI DISABLED NON-ME D	41,883.00	41,834.00	41,921.00	41,829.00	41,755.00	41,643.00	41,568.00	41,651.00	41,839.00	41,906.00	0.00	0.00		417,829.00		
2220	SSI DISABLED WITH Q M	25,026.00	25,023.00	25,226.00	25,247.00	25,151.00	25,098.00	25,666.00	25,579.00	25,792.00	25,866.00	0.00	0.00		253,674.00		
2300	SSI BLIND WITH MEDIC	36.00	37.00	34.00	36.00	37.00	37.00	35.00	34.00	37.00	35.00	0.00	0.00		358.00		
2310	SSI BLIND NON-MEDIC A	428.00	426.00	425.00	424.00	422.00	428.00	435.00	437.00	437.00	444.00	0.00	0.00		4,306.00		
2320	SSI BLIND WITH QMB	248.00	243.00	245.00	247.00	245.00	248.00	246.00	245.00	245.00	247.00	0.00	0.00		2,459.00		
4300	SOBRA CHILD WITH M ED	0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00		5.00		
4310	SOBRA CHILD NON-ME DI	19,433.00	19,952.00	20,164.00	19,995.00	19,347.00	19,163.00	18,872.00	18,958.00	19,463.00	20,428.00	0.00	0.00		195,775.00		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	51.00	48.00	47.00	47.00	52.00	53.00	51.00	49.00	46.00	42.00	0.00	0.00		486.00		
5010	SOBRA PREGNANT WO MAN	13,724.00	13,811.00	13,824.00	13,578.00	13,182.00	12,987.00	12,886.00	13,426.00	14,409.00	15,772.00	0.00	0.00		137,599.00		
5020	SOBRA PREGNANT WO MAN	5.00	4.00	6.00	5.00	8.00	10.00	10.00	8.00	7.00	4.00	0.00	0.00		67.00		
	286,470.00	291,643.00	295,252.00	295,779.00	291,651.00	290,971.00	288,814.00	287,651.00	287,138.00	286,253.00	0.00	0.00	2,901,622.00		

1100	TANF EXPANDED FPR FI	5,598.00	5,631.00	5,705.00	5,771.00	5,653.00	5,621.00	5,593.00	5,504.00	5,615.00	5,639.00	0.00	0.00		56,330.00	
1110	TANF EXPANDED FOR FI	111,246.00	115,026.00	117,472.00	118,665.00	116,530.00	115,938.00	114,649.00	113,854.00	115,808.00	117,677.00	0.00	0.00		1,156,865.00	
1120	TANF EXPANDED FOR FI	260.00	293.00	367.00	383.00	448.00	527.00	591.00	681.00	970.00	1,186.00	0.00	0.00		5,706.00	
2400	SSI AGED EXPANDED WI	528.00	554.00	526.00	491.00	533.00	528.00	669.00	658.00	662.00	609.00	0.00	0.00		5,758.00	
2410	SSI AGED EXPANDED NO	1,263.00	1,218.00	1,182.00	1,238.00	1,251.00	1,257.00	1,240.00	1,247.00	1,303.00	1,345.00	0.00	0.00		12,544.00	
2420	SSI AGED EXPANDED WI	21,751.00	21,850.00	22,058.00	22,449.00	22,820.00	23,256.00	23,292.00	23,529.00	23,984.00	24,255.00	0.00	0.00		229,244.00	
2510	SSI BLIND EXPANDED N	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00		22.00	
2520	SSI BLIND EXPANDED W	5.00	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00		24.00	
2600	SSI DISABLED EXPAND E	434.00	473.00	483.00	495.00	520.00	530.00	516.00	484.00	335.00	284.00	0.00	0.00		4,554.00	
2610	SSI DISABLED EXPAND E	1,284.00	1,313.00	1,271.00	1,213.00	1,112.00	1,026.00	1,094.00	1,222.00	1,629.00	2,056.00	0.00	0.00		13,220.00	
2620	SSI DISABLED EXPAND E	8,073.00	8,089.00	8,369.00	8,582.00	8,787.00	9,027.00	8,804.00	9,154.00	9,989.00	10,835.00	0.00	0.00		89,709.00	
	150,445.00	154,453.00	157,438.00	159,291.00	157,658.00	157,714.00	156,452.00	156,337.00	160,299.00	163,889.00	0.00	0.00	1,573,976.00	

SUBTOTAL:

3300	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	
3310	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	
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	

SUBTOTAL:

SUBTOTAL:

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	555.00	402.00	302.00	248.00	207.00	0.00	0.00		4,203.00	
3510	ADULT 40-100% FOR FI	55,683.00	59,624.00	62,218.00	64,375.00	65,580.00	67,843.00	68,555.00	69,529.00	70,608.00	73,785.00	0.00	0.00		657,800.00	
3520	ADULT 40-100% FOR FI	40.00	55.00	38.00	36.00	39.00	40.00	29.00	31.00	39.00	32.00	0.00	0.00		379.00	
3700	ADULT <40% EXP FOR F	473.00	514.00	393.00	414.00	446.00	478.00	291.00	222.00	200.00	155.00	0.00	0.00		3,586.00	
3710	AHC CARE EXPANDED FO	173,747.00	182,153.00	189,116.00	194,598.00	197,424.00	199,936.00	201,699.00	197,365.00	199,106.00	198,094.00	0.00	0.00		1,933,238.00	
3720	AHC CARE EXPANDED FO	14.00	17.00	28.00	28.00	29.00	28.00	15.00	24.00	29.00	25.00	0.00	0.00		237.00	
	230,469.00	242,886.00	252,254.00	259,934.00	264,028.00	268,880.00	270,991.00	267,473.00	270,230.00	272,298.00	0.00	0.00	2,599,443.00	

SUBTOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3600	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		
3610	AHC CARE EXPANDED FO	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		
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		

3900	NEWLY ELIGIBLE FOR F	728.00	641.00	184.00	149.00	151.00	109.00	83.00	66.00	82.00	83.00	0.00	0.00		2,276.00	
3910	NEWLY ELIGIBLE FOR F	23,639.00	26,432.00	28,109.00	29,664.00	30,659.00	32,235.00	35,993.00	36,979.00	41,540.00	50,389.00	0.00	0.00		335,639.00	
3920	NEWLY ELIGIBLE FOR F	7.00	13.00	12.00	4.00	3.00	3.00	1.00	3.00	2.00	7.00	0.00	0.00		55.00	
	24,374.00	27,086.00	28,305.00	29,817.00	30,813.00	32,347.00	36,077.00	37,048.00	41,624.00	50,479.00	0.00	0.00	337,970.00	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	3,391.00	2,676.00	3,014.00	3,545.00	0.00	0.00		28,204.00	
	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	3,391.00	2,676.00	3,014.00	3,545.00	0.00	0.00	28,204.00	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	321.00	317.00	320.00	316.00	315.00	308.00	306.00	300.00	299.00	296.00	0.00	0.00		3,098.00	
4610	CC PATIENT FOR FINA N	46.00	46.00	45.00	44.00	46.00	47.00	46.00	44.00	45.00	42.00	0.00	0.00		451.00	
	367.00	363.00	365.00	360.00	361.00	355.00	352.00	344.00	344.00	338.00	0.00	0.00	3,549.00	

SUBTOTAL:

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	859.00	855.00	890.00	907.00	930.00	940.00	969.00	962.00	947.00	956.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	146.00	149.00	159.00	165.00	168.00	172.00	170.00	172.00	172.00	182.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	122.00	128.00	137.00	140.00	140.00	142.00	143.00	144.00	141.00	141.00	0.00	0.00	
SUBTOTAL:	1,128.00	1,133.00	1,187.00	1,213.00	1,239.00	1,255.00	1,283.00	1,279.00	1,261.00	1,280.00	0.00	0.	

10.00	
9,215.00	
1,655.00	
1,378.00	
12,258.00	

00

TOTAL:	695,230.00	719,856.00	737,356.00	749,235.00	748,596.00	754,605.00	757,360.00	752,808.00	763,910.00	778,082.00	0.00	0.00	7,457,038.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending April 30, 2015	
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	1,219,851.60	1,171,796.84	1,116,349.04	1,065,356.54	0.00	0.00		15,130,955.47		
2210	SSI DISABLED NON-ME D	403,827.58	407,211.61	407,211.61	317,900.72	327,142.02	355,792.33	312,355.94	318,824.85	321,597.24	331,588.74	0.00	0.00		3,503,452.64		
2310	SSI BLIND NON-MEDIC A	1,128.01	1,128.01	1,128.01	924.13	924.13	1,255.63	924.13	924.13	924.13	928.82	0.00	0.00		10,189.13		
4310	SOBRA CHILD NON-ME DI	14,048,236.54	14,167,805.60	14,499,440.54	12,119,964.95	12,211,453.82	13,479,411.81	12,525,658.02     12,752,069.87	12,978,481.72	13,227,325.62	0.00	0.00		132,009,848.49		
5010	SOBRA PREGNANT WO MAN	18,048.16	21,432.19	18,048.16	13,861.95	12,937.82	21,687.08	23,103.25	22,179.12	19,406.73	19,505.22	0.00	0.00		190,209.68		
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	14,081,892.94	14,265,794.81	14,436,758.86	14,644,704.94	0.00	0.00	150,844,655.41		

4410	SOBRA 100-133% FOR F	15,792.14	15,792.14	18,048.16	17,558.47	26,799.77	29,572.16	38,813.46	32,344.55	33,268.68	41,796.90	0.00	0.00		269,786.43	
	15,792.14	15,792.14	18,048.16	17,558.47	26,799.77	29,572.16	38,813.46	32,344.55	33,268.68	41,796.90	0.00	0.00	269,786.43	

SUBTOTAL:

1110	TANF EXPANDED FOR FI	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	
2610	SSI DISABLED EXPAND E	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	
	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	

SUBTOTAL:

16,576,106.95	16,638,147.50	16,847,957.36	13,954,363.00	13,986,707.55	15,536,818.97	14,120,706.40	14,298,139.36	14,470,027.54	14,686,501.84	0.00	0.00	151,115,476.47	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending April 30, 2015	
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	1,320.00	1,268.00	1,208.00	1,147.00	0.00	0.00		14,802.00		
2210	SSI DISABLED NON-ME D	358.00	361.00	361.00	344.00	354.00	341.00	338.00	345.00	348.00	357.00	0.00	0.00		3,507.00		
2310	SSI BLIND NON-MEDIC A	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
4310	SOBRA CHILD NON-ME DI	12,454.00	12,560.00	12,854.00	13,115.00	13,214.00	13,395.00	13,554.00	13,799.00	14,044.00	14,241.00	0.00	0.00		133,230.00		
5010	SOBRA PREGNANT WO MAN	16.00	19.00	16.00	15.00	14.00	20.00	25.00	24.00	21.00	21.00	0.00	0.00		191.00		
SUBTOTAL:	14,681.00	14,736.00	14,920.00	15,081.00	15,106.00	15,152.00	15,238.00	15,437.00	15,622.00	15,767.00	0.00	0.00	151,740.00		

4410	SOBRA 100-133% FOR F	14.00	14.00	16.00	19.00	29.00	32.00	42.00	35.00	36.00	45.00	0.00	0.00		282.00	
	14.00	14.00	16.00	19.00	29.00	32.00	42.00	35.00	36.00	45.00	0.00	0.00	282.00	

SUBTOTAL:

1110	TANF EXPANDED FOR FI	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	
2610	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	

SUBTOTAL:

TOTAL:	14,695.00	14,750.00	14,936.00	15,100.00	15,135.00	15,185.00	15,280.00	15,472.00	15,658.00	15,812.00	0.00	0.00	152,023.00		

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	416.93	416.93	416.93	833.86	416.93	0.00	0.00	0.00		2,501.58	
1113	TANF EXPANDED 06-13	0.00	393.96	0.00	0.00	0.00	416.93	416.93	416.93	833.86	833.88	0.00	0.00		3,312.49	
1114	TANF EXPANDED 14-20	0.00	1,575.84	1,181.88	1,250.79	833.86	833.86	833.86	833.86	416.93	416.94	0.00	0.00		8,177.82	
1115	TANF EXPANDED 14-20	0.00	787.92	393.96	416.93	833.86	833.86	833.86	0.00	0.00	0.00	0.00	0.00		4,100.39	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00		416.93	
	0.00	2,757.72	1,575.84	1,667.72	2,084.65	2,501.58	2,501.58	2,501.58	1,667.72	1,250.82	0.00	0.00	18,509.21	

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending April 30, 2015	
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	502.99	1,005.98	1,005.98	1,008.42	0.00	0.00		5,989.84		
1010	TANF NON-MEDICARE	0.00	123,517.50	122,560.00	128,262.45	128,262.45	129,268.43	130,274.41	130,274.41	130,777.40	132,607.23	0.00	0.00		1,155,804.28		
1011	TANF <1 M & F NON-ME	0.00	12,975.87	13,933.37	18,298.97	17,379.05	18,298.97	18,960.71	15,539.21	15,036.22	13,206.36	0.00	0.00		143,628.73		
1012	TANF 01-05 M & F NON	0.00	61,123.78	60,251.07	65,067.82	62,983.17	63,227.98	58,641.75	56,557.10	51,467.88	45,640.41	0.00	0.00		524,960.96		
1013	TANF 06-13 M & F NON	0.00	63,038.78	61,602.53	67,655.46	65,901.68	64,736.95	62,566.24	58,813.87	52,142.99	45,814.95	0.00	0.00		542,273.45		
1014	TANF 14-20 MALE NON-	0.00	13,170.26	13,170.26	13,513.88	14,850.73	16,101.52	15,267.66	14,016.87	13,096.95	11,848.86	0.00	0.00		125,036.99		
1015	TANF 14-20 FEMALE N O	0.00	16,885.48	17,279.44	16,604.51	17,941.36	18,775.22	19,192.15	17,855.30	17,855.30	15,775.86	0.00	0.00		158,164.62		
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	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		
2110	SSI AGED NON-MEDIC AR	0.00	393.96	393.96	416.93	416.93	416.93	0.00	0.00	0.00	416.94	0.00	0.00		2,455.65		
2200	SSI DISABLED WITH M E	0.00	3,266.46	3,745.21	5,446.83	7,961.78	6,955.80	7,961.78	10,390.67	10,893.66	9,075.78	0.00	0.00		65,697.97		
2210	SSI DISABLED NON-ME D	0.00	2,861,956.87	2,859,338.74	3,012,217.32	3,020,265.16	3,016,989.04	3,025,698.62	3,030,311.59	3,035,930.54	3,047,918.91	0.00	0.00		26,910,626.79		
2220	SSI DISABLED WITH Q M	0.00	16,980.63	17,065.42	15,003.64	16,009.62	18,021.58	18,524.57	20,033.54	19,530.55	20,915.01	0.00	0.00		162,084.56		
2300	SSI BLIND WITH MEDIC	0.00	957.50	957.50	1,005.98	1,005.98	1,005.98	1,005.98	502.99	502.99	504.21	0.00	0.00		7,449.11		
2310	SSI BLIND NON-MEDIC A	0.00	26,919.60	26,525.64	28,484.94	28,068.01	29,490.92	29,490.92	28,484.94	28,154.07	28,216.35	0.00	0.00		253,835.39		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	502.99	502.99	504.21	0.00	0.00		1,510.19		
4311	SOBRA CHILD <1 M & F	0.00	16,357.11	16,187.53	20,827.29	20,827.29	20,165.55	17,822.72	19,000.82	20,165.55	21,777.93	0.00	0.00		173,131.79		
4312	SOBRA CHILD 01-05 M	0.00	94,547.40	94,377.82	93,422.44	87,744.17	92,012.90	93,435.81	99,114.08	105,871.02	116,423.76	0.00	0.00		876,949.40		
4313	SOBRA CHILD 06-13 M	0.00	75,058.24	83,730.54	90,119.58	92,303.66	88,954.85	90,205.64	94,057.44	100,999.87	102,984.63	0.00	0.00		818,414.45		
4314	SOBRA CHILD 14-20 MA	0.00	19,284.41	20,466.29	22,408.95	19,735.25	19,907.37	19,245.63	18,987.45	20,324.30	21,360.99	0.00	0.00		181,720.64		
4315	SOBRA CHILD 14-20 FE	0.00	23,957.13	24,435.88	24,003.98	24,090.04	25,096.02	26,015.94	27,352.79	26,849.80	29,059.86	0.00	0.00		230,861.44		
5015	SOBRA PREG 14-20 FE M	0.00	1,351.46	872.71	919.92	919.92	919.92	919.92	1,250.79	1,250.79	833.88	0.00	0.00		9,239.31		
	0.00	3,432,221.19	3,437,372.66	3,624,183.88	3,627,169.24	3,631,682.78	3,635,733.44	3,644,052.83	3,652,358.85	3,665,894.55	0.00	0.00	32,350,669.42		

3,706.44	
833.87	
64,306.22	
37,852.30	
3,289.51	
6,162.08	

SUBTOTAL:

3514	ADULT 40-100% MALE
1	0.00	393.96	393.96	416.93	416.93	416.93	416.93	416.93	416.93	416.94	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	416.94	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	6,697.32	5,909.40	6,253.95	6,670.88	7,504.74	7,504.74	8,338.60	7,921.67	7,504.92	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	3,939.60	4,727.52	4,586.23	3,752.37	4,586.23	4,586.23	4,169.30	4,169.30	3,335.52	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	393.96	393.96	0.00	416.93	416.93	416.93	416.93	416.93	416.94	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	787.92	787.92	833.86	833.86	833.86	416.93	833.86	416.93	416.94	0.00	0.00	

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	12,212.76	12,212.76	12,090.97	12,507.90	13,758.69	13,341.76	14,175.62	13,341.76	12,508.20	0.00	0.00	116,150.42		

4413	SOBRA 100-133% M&F
6	0.00	3,939.60	3,939.60	4,169.30	4,169.30	4,169.30	5,420.09	4,169.30	5,003.16	5,090.55	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	1,181.88	1,181.88	1,667.72	2,170.71	2,170.71	2,170.71	1,336.85	1,336.85	1,338.09	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	1,181.88	1,181.88	1,667.72	1,250.79	1,250.79	833.86	416.93	416.93	416.94	0.00	0.00	
SUBTOTAL:	0.00	6,303.36	6,303.36	7,504.74	7,590.80	7,590.80	8,424.66	5,923.08	6,756.94	6,845.58	0.00	0.	

40,070.20	
14,555.40	
8,617.72	
63,243.32	

3,457,464.62	3,645,447.31	3,649,352.59	3,655,533.85	3,660,001.44	3,666,653.11	3,674,125.27	3,686,499.15	0.00	0.00	32,548,572.37	

00

TOTAL:

0.00

3,453,495.03

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	1.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00		6.00	
1113	TANF EXPANDED 06-13	0.00	1.00	0.00	0.00	0.00	1.00	1.00	1.00	2.00	2.00	0.00	0.00		8.00	
1114	TANF EXPANDED 14-20	0.00	4.00	3.00	3.00	2.00	2.00	2.00	2.00	1.00	1.00	0.00	0.00		20.00	
1115	TANF EXPANDED 14-20	0.00	2.00	1.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00		10.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00		1.00	
	0.00	7.00	4.00	4.00	5.00	6.00	6.00	6.00	4.00	3.00	0.00	0.00	45.00	

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2015	
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	1.00	2.00	2.00	2.00	0.00	0.00		12.00		
1010	TANF NON-MEDICARE	0.00	258.00	256.00	255.00	255.00	257.00	259.00	259.00	260.00	263.00	0.00	0.00		2,322.00		
1011	TANF <1 M & F NON-ME	0.00	31.00	33.00	41.00	39.00	41.00	43.00	35.00	34.00	30.00	0.00	0.00		327.00		
1012	TANF 01-05 M & F NON	0.00	153.00	151.00	154.00	149.00	150.00	139.00	134.00	122.00	108.00	0.00	0.00		1,260.00		
1013	TANF 06-13 M & F NON	0.00	157.00	154.00	160.00	156.00	153.00	148.00	139.00	123.00	108.00	0.00	0.00		1,298.00		
1014	TANF 14-20 MALE NON-	0.00	33.00	33.00	32.00	35.00	38.00	36.00	33.00	31.00	28.00	0.00	0.00		299.00		
1015	TANF 14-20 FEMALE N O	0.00	42.00	43.00	39.00	42.00	44.00	45.00	42.00	42.00	37.00	0.00	0.00		376.00		
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	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		
2110	SSI AGED NON-MEDIC AR	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	1.00	0.00	0.00		6.00		
2200	SSI DISABLED WITH M E	0.00	7.00	8.00	11.00	16.00	14.00	16.00	21.00	22.00	18.00	0.00	0.00		133.00		
2210	SSI DISABLED NON-ME D	0.00	6,066.00	6,060.00	6,074.00	6,090.00	6,084.00	6,102.00	6,111.00	6,122.00	6,132.00	0.00	0.00		54,841.00		
2220	SSI DISABLED WITH Q M	0.00	36.00	36.00	30.00	32.00	36.00	37.00	40.00	39.00	42.00	0.00	0.00		328.00		
2300	SSI BLIND WITH MEDIC	0.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00		15.00		
2310	SSI BLIND NON-MEDIC A	0.00	58.00	57.00	58.00	57.00	60.00	60.00	58.00	57.00	57.00	0.00	0.00		522.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00		3.00		
4311	SOBRA CHILD <1 M & F	0.00	37.00	37.00	45.00	45.00	43.00	38.00	40.00	43.00	47.00	0.00	0.00		375.00		
4312	SOBRA CHILD 01-05 M	0.00	209.00	209.00	196.00	183.00	192.00	195.00	208.00	224.00	247.00	0.00	0.00		1,863.00		
4313	SOBRA CHILD 06-13 M	0.00	169.00	188.00	192.00	196.00	189.00	192.00	200.00	215.00	220.00	0.00	0.00		1,761.00		
4314	SOBRA CHILD 14-20 MA	0.00	44.00	47.00	49.00	43.00	43.00	41.00	41.00	44.00	46.00	0.00	0.00		398.00		
4315	SOBRA CHILD 14-20 FE	0.00	55.00	56.00	52.00	52.00	54.00	56.00	59.00	58.00	63.00	0.00	0.00		505.00		
5015	SOBRA PREG 14-20 FE M	0.00	3.00	2.00	2.00	2.00	2.00	2.00	3.00	3.00	2.00	0.00	0.00		21.00		
	0.00	7,362.00	7,374.00	7,394.00	7,396.00	7,406.00	7,412.00	7,427.00	7,443.00	7,453.00	0.00	0.00	66,667.00		

9.00	
2.00	
156.00	
92.00	
8.00	
15.00	

SUBTOTAL:

3514	ADULT 40-100% MALE
1	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	17.00	15.00	15.00	16.00	18.00	18.00	20.00	19.00	18.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	10.00	12.00	11.00	9.00	11.00	11.00	10.00	10.00	8.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	1.00	1.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	2.00	2.00	2.00	2.00	2.00	1.00	2.00	1.00	1.00	0.00	0.00	

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	31.00	31.00	29.00	30.00	33.00	32.00	34.00	32.00	30.00	0.00	0.00	282.00		

4413	SOBRA 100-133% M&F
6	0.00	10.00	10.00	10.00	10.00	10.00	13.00	10.00	12.00	12.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	3.00	3.00	4.00	5.00	5.00	5.00	3.00	3.00	3.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	3.00	3.00	4.00	3.00	3.00	2.00	1.00	1.00	1.00	0.00	0.00	
SUBTOTAL:	0.00	16.00	16.00	18.00	18.00	18.00	20.00	14.00	16.00	16.00	0.00	0.	

97.00	
34.00	
21.00	
152.00	

00

TOTAL:	0.00	7,416.00	7,425.00	7,445.00	7,449.00	7,463.00	7,470.00	7,481.00	7,495.00	7,502.00	0.00	0.00	67,146.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
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	6,033.69	4,834.00	7,501.30	12,165.46	0.00	0.00		95,466.71		
1007	TANF 21-44 FEMALE WI	23,137.76	17,832.63	43,923.29	20,080.22	22,545.94	14,940.01	15,488.56	12,950.89	31,281.28	15,867.62	0.00	0.00		218,048.20		
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	4,941.15	4,953.17	17,143.68	19,188.06	0.00	0.00		113,797.30		
1009	TANF 65+ M & F WITH	3,332.06	859.77	638.60	2,223.59	1,402.46	1,700.77	1,811.21	2,786.20	3,349.76	3,270.48	0.00	0.00		21,374.90		
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	2,311,129.80	1,626,197.33	2,120,965.52	1,843,775.72	0.00	0.00		18,769,335.78		
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	2,375,105.52	2,861,659.66	3,256,533.69	2,216,369.84	0.00	0.00		26,936,607.35		
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	3,337,125.74	4,015,311.07	4,720,757.98	3,800,447.20	0.00	0.00		41,073,202.30		
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	590,489.78	596,034.85	950,027.84	754,014.31	0.00	0.00		8,074,879.65		
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	1,046,923.79	1,050,508.43	1,633,371.49	1,083,953.40	0.00	0.00		12,901,904.39		
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	1,286,788.54	1,366,198.92	1,800,401.32	1,605,267.80	0.00	0.00		15,431,820.74		
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	6,067,053.27	6,176,652.42	7,996,505.94	6,781,832.37	0.00	0.00		70,803,917.97		
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	1,598,034.59	2,121,472.68	2,202,925.56	2,069,278.11	0.00	0.00		20,379,496.12		
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	2,934.94	2,394.00	342.00	3,999.57	0.00	0.00		37,261.74		
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	133.88	0.00	0.00		7,785.66		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	4,002.06	3,093.38	3,602.33	1,169.07	2,296.69	986.72	8.34	0.00	0.00		15,158.59		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,148.32	1,276.19	0.00	0.00		2,424.51		
2100	SSI AGED WITH MEDIC A	112,069.05	103,882.05	140,484.93	100,297.57	77,397.17	103,109.29	81,693.31	72,295.32	130,633.84	133,784.12	0.00	0.00		1,055,646.65		
2110	SSI AGED NON-MEDIC AR	179,464.34	152,722.12	161,825.86	180,615.64	163,448.68	230,859.65	137,240.88	191,763.93	182,010.04	173,776.54	0.00	0.00		1,753,727.68		
2120	SSI AGED WITH QMB	504,498.36	451,023.64	458,040.53	525,035.77	405,416.73	525,150.24	409,040.16	455,540.74	580,443.87	438,379.51	0.00	0.00		4,752,569.55		
2200	SSI DISABLED WITH M E	423,542.79	375,979.18	320,212.46	334,111.62	206,083.73	441,710.57	392,475.18	281,583.60	470,965.60	421,304.01	0.00	0.00		3,667,968.74		
2210	SSI DISABLED NON-ME D	9,192,572.30	8,115,791.88	8,638,107.12	8,116,472.87	7,615,207.99	8,735,597.68	6,952,914.81	7,651,865.13	9,663,522.50	8,715,898.79	0.00	0.00		83,397,951.07		
2220	SSI DISABLED WITH Q M	1,557,854.20	1,144,568.81	1,176,467.90	1,432,747.51	1,018,249.58	1,449,274.39	1,119,117.62	1,082,919.08	1,695,491.26	1,226,929.72	0.00	0.00		12,903,620.07		
2300	SSI BLIND WITH MEDIC	2,028.97	1,798.82	712.93	779.03	1,792.91	2,233.24	684.08	576.15	1,001.18	1,738.25	0.00	0.00		13,345.56		
2310	SSI BLIND NON-MEDIC A	119,577.24	87,006.17	112,595.00	124,841.37	81,261.78	134,625.27	86,914.00	93,172.98	104,970.75	114,728.58	0.00	0.00		1,059,693.14		
2320	SSI BLIND WITH QMB	22,834.90	18,680.13	11,066.96	14,435.28	15,566.43	17,746.70	11,213.63	13,613.33	19,473.05	16,264.97	0.00	0.00		160,895.38		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.99	0.00	0.00		8.99		
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	1,692,096.43	1,441,711.18	3,307,166.80	2,452,686.97	0.00	0.00		21,019,395.38		
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	1,240,531.70	1,629,641.48	2,261,744.01	2,098,537.14	0.00	0.00		15,932,768.19		
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	1,569,582.41	1,846,848.05	2,625,797.31	2,626,722.62	0.00	0.00		20,438,822.63		
4314	SOBRA CHILD 14-20 MA	931,900.37	820,506.24	855,134.37	647,871.48	790,168.58	957,728.71	583,764.97	612,177.16	887,280.87	833,167.91	0.00	0.00		7,919,700.66		
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	693,415.03	830,331.75	1,067,176.49	1,033,447.91	0.00	0.00		10,072,152.55		
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	1,945.85	632.45	32.95	448.60	146.34	1,899.64	-62.66	257.67	324.26	0.00	0.00	0.00		5,625.10		
5015	SOBRA PREG 14-20 FE M	485,491.24	423,602.92	427,141.69	320,730.37	359,622.33	356,962.43	326,417.18	255,668.80	381,772.50	315,969.92	0.00	0.00		3,653,379.38		
5017	SOBRA PREG 21-44 FE M	1,579,257.75	1,309,225.62	1,576,807.86	1,308,394.70	1,188,511.62	1,456,348.89	1,133,808.65	1,110,684.90	1,772,579.25	1,407,820.90	0.00	0.00		13,843,440.14		
5018	SOBRA PREG 45-64 FE M	-16,663.69	3,520.34	3,457.60	2,564.54	2,644.47	1,594.61	1,426.57	1,373.25	1,720.33	1,104.43	0.00	0.00		2,742.45		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	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		
	45,790,665.31	39,834,205.77	43,727,649.61	40,079,652.63	38,839,649.72	43,654,837.73	35,077,303.60	37,416,274.81	49,897,316.31	42,223,119.63	0.00	0.00	416,540,675.12		

SUBTOTAL:

1106	TANF EXPANDED 21-44	27,367.94	12,614.40	10,427.70	24,113.60	23,226.98	31,363.67	13,580.88	8,758.21	20,447.74	13,055.46	0.00	0.00	
1107	TANF EXPANDED 21-44	44,839.69	28,542.92	25,156.80	38,488.24	24,965.37	45,986.73	28,641.23	30,198.41	47,097.63	30,714.71	0.00	0.00	
1108	TANF EXPANDED 45-64	101,282.81	76,431.82	88,146.44	95,565.29	69,054.35	114,865.77	91,977.42	77,472.62	129,598.23	84,778.38	0.00	0.00	
1109	TANF EXPANDED 65+
M&	28,221.65	29,488.63	32,284.70	33,881.19	20,115.81	23,180.75	19,443.48	23,450.35	45,716.46	39,641.97	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	390.77	148.71	0.00	0.00	830.08	342.00	2,686.16	342.00	708.06	1,114.38	0.00	0.00	
1112	TANF EXPANDED 01-05	13,437.17	10,204.60	16,836.91	8,288.80	9,240.13	9,917.31	9,751.90	5,953.23	11,674.96	15,452.34	0.00	0.00	
1113	TANF EXPANDED 06-13	57,770.47	48,403.09	59,938.89	59,164.05	62,574.48	58,490.38	36,108.26	52,413.93	49,671.77	45,192.11	0.00	0.00	
1114	TANF EXPANDED 14-20	24,761.78	17,015.17	21,300.11	19,559.85	23,327.49	25,498.74	27,870.63	56,177.42	54,704.99	34,966.04	0.00	0.00	
1115	TANF EXPANDED 14-20	57,511.45	71,816.30	60,997.19	47,691.85	56,330.58	51,051.81	36,418.44	60,736.14	51,056.94	70,789.53	0.00	0.00	
1116	TANF EXPANDED 21-44	796,257.60	738,761.31	908,020.34	729,904.03	703,394.58	874,936.78	707,183.84	781,673.67	805,065.02	751,462.39	0.00	0.00	
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	1,514,951.01	1,685,241.79	2,106,356.52	1,857,988.30	0.00	0.00	
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	910,681.94	1,116,840.90	1,412,067.20	1,350,856.98	0.00	0.00	
1119	TANF EXPANDED 65+
M&	2,554.51	4,344.81	1,345.01	12,070.16	2,076.31	5,155.06	2,691.82	2,225.12	10,917.29	3,226.97	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	77.42	0.00	136.46	103.16	2,391.05	2,163.47	0.00	0.00	
1127	TANF EXPANDED 21-44	151.39	8.27	94.46	110.11	120.37	8.72	0.00	129.06	1,295.63	1,328.14	0.00	0.00	
1128	TANF EXPANDED 45-64	9,482.43	4,293.81	9,336.06	14,285.20	3,361.88	9,472.80	11,735.00	10,635.50	12,793.86	15,870.65	0.00	0.00	
1129	TANF EXPANDED 65+
M&	5,633.26	4,920.53	2,598.09	5,133.75	5,915.54	2,467.29	1,820.56	4,625.77	8,062.79	7,775.81	0.00	0.00	
2400	SSI AGED EXPANDED WI	21,197.10	14,263.07	31,200.01	36,552.07	23,674.18	26,863.52	22,505.60	33,422.91	32,430.35	27,556.16	0.00	0.00	
2410	SSI AGED EXPANDED NO	147,386.35	121,937.93	114,828.74	75,978.09	76,263.80	75,346.32	50,306.40	81,057.42	110,793.54	73,469.43	0.00	0.00	
2420	SSI AGED EXPANDED WI	470,852.93	408,920.65	374,872.37	511,594.90	380,311.41	457,177.15	358,212.38	403,465.74	571,484.13	414,562.29	0.00	0.00	
2510	SSI BLIND EXPANDED N	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	13,130.91	11,817.76	9,192.27	10,627.71	10,689.81	16,690.93	14,489.84	20,322.50	10,460.87	11,649.55	0.00	0.00	
2610	SSI DISABLED EXPAND E	107,386.52	106,898.65	76,899.90	89,852.33	79,337.60	124,985.71	75,222.66	65,592.37	137,445.76	243,783.08	0.00	0.00	
2620	SSI DISABLED EXPAND E	231,908.23	184,557.12	168,972.41	224,275.77	164,347.57	231,635.24	168,301.36	182,279.09	292,613.66	235,327.78	0.00	0.00	
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	4,104,717.27	4,703,117.31	5,924,854.45	5,332,725.92	0.00	0.	

184,956.58	
344,631.73	
929,173.13	
295,424.99	
6,562.16	
110,757.35	
529,727.43	
305,182.22	
564,400.23	
7,796,659.56	
18,348,642.86	
11,912,447.62	
46,607.06	
4,871.56	
3,246.15	
101,267.19	
48,953.39	
269,664.97	
927,368.02	
4,351,453.95	
-330.00	
129,072.15	
1,107,404.58	
2,084,218.23	
50,402,363.11	

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-216.52	0.00	0.00	0.00		-216.52	
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	-605.00	0.00	0.00	0.00	0.00	0.00		494.13	
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	-1,984.54	221.86	-7,260.00	0.00	0.00		28,362.72	
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	
	16,374.52	24,084.56	1,757.61	2,152.41	158.77	-629.81	-605.00	-1,984.54	5.34	-7,260.00	0.00	0.00	34,053.86	

00

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	-23.88	-86.21	0.00	-117.44	0.00	0.00	0.00	0.00	133.12	0.00	0.00	0.00	-94.41

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3410	MED ELIGIBILITY NON-	0.00	-121.13	-588.00	0.00	0.00	-1,377.33	0.00	0.00	-663.30	0.00	0.00	0.00		-2,749.76		
3607	AHC CARE/MI FEMALE 2	41.99	0.00	3.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.74		
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	-2,571.53	0.00	0.00	0.00	0.00		12,855.79		
3615	AHC CARE/MI FEMALE 1	7,211.81	1,363.64	773.45	2,378.64	429.84	83.02	169.72	0.00	52.79	0.00	0.00	0.00		12,462.91		
3616	AHC CARE/MI MALE 21-	20,576.90	24,442.36	15,689.92	16,319.52	2,550.05	32,295.32	17,423.02	-14,258.77	-2,078.56	137.19	0.00	0.00		113,096.95		
3617	AHC CARE/MI FEMALE 2	-6,005.41	61,825.29	935.30	15,317.50	2,067.95	-937.02	0.00	-4,024.21	-715.08	352.67	0.00	0.00		68,816.99		
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	2,596.68	-12,410.31	12,350.66	-418.86	0.00	0.00		259,616.00		
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		
	137,502.69	224,169.47	22,649.64	63,529.84	-3,763.45	32,287.59	20,189.42	-33,264.82	9,079.63	71.00	0.00	0.00	472,451.01		

27,161.87	
0.00	
193,476.80	
21,457.04	
182,095.60	
423,796.02	
4,660,338.61	
4,703,361.37	
15,467,361.79	
8,295.95	
5,767.32	
945.02	
26,152.87	
34,810.08	
216,061.24	
10,059.67	
3,279,740.87	
3,958,097.64	
58,601,964.85	
33,871,101.81	
76,482,773.47	
97,953.35	
380.32	
6,391.97	
20,209.86	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	684.00	3,580.48	1,303.73	3,103.25	3,193.53	1,838.90	2,671.57	4,827.33	3,265.74	2,693.34	0.00	0.00	
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	
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	12,812.85	10,597.20	14,029.55	13,621.76	0.00	0.00	
3509	ADULT 40-100% M&F 65	7,038.51	3,738.82	2,054.88	94.34	-53.02	2,462.77	1,458.97	541.65	2,293.86	1,826.26	0.00	0.00	
3514	ADULT 40-100% MALE
1	12,687.18	16,373.68	22,458.35	8,580.44	8,918.07	20,901.71	29,493.32	20,331.30	22,305.18	20,046.37	0.00	0.00	
3515	ADULT 40-100% FEMAL E	32,086.25	36,991.08	45,390.22	98,253.80	32,669.80	31,839.90	28,611.24	33,109.68	47,093.59	37,750.46	0.00	0.00	
3516	ADULT 40-100% MALE
2	305,234.79	351,770.07	576,346.80	465,211.13	437,893.25	398,521.83	462,732.13	480,277.93	546,763.36	635,587.32	0.00	0.00	
3517	ADULT 40-100% FEMAL E	436,287.52	386,457.94	478,010.90	423,309.93	426,762.12	494,193.60	391,209.70	466,880.65	579,819.90	620,429.11	0.00	0.00	
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	1,183,072.83	1,497,644.41	2,183,138.91	1,617,700.01	0.00	0.00	
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	1,710.00	1,026.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	33.73	0.00	129.06	59.40	0.00	935.15	1,098.17	1,258.10	1,519.71	734.00	0.00	0.00	
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	105.78	0.00	0.00	
3706	ADULT <40% EXP MAL E	1,792.92	1,968.09	902.92	316.42	110.71	2,629.57	5,080.98	1,787.32	5,945.61	5,618.33	0.00	0.00	
3707	ADULT <40% EXP FEM AL	2,767.07	1,278.08	-370.33	3,691.15	918.46	6,145.09	4,522.80	6,753.41	4,959.38	4,144.97	0.00	0.00	
3708	ADULT <40% EXP M&F 4	42,387.39	19,031.85	18,960.72	46,284.65	13,203.70	16,691.36	6,905.11	7,332.72	18,538.55	26,725.19	0.00	0.00	
3709	ADULT <40% EXP M&F 6	3,535.49	168.39	1,548.60	1,648.72	1,389.56	684.26	824.90	-15.53	275.28	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	347,633.63	347,324.94	317,071.70	269,612.77	314,440.60	359,189.97	318,426.94	292,337.39	327,760.85	385,942.08	0.00	0.00	
3715	ADULT <40% EXP FEM AL	438,080.79	431,929.74	423,714.83	416,138.04	313,484.58	395,707.36	356,232.51	328,484.41	471,686.71	382,638.67	0.00	0.00	
3716	ADULT <40% EXP MAL E	6,263,512.29	5,519,096.64	5,963,654.37	5,617,859.72	5,103,187.41	5,865,815.73	5,260,885.56	5,564,589.85	7,170,460.98	6,272,902.30	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,575,464.37	3,382,124.05	3,905,064.56	3,334,687.58	3,112,141.29	3,454,030.29	2,921,366.47	3,025,328.09	3,911,175.05	3,249,720.06	0.00	0.00	
3718	ADULT <40% EXP M&F 4	7,929,765.21	6,957,856.36	8,103,595.28	7,102,447.58	7,155,297.54	7,897,153.90	6,795,102.61	7,287,355.11	9,074,210.18	8,179,989.70	0.00	0.00	
3719	ADULT <40% EXP M&F 6	3,910.92	3,664.70	41,258.90	8,231.44	11,930.57	8,451.44	7,806.99	6,003.97	2,472.38	4,222.04	0.00	0.00	
3726	ADULT <40% EXP MAL E	0.00	15.75	0.00	0.00	342.00	0.00	0.00	0.00	0.00	22.57	0.00	0.00	
3727	ADULT <40% EXP FEM AL	57.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,226.53	1,108.37	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	1,026.00	2,681.16	7,969.67	241.90	2,345.84	2,109.61	1,291.46	3,156.67	-612.45	0.00	0.00	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	177.00	0.00	0.00	0.00	0.00	0.00		177.00		
	20,863,498.73	18,991,478.51	21,575,506.02	19,207,914.01	18,324,271.37	20,646,194.83	17,792,602.26	19,036,716.45	24,397,807.97	21,463,942.24	0.00	0.00	202,299,932.39		

3906	NEWLY ELIGIBLE MALE	282.87	244.78	3,954.66	845.41	701.91	236.40	-321.76	0.00	144.81	0.00	0.00	0.00		6,089.08	
3907	NEWLY ELIGIBLE FEMA L	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	
3908	NEWLY ELIGIBLE M&F 4	36,628.12	26,922.19	16,205.75	17,898.74	3,618.14	12,067.32	9,886.14	4,162.18	5,037.36	6,309.84	0.00	0.00		138,735.78	
3909	NEWLY ELIGIBLE M&F 6	735.29	4,495.57	6,089.30	2,028.30	2,167.62	342.00	99.22	608.01	796.03	1,527.33	0.00	0.00		18,888.67	
3914	NEWLY ELIGIBLE MALE	4,432.09	7,350.77	4,425.47	2,808.00	1,742.16	2,107.98	5,666.67	4,937.79	11,670.48	6,062.76	0.00	0.00		51,204.17	
3915	NEWLY ELIGIBLE FEMA L	8,684.59	8,570.78	11,952.24	18,573.34	12,779.98	12,708.05	4,956.94	12,646.79	10,037.06	8,503.19	0.00	0.00		109,412.96	
3916	NEWLY ELIGIBLE MALE	190,656.56	140,972.52	172,124.15	179,726.97	158,777.12	227,695.34	231,625.27	346,555.06	351,022.51	249,169.80	0.00	0.00		2,248,325.30	
3917	NEWLY ELIGIBLE FEMA L	152,717.83	182,054.27	259,830.54	161,208.72	156,299.82	232,362.08	175,609.53	209,856.65	281,160.39	313,805.57	0.00	0.00		2,124,905.40	
3918	NEWLY ELIGIBLE M&F 4	668,831.27	599,382.33	855,754.73	702,966.02	618,574.51	782,636.29	588,211.52	862,113.03	1,062,862.35	1,066,609.94	0.00	0.00		7,807,941.99	
3919	NEWLY ELIGIBLE M&F 6	1,429.82	731.49	342.00	342.00	684.00	342.00	57.05	3,594.95	112.46	703.62	0.00	0.00		8,339.39	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	1,828.80	0.00	0.00	81.04	-50.26	12.33	0.00	0.00	0.00	0.00		1,871.91	
	1,065,235.26	970,724.70	1,334,263.95	1,086,739.50	955,345.26	1,273,063.52	1,015,740.32	1,444,486.79	1,722,843.45	1,652,692.05	0.00	0.00	12,521,134.80	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	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	
4413	SOBRA 100-133% M&F
6	235,987.47	238,080.25	286,276.53	229,804.63	264,183.88	304,736.60	169,207.95	219,567.51	298,907.04	230,387.61	0.00	0.00		2,477,139.47	
4414	SOBRA 100-133% MALE	85,340.26	87,080.59	94,321.88	83,076.40	84,875.99	136,385.23	81,546.19	82,459.59	84,081.31	104,967.08	0.00	0.00		924,134.52	
4415	SOBRA 100-133% FEM AL	113,390.65	105,222.91	136,439.88	96,722.72	157,919.51	127,832.08	102,743.98	166,855.22	126,623.19	119,021.88	0.00	0.00		1,252,772.02	
	439,695.94	432,777.75	518,755.86	410,971.75	508,005.38	569,295.91	353,498.12	468,882.32	509,611.54	454,376.57	0.00	0.00	4,665,871.14	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	2,688.00	342.00	0.00	1,026.00	5,195.38	2,564.21	11,685.00	34,409.00	1,789.19	0.00	0.00		59,698.78	
4518	BC PATIENT FEMALE 4 5	40,445.07	20,543.90	18,293.18	13,540.70	26,903.84	32,443.64	19,337.76	10,353.81	47,970.06	70,365.83	0.00	0.00		300,197.79	
4617	CC PATIENT FEMALE 2 1	2,736.00	0.00	469.34	442.17	0.00	0.00	0.00	0.00	0.00	2,604.96	0.00	0.00		6,252.47	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,381.31	1,392.00	0.00	0.00		2,773.31	
	43,181.07	23,231.90	19,104.52	13,982.87	27,929.84	37,639.02	21,901.97	22,038.81	83,760.37	76,151.98	0.00	0.00	368,922.35	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	3,947.35	5,987.91	4,342.90	1,505.21	2,846.98	2,695.31	1,033.09	3,119.13	7,924.56	2,123.51	0.00	0.00		35,525.95	
8710	SSI DISABLED FREEDO M	2,758.57	2,394.00	2,736.00	2,775.74	1,026.00	3,684.21	1,452.58	2,219.00	2,767.43	2,597.07	0.00	0.00		24,410.60	
8720	SSI DISABLED FREEDO M	266.39	131.57	188.92	230.40	600.19	313.77	88.11	283.41	342.09	473.77	0.00	0.00		2,918.62	
	6,972.31	8,513.48	7,267.82	4,511.35	4,473.17	6,693.29	2,573.78	5,621.54	11,034.08	5,194.35	0.00	0.00	62,855.17	

SUBTOTAL:

SUBTOTAL:

73,620,949.02	65,361,610.46	72,510,278.80	65,830,204.53	63,196,413.68	71,641,665.17	58,387,921.74	63,061,888.67	82,556,313.14	71,201,013.74	0.00	0.00	687,368,258.95	

TOTAL:

110.22	
268.01	
1,273.78	
1,403.35	
164.69	
13,353.78	
68,851.77	
254,439.55	
109,070.16	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 2015	
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	12.33	47.25	0.00	0.00		59.58		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	312.04	0.00	0.00	0.00	0.00	72.95	1,449.57	0.00	0.00		1,834.56		
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	136.65	466.48	1,065.20	0.00	0.00	0.00		2,188.77		
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	2,174.56	19,795.98	4,474.62	8,185.96	0.00	0.00		63,621.54		
1016	TANF 21-44 MALE NON-	2,387.41	9,567.79	17,302.15	13,267.56	35,827.77	20,290.01	15,549.60	32,058.55	27,696.29	25,909.37	0.00	0.00		199,856.50		
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	64,682.94	61,396.77	110,094.65	100,490.37	0.00	0.00		712,048.34		
1018	TANF 45-64 M & F NON	624.62	13,353.85	27,439.42	40,475.30	7,025.75	13,426.28	14,157.98	13,392.10	57,453.24	39,632.62	0.00	0.00		226,981.16		
2100	SSI AGED WITH MEDIC A	922.64	226.91	3,074.97	4,272.30	2,918.09	5,445.46	926.86	2,136.83	1,818.82	749.88	0.00	0.00		22,492.76		
2110	SSI AGED NON-MEDIC AR	3,789.39	1,046.16	4,455.25	5,266.94	3,072.79	6,876.52	11,272.65	11,329.21	18,478.10	22,481.72	0.00	0.00		88,068.73		
2120	SSI AGED WITH QMB	0.00	0.00	43.35	27.25	0.00	402.08	0.00	0.00	0.00	69.27	0.00	0.00		541.95		
2200	SSI DISABLED WITH M E	0.00	36.29	1,193.01	3,296.07	1,930.40	3,154.15	210.99	3,471.77	1,297.87	35.97	0.00	0.00		14,626.52		
2210	SSI DISABLED NON-ME D	4,511.70	7,150.54	20,268.15	15,221.00	9,243.14	31,138.01	7,916.38	21,094.52	39,360.25	18,663.45	0.00	0.00		174,567.14		
2220	SSI DISABLED WITH Q M	0.00	0.00	60.89	35.65	0.00	5.28	0.00	0.00	0.00	34.71	0.00	0.00		136.53		
4311	SOBRA CHILD <1 M & F	15,885.00	10,600.80	28,405.64	12,784.46	21,118.59	22,160.24	101,515.17	56,029.89	64,443.18	82,970.83	0.00	0.00		415,913.80		
4312	SOBRA CHILD 01-05 M	2,904.79	7,758.18	15,385.96	12,507.49	16,211.93	17,380.55	13,391.93	64,143.75	38,411.60	42,677.26	0.00	0.00		230,773.44		
4313	SOBRA CHILD 06-13 M	555.73	16,453.57	21,123.59	8,585.74	9,363.97	7,859.27	13,451.35	12,723.89	30,070.94	23,413.33	0.00	0.00		143,601.38		
4314	SOBRA CHILD 14-20 MA	617.95	3,921.06	15,040.43	9,192.10	37,618.64	5,635.75	15,901.43	10,423.34	29,706.53	14,883.66	0.00	0.00		142,940.89		
4315	SOBRA CHILD 14-20 FE	381.31	4,618.73	9,526.84	11,858.83	42,202.80	20,233.43	28,693.65	15,004.09	30,659.91	27,206.77	0.00	0.00		190,386.36		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	448.06	23.52	1,553.29	49.20	0.00	0.00	0.00		2,074.07		
5015	SOBRA PREG 14-20 FE M	1,449.77	842.30	13,180.05	7,897.65	6,334.28	10,134.33	22,457.88	7,696.23	10,277.95	14,039.65	0.00	0.00		94,310.09		
5017	SOBRA PREG 21-44 FE M	10,432.36	23,430.15	28,335.79	14,201.19	26,830.86	33,564.95	50,811.98	28,431.90	43,225.45	39,107.16	0.00	0.00		298,371.79		
5018	SOBRA PREG 45-64 FE M	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		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,234.74	2,303.02	0.00	0.00		13,537.76		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,805.27	135.83	0.00	0.00		9,941.10		
SUBTOTAL:	53,294.52	157,635.55	269,130.99	293,245.96	282,045.72	276,897.96	363,275.52	361,148.59	529,709.09	464,487.65	0.00	0.00	3,050,871.55		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110.22	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	268.01	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	1.85	0.00	50.13	1,203.84	17.96	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	634.57	450.34	318.44	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	164.69	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	5,776.18	9.61	70.12	586.16	1,322.96	-6.51	1,737.97	3,857.29	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	3,813.91	752.45	4,079.46	9,478.44	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	8,075.08	8,182.53	35,862.94	49,241.44	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	22,663.74	7,881.99	43,533.59	17,122.36	0.00	0.00	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED WI	21.47	5,168.71	2,839.31	9,171.19	7,188.90	5,595.18	9,999.20	12,892.81	8,921.38	6,169.02	0.00	0.00		67,967.17		
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	549.49	4,157.22	1,510.69	435.19	2,172.09	2,873.52	0.00	0.00		11,698.20		
2420	SSI AGED EXPANDED WI	73.59	17.48	29.02	715.75	860.83	451.42	285.55	321.46	225.92	117.44	0.00	0.00		3,098.46		
2600	SSI DISABLED EXPAND E	285.27	275.92	826.59	5,724.38	747.90	5,580.91	1,502.83	528.80	7,762.87	2,988.57	0.00	0.00		26,224.04		
2610	SSI DISABLED EXPAND E	0.00	985.61	2,246.18	2,538.65	2,363.17	946.53	3,989.66	15,029.64	22,774.00	3,164.40	0.00	0.00		54,037.84		
2620	SSI DISABLED EXPAND E	11.55	0.00	136.55	8.67	826.47	78.96	0.00	10.14	288.80	203.92	0.00	0.00		1,565.06		
	3,630.12	27,899.45	103,708.25	37,878.11	46,959.50	69,549.82	53,532.19	47,232.34	127,919.90	95,216.40	0.00	0.00	613,526.08		

3508	ADULT 40-100% M&F 45	0.00	0.00	451.74	365.75	0.00	0.00	0.00	2,190.74	1,679.09	0.00	0.00	0.00		4,687.32	
3514	ADULT 40-100% MALE
1	171.21	3,225.92	147.79	144.57	774.92	3,726.75	818.56	1,188.54	1,863.63	2,110.74	0.00	0.00		14,172.63	
3515	ADULT 40-100% FEMAL E	0.00	439.63	3,768.03	1,871.01	11,838.80	1,390.18	1,184.15	6,165.05	7,200.75	662.06	0.00	0.00		34,519.66	
3516	ADULT 40-100% MALE
2	247.60	2,157.04	12,408.98	7,765.36	20,089.45	11,926.07	11,135.28	32,096.33	19,938.50	30,159.31	0.00	0.00		147,923.92	
3517	ADULT 40-100% FEMAL E	1,176.50	5,293.82	12,225.76	5,188.29	13,161.94	14,278.15	13,786.20	9,867.13	19,395.57	27,860.82	0.00	0.00		122,234.18	
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	33,041.45	65,650.27	105,912.12	86,557.41	0.00	0.00		509,044.08	
3706	ADULT <40% EXP MAL E	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	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	1,145.05	101.93	0.00	1,092.47	0.00	0.00		2,339.45	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125.79	0.00	700.76	0.00	0.00		826.55	
3714	ADULT <40% EXP MAL E	0.00	1,327.29	1,482.68	10,022.27	7,462.66	6,584.44	23,787.04	9,491.16	31,570.99	30,996.95	0.00	0.00		122,725.48	
3715	ADULT <40% EXP FEM AL	376.67	4,178.34	3,217.57	14,484.38	9,919.13	11,695.72	7,004.36	11,457.41	15,453.34	10,559.18	0.00	0.00		88,346.10	
3716	ADULT <40% EXP MAL E	6,067.34	85,317.95	190,168.66	239,964.51	242,409.34	353,486.46	277,547.62	239,469.21	458,059.41	201,301.90	0.00	0.00		2,293,792.40	
3717	ADULT <40% EXP FEM AL	2,907.86	29,170.77	55,381.77	123,684.49	99,596.39	116,908.79	143,091.55	97,248.08	172,154.34	127,786.41	0.00	0.00		967,930.45	
3718	ADULT <40% EXP M&F 4	28,847.18	115,592.61	182,495.36	255,086.77	332,583.15	340,182.67	345,174.37	296,338.62	404,935.46	367,330.01	0.00	0.00		2,668,566.20	
	48,337.18	288,251.92	496,322.01	688,306.95	764,481.54	937,115.11	857,715.63	771,390.26	1,238,163.20	887,118.02	0.00	0.00	6,977,201.82	

SUBTOTAL:

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	1,148.98	122.98	0.00	0.00	0.00	0.00	0.00		1,271.96	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	69.43	0.00	38.20	0.00	0.00	0.00	0.00	0.00		107.63	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	659.08	1,208.21	0.00	812.47	1,300.68	1,208.50	0.00	0.00		5,188.94	
3915	NEWLY ELIGIBLE FEMA L	0.00	887.29	164.59	0.00	6,134.20	2,882.87	46.44	1,197.84	6,803.91	5,435.13	0.00	0.00		23,552.27	
3916	NEWLY ELIGIBLE MALE	2,219.12	5,544.41	9,292.86	24,648.69	7,777.48	24,322.11	23,401.04	26,014.01	53,676.65	29,778.17	0.00	0.00		206,674.54	
3917	NEWLY ELIGIBLE FEMA L	3,257.75	6,212.67	23,034.92	50,690.42	17,726.88	16,133.68	23,222.13	25,076.48	45,657.55	18,185.62	0.00	0.00		229,198.10	
3918	NEWLY ELIGIBLE M&F 4	3,025.43	23,641.19	61,731.84	40,358.62	28,980.47	45,443.97	30,183.77	36,282.20	132,081.88	55,495.21	0.00	0.00		457,224.58	
	8,502.30	36,285.56	94,224.21	115,697.73	61,347.54	91,139.82	77,014.56	89,383.00	239,520.67	110,102.63	0.00	0.00	923,218.02	

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	2,402.45	3,556.80	758.88	1,511.11	4,010.82	372.96	599.23	5,523.73	36,389.50	19,929.20	0.00	0.00		75,054.68	
4414	SOBRA 100-133% MALE	1,368.00	0.00	115.26	4,802.82	3,639.31	513.21	4,222.25	4,914.49	5,592.94	5,923.26	0.00	0.00		31,091.54	
4415	SOBRA 100-133% FEM AL	0.00	1,932.86	2,685.30	0.00	500.44	747.39	153.62	2,373.38	3,137.11	1,907.99	0.00	0.00		13,438.09	
	3,770.45	5,489.66	3,559.44	6,313.93	8,150.57	1,633.56	4,975.10	12,811.60	45,119.55	27,760.45	0.00	0.00	119,584.31	

SUBTOTAL:

SUBTOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8700	SSI DISABLED FREEDO M	217.38	148.32	34.58	47.33	0.00	218.10	2,479.33	0.00	230.54	15.75	0.00	0.00		3,391.33		
8710	SSI DISABLED FREEDO M	0.00	326.52	0.00	58.14	204.43	0.00	0.00	0.00	359.31	233.92	0.00	0.00		1,182.32		
	217.38	474.84	34.58	105.47	204.43	218.10	2,479.33	0.00	589.85	249.67	0.00	0.00	4,573.65		

SUBTOTAL:

TOTAL:	117,751.95	516,036.98	966,979.48	1,141,548.15	1,163,189.30	1,376,554.37	1,358,992.33	1,281,965.79	2,181,022.26	1,584,934.82	0.00	0.00	11,688,975.43		

SUBTOTAL:

FAMILY PLANNING SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	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 April 30, 2015	
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	90.78	0.00	-3,525.79	0.00	0.00	0.00		239.68		
1011	TANF <1 M & F NON-ME	926.83	0.00	0.00	0.00	0.00	0.00	0.00	29.79	11,402.23	1,189.02	0.00	0.00		13,547.87		
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	6,021.07	7,883.53	20,991.08	27,420.24	0.00	0.00		198,316.13		
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	61,989.10	43,490.27	42,154.81	47,743.39	0.00	0.00		445,682.10		
1014	TANF 14-20 MALE NON-	101,456.98	83,053.44	96,673.15	84,992.05	89,208.10	92,977.76	87,794.40	118,633.47	185,949.33	134,950.29	0.00	0.00		1,075,688.97		
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	455,044.45	323,439.71	537,746.60	387,029.94	0.00	0.00		4,499,711.08		
1016	TANF 21-44 MALE NON-	131,895.09	136,642.01	151,856.35	134,645.69	127,636.42	91,096.33	76,588.45	62,053.27	117,567.19	116,382.65	0.00	0.00		1,146,363.45		
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	3,189,412.46	2,223,998.39	2,720,809.81	2,824,915.10	0.00	0.00		30,091,814.06		
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	147,772.28	75,186.05	156,503.22	183,825.73	0.00	0.00		1,716,782.36		
1019	TANF 65+ M & F NON-M	1,367.38	50.36	3,006.83	0.00	-161.09	692.33	1,671.52	5,651.36	5,426.31	287.99	0.00	0.00		17,992.99		
2100	SSI AGED WITH MEDIC A	8,124.92	3,462.59	4,105.19	2,493.51	120.16	4,717.93	5,093.15	2,646.83	15,004.48	2,806.20	0.00	0.00		48,574.96		
2110	SSI AGED NON-MEDIC AR	686,565.89	486,327.79	526,332.11	560,946.82	537,125.71	526,717.30	609,611.84	609,458.13	791,049.41	734,726.95	0.00	0.00		6,068,861.95		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	715.17	0.00	83.78	432.05	0.00	0.00		1,231.00		
2200	SSI DISABLED WITH M E	28,071.60	29,258.47	34,565.50	45,650.11	17,524.46	25,593.27	26,472.29	21,415.87	46,024.78	46,388.49	0.00	0.00		320,964.84		
2210	SSI DISABLED NON-ME D	811,372.82	739,101.65	783,464.79	843,599.64	701,699.32	729,302.07	621,722.56	636,064.72	950,296.19	947,496.29	0.00	0.00		7,764,120.05		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	47.95	703.80	0.00	0.00	0.00	0.00	0.00		751.75		
2310	SSI BLIND NON-MEDIC A	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		
	6,645,181.08	5,482,310.95	6,208,134.21	4,523,950.45	5,454,737.92	4,624,811.69	5,290,703.32	4,129,951.39	5,597,483.43	5,455,594.33	0.00	0.00	53,412,858.77		

1106	TANF EXPANDED 21-44	1,613.67	653.56	4,201.04	932.00	6,011.41	4,346.63	5,317.22	3,730.76	3,939.98	4,993.47	0.00	0.00		35,739.74	
1107	TANF EXPANDED 21-44	81.76	74.69	768.84	1,261.10	610.94	1,300.30	861.41	0.00	1,450.41	713.85	0.00	0.00		7,123.30	
1108	TANF EXPANDED 45-64	1,746.90	240.92	1,203.84	0.00	826.52	1,221.91	1,204.03	1,167.74	2,264.04	3,933.80	0.00	0.00		13,809.70	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	183.54	0.00	0.00	0.00		183.54	
1113	TANF EXPANDED 06-13	0.00	5.83	5.83	370.29	228.11	0.00	326.92	189.89	0.00	55.65	0.00	0.00		1,182.52	
1114	TANF EXPANDED 14-20	34.97	2,450.74	93.40	72.00	5,093.00	547.20	76.12	661.91	545.08	233.77	0.00	0.00		9,808.19	
1115	TANF EXPANDED 14-20	11,771.70	25,932.07	7,814.64	9,083.11	10,651.78	13,124.73	4,748.75	12,070.86	8,824.05	10,683.34	0.00	0.00		114,705.03	
1116	TANF EXPANDED 21-44	358,572.55	390,495.13	377,975.49	320,628.22	336,243.28	391,983.27	469,037.82	268,191.02	170,070.16	634,566.00	0.00	0.00		3,717,762.94	
1117	TANF EXPANDED 21-44	758,042.25	533,723.61	653,487.41	502,738.23	544,247.18	511,021.63	541,118.75	423,711.73	688,128.43	775,580.88	0.00	0.00		5,931,800.10	
1118	TANF EXPANDED 45-64	283,242.10	270,641.84	259,763.19	165,989.07	242,889.62	239,410.69	190,769.52	151,617.15	259,013.67	265,945.94	0.00	0.00		2,329,282.79	
1119	TANF EXPANDED 65+
M&	214.96	7.57	2,777.49	1,386.84	1,163.27	5,059.60	-47.05	3,678.59	3,857.01	2,360.05	0.00	0.00		20,458.33	
2400	SSI AGED EXPANDED WI	0.00	72.72	0.00	672.78	204.43	798.70	272.80	2,008.30	1,219.05	2,242.77	0.00	0.00		7,491.55	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	823.73	10,080.28	4,664.21	40,027.62	70,922.27	44,300.28	81,178.66	0.00	0.00		251,997.05	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	3,206.17	0.00	0.00	4,235.46	1.85	3,441.15	2,351.85	0.00	0.00		13,236.48	
2610	SSI DISABLED EXPAND E	2,523.41	-12.00	0.00	9,480.23	4,291.44	7,852.30	18,419.50	12,031.61	16,587.18	36,168.60	0.00	0.00		107,342.27	
	1,417,844.27	1,224,286.68	1,308,091.17	1,016,643.77	1,162,541.26	1,181,331.17	1,276,368.87	949,983.68	1,203,824.03	1,821,008.63	0.00	0.00	12,561,923.53	

SUBTOTAL:

SUBTOTAL:

3514	ADULT 40-100% MALE
1	1,415.88	1,411.95	0.00	-1,562.84	-142.77	-93.40	-1,175.78	0.00	0.00	0.00	0.00	0.00	

-146.96

FEDERAL EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3515	ADULT 40-100% FEMAL E	2,289.04	578.80	0.00	-10,263.12	0.00	-683.25	-3,620.01	0.00	0.00	0.00	0.00	0.00		-11,698.54		
3516	ADULT 40-100% MALE
2	89,472.61	22,341.03	-2,887.03	-68,913.35	-13,282.13	-7,310.29	-53,487.10	0.00	-163.66	-240.92	0.00	0.00		-34,470.84		
3517	ADULT 40-100% FEMAL E	14,241.72	16,722.07	0.00	-17,419.95	-4,549.21	-8,769.93	-22,063.57	0.00	-5,468.51	0.00	0.00	0.00		-27,307.38		
3518	ADULT 40-100% M&F 45	105,362.43	111,303.89	-865.58	-207,554.32	-34,663.95	-57,332.76	-87,621.09	-7,778.36	0.00	0.00	0.00	0.00		-179,149.74		
3707	ADULT <40% EXP FEM AL	777.07	47.95	0.00	0.00	-95.90	0.00	-729.12	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MAL E	11,927.67	105,433.15	-536.88	-44,480.41	-2,343.54	-74,466.08	-39,062.24	0.00	0.00	0.00	0.00	0.00		-43,528.33		
3715	ADULT <40% EXP FEM AL	10,875.16	21,482.86	0.00	-14,142.67	-14,558.95	-13,216.50	-16,472.19	0.00	0.00	0.00	0.00	0.00		-26,032.29		
3716	ADULT <40% EXP MAL E	331,193.61	259,868.44	-2,536.72	-383,740.56	-44,770.42	-125,417.31	-351,338.15	-73,086.70	0.00	0.00	0.00	0.00		-389,827.81		
3717	ADULT <40% EXP FEM AL	54,689.87	132,072.18	-12,698.30	-115,825.12	-56,903.90	-24,554.58	-68,204.03	-6,998.88	0.00	0.00	0.00	0.00		-98,422.76		
3718	ADULT <40% EXP M&F 4	516,687.58	466,084.08	-18,915.90	-824,729.77	-71,025.11	-124,302.94	-645,762.27	-163,110.97	-3,432.44	0.00	0.00	0.00		-868,507.74		
3719	ADULT <40% EXP M&F 6	1,353.93	3,879.07	0.00	-6,171.01	-459.02	-793.05	-9,192.41	0.00	0.00	-240.92	0.00	0.00		-11,623.41		
	1,140,286.57	1,141,225.47	-38,440.41	-1,694,803.12	-242,794.90	-436,940.09	-1,298,727.96	-250,974.91	-9,064.61	-481.84	0.00	0.00	-1,690,715.80		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.74	0.00	0.00		14.74	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	749.65	0.00	-47.95	0.00	-701.70	0.00	0.00	0.00	0.00	0.00		0.00	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	21.42	693.71	752.34	1,847.89	269.00	3,171.65	3,159.66	0.00	0.00		9,915.67	
3914	NEWLY ELIGIBLE MALE	270.58	862.62	64,766.14	58,834.17	51,644.05	88,086.88	41,200.58	46,121.33	32,113.51	20,442.56	0.00	0.00		404,342.42	
3915	NEWLY ELIGIBLE FEMA L	700.41	7.57	2,697.89	32,902.85	29,592.58	27,009.85	29,891.05	10,850.81	14,235.93	27,610.31	0.00	0.00		175,499.25	
3916	NEWLY ELIGIBLE MALE	68,081.76	19,874.30	250,395.78	840,040.37	363,819.59	454,948.85	622,188.14	293,345.94	785,156.82	440,668.70	0.00	0.00		4,138,520.25	
3917	NEWLY ELIGIBLE FEMA L	19,080.23	35,620.91	121,474.29	390,053.08	186,749.25	174,831.75	212,975.72	186,116.71	284,384.30	192,376.31	0.00	0.00		1,803,662.55	
3918	NEWLY ELIGIBLE M&F 4	46,459.07	34,571.04	819,625.84	1,521,424.01	640,984.14	1,015,084.30	1,332,463.36	680,017.19	1,072,694.56	950,421.77	0.00	0.00		8,113,745.28	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	2,058.48	33,555.09	9,020.88	8,034.89	17,067.18	11,491.88	50,261.19	-1,269.09	0.00	0.00		130,220.50	
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	730.36	228.09	47.95	2,206.96	729.12	759.55	709.50	0.00	0.00		5,411.53	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	451.59	1,066.29	1,324.04	0.00	0.00		2,841.92	
	134,592.05	90,936.44	1,261,768.07	2,877,561.35	1,282,684.34	1,768,796.81	2,259,139.18	1,229,393.57	2,243,843.80	1,635,458.50	0.00	0.00	14,784,174.11	

SUBTOTAL:

SUBTOTAL:

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	7,527,483.41	6,058,353.73	9,036,086.65	8,911,579.62	0.00	0.00	79,068,240.61		

SUBTOTAL:

FEDERAL ESP CHRONIC SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	605.12	0.00	0.00	0.00		605.12		
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		
	0.00	0.00	0.00	865.99	-865.99	0.00	0.00	0.00	605.12	0.00	0.00	0.00	605.12		

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	
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.	

2,971.56

0.00	3,837.55	-865.99	0.00	0.00	0.00	605.12	0.00	0.00	0.00	3,576.68	

00	2,971.56

TOTAL:

0.00

0.00

QMB - FEE FOR SERVICE

For The Period Ending April 30, 2015	
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	333,888.22	319,483.77	385,652.22	229,556.92	0.00	0.00		2,785,892.32		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	613.83	0.00	0.00	0.00		613.83		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.46	0.00	0.00	0.00		24.46		
	227,508.42	323,661.58	198,990.91	336,157.76	204,441.28	226,551.24	333,888.22	319,483.77	386,290.51	229,556.92	0.00	0.00	2,786,530.61		

SUBTOTAL:

TOTAL:	227,508.42	323,661.58	198,990.91	336,157.76	204,441.28	226,551.24	333,888.22	319,483.77	386,290.51	229,556.92	0.00	0.00	2,786,530.61		

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,368.55	0.00	0.00	0.00		3,368.55	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	764.04	0.00	0.00	6,519.29	0.00	0.00	0.00		7,283.33	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	34.97	0.00	0.00	0.00	0.00	0.00		34.97	
	0.00	0.00	0.00	0.00	0.00	764.04	34.97	0.00	9,887.84	0.00	0.00	0.00	10,686.85	

SUBTOTAL:

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	1,750.41	0.00	7,007.66	0.00	0.00	0.00	347.16	0.00	955.38	0.00	0.00	0.00		10,060.61		
2100	SSI AGED WITH MEDIC A	44,497.58	8,807.48	14,389.41	100,947.49	9,925.17	48,431.00	70,303.59	17,974.68	56,048.85	31,332.67	0.00	0.00		402,657.92		
2110	SSI AGED NON-MEDIC AR	73,301.36	82,631.11	79,441.64	159,588.26	151,232.95	36,892.25	18,786.53	49,846.74	84,953.82	70,346.65	0.00	0.00		807,021.31		
2120	SSI AGED WITH QMB	13,915.92	7,995.79	8,126.46	75,732.32	2,333.40	2,031.15	15,769.22	7,615.20	15,762.80	0.00	0.00	0.00		149,282.26		
2200	SSI DISABLED WITH M E	4,073.14	0.00	519.72	388.90	9.61	636.26	33.80	1,840.03	777.77	20,676.81	0.00	0.00		28,956.04		
2210	SSI DISABLED NON-ME D	0.00	1,038.51	808.37	14,554.04	2,640.66	16,172.13	8,250.49	3,651.79	102.14	109.21	0.00	0.00		47,327.34		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	6,704.90	1,289.67	10,932.37	16,792.07	0.00	0.00		35,719.01		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,404.96	0.00	0.00	0.00	0.00		1,404.96		
5017	SOBRA PREG 21-44 FE M	1,975.23	16,840.57	8,486.35	5,052.05	6,307.10	5,854.20	0.00	0.00	0.00	360.10	0.00	0.00		44,875.60		
	139,513.64	117,313.46	118,779.61	356,263.06	172,448.89	110,016.99	120,195.69	83,623.07	169,533.13	139,617.51	0.00	0.00	1,527,305.05		

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	-165.70	0.00	0.00	0.00		-165.70	
	0.00	0.00	0.00	-59,680.05	0.00	0.00	0.00	0.00	-165.70	0.00	0.00	0.00	-59,845.75	

SUBTOTAL:

3516	ADULT 40-100% MALE
2	0.00	174.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,013.18	0.00	0.00		1,188.14	
3518	ADULT 40-100% M&F 45	172.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172.49	
3706	ADULT <40% EXP MAL E	17,224.61	10,190.95	16,468.17	9,132.98	3,439.72	2,236.30	9,078.33	15,067.33	5,455.77	6,308.88	0.00	0.00		94,603.04	
3707	ADULT <40% EXP FEM AL	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	
3708	ADULT <40% EXP M&F 4	28,660.93	43,321.56	11,908.91	-426.94	1,269.10	7,305.58	14,339.39	84,347.92	6,128.70	3,423.75	0.00	0.00		200,278.90	
3714	ADULT <40% EXP MAL E	821.12	634.83	374.49	721.28	0.00	0.00	2,535.24	114.36	0.00	0.00	0.00	0.00		5,201.32	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	5,052.05	0.00	0.00	0.00	0.00	0.00		5,052.05	
3716	ADULT <40% EXP MAL E	239,576.63	251,224.77	186,647.70	203,044.50	79,944.10	302,120.33	100,005.11	104,988.82	204,276.97	291,034.39	0.00	0.00		1,962,863.32	
3717	ADULT <40% EXP FEM AL	6,841.48	3,338.30	14,739.60	22,819.43	2,293.72	21,464.58	4,419.14	3,697.07	5,941.47	2,262.80	0.00	0.00		87,817.59	
3718	ADULT <40% EXP M&F 4	193,944.21	209,147.18	241,670.75	448,656.73	194,257.48	232,053.95	276,700.23	242,912.22	323,198.76	343,156.89	0.00	0.00		2,705,698.40	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	468.00	1,743.15	0.00	0.00		2,211.15	
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	17,696.35	0.00	0.00		17,696.35	
	487,477.64	518,148.69	471,809.62	683,947.98	281,204.12	565,180.74	412,129.49	451,127.72	545,469.67	666,639.39	0.00	0.00	5,083,135.06	

SUBTOTAL:

2,736.73	
136,131.43	
360.10	
58,410.35	

SUBTOTAL:

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	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	21,268.71	5,903.84	68,757.94	6,597.41	3,436.13	855.47	17,241.06	12,070.87	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	360.10	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	1,987.81	-428.11	0.00	728.20	5,809.25	14,832.22	28,247.21	7,233.77	0.00	0.00	

SUBTOTAL:

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	23,256.52	5,475.73	68,757.94	10,062.34	9,605.48	15,687.69	45,488.27	19,304.64	0.00	0.00	197,638.61		

626,991.28	635,462.15	613,845.75	986,006.72	522,410.95	686,024.11	541,965.63	550,438.48	770,213.21	825,561.54	0.00	0.00	6,758,919.82	

TOTAL:

COCHISE COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,020.01	0.00	0.00	0.00		2,020.01		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,020.01	0.00	0.00	0.00	2,020.01		

SUBTOTAL:

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,020.01	0.00	0.00	0.00	2,020.01		

3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,199.72	0.00	0.00		3,199.72	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	7,648.95	104.68	757.71	6,877.39	0.00	0.00		15,388.73	
	0.00	0.00	0.00	0.00	0.00	0.00	7,648.95	104.68	757.71	10,077.11	0.00	0.00	18,588.45	

SUBTOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2200	SSI DISABLED WITH M E	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		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	2,622.96	0.00	0.00	0.00	849.51	0.00	0.00		3,472.47		
	0.00	0.00	5,262.44	177.08	7.00	2,622.96	0.00	0.00	0.00	849.51	0.00	0.00	8,918.99		

SUBTOTAL:

0.00	0.00	5,262.44	177.08	7.00	2,622.96	7,648.95	104.68	757.71	10,926.62	0.00	0.00	27,507.44	

TOTAL:

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,193.70	0.00	0.00	0.00		7,193.70	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	590.17	0.00	4,080.16	0.00	0.00	0.00	0.00	0.00		4,670.33	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	1,490.40	571.12	2,471.90	41.48	1,685.01	1,483.27	4,470.49	0.00	0.00		12,213.67	
	0.00	0.00	0.00	1,490.40	1,161.29	2,471.90	4,121.64	1,685.01	8,676.97	4,470.49	0.00	0.00	24,077.70	

SUBTOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
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	34.38	0.00	0.00	0.00	0.00	0.00		2,074.61		
1016	TANF 21-44 MALE NON-	0.00	0.00	1,290.19	0.00	0.00	250.64	12,240.47	0.00	2,807.45	4,039.06	0.00	0.00		20,627.81		
1017	TANF 21-44 FEMALE N O	0.00	0.00	351.85	1,661.98	813.37	32.27	0.00	0.00	15,274.93	973.67	0.00	0.00		19,108.07		
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		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	53.73	334.01	0.00	0.00	0.00	0.00		387.74		
2200	SSI DISABLED WITH M E	3,365.09	0.00	417.09	744.21	0.00	0.00	3,635.30	20.39	0.00	20.74	0.00	0.00		8,202.82		
2210	SSI DISABLED NON-ME D	0.00	0.00	4,190.71	2,375.47	7,477.28	21,506.83	6,297.77	4,670.49	71,220.97	10,381.76	0.00	0.00		128,121.28		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	88.36	218.27	30.96	99.62	0.00	1,069.67	1,032.62	0.00	0.00		2,539.50		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	607.93	0.00	5,100.20	0.00	0.00	0.00	0.00	0.00		5,708.13		
5015	SOBRA PREG 14-20 FE M	235.45	0.00	0.00	2,561.94	0.00	0.00	280.36	0.00	3,019.72	0.00	0.00	0.00		6,097.47		
5017	SOBRA PREG 21-44 FE M	1,433.60	2,561.94	4,466.26	1,855.40	6,284.34	9,372.17	13,650.19	360.10	12,240.96	3,829.12	0.00	0.00		56,054.08		
	5,034.14	2,561.94	11,151.49	9,287.36	15,401.19	35,252.98	41,392.02	5,384.99	105,633.70	20,276.97	0.00	0.00	251,376.78		

SUBTOTAL:

3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	3,536.84	79.49	0.00	18,723.18	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	2,764.06	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	429.04	0.00	0.00	0.00	0.00	8,294.93	0.00	0.00	66.46	0.00	0.00	
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	570.20	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.37	279.58	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	33,401.37	0.00	0.00	
3716	ADULT <40% EXP MAL E	8,220.27	3,894.04	23,019.10	13,678.57	31,422.79	86,232.82	38,064.80	7,944.97	55,328.71	48,264.99	0.00	0.00	
3717	ADULT <40% EXP FEM AL	4,470.06	0.00	69.43	2,092.40	2,806.07	19,138.49	4,037.92	310.22	24,767.68	11,828.30	0.00	0.00	
3718	ADULT <40% EXP M&F 4	398.58	2,007.44	560.46	4,482.41	29,462.98	19,974.03	69,787.28	6,533.27	36,047.88	48,078.31	0.00	0.00	
SUBTOTAL:	13,088.91	6,330.52	23,648.99	20,638.66	67,228.68	125,424.83	120,184.93	33,511.64	116,151.64	145,253.27	0.00	0.	

22,339.51	
2,764.06	
8,790.43	
955.48	
286.95	
33,401.37	
316,071.06	
69,520.57	
217,332.64	
671,462.07	

00

TOTAL:	18,123.05	8,892.46	34,800.48	31,416.42	83,791.16	163,149.71	165,698.59	40,581.64	230,462.31	170,000.73	0.00	0.00	946,916.55		

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	1,471.06	0.00	0.00	0.00	6,228.08	0.00	0.00	0.00		7,699.14	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	811.07	-128.00	0.00	0.00	0.00	0.00		683.07	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	1,958.42	969.97	269.80	0.00	0.00	0.00	0.00	0.00		3,198.19	
	0.00	0.00	0.00	0.00	3,429.48	969.97	1,080.87	-128.00	6,228.08	0.00	0.00	0.00	11,580.40	

SUBTOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	443.20	0.00	0.00	0.00	1,999.89	3,098.74	13,814.90	0.00	5,313.81	0.00	0.00	0.00		24,670.54		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	233.09	0.00	0.00	0.00	0.00		233.09		
2200	SSI DISABLED WITH M E	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		
2210	SSI DISABLED NON-ME D	0.00	2,281.13	549.96	170.77	0.00	176.90	2,026.35	0.00	4,623.98	0.00	0.00	0.00		9,829.09		
2220	SSI DISABLED WITH Q M	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	293.85	6,564.29	12,457.19	1,872.28	0.00	0.00		23,296.82		
5017	SOBRA PREG 21-44 FE M	6,591.20	3,917.51	1,120.00	0.00	4,754.81	1,080.75	470.90	4,271.86	9,923.95	470.90	0.00	0.00		32,601.88		
	7,294.04	6,198.64	3,723.92	753.54	6,754.70	8,059.32	16,606.00	11,069.24	32,318.93	2,343.18	0.00	0.00	95,121.51		

SUBTOTAL:

3716	ADULT <40% EXP MAL E	2,763.39	17,422.92	0.00	0.00	860.29	0.00	3,443.63	5,065.88	4,225.13	3,138.08	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.88	0.00	470.07	0.00	0.00	
3718	ADULT <40% EXP M&F 4	1,679.53	17,584.14	0.00	0.00	0.00	114.76	430.37	2,026.35	0.00	4,134.58	0.00	0.00	
SUBTOTAL:	4,442.92	35,007.06	0.00	0.00	860.29	114.76	3,874.00	7,341.11	4,225.13	7,742.73	0.00	0.	

36,919.32	
718.95	
25,969.73	
63,608.00	

00

11,736.96	41,205.70	3,723.92	753.54	11,044.47	9,144.05	21,560.87	18,282.35	42,772.14	10,085.91	0.00	0.00	170,309.91	

TOTAL:

2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	3,093.20	547.38	0.00	0.00	0.00	0.00	0.00		3,640.58	
2600	SSI DISABLED EXPAND E	2,451.81	8,946.30	2,253.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,651.35	
	2,451.81	8,946.30	2,253.24	0.00	0.00	3,093.20	547.38	0.00	0.00	0.00	0.00	0.00	17,291.93	

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
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	279.25	0.00	0.00	0.00	0.00	0.00		910.62		
1017	TANF 21-44 FEMALE N O	0.00	147.09	15,987.28	0.00	0.00	9.61	221.60	0.00	0.00	0.00	0.00	0.00		16,365.58		
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	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		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	3,335.39	0.00	0.00	0.00	0.00	3,324.55	0.00	0.00		6,659.94		
SUBTOTAL:	1,230.46	2,047.98	18,367.94	480.81	3,909.53	337.56	500.85	0.00	0.00	3,324.55	0.00	0.00	30,199.68		

SUBTOTAL:

3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	1,593.96	0.00	0.00	1,296.81	0.00	0.00	0.00	0.00	0.00		2,890.77	
3716	ADULT <40% EXP MAL E	69,885.82	4,424.13	2,585.73	22,219.69	3,665.16	0.00	1,008.91	10,105.39	0.00	988.29	0.00	0.00		114,883.12	
3717	ADULT <40% EXP FEM AL	416.43	377.59	585.05	327.95	3,373.41	0.00	2,896.31	211.64	4,420.04	0.00	0.00	0.00		12,608.42	
3718	ADULT <40% EXP M&F 4	10,106.81	34,737.21	3,139.28	9,368.47	166.89	2,563.48	5,255.21	6,001.58	0.00	5,113.59	0.00	0.00		76,452.52	
SUBTOTAL:	80,409.06	39,538.93	6,310.06	33,510.07	7,205.46	2,563.48	10,457.24	16,318.61	4,420.04	6,101.88	0.00	0.00	206,834.83	

TOTAL:	84,091.33	50,533.21	26,931.24	33,990.88	11,114.99	5,994.24	11,505.47	16,318.61	4,420.04	9,426.43	0.00	0.00	254,326.44		

SUBTOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.22	0.00	0.00		259.22		
3717	ADULT <40% EXP FEM AL	0.00	0.00	277.25	0.00	0.00	0.00	0.00	0.00	0.00	1,617.26	0.00	0.00		1,894.51		
	0.00	0.00	277.25	0.00	0.00	0.00	0.00	0.00	0.00	1,876.48	0.00	0.00	2,153.73		

0.00	0.00	277.25	0.00	0.00	0.00	0.00	0.00	0.00	1,876.48	0.00	0.00	2,153.73	

TOTAL:

8710	SSI DISABLED FREEDO M	0.00	4,587.51	2,336.85	2,296.32	2,122.56	0.00	4,582.80	1,656.24	1,955.88	2,058.24	0.00	0.00		21,596.40	
8720	SSI DISABLED FREEDO M	2,742.24	2,647.68	2,966.82	2,957.30	3,061.20	3,376.80	1,688.40	506.52	1,242.18	2,990.88	0.00	0.00		24,180.02	
	2,742.24	7,235.19	5,303.67	5,253.62	5,183.76	3,376.80	6,271.20	2,162.76	3,198.06	5,049.12	0.00	0.00	45,776.42	

SUBTOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD

For The Period Ending April 30, 2015	
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	48.60	0.00	684.00	684.00	0.00	0.00		7,974.56		
2100	SSI AGED WITH MEDIC A	2,949,233.74	2,553,248.28	2,547,707.72	2,744,556.33	2,405,191.82	2,784,284.23	2,392,209.29	2,290,987.78	3,236,280.08	2,470,227.29	0.00	0.00		26,373,926.56		
2110	SSI AGED NON-MEDIC AR	257,831.11	199,089.40	169,264.15	223,213.39	181,007.22	225,151.12	201,815.22	195,728.63	256,669.51	127,399.06	0.00	0.00		2,037,168.81		
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	2,955,925.96	3,063,710.31	3,610,854.02	3,106,160.55	0.00	0.00		31,988,057.87		
2200	SSI DISABLED WITH M E	523,308.04	521,024.91	487,724.77	554,282.95	462,207.52	564,753.44	434,338.67	489,011.92	539,465.71	501,804.43	0.00	0.00		5,077,922.36		
2210	SSI DISABLED NON-ME D	2,765,516.29	2,446,767.02	2,597,908.87	2,501,535.56	2,407,162.22	2,908,436.23	2,418,562.52	2,223,586.20	3,469,971.46	2,886,989.27	0.00	0.00		26,626,435.64		
2220	SSI DISABLED WITH Q M	753,716.70	682,052.47	662,908.96	785,228.13	684,943.10	764,049.01	676,618.50	637,727.30	784,897.53	626,445.76	0.00	0.00		7,058,587.46		
2300	SSI BLIND WITH MEDIC	406.36	101.07	204.74	-96.39	265.35	0.00	94.15	197.19	2,494.65	0.00	0.00	0.00		3,667.12		
2310	SSI BLIND NON-MEDIC A	19,566.98	22,981.57	20,585.98	14,407.35	22,039.39	20,409.60	25,779.80	17,665.86	15,478.07	20,492.57	0.00	0.00		199,407.17		
2320	SSI BLIND WITH QMB	8,634.19	8,670.31	5,363.33	10,825.38	7,786.37	6,206.17	7,701.17	6,006.31	8,256.34	8,756.47	0.00	0.00		78,206.04		
	10,674,444.22	9,396,118.45	9,491,866.15	10,312,742.38	9,245,674.28	10,618,781.96	9,113,093.88	8,924,621.50	11,925,051.37	9,748,959.40	0.00	0.00	99,451,353.59		

SUBTOTAL:

TOTAL:	10,677,186.46	9,403,353.64	9,497,169.82	10,317,996.00	9,250,858.04	10,622,158.76	9,119,365.08	8,926,784.26	11,928,249.43	9,754,008.52	0.00	0.00	99,497,130.01		

SUBTOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	10,604.85	6,556.27	4,904.83	21,431.27	21,860.24	23,681.17	18,407.87	18,612.45	18,472.89	9,720.21	0.00	0.00		154,252.05		
2110	SSI AGED NON-MEDIC AR	0.00	3,762.00	679.61	0.00	0.00	2,533.71	6,727.94	44,406.20	0.00	0.00	0.00	0.00		58,109.46		
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	909.00	1,038.77	2,561.60	-47.66	257.00	552.69	473.89	2,228.61	1,002.65	2,281.95	0.00	0.00		11,258.50		
2210	SSI DISABLED NON-ME D	14,258.99	13,715.98	2,327.42	9,892.81	28,252.23	2,844.75	2,417.58	3,773.05	2,260.13	66,847.08	0.00	0.00		146,590.02		
2220	SSI DISABLED WITH Q M	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		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	169.45	50.00	0.00	0.00	0.00	247.71	0.00	0.00	0.00		467.16		
	26,197.25	25,829.67	11,048.46	31,445.87	50,419.47	30,113.37	28,027.28	69,020.31	21,983.38	78,849.24	0.00	0.00	372,934.30		

26,197.25	25,829.67	11,048.46	31,445.87	50,419.47	30,113.37	28,027.28	69,020.31	21,983.38	78,849.24	0.00	0.00	372,934.30	

TOTAL:

1112	TANF EXPANDED 01-05	579.40	170.25	323.23	716.42	325.87	625.38	560.85	740.44	1,287.40	544.87	0.00	0.00		5,874.11	
1113	TANF EXPANDED 06-13	2,647.22	1,130.45	1,072.47	2,889.46	2,761.88	3,345.11	4,301.59	3,797.62	5,155.44	3,742.48	0.00	0.00		30,843.72	
1114	TANF EXPANDED 14-20	454.98	239.78	28.68	176.36	302.79	298.73	66.04	200.51	322.03	261.16	0.00	0.00		2,351.06	
1115	TANF EXPANDED 14-20	332.61	217.88	0.00	123.15	178.38	47.48	5.48	134.68	159.84	64.17	0.00	0.00		1,263.67	
2610	SSI DISABLED EXPAND E	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	4,933.96	4,873.25	6,924.71	4,612.68	0.00	0.00	40,702.62	

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending April 30, 2015	
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	44,538.90	73,532.97	105,067.05	62,951.85	0.00	0.00		580,889.08		
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	116,681.68	145,174.77	212,339.44	136,623.66	0.00	0.00		1,206,256.74		
1014	TANF 14-20 MALE NON-	9,642.30	4,300.62	5,068.51	9,775.48	12,866.13	9,766.78	8,635.62	13,492.75	19,532.41	11,532.99	0.00	0.00		104,613.59		
1015	TANF 14-20 FEMALE N O	5,937.29	1,659.32	2,048.84	3,615.92	5,239.75	3,650.77	4,231.37	3,983.31	6,935.29	4,783.37	0.00	0.00		42,085.23		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	80.28	265.75	191.53	0.00	0.00	0.00		537.56		
2210	SSI DISABLED NON-ME D	285,353.96	141,414.07	121,637.11	157,813.34	213,277.49	206,317.70	199,567.39	241,291.52	360,742.54	260,006.05	0.00	0.00		2,187,421.17		
2220	SSI DISABLED WITH Q M	-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	116.85	296.21	420.93	166.75	0.00	0.00		1,718.06		
2310	SSI BLIND NON-MEDIC A	1,150.83	776.30	790.05	1,583.20	1,457.92	1,381.84	2,038.74	1,547.96	3,445.44	1,376.89	0.00	0.00		15,549.17		
4305	SOBRA CHILD 14-20 FE	125.02	0.00	0.00	0.00	7.97	0.00	16.10	35.45	0.00	35.79	0.00	0.00		220.33		
4312	SOBRA CHILD 01-05 M	85,612.86	51,376.50	33,585.46	58,256.39	67,044.94	61,691.24	55,856.22	89,259.82	128,449.86	85,488.56	0.00	0.00		716,621.85		
4313	SOBRA CHILD 06-13 M	125,563.85	40,259.17	40,961.40	104,479.42	103,459.44	100,930.99	94,592.05	132,652.38	220,021.35	146,195.59	0.00	0.00		1,109,115.64		
4314	SOBRA CHILD 14-20 MA	8,367.62	3,051.25	3,874.19	6,993.04	9,561.27	7,347.82	8,750.39	8,678.91	16,214.88	11,143.99	0.00	0.00		83,983.36		
4315	SOBRA CHILD 14-20 FE	4,600.75	1,396.66	1,644.07	4,087.51	4,202.74	4,302.21	3,282.55	4,979.66	9,843.77	6,373.27	0.00	0.00		44,713.19		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	102.54	0.00	82.20	0.00	21.90	64.83	6.43	24.29	0.00	0.00		302.19		
SUBTOTAL:	752,725.57	338,135.09	284,642.09	501,123.06	590,395.05	563,409.39	538,410.04	715,256.29	1,083,210.92	726,703.05	0.00	0.00	6,094,010.55		

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	
SUBTOTAL:	-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	

SUBTOTAL:

3514	ADULT 40-100% MALE
1	155.62	48.90	0.00	0.00	0.00	0.00	0.00	0.00	54.68	82.02	0.00	0.00		341.22	
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	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.78	0.00	0.00	0.00		23.78	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.05	0.00	0.00	0.00	0.00		13.05	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.05	65.47	0.00	0.00	0.00		78.52	
3714	ADULT <40% EXP MAL E	476.23	94.36	149.28	281.22	863.97	184.08	584.52	411.25	1,599.79	1,654.50	0.00	0.00		6,299.20	
3715	ADULT <40% EXP FEM AL	271.22	13.06	39.15	258.50	195.25	170.26	275.11	158.80	381.31	568.02	0.00	0.00		2,330.68	
	956.67	156.32	188.43	539.72	1,076.50	354.34	859.63	596.15	2,125.03	2,304.54	0.00	0.00	9,157.33	

3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270.72	75.04	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270.72	75.04	0.00	0.	

345.76

00	345.76

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4412	SOBRA 100-133% M&F
1	35.71	0.00	0.00	177.55	0.00	0.00	0.00	0.00	0.00	43.80	0.00	0.00		257.06		
4413	SOBRA 100-133% M&F
6	18,746.09	7,134.23	6,336.04	15,638.70	15,231.03	12,082.98	12,523.69	17,191.93	31,491.17	22,279.52	0.00	0.00		158,655.38		
4414	SOBRA 100-133% MALE	1,596.05	456.57	462.77	1,508.43	1,650.31	1,127.89	1,222.17	3,642.30	3,983.80	1,971.73	0.00	0.00		17,622.02		
4415	SOBRA 100-133% FEM AL	1,702.55	3,076.73	516.64	348.60	897.28	2,212.92	911.90	1,366.67	1,294.85	302.91	0.00	0.00		12,631.05		
	22,080.40	10,667.53	7,315.45	17,673.28	17,778.62	15,423.79	14,657.76	22,200.90	36,769.82	24,597.96	0.00	0.00	189,165.51		

SUBTOTAL:

TOTAL:	780,070.90	350,781.83	293,570.35	523,241.45	612,819.09	583,504.22	558,861.39	742,926.59	1,129,301.20	758,293.27	0.00	0.00	6,333,370.29		

SUBTOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	318.96	444.35	77.16	0.00	0.00		840.47		
1010	TANF NON-MEDICARE	47,470.63	21,432.22	18,846.93	27,265.06	38,488.55	31,282.82	27,141.19	43,268.87	65,457.82	41,189.62	0.00	0.00		361,843.71		
2200	SSI DISABLED WITH M E	1,412.38	2,144.04	684.80	346.92	1,036.53	1,490.74	1,766.14	807.90	1,509.48	2,143.07	0.00	0.00		13,342.00		
2210	SSI DISABLED NON-ME D	1,478,954.03	694,004.94	538,459.10	721,921.58	996,957.59	956,672.26	883,268.48	1,056,189.65	1,742,027.60	1,166,688.10	0.00	0.00		10,235,143.33		
2220	SSI DISABLED WITH Q M	4,777.36	3,124.80	1,162.93	1,707.31	2,323.90	1,567.20	1,608.48	2,348.21	2,057.80	1,896.85	0.00	0.00		22,574.84		
2310	SSI BLIND NON-MEDIC A	10,115.61	3,200.88	2,535.87	6,084.02	9,657.23	3,274.40	3,950.59	5,487.47	15,301.31	4,908.41	0.00	0.00		64,515.79		
	1,542,730.01	723,906.88	561,689.63	757,324.89	1,048,463.80	994,287.42	917,734.88	1,108,421.06	1,826,798.36	1,216,903.21	0.00	0.00	10,698,260.14		

1,542,730.01	723,906.88	561,689.63	757,324.89	1,048,463.80	994,287.42	917,734.88	1,108,421.06	1,826,798.36	1,216,903.21	0.00	0.00	10,698,260.14	

TOTAL:

SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending April 30, 2015	
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	32,872.75	0.00	0.00	0.00	0.00	0.00		32,872.75		
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	255,222.89	483,022.48	692,904.36	40,872.68	0.00	0.00		5,497,658.43		
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	11,492.45	93,404.62	37,242.45	56,692.42	0.00	0.00		968,801.98		
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	280,816.99	262,129.83	66,364.47	94,232.34	0.00	0.00		1,467,372.86		
1014	TANF 14-20 MALE NON-	108,649.47	-4,443.77	374,095.78	-5,681.49	38,532.76	6,541.63	-40,863.89	72,433.85	49,814.16	-400.11	0.00	0.00		598,678.39		
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	47,321.10	65,739.09	13,000.26	23,787.16	0.00	0.00		344,361.08		
1016	TANF 21-44 MALE NON-	132,385.08	173,376.31	292,747.33	64,996.50	173,255.89	281,541.76	137,169.78	145,244.48	127,179.79	98,194.33	0.00	0.00		1,626,091.25		
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	162,858.28	243,887.25	105,096.73	166,613.85	0.00	0.00		2,133,844.49		
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	10,556.23	98,712.80	91,885.83	176,851.19	0.00	0.00		1,378,496.00		
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	379.93	0.00	0.00		-12,003.39		
2100	SSI AGED WITH MEDIC A	-11,064.51	20,679.74	9,511.66	1,576.15	24,489.13	27,219.93	4,114.76	10,893.97	5,956.14	3,778.79	0.00	0.00		97,155.76		
2110	SSI AGED NON-MEDIC AR	128,077.73	94,236.33	91,762.23	118,229.74	226,009.71	18,714.07	-19,820.65	184,581.25	21,100.51	44,504.89	0.00	0.00		907,395.81		
2200	SSI DISABLED WITH M E	20,315.85	-10,671.36	54,805.16	6,873.58	27,635.54	1,367.03	84,262.17	29,742.02	410.17	1,757.71	0.00	0.00		216,497.87		
2210	SSI DISABLED NON-ME D	5,320,586.01	3,420,318.63	5,707,039.79	2,816,813.74	2,906,532.02	4,191,007.69	2,826,771.61	6,238,128.48	2,574,198.31	2,365,539.44	0.00	0.00		38,366,935.72		
2310	SSI BLIND NON-MEDIC A	2,687.38	-11,640.56	0.00	1,357.93	0.00	440.17	0.00	0.00	18,170.89	3,176.67	0.00	0.00		14,192.48		
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	45,220.96	1,464,391.10	725,796.28	365,868.62	0.00	0.00		9,327,628.94		
4312	SOBRA CHILD 01-05 M	42,898.59	31,960.46	446,875.71	273,059.72	368,592.56	192,282.66	376,449.07	501,559.17	292,182.09	26,958.60	0.00	0.00		2,552,818.63		
4313	SOBRA CHILD 06-13 M	342,577.75	67,788.19	560,809.73	148,080.44	221,081.64	-46,918.23	561,303.92	325,123.90	-7,144.61	162,967.35	0.00	0.00		2,335,670.08		
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	793,571.60	1,002,138.60	-389,779.24	340,856.73	0.00	0.00		5,394,136.44		
4315	SOBRA CHILD 14-20 FE	190,628.79	20,582.43	116,774.64	75,863.10	25,241.70	129,725.31	158.92	49,122.12	5,063.61	21,082.01	0.00	0.00		634,242.63		
5015	SOBRA PREG 14-20 FE M	-5,501.24	7,852.13	37,376.93	6,376.31	0.00	12,487.96	0.00	455.27	24,400.68	0.00	0.00	0.00		83,448.04		
5017	SOBRA PREG 21-44 FE M	35,660.75	7,458.14	102,096.78	3,037.03	24,380.94	23,590.53	-927.00	11,332.79	12,972.55	13,802.24	0.00	0.00		233,404.75		
	9,969,923.69	4,909,635.73	10,369,217.45	6,271,221.32	10,598,297.11	6,756,478.41	5,568,551.94	11,282,043.07	4,466,815.43	4,007,516.84	0.00	0.00	74,199,700.99		

3100	TRANSPLANT OPTION 1	0.00	-4.00	85.99	-6.06	-79.63	79.04	1.33	-2.49	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-4.00	85.99	-6.06	-79.63	79.04	1.33	-2.49	0.00	0.00	0.00	0.	

74.18

22,208.03	
0.00	
527,863.09	
17,303.13	
19,769.63	
904,807.69	
845,519.55	
725,345.90	
-8,365.50	
11,556.63	

00	74.18

1106	TANF EXPANDED 21-44	5,783.54	13,350.95	542.92	133.36	894.09	319.90	395.62	629.51	7.38	150.76	0.00	0.00	
1107	TANF EXPANDED 21-44	1,873.11	0.00	-1,714.13	0.00	0.00	0.00	-158.98	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	42,109.88	46,107.91	321,958.95	-43.59	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	12,500.50	0.00	0.00	55.30	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	34,825.84	15,001.80	193,173.87	-352,639.72	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	75,686.54	84,483.14	121,767.57	78,622.54	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	31,462.75	11,782.26	109,761.66	118,002.86	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	-9,938.86	0.00	0.00	0.00	1,541.09	0.00	32.27	0.00	0.00	
2400	SSI AGED EXPANDED WI	8,461.10	0.00	124.35	10.98	68.32	459.77	116.19	1,734.24	581.68	0.00	0.00	0.00	

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	7,276.69	0.00	0.00	0.00	0.00		36,681.64	
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	350.14	1,692.26	-459.69	1,336.24	0.00	0.00		40,500.38	
	15,060.12	11,589.46	6,978.27	6,365.64	25,306.44	-40,862.07	350.14	8,968.95	-459.69	1,336.24	0.00	0.00	34,633.50	

SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2410	SSI AGED EXPANDED NO	10,343.80	38,833.17	48,929.18	16,878.16	22,843.52	68,692.05	571.15	18,065.85	32,338.97	2,344.11	0.00	0.00		259,839.96		
2600	SSI DISABLED EXPAND E	6,615.59	41.18	259.67	-43.69	660.99	288.03	40.81	322.72	16,290.29	198,191.76	0.00	0.00		222,667.35		
2610	SSI DISABLED EXPAND E	33,618.83	26,765.25	35,130.20	64,258.30	57,942.72	10,140.23	9,259.53	25,756.77	-4,840.10	77,972.30	0.00	0.00		336,004.03		
	411,268.37	348,182.66	822,006.30	270,681.26	382,850.43	323,566.49	206,809.83	205,425.29	791,040.27	122,688.59	0.00	0.00	3,884,519.49		

3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	-6,845.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6,845.12	
3606	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	3,721.52	0.00	0.00	0.00	0.00	0.00		3,721.52	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	29,475.72	0.00	0.00	0.00	0.00	0.00		29,475.72	
3614	AHC CARE/MI MALE 14-	284.63	19,818.72	0.00	11,716.84	5,773.81	0.00	0.00	7,425.60	0.00	0.00	0.00	0.00		45,019.60	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	-14,175.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14,175.29	
3616	AHC CARE/MI MALE 21-	35,449.75	5,486.62	11,138.39	3,366.22	-45,704.27	3,778.33	-4,007.40	37,106.90	3,401.71	62,465.59	0.00	0.00		112,481.84	
3617	AHC CARE/MI FEMALE 2	2,346.33	149.94	2,110.32	-3,857.24	2,459.56	58.52	-41,223.31	1,590.42	588.87	3,402.54	0.00	0.00		-32,374.05	
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	8,172.28	-26,862.54	-23,341.50	13,440.18	0.00	0.00		392,705.07	
	130,757.71	107,177.23	43,403.96	30,286.20	91,575.14	51,452.47	-3,861.19	19,260.38	-19,350.92	79,308.31	0.00	0.00	530,009.29	

SUBTOTAL:

18,002.70	
185.27	
378,246.89	
923,012.31	
187,967.89	
1,893,898.96	
0.00	
7,873.45	
0.00	
763,369.13	
94,950.03	
5,313,183.13	
959,813.01	
6,780,896.01	
10,189.10	

SUBTOTAL:

3508	ADULT 40-100% M&F 45	0.00	1,491.78	0.00	0.00	0.00	0.00	-1,491.78	0.00	18,002.70	0.00	0.00	0.00	
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	
3514	ADULT 40-100% MALE
1	151,764.97	87.21	121,941.25	219.47	110,342.75	0.00	105.82	3,201.32	19.13	-9,435.03	0.00	0.00	
3516	ADULT 40-100% MALE
2	110,085.04	28,336.63	12,796.30	50,169.11	99,573.81	224,907.71	187,648.40	129,519.66	19,576.63	60,399.02	0.00	0.00	
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	45,173.81	41,945.04	18,511.20	0.00	0.00	
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	39,846.62	404,127.58	167,999.91	300,331.59	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	20.06	-20.06	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	321.77	2,973.17	2,209.46	2,081.23	5,059.04	1,977.19	94.48	-14,127.99	7,285.10	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	1,239.45	0.00	0.00	0.00	28,911.83	-28,911.83	-1,239.45	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	60,063.28	970.09	86,261.30	67,956.06	23,765.17	76,106.60	92,663.56	183,513.56	80,117.68	91,951.83	0.00	0.00	
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	33,525.55	16,363.78	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	527,880.83	612,804.86	986,924.78	428,531.24	470,042.16	478,072.08	285,229.04	870,308.36	139,549.85	513,839.93	0.00	0.00	
3717	ADULT <40% EXP FEM AL	203,328.99	-85,250.98	39,308.70	113,882.18	151,084.88	49,542.39	8,993.32	150,592.94	193,747.76	134,582.83	0.00	0.00	
3718	ADULT <40% EXP M&F 4	547,533.52	560,814.97	721,102.11	723,238.79	847,355.37	710,375.64	121,439.41	960,327.88	885,619.55	703,088.77	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	10,496.54	-10,496.54	10,189.10	0.00	0.00	0.00	0.00	

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	1,443.90	0.00	0.00	981.00	0.00	0.00	0.00	0.00		2,424.90	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	6.06	0.00	-11.07	0.00	0.00	0.00	0.00	2,218.32	0.00	0.00		2,213.31	
3915	NEWLY ELIGIBLE FEMA L	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		8,654.38	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	14,764.01	-13,290.27	55,460.02	0.00	0.00	51,449.98	2,139.59	14,575.02	0.00	0.00		125,098.35	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	6,908.43	8,777.52	0.00	0.00	0.00	7,092.04	20,538.98	0.00	0.00	0.00		43,316.97	
3918	NEWLY ELIGIBLE M&F 4	22,286.86	20,209.37	79,895.32	96,867.66	58,966.76	96,227.90	7,118.96	116,248.44	178,664.14	101,950.56	0.00	0.00		778,435.97	
	22,286.86	20,209.37	101,573.82	92,354.91	115,859.61	104,882.28	7,118.96	175,771.46	201,342.71	118,743.90	0.00	0.00	960,143.88	

SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	1,767,893.62	1,250,975.66	2,131,083.91	1,550,815.81	1,951,045.58	1,795,154.19	754,826.87	2,761,662.41	1,547,594.65	1,820,535.18	0.00	0.00	17,331,587.88		

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	37,077.11	6.56	0.00	2,971.16	0.00	0.00		135,535.04	
4414	SOBRA 100-133% MALE	65.18	19,810.58	102,761.85	37,400.05	51,462.07	52,674.99	0.00	67,413.34	10,533.78	-62,223.31	0.00	0.00		279,898.53	
4415	SOBRA 100-133% FEM AL	0.00	-7,529.00	17,232.86	18,975.57	5,920.80	18,710.25	25,530.94	4,828.84	23,012.74	34,107.33	0.00	0.00		140,790.33	
	14,377.85	21,036.04	144,790.40	62,535.36	95,396.90	74,828.86	62,608.05	72,248.74	33,546.52	-25,144.82	0.00	0.00	556,223.90	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	6,209.80	0.00	0.00	37,383.41	0.00	0.00	0.00	0.00		43,593.21	
4518	BC PATIENT FEMALE 4 5	10,313.98	4,032.69	22,493.05	16,045.91	-7,955.29	29,895.59	2,671.74	0.00	0.00	5,041.96	0.00	0.00		82,539.63	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	2,131.29	9,032.07	-736.94	2,553.51	0.00	-923.98	1,519.36	0.00	0.00	0.00		13,575.31	
4618	CC PATIENT FEMALE 4 5	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	
	16,429.10	-2,024.96	24,624.34	25,077.98	-2,482.43	32,449.10	2,671.74	36,459.43	1,519.36	5,041.96	0.00	0.00	139,765.62	

SUBTOTAL:

8710	SSI DISABLED FREEDO M	2,558.36	99,193.33	35,512.47	-10,364.78	16,562.70	61,345.08	71,090.14	-6,413.72	0.00	8,972.08	0.00	0.00		278,455.66	
	2,558.36	99,193.33	35,512.47	-10,364.78	16,562.70	61,345.08	71,090.14	-6,413.72	0.00	8,972.08	0.00	0.00	278,455.66	

SUBTOTAL:

SUBTOTAL:

TOTAL:	12,350,555.68	6,765,970.52	13,679,276.91	8,298,967.64	13,274,331.85	9,159,373.85	6,670,167.81	14,555,423.52	7,022,048.33	6,138,998.28	0.00	0.00	97,915,114.39		

SUBTOTAL:

LONG TERM CARE REINSURANCE

For The Period Ending April 30, 2015	
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	864.93	-2,447.15	43,973.60	5,477.69	0.00	0.00		61,086.52		
2100	SSI AGED WITH MEDIC A	444,766.14	302,713.80	603,255.00	438,652.82	415,507.67	409,138.80	29,189.63	192,492.90	50,649.37	230,083.88	0.00	0.00		3,116,450.01		
2110	SSI AGED NON-MEDIC AR	94,778.89	68,228.22	239,845.11	302,132.92	162,138.93	30,008.81	69,598.41	102,452.50	88,798.10	140,447.69	0.00	0.00		1,298,429.58		
2200	SSI DISABLED WITH M E	542,384.64	745,227.77	1,060,996.47	700,811.88	851,980.42	768,131.50	361,127.85	663,652.71	383,920.11	380,484.84	0.00	0.00		6,458,718.19		
2210	SSI DISABLED NON-ME D	2,252,785.70	2,463,223.47	3,374,452.37	3,279,509.10	3,025,825.21	2,777,342.31	1,464,002.55	2,331,746.99	1,365,896.31	1,508,285.65	0.00	0.00		23,843,069.66		
2310	SSI BLIND NON-MEDIC A	16,178.78	10,868.82	46,055.83	13,881.85	24,909.97	7,853.23	-2,301.66	16,902.91	16,704.82	24,841.66	0.00	0.00		175,896.21		
	3,351,664.59	3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	3,996,173.95	1,922,481.71	3,304,800.86	1,949,942.31	2,289,621.41	0.00	0.00	34,953,650.17		

3,351,664.59	3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	3,996,173.95	1,922,481.71	3,304,800.86	1,949,942.31	2,289,621.41	0.00	0.00	34,953,650.17	

TOTAL:

SUBTOTAL:

ACUTE SMIB

For The Period Ending April 30, 2015	
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	66,296.80	67,028.80	57,695.00	64,408.60	0.00	0.00		631,840.30		
1010	TANF NON-MEDICARE	314.70	314.70	314.70	209.80	209.80	2,098.00	209.80	734.30	209.80	314.70	0.00	0.00		4,930.30		
1020	TANF WITH QMB	1,993.10	1,888.20	1,783.30	3,671.50	4,300.90	4,930.30	5,349.90	5,140.10	5,664.60	9,021.40	0.00	0.00		43,743.30		
2100	SSI AGED WITH MEDIC A	233,087.80	189,316.60	73,485.90	77,472.10	70,338.90	66,341.40	59,274.40	71,916.30	71,486.90	62,415.50	0.00	0.00		975,135.80		
2110	SSI AGED NON-MEDIC AR	400,566.10	392,011.30	395,473.00	394,528.90	402,711.10	429,939.30	395,263.20	404,993.90	394,528.90	395,053.40	0.00	0.00		4,005,069.10		
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	2,489,836.40	2,491,340.60	2,394,030.20	2,351,615.40	0.00	0.00		24,347,697.00		
2200	SSI DISABLED WITH M E	431,726.00	393,804.40	196,687.50	205,227.90	198,475.80	200,463.90	205,708.90	213,366.60	208,960.80	157,559.80	0.00	0.00		2,411,981.60		
2210	SSI DISABLED NON-ME D	325,924.30	328,756.60	332,702.80	334,897.50	332,533.00	435,540.40	336,519.20	336,099.60	330,378.30	332,133.40	0.00	0.00		3,425,485.10		
2220	SSI DISABLED WITH Q M	2,938,167.40	2,948,060.50	2,962,742.20	2,977,216.20	2,936,899.20	2,934,259.70	3,016,286.60	3,024,370.70	3,002,896.20	3,045,443.80	0.00	0.00		29,786,342.50		
2300	SSI BLIND WITH MEDIC	2,307.80	2,098.00	209.80	209.80	629.40	419.60	314.70	209.80	419.60	419.60	0.00	0.00		7,238.10		
2310	SSI BLIND NON-MEDIC A	3,356.80	3,461.70	3,356.80	3,356.80	3,776.40	3,881.30	3,566.60	3,461.70	3,356.80	3,356.80	0.00	0.00		34,931.70		
2320	SSI BLIND WITH QMB	26,329.90	26,130.10	26,434.80	23,517.60	26,329.90	26,539.70	27,064.20	26,434.80	26,225.00	26,434.80	0.00	0.00		261,440.80		
4300	SOBRA CHILD WITH M ED	0.00	0.00	104.90	104.90	104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00		839.20		
4310	SOBRA CHILD NON-ME DI	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		
5000	SOBRA PREGNANT WO MAN	0.00	104.90	2,307.80	3,147.00	2,412.70	3,566.60	4,510.70	2,832.30	3,042.10	3,147.00	0.00	0.00		25,071.10		
5020	SOBRA PREGNANT WO MAN	314.70	419.60	524.50	1,573.50	629.40	1,049.00	839.20	1,049.00	734.30	629.40	0.00	0.00		7,762.60		
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	-209.80	0.00	0.00		281,481.40		
8020	QMB ONLY	451,354.50	444,411.20	440,537.90	446,707.80	471,183.60	459,943.30	446,624.00	454,429.60	466,811.30	474,364.10	0.00	0.00		4,556,367.30		
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	3,232,464.80	3,268,616.20	3,270,430.80	3,377,414.60	0.00	0.00		31,809,724.40		
8888	SMIB ONLY NOT ELIGIB	10,545.90	53,013.10	-122,308.40	-7,552.80	-13,010.50	-14,790.90	-8,496.90	-12,692.90	-11,958.60	30,630.80	0.00	0.00		-96,621.20		
9999	SMIB ONLY NOT ELIGIB	104,243.20	279,672.30	-49,755.80	165,466.10	243,117.50	-62,544.30	145,987.80	117,745.80	148,238.90	98,183.10	0.00	0.00		1,190,354.60		
	10,393,669.50	10,609,177.00	9,816,709.20	10,373,227.10	10,541,022.40	10,266,510.30	10,427,725.20	10,477,182.10	10,373,255.80	10,432,441.30	0.00	0.00	103,710,919.90		

9910	TANF & SOBRA CHILDR E	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	
-104.90	
-314.70	

4,819,603.10	
2,622.50	
504,673.90	
360,109.30	
10,490.00	
24,843,811.50	
2,622.50	
105,019.90	
209.80	
10,861,928.70	

00

1100	TANF EXPANDED FPR FI	839.20	1,388.40	598,877.80	613,200.10	634,134.00	590,013.20	590,074.00	593,633.70	589,437.70	608,005.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	314.70	419.60	314.70	314.70	314.70	314.70	314.70	314.70	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	38,708.10	45,002.10	43,323.70	53,813.70	61,891.00	72,276.10	75,842.70	113,816.50	0.00	0.00	
2400	SSI AGED EXPANDED WI	106,596.20	97,002.30	18,986.90	25,385.80	17,728.10	17,098.70	17,728.10	17,518.30	19,406.50	22,658.40	0.00	0.00	
2410	SSI AGED EXPANDED NO	1,468.60	1,153.90	1,153.90	629.40	1,153.90	2,307.80	839.20	524.50	629.40	629.40	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,329,792.40	2,507,887.80	2,428,160.60	2,436,748.60	2,470,650.30	2,510,011.30	2,523,619.60	2,540,854.90	2,525,420.90	2,570,665.10	0.00	0.00	
2520	SSI BLIND EXPANDED W	524.50	419.60	314.70	209.80	209.80	209.80	209.80	209.80	209.80	104.90	0.00	0.00	
2600	SSI DISABLED EXPAND E	49,093.20	56,031.60	-209.80	0.00	0.00	314.70	-629.40	209.80	104.90	104.90	0.00	0.00	
2610	SSI DISABLED EXPAND E	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	951,712.70	1,111,220.00	1,014,433.70	1,044,837.50	1,063,832.20	1,091,853.60	1,046,097.50	1,102,337.70	1,155,131.70	1,280,472.10	0.00	0.00	

9900	HOSP. KICK PAYMENT A	8,811.60	11,853.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,665.30	
	8,811.60	11,853.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,665.30	

SUBTOTAL:

ACUTE SMIB

For The Period Ending April 30, 2015	
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	4,240,144.50	4,327,879.50	4,366,498.30	4,596,771.00	0.00	0.00	41,511,091.20		

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	3,671.50	3,356.80	3,881.30	5,035.20	0.00	0.00		40,701.20	
3700	ADULT <40% EXP FOR F	0.00	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.70	
3720	AHC CARE EXPANDED FO	1,049.00	1,153.90	2,517.60	3,671.50	2,727.40	2,098.00	1,783.30	1,049.00	2,307.80	2,412.70	0.00	0.00		20,770.20	
	4,510.70	6,245.00	7,343.00	7,447.90	6,818.50	7,972.40	5,454.80	4,405.80	6,189.10	7,447.90	0.00	0.00	63,835.10	

SUBTOTAL:

3900	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	
3920	NEWLY ELIGIBLE FOR F	1,258.80	734.30	1,678.40	1,783.30	1,153.90	209.80	209.80	209.80	209.80	314.70	0.00	0.00		7,762.60	
	1,258.80	839.20	1,678.40	1,783.30	1,153.90	209.80	209.80	209.80	209.80	314.70	0.00	0.00	7,867.50	

SUBTOTAL:

SUBTOTAL:

8700	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	
8720	SSI DISABLED FREEDO M	16,154.60	17,833.00	19,931.00	20,140.80	19,511.40	20,875.10	19,826.10	20,980.00	19,301.60	20,350.60	0.00	0.00	
SUBTOTAL:	17,203.60	18,882.00	19,931.00	20,140.80	19,511.40	20,875.10	19,826.10	20,980.00	19,301.60	20,350.60	0.00	0.	

2,098.00	
194,904.20	
197,002.20	

00

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	14,693,360.40	14,830,657.20	14,765,454.60	15,057,325.50	0.00	0.00	145,511,066.50		

2420	SSI AGED EXPANDED WI	2,805.80	1,938.00	1,938.00	1,938.00	3,216.00	2,364.00	2,057.00	4,739.00	3,073.00	4,416.10	0.00	0.00		28,484.90	
	2,805.80	1,938.00	1,938.00	1,938.00	3,216.00	2,364.00	2,057.00	4,739.00	3,073.00	4,416.10	0.00	0.00	28,484.90	

SUBTOTAL:

ACUTE HIB

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	-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		
2110	SSI AGED NON-MEDIC AR	-7,299.40	5,613.00	0.00	0.00	0.00	0.00	0.00	407.00	672.00	0.00	0.00	0.00		-607.40		
2120	SSI AGED WITH QMB	138,085.50	183,470.40	180,831.60	183,415.80	188,884.20	176,824.20	168,672.20	174,146.90	173,362.20	176,354.00	0.00	0.00		1,744,047.00		
2200	SSI DISABLED WITH M E	-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		
2210	SSI DISABLED NON-ME D	-890.50	0.00	0.00	0.00	0.00	0.00	0.00	160.60	0.00	1,343.10	0.00	0.00		613.20		
2220	SSI DISABLED WITH Q M	22,759.60	81,575.40	79,871.40	85,989.00	81,256.80	91,522.80	86,171.90	88,009.50	78,264.40	89,841.00	0.00	0.00		785,261.80		
2320	SSI BLIND WITH QMB	426.00	426.00	426.00	426.00	426.00	426.00	407.00	407.00	407.00	407.00	0.00	0.00		4,184.00		
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	-139.00	0.00	0.00	0.00	0.00	0.00		-1,079.60		
8020	QMB ONLY	1,908.80	5,046.60	3,918.60	2,734.20	3,090.00	3,090.00	2,818.10	2,505.40	2,505.40	2,953.10	0.00	0.00		30,570.20		
9999	SMIB ONLY NOT ELIGIB	-89,633.40	-5,389.20	-6,432.00	-2,187.00	1,043.40	-9,115.80	-2,708.20	-7,250.60	-3,458.30	-2,849.00	0.00	0.00		-127,980.10		
	58,791.90	272,446.20	259,041.60	269,952.00	274,700.40	262,747.20	255,222.00	258,385.80	251,752.70	268,049.20	0.00	0.00	2,431,089.00		

SUBTOTAL:

61,597.70	274,384.20	260,979.60	271,890.00	277,916.40	265,111.20	257,279.00	263,124.80	254,825.70	272,465.30	0.00	0.00	2,459,573.90	

TOTAL:

Q1

For The Period Ending April 30, 2015	
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	1,783,536.20	1,763,085.70	1,774,645.30	39,552.20	0.00	0.00		16,170,860.60		
9999	SMIB ONLY NOT ELIGIB	12,692.90	46,532.10	-64,720.20	944.10	1,573.50	16,259.50	2,412.70	13,112.50	5,454.80	1,624,976.30	0.00	0.00		1,659,238.20		
	1,627,402.40	1,621,788.40	1,982,589.50	1,886,090.00	1,928,653.50	1,776,799.30	1,785,948.90	1,776,198.20	1,780,100.10	1,664,528.50	0.00	0.00	17,830,098.80		

SUBTOTAL:

TOTAL:	1,627,402.40	1,621,788.40	1,982,589.50	1,886,090.00	1,928,653.50	1,776,799.30	1,785,948.90	1,776,198.20	1,780,100.10	1,664,528.50	0.00	0.00	17,830,098.80		

8720	SSI DISABLED FREEDO M	524.50	524.50	419.60	314.70	314.70	314.70	419.60	419.60	419.60	524.50	0.00	0.00		4,196.00	
	524.50	524.50	419.60	314.70	314.70	314.70	419.60	419.60	419.60	524.50	0.00	0.00	4,196.00	

SUBTOTAL:

LTC SMIB

For The Period Ending April 30, 2015	
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	209.80	209.80	209.80	839.20	0.00	0.00		2,727.40		
1020	TANF WITH QMB	209.80	209.80	209.80	104.90	104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00		1,363.70		
2100	SSI AGED WITH MEDIC A	888,555.70	873,534.60	857,715.10	861,295.50	876,233.40	856,197.50	888,924.30	860,491.50	858,133.70	878,903.90	0.00	0.00		8,699,985.20		
2110	SSI AGED NON-MEDIC AR	152,419.70	154,098.10	154,307.90	156,615.70	156,091.20	182,838.10	158,503.90	157,979.40	158,189.20	158,818.60	0.00	0.00		1,589,861.80		
2120	SSI AGED WITH QMB	701,571.20	723,659.60	742,796.90	743,761.00	748,566.40	754,650.60	751,818.30	748,769.70	765,140.60	769,112.80	0.00	0.00		7,449,847.10		
2200	SSI DISABLED WITH M E	332,642.90	322,652.70	317,112.70	316,378.40	317,742.10	326,084.70	322,147.90	329,071.30	314,804.90	310,818.70	0.00	0.00		3,209,456.30		
2210	SSI DISABLED NON-ME D	15,525.20	15,839.90	16,574.20	17,098.70	16,469.30	31,770.50	18,252.60	18,147.70	14,476.20	15,420.30	0.00	0.00		179,574.60		
2220	SSI DISABLED WITH Q M	663,338.30	680,244.30	688,514.30	693,444.60	693,969.10	695,128.00	696,171.00	696,380.80	701,311.10	704,877.70	0.00	0.00		6,913,379.20		
2300	SSI BLIND WITH MEDIC	1,049.00	839.20	839.20	839.20	1,258.80	1,153.90	1,049.00	1,153.90	944.10	944.10	0.00	0.00		10,070.40		
2310	SSI BLIND NON-MEDIC A	209.80	314.70	314.70	314.70	314.70	314.70	314.70	314.70	209.80	209.80	0.00	0.00		2,832.30		
2320	SSI BLIND WITH QMB	4,300.90	4,300.90	4,300.90	4,196.00	4,196.00	4,091.10	4,091.10	4,091.10	3,986.20	4,405.80	0.00	0.00		41,960.00		
	2,760,032.30	2,775,903.60	2,782,895.50	2,794,258.50	2,815,155.70	2,852,543.80	2,841,587.50	2,816,714.80	2,817,510.50	2,844,455.80	0.00	0.00	28,101,058.00		

SUBTOTAL:

2,760,556.80	2,776,428.10	2,783,315.10	2,794,573.20	2,815,470.40	2,852,858.50	2,842,007.10	2,817,134.40	2,817,930.10	2,844,980.30	0.00	0.00	28,105,254.00	

TOTAL:

LTC HIB

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	-5,106.60	0.00	0.00	426.00	0.00	0.00	0.00	0.00	0.00	407.00	0.00	0.00		-4,273.60		
2110	SSI AGED NON-MEDIC AR	-6,887.80	5,613.00	0.00	0.00	0.00	0.00	1,259.00	814.00	0.00	0.00	0.00	0.00		798.20		
2120	SSI AGED WITH QMB	148,322.10	262,344.00	258,760.20	266,282.40	261,745.20	267,816.60	251,613.10	252,892.10	249,764.80	259,633.20	0.00	0.00		2,479,173.70		
2200	SSI DISABLED WITH M E	-1,539.40	0.00	426.00	-852.00	426.00	-426.00	0.00	407.00	-407.00	0.00	0.00	0.00		-1,965.40		
2210	SSI DISABLED NON-ME D	-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		
2220	SSI DISABLED WITH Q M	-3,868.30	7,956.00	7,338.60	12,054.60	10,350.60	12,906.60	-11,385.90	11,111.70	13,146.70	14,489.80	0.00	0.00		74,100.40		
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		
	121,568.30	275,913.00	266,524.80	277,911.00	272,521.80	280,297.20	241,486.20	265,224.80	262,504.50	274,530.00	0.00	0.00	2,538,481.60		

SUBTOTAL:

TOTAL:	121,568.30	275,913.00	266,524.80	277,911.00	272,521.80	280,297.20	241,486.20	265,224.80	262,504.50	274,530.00	0.00	0.00	2,538,481.60		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
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	840.52	309.04	969.11	1,001.68	0.00	0.00		11,332.02		
1007	TANF 21-44 FEMALE WI	7,891.55	4,440.10	37,095.67	5,204.05	11,335.82	2,581.58	1,798.57	2,939.33	6,748.96	3,373.97	0.00	0.00		83,409.60		
1008	TANF 45-64 M & F WIT	688.07	4,551.70	6,186.60	7,407.18	3,733.34	312.18	2,076.44	2,330.31	3,408.43	9,475.84	0.00	0.00		40,170.09		
1009	TANF 65+ M & F WITH	2,777.42	692.23	471.06	1,233.62	976.10	307.15	802.52	926.29	2,647.08	1,886.14	0.00	0.00		12,719.61		
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	922,741.39	1,003,028.20	1,351,741.01	1,047,948.53	0.00	0.00		10,541,799.90		
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	1,586,945.06	2,201,766.17	2,494,562.84	1,746,046.14	0.00	0.00		20,782,372.28		
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	2,591,072.80	3,354,039.50	3,987,271.40	3,276,424.61	0.00	0.00		34,588,958.26		
1014	TANF 14-20 MALE NON-	789,166.76	666,853.53	701,533.91	576,596.64	650,572.47	767,365.89	449,885.90	474,295.77	790,999.71	582,624.52	0.00	0.00		6,449,895.10		
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	784,045.60	793,833.53	1,337,202.46	815,430.41	0.00	0.00		10,192,057.69		
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	799,698.99	896,276.46	1,149,815.18	1,031,711.38	0.00	0.00		10,417,194.90		
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	4,253,591.73	4,499,764.32	5,707,881.87	5,103,954.39	0.00	0.00		52,040,875.25		
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	1,096,969.28	1,379,804.54	1,494,789.37	1,419,223.43	0.00	0.00		14,233,623.52		
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	2,745.74	2,394.00	342.00	3,078.00	0.00	0.00		33,520.69		
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	620.34	1,262.08	817.96	8.34	0.00	0.00		7,810.13		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	569.09	1,086.71	0.00	0.00		1,655.80		
2100	SSI AGED WITH MEDIC A	55,280.06	61,807.18	52,962.78	58,259.92	35,963.52	59,958.11	35,933.80	35,795.18	45,650.50	45,546.90	0.00	0.00		487,157.95		
2110	SSI AGED NON-MEDIC AR	122,058.59	95,993.44	111,925.93	121,536.53	82,043.81	86,766.66	68,522.22	83,387.37	75,127.27	85,203.16	0.00	0.00		932,564.98		
2120	SSI AGED WITH QMB	240,326.58	230,567.57	231,158.40	261,929.02	195,589.88	219,414.41	179,922.38	207,744.06	259,054.39	229,262.42	0.00	0.00		2,254,969.11		
2200	SSI DISABLED WITH M E	141,948.53	159,969.16	144,932.50	155,742.39	92,640.10	143,291.60	143,731.94	109,547.14	166,737.12	191,759.17	0.00	0.00		1,450,299.65		
2210	SSI DISABLED NON-ME D	5,600,784.07	4,878,415.73	5,361,312.61	4,421,143.38	4,225,871.37	4,693,928.62	3,813,647.06	4,201,555.09	5,359,485.26	4,793,832.03	0.00	0.00		47,349,975.22		
2220	SSI DISABLED WITH Q M	505,684.41	462,707.23	465,266.11	509,682.34	379,838.90	421,292.32	349,349.81	379,708.58	532,600.98	476,588.73	0.00	0.00		4,482,719.41		
2300	SSI BLIND WITH MEDIC	732.05	1,083.49	134.57	670.80	1,194.98	875.15	423.84	144.47	712.99	1,551.77	0.00	0.00		7,524.11		
2310	SSI BLIND NON-MEDIC A	58,811.72	53,564.21	70,414.36	74,538.56	53,470.42	69,424.73	34,831.52	46,276.01	44,673.87	59,568.83	0.00	0.00		565,574.23		
2320	SSI BLIND WITH QMB	6,877.81	7,105.79	5,428.99	6,812.69	6,272.52	8,344.86	5,437.57	6,037.49	6,781.00	9,171.07	0.00	0.00		68,269.79		
4303	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		
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	978,359.78	1,003,082.40	1,541,561.65	1,246,089.22	0.00	0.00		11,550,736.07		
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	954,574.13	1,304,756.27	1,835,378.19	1,674,354.92	0.00	0.00		12,946,995.34		
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	1,228,421.82	1,529,467.95	2,186,336.32	2,232,328.47	0.00	0.00		17,292,834.67		
4314	SOBRA CHILD 14-20 MA	819,236.05	706,030.79	717,542.51	535,873.37	620,642.56	716,514.91	442,699.32	448,904.02	747,831.31	679,691.08	0.00	0.00		6,434,965.92		
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	544,275.68	662,284.25	882,460.53	865,130.22	0.00	0.00		8,461,617.14		
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	158.10	59.40	571.42	179.57	146.34	1,431.61	-187.36	8.27	199.56	0.00	0.00	0.00		2,566.91		
5015	SOBRA PREG 14-20 FE M	327,656.19	297,669.00	310,183.13	221,676.68	249,107.46	261,990.76	215,000.49	150,119.99	280,877.31	229,478.33	0.00	0.00		2,543,759.34		
5017	SOBRA PREG 21-44 FE M	1,091,567.67	946,301.56	1,169,090.06	986,816.43	812,410.05	1,029,774.56	756,549.17	782,130.26	1,317,359.62	961,712.29	0.00	0.00		9,853,711.67		
5018	SOBRA PREG 45-64 FE M	-18,468.00	3,071.60	3,420.00	2,475.20	1,072.59	1,594.61	1,430.79	1,068.57	1,720.33	1,104.43	0.00	0.00		-1,509.88		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	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		
	32,382,594.67	28,601,266.16	31,847,181.90	27,184,793.60	26,943,262.92	28,922,808.43	22,246,758.84	25,564,986.91	33,614,314.67	28,825,647.13	0.00	0.00	286,133,615.23		

SUBTOTAL:

1106	TANF EXPANDED 21-44	6,408.48	4,488.35	5,192.83	7,061.09	6,710.30	5,496.78	3,933.70	2,685.75	5,907.21	4,930.31	0.00	0.00	
1107	TANF EXPANDED 21-44	13,495.32	12,706.18	10,880.70	10,508.67	8,592.03	12,279.11	9,105.78	11,694.18	14,930.68	15,937.92	0.00	0.00	
1108	TANF EXPANDED 45-64	30,378.85	28,533.23	34,497.12	29,931.18	22,272.49	27,607.53	26,441.90	27,303.66	46,674.59	30,586.28	0.00	0.00	
1109	TANF EXPANDED 65+
M&	19,280.09	19,116.75	18,240.76	17,222.69	11,053.75	15,431.13	9,846.67	12,154.75	20,964.07	25,776.76	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	342.00	0.00	0.00	0.00	342.00	342.00	1,710.00	342.00	342.00	1,026.00	0.00	0.00	
1112	TANF EXPANDED 01-05	9,006.00	8,938.95	11,623.85	5,501.17	6,653.58	5,484.79	6,582.05	4,788.00	6,890.55	10,326.94	0.00	0.00	
1113	TANF EXPANDED 06-13	51,575.17	42,983.60	52,423.69	50,487.63	57,785.04	47,271.00	27,775.52	44,684.43	42,585.52	38,469.43	0.00	0.00	
1114	TANF EXPANDED 14-20	22,170.63	16,255.50	17,324.79	18,051.36	18,982.88	22,351.06	25,725.01	52,552.79	46,565.21	30,291.85	0.00	0.00	
1115	TANF EXPANDED 14-20	47,309.83	42,419.66	54,623.86	31,881.60	46,287.05	42,037.66	28,885.07	51,893.29	41,410.09	56,391.93	0.00	0.00	
1116	TANF EXPANDED 21-44	591,969.39	562,199.70	684,810.63	500,868.98	492,500.09	560,038.93	460,449.58	484,118.46	580,533.53	521,458.43	0.00	0.00	
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	1,182,113.05	1,389,889.49	1,656,665.96	1,483,691.17	0.00	0.00	
1118	TANF EXPANDED 45-64	886,655.00	786,372.06	880,244.74	764,652.74	796,223.77	892,362.93	632,666.34	828,942.56	1,003,120.38	931,069.49	0.00	0.00	
1119	TANF EXPANDED 65+
M&	342.00	684.00	1,026.00	2,394.00	1,098.14	2,684.77	1,368.00	2,036.43	10,909.62	1,710.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	77.42	0.00	0.00	0.00	342.00	384.63	0.00	0.00	
1127	TANF EXPANDED 21-44	151.39	8.27	94.46	110.11	120.37	8.72	0.00	129.06	150.66	909.93	0.00	0.00	
1128	TANF EXPANDED 45-64	3,030.80	783.84	3,283.40	3,586.48	2,660.39	3,064.79	2,944.46	4,378.11	6,134.55	3,388.98	0.00	0.00	
1129	TANF EXPANDED 65+
M&	1,058.72	1,787.21	1,215.52	2,075.30	1,251.94	1,458.13	1,341.40	1,858.65	2,941.62	4,386.82	0.00	0.00	
2400	SSI AGED EXPANDED WI	12,551.22	7,567.69	11,266.27	27,257.02	13,480.55	15,042.13	9,511.72	17,979.04	14,580.77	15,829.06	0.00	0.00	
2410	SSI AGED EXPANDED NO	47,919.09	48,564.00	54,031.56	45,796.97	42,956.65	40,428.58	38,775.80	50,472.22	47,782.54	42,694.51	0.00	0.00	
2420	SSI AGED EXPANDED WI	205,652.65	186,044.63	175,582.01	231,675.45	161,533.14	187,518.19	142,647.15	168,228.97	215,243.13	192,218.81	0.00	0.00	
2510	SSI BLIND EXPANDED N	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	7,548.42	2,210.05	3,730.20	4,895.87	5,234.34	5,439.89	6,607.19	10,055.38	6,396.40	7,692.31	0.00	0.00	
2610	SSI DISABLED EXPAND E	70,066.79	61,883.80	57,114.09	58,998.22	50,285.44	89,316.44	50,845.49	51,062.36	92,652.22	169,117.40	0.00	0.00	
2620	SSI DISABLED EXPAND E	85,071.68	74,095.59	69,290.34	83,409.55	61,957.41	79,231.76	46,668.99	65,480.76	93,946.27	85,085.65	0.00	0.00	
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	2,715,944.87	3,282,730.34	3,957,669.57	3,673,374.61	0.00	0.	

52,814.80	
120,130.57	
304,226.83	
169,087.42	
4,446.00	
75,795.88	
456,041.03	
270,271.08	
443,140.04	
5,438,947.72	
14,624,570.64	
8,402,310.01	
24,252.96	
804.05	
1,682.97	
33,255.80	
19,375.31	
145,065.47	
459,421.92	
1,866,344.13	
-330.00	
59,810.05	
751,342.25	
744,238.00	
34,467,044.93	

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	
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	-605.00	0.00	0.00	0.00	0.00	0.00		2,463.10	
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	-1,967.51	0.00	-7,260.00	0.00	0.00		27,726.13	
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	
	17,045.43	24,002.17	1,934.93	2,024.35	90.60	694.12	-605.00	-1,967.51	0.00	-7,260.00	0.00	0.00	35,959.09	

00

SUBTOTAL:

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	0.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		-588.00		
3607	AHC CARE/MI FEMALE 2	41.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.99		
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	-2,571.53	0.00	0.00	0.00	0.00		11,905.88		
3615	AHC CARE/MI FEMALE 1	6,338.94	1,363.64	688.74	341.22	429.84	83.02	169.72	0.00	0.00	0.00	0.00	0.00		9,415.12		
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	-14,108.07	-1,465.00	0.00	0.00	0.00		41,550.63		
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	-4,024.21	-486.00	0.00	0.00	0.00		8,402.18		
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	26.45	-12,422.19	-1,284.00	-330.00	0.00	0.00		161,376.58		
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		
	120,424.68	90,938.20	7,525.53	47,379.66	-4,390.18	9,611.96	196.17	-33,126.00	-3,235.00	-330.00	0.00	0.00	234,995.02		

7,830.04	
0.00	
71,234.93	
16,983.72	
108,791.23	
285,478.78	
2,949,008.25	
3,583,018.38	
11,135,799.21	
6,192.00	
2,170.47	
945.02	
7,696.43	
12,074.28	
74,733.83	
7,738.71	
2,181,808.71	
3,153,995.86	
35,648,373.36	
24,048,508.53	
49,464,848.60	
70,510.11	
380.32	
1,609.87	
3,918.56	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	684.00	2,736.00	0.00	1,368.00	435.98	59.40	1,149.86	192.75	846.33	357.72	0.00	0.00	
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	
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	5,221.88	2,884.52	2,982.14	7,257.75	0.00	0.00	
3509	ADULT 40-100% M&F 65	4,900.96	3,425.25	1,759.86	24.59	-138.22	1,898.97	1,180.71	520.23	1,930.48	1,480.89	0.00	0.00	
3514	ADULT 40-100% MALE
1	11,956.88	15,259.04	11,015.99	6,091.76	5,163.66	7,591.36	9,617.94	10,086.00	14,932.64	17,075.96	0.00	0.00	
3515	ADULT 40-100% FEMAL E	30,135.72	25,033.04	38,775.33	28,669.44	27,488.27	23,746.53	20,998.08	27,883.50	35,357.42	27,391.45	0.00	0.00	
3516	ADULT 40-100% MALE
2	214,543.22	272,200.59	396,809.12	243,752.03	248,328.90	272,105.94	294,779.00	269,041.77	332,204.19	405,243.49	0.00	0.00	
3517	ADULT 40-100% FEMAL E	353,269.80	308,087.27	365,630.82	332,449.95	338,773.56	368,657.12	282,751.34	372,281.55	444,078.48	417,038.49	0.00	0.00	
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	834,805.23	1,022,018.99	1,644,965.85	1,142,758.70	0.00	0.00	
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	1,710.00	1,026.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	23.40	0.00	129.06	59.40	0.00	-59.40	560.64	659.67	63.70	734.00	0.00	0.00	
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	105.78	0.00	0.00	
3706	ADULT <40% EXP MAL E	1,792.92	1,968.09	297.17	182.40	627.67	192.00	112.63	0.00	406.44	2,117.11	0.00	0.00	
3707	ADULT <40% EXP FEM AL	1,067.23	420.38	-251.10	1,380.33	741.96	1,349.39	1,097.93	2,569.09	1,223.39	2,475.68	0.00	0.00	
3708	ADULT <40% EXP M&F 4	14,748.72	7,103.33	9,806.11	6,948.85	3,447.77	5,941.34	5,210.77	5,400.35	6,395.08	9,731.51	0.00	0.00	
3709	ADULT <40% EXP M&F 6	3,515.98	93.07	1,056.57	879.12	1,071.81	0.00	846.88	0.00	275.28	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	239,581.44	231,188.42	205,950.10	196,940.37	253,893.37	214,249.35	199,350.54	210,257.27	232,505.20	197,892.65	0.00	0.00	
3715	ADULT <40% EXP FEM AL	359,309.33	351,228.87	363,914.24	341,840.78	251,734.54	295,640.31	274,989.12	251,526.05	354,333.46	309,479.16	0.00	0.00	
3716	ADULT <40% EXP MAL E	3,847,800.35	3,546,062.74	4,041,892.63	3,442,949.46	3,052,156.77	3,352,667.69	3,181,190.42	3,262,614.68	4,342,455.20	3,578,583.42	0.00	0.00	
3717	ADULT <40% EXP FEM AL	2,702,957.26	2,499,001.62	2,930,369.65	2,323,636.33	2,219,259.83	2,273,036.74	1,984,703.79	2,115,723.72	2,656,035.32	2,343,784.27	0.00	0.00	
3718	ADULT <40% EXP M&F 4	5,364,337.66	4,940,915.69	5,614,113.55	4,577,348.60	4,831,791.23	4,906,661.89	4,008,898.10	4,653,314.08	5,409,763.35	5,157,704.45	0.00	0.00	
3719	ADULT <40% EXP M&F 6	2,748.00	1,368.00	39,287.82	1,710.00	5,814.00	4,350.29	4,443.66	5,130.00	1,436.30	4,222.04	0.00	0.00	
3726	ADULT <40% EXP MAL E	0.00	15.75	0.00	0.00	342.00	0.00	0.00	0.00	0.00	22.57	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	750.80	859.07	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	1,026.00	0.00	569.61	193.95	342.00	17.60	1,026.00	684.00	59.40	0.00	0.00	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	177.00	0.00	0.00	0.00	0.00	0.00		177.00		
	14,288,592.20	13,293,822.90	15,303,619.55	12,461,534.03	12,212,840.75	12,845,446.82	11,112,103.12	12,213,130.22	15,485,335.05	13,627,401.56	0.00	0.00	132,843,826.20		

3906	NEWLY ELIGIBLE MALE	0.00	203.20	1,275.39	828.81	701.91	236.40	-321.76	0.00	144.81	0.00	0.00	0.00		3,068.76	
3907	NEWLY ELIGIBLE FEMA L	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	
3908	NEWLY ELIGIBLE M&F 4	15,345.28	11,628.43	8,100.42	10,133.07	1,752.05	4,453.59	7,582.29	3,898.85	5,012.67	4,024.10	0.00	0.00		71,930.75	
3909	NEWLY ELIGIBLE M&F 6	735.29	3,671.34	5,409.63	1,978.28	869.70	342.00	99.22	403.75	612.48	1,382.74	0.00	0.00		15,504.43	
3914	NEWLY ELIGIBLE MALE	4,167.88	7,302.00	4,425.47	2,808.00	1,488.00	2,100.00	5,310.68	3,762.00	6,841.18	4,804.00	0.00	0.00		43,009.21	
3915	NEWLY ELIGIBLE FEMA L	6,849.61	5,130.00	5,153.95	16,192.56	9,918.00	8,892.00	4,788.00	12,046.00	7,773.68	6,506.00	0.00	0.00		83,249.80	
3916	NEWLY ELIGIBLE MALE	163,852.24	96,121.50	114,419.26	136,067.12	99,557.58	147,259.86	180,796.79	248,927.91	208,787.19	184,361.36	0.00	0.00		1,580,150.81	
3917	NEWLY ELIGIBLE FEMA L	130,991.21	153,945.73	161,583.42	119,051.66	120,153.83	182,779.87	141,743.79	143,163.76	214,682.56	247,674.01	0.00	0.00		1,615,769.84	
3918	NEWLY ELIGIBLE M&F 4	497,280.63	460,771.54	605,755.88	482,433.85	408,590.11	510,683.87	396,880.22	640,738.13	737,814.28	721,593.94	0.00	0.00		5,462,542.45	
3919	NEWLY ELIGIBLE M&F 6	1,368.00	684.00	342.00	342.00	684.00	342.00	0.00	3,078.00	0.00	684.00	0.00	0.00		7,524.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	1,828.80	0.00	0.00	81.04	-50.26	12.33	0.00	0.00	0.00	0.00		1,871.91	
	821,286.14	739,457.74	910,004.22	770,177.35	643,715.18	859,564.63	736,828.97	1,056,030.73	1,181,668.85	1,171,030.15	0.00	0.00	8,889,763.96	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	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	
4413	SOBRA 100-133% M&F
6	220,130.89	222,012.81	266,413.75	194,465.10	218,511.10	269,032.43	147,392.76	188,647.69	240,154.55	204,076.50	0.00	0.00		2,170,837.58	
4414	SOBRA 100-133% MALE	72,117.92	76,274.16	82,444.14	73,759.67	76,608.64	119,426.62	63,981.86	66,257.48	68,753.70	93,817.27	0.00	0.00		793,441.46	
4415	SOBRA 100-133% FEM AL	96,355.37	96,932.98	126,797.45	85,782.45	115,138.49	95,705.82	68,567.55	89,173.70	92,053.26	101,927.57	0.00	0.00		968,434.64	
	393,242.18	397,613.95	477,365.34	355,375.22	411,284.23	484,506.87	279,942.17	344,078.87	400,961.51	399,821.34	0.00	0.00	3,944,191.68	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	2,688.00	342.00	0.00	1,026.00	5,195.38	2,564.21	11,685.00	34,409.00	1,718.00	0.00	0.00		59,627.59	
4518	BC PATIENT FEMALE 4 5	32,045.00	11,844.27	17,920.12	9,400.87	6,805.04	4,847.40	2,393.56	8,919.68	14,305.45	13,004.00	0.00	0.00		121,485.39	
4617	CC PATIENT FEMALE 2 1	2,736.00	0.00	342.00	342.00	0.00	0.00	0.00	0.00	0.00	1,710.00	0.00	0.00		5,130.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,392.00	0.00	0.00		1,392.00	
	34,781.00	14,532.27	18,604.12	9,742.87	7,831.04	10,042.78	4,957.77	20,604.68	48,714.45	17,824.00	0.00	0.00	187,634.98	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	1,454.42	423.99	3,462.33	95.70	1,337.44	1,055.50	146.04	1,367.26	3,920.05	714.56	0.00	0.00		13,977.29	
8710	SSI DISABLED FREEDO M	2,736.00	2,394.00	2,736.00	2,394.00	1,026.00	3,420.00	1,368.00	2,219.00	2,736.00	1,710.00	0.00	0.00		22,739.00	
8720	SSI DISABLED FREEDO M	256.13	68.12	137.78	69.66	559.18	188.46	20.52	283.41	342.09	473.77	0.00	0.00		2,399.12	
	4,446.55	2,886.11	6,336.11	2,559.36	2,922.62	4,663.96	1,534.56	3,869.67	6,998.14	2,898.33	0.00	0.00	39,115.41	

SUBTOTAL:

SUBTOTAL:

51,730,894.65	46,543,716.02	52,449,229.88	44,102,769.25	43,346,336.90	46,652,366.06	37,097,661.47	42,450,337.91	54,692,427.24	47,710,407.12	0.00	0.00	466,776,146.50	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
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	4,546.68	3,865.42	6,352.51	10,959.77	0.00	0.00		76,572.17		
1007	TANF 21-44 FEMALE WI	15,246.21	13,392.53	6,751.56	14,675.65	9,577.76	11,336.80	13,046.54	10,011.56	23,844.79	9,366.18	0.00	0.00		127,249.58		
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	1,835.59	2,622.86	12,551.73	9,579.73	0.00	0.00		42,411.84		
1009	TANF 65+ M & F WITH	554.64	167.54	167.54	989.97	404.94	1,330.92	1,008.69	656.07	679.26	1,384.34	0.00	0.00		7,343.91		
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	456,631.93	425,194.69	663,302.33	740,896.86	0.00	0.00		6,260,241.15		
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	572,543.00	557,355.22	623,306.06	407,329.67	0.00	0.00		5,288,087.57		
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	690,135.42	616,575.45	679,618.61	494,139.86	0.00	0.00		6,064,940.27		
1014	TANF 14-20 MALE NON-	215,330.10	202,961.83	122,006.47	131,859.01	138,434.30	149,689.00	136,427.78	114,447.36	125,415.76	166,436.20	0.00	0.00		1,503,007.81		
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	238,453.29	228,691.01	255,159.10	232,071.97	0.00	0.00		2,395,349.89		
1016	TANF 21-44 MALE NON-	445,479.43	357,175.48	371,805.96	385,447.27	373,782.12	534,280.58	426,230.07	400,938.91	594,364.11	555,651.35	0.00	0.00		4,445,155.28		
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	1,623,175.53	1,457,162.19	2,029,974.24	1,501,829.79	0.00	0.00		16,432,905.46		
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	456,540.50	697,957.34	623,594.14	619,771.05	0.00	0.00		5,591,252.18		
1019	TANF 65+ M & F NON-M	0.00	1,192.98	168.02	129.21	0.00	267.82	189.20	0.00	0.00	921.57	0.00	0.00		2,868.80		
1027	TANF 21-44 FEMALE WI	453.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133.88	0.00	0.00		586.90		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	1,898.77	48.02	1,153.89	548.73	1,034.61	161.39	0.00	0.00	0.00		4,845.41		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	579.23	189.48	0.00	0.00		768.71		
2100	SSI AGED WITH MEDIC A	52,744.87	38,379.36	63,306.89	38,592.69	38,601.30	41,184.93	42,731.47	32,952.03	64,058.11	52,017.20	0.00	0.00		464,568.85		
2110	SSI AGED NON-MEDIC AR	35,489.62	32,547.24	28,257.86	33,757.70	62,370.88	91,648.46	62,061.81	88,287.05	92,205.07	56,726.59	0.00	0.00		583,352.28		
2120	SSI AGED WITH QMB	242,074.39	213,448.56	215,432.79	251,120.09	199,731.99	296,487.60	216,161.35	232,684.94	301,368.74	204,549.54	0.00	0.00		2,373,059.99		
2200	SSI DISABLED WITH M E	266,485.96	172,649.08	166,477.74	168,126.72	107,342.11	208,194.12	235,382.60	162,186.11	266,128.37	220,270.27	0.00	0.00		1,973,243.08		
2210	SSI DISABLED NON-ME D	3,163,355.90	2,743,716.75	2,913,378.24	3,184,896.21	2,948,173.40	3,422,126.69	2,949,460.38	3,079,807.02	3,889,766.54	3,617,020.05	0.00	0.00		31,911,701.18		
2220	SSI DISABLED WITH Q M	1,005,134.11	652,376.80	671,203.10	879,517.48	604,374.03	971,973.67	725,474.26	663,349.59	1,094,513.43	713,219.60	0.00	0.00		7,981,136.07		
2300	SSI BLIND WITH MEDIC	1,296.92	715.33	578.36	108.23	597.93	1,358.09	247.77	420.92	55.06	120.62	0.00	0.00		5,499.23		
2310	SSI BLIND NON-MEDIC A	59,530.65	29,246.29	32,265.52	41,267.97	24,024.61	47,182.28	47,266.26	39,899.23	56,214.94	54,624.18	0.00	0.00		431,521.93		
2320	SSI BLIND WITH QMB	15,673.05	11,384.27	5,603.15	7,539.34	7,929.81	7,979.93	5,733.82	6,481.34	12,497.82	7,045.44	0.00	0.00		87,867.97		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.99	0.00	0.00		8.99		
4311	SOBRA CHILD <1 M & F	980,037.24	310,735.71	613,881.86	590,179.30	786,237.87	817,256.11	633,926.10	379,441.96	918,036.56	534,661.57	0.00	0.00		6,564,394.28		
4312	SOBRA CHILD 01-05 M	201,675.08	181,056.35	215,879.69	244,914.68	206,873.63	264,302.95	255,812.55	295,958.16	356,440.24	377,894.40	0.00	0.00		2,600,807.73		
4313	SOBRA CHILD 06-13 M	183,132.69	165,135.66	233,840.47	255,298.13	259,773.05	336,593.81	320,125.16	286,904.20	402,218.56	363,583.12	0.00	0.00		2,806,604.85		
4314	SOBRA CHILD 14-20 MA	100,507.75	88,002.42	83,325.00	101,286.62	131,567.89	224,273.14	127,095.05	88,077.85	109,147.07	131,607.80	0.00	0.00		1,184,890.59		
4315	SOBRA CHILD 14-20 FE	122,461.08	134,721.79	118,638.74	142,115.11	102,471.48	188,434.83	137,682.28	156,066.10	165,435.25	156,058.46	0.00	0.00		1,424,085.12		
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	29.51	573.05	-538.47	269.03	0.00	468.03	124.70	249.40	124.70	0.00	0.00	0.00		1,299.95		
5015	SOBRA PREG 14-20 FE M	139,377.14	102,991.33	94,124.61	75,488.88	92,219.48	72,357.05	76,567.97	96,907.50	94,353.38	72,009.18	0.00	0.00		916,396.52		
5017	SOBRA PREG 21-44 FE M	432,998.83	322,833.36	357,939.48	266,537.43	275,999.85	346,819.94	304,264.37	262,360.54	383,760.76	392,613.80	0.00	0.00		3,346,128.36		
5018	SOBRA PREG 45-64 FE M	1,755.04	448.74	37.60	89.34	1,571.88	0.00	-4.22	304.68	0.00	0.00	0.00	0.00		4,203.06		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
	12,024,874.74	9,732,874.71	10,510,025.42	10,831,619.88	10,075,545.71	13,029,659.90	10,761,426.63	10,388,851.31	13,845,227.86	11,704,692.51	0.00	0.00	112,904,798.67		

SUBTOTAL:

1106	TANF EXPANDED 21-44	20,739.17	8,100.82	5,105.04	16,969.98	16,315.91	25,654.78	9,065.90	6,072.46	11,075.92	7,080.24	0.00	0.00	
1107	TANF EXPANDED 21-44	29,774.01	15,342.27	11,557.24	27,241.00	15,808.78	31,606.96	19,031.27	17,814.69	28,948.99	14,450.62	0.00	0.00	
1108	TANF EXPANDED 45-64	68,920.08	45,889.75	52,345.68	63,765.68	44,053.64	83,548.49	61,984.50	48,297.66	81,044.60	52,240.76	0.00	0.00	
1109	TANF EXPANDED 65+
M&	7,438.23	9,025.57	11,942.73	14,963.64	7,844.84	7,355.78	9,384.41	11,139.56	21,453.86	13,865.21	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	48.77	99.94	0.00	0.00	488.08	0.00	976.16	0.00	366.06	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	4,152.37	748.37	5,140.86	2,399.27	2,463.17	3,860.05	3,169.85	656.36	4,046.94	4,772.64	0.00	0.00	
1113	TANF EXPANDED 06-13	6,195.30	5,396.23	5,514.09	8,387.09	4,731.25	11,193.70	8,196.01	7,361.38	6,212.15	6,722.68	0.00	0.00	
1114	TANF EXPANDED 14-20	1,476.39	759.67	2,431.97	793.98	4,046.68	3,130.26	2,069.88	2,621.11	3,004.84	4,460.47	0.00	0.00	
1115	TANF EXPANDED 14-20	8,362.55	3,636.28	5,678.74	11,722.66	9,565.08	8,621.41	6,375.46	9,133.47	9,118.39	11,857.76	0.00	0.00	
1116	TANF EXPANDED 21-44	160,136.01	138,780.95	155,648.92	181,818.28	166,653.11	251,575.84	239,363.40	256,006.56	202,898.29	200,303.13	0.00	0.00	
1117	TANF EXPANDED 21-44	325,927.10	311,091.45	313,484.04	303,205.38	282,787.57	356,435.46	280,238.60	216,260.67	371,552.72	309,239.67	0.00	0.00	
1118	TANF EXPANDED 45-64	213,882.58	282,231.58	291,882.45	403,598.03	308,839.42	406,130.11	268,988.75	259,799.04	315,497.38	342,211.53	0.00	0.00	
1119	TANF EXPANDED 65+
M&	2,212.51	3,660.81	319.01	9,424.88	978.17	2,470.29	1,323.82	188.69	7.67	1,516.97	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	136.46	103.16	2,049.05	1,778.84	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	1,144.97	418.21	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	8,788.71	5,329.02	6,434.73	11,838.31	0.00	0.00	
1129	TANF EXPANDED 65+
M&	4,480.09	3,133.32	1,382.57	3,058.45	4,663.60	1,009.16	479.16	2,767.12	5,121.17	3,388.99	0.00	0.00	
2400	SSI AGED EXPANDED WI	7,771.38	3,949.84	19,571.19	6,356.10	9,431.96	8,764.17	11,866.03	14,163.92	16,194.88	9,326.98	0.00	0.00	
2410	SSI AGED EXPANDED NO	97,330.44	71,054.90	28,493.77	28,675.55	24,511.62	30,078.51	10,883.51	29,308.55	62,343.55	28,535.15	0.00	0.00	
2420	SSI AGED EXPANDED WI	251,590.15	212,198.30	189,287.96	257,492.94	202,736.41	251,513.82	199,307.73	218,771.58	338,951.96	209,932.64	0.00	0.00	
2510	SSI BLIND EXPANDED 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	
2600	SSI DISABLED EXPAND E	5,268.61	6,530.52	5,282.47	4,928.44	5,127.86	10,453.85	7,678.10	7,382.07	3,259.78	1,464.87	0.00	0.00	
2610	SSI DISABLED EXPAND E	37,110.66	44,135.71	18,879.29	30,701.48	24,963.28	34,062.73	22,299.50	13,031.97	36,336.79	66,047.47	0.00	0.00	
2620	SSI DISABLED EXPAND E	140,475.36	103,873.91	91,251.84	130,395.87	96,370.81	142,403.88	113,173.20	108,358.50	184,855.31	140,108.27	0.00	0.00	
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	1,284,780.41	1,234,567.54	1,711,920.00	1,441,561.41	0.00	0.	

126,180.22	
211,575.83	
602,090.84	
114,413.83	
1,979.01	
31,409.88	
69,909.88	
24,795.25	
84,071.80	
1,953,184.49	
3,070,222.66	
3,093,060.87	
22,102.82	
4,067.51	
1,563.18	
65,737.73	
29,483.63	
107,396.45	
411,215.55	
2,331,783.49	
0.00	
57,376.57	
327,568.88	
1,251,266.95	
13,992,457.32	

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-216.52	0.00	0.00	0.00		-216.52	
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	-17.03	221.86	0.00	0.00	0.00		636.59	
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	
	-670.91	82.39	-177.32	128.06	68.17	-707.22	0.00	-17.03	5.34	0.00	0.00	0.00	-1,288.52	

00

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	-23.88	-86.21	0.00	-117.44	0.00	0.00	0.00	0.00	133.12	0.00	0.00	0.00	-94.41

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		-869.16		
3607	AHC CARE/MI FEMALE 2	0.00	0.00	3.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.75		
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	52.79	0.00	0.00	0.00		3,047.79		
3616	AHC CARE/MI MALE 21-	5,204.61	2,086.43	11,947.67	1,364.39	583.15	29,891.97	-22.04	-150.70	-613.56	0.00	0.00	0.00		50,291.92		
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	-229.08	352.67	0.00	0.00		24,774.42		
3618	AHC CARE/MI M&F 45-6	903.34	18,611.19	-266.03	755.16	111.01	-2,993.93	211.68	11.88	472.02	0.00	0.00	0.00		17,816.32		
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		
	12,870.75	42,748.13	12,694.35	6,495.04	639.13	23,304.93	189.64	-138.82	-184.71	352.67	0.00	0.00	98,971.11		

17,957.72	
0.00	
119,048.92	
4,224.37	
65,509.08	
63,339.27	
1,221,909.36	
852,422.69	
3,405,851.07	
2,103.95	
1,406.28	
0.00	
18,923.15	
22,950.14	
125,523.77	
1,857.50	
848,453.61	
709,799.83	
20,023,587.64	
8,553,207.00	
24,343,523.07	
27,443.24	
0.00	
4,782.10	
14,113.93	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	0.00	844.48	47.95	1,648.42	2,757.55	1,748.00	1,521.71	4,634.58	2,419.41	2,335.62	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	
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	6,733.29	7,624.19	9,536.38	6,364.01	0.00	0.00	
3509	ADULT 40-100% M&F 65	2,137.55	313.57	295.02	69.75	85.20	563.80	29.31	21.42	363.38	345.37	0.00	0.00	
3514	ADULT 40-100% MALE
1	299.88	76.69	10,062.27	2,334.06	3,113.47	11,571.62	19,246.97	10,245.30	5,588.41	2,970.41	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,481.60	6,383.38	6,313.09	10,036.45	4,665.75	6,673.90	4,725.95	4,671.30	8,598.00	9,789.85	0.00	0.00	
3516	ADULT 40-100% MALE
2	68,950.30	58,982.36	145,718.92	166,430.07	89,814.56	87,042.44	107,234.28	169,419.80	164,358.50	163,958.13	0.00	0.00	
3517	ADULT 40-100% FEMAL E	48,033.43	59,177.22	71,542.32	75,673.56	70,564.22	104,667.64	86,783.29	65,435.82	108,672.45	161,872.74	0.00	0.00	
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	289,143.38	352,567.93	444,677.04	377,453.81	0.00	0.00	
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	
3528	ADULT 40-100% M&F 45	10.33	0.00	0.00	0.00	0.00	994.55	275.65	125.75	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	
3706	ADULT <40% EXP MAL E	0.00	0.00	706.88	0.00	0.00	2,437.57	4,968.35	1,769.96	5,539.17	3,501.22	0.00	0.00	
3707	ADULT <40% EXP FEM AL	1,699.84	857.70	202.77	2,310.82	176.50	4,795.70	3,424.87	4,184.32	3,735.99	1,561.63	0.00	0.00	
3708	ADULT <40% EXP M&F 4	25,187.13	9,795.84	8,317.14	34,199.09	8,292.32	10,892.19	1,625.70	1,277.57	10,915.08	15,021.71	0.00	0.00	
3709	ADULT <40% EXP M&F 6	19.51	59.79	399.85	769.60	317.75	328.51	-21.98	-15.53	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	96,519.59	99,948.03	73,933.94	60,810.15	54,671.59	94,256.37	93,212.17	68,722.36	86,716.05	119,663.36	0.00	0.00	
3715	ADULT <40% EXP FEM AL	70,257.57	72,084.69	50,645.92	61,101.00	55,344.12	89,415.91	74,986.22	67,878.93	100,255.94	67,829.53	0.00	0.00	
3716	ADULT <40% EXP MAL E	2,056,952.53	1,717,512.69	1,635,655.49	1,942,921.88	1,764,448.36	2,192,772.90	1,865,496.71	2,058,308.59	2,484,583.01	2,304,935.48	0.00	0.00	
3717	ADULT <40% EXP FEM AL	763,329.78	694,754.25	852,786.42	872,179.85	771,277.55	1,138,319.38	790,511.47	759,837.69	1,090,777.50	819,433.11	0.00	0.00	
3718	ADULT <40% EXP M&F 4	2,272,604.78	1,714,216.40	2,195,997.31	2,260,024.67	2,159,280.04	2,731,933.74	2,422,694.32	2,386,383.08	3,380,681.38	2,819,707.35	0.00	0.00	
3719	ADULT <40% EXP M&F 6	1,162.92	2,296.70	1,971.08	6,521.44	6,116.57	4,101.15	3,363.33	873.97	1,036.08	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL 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	
3727	ADULT <40% EXP FEM AL	57.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,475.73	249.30	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	2,562.03	5,966.87	47.95	2,003.84	2,092.01	265.46	1,895.59	-719.82	0.00	0.00	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3729	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		
	5,669,460.82	4,764,474.08	5,331,290.31	5,835,977.65	5,346,772.57	6,966,584.87	5,778,047.00	5,964,232.49	7,914,825.09	6,876,272.81	0.00	0.00	60,447,937.69		

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	
3907	NEWLY ELIGIBLE FEMA L	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	
3908	NEWLY ELIGIBLE M&F 4	20,470.96	14,484.59	7,064.47	7,393.77	1,680.78	5,096.67	2,303.85	179.83	24.69	2,285.74	0.00	0.00		60,985.35	
3909	NEWLY ELIGIBLE M&F 6	0.00	824.23	603.22	0.00	1,297.92	0.00	0.00	204.26	183.55	144.59	0.00	0.00		3,257.77	
3914	NEWLY ELIGIBLE MALE	264.21	48.77	0.00	0.00	48.87	7.98	355.99	1,175.79	871.07	1,204.48	0.00	0.00		3,977.16	
3915	NEWLY ELIGIBLE FEMA L	1,257.16	3,440.78	6,661.64	2,380.78	2,672.71	3,816.05	168.94	600.79	2,263.38	1,548.28	0.00	0.00		24,810.51	
3916	NEWLY ELIGIBLE MALE	15,313.98	25,583.75	54,954.73	33,336.11	40,173.16	61,938.90	47,044.99	89,938.29	127,965.37	58,992.71	0.00	0.00		555,241.99	
3917	NEWLY ELIGIBLE FEMA L	15,483.34	24,987.66	67,374.92	31,854.35	20,317.81	34,921.96	26,304.11	33,178.90	45,931.02	58,112.53	0.00	0.00		358,466.60	
3918	NEWLY ELIGIBLE M&F 4	112,833.00	101,863.69	155,676.62	183,213.83	130,258.68	239,047.46	172,931.09	176,311.38	272,814.56	301,260.82	0.00	0.00		1,846,211.13	
3919	NEWLY ELIGIBLE M&F 6	61.82	47.49	0.00	0.00	0.00	0.00	57.05	516.95	112.46	19.62	0.00	0.00		815.39	
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	
	165,883.05	171,322.54	295,061.18	258,195.44	196,449.93	344,920.04	249,166.02	302,106.19	450,166.10	423,568.77	0.00	0.00	2,856,839.26	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	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	
4413	SOBRA 100-133% M&F
6	14,205.19	14,325.32	18,387.82	24,979.21	36,364.33	32,560.15	20,253.76	29,575.06	55,625.35	25,028.34	0.00	0.00		271,304.53	
4414	SOBRA 100-133% MALE	6,204.87	7,600.45	11,674.28	8,788.49	8,007.27	15,799.06	11,504.25	15,015.80	14,992.28	9,782.37	0.00	0.00		109,369.12	
4415	SOBRA 100-133% FEM AL	15,855.01	8,205.55	8,660.55	9,568.56	32,813.48	28,423.23	33,965.54	76,544.21	30,372.11	16,282.95	0.00	0.00		260,691.19	
	36,520.57	30,131.32	38,730.22	43,336.26	77,185.08	76,782.44	65,723.55	121,135.07	100,989.74	51,093.66	0.00	0.00	641,627.91	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71.19	0.00	0.00		71.19	
4518	BC PATIENT FEMALE 4 5	5,769.75	6,234.29	251.86	1,499.08	9,441.42	20,348.27	13,521.38	1,434.13	32,885.76	57,361.83	0.00	0.00		148,747.77	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	127.34	100.17	0.00	0.00	0.00	0.00	0.00	894.96	0.00	0.00		1,122.47	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,381.31	0.00	0.00	0.00		1,381.31	
	5,769.75	6,234.29	379.20	1,599.25	9,441.42	20,348.27	13,521.38	1,434.13	34,267.07	58,327.98	0.00	0.00	151,322.74	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	2,168.55	5,501.70	880.57	1,409.51	1,509.54	1,639.81	887.05	1,751.87	3,064.18	1,408.95	0.00	0.00		20,221.73	
8710	SSI DISABLED FREEDO M	22.57	0.00	0.00	381.74	0.00	174.86	84.58	0.00	31.43	887.07	0.00	0.00		1,582.25	
8720	SSI DISABLED FREEDO M	10.26	26.01	32.42	0.00	41.01	125.31	30.15	0.00	0.00	0.00	0.00	0.00		265.16	
	2,201.38	5,527.71	912.99	1,791.25	1,550.55	1,939.98	1,001.78	1,751.87	3,095.61	2,296.02	0.00	0.00	22,069.14	

SUBTOTAL:

SUBTOTAL:

TOTAL:	19,316,598.26	16,026,545.33	17,410,168.87	18,495,681.05	16,940,215.92	22,139,268.80	18,153,856.41	18,013,922.75	24,060,312.10	20,558,165.83	0.00	0.00	191,114,735.32		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
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		
1029	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		
2100	SSI AGED WITH 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		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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		
4303	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		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE 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		
5017	SOBRA PREG 21-44 FE 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		
5018	SOBRA PREG 45-64 FE 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		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		

SUBTOTAL:

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	
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	
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	
1109	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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
1129	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	
2400	SSI AGED EXPANDED 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	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED 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	
2510	SSI BLIND EXPANDED 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	
2600	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	
2610	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	
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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

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

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

00

SUBTOTAL:

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	0.00

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3607	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		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		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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:

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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
3706	ADULT <40% EXP MAL 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	
3707	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	
3708	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	
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	
3714	ADULT <40% EXP MAL 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	
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	
3716	ADULT <40% EXP MAL 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	
3717	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	
3718	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	
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	
3726	ADULT <40% EXP MAL 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	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3729	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		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3908	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	
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	
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	0.00	0.00	0.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	

SUBTOTAL:

4412	SOBRA 100-133% 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		0.00	
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	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	0.00	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:

4517	BC 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	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	0.00	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:

8700	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	
8710	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	
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:

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:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
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	723.19	0.00	0.00		723.19		
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	1,203.84	23.42	0.00	0.00	0.00		1,311.38		
1011	TANF <1 M & F NON-ME	32,641.98	541.56	2,292.08	1,081.20	3,965.35	15,581.06	662.96	2,432.26	1,268.93	10,092.12	0.00	0.00		70,559.50		
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	5,971.50	5,204.73	11,226.30	7,016.87	0.00	0.00		127,677.17		
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	5,311.10	1,930.52	9,082.92	8,168.08	0.00	0.00		56,964.49		
1014	TANF 14-20 MALE NON-	2,637.34	782.94	303.02	437.44	453.26	2,663.94	561.81	5,134.42	417.33	2,175.96	0.00	0.00		15,567.46		
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	3,249.69	7,930.12	14,244.70	4,163.12	0.00	0.00		95,401.82		
1016	TANF 21-44 MALE NON-	-210.03	1,528.38	2,803.51	3,725.36	13,026.52	3,548.64	44,918.80	17,557.97	4,684.59	2,584.49	0.00	0.00		94,168.23		
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	16,354.02	25,474.65	15,881.46	47,451.63	0.00	0.00		237,574.39		
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	2,475.23	1,337.50	17,305.88	5,455.60	0.00	0.00		85,604.54		
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		
1029	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		
2100	SSI AGED WITH MEDIC A	637.35	193.42	1,743.48	-72.49	2,408.61	193.66	-955.60	880.07	11,912.77	2,885.50	0.00	0.00		19,826.77		
2110	SSI AGED NON-MEDIC AR	18,494.71	22,036.44	13,385.43	24,808.71	11,022.36	27,393.53	2,646.53	10,662.13	8,305.40	28,767.51	0.00	0.00		167,522.75		
2120	SSI AGED WITH QMB	2,170.55	-2,697.32	219.69	106.83	2,442.67	-237.53	728.62	3,504.81	647.46	38.08	0.00	0.00		6,923.86		
2200	SSI DISABLED WITH M E	1,445.44	827.70	195.47	2,076.72	3,265.80	496.16	427.63	546.76	218.12	2,378.37	0.00	0.00		11,878.17		
2210	SSI DISABLED NON-ME D	105,053.82	209,122.34	14,233.08	27,623.51	41,144.54	124,521.23	49,712.76	19,611.03	89,415.36	31,569.34	0.00	0.00		712,007.01		
2220	SSI DISABLED WITH Q M	2,636.06	979.86	2,151.99	2,424.99	2,291.51	4,084.45	1,766.80	5,205.80	12,833.61	3,725.95	0.00	0.00		38,101.02		
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	66.53	0.00	0.00		66.53		
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		
4303	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		
4311	SOBRA CHILD <1 M & F	8,105.05	57,230.54	20,360.21	9,731.03	49,225.51	12,273.85	3,781.84	12,428.12	10,593.69	51,152.79	0.00	0.00		234,882.63		
4312	SOBRA CHILD 01-05 M	16,415.77	14,505.47	9,347.09	10,961.16	10,489.07	21,762.07	12,458.94	12,416.09	40,746.80	18,531.08	0.00	0.00		167,633.54		
4313	SOBRA CHILD 06-13 M	8,910.38	15,869.21	40,306.43	6,741.09	3,265.01	5,619.73	8,722.01	9,010.99	11,886.05	12,791.38	0.00	0.00		123,122.28		
4314	SOBRA CHILD 14-20 MA	3,167.94	14,900.22	4,753.71	1,882.40	27,838.60	5,260.76	4,820.81	8,972.96	8,843.07	13,977.17	0.00	0.00		94,417.64		
4315	SOBRA CHILD 14-20 FE	7,512.52	8,420.80	1,209.35	2,403.18	12,599.13	8,227.55	2,153.29	2,996.44	9,837.65	5,443.13	0.00	0.00		60,803.04		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	355.24	6,402.33	543.66	4,185.11	1,979.78	2,453.44	10,639.72	3,592.32	-1,517.75	6,668.41	0.00	0.00		35,302.26		
5017	SOBRA PREG 21-44 FE M	8,677.15	1,983.35	8,295.19	11,055.70	14,341.20	6,590.59	12,448.89	11,107.24	23,965.56	19,354.64	0.00	0.00		117,819.51		
5018	SOBRA PREG 45-64 FE 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		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
	279,494.58	400,131.33	195,187.72	183,953.45	243,712.09	328,694.43	188,857.35	169,140.77	301,823.32	285,180.94	0.00	0.00	2,576,175.98		

SUBTOTAL:

1106	TANF EXPANDED 21-44	100.87	0.00	51.03	34.58	1.71	57.07	537.44	0.00	51.91	841.65	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	9.77	0.00	205.74	104.50	543.58	14.51	0.00	0.00	
1108	TANF EXPANDED 45-64	556.81	778.47	121.83	27.05	48.02	1,829.93	105.27	33.58	210.74	150.59	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	12.33	0.00	73.33	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	48.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88.38	0.00	0.00	
1112	TANF EXPANDED 01-05	278.80	517.28	0.00	0.00	0.00	47.05	0.00	508.87	737.47	287.62	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	65.60	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	75.74	259.34	9.52	213.72	0.00	0.00	
1115	TANF EXPANDED 14-20	1,795.17	675.99	18.36	46.44	478.45	105.17	0.00	-396.32	279.31	2,104.72	0.00	0.00	
1116	TANF EXPANDED 21-44	8,190.51	8,056.75	2,683.69	7,220.52	14,719.71	14,535.28	2,495.65	19,199.76	847.38	11,941.21	0.00	0.00	
1117	TANF EXPANDED 21-44	18,106.82	9,214.66	10,448.05	2,162.79	6,352.61	7,298.26	5,797.94	12,263.89	16,085.88	18,980.80	0.00	0.00	
1118	TANF EXPANDED 45-64	12,066.69	7,108.61	8,473.65	2,086.26	460.87	5,755.51	2,315.51	14,755.27	16,831.20	41,428.56	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	
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	
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	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	519.37	-158.33	1.83	586.92	19.04	0.00	0.00	0.00	
1129	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	
2400	SSI AGED EXPANDED WI	79.87	2,681.23	65.99	2,450.62	228.71	2,882.84	338.27	1,228.66	1,577.66	2,341.45	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	1,192.03	0.00	1,323.58	898.69	107.68	279.55	130.72	170.11	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	1,266.08	1,879.33	-20.58	613.30	3,749.81	1,859.92	2,670.11	1,066.42	1,021.36	648.90	0.00	0.00	
2510	SSI BLIND EXPANDED 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	
2600	SSI DISABLED EXPAND E	221.18	1,442.53	26.49	170.03	81.86	21.80	77.60	1,261.94	747.67	1,195.03	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	364.40	0.00	3,604.19	-84.18	1,518.47	455.43	6,969.97	5,121.03	0.00	0.00	
2620	SSI DISABLED EXPAND E	504.00	504.00	0.00	151.88	1,131.21	302.92	729.60	595.67	991.91	1,887.59	0.00	0.00	
SUBTOTAL:	44,281.56	34,099.65	23,776.26	16,287.05	32,582.91	34,578.34	17,161.05	52,054.65	47,233.64	87,245.76	0.00	0.	

1,676.26	
878.10	
3,862.29	
85.66	
137.15	
2,377.09	
65.60	
3,531.78	
5,107.29	
89,890.46	
106,711.70	
111,282.13	
0.00	
0.00	
0.00	
968.83	
0.00	
13,875.30	
4,102.36	
14,754.65	
0.00	
5,246.13	
17,949.31	
6,798.78	
389,300.87	

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	
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	
	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	

00

SUBTOTAL:

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	0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	-629.30	0.00	0.00	-663.30	0.00	0.00	0.00		-1,292.60		
3607	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	137.19	0.00	0.00		2,222.66		
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	2,358.55	0.00	13,162.64	-88.86	0.00	0.00		75,807.30		
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		
	327.33	88,893.65	2,429.76	8,628.51	-12.40	-629.30	2,358.55	0.00	12,499.34	48.33	0.00	0.00	114,543.77		

0.00	
0.00	
288.01	
0.00	
6,128.04	
8,375.59	
210,118.17	
76,392.17	
436,872.39	
0.00	
2,047.01	
0.00	
-466.71	
-352.31	
5,465.35	
0.00	
45,957.10	
20,690.56	
723,994.18	
225,489.12	
740,031.46	
0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

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	
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	
3508	ADULT 40-100% M&F 45	0.00	28.68	0.00	207.88	0.00	0.00	0.00	51.45	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	
3514	ADULT 40-100% MALE
1	0.00	1,037.95	1,111.41	154.62	640.94	1,401.60	-2.61	0.00	1,784.13	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	468.93	4,952.17	301.80	0.00	426.91	586.91	558.08	554.88	733.30	-207.39	0.00	0.00	
3516	ADULT 40-100% MALE
2	11,090.38	8,180.30	12,187.52	8,047.54	47,784.89	24,877.47	35,245.89	23,201.48	12,408.35	27,094.35	0.00	0.00	
3517	ADULT 40-100% FEMAL E	11,245.70	3,906.95	14,416.97	8,265.10	5,315.72	7,064.14	5,901.85	3,851.20	9,548.67	6,875.87	0.00	0.00	
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	27,535.39	36,841.44	36,807.49	40,057.77	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	118.32	472.68	1,456.01	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	
3706	ADULT <40% EXP MAL E	0.00	0.00	-101.13	134.02	-516.96	0.00	0.00	17.36	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	-352.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	-72.49	0.00	2,629.57	1,220.98	-171.35	0.00	654.80	1,203.84	0.00	0.00	0.00	
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	
3714	ADULT <40% EXP MAL E	2,032.24	5,562.92	16,066.16	20.67	2,194.40	10,833.05	1,242.77	2,958.48	1,454.51	3,591.90	0.00	0.00	
3715	ADULT <40% EXP FEM AL	3,136.03	1,842.31	1,286.62	2,814.13	1,954.28	1,812.42	1,032.73	2,400.76	2,760.02	1,651.26	0.00	0.00	
3716	ADULT <40% EXP MAL E	81,484.42	56,813.62	41,056.81	57,543.56	55,410.44	121,662.05	47,360.44	70,566.21	74,033.75	118,062.88	0.00	0.00	
3717	ADULT <40% EXP FEM AL	15,464.69	7,575.62	11,004.31	18,345.03	15,707.90	25,521.33	61,116.83	26,314.24	22,945.85	21,493.32	0.00	0.00	
3718	ADULT <40% EXP M&F 4	68,101.26	119,344.07	112,828.42	120,940.44	53,059.86	61,079.88	53,546.39	18,692.31	87,740.89	44,697.94	0.00	0.00	
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	
3726	ADULT <40% EXP MAL 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	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3729	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		
	227,751.86	286,720.57	258,100.30	287,145.84	199,194.56	305,688.92	233,656.08	186,577.29	252,876.81	263,317.90	0.00	0.00	2,501,030.13		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3907	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	
3908	NEWLY ELIGIBLE M&F 4	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	
3909	NEWLY ELIGIBLE M&F 6	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	3,503.01	6,302.13	3,109.36	3,455.34	0.00	0.00		65,031.72	
3917	NEWLY ELIGIBLE FEMA L	169.41	212.50	2,051.45	5,094.89	9,685.39	12,406.06	1,912.39	20,065.45	4,056.67	1,867.58	0.00	0.00		57,521.79	
3918	NEWLY ELIGIBLE M&F 4	45,902.49	23,614.63	57,874.92	12,240.95	1,212.37	15,337.49	6,380.33	13,574.40	20,728.56	22,503.27	0.00	0.00		219,369.41	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
	57,698.27	37,109.02	60,846.78	18,139.57	27,613.21	34,097.02	11,795.73	39,941.98	27,894.59	27,826.19	0.00	0.00	342,962.36	

SUBTOTAL:

4412	SOBRA 100-133% 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		0.00	
4413	SOBRA 100-133% M&F
6	145.71	286.93	175.46	86.90	461.89	139.55	326.37	544.21	895.69	361.01	0.00	0.00		3,423.72	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160.89	335.33	0.00	0.00	0.00		496.22	
4415	SOBRA 100-133% FEM AL	798.96	84.38	662.74	231.12	54.53	0.00	123.06	163.98	0.00	3.02	0.00	0.00		2,121.79	
	944.67	371.31	838.20	318.02	516.42	139.55	449.43	869.08	1,231.02	364.03	0.00	0.00	6,041.73	

SUBTOTAL:

4517	BC 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	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	63.08	0.00	5,650.43	4,681.60	0.00	0.00	256.94	0.00	0.00	0.00		10,652.05	
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	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	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	256.94	0.00	0.00	0.00	10,652.05	

SUBTOTAL:

8700	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	
8710	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	
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:

SUBTOTAL:

TOTAL:	610,498.27	847,325.53	541,242.10	514,472.44	509,257.22	706,633.85	454,278.19	448,583.77	643,815.66	663,983.15	0.00	0.00	5,940,090.18		

SUBTOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
8020	QMB ONLY	20,749.45	33,935.21	14,028.32	27,958.67	25,170.82	15,406.80	20,443.40	23,873.25	27,525.01	23,236.64	0.00	0.00		232,327.57		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	594.92	0.00	0.00	0.00		594.92		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	20,749.45	33,935.21	14,028.32	27,958.67	25,170.82	15,406.80	20,443.40	23,873.25	28,119.93	23,236.64	0.00	0.00	232,922.49		

20,749.45	33,935.21	14,028.32	27,958.67	25,170.82	15,406.80	20,443.40	23,873.25	28,119.93	23,236.64	0.00	0.00	232,922.49	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	349.92	0.00	202.46	0.00	0.00	0.00		552.38		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	349.92	0.00	202.46	0.00	0.00	0.00	552.38		

SUBTOTAL:

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	349.92	0.00	202.46	0.00	0.00	0.00	552.38		

SUBTOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
8020	QMB ONLY	206,280.04	288,775.58	184,962.59	308,199.09	179,270.46	211,109.78	313,044.03	295,514.04	357,924.75	206,373.85	0.00	0.00		2,551,454.21		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.91	0.00	0.00	0.00		18.91		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.46	0.00	0.00	0.00		24.46		
	206,280.04	288,775.58	184,962.59	308,199.09	179,270.46	211,109.78	313,044.03	295,514.04	357,968.12	206,373.85	0.00	0.00	2,551,497.58		

206,280.04	288,775.58	184,962.59	308,199.09	179,270.46	211,109.78	313,044.03	295,514.04	357,968.12	206,373.85	0.00	0.00	2,551,497.58	

TOTAL:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
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	646.49	659.54	179.68	204.01	0.00	0.00		7,562.52		
1007	TANF 21-44 FEMALE WI	0.00	0.00	76.06	200.52	1,632.36	1,021.63	643.45	0.00	687.53	2,404.28	0.00	0.00		6,665.83		
1008	TANF 45-64 M & F WIT	17,781.02	3,645.96	1,696.48	3,172.67	1,729.21	528.10	1,029.12	0.00	1,183.52	132.49	0.00	0.00		30,898.57		
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	77,920.23	72,794.18	104,653.25	44,838.21	0.00	0.00		775,891.43		
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	29,931.96	52,276.54	54,439.49	28,141.16	0.00	0.00		375,948.11		
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	50,606.42	42,765.60	44,785.05	21,714.65	0.00	0.00		362,339.28		
1014	TANF 14-20 MALE NON-	15,430.38	11,665.16	7,111.65	20,421.48	7,244.37	2,791.98	3,614.29	2,157.30	33,195.04	2,777.63	0.00	0.00		106,409.28		
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	21,175.21	20,053.77	26,765.23	32,287.90	0.00	0.00		219,094.99		
1016	TANF 21-44 MALE NON-	31,438.66	90,378.80	52,569.64	34,461.16	108,919.86	23,309.93	15,940.68	51,425.58	51,537.44	15,320.58	0.00	0.00		475,302.33		
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	173,931.99	194,251.26	242,768.37	128,596.56	0.00	0.00		2,092,562.87		
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	42,049.58	42,373.30	67,236.17	24,828.03	0.00	0.00		469,015.88		
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	7.37	0.00	0.00	0.00		2,503.05		
1029	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		
2100	SSI AGED WITH MEDIC A	3,406.77	3,502.09	22,471.78	3,517.45	423.74	1,772.59	3,983.64	2,668.04	9,012.46	33,334.52	0.00	0.00		84,093.08		
2110	SSI AGED NON-MEDIC AR	3,421.42	2,145.00	8,256.64	512.70	8,011.63	25,051.00	4,010.32	9,427.38	6,372.30	3,079.28	0.00	0.00		70,287.67		
2120	SSI AGED WITH QMB	19,926.84	9,704.83	11,229.65	11,879.83	7,652.19	9,485.76	12,227.81	11,606.93	19,373.28	4,529.47	0.00	0.00		117,616.59		
2200	SSI DISABLED WITH M E	13,662.86	42,533.24	8,606.75	8,165.79	2,835.72	7,637.69	12,933.01	9,303.59	37,881.99	6,896.20	0.00	0.00		150,456.84		
2210	SSI DISABLED NON-ME D	304,798.51	274,300.06	347,966.26	367,239.77	297,453.68	425,900.14	140,094.61	350,891.99	324,855.34	252,871.37	0.00	0.00		3,086,371.73		
2220	SSI DISABLED WITH Q M	44,399.62	28,504.92	37,846.70	41,122.70	31,745.14	51,923.95	42,526.75	34,655.11	55,543.24	33,395.44	0.00	0.00		401,663.57		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	12.47	10.76	233.13	65.86	0.00	0.00		322.22		
2310	SSI BLIND NON-MEDIC A	1,234.87	4,195.67	9,915.12	9,034.84	3,766.75	18,018.26	4,816.22	6,997.74	4,081.94	469.04	0.00	0.00		62,530.45		
2320	SSI BLIND WITH QMB	284.04	190.07	34.82	83.25	1,364.10	1,421.91	42.24	1,094.50	194.23	48.46	0.00	0.00		4,757.62		
4303	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		
4311	SOBRA CHILD <1 M & F	68,145.48	122,295.23	44,411.54	51,135.66	70,020.85	80,802.76	76,028.71	46,758.70	76,206.40	87,975.39	0.00	0.00		723,780.72		
4312	SOBRA CHILD 01-05 M	35,241.49	10,786.90	16,480.16	10,148.36	38,674.66	14,867.45	17,686.08	16,510.96	29,178.78	27,756.74	0.00	0.00		217,331.58		
4313	SOBRA CHILD 06-13 M	30,113.38	19,957.23	13,761.72	18,897.97	31,261.64	25,114.53	12,313.42	21,464.91	25,356.38	18,019.65	0.00	0.00		216,260.83		
4314	SOBRA CHILD 14-20 MA	8,988.63	11,572.81	49,513.15	8,829.09	10,119.53	11,679.90	9,149.79	66,222.33	21,459.42	7,891.86	0.00	0.00		205,426.51		
4315	SOBRA CHILD 14-20 FE	5,849.26	9,327.77	19,160.53	25,805.46	6,059.50	24,896.83	9,303.78	8,984.96	9,443.06	6,816.10	0.00	0.00		125,647.25		
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	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		
5015	SOBRA PREG 14-20 FE M	18,102.67	16,540.26	22,290.29	19,379.70	16,315.61	20,161.18	24,209.00	5,048.99	8,059.56	7,814.00	0.00	0.00		157,921.26		
5017	SOBRA PREG 21-44 FE M	46,014.10	38,107.35	41,483.13	43,985.14	85,760.52	73,163.80	60,546.22	55,086.86	47,493.31	34,140.17	0.00	0.00		525,780.60		
5018	SOBRA PREG 45-64 FE M	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		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
	1,085,121.32	1,077,656.57	1,170,342.64	1,135,696.52	1,284,454.27	1,222,462.97	847,373.49	1,125,490.82	1,302,182.96	826,349.05	0.00	0.00	11,077,130.61		

SUBTOTAL:

1106	TANF EXPANDED 21-44	119.42	25.23	78.80	47.95	199.06	155.04	43.84	0.00	3,412.70	203.26	0.00	0.00	
1107	TANF EXPANDED 21-44	1,570.36	494.47	2,718.86	738.57	554.79	2,100.66	298.44	585.04	2,674.38	311.66	0.00	0.00	
1108	TANF EXPANDED 45-64	1,427.07	1,230.37	1,181.81	1,841.38	2,680.20	1,879.82	3,445.75	1,837.72	1,668.30	1,800.75	0.00	0.00	
1109	TANF EXPANDED 65+
M&	1,503.33	1,346.31	2,101.21	1,694.86	1,217.22	393.84	200.07	156.04	3,225.20	0.00	0.00	0.00	
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	
1112	TANF EXPANDED 01-05	0.00	0.00	72.20	388.36	123.38	525.42	0.00	0.00	0.00	65.14	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	23.26	2,001.11	289.33	58.19	25.68	136.73	368.12	808.50	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	714.51	0.00	0.00	0.00	744.18	5,125.42	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	43.90	25,084.37	676.23	4,041.15	0.00	287.57	1,157.91	105.70	249.15	435.12	0.00	0.00	
1116	TANF EXPANDED 21-44	35,961.69	29,723.91	64,877.10	39,996.25	29,521.67	48,786.73	4,875.21	22,348.89	20,785.82	17,759.62	0.00	0.00	
1117	TANF EXPANDED 21-44	58,248.53	64,960.99	41,406.57	64,814.97	44,661.09	51,287.93	46,801.42	66,827.74	62,051.96	46,076.66	0.00	0.00	
1118	TANF EXPANDED 45-64	24,913.23	24,501.96	14,774.51	10,276.28	36,244.58	57,446.04	6,711.34	13,344.03	76,618.24	36,147.40	0.00	0.00	
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	
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	
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	
1128	TANF EXPANDED 45-64	55.28	0.00	0.00	59.20	0.00	0.00	0.00	341.45	205.54	643.36	0.00	0.00	
1129	TANF EXPANDED 65+
M&	94.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	794.63	64.31	296.56	488.33	532.96	174.38	789.58	51.29	77.04	58.67	0.00	0.00	
2410	SSI AGED EXPANDED NO	2,136.82	1,127.00	32,303.41	181.99	7,896.84	4,731.55	367.54	1,145.93	497.34	2,239.77	0.00	0.00	
2420	SSI AGED EXPANDED WI	12,344.05	8,798.39	10,022.98	21,813.21	12,292.05	16,285.22	13,587.39	15,398.77	16,267.68	11,761.94	0.00	0.00	
2510	SSI BLIND EXPANDED 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	
2600	SSI DISABLED EXPAND E	92.70	1,634.66	153.11	633.37	245.75	775.39	126.95	1,623.11	57.02	1,297.34	0.00	0.00	
2610	SSI DISABLED EXPAND E	209.07	879.14	542.12	152.63	484.69	1,690.72	559.20	1,042.61	1,486.78	3,497.18	0.00	0.00	
2620	SSI DISABLED EXPAND E	5,857.19	6,083.62	8,430.23	10,318.47	4,888.14	9,696.68	7,729.57	7,844.16	12,820.17	8,246.27	0.00	0.00	
SUBTOTAL:	145,371.72	165,977.99	181,636.81	158,742.09	141,600.61	196,242.67	86,830.94	133,764.78	208,031.24	130,544.14	0.00	0.	

4,285.30	
12,047.23	
18,993.17	
11,838.08	
0.00	
1,174.50	
3,710.92	
6,584.11	
32,081.10	
314,636.89	
547,137.86	
300,977.61	
251.28	
0.00	
0.00	
1,304.83	
94.45	
3,327.75	
52,628.19	
138,571.68	
0.00	
6,639.40	
10,544.14	
81,914.50	
1,548,742.99	

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

00

SUBTOTAL:

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	0.00

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3607	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3608	AHC CARE/MI M&F 45-6	240.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	17,445.06	0.00	0.00	0.00	0.00	0.00		19,031.74		
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		
	3,879.93	1,589.49	0.00	1,026.63	0.00	0.00	17,445.06	0.00	0.00	0.00	0.00	0.00	23,941.11		

1,374.11	
0.00	
2,904.94	
248.95	
1,667.25	
66,602.38	
279,302.83	
191,528.13	
488,839.12	
0.00	
143.56	
0.00	
0.00	
137.97	
10,338.29	
463.46	
203,521.45	
73,611.39	
2,132,697.67	
1,035,554.16	
1,912,810.34	
0.00	
0.00	
0.00	
2,177.37	

SUBTOTAL:

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	
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	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	238.95	260.24	857.68	37.04	1,511.03	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	248.95	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	631.02	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	622.49	0.00	59,547.91	88.87	832.56	2,329.13	0.00	2,404.87	776.55	0.00	0.00	
3516	ADULT 40-100% MALE
2	10,650.89	12,406.82	21,631.24	46,981.49	51,964.90	14,495.98	25,472.96	18,614.88	37,792.32	39,291.35	0.00	0.00	
3517	ADULT 40-100% FEMAL E	23,738.59	15,286.50	26,420.79	6,921.32	12,108.62	13,804.70	15,773.22	25,312.08	17,520.30	34,642.01	0.00	0.00	
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	31,588.83	86,216.05	56,688.53	57,429.73	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	143.56	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	
3706	ADULT <40% EXP MAL 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	
3707	ADULT <40% EXP FEM AL	0.00	0.00	30.31	0.00	0.00	0.00	0.00	0.00	0.00	107.66	0.00	0.00	
3708	ADULT <40% EXP M&F 4	2,451.54	2,205.17	837.47	2,507.14	242.63	29.18	68.64	0.00	24.55	1,971.97	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	15.53	92.18	0.00	0.00	355.75	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	9,500.36	10,625.57	21,121.50	11,841.58	3,681.24	39,851.20	24,621.46	10,399.28	7,085.09	64,794.17	0.00	0.00	
3715	ADULT <40% EXP FEM AL	5,377.86	6,773.87	7,868.05	10,382.13	4,451.64	8,838.72	5,224.44	6,678.67	14,337.29	3,678.72	0.00	0.00	
3716	ADULT <40% EXP MAL E	277,274.99	198,707.59	245,049.44	174,444.82	231,171.84	198,713.09	166,837.99	173,100.37	269,389.02	198,008.52	0.00	0.00	
3717	ADULT <40% EXP FEM AL	85,369.64	98,701.56	110,904.18	120,526.37	105,896.01	99,243.84	85,034.38	123,452.44	141,416.38	65,009.36	0.00	0.00	
3718	ADULT <40% EXP M&F 4	224,721.51	183,380.20	180,656.00	144,133.87	101,728.41	197,478.39	309,963.80	228,965.64	196,024.56	145,757.96	0.00	0.00	
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	
3726	ADULT <40% EXP MAL 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	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	119.13	1,433.19	0.00	0.00	0.00	0.00	577.08	47.97	0.00	0.00	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3729	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		
	669,350.85	564,369.96	682,495.86	623,256.49	556,025.49	610,565.22	668,796.06	672,776.45	744,771.02	611,515.97	0.00	0.00	6,403,923.37		

3906	NEWLY ELIGIBLE MALE	225.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.11	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3908	NEWLY ELIGIBLE M&F 4	586.88	785.65	1,040.86	371.90	185.31	2,517.06	0.00	83.50	0.00	0.00	0.00	0.00		5,571.16	
3909	NEWLY ELIGIBLE M&F 6	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	3,958.23	54.28	0.00	0.00		4,217.80	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	189.27	0.00	0.00	0.00	0.00	448.91	0.00	0.00		638.18	
3916	NEWLY ELIGIBLE MALE	666.79	6,008.90	2,042.85	9,520.01	2,330.93	12,143.11	280.48	1,386.73	11,160.59	2,360.39	0.00	0.00		47,900.78	
3917	NEWLY ELIGIBLE FEMA L	6,073.87	2,908.38	28,820.75	5,207.82	6,142.79	2,254.19	5,649.24	13,448.54	16,490.14	6,151.45	0.00	0.00		93,147.17	
3918	NEWLY ELIGIBLE M&F 4	12,815.15	13,132.47	36,447.31	25,077.39	78,513.35	17,567.47	12,019.88	31,489.12	31,504.95	21,251.91	0.00	0.00		279,819.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
	20,367.80	22,835.40	68,351.77	40,227.14	87,566.94	34,481.83	17,949.60	46,407.89	63,113.91	30,266.94	0.00	0.00	431,569.22	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	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	
4413	SOBRA 100-133% M&F
6	1,505.68	1,455.19	1,299.50	10,273.42	8,846.56	3,004.47	1,235.06	800.55	2,231.45	921.76	0.00	0.00		31,573.64	
4414	SOBRA 100-133% MALE	7,017.47	3,205.98	203.46	528.24	260.08	1,159.55	6,060.08	1,025.42	0.00	1,367.44	0.00	0.00		20,827.72	
4415	SOBRA 100-133% FEM AL	381.31	0.00	319.14	1,140.59	9,913.01	3,703.03	87.83	973.33	4,197.82	808.34	0.00	0.00		21,524.40	
	8,988.52	4,661.17	1,822.10	11,942.25	19,019.65	7,867.05	7,382.97	2,799.30	6,429.27	3,097.54	0.00	0.00	74,009.82	

SUBTOTAL:

4517	BC 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	
4518	BC PATIENT FEMALE 4 5	2,630.32	2,465.34	58.12	2,640.75	5,006.95	2,566.37	3,422.82	0.00	521.91	0.00	0.00	0.00		19,312.58	
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	
4618	CC PATIENT FEMALE 4 5	0.00	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	3,422.82	0.00	521.91	0.00	0.00	0.00	19,312.58	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	324.38	62.22	0.00	0.00	0.00	0.00	0.00	0.00	940.33	0.00	0.00	0.00		1,326.93	
8710	SSI DISABLED FREEDO M	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	
8720	SSI DISABLED FREEDO M	0.00	37.44	18.72	160.74	0.00	0.00	37.44	0.00	0.00	0.00	0.00	0.00		254.34	
	324.38	99.66	18.72	160.74	0.00	89.35	37.44	0.00	940.33	0.00	0.00	0.00	1,670.62	

SUBTOTAL:

SUBTOTAL:

TOTAL:	1,936,034.84	1,839,655.58	2,104,726.02	1,973,692.61	2,093,673.91	2,074,275.46	1,649,238.38	1,981,239.24	2,325,990.64	1,601,773.64	0.00	0.00	19,580,300.32		

8710	SSI DISABLED FREEDO M	0.00	43.89	51.65	121.44	0.00	0.00	0.00	0.00	154.92	0.00	0.00	0.00		371.90	
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	43.89	51.65	121.44	0.00	0.00	0.00	0.00	154.92	0.00	0.00	0.00	371.90	

SUBTOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER

For The Period Ending April 30, 2015	
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	48.60	0.00	684.00	684.00	0.00	0.00		7,974.56		
2100	SSI AGED WITH MEDIC A	182,999.78	206,203.74	177,774.65	192,246.43	141,311.29	189,450.03	164,492.17	156,930.78	276,365.47	174,489.71	0.00	0.00		1,862,264.05		
2110	SSI AGED NON-MEDIC AR	69,456.96	25,781.96	23,642.14	45,010.52	21,237.89	49,688.78	18,544.86	46,293.09	39,794.40	20,902.29	0.00	0.00		360,352.89		
2120	SSI AGED WITH QMB	194,238.72	171,693.51	188,023.41	210,964.33	149,565.05	176,178.38	156,993.85	157,788.67	200,330.47	164,388.18	0.00	0.00		1,770,164.57		
2200	SSI DISABLED WITH M E	45,131.68	36,659.49	44,022.63	49,795.83	32,822.35	35,765.73	29,162.27	29,998.86	44,471.22	38,050.86	0.00	0.00		385,880.92		
2210	SSI DISABLED NON-ME D	893,176.80	795,148.70	804,113.36	726,804.46	660,524.02	780,792.25	607,604.95	655,385.27	913,413.46	786,063.20	0.00	0.00		7,623,026.47		
2220	SSI DISABLED WITH Q M	75,691.55	64,844.94	78,301.76	97,280.92	63,449.00	77,800.76	60,524.31	53,527.37	76,351.94	60,028.09	0.00	0.00		707,800.64		
2300	SSI BLIND WITH MEDIC	0.00	80.33	204.74	-96.39	265.35	0.00	0.00	52.25	0.00	0.00	0.00	0.00		506.28		
2310	SSI BLIND NON-MEDIC A	9,875.35	16,860.00	11,977.29	7,137.09	10,464.54	8,935.89	19,352.16	10,602.00	7,866.00	11,194.79	0.00	0.00		114,265.11		
2320	SSI BLIND WITH QMB	144.17	131.13	248.54	758.75	457.24	1,165.03	357.32	117.00	609.01	30.20	0.00	0.00		4,018.39		
	1,471,411.01	1,318,771.80	1,330,018.52	1,331,659.90	1,080,438.73	1,320,460.85	1,057,080.49	1,110,695.29	1,559,885.97	1,255,831.32	0.00	0.00	12,836,253.88		

SUBTOTAL:

1,471,411.01	1,318,815.69	1,330,070.17	1,331,781.34	1,080,438.73	1,320,460.85	1,057,080.49	1,110,695.29	1,560,040.89	1,255,831.32	0.00	0.00	12,836,625.78	

TOTAL:

8710	SSI DISABLED FREEDO M	0.00	4,543.62	2,285.20	2,174.88	2,122.56	0.00	4,582.80	1,656.24	1,800.96	2,058.24	0.00	0.00		21,224.50	
8720	SSI DISABLED FREEDO M	2,742.24	2,647.68	2,966.82	2,957.30	3,061.20	3,376.80	1,688.40	506.52	1,242.18	2,990.88	0.00	0.00		24,180.02	
	2,742.24	7,191.30	5,252.02	5,132.18	5,183.76	3,376.80	6,271.20	2,162.76	3,043.14	5,049.12	0.00	0.00	45,404.52	

SUBTOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending April 30, 2015	
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	2,664,791.67	2,286,017.04	2,299,939.18	2,502,189.39	2,230,289.96	2,506,926.63	2,180,726.34	2,080,624.01	2,842,635.18	2,229,654.11	0.00	0.00		23,823,793.51		
2110	SSI AGED NON-MEDIC AR	179,461.32	166,339.47	142,936.57	138,988.15	157,154.98	155,955.08	181,153.73	146,860.01	209,264.27	131,264.77	0.00	0.00		1,609,378.35		
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	2,780,018.44	2,885,520.37	3,387,551.62	2,924,055.18	0.00	0.00		30,028,153.87		
2200	SSI DISABLED WITH M E	466,608.06	464,804.54	438,058.71	500,388.76	427,476.48	524,802.68	397,076.96	457,472.85	483,961.70	451,340.31	0.00	0.00		4,611,991.05		
2210	SSI DISABLED NON-ME D	1,779,146.34	1,594,652.73	1,743,036.88	1,697,019.69	1,672,951.87	2,048,985.48	1,736,622.86	1,494,859.65	2,420,665.89	1,998,078.04	0.00	0.00		18,186,019.43		
2220	SSI DISABLED WITH Q M	668,132.19	607,853.55	577,938.21	677,284.14	613,119.73	679,406.95	608,068.65	575,512.83	695,569.98	557,702.01	0.00	0.00		6,260,588.24		
2300	SSI BLIND WITH MEDIC	379.43	20.74	0.00	0.00	0.00	0.00	94.15	144.94	2,494.65	0.00	0.00	0.00		3,133.91		
2310	SSI BLIND NON-MEDIC A	9,691.63	6,114.88	7,549.04	7,270.26	11,574.85	10,740.90	6,427.64	7,063.86	7,612.07	9,297.78	0.00	0.00		83,342.91		
2320	SSI BLIND WITH QMB	8,442.00	8,076.27	4,987.34	10,018.61	7,281.11	4,993.12	7,295.83	5,554.15	7,599.36	8,678.30	0.00	0.00		72,926.09		
	8,958,286.43	7,902,754.78	8,007,612.46	8,777,861.74	8,031,960.94	9,082,328.52	7,897,484.60	7,653,612.67	10,057,354.72	8,310,070.50	0.00	0.00	84,679,327.36		

SUBTOTAL:

TOTAL:	8,961,028.67	7,909,946.08	8,012,864.48	8,782,993.92	8,037,144.70	9,085,705.32	7,903,755.80	7,655,775.43	10,060,397.86	8,315,119.62	0.00	0.00	84,724,731.88		

8710	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	
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:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2015	
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	46,355.76	35,342.62	62,560.09	36,171.51	18,075.85	52,064.05	15,270.90	41,271.41	101,771.68	17,178.90	0.00	0.00		426,062.77		
2110	SSI AGED NON-MEDIC AR	8,709.42	6,954.55	2,685.44	39,124.80	247.92	14,408.00	1,933.40	2,575.53	7,610.84	-24,937.03	0.00	0.00		59,312.87		
2120	SSI AGED WITH QMB	1,098.73	24.23	571.16	751.60	76.49	4,648.31	50.43	4,902.55	220.84	27.11	0.00	0.00		12,371.45		
2200	SSI DISABLED WITH M E	4,865.65	14,348.75	3,854.67	2,379.84	-342.84	1,804.64	7,701.35	341.45	6,288.05	10,326.44	0.00	0.00		51,568.00		
2210	SSI DISABLED NON-ME D	28,693.95	27,064.64	25,095.06	37,137.90	10,069.22	36,168.46	10,787.85	19,375.04	23,580.21	12,543.12	0.00	0.00		230,515.45		
2220	SSI DISABLED WITH Q M	2,249.80	1,733.79	2,228.64	353.86	4,127.59	905.92	2,947.83	408.55	3,995.54	6,430.19	0.00	0.00		25,381.71		
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		
	91,973.31	85,468.58	96,995.06	115,919.51	32,254.23	109,999.38	38,691.76	68,874.53	143,467.16	21,568.73	0.00	0.00	805,212.25		

SUBTOTAL:

91,973.31	85,468.58	96,995.06	115,919.51	32,254.23	109,999.38	38,691.76	68,874.53	143,467.16	21,568.73	0.00	0.00	805,212.25	

TOTAL:

8710	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	
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:

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV

For The Period Ending April 30, 2015	
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	55,086.53	25,684.88	7,433.80	13,949.00	15,514.72	35,843.52	31,719.88	12,161.58	15,507.75	48,904.57	0.00	0.00		261,806.23		
2110	SSI AGED NON-MEDIC AR	203.41	13.42	0.00	89.92	2,366.43	5,099.26	183.23	0.00	0.00	169.03	0.00	0.00		8,124.70		
2120	SSI AGED WITH QMB	18,563.57	20,222.12	16,726.53	20,613.05	12,975.79	13,463.79	18,863.24	15,498.72	22,751.09	17,690.08	0.00	0.00		177,367.98		
2200	SSI DISABLED WITH M E	6,702.65	5,212.13	1,788.76	1,718.52	2,251.53	2,380.39	398.09	1,198.76	4,744.74	2,086.82	0.00	0.00		28,482.39		
2210	SSI DISABLED NON-ME D	64,499.20	29,900.95	25,663.57	40,573.51	63,617.11	42,490.04	63,546.86	53,966.24	112,311.90	90,304.91	0.00	0.00		586,874.29		
2220	SSI DISABLED WITH Q M	7,643.16	7,620.19	4,440.35	10,309.21	4,246.78	5,935.38	5,077.71	8,278.55	8,980.07	2,285.47	0.00	0.00		64,816.87		
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	48.02	335.16	47.97	47.97	0.00	0.00		1,261.56		
	152,773.47	89,123.29	57,240.11	87,301.23	101,020.38	105,993.21	119,837.03	91,439.01	164,343.52	161,488.85	0.00	0.00	1,130,560.10		

SUBTOTAL:

TOTAL:	152,773.47	89,123.29	57,240.11	87,301.23	101,020.38	105,993.21	119,837.03	91,439.01	164,343.52	161,488.85	0.00	0.00	1,130,560.10		

SUBTOTAL:

KidsCare - CAPITATION AMOUNTS

For The Period Ending April 30, 2015	
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	2,862.48	1,428.51	1,428.51	1,471.08	0.00	0.00		54,875.23		
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	1,406.25	1,370.76	1,306.51	902.25	0.00	0.00		145,205.94		
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	113,266.46	99,617.56	94,139.78	78,022.61	0.00	0.00		1,467,973.03		
6014	KIDS 14-19 MALE NON-	69,288.89	68,444.73	69,540.30	73,816.22	72,411.46	204,535.12	75,618.97	71,929.90	71,135.63	59,670.36	0.00	0.00		836,391.58		
6015	KIDS 14-19 FEMALE NO	110,216.77	112,119.60	111,831.80	118,788.21	118,988.95	309,764.55	120,579.60	111,421.86	110,702.54	91,202.68	0.00	0.00		1,315,616.56		
9960	KIDSCARE KICK PAYM EN	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		
	317,921.81	319,265.24	311,916.90	324,341.71	320,128.32	1,129,266.34	313,733.76	285,768.59	278,712.97	231,268.98	0.00	0.00	3,832,324.62		

317,921.81	319,265.24	311,916.90	324,341.71	320,128.32	1,129,266.34	313,733.76	285,768.59	278,712.97	231,268.98	0.00	0.00	3,832,324.62	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2015	
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	6.00	3.00	3.00	3.00	0.00	0.00		67.86		
6012	KIDS 1-5 M & F NON-M	38.83	26.67	28.00	23.00	18.00	14.00	13.00	12.67	11.99	8.00	0.00	0.00		194.16		
6013	KIDS 6-13 M & F NON-	1,047.73	1,020.93	1,001.01	984.05	956.82	936.50	908.88	796.91	763.86	606.38	0.00	0.00		9,023.07		
6014	KIDS 14-19 MALE NON-	406.52	407.06	414.19	419.20	417.00	421.24	425.76	405.40	399.75	322.67	0.00	0.00		4,038.79		
6015	KIDS 14-19 FEMALE NO	440.63	448.54	447.83	452.69	453.00	456.52	455.12	420.93	415.73	334.96	0.00	0.00		4,325.95		
9960	KIDSCARE KICK PAYM EN	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		
	1,943.71	1,914.65	1,901.03	1,887.94	1,851.82	1,835.67	1,808.76	1,638.91	1,594.33	1,275.01	0.00	0.00	17,651.83		

SUBTOTAL:

TOTAL:	1,943.71	1,914.65	1,901.03	1,887.94	1,851.82	1,835.67	1,808.76	1,638.91	1,594.33	1,275.01	0.00	0.00	17,651.83		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending April 30, 2015	
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	259.98	148.56	148.56	150.20	0.00	0.00		3,984.68		
6012	KIDS 1-5 M & F NON-M	1,488.00	1,190.40	1,078.80	891.36	705.66	26,429.12	482.82	445.68	445.68	300.40	0.00	0.00		33,457.92		
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	33,797.40	28,969.20	28,263.54	22,454.90	0.00	0.00		402,443.42		
6014	KIDS 14-19 MALE NON-	15,387.26	15,555.32	15,807.19	15,809.34	15,758.22	35,406.12	16,132.23	15,085.32	14,955.54	11,961.68	0.00	0.00		171,858.22		
6015	KIDS 14-19 FEMALE NO	17,426.93	17,678.80	17,772.90	17,525.61	17,618.67	36,740.15	17,734.89	16,186.38	15,882.27	13,020.20	0.00	0.00		187,586.80		
SUBTOTAL:	73,362.19	72,703.32	72,044.89	70,846.35	69,736.95	203,811.91	68,407.32	60,835.14	59,695.59	47,887.38	0.00	0.00	799,331.04		

TOTAL:

73,362.19

72,044.89	70,846.35	69,736.95	203,811.91	68,407.32	60,835.14	59,695.59	47,887.38	0.00	0.00	799,331.04	

72,703.32

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2015	
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	7.00	4.00	4.00	4.00	0.00	0.00		77.00		
6012	KIDS 1-5 M & F NON-M	40.00	32.00	29.00	24.00	19.00	14.00	13.00	12.00	12.00	8.00	0.00	0.00		203.00		
6013	KIDS 6-13 M & F NON-	1,039.00	1,018.00	994.00	976.00	952.00	937.00	910.00	780.00	761.00	598.00	0.00	0.00		8,965.00		
6014	KIDS 14-19 MALE NON-	402.00	405.00	410.00	414.00	413.00	416.00	421.00	393.00	388.00	304.00	0.00	0.00		3,966.00		
6015	KIDS 14-19 FEMALE NO	450.00	455.00	455.00	454.00	455.00	459.00	457.00	417.00	409.00	328.00	0.00	0.00		4,339.00		
SUBTOTAL:	1,942.00	1,921.00	1,899.00	1,878.00	1,847.00	1,833.00	1,808.00	1,606.00	1,574.00	1,242.00	0.00	0.00	17,550.00		

TOTAL:	1,942.00	1,921.00	1,899.00	1,878.00	1,847.00	1,833.00	1,808.00	1,606.00	1,574.00	1,242.00	0.00	0.00	17,550.00		

SUBTOTAL:

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending April 30, 2015	
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	416.93	416.93	416.93	416.94	0.00	0.00		2,501.59		
	0.00	393.96		393.96		416.93	416.93	416.93	416.93	416.93	416.93	416.94	0.00	0.00	3,706.44		

0.00	393.96	393.96	416.93	416.93	416.93	416.93	416.93	416.93	416.94	0.00	0.00	3,706.44	

TOTAL:

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2015	
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	1.00	1.00	1.00	1.00	0.00	0.00		6.00		
	0.00	1.00		1.0		1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	9.00		

SUBTOTAL:	0

TOTAL:	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	9.00		

KidsCare - FEE FOR SERVICE

For The Period Ending April 30, 2015	
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	-2,035.58	15.43	0.00	0.00	0.00		9,980.10		
6013	KIDS 6-13 M & F NON-	5,620.16	8,092.01	1,382.10	804.49	2,599.71	1,050.09	660.82	1,847.38	1,012.69	1,456.02	0.00	0.00		24,525.47		
6014	KIDS 14-19 MALE NON-	1,847.16	1,367.27	5,093.48	1,279.55	804.58	1,224.83	18.41	0.00	226.86	238.15	0.00	0.00		12,100.29		
6015	KIDS 14-19 FEMALE NO	6,826.40	349.49	512.47	967.25	538.76	690.08	728.12	-2,144.25	818.46	1,599.22	0.00	0.00		10,886.00		
SUBTOTAL:	20,032.56	15,147.84	7,668.80	3,767.34	3,981.38	2,965.00	1,407.35	-2,332.45	2,073.44	3,293.39	0.00	0.00	58,004.65		

TOTAL:

20,032.56

7,668.80	3,767.34	3,981.38	2,965.00	1,407.35	-2,332.45	2,073.44	3,293.39	0.00	0.00	58,004.65	

15,147.84

KidsCare - REINSURANCE

For The Period Ending April 30, 2015	
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	109.66	0.00	4,645.10	0.00	0.00		-158,025.61		
6013	KIDS 6-13 M & F NON-	35,860.62	11,331.51	30,472.34	-358.55	84.10	29,570.11	11.18	16,016.45	27,825.57	45,436.48	0.00	0.00		196,249.81		
6014	KIDS 14-19 MALE NON-	28,000.15	0.00	54,765.76	-77.00	26,962.45	382.84	27,539.16	27,314.91	0.00	31,624.99	0.00	0.00		196,513.26		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	2,057.84	0.00	0.00	0.00	0.00	0.00		2,057.84		
	-99,947.16	14,868.46	81,729.60	563.56	27,046.55	29,952.95	29,608.18	43,441.02	27,825.57	81,706.57	0.00	0.00	236,795.30		

SUBTOTAL:

TOTAL:	-99,947.16	14,868.46	81,729.60	563.56	27,046.55	29,952.95	29,608.18	43,441.02	27,825.57	81,706.57	0.00	0.00	236,795.30		

SUBTOTAL:

KidsCare - TRANSPLANT REINSURANCE

For The Period Ending April 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,204.49	0.00	0.00	0.00		76,204.49		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,204.49	0.00	0.00	0.00	76,204.49		

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,204.49	0.00	0.00	0.00	76,204.49	

TOTAL:

110007

DES-DD - CAP MEMBER MONTHS

For The Period Ending April, 2015

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	2.00	2.00	2.00	2.00	0.00	0.00		20.00	
1010	TANF NON-MEDICARE	618.38	616.83	616.45	620.62	620.62	620.96	623.79	632.33	636.68	637.80	0.00	0.00		6,244.46	
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	1.00	1.00	1.00	1.00	0.00	0.00		13.00	
2100	SSI AGED WITH MEDICA	146.99	145.63	148.00	147.00	146.33	150.00	151.00	155.00	155.00	165.04	0.00	0.00		1,509.99	
2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	4.00	4.00	0.00	0.00		48.00	
2120	SSI AGED WITH QMB	236.79	237.09	241.99	240.01	240.00	243.77	236.01	249.00	263.00	259.64	0.00	0.00		2,447.30	
2200	SSI DISABLED WITH ME	1,737.61	1,747.31	1,738.54	1,777.91	1,778.76	1,796.54	1,803.94	1,732.48	1,717.80	1,716.99	0.00	0.00		17,547.88	
220Z	SSI DISABLED WITH ME	0.00	0.00	0.00	3.73	0.00	0.00	2.35	0.00	0.00	0.00	0.00	0.00		6.08	
2210	SSI DISABLED NON-MED	20,351.11	20,460.87	20,577.35	20,616.28	20,717.99	20,869.76	20,914.75	21,013.48	21,265.57	21,257.96	0.00	0.00		208,045.12	
221Z	SSI DISABLED NON-MED	0.00	0.00	0.00	0.06	0.00	0.00	0.03	0.00	0.00	7.32	0.00	0.00		7.41	
2220	SSI DISABLED WITH QM	3,823.28	3,835.07	3,863.93	3,862.06	3,863.77	3,876.25	3,892.26	3,948.88	3,962.31	3,987.66	0.00	0.00		38,915.47	
2300	SSI BLIND WITH MEDIC	15.00	15.00	15.00	15.00	13.38	16.00	17.00	14.00	14.00	14.00	0.00	0.00		148.38	
2310	SSI BLIND NON-MEDICA	112.93	113.00	113.73	114.00	115.36	118.00	118.00	114.92	115.00	113.00	0.00	0.00		1,147.94	
2320	SSI BLIND WITH QMB	29.00	28.00	26.93	28.00	27.00	25.00	25.00	27.00	26.00	26.00	0.00	0.00		267.93	
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	0.00	0.00		70.00	
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00		20.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	3.00	0.00	0.00		24.00	
SUBTOTAL:	27,092.09	27,219.80	27,361.92	27,443.67	27,542.21	27,735.73	27,803.13	27,906.09	28,174.36	28,204.41	0.00	0.00	276,483.41	
TOTAL:	27,092.09	27,219.80	27,361.92	27,443.67	27,542.21	27,735.73	27,803.13	27,906.09	28,174.36	28,204.41	0.00	0.00	276,483.41	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD  EXPENDITURES
For the Period Ending April 30, 2015

EPD/DD  CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	378,800.20	377,975.63	376,641.36	377,090.04	376,452.78	372,298.89	368,910.84	374,105.76	371,853.88	368,450.62	0.00	0.00	3,742,580.00	
EPD	81,832,334.90	91,563,188.35	82,730,279.25	83,774,273.60	93,279,309.59	84,421,747.15	83,617,697.83	96,221,860.48	84,003,373.04	85,358,376.28	0.00	0.00	866,802,440.47	
TOTAL AHCCCS LTC	82,211,135.10	91,941,163.98	83,106,920.61	84,151,363.64	93,655,762.37	84,794,046.04	83,986,608.67	96,595,966.24	84,375,226.92	85,726,826.90	0.00	0.00	870,545,020.47	
DES/DD	90,441,057.34	90,874,990.67	91,356,447.37	91,810,801.83	92,142,171.96	93,945,839.51	93,016,958.34	93,363,074.13	94,258,277.93	94,721,707.64	0.00	0.00	925,931,326.72	
TOTAL DES LTC	90,441,057.34	90,874,990.67	91,356,447.37	91,810,801.83	92,142,171.96	93,945,839.51	93,016,958.34	93,363,074.13	94,258,277.93	94,721,707.64	0.00	0.00	925,931,326.72	
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	177,003,567.01	189,959,040.37	178,633,504.85	180,448,534.54	0.00	0.00	1,796,476,347.19	

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	9,403,353.64	9,497,169.82	10,317,996.00	9,250,858.04	10,622,158.76	9,119,365.08	8,926,784.26	11,928,249.43	9,754,008.52	0.00	0.00	99,497,130.01	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	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	9,119,365.08	8,926,784.26	11,928,249.43	9,754,008.52	0.00	0.00	99,497,130.01	

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	3,372,978.62	4,928,777.99	4,472,011.06	4,152,641.85	3,769,357.44	1,692,164.80	2,802,698.52	1,720,992.47	2,099,202.43	0.00	0.00	32,114,975.73	
	247,514.04	218,495.45	397,973.54	266,868.90	329,217.93	226,816.51	230,316.91	502,102.34	228,949.84	190,418.98	0.00	0.00	2,838,674.44	
	247,514.04	218,495.45	397,973.54	266,868.90	329,217.93	226,816.51	230,316.91	502,102.34	228,949.84	190,418.98	0.00	0.00	2,838,674.44	
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	1,922,481.71	3,304,800.86	1,949,942.31	2,289,621.41	0.00	0.00	34,953,650.17	

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	3,083,493.30	3,082,359.20	3,080,434.60	3,119,510.30	0.00	0.00	30,643,735.60	

Note to the ASR:
EPD reflects the Federal and County share for both acute and LTC services.
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.

124

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending April 30, 2015

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	13,076,158.03	12,988,764.66	13,143,813.21	13,208,062.52	0.00	0.00	133,941,270.17	
010145	CRS ACUTE SEMI INTEGRATED - CAP	140,282.17	106,532.24	121,467.59	113,733.94	117,439.75	133,572.59	117,558.70	110,227.65	112,850.37	116,595.06	0.00	0.00	1,190,260.06	
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	3,188,453.61	3,200,525.37	3,210,082.18	3,227,448.21	0.00	0.00	28,356,398.33	
999135	CRS ONLY PLAN - CAP	0.00	450,296.28	451,872.12	481,137.22	471,964.76	476,134.06	471,547.83	466,127.74	464,043.09	459,050.94	0.00	0.00	4,192,174.04	
	14,492,208.86	16,256,282.82	16,396,452.81	17,073,143.25	17,042,615.47	18,858,090.22	16,853,718.17	16,765,645.42	16,930,788.85	17,011,156.73	0.00	0.00	167,680,102.60	

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

TOTAL

Wednesday, May 20, 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	1,690,822.53	2,605,059.50	1,068,247.98	347,788.56	0.00	0.00	12,484,783.63	
	2,324,970.00	490,042.82	1,745,299.36	450,149.05	1,230,087.38	532,316.45	1,690,822.53	2,605,059.50	1,068,247.98	347,788.56	0.00	0.00	12,484,783.63	

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	49,866.24	45,970.44	44,412.12	35,031.47	0.00	0.00	591,523.89	
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	416.93	416.93	416.93	416.94	0.00	0.00	3,706.44	
	52,459.25	49,601.40	49,561.87	52,394.44	52,544.77	162,829.26	50,283.17	46,387.37	44,829.05	35,448.41	0.00	0.00	596,338.99	

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	18,594,823.87	19,417,092.29	18,043,865.88	17,394,393.70	0.00	0.00	180,761,225.22	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending April 30, 2015

010115	CRS FULLY INTEGRATED PLAN - MM	19,358.09	17,125.68	17,289.14	17,094.47	17,044.52	16,953.90	16,779.63	16,667.78	16,866.13	16,728.18	0.00	0.00	171,907.52	
010145	CRS ACUTE SEMI INTEGRATED - MM	213.57	162.16	184.98	164.14	169.52	171.53	169.53	158.99	162.74	166.03	0.00	0.00	1,723.19	
999125	CRS SEMI INTEGRATED PLAN - MM	0.00	6,273.00	6,278.00	6,291.00	6,317.00	6,321.00	6,339.00	6,363.00	6,382.00	6,401.00	0.00	0.00	56,965.00	
999135	CRS ONLY PLAN - MM	0.00	1,143.00	1,147.00	1,154.00	1,132.00	1,142.00	1,131.00	1,118.00	1,113.00	1,101.00	0.00	0.00	10,181.00	
	19,571.66	24,703.84	24,899.12	24,703.61	24,663.04	24,588.43	24,419.16	24,307.77	24,523.87	24,396.21	0.00	0.00	240,776.71	

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

TOTAL

Wednesday, May 20, 2015

010115	CRS FULLY INTEGRATED PLAN - KC MM	70.77	66.38	66.38	66.69	67.00	64.70	64.00	59.00	56.99	44.36	0.00	0.00	626.27	
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	1.00	1.00	1.00	1.00	0.00	0.00	9.00	
	70.77	67.38	67.38	67.69	68.00	65.70	65.00	60.00	57.99	45.36	0.00	0.00	635.27	

Subtotal

Subtotal

19,642.43	24,771.22	24,966.50	24,771.30	24,731.04	24,654.13	24,484.16	24,367.77	24,581.86	24,441.57	0.00	0.00	241,411.98	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending April 30, 2015

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	45,310,516.77	45,173,361.35	45,549,799.05	45,800,731.37	0.00	0.00	443,145,522.00	
	41,786,965.61	42,950,978.28	43,354,678.66	43,620,639.57	44,539,840.33	45,058,011.01	45,310,516.77	45,173,361.35	45,549,799.05	45,800,731.37	0.00	0.00	443,145,522.00	

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

TOTAL

Wednesday, May 20, 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	45,310,516.77	45,173,361.35	45,549,799.05	45,800,731.37	0.00	0.00	443,145,522.00	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending April 30, 2015

078999	MERCY MARICOPA INTEGRATED - MM	17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	18,785.29	18,890.03	18,833.04	18,989.47	18,872.55	0.00	0.00	183,939.46	
	17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	18,785.29	18,890.03	18,833.04	18,989.47	18,872.55	0.00	0.00	183,939.46	

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

TOTAL

Wednesday, May 20, 2015

Subtotal

17,228.49	17,708.29	17,876.02	18,186.13	18,570.15	18,785.29	18,890.03	18,833.04	18,989.47	18,872.55	0.00	0.00	183,939.46	

GRAND TOTAL