June 30, 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 May 31, 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 May
31, 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

It has been determined that ADHS will not need any of the authorized $10 million.  Based on these appropriation adjustments, AHCCCS is projecting a potential surplus of $165.0 million Total Fund ($52.5 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. June 30, 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 – May 2015 enrollment is 1,680,606 members, a 20,443 member increase over the prior month.  Enrollment for June 2015 increased to 1,709,547 members, a 28,941 member increase.

Major June changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 20,156; Supplemental Security Income – decrease of 300; Prop 204 Restoration - decrease of 1,948; Adult Expansion - increase of 6,408; Medicare Cost Sharing – decrease of
496; and Emergency Services - increase of 5,248.

Tobacco Funds Revenue Update – Tobacco tax collections through May 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 May	31, 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 May 31, 2015
SUMMARY OF APPROPRIATED EXPENDITURES

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

APPROPRIATIONS:

ADMINISTRATION

AHCCCS Operating Lump Sum	$	90,661,000		$	82,713,200		$	72,898,685		$	9,814,515		$	90,661,000		$	-	
AHCCCS Prop 204 Administration	6,863,900		6,320,500		6,584,976		(264,476)		6,863,900		-	
DES Eligibility	90,474,500		68,370,800		66,663,704		1,707,096		90,474,500		-	
DES Prop 204 Eligibility	38,358,700		35,357,900		24,348,305		11,009,595		38,358,700		-	
TOTAL ADMINISTRATION	226,358,100		192,762,400		170,495,669		22,266,731		226,358,100		-	

Traditional Medicaid Services	3,562,526,000		3,298,748,900		3,082,570,839		216,178,061		3,397,526,000		165,000,000	
Proposition 204 Services	2,438,937,900		2,130,150,200		2,084,697,253		45,452,947		2,438,937,900		-	
ACA Adult Expansion	212,369,700		203,606,800		176,376,194		27,230,606		212,369,700		-	
Children's Rehabilitative Services	222,042,400		195,808,300		197,017,774		(1,209,474)		222,042,400		-	
KidsCare Services	7,512,500		7,103,500		6,344,639		758,861		7,512,500		-	
ALTCS Services	1,348,569,500		1,238,130,900		1,181,369,426		56,761,474		1,348,569,500		-	
Disproportionate Share Payments	13,487,100	-	-	-	13,487,100	-	
Rural Hospitals	22,650,000		22,115,400		22,115,340		60		22,650,000		-	
Voluntary Political Subdivision Programs	324,060,600		304,980,400		304,980,351		49		324,060,600		-	
TOTAL PROGRAMMATIC	8,152,155,700	7,400,644,400	7,055,471,816	345,172,584	7,987,155,700	165,000,000

$	8,378,513,800		$    7,593,406,800		$   7,225,967,485		$	367,439,315		$  8,213,513,800		$   165,000,000	

TOTAL EXPENDITURES

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2015 APPROPRIATION STATUS REPORT For the Period Ending May 31, 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		$ 	50,908,900		$ 	50,222,739		686,161		$ 	55,488,700		$ 	-	
Proposition 204 - Administrative  Expenditures	19,658,700		18,119,900		11,090,441		7,029,459		19,658,700		-	
Programmatic  Expenditures
Traditional Medicaid Services	
821,633,300		
666,997,900		
745,228,027		
(78,230,127)		
769,133,300		
52,500,000	
Proposition 204 Services	79,700,000		109,835,300		12,145,040		97,690,260		79,700,000		-	
Children's Rehabilitative  Services	70,248,100		57,047,400		62,688,859		(5,641,459)		70,248,100		-	
KidsCare Services	1,257,200		1,193,100		1,112,935		80,165		1,257,200		-	
ALTCS Services	167,797,400		153,477,200		153,814,278		(337,078)		167,797,400		-	
DSH and Rural Hospitals	10,099,300		7,143,900		6,636,240		507,660		10,099,300		-	
TOTAL GF EXPENDITURES	1,225,882,700		1,064,723,600		1,042,938,560		21,785,040		1,173,382,700		52,500,000	

Administrative  Expenditures	125,444,100		100,025,700		89,195,784		10,829,916		125,444,100		-	
Proposition 204 - Administrative  Expenditures	22,179,500		20,438,700		17,304,539		3,134,161		22,179,500		-	
Programmatic  Expenditures
Traditional Medicaid Services	
2,347,057,100		
2,304,412,800		
1,990,282,701		
314,130,099		
2,234,557,100		
112,500,000	
Proposition 204 Services	1,932,368,400		1,597,825,800		1,703,985,605		(106,159,805)		1,932,368,400		-	
ACA Adult Expansion	212,369,700		203,606,800		176,376,194		27,230,606		212,369,700		-	
Children's Rehabilitative  Services	151,794,300		138,760,900		134,328,915		4,431,985		151,794,300		-	
KidsCare Services	5,885,300		5,569,300		4,626,454		942,846		5,885,300		-	
ALTCS Services and Nursing Facility Assessment	887,843,500		822,098,400		775,399,907		46,698,493		887,843,500		-	
DSH and Rural Hospitals	26,037,800		14,971,500		15,479,100		(507,600)		26,037,800		-	
Voluntary Political Subdivision Programs - See Note 5	219,339,000		204,327,600		204,327,581		19		219,339,000		-	
TOTAL FEDERAL EXPENDITURES	5,930,318,700		5,412,037,500		5,111,306,781		300,730,719		5,817,818,700		112,500,000	

Administrative  Expenditures  Proposition 204 - BNCF 	3,384,400 	3,119,800 	2,538,300 	581,500 	3,384,400 	- Programmatic  Expenditures
Traditional Medicaid Services Acute Care 	     50,199,900 		  46,016,300 		46,016,300 		- 		  50,199,900 	   - ALTCS Services 	245,196,200 	224,290,400 	210,879,979 	13,410,421 	245,196,200 	- TOTAL COUNTY EXPENDITURES	   298,780,500 		273,426,500 	   259,434,579 	   13,991,921 		298,780,500 	   -

Programmatic  Expenditures

TOBACCO FUNDS

Traditional Medicaid Services Acute Care - Medically Needy 	     34,178,800 		   31,537,700 		34,178,800 	   (2,641,100) 		  34,178,800 	   - Proposition 204 Services - Emergency Health Services 	  18,202,400 		16,805,400 	17,676,984 	   (871,584) 	  18,202,400 	- Proposition 204 Services - Proposition 204 Protection 	  38,225,000 		35,271,200 	37,121,667 	(1,850,467) 	  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 		 183,614,300 	 188,952,421 	   (5,338,121) 		190,606,200 	   -

Administrative  Expenditures

OTHER

Prescription Drug Rebate Program 	202,700 	149,400 	143,865 	5,535 	202,700 	- Programmatic  Expenditures
Acute Care - Prescription Drug Rebate Program State Match 	     73,669,800 		   67,610,000 		67,610,033 			 (33) 		  73,669,800 	   - Acute Care - Prescription Drug Rebate Program Federal Authority 	235,561,200 	182,014,800 	198,561,200 	(16,546,400) 	235,561,200 	- Long Term Care - Prescription Drug Rebate Program State Match 	    5,162,500 		 4,722,000 	    4,732,292 		(10,292) 		 5,162,500 	- Long Term Care - Prescription Drug Rebate Program Federal Authority 	  25,398,100 		16,371,100 	  17,898,100 	  (1,527,000) 	  25,398,100 	- Proposition 204 Services - Hospital Assessment 	270,442,100 	270,412,500 	213,792,987 	 56,619,513 	270,442,100 	- Traditional Medicaid Services - TPL 		194,700 		     129,800 		  650,258 	     (520,458) 		    194,700 	- ALTCS Services - TPL 			- 			      - 		  710,608 	     (710,608) 			- 	- ALTCS Services - Nursing Facility Assessment 	  17,171,800 		17,171,800 	  17,934,263 	     (762,463) 	  17,171,800 	- KidsCare Services Premiums 		370,000 		     341,100 		  605,249 	     (264,149) 		    370,000 	- Freedom to Work Premiums 		  31,200 			29,600 		    43,520 		(13,920) 		      31,200 	- Voluntary Political Subdivision Programs - See Note 5 	104,721,600 	100,652,800 	100,652,770 			30 	104,721,600 	- TOTAL OTHER  EXPENDITURES	   732,925,700 		 659,604,900 	   623,335,144 	    36,269,756 		732,925,700 	   -

TOTAL

Administrative  Expenditures 	   226,358,100 		192,762,400 	   170,495,669 	  22,266,731 		226,358,100 		- Acute Care 	6,803,586,200 	6,162,513,500 	5,874,102,390 	288,411,110 	6,638,586,200 	165,000,000
Long Term Care 	1,348,569,500 	1,238,130,900 	1,181,369,426 	56,761,474 	1,348,569,500 	-

TOTAL EXPENDITURES

$ 	8,378,513,800

$ 	7,593,406,800

$ 	7,225,967,485 	$

367,439,315

$ 	8,213,513,800

$ 	165,000,000

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

BUDGET 	BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	957,469,400		$	782,098,100		$	864,775,866	
Proposition 204 Services & Administrative	99,358,700		127,955,200		22,985,210	
KidsCare Services	1,257,200		1,193,100		1,112,935	
ALTCS Services	167,797,400		153,477,200		153,814,278	
TOTAL	1,225,882,700		1,064,723,600		1,042,688,290	

FEDERAL:
Acute & Administrative	5,036,589,900		4,584,369,800		4,893,678,330	
KidsCare Services	5,885,300		5,569,300		6,396,773	
ALTCS Services	887,843,500		822,098,400		782,152,688	
TOTAL	5,930,318,700		5,412,037,500		5,682,227,791	

COUNTY:
Acute & Administrative	53,584,300		49,136,100		49,253,993	
ALTCS Services	245,196,200		224,290,400		224,763,198	
TOTAL	298,780,500		273,426,500		274,017,191	

TOBACCO FUNDS:
Traditional Medicaid Services	34,178,800		31,537,700		34,178,800	
Proposition 204 Services	156,427,400		152,076,600		154,773,621	
TOTAL	190,606,200		183,614,300		188,952,421	

OTHER:
Administrative	202,700		149,400		143,865	
Acute Care - Prescription Drug Rebate Program	309,231,000		249,624,800		266,171,233	
Long Term Care - Prescription Drug Rebate Program	30,560,600		21,093,100		22,630,392	
Hospital Assessment	270,442,100		270,412,500		263,058,472	
ALTCS - Nursing Facility Assessment	17,171,800		17,171,800		18,362,370	
Acute TPL - Note 1	194,700		129,800		650,258	
LTC TPL - Note 1	-		-		710,608	
KidsCare TPL - Note 1	-		-		6,282	
Member Premiums - CHIP	370,000		341,100		595,698	
Member Premiums - Freedom to Work	31,200		29,600		43,520	
Voluntary Political Subdivision - State Match	104,721,600		100,652,800		66,515,957	
TOTAL	732,925,700		659,604,900		638,888,654	

TOTAL REVENUE

$	8,378,513,800

$	7,593,406,800

$	7,826,774,348

Appropriation Status Report

Footnotes

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

Note 1:	Third Party Liability Collections: Gross Collections:	May 2015		May 2014		July 1, 2014
May 31, 2015		July 1, 2013
May 31, 2014	
	Acute	$ 	505,864		$ 	677,837		$ 	4,866,074		$ 	7,310,240	
	LTC	343,515		523,563		3,132,913		3,663,161	
	KidsCare	4,511		375		39,815		13,098	
	Total TPL Collections	$ 	853,890		$ 	1,201,775		$ 	8,038,802		$ 	10,986,499	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$ 	52,511		$ 	95,903		$ 	650,258		$ 	844,304	
LTC	59,392		129,063		710,608		888,262	
KidsCare	625		74		6,282		2,405	
Total Expenditure Offsets	$ 	112,528		$ 	225,040		$ 	1,367,148		$ 	1,734,971	

FY 15 Total

Note 2:	Authorized Positions	1,032.2	
	Actual Positions as of May 31, 2015	922.4	

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2014	

$ 	2,092,063	
	Revenues	7,451,293	
	Transfers-In	 	220,875 		
	Total Revenues	 	7,672,168 		
	Expenditures	6,101,897	
	Transfers-out	 	742,500 		
	Total Expenditures	 	6,844,397 		

Ending Balance May 31, 2015

$ 	2,919,833

Of the $2,919,833 ending balance, $2,053,922 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through June 2015.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities
As of May 31, 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 May 31, 2015

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of May 31, 2015
Expenditures

State Match 	Federal 	Total

DSH Voluntary

$ 	7,352,040 	$

14,291,445 	$

21,643,485

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

$ 	100,652,770 	$

204,327,581 	$

304,980,351

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 May 31, 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 May 31, 2015

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	258,132,293	0	2,755,594,028	
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	193,000,700	0	1,989,477,047	
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	23,579,598	0	257,904,922	
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	10,148,431	0	110,810,042	
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	13,651,382	0	147,747,511	
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	14,706,936	0	165,821,378	
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	3,692,782	0	36,106,695	
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	36,540,823	0	458,179,147	
FFS - PRIOR QUARTER COVERAGE	57,282	163,600	272,725	299,665	290,401	278,750	370,730	373,960	575,418	492,498	361,260	0	3,536,289	
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	4,110,778	0	57,523,637	
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	641,607	0	6,924,783	
QMB - FEE FOR SERVICE	227,508	323,662	198,991	336,158	204,441	226,551	333,888	319,484	386,291	229,557	356,091	0	3,142,622	
INPATIENT INMATES FFS	139,514	117,313	118,780	356,263	172,449	110,017	120,196	83,623	169,533	139,618	167,440	0	1,694,745	
PINAL COUNTY INMATES FFS	1,230	2,048	18,368	481	3,910	338	501	0	0	3,325	4,493	0	34,693	
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	7,223	0	102,345	
MARICOPA CTY INMATES FFS	5,034	2,562	11,151	9,287	15,401	35,253	41,392	5,385	105,634	20,277	30,993	0	282,370	
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	9,303,949	0	108,801,079	
LFFS - PRIOR QUARTER COVERAGE	26,197	25,830	11,048	31,446	50,419	30,113	28,027	69,020	21,983	78,849	-36,220	0	336,714	
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	1,251,385	0	11,949,645	
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	7,845,523	0	83,019,743	
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	5,699,247	0	40,652,897	
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	10,369,816	0	114,277,423	
HIB - ACUTE	58,792	272,446	259,042	269,952	274,700	262,747	255,222	258,386	251,753	268,049	256,221	0	2,687,310	
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	1,574,177	0	19,404,276	
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	2,828,538	0	30,933,792	
HIB - LTC	121,568	275,913	266,525	277,911	272,522	280,297	241,486	265,225	262,505	274,530	276,811	0	2,815,293	
	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	598,502,278	0	6,417,621,168	

TITLE XIX TRADITIONAL

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

TOTAL

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending May 31, 2015

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	175,309,137	0	1,886,308,172	
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	132,101	0	2,029,932	
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	14,730,948	0	155,788,636	
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	19,815,655	0	208,720,378	
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	12,091	0	146,751	
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	22,663,511	0	275,872,311	
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	776,311	0	8,367,039	
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	1,382,504	0	12,253,711	
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	5,697	0	55,546	
INPATIENT INMATES FFS	487,478	518,149	471,810	624,268	281,204	565,945	412,164	451,128	555,192	666,639	528,595	0	5,562,571	
COCONINO COUNTY INMATES FFS	0	0	0	0	0	0	7,649	105	758	10,077	0	0	18,588	
YAVAPAI COUNTY INMATES FFS	0	0	277	0	0	0	0	0	0	1,876	5,908	0	8,062	
PINAL COUNTY INMATES FFS	82,861	48,485	8,563	33,510	7,205	5,657	11,005	16,319	4,420	6,102	5,176	0	229,303	
PIMA COUNTY INMATES FFS	4,443	35,007	0	0	4,290	1,085	4,955	7,213	10,453	7,743	17,847	0	93,036	
MARICOPA CTY INMATES FFS	13,089	6,331	23,649	22,129	68,390	127,897	124,307	35,197	124,829	149,724	64,310	0	759,849	
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	4,026,669	0	25,807,419	
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	5,223,424	0	46,819,015	
HIB - ACUTE	2,806	1,938	1,938	1,938	3,216	2,364	2,057	4,739	3,073	4,416	6,227	0	34,712	
	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	244,706,111	0	2,630,752,576	

TITLE XIX PROP 204

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

TOTAL

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending May 31, 2015

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

TITLE XIX ACA ADULT EXPANSION

TOTAL

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	19,944,055	0	157,176,310	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	2,681,711	0	0	2,681,711	
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	1,861,380	0	13,170,972	
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	2,503,876	0	17,702,124	
CHILDREN'S REHAB SERVICES	0	0	0	0	0	0	0	0	0	0	417	0	417	
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	1,489,977	0	14,011,112	
FFS - PRIOR QUARTER COVERAGE	8,502	36,286	94,224	115,698	61,348	91,140	77,015	89,383	239,521	110,103	205,621	0	1,128,839	
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	1,469,019	0	16,253,193	
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	9,887	0	207,525	
MARICOPA CTY INMATES FFS	0	0	0	0	0	0	0	0	0	0	464	0	464	
REINSURANCE - ACUTE	22,287	20,209	101,574	92,355	115,860	104,882	7,119	175,771	201,343	118,744	298,242	0	1,258,386	
SMIB - ACUTE	1,259	839	1,678	1,783	1,154	210	210	210	210	315	1,154	0	9,021	
	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	29,008,213	27,784,092	0	223,603,391	
	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	872,941,229	870,992,481	0	9,271,977,136	

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	223,158	0	4,055,482	
KidsCare - FEE FOR SERVICE	20,033	15,148	7,669	3,767	3,981	2,965	1,407	-2,332	2,073	3,293	1,453	0	59,457	
KidsCare - MENTAL HEALTH	73,362	72,703	72,045	70,846	69,737	203,812	68,407	60,835	59,696	47,887	46,043	0	845,374	
KidsCare - REINSURANCE	-99,947	14,868	81,730	564	27,047	29,953	29,608	43,441	27,826	81,707	36,041	0	272,836	
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	417	0	4,123	

311,369	422,379	473,754	399,936	421,310	1,366,413	413,574	388,129	444,929	364,573	307,112	0	5,313,478	

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	873,305,802	871,299,593	0	9,277,290,614	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	489.02	0.00	489.02

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	113.17	0.00	1,469.10

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	45,878.37	0.00	288,735.06

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	154,253.09	0.00	1,325,324.02

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	212,571.18	0.00	1,204,034.21

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	54,758.59	0.00	311,249.82

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	3,861.70	0.00	14,890.07

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	7,174.34	0.00	40,278.38

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	48,956.40	0.00	123,788.26

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	12,972.00	0.00	35,668.37

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	7,016,513.16	0.00	78,470,557.66

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	6,629,919.98	0.00	98,393,392.81

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     11,015,941.16	0.00	158,081,606.77

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	3,355,488.19	0.00	45,577,915.40

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	6,159,256.73	0.00	81,915,374.34

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	4,279,224.30	0.00	41,511,273.17

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     23,415,711.37	0.00	251,958,388.13

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	8,985,705.53	0.00	88,954,485.84

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	33,485.19	0.00	283,263.79

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	819,939.72	0.00	4,270,777.73

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	44,240.19	0.00	1,340,523.89

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	48,403.32	0.00	1,589,060.84

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	39,868.67	0.00	1,034,321.42

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	83,631.90	0.00	1,718,653.19

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	438,112.06	0.00	3,265,811.48

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	969,395.55	0.00	9,201,002.33

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	684,549.62	0.00	5,906,423.93

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	13,119.13	0.00	51,144.00

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	15,120.88	0.00	46,469.27

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	47,391.17	0.00	165,751.46

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	49,184.14	0.00	140,117.73

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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	22,560.23	0.00	47,645.05

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	103.95	0.00	245.38

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	162.09	0.00	1,477.89

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	4,585.76	0.00	11,327.42

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	530.14	0.00	1,301.25

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

682,116.95	665,548.05	675,360.22	689,644.65	673,487.78	742,109.30	697,314.27	675,877.96	662,354.14	685,638.26	661,608.42	0.00	7,511,060.00

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	37,471.36	0.00	403,068.22

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	4,916,148.81	0.00	54,904,022.73

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	112,863.81	0.00	3,225,364.82

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	3,095,136.98	0.00	40,510,516.62

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

39,895.21	21,261.96	14,694.28	14,818.73	26,077.56	30,588.73	5,865.99	5,526.77	5,748.70	5,291.10	6,939.37	0.00	176,708.40

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	1,483,726.42	0.00	18,225,272.00

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	17,089.83	0.00	256,803.02

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     55,425,754.75	0.00	614,406,681.80

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	551,316.19	0.00	7,565,767.94

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     10,615,771.92	0.00	118,240,749.91

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	4,860.19	0.00	53,476.46

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	4,271.22	0.00	60,904.87

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

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

333,362.58	333,314.84	333,723.66	349,198.67	348,076.29	396,678.85	359,577.60	356,439.13	358,271.38	368,368.53	366,415.98	0.00	3,903,427.51

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	7,936.37	0.00	57,148.19

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	47,333.60	0.00	468,796.45

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	128.67	0.00	3,504.93

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	227.07	0.00	1,995.53

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	185.24	0.00	1,685.57

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	789.59	0.00	8,639.98

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

430B	SOBRA CHILD 01-05 M	311.15	623.49	0.00	0.00	0.00	184.43	99.94	0.00	125.96	45.27	-65.03	0.00	1,325.21

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	137.87	0.00	813.82

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     18,516,522.16	0.00	178,911,477.78

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     16,613,198.27	0.00	144,847,261.35

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     21,210,388.84	0.00	182,287,186.19

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	7,270,789.16	0.00	64,429,417.76

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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     10,953,977.59	0.00	95,946,411.72

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	1,209,114.34	0.00	12,922,545.38

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	495,236.07	0.00	5,126,383.40

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	627,464.87	0.00	5,346,667.87

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	421,851.02	0.00	4,144,380.82

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	527,061.58	0.00	4,987,648.13

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	108.61	0.00	695.27

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	169.75	0.00	311.93

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
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
500H	SOBRA PREG 45-64 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT

21,833.03	22,940.47	24,900.15	25,248.13	31,205.32	32,605.08	33,298.06	34,969.56	35,082.99	35,372.44	31,710.71	0.00	329,165.94

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	450.45	0.00	12,925.42

411.89	2,270.17	121.17	666.48	1,221.73	164.35	38.11	2,906.54	557.43	233.92	1,020.60	0.00	9,612.39

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

0.00	0.00	228.55	394.56	326.07	602.60	565.48	514.33	589.29	609.71	361.44	0.00	4,192.03

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	950,884.35	0.00	8,721,043.50

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	3,838,335.93	0.00	31,554,100.62

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	24,447.53	0.00	216,227.57

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

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	81,127.84	0.00	928,042.07

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	334,705.24	0.00	3,382,791.44

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	1,416.96	0.00	32,566.60

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	1,403.45	0.00	50,052.76

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

0.00	407.18	0.00	0.00	0.00	28.47	0.00	14.06	0.00	0.00	198.62	0.00	648.33

-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

9910	TANF & SOBRA CHILDR	6,571,134.40	6,179,708.87	6,623,616.05	6,325,435.24	5,921,355.59	7,121,844.89	6,027,669.23	4,910,877.04	5,265,275.46	4,227,424.89	3,693,480.74	0.00	
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	48,991.56	0.00	
9921	SSI W/O MEDICARE KIC	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	199,797.21	0.00	
9950	S.O.B.R.A. KICK PAYM	11,246,691.84	10,572,592.25	11,574,315.84	11,668,848.01	9,191,678.49	11,395,806.09	10,497,875.29	9,682,295.41	10,918,931.44	10,570,951.68	11,136,542.88	0.00	
SUBTOTAL:	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	15,078,812.39	0.	

SUBTOTAL:

219,325,258.77

215,820,558.09   216,718,395.63   225,832,636.97   223,739,145.50   246,871,627.22   223,984,470.14   223,964,438.43   226,956,098.03   233,081,506.50   235,181,166.00	0.00	2,491,475,301.28

62,867,822.40	
621,585.11	
2,162,094.87	
118,456,529.22	
184,108,031.60	

E

00

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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

0.00	0.00	19.80	33.00	33.00	33.00	33.00	33.00	33.00	33.00	40.45	0.00	291.25

0.00	0.00	29.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.55	0.00	55.25

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

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

SUBTOTAL:

0.00

0.00

49.50	33.00	66.00	49.50	49.50	49.50	49.50	33.00	66.00	0.00	445.50

483.38	
2,481,413.39	
8,908,763.47	
14,160,060.04	
3,768,353.03	
49,817.29	
119,526.50	
388,374.14	
199,341.04	
203,556.87	
1,014,508.60	
3,259,112.05	
2,305,194.79	
6,912,122.33	
47,899,844.83	
163,435,268.94	
96,393,557.92	
309,518.27	
26,654.67	
13,683.97	
40,426.83	
97,150.33	
249,887.14	
3,179,350.73	
6,825,649.10	
6,179,464.63	
122,810.83	
519.82	
383,920.27	
1,016,664.41	

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	207,855.67	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	753,950.29	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	1,241,967.60	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	336,732.93	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	841.15	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	737.29	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	4,899.60	0.00

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

22,286.04	20,455.08	7,163.10	17,804.09	19,956.72	10,994.29	12,428.07	32,764.40	47,249.41	7,457.56	782.28	0.00

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	14,306.99	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	66,487.63	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	223,445.73	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	160,558.46	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	512,931.02	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	4,130,961.71	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     14,528,845.58	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	8,967,273.80	0.00

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

17,823.07	20,468.09	20,106.66	25,686.73	19,036.78	25,048.05	25,859.77	31,872.92	38,243.75	42,283.64	43,088.81	0.00

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	344.99	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	681.37	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	2,338.41	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	6,307.10	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	44,685.11	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	103,932.06	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	75,736.90	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	309.96	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	259.91	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	73,741.99	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	217,754.32	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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	269,343.04	0.00	1,615,106.87

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	96,520.32	0.00	538,770.59

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	185.59	0.00	4,637.63

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	3,155.90	0.00	45,482.98

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

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

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	99,474.12	0.00	1,331,014.91

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	24,886.57	0.00	655,156.51

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	1,098,056.69	0.00	11,527,815.01

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	12,865.52	0.00	1,180,494.55

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	5,424,195.80	0.00	55,190,952.08

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	8,936.18	0.00	350,555.89

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	1,458.65	0.00	16,991.75

693.76	329.64	329.64	248.57	248.57	447.51	248.57	248.57	248.57	124.99	124.99	0.00	3,293.38

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	149,021.05	0.00	3,125,965.17

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	15,891.24	0.00	358,539.52

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	2,350,096.11	0.00	20,637,420.33

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	24,236.20	0.00	1,031,775.19

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	6,641,009.60	0.00	56,932,359.08

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	8,136.60	0.00	102,695.46

SUBTOTAL:

47,192,060.43

45,561,816.56     45,681,882.77     47,838,621.40     46,954,797.80     51,249,495.41     46,928,276.29     47,249,516.39     49,467,239.09     48,552,450.41     47,949,352.83	0.00	524,625,509.38

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

428,501.25	401,669.98	522,606.09	543,298.08	363,461.74	655,950.94	522,754.26	477,576.06	469,749.99	652,597.11	634,320.29	0.00

5,672,485.79	
114,954.77	
35,685.58	
5,823,126.14	

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	18,243.86	0.00

0.00	5,731.51	0.00	0.00	0.00	6,081.33	0.00	11,440.46	0.00	6,216.14	6,216.14	0.00

SUBTOTAL:

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	658,780.29

0.00

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	

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
3308	AHC CARE M&F 45-64
W

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

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

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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

331E	AHC CARE FEMALE 14-
2

0.00	0.00	6,631.50	0.00	0.00	0.00	0.00	0.00	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
3328	AHC CARE M&F 45-64
W

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

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

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

SUBTOTAL:

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

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	453.95

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	86.31

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	663.88

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

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	72.67

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

3615	AHC CARE/MI FEMALE
1

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

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

3617	AHC CARE/MI FEMALE
2

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

3618	AHC CARE/MI M&F 45-6	461.59	-389.23	461.59	-736.40	0.00	915,745.51	0.00	0.00	-466.86	0.00	0.00	0.00	915,076.20

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

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

361E	AHC CARE/MI FEMALE
1

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

361F	AHC CARE/MI MALE 21-	1,336.72	-426.98	8,189.22	6,152.04	0.00	0.00	0.00	0.00	-683.56	0.00	0.00	0.00	14,567.44

361G	AHC CARE/MI FEMALE
2

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

361H	AHC CARE/MI M&F 45-6	0.00	1,737.54	11,895.88	2,734.24	0.00	0.00	1,367.12	0.00	0.00	-2,050.68	0.00	0.00	15,684.10

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

SUBTOTAL:

5,457.46

306.55	
233,484.64	
172,150.30	
1,131,343.65	
273,347.79	
67.93	
44,093.29	

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	0.00	2,288,678.88

3505	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	306.55	0.00

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	13,532.68	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	9,714.98	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	39,401.50	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	28,391.49	0.00

350E	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	67.93	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	553.94	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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	687.33	0.00	48,257.56

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	12,826.53	0.00	217,294.29

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	99,327.12

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	1,155,565.93	0.00	10,303,945.54

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	1,480,055.71	0.00	13,763,980.93

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	7,359,852.26	0.00	71,369,755.37

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	6,592,740.27	0.00	66,949,082.53

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     14,768,723.22	0.00	143,820,462.52

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	13,075.25	0.00	204,159.27

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	106,734.59	0.00	1,601,249.87

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	144,313.50	0.00	2,264,050.18

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	761,732.56	0.00	12,743,950.89

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	483,083.51	0.00	10,508,036.73

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	1,349,472.77	0.00	22,870,609.83

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	15,890.21	0.00	360,237.97

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	4,230.95	0.00	28,938.57

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	332.74	0.00	16,651.35

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	6,683.52	0.00	84,804.83

3529	ADULT 40-100% M&F 65	2,418.24	5,799.29	2,157.44	-888.39	3,354.67	5,592.65	3,728.28	5,442.02	6,593.82	4,953.04	3,393.53	0.00	42,544.59

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	443.15	0.00	22,257.89

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	797.67	0.00	16,116.12

3704	ADULT <40% EXP MALE	358.14	358.14	767.56	372.61	0.00	431.69	446.08	446.08	0.00	0.00	2,426.39	0.00	5,606.69

3705	ADULT <40% EXP FEM AL

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

3706	ADULT <40% EXP MALE	66,342.05	90,906.49	64,804.70	11,629.81	85,235.20	82,474.29	54,597.00	55,899.55	41,417.96	30,565.44	28,069.42	0.00	611,941.91

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

27,895.47	28,762.05	25,344.58	5,617.72	34,819.31	32,594.15	20,407.53	11,316.34	12,719.90	8,261.40	13,852.79	0.00	221,591.24

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	51,334.53	0.00	1,252,348.83

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	6,528.47	0.00	95,540.60

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

370E	ADULT <40% EXP FEM AL

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

370F	ADULT <40% EXP MALE	9,711.72	8,915.14	7,256.19	4,079.50	3,031.09	22,002.44	4,687.43	4,543.85	5,106.44	2,001.85	5,112.60	0.00	76,448.25

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

14,796.79	2,816.57	2,643.56	-3,666.11	847.71	8,159.37	-624.29	3,346.17	7,448.24	52.08	2,389.57	0.00	38,209.66

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	8,986.70	0.00	183,415.07

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 MALE	4,660,701.72	4,609,307.78	4,699,719.76	4,983,993.27	4,967,501.61	4,920,258.73	4,892,866.81	4,749,896.92	4,724,125.48	4,565,041.47	4,398,117.73	0.00	52,171,531.28

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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	3,850,451.52	0.00	46,335,796.53

3716	ADULT <40% EXP MALE    20,467,726.18    21,642,151.29     22,652,596.64     24,114,702.02     24,867,544.52     25,650,195.34     26,115,755.85     25,450,749.34     26,484,548.11     26,899,254.30     26,934,511.51	0.00	271,279,735.10

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

13,101,290.86    13,787,135.05     14,316,548.26     15,186,356.28     15,607,747.20     16,014,494.76     16,156,133.04     15,844,503.83     16,283,869.41     16,443,871.07     16,565,489.19	0.00	169,307,438.95

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     33,260,517.99	0.00	339,640,701.14

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	31,907.83	0.00	338,051.84

371D	ADULT <40% EXP MALE	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	333,824.69	0.00	5,566,139.77

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	289,640.66	0.00	4,908,497.81

371F	ADULT <40% EXP MALE	4,492,505.58	3,143,839.58	3,233,348.06	2,433,416.79	3,018,935.25	2,875,754.38	3,318,420.97	3,905,872.55	5,052,282.29	3,006,799.32	2,379,662.32	0.00	36,860,837.09

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

3,159,846.04	1,948,048.39	1,745,769.58	1,455,033.81	1,885,867.58	1,719,887.70	1,832,113.18	2,065,982.02	2,799,049.40	1,792,463.94	1,259,827.29	0.00	21,663,888.93

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	2,249,065.27	0.00	36,887,039.83

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	4,565.39	0.00	181,142.04

3724	ADULT <40% EXP MALE	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 MALE	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	8,349.20	0.00	40,884.97

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6
372E	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	1,893.48	0.00	36,606.98

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	15,516.37	0.00	91,486.48

0.00	408.64	0.00	886.78	813.50	446.08	0.00	757.92	1,113.93	811.50	1,231.98	0.00	6,470.33

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 MALE	0.00	1,191.11	963.60	-89.39	160.38	0.00	464.05	0.00	484.74	0.00	1,230.82	0.00	4,405.31

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

0.00	0.00	0.00	736.84	412.40	0.00	0.00	0.00	1,177.49	137.38	1,653.28	0.00	4,117.39

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	1,732.13	0.00	15,332.80

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

SUBTOTAL:

117,597,157.42

111,745,075.69   114,847,592.00   115,780,591.10   120,463,750.59   123,829,238.48   126,976,213.14   126,210,982.78   135,623,028.78   127,920,287.14   126,060,493.39	0.00	1,347,054,410.51

9935	BIRTH SUPP PAYMENT A
9937	BIRTH SUPP PAYMENT
A

98,220.75	87,414.00	107,601.65	153,761.10	103,593.59	147,194.59	172,540.00	165,236.52	166,589.06	145,724.49	209,054.29	0.00	1,556,930.04

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	431,456.10	0.00	4,198,587.07

1,515.27	
106,754.00	
49,238.38	
567,739.98	
143,346.56	
50,487.85	
13,354.18	
177,601.46	
73,637.51	

SUBTOTAL:

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	640,510.39	0.00	5,755,517.11

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	7,442.80	0.00

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

26,377.26	15,963.72	563.90	-5,494.61	1,120.32	733.46	1,561.76	1,267.60	1,713.60	4,035.03	1,396.34	0.00

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	24,802.57	0.00

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	8,030.07	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	3,029.39	0.00

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

2,569.58	0.00	2,416.36	-154.91	44.53	237.91	3,272.84	0.00	2,632.32	0.00	2,335.55	0.00

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	5,757.71	0.00

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	3,489.05	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015

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

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	412,293.45	0.00	2,992,236.42

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	510,068.14	0.00	3,422,674.25

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	4,262,060.17	0.00	28,899,716.79

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

1,523,387.26	1,659,829.76	1,794,161.03	1,917,666.25	2,038,851.82	2,314,584.82	2,581,102.44	2,757,362.30	3,540,349.92	4,476,696.66	5,058,454.41	0.00	29,662,446.67

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	7,474,955.01	0.00	60,083,065.77

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	12,588.10	0.00	88,391.79

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	49,181.25	0.00	556,612.87

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	48,572.06	0.00	641,539.16

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	523,043.20	0.00	6,946,239.01

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

994,884.35	500,397.47	530,077.84	215,322.26	293,231.97	699,529.06	805,085.73	922,152.47	1,574,488.21	618,205.45	649,765.67	0.00	7,803,140.48

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	686,283.33	0.00	13,577,471.49

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	12,544.02	0.00	193,076.52

3926	NEWLY ELIGIBLE MALE	252.25	252.25	0.00	-298.76	315.97	0.00	0.00	0.00	0.00	0.00	637.61	0.00	1,159.32

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

0.00	0.00	0.00	-1,421.61	0.00	0.00	0.00	0.00	362.83	665.52	919.14	0.00	525.88

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	1,184.66	0.00	7,850.63

329.92	1,011.25	1,123.60	-614.82	0.00	0.00	0.00	0.00	250.47	851.89	318.42	0.00	3,270.73

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

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

0.00	0.00	0.00	-423.69	0.00	0.00	0.00	0.00	1,383.24	0.00	0.00	0.00	959.55

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

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

SUBTOTAL:

12,589,736.31

10,547,340.43     11,038,637.59     10,090,648.59     10,775,089.92     13,116,392.57     14,636,265.64     15,236,311.11     19,711,736.86     18,567,344.71     19,759,152.12	0.00	156,068,655.85

N
SUBTOTAL:

9939	BIRTH SUPP PAYMENT	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	184,902.82	0.00		1,107,654.21	
	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	184,902.82	0.00	1,107,654.21	

4411	SOBRA 100-133% M&F
<
4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	492.63	503.61	503.61	0.00	1,499.85

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	439.18	0.00	34,862.46

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	2,803,332.29	0.00	25,503,143.82

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	1,255,348.53	0.00	12,156,006.43

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

1,582,957.43	1,403,586.79	1,451,664.27	1,560,929.24	1,566,904.79	1,629,020.26	1,709,569.32	1,459,438.04	1,691,999.44	1,946,987.92	1,823,298.73	0.00	17,826,356.23

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

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	12,058.05	0.00	1,342,469.80

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	11,472.80	0.00	1,231,081.82

441E	SOBRA 100-133% FEMA L

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	12,480.77	0.00	1,404,238.13

SUBTOTAL:

6,088,102.49

4,621,221.13	4,765,216.27	4,904,476.80	4,860,977.15	5,312,891.60	5,471,248.95	4,960,520.94	6,243,584.82	6,353,500.15	5,918,933.96	0.00	59,500,674.26

9944	BIRTH SUPP PAYMENT	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	24,031.83	0.00	

331,823.73
S

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	24,031.83	0.00	331,823.73		

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

8,839.74	8,852.79	8,743.39	9,457.02	9,986.80	10,958.60	9,584.51	8,323.18	7,754.80	7,967.09	7,001.31	0.00	97,469.23

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	113,600.25	0.00	1,312,490.02

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

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

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	2,068.50	0.00	23,926.96

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

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	6,448.38	0.00	88,982.89

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	7,757.51	0.00	89,135.56

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

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

SUBTOTAL:

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	136,875.95	0.00	1,622,978.68

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

111.47	111.47	111.47	110.58	110.58	110.58	110.58	110.58	110.58	119.15	119.15	0.00	1,236.19

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	1,368,382.54	0.00	14,320,061.45

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	10,610.26	0.00	77,474.56

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	240,665.42	0.00	2,265,108.75

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	12,072.42	0.00	269,956.86

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	160,044.39	0.00	1,612,285.87

1,299.02	2,799.55	1,846.22	643.95	242.10	0.00	524.78	705.63	0.00	74.89	513.12	0.00	8,649.26

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	1,792,407.30	0.00	18,554,772.94

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	453,385,485.27	0.00	4,799,078,509.96	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	1.00

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	1.00	0.00	13.00

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	160.59	0.00	1,141.26

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	317.40	0.00	2,709.71

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	382.75	0.00	2,293.96

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	126.85	0.00	763.18

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	22.52	0.00	88.43

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	35.50	0.00	202.71

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	110.97	0.00	291.86

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	32.43	0.00	95.54

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	13,944.01	0.00	163,289.97

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	54,061.90	0.00	842,791.44

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	89,240.97	0.00	1,352,583.98

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	19,333.25	0.00	271,563.84

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	23,329.84	0.00	321,139.44

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	25,407.29	0.00	255,156.12

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	88,265.76	0.00	982,749.01

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	20,797.50	0.00	210,941.34

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	80.02	0.00	677.29

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	730.60	0.00	3,888.20

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	719.07	0.00	22,906.89

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	794.87	0.00	27,102.03

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	237.40	0.00	6,213.72

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	415.09	0.00	8,690.26

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	2,625.34	0.00	19,613.50

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	4,822.61	0.00	46,461.84

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	1,629.14	0.00	14,081.45

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	31.51	0.00	128.65

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	52.83	0.00	140.92

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	84.40	0.00	292.30

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	90.38	0.00	247.97

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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	49.62	0.00	113.10

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	0.64	0.00	1.48

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	0.73	0.00	7.34

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	14.36	0.00	29.50

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	1.34	0.00	3.73

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

4,370.68	4,347.93	4,360.25	4,520.65	4,374.48	4,436.34	4,491.10	4,409.73	4,274.38	4,214.40	4,078.62	0.00	47,878.56

902.84	381.78	183.85	232.94	184.97	1,080.72	75.10	133.16	426.34	372.24	396.03	0.00	4,369.97

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	6,113.93	0.00	69,743.66

1,881.26	947.08	682.35	432.93	480.61	330.10	370.96	410.79	494.70	283.55	215.56	0.00	6,529.89

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	17,664.26	0.00	234,886.67

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

435.63	230.59	152.26	158.11	294.87	338.55	61.21	58.83	62.08	54.62	72.61	0.00	1,919.36

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	3,753.22	0.00	47,066.38

659.56	304.25	203.76	241.91	174.16	192.23	158.08	184.17	289.73	213.35	190.53	0.00	2,811.73

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	57,326.78	0.00	636,086.53

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	1,090.77	0.00	15,626.94

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	24,971.74	0.00	281,655.53

97.75	112.63	39.47	40.20	26.57	52.19	49.65	30.69	43.89	44.54	50.57	0.00	588.15

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	28.00	0.00	328.10

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
231Z	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	441.57	0.00	4,769.76

9.31	5.91	15.12	21.47	9.26	1.34	2.18	6.73	18.30	7.46	14.40	0.00	111.48

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	212.88	0.00	2,290.97

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	1.04	0.00	20.65

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	2.00	0.00	18.14

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	1.16	0.00	10.86

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	1.00	0.00	11.00

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	-1.03	0.00	21.89

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	0.83	0.00	5.11

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	36,803.55	0.00	371,973.77

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	129,787.53	0.00	1,176,513.70

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	165,850.26	0.00	1,484,442.64

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	41,573.94	0.00	377,863.39

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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	41,731.69	0.00	375,148.48

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	1,094.89	0.00	11,938.70

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	7,738.68	0.00	81,692.11

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	10,032.67	0.00	84,768.14

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	2,490.55	0.00	24,190.72

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	2,583.68	0.00	24,624.01

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	1.00	0.00	6.87

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	1.00	0.00	2.00

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
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
500H	SOBRA PREG 45-64 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT

50.81	50.91	49.36	50.40	57.73	58.08	56.76	58.77	55.15	52.26	46.13	0.00	586.36

4.00	3.00	3.00	3.00	3.00	3.00	4.03	2.00	2.70	1.00	1.00	0.00	29.73

2.15	12.05	0.63	3.44	6.26	0.83	0.19	14.75	2.82	0.93	4.24	0.00	48.29

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

0.00	0.00	1.00	2.51	2.00	3.00	3.00	2.32	3.00	3.00	2.00	0.00	21.83

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	3,669.75	0.00	34,816.54

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	14,919.72	0.00	127,172.78

51.43	43.50	44.09	42.44	44.04	44.37	49.63	45.99	53.27	55.78	58.87	0.00	533.41

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

491.51	473.50	375.36	358.09	348.92	353.73	340.74	510.03	548.95	473.75	401.12	0.00	4,675.70

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	1,666.48	0.00	17,078.99

8.54	1.48	13.89	5.54	4.92	9.60	6.35	0.99	23.70	10.18	3.08	0.00	88.27

5.99	5.87	7.00	6.00	10.00	12.83	11.00	9.92	9.00	4.00	5.90	0.00	87.51

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

0.00	2.12	0.00	0.00	0.00	0.16	0.00	0.07	0.00	0.00	1.00	0.00	3.35

-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

9910	TANF & SOBRA CHILDR	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	606.00	0.00	
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	8.00	0.00	
9921	SSI W/O MEDICARE KIC	43.00	27.00	32.00	37.00	29.00	41.00	26.00	34.00	32.00	25.00	33.00	0.00	
9950	S.O.B.R.A. KICK PAYM	1,908.00	1,791.00	1,960.00	1,919.00	1,511.00	1,869.00	1,728.00	1,591.00	1,793.00	1,739.00	1,830.00	0.00	
SUBTOTAL:	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	2,477.00	0.	

SUBTOTAL:

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	925,046.68	0.00	10,113,485.80

10,431.00	
103.00	
359.00	
19,639.00	
30,532.00	

E

00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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

0.00	0.00	1.19	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.45	0.00	17.64

0.00	0.00	1.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.54	0.00	3.33

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

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

SUBTOTAL:

0.00

0.00

2.98	2.00	3.99	3.00	3.00	3.00	3.00	2.00	3.99	0.00	26.96

2.00	
8,397.41	
18,029.37	
27,567.66	
8,919.78	
300.50	
600.97	
928.98	
511.48	
417.85	
8,778.60	
27,355.50	
13,880.67	
27,681.85	
306,373.70	
660,263.99	
233,729.93	
761.00	
24.21	
233.59	
698.66	
587.83	
1,261.71	
19,147.93	
34,646.03	
15,054.86	
301.02	
2.00	
1,007.08	
2,042.80	

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	682.87	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	1,440.22	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	2,348.76	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	778.73	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	4.27	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	3.33	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	10.62	0.00

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

55.56	60.96	17.40	46.48	50.67	26.93	29.71	81.81	123.71	16.55	1.70	0.00

41.95	37.93	39.85	37.30	44.65	42.17	37.27	36.88	40.86	31.00	27.99	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	535.02	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	1,788.70	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	948.99	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	1,983.58	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	25,485.38	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	56,757.78	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	21,087.93	0.00

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

45.63	52.61	51.87	65.37	47.16	57.27	63.52	78.61	94.44	101.20	103.32	0.00

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	5.86	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	11.52	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	13.97	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	31.92	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	270.36	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	518.02	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	179.63	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	0.67	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	1.00	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	189.48	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	413.93	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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	481.63	0.00	2,918.16

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	216.19	0.00	1,248.69

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	1.12	0.00	25.12

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	8.80	0.00	117.83

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

32.48	11.34	0.16	0.00	10.06	0.00	0.48	1.88	6.73	0.00	0.00	0.00	63.13

581.54	565.94	599.57	644.56	580.35	657.07	731.43	709.85	781.59	673.17	582.51	0.00	7,107.58

491.82	374.01	631.37	528.24	448.28	1,561.33	573.80	778.71	1,078.04	402.82	284.52	0.00	7,152.94

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	1,339.81	0.00	14,284.15

347.68	242.29	309.35	378.83	239.87	233.89	160.39	208.24	183.90	66.51	24.65	0.00	2,395.60

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	26,525.82	0.00	252,093.77

487.45	464.59	370.63	421.41	475.31	710.65	225.05	225.31	210.17	134.52	96.25	0.00	3,821.34

3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	24.00

5.00	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	0.00	25.00

603.87	594.65	641.21	908.50	647.65	681.67	661.83	606.07	507.38	408.91	363.85	0.00	6,625.59

395.75	352.07	238.17	313.99	201.45	440.52	382.59	500.11	585.28	334.64	175.16	0.00	3,919.73

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	2,480.75	0.00	18,840.72

315.29	156.53	172.63	100.03	81.04	266.85	208.46	363.57	361.30	57.70	49.51	0.00	2,132.91

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	13,679.64	0.00	115,290.19

113.19	110.35	107.80	89.28	112.15	113.00	121.93	79.66	143.80	62.38	90.62	0.00	1,144.16

SUBTOTAL:

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	162,029.38	0.00	1,858,775.03

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

72.00	68.00	88.00	89.00	60.00	108.00	86.00	78.00	77.00	107.00	104.00	0.00

937.00	
19.00	
6.00	
962.00	

1.00	0.00	2.00	2.00	1.00	1.00	1.00	1.00	3.00	4.00	3.00	0.00

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

SUBTOTAL:

73.00

69.00	90.00	91.00	61.00	110.00	87.00	81.00	80.00	112.00	108.00

0.00

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

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
3308	AHC CARE M&F 45-64
W

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

0.00	0.00	0.00	-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

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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

331E	AHC CARE FEMALE 14-
2

0.00	0.00	9.00	0.00	0.00	0.00	0.00	0.00	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
3328	AHC CARE M&F 45-64
W

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

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

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

SUBTOTAL:

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

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	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

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

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	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	-4.43

3615	AHC CARE/MI FEMALE
1

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

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

3617	AHC CARE/MI FEMALE
2

0.96	2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	6.96

3618	AHC CARE/MI M&F 45-6	1.00	-1.00	1.00	-2.00	0.00	0.00	0.00	0.00	-1.10	0.00	0.00	0.00	-2.10

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

361D	AHC CARE/MI MALE 14-	8.00	0.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

361E	AHC CARE/MI FEMALE
1

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

361F	AHC CARE/MI MALE 21-	2.00	-0.81	12.00	9.00	0.00	0.00	0.00	0.00	-1.00	0.00	0.00	0.00	21.19

361G	AHC CARE/MI FEMALE
2

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

361H	AHC CARE/MI M&F 45-6	0.00	2.00	16.00	4.00	0.00	0.00	2.00	0.00	0.00	-3.00	0.00	0.00	21.00

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

SUBTOTAL:

5.23

0.87	
389.79	
259.78	
2,440.91	
660.17	
0.12	
62.29	

4.19	42.00	15.00	0.97	1.00	2.00	0.00	-2.10	-3.00	0.00	0.00	65.29

3505	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	0.87	0.00

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	15.63	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	13.00	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	83.92	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	67.99	0.00

350E	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	0.12	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	0.80	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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	1.00	0.00	67.37

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	21.32	0.00	325.69

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	143.01

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	2,649.21	0.00	24,376.63

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	3,376.61	0.00	32,329.89

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	16,926.00	0.00	169,118.07

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	15,073.05	0.00	157,639.35

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	34,224.63	0.00	343,009.80

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	31.31	0.00	506.00

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	159.90	0.00	2,398.90

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	217.31	0.00	3,381.31

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	1,132.58	0.00	19,212.63

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	723.66	0.00	15,818.69

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	2,016.98	0.00	34,276.50

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	25.65	0.00	548.71

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	5.00	0.00	34.58

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	0.67	0.00	20.54

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	16.02	0.00	197.84

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	7.83	0.00	107.75

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	0.64	0.00	33.65

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	1.16	0.00	23.42

3704	ADULT <40% EXP MALE	1.00	1.00	2.00	1.00	0.00	0.96	1.00	1.00	0.00	0.00	1.00	0.00	8.96

3705	ADULT <40% EXP FEM AL

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

3706	ADULT <40% EXP MALE	103.25	111.71	84.84	-54.92	97.69	100.71	63.98	57.24	45.04	39.21	33.60	0.00	682.35

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

48.48	48.94	35.43	-13.67	42.10	42.98	19.30	12.74	14.33	8.96	11.81	0.00	271.40

283.95	338.46	268.52	-23.74	322.09	351.54	223.06	153.20	137.71	106.71	90.78	0.00	2,252.28

56.31	44.45	21.90	-12.92	22.56	18.00	15.00	19.00	22.28	17.23	16.00	0.00	239.81

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

370E	ADULT <40% EXP FEM AL

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

370F	ADULT <40% EXP MALE	14.26	15.04	9.01	7.43	4.35	32.34	6.85	6.95	7.70	3.00	8.25	0.00	115.18

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

21.77	4.58	4.07	-5.93	1.22	10.07	-0.80	4.23	11.02	0.06	3.61	0.00	53.90

42.46	16.69	26.64	3.98	25.98	8.31	34.19	27.72	72.00	2.88	12.80	0.00	273.65

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 MALE	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	9,856.97	0.00	120,734.19

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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	8,674.93	0.00	107,418.91

3716	ADULT <40% EXP MALE	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	58,494.85	0.00	609,361.11

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

30,195.28	31,546.27	32,673.10	33,708.32	34,395.28	35,190.31	35,519.66	34,781.10	35,580.71	35,222.32	35,232.41	0.00	374,044.76

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	72,773.67	0.00	771,236.71

44.36	54.24	72.42	140.60	59.26	69.99	67.23	70.15	77.21	79.63	71.80	0.00	806.89

371D	ADULT <40% EXP MALE	1,088.95	744.05	996.81	659.46	547.41	567.99	795.23	718.56	1,058.18	688.78	497.39	0.00	8,362.81

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	432.83	0.00	7,355.70

371F	ADULT <40% EXP MALE	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	3,552.92	0.00	55,298.23

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

4,743.81	2,946.56	2,646.68	2,192.59	2,859.20	2,563.81	2,727.44	3,111.78	4,196.22	2,662.17	1,896.64	0.00	32,546.90

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	3,338.93	0.00	54,893.88

66.80	27.72	19.23	12.58	28.72	14.02	41.72	29.80	14.48	22.36	7.19	0.00	284.62

3724	ADULT <40% EXP MALE	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 MALE	3.54	4.47	6.56	-4.39	4.76	8.41	4.92	7.00	8.18	7.00	9.76	0.00	60.21

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6
372E	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	4.28	0.00	34.60

10.28	10.22	20.13	-8.43	15.54	16.12	10.18	13.00	8.86	15.99	19.87	0.00	131.76

0.00	1.00	0.00	1.96	2.00	1.00	0.00	2.00	3.00	2.00	3.00	0.00	15.96

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 MALE	0.00	2.19	1.43	-0.16	0.23	0.00	0.87	0.00	0.80	0.00	1.76	0.00	7.12

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

0.00	0.00	0.00	0.87	0.60	0.00	0.00	0.00	1.51	0.20	2.24	0.00	5.42

3.70	6.75	0.26	-5.27	4.80	1.19	2.80	1.00	3.12	0.00	2.73	0.00	21.08

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

SUBTOTAL:

257,226.96

251,422.78	258,778.78	257,494.33	265,705.06	272,322.45	277,392.21	274,768.57	291,090.03	275,916.51	271,844.88	0.00	2,953,962.56

9935	BIRTH SUPP PAYMENT A
9937	BIRTH SUPP PAYMENT
A

17.00	15.00	18.00	25.00	17.00	24.00	28.00	27.00	27.00	24.00	34.00	0.00	256.00

36.00	54.00	71.00	64.00	64.00	61.00	69.00	66.00	69.00	68.00	70.00	0.00	692.00

5.00	
199.82	
77.50	
1,482.56	
469.28	
148.61	
43.77	
559.70	
222.88	

SUBTOTAL:

53.00

69.00	89.00	89.00	81.00	85.00	97.00	93.00	96.00	92.00	104.00	0.00	948.00

3905	NEWLY ELIGIBLE FEMA L

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

3906	NEWLY ELIGIBLE MALE	62.36	50.69	9.18	-5.36	10.12	9.00	9.08	10.63	18.20	15.55	10.37	0.00

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

36.64	25.00	2.23	-17.92	3.86	2.31	5.12	4.39	5.56	6.00	4.31	0.00

583.32	464.17	124.90	-125.92	104.09	72.15	51.92	34.84	56.58	64.22	52.29	0.00

71.12	106.14	55.47	11.21	45.00	34.89	27.36	27.54	37.86	26.67	26.02	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	9.58	0.00

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

9.32	0.00	8.76	-1.05	0.13	0.67	11.86	0.00	7.41	0.00	6.67	0.00

131.86	92.81	26.55	-40.06	36.83	46.15	13.19	53.96	147.78	32.92	17.71	0.00

35.81	29.02	9.48	4.21	10.00	8.74	19.59	6.41	12.11	75.23	12.28	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015

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

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	1,280.07	0.00	9,447.46

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	1,570.19	0.00	10,615.80

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	13,193.43	0.00	92,031.49

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

5,051.42	5,501.50	5,946.45	6,133.41	6,472.28	7,361.08	8,222.68	8,758.33	11,220.75	13,888.93	15,755.55	0.00	94,312.38

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	23,297.29	0.00	192,616.21

12.97	16.28	21.99	23.89	13.90	20.47	19.89	32.63	45.09	44.92	41.03	0.00	293.06

391D	NEWLY ELIGIBLE MALE	139.88	114.69	172.17	38.05	75.44	156.21	138.95	198.37	405.34	91.82	147.15	0.00	1,678.07

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	146.96	0.00	1,921.84

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	1,577.14	0.00	21,008.49

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

3,026.68	1,519.30	1,615.35	644.99	889.23	2,124.06	2,425.64	2,780.33	4,726.49	1,846.48	1,949.87	0.00	23,548.42

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	2,068.02	0.00	40,995.16

68.94	33.73	31.96	17.08	9.10	49.51	75.02	87.26	139.28	46.79	36.91	0.00	595.58

3926	NEWLY ELIGIBLE MALE	1.00	1.00	0.00	-0.87	1.00	0.00	0.00	0.00	0.00	0.00	2.00	0.00	4.13

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

0.00	0.00	0.00	-4.73	0.00	0.00	0.00	0.00	1.09	2.00	3.00	0.00	1.36

6.28	12.94	6.70	-20.66	2.00	3.00	1.00	3.00	1.00	6.02	4.00	0.00	25.28

1.00	3.45	4.00	-2.00	0.00	0.00	0.00	0.00	1.00	2.79	1.00	0.00	11.24

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
392H	NEWLY ELIGIBLE M&F
4
392J	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	-1.25	0.00	0.00	0.00	0.00	3.89	0.00	0.00	0.00	2.64

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

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

SUBTOTAL:

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	61,212.84	0.00	492,331.23

N
SUBTOTAL:

9939	BIRTH SUPP PAYMENT	5.00	4.00	6.00	8.00	12.00	19.00	23.00	16.00	28.00	31.00	30.00	0.00		182.00	
	5.00	4.00	6.00	8.00	12.00	19.00	23.00	16.00	28.00	31.00	30.00	0.00	182.00	

4411	SOBRA 100-133% M&F
<
4412	SOBRA 100-133% M&F
1
4413	SOBRA 100-133% M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	3.00

128.25	116.83	18.70	19.00	12.81	7.00	4.00	2.00	1.00	2.00	4.00	0.00	315.59

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	22,807.94	0.00	213,303.23

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	7,350.90	0.00	73,165.23

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

5,923.23	5,777.63	5,977.89	6,132.81	6,154.98	6,421.65	6,727.70	5,713.39	6,663.54	7,443.66	6,986.07	0.00	69,922.55

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

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	193.70	0.00	22,607.37

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	70.72	0.00	7,424.89

441E	SOBRA 100-133% FEMA L

1,079.50	551.61	600.34	322.06	278.12	780.92	738.21	841.57	1,768.89	112.93	62.58	0.00	7,136.73

SUBTOTAL:

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	37,476.91	0.00	393,897.81

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

55.00
S

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	6.00	5.00	4.00	4.00	3.00	6.00	8.00	5.00	5.00	5.00	4.00	0.00	55.00		

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

38.00	37.90	37.32	38.47	40.56	41.00	38.87	34.00	32.00	32.00	28.00	0.00	398.12

288.12	281.92	279.22	281.82	275.75	271.77	270.15	263.48	264.29	261.06	253.96	0.00	2,991.54

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

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

1.32	7.91	3.09	1.14	10.29	4.90	9.39	7.49	1.50	0.93	5.00	0.00	52.96

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

25.51	25.80	25.39	26.48	26.90	27.96	25.25	24.21	25.00	14.61	17.00	0.00	264.11

18.73	20.00	20.00	19.44	20.73	20.96	19.00	19.00	19.00	20.00	18.00	0.00	214.86

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

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

SUBTOTAL:

383.44

379.77	367.61	372.91	378.02	373.63	362.78	349.96	341.79	328.60	321.96	0.00	3,960.47

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

1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	11.00

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	1,464.05	0.00	15,484.27

70.71	116.78	35.90	106.49	41.63	125.95	39.69	12.10	51.18	128.33	110.97	0.00	839.73

176.19	177.36	190.82	202.81	198.67	199.63	199.66	201.05	203.81	218.33	229.23	0.00	2,197.56

38.70	38.74	74.53	112.44	43.27	48.81	45.08	9.91	36.60	99.48	22.71	0.00	570.27

175.01	179.64	188.72	193.91	191.13	194.90	196.66	195.66	190.96	198.65	203.51	0.00	2,108.75

16.33	32.61	19.26	6.60	2.66	0.00	5.32	7.89	0.00	1.23	5.76	0.00	97.66

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	2,037.23	0.00	21,309.24

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	1,462,696.87	0.00	15,870,507.40		

ACUTE CAPITATION RURAL HOSPITAL - AMOUNTS

For The Period Ending May 31, 2015

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

9810	RURAL HOSP PMT TACI	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
9814	RURAL HOSP PMT MAL
E
9816	RURAL HOSP PMT FMA
L
9818	RURAL HOSP PMT ADL
T
9821	RURAL HOSP PMT SSI
W

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

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

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

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

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

SUBTOTAL:

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

9811	RURAL HOSP PMT TACI	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
9815	RURAL HOSP PMT MAL
E
9817	RURAL HOSP PMT FMA
L
9819	RURAL HOSP PMT ADL
T
9823	RURAL HOSP PMT FOR
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

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

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

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

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

SUBTOTAL:

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

9836	RURAL HOSP PMT FOR	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
A
00	24.01

9835	RURAL HOSPITAL PMT A
9837	RURAL HOSPITAL PMT
A

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	776,789.24	0.00	0.00	776,789.24

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,904,921.37	0.00	0.00	1,904,921.37

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,681,710.61	0.00	0.00	2,681,710.61

9845	RURAL HOSP PMT FOR B
9846	RURAL HOSP PMT FOR
C

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

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

SUBTOTAL:

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

MT 
SUBTOTAL:

9887	RH PAYMENT FREEDO	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	

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,406,358.98	0.00	0.00	12,406,358.98	

TOTAL:

ACUTE CAPITATION RURAL HOSPITAL - MEMBER MONTHS

For The Period Ending May 31, 2015

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

9810	RURAL HOSP PMT TACI	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
9814	RURAL HOSP PMT MAL
E
9816	RURAL HOSP PMT FMA
L
9818	RURAL HOSP PMT ADL
T
9821	RURAL HOSP PMT SSI
W

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

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

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

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

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

SUBTOTAL:

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

9811	RURAL HOSP PMT TACI	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
9815	RURAL HOSP PMT MAL
E
9817	RURAL HOSP PMT FMA
L
9819	RURAL HOSP PMT ADL
T
9823	RURAL HOSP PMT FOR
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

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

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

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

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

SUBTOTAL:

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

9836	RURAL HOSP PMT FOR	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
A
00	0.03

9835	RURAL HOSPITAL PMT A
9837	RURAL HOSPITAL PMT
A

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	421.29	0.00	0.00	421.29

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,062.27	0.00	0.00	1,062.27

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,483.56	0.00	0.00	1,483.56

9845	RURAL HOSP PMT FOR B
9846	RURAL HOSP PMT FOR
C

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.24	0.00	0.00	0.24

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

9887	RH PAYMENT FREEDO	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:

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

MT 
SUBTOTAL:

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,402.45	0.00	0.00	3,402.45		

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending May 31, 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	10,313.30	0.00	108,838.18

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	2,212,965.00	0.00	23,617,074.95

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	3,358.43	0.00	46,956.13

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

30,836,613.84    34,570,502.80     30,935,967.12     31,372,866.59     35,239,337.50     31,439,888.23     31,000,379.57     36,305,791.08     31,172,446.91     31,549,981.07     36,507,121.65	0.00	360,930,896.36

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	631,558.77	0.00	7,562,187.38

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	3,068,524.82	0.00	29,842,351.50

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	36,892.86	0.00	227,263.49

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     21,986,413.66	0.00	211,360,635.51

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

12,889.07	8,676.88	5,467.70	10,321.54	11,974.16	26,197.41	14,953.30	9,536.24	20,844.45	19,830.63	15,663.31	0.00	156,354.69

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     14,989,582.73	0.00	157,577,507.56

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	67,441.39	0.00	916,438.97

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     90,277,988.24	0.00	956,838,546.75

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	15,895.41	0.00	416,535.51

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     22,292,779.62	0.00	230,367,618.66

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	73,952.39	0.00	794,907.32

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
231Z	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	475,911.97	0.00	5,238,516.33

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

2320	SSI BLIND WITH QMB	126,705.55	125,345.33	117,181.83	121,490.14	121,496.86	118,939.74	117,692.70	122,813.09	120,915.98	121,703.60	119,556.42	0.00	1,333,841.24

SUBTOTAL:

172,463,262.81

182,618,498.68   174,288,831.72   175,786,182.74   185,603,284.58   178,547,267.15   176,820,682.36   189,755,326.17   178,443,192.44   180,253,697.12   192,785,919.97	0.00	1,987,366,145.74

8700	SSI DISABLED FREEDO M
870Z	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

67,556.86	73,398.32	64,735.65	65,903.92	71,492.44	69,307.88	65,903.92	76,007.71	66,142.28	69,851.71	77,245.10	0.00	767,545.79

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

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	116,814.52	0.00	1,175,727.25

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

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	20,720.60	0.00	157,156.77

SUBTOTAL:

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	214,780.22	0.00	2,110,901.64

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	193,000,700.19	0.00	1,989,477,047.38	

TOTAL:

LONG TERM CARE MEMBER MONTHS

For The Period Ending May 31, 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	3.00	0.00	33.00

1010	TANF NON-MEDICARE	633.10	629.83	627.45	631.62	631.62	631.96	634.79	642.33	646.68	647.80	653.61	0.00	7,010.79

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	1.00	0.00	14.00

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

11,510.64	11,449.32	11,525.89	11,554.03	11,529.19	11,528.39	11,403.72	11,451.83	11,446.48	11,399.17	11,373.95	0.00	126,172.61

680.99	812.44	766.78	736.17	639.15	744.01	740.52	732.75	785.92	804.54	656.06	0.00	8,099.33

604.41	604.39	593.07	596.85	602.22	588.71	587.77	597.36	617.63	631.68	635.69	0.00	6,659.78

22.69	16.62	8.62	39.07	13.49	18.23	9.06	8.01	28.76	39.68	37.06	0.00	241.29

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	7,348.91	0.00	79,280.97

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

14.44	9.92	5.94	11.10	12.60	27.46	16.06	10.52	21.54	21.46	16.69	0.00	167.73

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	4,505.06	0.00	51,004.28

91.28	112.25	91.86	124.95	76.51	80.55	69.15	57.14	93.40	107.45	68.32	0.00	972.86

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	25,522.25	0.00	274,709.64

34.40	38.90	29.82	40.98	31.55	32.11	60.95	47.93	32.75	57.52	16.03	0.00	422.94

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	6,778.27	0.00	73,487.91

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	22.00	0.00	246.44

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
231Z	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	136.99	0.00	1,509.78

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

2320	SSI BLIND WITH QMB	42.00	40.38	38.92	40.00	39.00	39.00	39.00	39.00	40.00	40.00	37.80	0.00	435.10

SUBTOTAL:

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	57,812.69	0.00	630,499.44

8700	SSI DISABLED FREEDO M
870Z	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

22.00	22.00	21.00	21.00	21.00	22.03	21.00	22.00	21.00	22.00	22.00	0.00	237.03

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

23.32	23.00	23.00	23.00	23.86	24.00	24.00	24.00	25.00	25.00	24.76	0.00	262.94

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

6.00	6.00	4.00	4.00	4.00	5.00	5.00	5.00	6.00	6.00	7.00	0.00	58.00

SUBTOTAL:

54.99

51.00	48.00	48.00	50.99	56.99	50.00	51.00	52.00	53.00	53.76	0.00	569.73

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	57,866.45	0.00	631,069.17		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending May 31, 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	37.55	0.00	492.62

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	7,595,013.20	0.00	112,850,125.43

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-MEDICA R

0.00	0.00	0.00	0.00	0.00	37.14	37.14	37.14	37.14	37.55	37.55	0.00	223.66

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

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
4320	SOBRA CHILD WITH Q
MB
5010	SOBRA PREGNANT WO
MAN

37.20	37.20	74.40	74.28	74.28	124.44	111.42	111.42	111.42	112.65	37.55	0.00	906.26

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	434,153.10	0.00	4,792,159.57

297.60	297.60	297.60	297.12	297.12	329.42	259.98	259.98	222.84	187.75	262.85	0.00	3,009.86

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	1,539.55	0.00	17,492.02

74.40	148.80	74.40	37.14	74.28	194.38	148.56	148.56	185.70	187.75	187.75	0.00	1,461.72

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     14,250,375.20	0.00	128,087,100.82

0.00	0.00	0.00	0.00	0.00	0.00	0.00	37.14	297.12	638.35	225.30	0.00	1,197.91

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	15,695.90	0.00	138,131.06

SUBTOTAL:

21,922,666.80

22,293,290.40     22,580,437.20     22,671,221.64     22,251,465.36     24,723,572.02     21,911,002.98     21,706,881.54     21,670,521.48     21,863,863.00     22,297,565.50	0.00	245,892,487.92

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

198,090.00	197,941.20	199,243.20	198,884.70	194,502.18	223,914.02	184,511.52	181,168.92	169,506.96	149,336.35	132,063.35	0.00	2,029,162.40

74.40	74.40	74.40	74.28	74.28	95.98	74.28	74.28	74.28	37.55	37.55	0.00	765.68

3610	AHC CARE EXPANDED	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	

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	132,100.90

0.00	2,029,928.08

FO
SUBTOTAL:

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,017,829.20	1,035,387.60	1,038,438.00	1,047,459.42	1,051,470.54	1,044,228.24	1,095,110.04	941,944.68	1,089,761.88	1,368,772.60	1,282,032.10	0.00		12,012,434.30	
	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	1,282,032.10	0.00	12,012,434.30	

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	23,711,698.50	0.00	259,934,854.64	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending May 31, 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	1.00	0.00	13.00

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	202,264.00	0.00	2,999,351.00

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-MEDICA R

0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	6.00

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

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
4320	SOBRA CHILD WITH Q
MB
5010	SOBRA PREGNANT WO
MAN

1.00	1.00	2.00	2.00	2.00	3.00	3.00	3.00	3.00	3.00	1.00	0.00	24.00

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	11,562.00	0.00	126,933.00

8.00	8.00	8.00	8.00	8.00	7.00	7.00	7.00	6.00	5.00	7.00	0.00	79.00

39.00	39.00	39.00	41.00	43.00	47.00	45.00	45.00	41.00	41.00	41.00	0.00	461.00

2.00	4.00	2.00	1.00	2.00	5.00	4.00	4.00	5.00	5.00	5.00	0.00	39.00

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	379,504.00	0.00	3,406,319.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	8.00	17.00	6.00	0.00	32.00

340.00	337.00	346.00	326.00	339.00	314.00	287.00	294.00	304.00	348.00	418.00	0.00	3,653.00

SUBTOTAL:

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	593,810.00	0.00	6,536,915.00

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

5,325.00	5,321.00	5,356.00	5,355.00	5,237.00	5,253.00	4,968.00	4,878.00	4,564.00	3,977.00	3,517.00	0.00	53,751.00

2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	0.00	20.00

3610	AHC CARE EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	0.00	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:

5,327.00

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	3,518.00

0.00	53,771.00

FO

4410	SOBRA 100-133% FOR	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	34,142.00	0.00		322,523.00	
	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	34,142.00	0.00	322,523.00	

SUBTOTAL:

F
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	631,470.00	0.00	6,913,209.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending May 31, 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	30,458.58	0.00	224,791.47

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	5,162,865.59	0.00	56,211,429.37

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	9,164.83	0.00	25,181.72

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

146,311.32	148,129.05	149,468.43	160,339.84	159,424.00	195,009.65	163,290.88	160,373.76	153,962.88	150,861.96	146,466.93	0.00	1,733,638.70

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	209,121.66	0.00	2,365,002.28

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	647,704.77	0.00	8,547,662.32

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

146,279.43	147,491.25	147,618.81	157,626.24	158,372.48	196,697.50	163,697.92	160,916.48	146,229.12	142,344.46	138,256.06	0.00	1,705,529.75

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	1,418,572.59	0.00	15,762,809.91

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	841,835.63	0.00	9,549,974.56

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	1,226.52	0.00	13,381.78

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	15,024.87	0.00	162,136.38

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	8,415.29	0.00	92,554.48

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

0.00	31.89	0.00	0.00	0.00	8.61	33.92	33.92	33.92	34.07	34.07	0.00	210.40

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	734,310.71	0.00	7,410,720.57

0.00	0.00	0.00	33.92	0.00	0.00	0.00	0.00	0.00	0.00	34.07	0.00	67.99

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	1,294.66	0.00	17,937.42

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	611,931.27	0.00	5,325,615.15

159.45	127.56	191.34	169.60	271.36	373.64	339.20	271.36	237.44	136.28	136.28	0.00	2,413.51

SUBTOTAL:

9,135,528.30

9,300,495.27	9,415,586.28     10,032,823.68	9,892,801.92     12,350,914.46	9,796,570.88	9,757,121.92	9,739,720.96	9,752,639.71	9,976,854.38	0.00	109,151,057.76

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

178,520.22	179,572.59	181,932.45	195,752.32	191,749.76	238,286.23	189,714.56	186,695.68	190,460.80	192,120.73	176,857.37	0.00	2,101,662.71

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	3,760,135.55	0.00	43,191,309.97

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	43,473.32	0.00	237,604.18

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	17,580.12	0.00	212,387.69

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	46,437.41	0.00	474,235.63

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	932,972.88	0.00	8,766,555.95

95.67	95.67	63.78	67.84	67.84	67.84	67.84	67.84	67.84	68.14	68.14	0.00	798.44

159.45	95.67	95.67	67.84	67.84	188.38	67.84	67.84	67.84	34.07	34.07	0.00	946.51

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	9,130.76	0.00	163,518.27

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	79,962.29	0.00	539,972.47

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	417,050.87	0.00	3,492,922.28

SUBTOTAL:

4,797,691.05

4,925,506.17	5,020,697.82	5,403,150.72	5,347,759.36	6,572,563.01	5,306,851.84	5,302,951.04	5,437,342.08	5,583,698.23	5,483,702.78	0.00	59,181,914.10

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

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

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

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

SUBTOTAL:

0.00

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

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending May 31, 2015

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

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

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

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

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

SUBTOTAL:

127.56

127.56

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

3500	ADULT 40-100% FOR FI	16,327.68	16,678.47	14,701.29	16,383.36	17,299.20	18,825.60	13,635.84	10,243.84	8,412.16	7,052.49	6,098.53	0.00	145,658.46

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	2,497,296.93	0.00	24,460,564.93

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	1,124.31	0.00	13,714.80

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

15,083.97	16,391.46	12,532.77	14,042.88	15,128.32	16,213.76	9,870.72	7,530.24	6,784.00	5,280.85	4,429.10	0.00	123,288.07

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	6,737,240.29	0.00	71,236,004.87

446.46	542.13	892.92	949.76	983.68	949.76	508.80	814.08	983.68	851.75	1,056.17	0.00	8,979.19

SUBTOTAL:

7,349,656.41

7,745,634.54	8,044,380.06	8,816,961.28	8,955,829.76	9,120,409.60	9,192,014.72	9,072,684.16	9,166,201.60	9,277,192.86	9,247,245.33	0.00	95,988,210.32

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

23,215.92	20,441.49	5,867.76	5,054.08	5,121.92	3,697.28	2,815.36	2,238.72	2,781.44	2,827.81	2,589.32	0.00	76,651.10

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	1,858,484.43	0.00	13,092,212.26

223.23	414.57	382.68	135.68	101.76	101.76	33.92	101.76	67.84	238.49	306.63	0.00	2,108.32

SUBTOTAL:

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	1,861,380.38	0.00	13,170,971.68

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	62,918.97	72,964.32	81,383.28	96,264.96	96,502.40	104,541.44	115,022.72	90,769.92	102,234.88	120,778.15	116,451.26	0.00		1,059,832.30	
	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	116,451.26	0.00	1,059,832.30	

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

10,236.69	10,109.13	10,204.80	10,718.72	10,684.80	13,202.56	10,379.52	10,176.00	10,142.08	10,084.72	9,641.81	0.00	115,580.83

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	1,260.59	0.00	16,743.03

SUBTOTAL:

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	10,902.40	0.00	132,323.86

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

31.89	31.89	31.89	33.92	33.92	33.92	33.92	33.92	33.92	34.07	34.07	0.00

367.33	
350,677.03	
63,471.17	
52,312.27	
466,827.80	

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	32,604.99	0.00

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	6,643.65	0.00

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	4,940.15	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	44,222.86

0.00

TOTAL:

22,170,884.70

22,956,207.84     23,514,282.84     25,414,051.20     25,392,376.32     29,935,107.78     25,689,651.20     25,535,247.36     25,911,827.20     26,509,253.74     26,740,759.39	0.00	279,769,649.57

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending May 31, 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	894.00	0.00	6,577.00

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	151,537.00	0.00	1,646,891.00

1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	44.00	45.00	56.00	80.00	120.00	269.00	0.00	739.00

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

4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	4,699.00	4,814.00	4,728.00	4,539.00	4,428.00	4,299.00	0.00	50,854.00

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	6,138.00	0.00	69,454.00

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	19,011.00	0.00	250,765.00

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

4,587.00	4,625.00	4,629.00	4,647.00	4,669.00	4,715.00	4,826.00	4,744.00	4,311.00	4,178.00	4,058.00	0.00	49,989.00

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	41,637.00	0.00	459,466.00

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	24,709.00	0.00	278,383.00

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	36.00	0.00	394.00

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	441.00	0.00	4,747.00

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	247.00	0.00	2,706.00

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

0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	6.00

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	21,553.00	0.00	217,328.00

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

51.00	48.00	47.00	47.00	52.00	53.00	51.00	49.00	46.00	42.00	38.00	0.00	524.00

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	17,961.00	0.00	155,560.00

5.00	4.00	6.00	5.00	8.00	10.00	10.00	8.00	7.00	4.00	4.00	0.00	71.00

SUBTOTAL:

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	292,834.00	0.00	3,194,456.00

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

5,598.00	5,631.00	5,705.00	5,771.00	5,653.00	5,621.00	5,593.00	5,504.00	5,615.00	5,639.00	5,191.00	0.00	61,521.00

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	110,365.00	0.00	1,267,230.00

260.00	293.00	367.00	383.00	448.00	527.00	591.00	681.00	970.00	1,186.00	1,276.00	0.00	6,982.00

528.00	554.00	526.00	491.00	533.00	528.00	669.00	658.00	662.00	609.00	516.00	0.00	6,274.00

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	1,363.00	0.00	13,907.00

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	27,384.00	0.00	256,628.00

3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	24.00

5.00	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	0.00	25.00

434.00	473.00	483.00	495.00	520.00	530.00	516.00	484.00	335.00	284.00	268.00	0.00	4,822.00

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	2,347.00	0.00	15,567.00

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	12,241.00	0.00	101,950.00

SUBTOTAL:

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	160,954.00	0.00	1,734,930.00

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

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

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

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

SUBTOTAL:

0.00

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending May 31, 2015

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

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

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

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

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

SUBTOTAL:

4.00

4.00

3.00	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	555.00	402.00	302.00	248.00	207.00	179.00	0.00	4,382.00

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	73,299.00	0.00	731,099.00

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	33.00	0.00	412.00

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

473.00	514.00	393.00	414.00	446.00	478.00	291.00	222.00	200.00	155.00	130.00	0.00	3,716.00

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	197,747.00	0.00	2,130,985.00

14.00	17.00	28.00	28.00	29.00	28.00	15.00	24.00	29.00	25.00	31.00	0.00	268.00

SUBTOTAL:

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	271,419.00	0.00	2,870,862.00

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

728.00	641.00	184.00	149.00	151.00	109.00	83.00	66.00	82.00	83.00	76.00	0.00	2,352.00

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	54,549.00	0.00	390,188.00

7.00	13.00	12.00	4.00	3.00	3.00	1.00	3.00	2.00	7.00	9.00	0.00	64.00

SUBTOTAL:

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	54,634.00	0.00	392,604.00

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	3,391.00	2,676.00	3,014.00	3,545.00	3,418.00	0.00		31,622.00	
	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	3,418.00	0.00	31,622.00	

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

321.00	317.00	320.00	316.00	315.00	308.00	306.00	300.00	299.00	296.00	283.00	0.00	3,381.00

46.00	46.00	45.00	44.00	46.00	47.00	46.00	44.00	45.00	42.00	37.00	0.00	488.00

SUBTOTAL:

367.00

363.00	365.00	360.00	361.00	355.00	352.00	344.00	344.00	338.00	320.00	0.00	3,869.00

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

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

11.00	
10,172.00	
1,850.00	
1,523.00	
13,556.00	

859.00	855.00	890.00	907.00	930.00	940.00	969.00	962.00	947.00	956.00	957.00	0.00

146.00	149.00	159.00	165.00	168.00	172.00	170.00	172.00	172.00	182.00	195.00	0.00

122.00	128.00	137.00	140.00	140.00	142.00	143.00	144.00	141.00	141.00	145.00	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	1,298.00

0.00

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	784,877.00	0.00	8,241,915.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending May 31, 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	40,972.02	0.00	299,717.97

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	6,944,940.71	0.00	74,993,769.11

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	12,328.27	0.00	33,512.33

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

213,846.68	216,503.45	218,461.07	208,602.51	207,411.00	227,555.43	212,441.82	208,646.64	200,306.07	202,935.24	197,023.17	0.00	2,313,733.08

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	281,304.54	0.00	3,157,482.28

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	871,274.13	0.00	11,406,928.39

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

213,800.07	215,571.25	215,757.69	205,072.11	206,042.97	228,910.55	212,971.38	209,352.72	190,244.43	191,477.74	185,978.14	0.00	2,275,179.05

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	1,908,223.71	0.00	20,968,022.96

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	1,132,413.47	0.00	12,700,782.89

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	1,649.88	0.00	17,900.16

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	20,211.03	0.00	216,191.61

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	11,320.01	0.00	123,320.38

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

0.00	46.61	0.00	0.00	0.00	4.88	44.13	44.13	44.13	45.83	45.83	0.00	275.54

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	987,773.99	0.00	9,896,758.90

0.00	0.00	0.00	44.13	0.00	0.00	0.00	0.00	0.00	0.00	45.83	0.00	89.96

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	1,741.54	0.00	23,875.96

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	823,152.63	0.00	7,097,281.38

233.05	186.44	279.66	220.65	353.04	460.82	441.30	353.04	308.91	183.32	183.32	0.00	3,203.55

SUBTOTAL:

13,352,366.70

13,593,480.23     13,761,695.72     13,052,727.27     12,870,558.63     14,246,839.35     12,745,361.82     12,694,038.63     12,671,399.94     13,118,974.99     13,420,582.22	0.00	145,528,025.50

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

260,922.78	262,460.91	265,910.05	254,674.23	249,466.89	275,046.01	246,819.09	242,891.52	247,789.95	258,435.37	237,903.53	0.00	2,802,320.33

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	5,058,027.95	0.00	57,656,379.54

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	58,479.08	0.00	315,870.98

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	23,648.28	0.00	284,284.76

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	62,466.29	0.00	632,810.79

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	1,255,008.72	0.00	11,681,759.14

139.83	139.83	93.22	88.26	88.26	88.26	88.26	88.26	88.26	91.66	91.66	0.00	1,085.76

233.05	139.83	139.83	88.26	88.26	156.58	88.26	88.26	88.26	45.83	45.83	0.00	1,202.25

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	12,282.44	0.00	218,707.90

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	107,563.01	0.00	714,892.81

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	561,005.03	0.00	4,645,094.06

SUBTOTAL:

7,012,241.45

7,199,054.33	7,338,185.18	7,029,511.83	6,957,447.54	7,653,039.86	6,904,226.76	6,899,151.81	7,073,994.87	7,511,032.87	7,376,521.82	0.00	78,954,408.32

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

0.00	0.00	0.00	0.00	0.00	204.96	0.00	0.00	0.00	0.00	0.00	0.00	204.96

0.00	0.00	0.00	0.00	0.00	80,441.92	0.00	0.00	0.00	0.00	0.00	0.00	80,441.92

0.00	0.00	0.00	0.00	0.00	156.16	0.00	0.00	0.00	0.00	0.00	0.00	156.16

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	80,803.04	0.00	0.00	0.00	0.00	0.00	0.00	80,803.04

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending May 31, 2015

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

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

0.00	0.00	0.00	0.00	0.00	131.76	0.00	0.00	0.00	0.00	0.00	0.00	131.76

186.44	186.44	139.83	132.39	44.13	269,366.45	0.00	0.00	0.00	0.00	0.00	0.00	270,055.68

0.00	0.00	0.00	0.00	0.00	9.76	0.00	0.00	0.00	0.00	0.00	0.00	9.76

SUBTOTAL:

186.44

186.44	139.83	132.39	44.13	269,507.97	0.00	0.00	0.00	0.00	0.00	0.00	270,197.20

3500	ADULT 40-100% FOR FI	23,864.32	24,377.03	21,487.21	21,314.79	22,506.30	24,492.15	17,740.26	13,327.26	10,944.24	9,486.81	8,203.57	0.00	197,743.94

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	3,359,293.17	0.00	32,953,703.67

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	1,512.39	0.00	18,621.90

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

22,046.53	23,957.54	18,317.73	18,269.82	19,681.98	21,094.14	12,841.83	9,796.86	8,826.00	7,103.65	5,957.90	0.00	167,893.98

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	9,062,745.01	0.00	96,064,937.43

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	1,420.73	0.00	12,068.36

SUBTOTAL:

10,742,160.09

11,320,916.46     11,757,558.94     11,470,887.42     11,651,555.64     11,865,674.40     11,958,832.83     11,803,583.49     11,925,249.90     12,479,417.34     12,439,132.77	0.00	129,414,969.28

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

33,932.08	29,877.01	8,576.24	6,575.37	6,663.63	4,810.17	3,662.79	2,912.58	3,618.66	3,803.89	3,483.08	0.00	107,915.50

1,101,813.79	1,231,995.52	1,310,160.49	1,309,072.32	1,352,981.67	1,422,530.55	1,588,371.09	1,631,883.27	1,833,160.20	2,309,327.87	2,499,980.67	0.00	17,591,277.44

326.27	605.93	559.32	176.52	132.39	132.39	44.13	132.39	88.26	320.81	412.47	0.00	2,930.88

SUBTOTAL:

1,136,072.14

1,262,478.46	1,319,296.05	1,315,824.21	1,359,777.69	1,427,473.11	1,592,078.01	1,634,928.24	1,836,867.12	2,313,452.57	2,503,876.22	0.00	17,702,123.82

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	91,961.53	106,643.68	118,948.72	125,240.94	125,549.85	136,008.66	149,644.83	118,091.88	133,007.82	162,467.35	156,646.94	0.00		1,424,212.20	
	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	156,646.94	0.00	1,424,212.20	

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

14,961.81	14,775.37	14,915.20	13,945.08	13,900.95	15,153.64	13,503.78	13,239.00	13,194.87	13,565.68	12,969.89	0.00	154,125.27

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	1,695.71	0.00	22,268.14

SUBTOTAL:

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	14,665.60	0.00	176,393.41

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

46.61	46.61	46.61	44.13	44.13	44.13	44.13	44.13	44.13	45.83	45.83	0.00

496.27	
464,632.06	
84,305.24	
69,446.51	
618,880.08	

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	43,859.31	0.00

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	8,936.85	0.00

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	6,645.35	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	59,487.34

0.00

TOTAL:

32,404,670.30

33,552,488.16     34,368,163.16     33,063,740.55     33,035,541.48     35,759,936.09     33,422,296.80     33,221,417.04     33,711,348.30     35,659,498.06     35,970,912.91	0.00	374,170,012.85

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending May 31, 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	894.00	0.00	6,577.00

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	151,537.00	0.00	1,646,891.00

1020	TANF WITH QMB	16.00	18.00	23.00	30.00	38.00	44.00	45.00	56.00	80.00	120.00	269.00	0.00	739.00

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

4,588.00	4,645.00	4,687.00	4,727.00	4,700.00	4,699.00	4,814.00	4,728.00	4,539.00	4,428.00	4,299.00	0.00	50,854.00

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	6,138.00	0.00	69,454.00

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	19,011.00	0.00	250,765.00

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

4,587.00	4,625.00	4,629.00	4,647.00	4,669.00	4,715.00	4,826.00	4,744.00	4,311.00	4,178.00	4,058.00	0.00	49,989.00

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	41,637.00	0.00	459,466.00

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	24,709.00	0.00	278,383.00

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	36.00	0.00	394.00

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	441.00	0.00	4,747.00

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	247.00	0.00	2,706.00

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

0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	6.00

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	21,553.00	0.00	217,328.00

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

51.00	48.00	47.00	47.00	52.00	53.00	51.00	49.00	46.00	42.00	38.00	0.00	524.00

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	17,961.00	0.00	155,560.00

5.00	4.00	6.00	5.00	8.00	10.00	10.00	8.00	7.00	4.00	4.00	0.00	71.00

SUBTOTAL:

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	292,834.00	0.00	3,194,456.00

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

5,598.00	5,631.00	5,705.00	5,771.00	5,653.00	5,621.00	5,593.00	5,504.00	5,615.00	5,639.00	5,191.00	0.00	61,521.00

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	110,365.00	0.00	1,267,230.00

260.00	293.00	367.00	383.00	448.00	527.00	591.00	681.00	970.00	1,186.00	1,276.00	0.00	6,982.00

528.00	554.00	526.00	491.00	533.00	528.00	669.00	658.00	662.00	609.00	516.00	0.00	6,274.00

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	1,363.00	0.00	13,907.00

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	27,384.00	0.00	256,628.00

3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	24.00

5.00	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	0.00	25.00

434.00	473.00	483.00	495.00	520.00	530.00	516.00	484.00	335.00	284.00	268.00	0.00	4,822.00

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	2,347.00	0.00	15,567.00

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	12,241.00	0.00	101,950.00

SUBTOTAL:

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	160,954.00	0.00	1,734,930.00

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

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

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

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

SUBTOTAL:

0.00

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending May 31, 2015

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

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

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

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

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

SUBTOTAL:

4.00

4.00

3.00	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00

3500	ADULT 40-100% FOR FI	512.00	523.00	461.00	483.00	510.00	555.00	402.00	302.00	248.00	207.00	179.00	0.00	4,382.00

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	73,299.00	0.00	731,099.00

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	33.00	0.00	412.00

3700	ADULT <40% EXP FOR F
3710	AHC CARE EXPANDED
FO
3720	AHC CARE EXPANDED
FO

473.00	514.00	393.00	414.00	446.00	478.00	291.00	222.00	200.00	155.00	130.00	0.00	3,716.00

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	197,747.00	0.00	2,130,985.00

14.00	17.00	28.00	28.00	29.00	28.00	15.00	24.00	29.00	25.00	31.00	0.00	268.00

SUBTOTAL:

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	271,419.00	0.00	2,870,862.00

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

728.00	641.00	184.00	149.00	151.00	109.00	83.00	66.00	82.00	83.00	76.00	0.00	2,352.00

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	54,549.00	0.00	390,188.00

7.00	13.00	12.00	4.00	3.00	3.00	1.00	3.00	2.00	7.00	9.00	0.00	64.00

SUBTOTAL:

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	54,634.00	0.00	392,604.00

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	1,973.00	2,288.00	2,552.00	2,838.00	2,845.00	3,082.00	3,391.00	2,676.00	3,014.00	3,545.00	3,418.00	0.00		31,622.00	
	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	3,418.00	0.00	31,622.00	

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

321.00	317.00	320.00	316.00	315.00	308.00	306.00	300.00	299.00	296.00	283.00	0.00	3,381.00

46.00	46.00	45.00	44.00	46.00	47.00	46.00	44.00	45.00	42.00	37.00	0.00	488.00

SUBTOTAL:

367.00

363.00	365.00	360.00	361.00	355.00	352.00	344.00	344.00	338.00	320.00	0.00	3,869.00

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

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

11.00	
10,172.00	
1,850.00	
1,523.00	
13,556.00	

859.00	855.00	890.00	907.00	930.00	940.00	969.00	962.00	947.00	956.00	957.00	0.00

146.00	149.00	159.00	165.00	168.00	172.00	170.00	172.00	172.00	182.00	195.00	0.00

122.00	128.00	137.00	140.00	140.00	142.00	143.00	144.00	141.00	141.00	145.00	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	1,298.00

0.00

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	784,877.00	0.00	8,241,915.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending May 31, 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	1,031,919.02	0.00	16,162,874.49

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

403,827.58	407,211.61	407,211.61	317,900.72	327,142.02	355,792.33	312,355.94	318,824.85	321,597.24	331,588.74	332,517.56	0.00	3,835,970.20

1,128.01	1,128.01	1,128.01	924.13	924.13	1,255.63	924.13	924.13	924.13	928.82	928.82	0.00	11,117.95

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     13,284,912.46	0.00	145,294,760.95

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	20,434.04	0.00	210,643.72

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     14,670,711.90	0.00	165,515,367.31

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	924.13	0.00	0.00	0.00	0.00	0.00	0.00	924.13

0.00	0.00	0.00	0.00	0.00	110.50	0.00	0.00	0.00	0.00	0.00	0.00	110.50

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	1,034.63	0.00	0.00	0.00	0.00	0.00	0.00	1,034.63

F
SUBTOTAL:

4410	SOBRA 100-133% FOR	15,792.14	15,792.14	18,048.16	17,558.47	26,799.77	29,572.16	38,813.46	32,344.55	33,268.68	41,796.90	36,223.98	0.00		306,010.41	
	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	36,223.98	0.00	306,010.41	

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	14,706,935.88	0.00	165,822,412.35	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending May 31, 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	1,111.00	0.00	15,913.00

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

358.00	361.00	361.00	344.00	354.00	341.00	338.00	345.00	348.00	357.00	358.00	0.00	3,865.00

1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	11.00

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	14,303.00	0.00	147,533.00

16.00	19.00	16.00	15.00	14.00	20.00	25.00	24.00	21.00	21.00	22.00	0.00	213.00

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	15,795.00	0.00	167,535.00

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E

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

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

4410	SOBRA 100-133% FOR	14.00	14.00	16.00	19.00	29.00	32.00	42.00	35.00	36.00	45.00	39.00	0.00		321.00	
	14.00	14.00	16.00	19.00	29.00	32.00	42.00	35.00	36.00	45.00	39.00	0.00	321.00	

SUBTOTAL:

0.00

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

F
SUBTOTAL:

TOTAL:	14,695.00	14,750.00	14,936.00	15,100.00	15,135.00	15,185.00	15,280.00	15,472.00	15,658.00	15,812.00	15,834.00	0.00	167,857.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending May 31, 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	1,008.42	0.00	6,998.26

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	133,111.44	0.00	1,288,915.72

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	11,781.00	0.00	155,409.73

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	39,299.04	0.00	564,260.00

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	44,147.19	0.00	586,420.64

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	10,181.10	0.00	135,218.09

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	13,603.89	0.00	171,768.51

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	0.00	0.00	416.93

1017	TANF 21-44 FEMALE N O
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

0.00	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	0.00	0.00	416.93

0.00	393.96	393.96	416.93	416.93	416.93	0.00	0.00	0.00	416.94	416.94	0.00	2,872.59

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	9,579.99	0.00	75,277.96

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	3,061,532.58	0.00	29,972,159.37

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	21,419.22	0.00	183,503.78

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	504.21	0.00	7,953.32

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	27,712.14	0.00	281,547.53

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	504.21	0.00	2,014.40

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	21,865.20	0.00	194,996.99

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	120,001.68	0.00	996,951.08

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	112,836.06	0.00	931,250.51

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	24,454.11	0.00	206,174.75

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	31,561.50	0.00	262,422.94

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	1,250.82	0.00	10,490.13

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	416.94	0.00		3,729.43	
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	416.94	0.00		8,594.76	
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	
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	416.94	0.00		416.94	
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	1,250.82	0.00	19,760.03	

SUBTOTAL:

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	3,686,770.74	0.00	36,037,440.16

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	416.94	0.00	
3515	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	416.93	0.00	0.00	0.00	0.00	416.94	833.88	0.00	
3714	ADULT <40% EXP MALE	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	6,254.10	0.00	
3715	ADULT <40% EXP FEM	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	2,501.64	0.00	
3716	ADULT <40% EXP MALE	0.00	393.96	393.96	0.00	416.93	416.93	416.93	416.93	416.93	416.94	416.94	0.00	

SUBTOTAL:

4,123.38	
1,667.75	
70,560.32	
40,353.94	
3,706.45	

E

AL

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending May 31, 2015

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

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	416.94	0.00	6,579.02

SUBTOTAL:

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	10,840.44	0.00	126,990.86

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	416.94	0.00	416.94

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	416.94	0.00	416.94

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	4,256.67	0.00	44,326.87

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	1,338.09	0.00	15,893.49

4415	SOBRA 100-133% FEMA L

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	416.94	0.00	9,034.66

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	6,011.70	0.00	69,255.02

0.00	3,453,495.03	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	3,705,290.64	0.00	36,253,863.01	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending May 31, 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	2.00	0.00	14.00

1010	TANF NON-MEDICARE	0.00	258.00	256.00	255.00	255.00	257.00	259.00	259.00	260.00	263.00	264.00	0.00	2,586.00

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	27.00	0.00	354.00

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	93.00	0.00	1,353.00

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	104.00	0.00	1,402.00

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	24.00	0.00	323.00

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	32.00	0.00	408.00

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

1017	TANF 21-44 FEMALE N O
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

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

0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	1.00	1.00	0.00	7.00

0.00	7.00	8.00	11.00	16.00	14.00	16.00	21.00	22.00	18.00	19.00	0.00	152.00

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	6,159.00	0.00	61,000.00

0.00	36.00	36.00	30.00	32.00	36.00	37.00	40.00	39.00	42.00	43.00	0.00	371.00

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	1.00	0.00	16.00

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	56.00	0.00	578.00

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	1.00	0.00	4.00

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	47.00	0.00	422.00

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	256.00	0.00	2,119.00

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	243.00	0.00	2,004.00

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	53.00	0.00	451.00

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	69.00	0.00	574.00

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	3.00	0.00	24.00

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	1.00	0.00		9.00	
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	1.00	0.00		21.00	
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	
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	1.00	0.00		1.00	
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	3.00	0.00	48.00	

SUBTOTAL:

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	7,497.00	0.00	74,164.00

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	1.00	0.00	
3515	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	1.00	2.00	0.00	
3714	ADULT <40% EXP MALE	0.00	17.00	15.00	15.00	16.00	18.00	18.00	20.00	19.00	18.00	15.00	0.00	
3715	ADULT <40% EXP FEM	0.00	10.00	12.00	11.00	9.00	11.00	11.00	10.00	10.00	8.00	6.00	0.00	
3716	ADULT <40% EXP MALE	0.00	1.00	1.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	

SUBTOTAL:

10.00	
4.00	
171.00	
98.00	
9.00	

E

AL

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending May 31, 2015

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

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	1.00	0.00	16.00

SUBTOTAL:

0.00

31.00	31.00	29.00	30.00	33.00	32.00	34.00	32.00	30.00	26.00	0.00	308.00

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	1.00	0.00	1.00

SUBTOTAL:

0.00

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

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	10.00	0.00	107.00

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	3.00	0.00	37.00

4415	SOBRA 100-133% FEMA L

0.00	3.00	3.00	4.00	3.00	3.00	2.00	1.00	1.00	1.00	1.00	0.00	22.00

SUBTOTAL:

0.00

16.00

16.00	18.00	18.00	18.00	20.00	14.00	16.00	16.00	14.00	0.00	166.00

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	7,541.00	0.00	74,687.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending May 31, 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	13,592.73	0.00	109,059.44

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	18,996.35	0.00	237,044.55

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	30,080.39	0.00	143,877.69

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	4,084.93	0.00	25,459.83

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	1,528,589.62	0.00	20,297,925.40

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	1,713,791.77	0.00	28,650,399.12

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	2,343,516.14	0.00	43,416,718.44

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	518,401.73	0.00	8,593,281.38

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	881,721.73	0.00	13,783,626.12

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	1,465,511.49	0.00	16,897,332.23

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	5,509,355.67	0.00	76,313,273.64

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	1,759,126.25	0.00	22,138,622.37

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	31,064.59	0.00	68,326.33

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	1,130.04	0.00	8,915.70

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	-565.94	0.00	14,592.65

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	2,968.82	0.00	5,393.33

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

112,069.05	103,882.05	140,484.93	100,297.57	77,397.17	103,109.29	81,693.31	72,295.32	130,633.84	133,784.12	128,760.48	0.00	1,184,407.13

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	152,123.79	0.00	1,905,851.47

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	456,551.21	0.00	5,209,120.76

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

423,542.79	375,979.18	320,212.46	334,111.62	206,083.73	441,710.57	392,475.18	281,583.60	470,965.60	421,304.01	394,773.09	0.00	4,062,741.83

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	8,063,927.52	0.00	91,461,878.59

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	1,220,984.90	0.00	14,124,604.97

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	3,680.29	0.00	17,025.85

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	86,024.19	0.00	1,145,717.33

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	20,015.81	0.00	180,911.19

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	1,897,635.61	0.00	22,917,030.99

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	2,035,843.88	0.00	17,968,612.07

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	2,564,970.03	0.00	23,003,792.66

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	790,274.45	0.00	8,709,975.11

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	905,674.15	0.00	10,977,826.70

4325	SOBRA CHILD 14-20 FE	0.00	0.00	90.66	359.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	449.90

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

1,945.85	632.45	32.95	448.60	146.34	1,899.64	-62.66	257.67	324.26	0.00	-45.51	0.00	5,579.59

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	314,883.98	0.00	3,968,263.36

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	1,275,165.45	0.00	15,118,605.59

-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	1,969.34	0.00	4,711.79

IT
SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	2,970.00	330.00	0.00	990.00	0.00	0.00	0.00	0.00	0.00	0.00	-316.00	0.00		3,974.00		
	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	36,134,262.97	0.00	452,674,938.09		

206,926.13	
382,218.16	
1,027,479.27	
332,705.94	
6,904.16	
117,570.93	
562,277.72	
337,682.14	
654,621.21	
8,271,281.85	
19,866,888.41	
12,894,800.54	
47,099.98	
10,979.79	
9,422.84	
110,208.78	
56,025.52	
300,844.68	
1,029,019.44	
4,837,219.12	
-330.00	
147,569.23	
1,217,088.07	
2,354,256.02	
54,780,759.93	

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	21,969.55	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	37,586.43	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	98,306.14	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

28,221.65	29,488.63	32,284.70	33,881.19	20,115.81	23,180.75	19,443.48	23,450.35	45,716.46	39,641.97	37,280.95	0.00

390.77	148.71	0.00	0.00	830.08	342.00	2,686.16	342.00	708.06	1,114.38	342.00	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	6,813.58	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	32,550.29	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	32,499.92	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	90,220.98	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	474,622.29	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	1,518,245.55	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	982,352.92	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	492.92	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	6,108.23	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	6,176.69	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	8,941.59	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

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	7,072.13	0.00

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	31,179.71	0.00

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	101,651.42	0.00

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	485,765.17	0.00

-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

13,130.91	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	18,497.08	0.00

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	109,683.49	0.00

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	270,037.79	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	4,378,396.82

0.00

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13.20	0.00

-13.20	
-216.52	
60.62	
-316.00	
2,522.66	
-3,613.87	
15,392.72	
-329.75	

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-216.52	0.00	0.00	0.00

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

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	-316.00	0.00

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	-2,844.00	0.00

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	-4,108.00	0.00

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	-12,970.00	0.00

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	-316.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	-20,567.20	0.00	13,486.66		

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

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	-316.00	0.00	12,539.79

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	-1,896.00	0.00	10,566.91

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	-18,928.36	0.00	94,168.59

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	-20,573.70	0.00	48,243.29

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	-48,680.68	0.00	210,935.32

3619	AHC CARE/MI M&F 65+	0.00	2,292.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,292.95

SUBTOTAL:

137,502.69

224,169.47	22,649.64	63,529.84	-3,763.45	32,287.59	20,189.42	-33,264.82	9,079.63	71.00	-90,394.74	0.00	382,056.27

29,278.67	
0.00	
200,583.82	
24,148.08	
198,196.40	
465,761.97	
5,237,858.87	
5,184,618.31	
17,023,448.80	
8,295.95	
6,729.69	
1,063.54	
31,823.60	
37,692.48	
242,233.35	
9,924.50	
3,544,939.37	
4,260,632.46	
63,437,431.18	
36,795,221.91	
83,827,262.12	
100,934.45	
572.34	

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	2,116.80	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	7,107.02	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	2,691.04	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	16,100.80	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	41,965.95	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	577,520.26	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	481,256.94	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	1,556,087.01	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	962.37	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	118.52	0.00

3706	ADULT <40% EXP MALE	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	5,670.73	0.00

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

2,767.07	1,278.08	-370.33	3,691.15	918.46	6,145.09	4,522.80	6,753.41	4,959.38	4,144.97	2,882.40	0.00

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	26,172.11	0.00

3,535.49	168.39	1,548.60	1,648.72	1,389.56	684.26	824.90	-15.53	275.28	0.00	-135.17	0.00

3714	ADULT <40% EXP MALE	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	265,198.50	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	302,534.82	0.00

3716	ADULT <40% EXP MALE	6,263,512.29	5,519,096.64	5,963,654.37	5,617,859.72	5,103,187.41	5,865,815.73	5,260,885.56	5,564,589.85	7,170,460.98	6,272,902.30	4,835,466.33	0.00

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

3,575,464.37	3,382,124.05	3,905,064.56	3,334,687.58	3,112,141.29	3,454,030.29	2,921,366.47	3,025,328.09	3,911,175.05	3,249,720.06	2,924,120.10	0.00

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	7,344,488.65	0.00

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	2,981.10	0.00

3726	ADULT <40% EXP MALE	0.00	15.75	0.00	0.00	342.00	0.00	0.00	0.00	0.00	22.57	192.02	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending May 31, 2015

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

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

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	6,391.97

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	577.64	0.00	20,787.50

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

SUBTOTAL:

20,863,498.73

18,991,478.51     21,575,506.02     19,207,914.01     18,324,271.37     20,646,194.83     17,792,602.26     19,036,716.45     24,397,807.97     21,463,942.24     18,396,075.94	0.00	220,696,008.33

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	12.32	0.00	6,101.40

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

836.82	0.00	1,756.31	342.00	0.00	2,485.02	0.00	0.00	0.00	0.00	0.00	0.00	5,420.15

36,628.12	26,922.19	16,205.75	17,898.74	3,618.14	12,067.32	9,886.14	4,162.18	5,037.36	6,309.84	6,730.12	0.00	145,465.90

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	607.25	0.00	19,495.92

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	3,593.00	0.00	54,797.17

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	11,578.58	0.00	120,991.54

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	251,909.68	0.00	2,500,234.98

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

152,717.83	182,054.27	259,830.54	161,208.72	156,299.82	232,362.08	175,609.53	209,856.65	281,160.39	313,805.57	366,651.07	0.00	2,491,556.47

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	848,894.80	0.00	8,656,836.79

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

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

SUBTOTAL:

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	1,489,976.82	0.00	14,011,111.62

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

4,977.56	2,394.00	1,717.57	1,368.00	1,026.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	11,825.13

235,987.47	238,080.25	286,276.53	229,804.63	264,183.88	304,736.60	169,207.95	219,567.51	298,907.04	230,387.61	201,049.84	0.00	2,678,189.31

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	85,418.16	0.00	1,009,552.68

4415	SOBRA 100-133% FEMA L

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	88,547.17	0.00	1,341,319.19

SUBTOTAL:

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	375,015.17	0.00	5,040,886.31

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	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	2,450.00	0.00	62,148.78

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	16,831.08	0.00	317,028.87

2,736.00	0.00	469.34	442.17	0.00	0.00	0.00	0.00	0.00	2,604.96	2,754.75	0.00	9,007.22

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,381.31	1,392.00	700.00	0.00	3,473.31

SUBTOTAL:

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	22,735.83	0.00	391,658.18

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

3,947.35	5,987.91	4,342.90	1,505.21	2,846.98	2,695.31	1,033.09	3,119.13	7,924.56	2,123.51	3,913.63	0.00	39,439.58

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	4,895.38	0.00	29,305.98

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

SUBTOTAL:

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	8,809.01	0.00	71,664.18

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	60,694,310.62	0.00	748,062,569.57	

TOTAL:

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

For The Period Ending May 31, 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	5,830.65	0.00	7,665.21

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	4,525.25	0.00	68,146.79

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	24,188.76	0.00	224,045.26

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	60,736.37	0.00	772,784.71

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	22,298.15	0.00	249,279.31

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

922.64	226.91	3,074.97	4,272.30	2,918.09	5,445.46	926.86	2,136.83	1,818.82	749.88	270.10	0.00	22,762.86

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	31,994.24	0.00	120,062.97

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

0.00	36.29	1,193.01	3,296.07	1,930.40	3,154.15	210.99	3,471.77	1,297.87	35.97	1,058.24	0.00	15,684.76

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	5,409.84	0.00	179,976.98

0.00	0.00	60.89	35.65	0.00	5.28	0.00	0.00	0.00	34.71	103.56	0.00	240.09

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	30,616.38	0.00	446,530.18

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	41,616.92	0.00	272,390.36

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	24,161.85	0.00	167,763.23

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	10,157.73	0.00	153,098.62

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	26,792.54	0.00	217,178.90

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

0.00	0.00	0.00	0.00	0.00	448.06	23.52	1,553.29	49.20	0.00	428.25	0.00	2,502.32

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	18,380.92	0.00	112,691.01

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	41,146.45	0.00	339,518.24

0.00	0.00	0.00	0.00	0.00	1,671.81	0.00	0.00	0.00	0.00	72.53	0.00	1,744.34

8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.28	0.00	34.28

8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,234.74	2,303.02	6,101.68	0.00	19,639.44

8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,805.27	135.83	532.15	0.00	10,473.25

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	244.68	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	12.33	0.00	
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	634.57	450.34	318.44	0.00	0.00	0.00	1,564.20	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	789.53	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	13,913.90	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	38,591.63	0.00	

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	356,456.84	0.00	3,407,328.39

110.22	
512.69	
1,286.11	
2,967.55	
164.69	
14,143.31	
82,765.67	
293,031.18	

M&

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

For The Period Ending May 31, 2015

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

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	31,976.81	0.00	141,046.97

2400	SSI AGED EXPANDED WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

21.47	5,168.71	2,839.31	9,171.19	7,188.90	5,595.18	9,999.20	12,892.81	8,921.38	6,169.02	3,667.99	0.00	71,635.16

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

73.59	17.48	29.02	715.75	860.83	451.42	285.55	321.46	225.92	117.44	82.60	0.00	3,181.06

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	1,986.28	0.00	28,210.32

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	4,339.15	0.00	58,376.99

11.55	0.00	136.55	8.67	826.47	78.96	0.00	10.14	288.80	203.92	423.91	0.00	1,988.97

SUBTOTAL:

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	97,593.01	0.00	711,119.09

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	40,537.53	0.00	54,710.16

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	2,546.33	0.00	37,065.99

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	18,657.37	0.00	166,581.29

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	25,000.79	0.00	147,234.97

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	43,639.78	0.00	552,683.86

3527	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	12.62	0.00	12.62

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	93.40	0.00	0.00	0.00	0.00	0.00	0.00	93.40

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

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

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 MALE	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	6,657.32	0.00	129,382.80

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	5,677.35	0.00	94,023.45

3716	ADULT <40% EXP MALE	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	214,625.24	0.00	2,508,417.64

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

2,907.86	29,170.77	55,381.77	123,684.49	99,596.39	116,908.79	143,091.55	97,248.08	172,154.34	127,786.41	77,492.88	0.00	1,045,423.33

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	243,870.55	0.00	2,912,436.75

SUBTOTAL:

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	678,717.76	0.00	7,655,919.58

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

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

0.00	0.00	0.00	0.00	69.43	0.00	38.20	0.00	0.00	0.00	750.53	0.00	858.16

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	488.01	0.00	5,676.95

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	5,867.26	0.00	29,419.53

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	36,296.67	0.00	242,971.21

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

3,257.75	6,212.67	23,034.92	50,690.42	17,726.88	16,133.68	23,222.13	25,076.48	45,657.55	18,185.62	31,217.72	0.00	260,415.82

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	131,000.62	0.00	588,225.20

SUBTOTAL:

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	205,620.81	0.00	1,128,838.83

4413	SOBRA 100-133% M&F	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	3,697.49	0.00	
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	318.29	0.00	
4415	SOBRA 100-133% FEMA	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	352.61	0.00	

78,752.17
6
31,409.83

13,790.70
L

SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	4,368.39	0.00	123,952.70		

8700	SSI DISABLED FREEDO M
8710	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	211.72	0.00	3,603.05

0.00	326.52	0.00	58.14	204.43	0.00	0.00	0.00	359.31	233.92	222.59	0.00	1,404.91

SUBTOTAL:

217.38

474.84	34.58	105.47	204.43	218.10	2,479.33	0.00	589.85	249.67	434.31	0.00	5,007.96

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	1,343,191.12	0.00	13,032,166.55		

IT
SUBTOTAL:

FAMILY PLANNING SERVICES

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	1,058.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,058.21		
	0.00	1,058.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,058.21		

0.00	1,058.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,058.21	

TOTAL:

FEDERAL EMERGENCY SERVICES

For The Period Ending May 31, 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	643.01	0.00	14,190.88

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	6,299.04	0.00	204,615.17

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	33,504.72	0.00	479,186.82

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	66,411.40	0.00	1,142,100.37

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	274,076.15	0.00	4,773,787.23

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	77,916.67	0.00	1,224,280.12

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	2,160,412.10	0.00	32,252,226.16

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	123,483.77	0.00	1,840,266.13

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	1,065.17	0.00	19,058.16

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

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	-1,632.79	0.00	46,942.17

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	621,960.79	0.00	6,690,822.74

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
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

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	13,026.57	0.00	333,991.41

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	733,611.43	0.00	8,497,731.48

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

2,582.38	0.00	107.59	-341.29	5.64	-138.79	0.00	0.00	0.00	0.00	0.00	0.00	2,215.53

SUBTOTAL:

6,645,181.08

5,482,310.95	6,208,134.21	4,523,950.45	5,454,737.92	4,624,811.69	5,290,703.32	4,129,951.39	5,597,483.43	5,455,594.33	4,110,778.03	0.00	57,523,636.80

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	893.51	0.00	36,633.25

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	-1,353.40	0.00	5,769.90

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	749.95	0.00	14,559.65

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	555.44	0.00	10,363.63

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	13,682.01	0.00	128,387.04

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	318,465.74	0.00	4,036,228.68

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	719,081.57	0.00	6,650,881.67

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	220,237.85	0.00	2,549,520.64

1119	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

214.96	7.57	2,777.49	1,386.84	1,163.27	5,059.60	-47.05	3,678.59	3,857.01	2,360.05	1,906.53	0.00	22,364.86

0.00	72.72	0.00	672.78	204.43	798.70	272.80	2,008.30	1,219.05	2,242.77	247.07	0.00	7,738.62

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	50,353.47	0.00	302,350.52

0.00	0.00	0.00	3,206.17	0.00	0.00	4,235.46	1.85	3,441.15	2,351.85	971.58	0.00	14,208.06

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	54,213.23	0.00	161,555.50

SUBTOTAL:

1,417,844.27

1,224,286.68	1,308,091.17	1,016,643.77	1,162,541.26	1,181,331.17	1,276,368.87	949,983.68	1,203,824.03	1,821,008.63	1,380,004.55	0.00	13,941,928.08

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 May 31, 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	7.67	0.00	-34,463.17

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 MALE	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 MALE	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	198.78	0.00	-389,629.03

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

54,689.87	132,072.18	-12,698.30	-115,825.12	-56,903.90	-24,554.58	-68,204.03	-6,998.88	0.00	0.00	0.00	0.00	-98,422.76

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	2,292.64	0.00	-866,215.10

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

SUBTOTAL:

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	2,499.09	0.00	-1,688,216.71

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
3908	NEWLY ELIGIBLE M&F
4

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

0.00	0.00	0.00	21.42	693.71	752.34	1,847.89	269.00	3,171.65	3,159.66	5,028.49	0.00	14,944.16

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	32,989.68	0.00	437,332.10

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	32,911.30	0.00	208,410.55

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	308,461.81	0.00	4,446,982.06

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3927	NEWLY ELIGIBLE FEMA
L
3928	NEWLY ELIGIBLE M&F
4

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	300,136.99	0.00	2,103,799.54

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	786,180.07	0.00	8,899,925.35

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	3,263.50	0.00	133,484.00

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	451.59	1,066.29	1,324.04	47.33	0.00	2,889.25

SUBTOTAL:

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	1,469,019.17	0.00	16,253,193.28

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	6,962,300.84	0.00	86,030,541.45		

A
SUBTOTAL:	0

FEDERAL ESP CHRONIC SERVICES

For The Period Ending May 31, 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	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		0.0		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	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

	00	2,971.56	
0.00	0.00	0.00	3,837.55	-865.99	0.00	0.00	0.00	605.12	0.00	0.00	0.00	3,576.68	

4

TOTAL:

QMB - FEE FOR SERVICE

For The Period Ending May 31, 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	356,090.89	0.00		3,141,983.21		
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		198,990.9		336,157.76	204,441.28	226,551.24	333,888.22	319,483.77	386,290.51	229,556.92	356,090.89	0.00	3,142,621.50		

SUBTOTAL:	1

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	356,090.89	0.00	3,142,621.50		

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending May 31, 2015

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

1017	TANF 21-44 FEMALE N O
2100	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R

1,750.41	0.00	7,007.66	0.00	0.00	0.00	347.16	0.00	955.38	0.00	332.40	0.00	10,393.01

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	74,653.60	0.00	477,311.52

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	69,843.58	0.00	876,864.89

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	82.08	0.00	149,364.34

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

4,073.14	0.00	519.72	388.90	9.61	636.26	33.80	1,840.03	777.77	20,676.81	13,659.65	0.00	42,615.69

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	11,423.14	0.00	58,750.48

0.00	0.00	0.00	0.00	0.00	0.00	6,704.90	1,289.67	10,932.37	16,792.07	-5,155.33	0.00	30,563.68

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	1,320.41	0.00	46,196.01

8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,280.45	0.00	1,280.45

SUBTOTAL:

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	167,439.98	0.00	1,694,745.03

3,713.55	
7,283.33	
34.97	
11,031.85	

E

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	345.00	0.00	
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	
2620	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	0.00	34.97	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	764.04	34.97	0.00	9,887.84	0.00	345.00	0.	

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	

00

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 MALE	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	89,169.65	0.00	183,772.69

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

236.17	116.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	352.31

28,660.93	43,321.56	11,908.91	-426.94	1,269.10	7,305.58	14,339.39	84,347.92	6,128.70	3,423.75	4,610.75	0.00	204,889.65

3714	ADULT <40% EXP MALE	821.12	634.83	374.49	721.28	0.00	0.00	2,535.24	114.36	0.00	0.00	80.80	0.00	5,282.12

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 MALE	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	219,282.41	0.00	2,182,145.73

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3728	ADULT <40% EXP M&F
4

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	8,096.60	0.00	95,914.19

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	205,979.43	0.00	2,911,677.83

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	468.00	1,743.15	559.37	0.00	2,770.52

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,696.35	471.28	0.00	18,167.63

SUBTOTAL:

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	528,250.29	0.00	5,611,385.35

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	11,905.62	0.00	
3917	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	360.10	0.00	0.00	0.00	0.00	0.00	

2,736.73

148,037.05

360.10
L

4
SUBTOTAL:

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3918	NEWLY ELIGIBLE M&F	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	-2,018.82	0.00		56,391.53		
	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	9,886.80	0.00	207,525.41		

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	705,922.07	0.00	7,464,841.89	

TOTAL:

COCHISE COUNTY INMATES FEE FOR SERVICE

For The Period Ending May 31, 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		

COCONINO COUNTY INMATES FEE FOR SERVICE

For The Period Ending May 31, 2015

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

2200	SSI DISABLED WITH M E
5017	SOBRA PREG 21-44 FE
M

0.00	0.00	5,262.44	177.08	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,446.52

0.00	0.00	0.00	0.00	0.00	2,622.96	0.00	0.00	0.00	849.51	0.00	0.00	3,472.47

SUBTOTAL:

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

4
SUBTOTAL:

3716	ADULT <40% EXP MALE	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	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	

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:

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending May 31, 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	393.60	0.00	21,021.41

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	713.57	0.00	19,821.64

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

0.00	0.00	0.00	0.00	0.00	0.00	53.73	334.01	0.00	0.00	4,680.08	0.00	5,067.82

3,365.09	0.00	417.09	744.21	0.00	0.00	3,635.30	20.39	0.00	20.74	3,322.01	0.00	11,524.83

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	9,094.23	0.00	137,215.51

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
5017	SOBRA PREG 21-44 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

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	11,921.32	0.00	67,975.40

SUBTOTAL:

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	30,124.81	0.00	281,501.59

E

22,339.51	
2,764.06	
8,790.43	
1,059.89	
447.84	
33,401.37	
357,914.19	
69,942.15	
239,003.03	
735,662.47	

SUBTOTAL:

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	109.21	0.00		7,302.91	
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	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	109.21	0.00	24,186.91	

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	104.41	0.00

3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.37	279.58	160.89	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 MALE	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	41,843.13	0.00

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

4,470.06	0.00	69.43	2,092.40	2,806.07	19,138.49	4,037.92	310.22	24,767.68	11,828.30	421.58	0.00

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	21,670.39	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	464.01	0.00		464.01	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	464.01	0.00	464.01	

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	64,200.40

0.00

8720	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	868.40	0.00		868.40	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	868.40	0.00	868.40	

SUBTOTAL:

M
SUBTOTAL:

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	95,766.83	0.00	1,042,683.38		

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending May 31, 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
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

0.00	0.00	1,359.40	160.87	0.00	1,593.72	0.00	0.00	0.00	0.00	0.00	0.00	3,113.99

0.00	2,281.13	549.96	170.77	0.00	176.90	2,026.35	0.00	4,623.98	0.00	0.00	0.00	9,829.09

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	412.23	0.00	23,709.05

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	6,811.07	0.00	39,412.95

SUBTOTAL:

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	7,223.30	0.00	102,344.81

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	249.30	0.00	7,948.44

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	246.93	0.00	246.93

2600	SSI DISABLED EXPAND E
2610	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

0.00	0.00	0.00	0.00	1,958.42	969.97	269.80	0.00	0.00	0.00	9,885.62	0.00	13,083.81

SUBTOTAL:

0.00

0.00	0.00	0.00	3,429.48	969.97	1,080.87	-128.00	6,228.08	0.00	10,381.85	0.00	21,962.25

3716	ADULT <40% EXP MALE	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	7,465.32	0.00	44,384.64

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.88	0.00	470.07	0.00	0.00	718.95

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	25,969.73

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	7,465.32	0.00	71,073.32

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	25,070.47	0.00	195,380.38	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending May 31, 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
2210	SSI DISABLED NON-ME
D

1,230.46	1,900.89	219.54	234.94	369.71	0.00	0.00	0.00	0.00	0.00	3,892.49	0.00	7,848.03

0.00	0.00	0.00	0.00	3,335.39	0.00	0.00	0.00	0.00	3,324.55	601.00	0.00	7,260.94

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	4,493.49	0.00	34,693.17

2400	SSI AGED EXPANDED WI
2600	SSI DISABLED EXPAND
E

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

2,451.81	8,946.30	2,253.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,651.35

SUBTOTAL:

2,451.81

8,946.30	2,253.24	0.00	0.00	3,093.20	547.38	0.00	0.00	0.00	0.00	0.00	17,291.93

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 MALE	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	3,960.07	0.00	118,843.19

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

416.43	377.59	585.05	327.95	3,373.41	0.00	2,896.31	211.64	4,420.04	0.00	0.00	0.00	12,608.42

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	1,216.38	0.00	77,668.90

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	5,176.45	0.00	212,011.28

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	9,669.94	0.00	263,996.38		

AL
SUBTOTAL:	5

YAVAPAI COUNTY INMATES FEE FOR SERVICE

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.22	5,908.47	0.00		6,167.69		
3717	ADULT <40% EXP FEM	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		277.2		0.00	0.00	0.00	0.00	0.00	0.00	1,876.48	5,908.47	0.00	8,062.20		

0.00	0.00	277.25	0.00	0.00	0.00	0.00	0.00	0.00	1,876.48	5,908.47	0.00	8,062.20	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD

For The Period Ending May 31, 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	342.00	0.00	8,316.56

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

2,949,233.74	2,553,248.28	2,547,707.72	2,744,556.33	2,405,191.82	2,784,284.23	2,392,209.29	2,290,987.78	3,236,280.08	2,470,227.29	2,421,266.81	0.00	28,795,193.37

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	187,974.52	0.00	2,225,143.33

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	2,984,435.39	0.00	34,972,493.26

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

523,308.04	521,024.91	487,724.77	554,282.95	462,207.52	564,753.44	434,338.67	489,011.92	539,465.71	501,804.43	491,157.64	0.00	5,569,080.00

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	2,484,773.03	0.00	29,111,208.67

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	710,759.91	0.00	7,769,347.37

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	14,358.56	0.00	213,765.73

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	5,695.35	0.00	83,901.39

SUBTOTAL:

10,674,444.22

9,396,118.45	9,491,866.15     10,312,742.38	9,245,674.28     10,618,781.96	9,113,093.88	8,924,621.50     11,925,051.37	9,748,959.40	9,300,763.21	0.00	108,752,116.80

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

0.00	4,587.51	2,336.85	2,296.32	2,122.56	0.00	4,582.80	1,656.24	1,955.88	2,058.24	1,738.41	0.00	23,334.81

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	1,447.20	0.00	25,627.22

SUBTOTAL:

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	3,185.61	0.00	48,962.03

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	9,303,948.82	0.00	108,801,078.83		

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

For The Period Ending May 31, 2015

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

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

10,604.85	6,556.27	4,904.83	21,431.27	21,860.24	23,681.17	18,407.87	18,612.45	18,472.89	9,720.21	12,656.63	0.00	166,908.68

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
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

909.00	1,038.77	2,561.60	-47.66	257.00	552.69	473.89	2,228.61	1,002.65	2,281.95	266.83	0.00	11,525.33

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	-49,143.73	0.00	97,446.29

424.41	420.94	525.00	0.00	0.00	110.00	0.00	0.00	0.00	0.00	0.00	0.00	1,480.35

0.00	0.00	0.00	169.45	50.00	0.00	0.00	0.00	247.71	0.00	0.00	0.00	467.16

SUBTOTAL:

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	-36,220.27	0.00	336,714.03

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	-36,220.27	0.00	336,714.03	

TOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending May 31, 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	47,152.77	0.00	628,041.85

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	105,173.83	0.00	1,311,430.57

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	11,771.46	0.00	116,385.05

1015	TANF 14-20 FEMALE N O
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

5,937.29	1,659.32	2,048.84	3,615.92	5,239.75	3,650.77	4,231.37	3,983.31	6,935.29	4,783.37	4,480.87	0.00	46,566.10

0.00	0.00	0.00	0.00	0.00	0.00	80.28	265.75	191.53	0.00	37.26	0.00	574.82

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	225,722.36	0.00	2,413,143.53

-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	3,101.74	0.00	18,650.91

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	153.50	0.00	153.50

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	14.18	0.00	234.51

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	73,187.96	0.00	789,809.81

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	129,048.41	0.00	1,238,164.05

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	10,859.97	0.00	94,843.33

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	5,742.31	0.00	50,455.50

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

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	299.78	0.00		6,173.89	
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	3,290.31	0.00		34,134.03	
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	254.70	0.00		2,605.76	
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	131.32	0.00		1,394.99	
2610	SSI DISABLED EXPAND	305.53	64.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370.06	
	4,319.74	1,822.89	1,424.38	3,905.39	3,568.92	4,316.70	4,933.96	4,873.25	6,924.71	4,612.68	3,976.11	0.00	44,678.73	

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	616,446.62	0.00	6,710,457.17

E
SUBTOTAL:

SUBTOTAL:

3314	AHC CARE MALE 14-20	-11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11.48	
	-11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11.48	

3514	ADULT 40-100% MALE 1	155.62	48.90	0.00	0.00	0.00	0.00	0.00	0.00	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
3707	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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.05	65.47	0.00	65.80	0.00	144.32

3714	ADULT <40% EXP MALE	476.23	94.36	149.28	281.22	863.97	184.08	584.52	411.25	1,599.79	1,654.50	1,529.57	0.00	7,828.77

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	125.96	0.00	2,456.64

SUBTOTAL:

956.67

156.32	188.43	539.72	1,076.50	354.34	859.63	596.15	2,125.03	2,304.54	1,721.33	0.00	10,878.66

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	345.76

SUBTOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270.72	75.04	0.00	0.00	345.76		

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

35.71	0.00	0.00	177.55	0.00	0.00	0.00	0.00	0.00	43.80	0.00	0.00	257.06

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	22,191.03	0.00	180,846.41

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	1,782.24	0.00	19,404.26

4415	SOBRA 100-133% FEMA L

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	1,186.74	0.00	13,817.79

SUBTOTAL:

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	25,160.01	0.00	214,325.52

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	647,304.07	0.00	6,980,674.36		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending May 31, 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	338.29	0.00	1,178.76

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	39,287.00	0.00	401,130.71

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

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	4,207.77	0.00	17,549.77

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	1,201,533.09	0.00	11,436,676.42

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	1,014.86	0.00	23,589.70

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	5,003.88	0.00	69,519.67

SUBTOTAL:

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	1,251,384.89	0.00	11,949,645.03

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	1,251,384.89	0.00	11,949,645.03	

TOTAL:

ACUTE REINSURANCE

For The Period Ending May 31, 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

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	10,397.94	0.00	10,397.94

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	583,314.74	0.00	6,080,973.17

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	155,779.71	0.00	1,124,581.69

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	219,782.10	0.00	1,687,154.96

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	125,954.76	0.00	724,633.15

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	702.82	0.00	345,063.90

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	95,789.23	0.00	1,721,880.48

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	250,262.87	0.00	2,384,107.36

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	121,434.93	0.00	1,499,930.93

1019	TANF 65+ M & F NON-M	1,093.03	0.00	-13,476.35	0.00	0.00	0.00	0.00	0.00	0.00	379.93	1,322.41	0.00	-10,680.98

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

-11,064.51	20,679.74	9,511.66	1,576.15	24,489.13	27,219.93	4,114.76	10,893.97	5,956.14	3,778.79	-939.37	0.00	96,216.39

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	178,804.52	0.00	1,086,200.33

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	13,026.71	0.00	229,524.58

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	3,361,863.33	0.00	41,728,799.05

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	14,555.70	0.00	28,748.18

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	859,713.92	0.00	10,187,342.86

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	439,837.95	0.00	2,992,656.58

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	144,560.39	0.00	2,480,230.47

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	1,057,469.90	0.00	6,451,606.34

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	85,600.93	0.00	719,843.56

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

-5,501.24	7,852.13	37,376.93	6,376.31	0.00	12,487.96	0.00	455.27	24,400.68	0.00	3,748.13	0.00	87,196.17

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	22,327.48	0.00	255,732.23

SUBTOTAL:

9,969,923.69

4,909,635.73     10,369,217.45	6,271,221.32     10,598,297.11	6,756,478.41	5,568,551.94     11,282,043.07	4,466,815.43	4,007,516.84	7,745,311.10	0.00	81,945,012.09

0.00	-4.00	85.99	-6.06	-79.63	79.04	1.33	-2.49	0.00	0.00	0.00	0.00		74.18	
0.00	-4.00	85.99	-6.06	-79.63	79.04	1.33	-2.49	0.00	0.00	0.00	0.00	74.18	

3100	TRANSPLANT OPTION
1

22,213.94	
0.00	
29,928.45	
527,906.68	
17,303.13	
19,769.63	
1,191,201.59	
931,294.03	
901,895.22	

SUBTOTAL:

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	5.91	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	
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	29,928.45	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	43.59	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	286,393.90	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	85,774.48	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	176,549.32	0.00	

ACUTE REINSURANCE

For The Period Ending May 31, 2015

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

1119	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

0.00	0.00	0.00	-9,938.86	0.00	0.00	0.00	1,541.09	0.00	32.27	244.22	0.00	-8,121.28

8,461.10	0.00	124.35	10.98	68.32	459.77	116.19	1,734.24	581.68	0.00	898.53	0.00	12,455.16

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	11,734.97	0.00	271,574.93

6,615.59	41.18	259.67	-43.69	660.99	288.03	40.81	322.72	16,290.29	198,191.76	249.56	0.00	222,916.91

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	156,666.83	0.00	492,670.86

SUBTOTAL:

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	748,489.76	0.00	4,633,009.25

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	-3,633.96	0.00	33,047.68

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	2,889.03	0.00	43,389.41

SUBTOTAL:

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	-744.93	0.00	33,888.57

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	3,204.82	0.00	48,224.42

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	183.09	0.00	112,664.93

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	6,999.00	0.00	399,704.07

SUBTOTAL:

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	10,386.91	0.00	540,396.20

19,252.19	
185.27	
390,843.59	
1,038,505.48	
221,804.01	
2,335,294.12	
0.00	
7,873.45	
9,838.72	
859,587.18	
160,056.82	
5,970,601.62	
1,249,200.58	
8,331,732.17	

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	1,249.49	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	12,596.70	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	115,493.17	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	33,836.12	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	441,395.16	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 MALE	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	9,838.72	0.00

3714	ADULT <40% EXP MALE	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	96,218.05	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	65,106.79	0.00

3716	ADULT <40% EXP MALE	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	657,418.49	0.00

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

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	289,387.57	0.00

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	1,550,836.16	0.00

6
SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	10,496.54	-10,496.54	10,189.10	0.00	0.00	-4,839.09	0.00		5,350.01		
	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	3,268,537.33	0.00	20,600,125.21		

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	8,185.95	0.00	10,610.85

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	7.48	0.00	2,220.79

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	20,040.96	0.00	145,139.31

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

0.00	0.00	6,908.43	8,777.52	0.00	0.00	0.00	7,092.04	20,538.98	0.00	12,697.88	0.00	56,014.85

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	247,120.97	0.00	1,025,556.94

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,189.10	0.00	10,189.10

SUBTOTAL:

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	298,242.34	0.00	1,258,386.22

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	24,037.37	0.00	159,572.41

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	62,792.16	0.00	342,690.69

4415	SOBRA 100-133% FEMA L

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

SUBTOTAL:

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	86,829.53	0.00	643,053.43

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	0.00	0.00	0.00	6,209.80	0.00	0.00	37,383.41	0.00	0.00	0.00	0.00	43,593.21

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

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

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

8710	SSI DISABLED FREEDO	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	13,382.11	0.00		291,837.77	
	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	13,382.11	0.00	291,837.77	

SUBTOTAL:

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

M
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	12,170,434.15	0.00	110,085,548.54		

LONG TERM CARE REINSURANCE

For The Period Ending May 31, 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
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

444,766.14	302,713.80	603,255.00	438,652.82	415,507.67	409,138.80	29,189.63	192,492.90	50,649.37	230,083.88	974,594.30	0.00	4,091,044.31

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	199,155.30	0.00	1,497,584.88

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	1,413,111.99	0.00	7,871,830.18

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	3,076,869.75	0.00	26,919,939.41

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	35,515.74	0.00	211,411.95

SUBTOTAL:

3,351,664.59

3,591,474.07	5,326,751.53	4,738,879.96	4,481,859.78	3,996,173.95	1,922,481.71	3,304,800.86	1,949,942.31	2,289,621.41	5,699,247.08	0.00	40,652,897.25

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	5,699,247.08	0.00	40,652,897.25	

TOTAL:

ACUTE SMIB

For The Period Ending May 31, 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	75,233.30	0.00	707,073.60

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	15,420.30	0.00	59,163.60

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

233,087.80	189,316.60	73,485.90	77,472.10	70,338.90	66,341.40	59,274.40	71,916.30	71,486.90	62,415.50	56,541.10	0.00	1,031,676.90

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	388,030.10	0.00	4,393,099.20

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	1,967,956.60	0.00	26,315,653.60

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

431,726.00	393,804.40	196,687.50	205,227.90	198,475.80	200,463.90	205,708.90	213,366.60	208,960.80	157,559.80	148,433.50	0.00	2,560,415.10

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	336,104.50	0.00	3,761,589.60

2,938,167.40	2,948,060.50	2,962,742.20	2,977,216.20	2,936,899.20	2,934,259.70	3,016,286.60	3,024,370.70	3,002,896.20	3,045,443.80	2,864,837.20	0.00	32,651,179.70

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	314.70	0.00	7,552.80

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	3,147.00	0.00	38,078.70

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	26,539.70	0.00	287,980.50

4300	SOBRA CHILD WITH ME D
4310	SOBRA CHILD NON-ME
DI
5000	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

0.00	0.00	104.90	104.90	104.90	104.90	104.90	104.90	104.90	104.90	104.90	0.00	944.10

0.00	0.00	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.90

0.00	104.90	2,307.80	3,147.00	2,412.70	3,566.60	4,510.70	2,832.30	3,042.10	3,147.00	2,307.80	0.00	27,378.90

314.70	419.60	524.50	1,573.50	629.40	1,049.00	839.20	1,049.00	734.30	629.40	629.40	0.00	8,392.00

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	-104.90	0.00	281,376.50

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	510,409.50	0.00	5,066,776.80

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	3,573,923.00	0.00	35,383,647.40

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	102,542.20	0.00	5,921.00

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	277,409.90	0.00	1,467,764.50

SUBTOTAL:

10,393,669.50

10,609,177.00	9,816,709.20     10,373,227.10     10,541,022.40     10,266,510.30     10,427,725.20     10,477,182.10     10,373,255.80     10,432,441.30     10,349,779.80	0.00	114,060,699.70

9910	TANF & SOBRA CHILDR	0.00	-209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	0.00	-104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.	

-209.80
E
-104.90

00	-314.70

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

839.20	1,388.40	598,877.80	613,200.10	634,134.00	590,013.20	590,074.00	593,633.70	589,437.70	608,005.00	619,298.90	0.00

5,438,902.00	
2,832.30	
635,119.50	
375,424.70	
11,014.50	
27,772,353.70	
2,727.40	
105,124.80	
209.80	
12,383,987.50	

0.00	0.00	314.70	419.60	314.70	314.70	314.70	314.70	314.70	314.70	209.80	0.00

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	130,445.60	0.00

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	15,315.40	0.00

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	524.50	0.00

2,329,792.40	2,507,887.80	2,428,160.60	2,436,748.60	2,470,650.30	2,510,011.30	2,523,619.60	2,540,854.90	2,525,420.90	2,570,665.10	2,928,542.20	0.00

524.50	419.60	314.70	209.80	209.80	209.80	209.80	209.80	209.80	104.90	104.90	0.00

49,093.20	56,031.60	-209.80	0.00	0.00	314.70	-629.40	209.80	104.90	104.90	104.90	0.00

104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

951,712.70	1,111,220.00	1,014,433.70	1,044,837.50	1,063,832.20	1,091,853.60	1,046,097.50	1,102,337.70	1,155,131.70	1,280,472.10	1,522,058.80	0.00

SUBTOTAL:

ACUTE SMIB

For The Period Ending May 31, 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	5,216,605.00	0.00	46,727,696.20		

A
SUBTOTAL:

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

3500	ADULT 40-100% FOR FI	419.60	475.50	0.00	0.00	0.00	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	2,049.00

3520	ADULT 40-100% FOR FI	3,042.10	4,300.90	4,825.40	3,776.40	4,091.10	4,720.50	3,671.50	3,356.80	3,881.30	5,035.20	4,510.70	0.00	45,211.90

3700	ADULT <40% EXP FOR F
3720	AHC CARE EXPANDED
FO

0.00	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314.70

1,049.00	1,153.90	2,517.60	3,671.50	2,727.40	2,098.00	1,783.30	1,049.00	2,307.80	2,412.70	2,307.80	0.00	23,078.00

SUBTOTAL:

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	6,818.50	0.00	70,653.60

3900	NEWLY ELIGIBLE FOR F
3920	NEWLY ELIGIBLE FOR
F

0.00	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.90

1,258.80	734.30	1,678.40	1,783.30	1,153.90	209.80	209.80	209.80	209.80	314.70	1,153.90	0.00	8,916.50

SUBTOTAL:

1,258.80

839.20	1,678.40	1,783.30	1,153.90	209.80	209.80	209.80	209.80	314.70	1,153.90	0.00	9,021.40

8700	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

1,049.00	1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,098.00

16,154.60	17,833.00	19,931.00	20,140.80	19,511.40	20,875.10	19,826.10	20,980.00	19,301.60	20,350.60	20,035.90	0.00	214,940.10

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	20,035.90

0.00	217,038.10

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	15,594,393.10	0.00	161,105,459.60		

ACUTE HIB

For The Period Ending May 31, 2015

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

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

-5,222.40	1,704.00	426.00	-426.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-3,518.40

-7,299.40	5,613.00	0.00	0.00	0.00	0.00	0.00	407.00	672.00	0.00	2,442.00	0.00	1,834.60

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	167,278.50	0.00	1,911,325.50

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

-185.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-185.40

-890.50	0.00	0.00	0.00	0.00	0.00	0.00	160.60	0.00	1,343.10	4,843.90	0.00	5,457.10

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	85,417.50	0.00	870,679.30

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	407.00	0.00	4,591.00

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	2,953.10	0.00	33,523.30

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	-7,120.60	0.00	-135,100.70

SUBTOTAL:

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	256,221.40	0.00	2,687,310.40

WI
SUBTOTAL:

2420	SSI AGED EXPANDED	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	6,227.40	0.00		34,712.30	
	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	6,227.40	0.00	34,712.30	

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	262,448.80	0.00	2,722,022.70	

TOTAL:

Q1

For The Period Ending May 31, 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	1,205.50	0.00		16,172,066.10		
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	1,572,971.70	0.00		3,232,209.90		
	1,627,402.40	1,621,788.40		1,982,589.5		1,886,090.00	1,928,653.50	1,776,799.30	1,785,948.90	1,776,198.20	1,780,100.10	1,664,528.50	1,574,177.20	0.00	19,404,276.00		

SUBTOTAL:	0

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	1,574,177.20	0.00	19,404,276.00		

LTC SMIB

For The Period Ending May 31, 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	314.70	0.00	3,042.10

1020	TANF WITH QMB	209.80	209.80	209.80	104.90	104.90	104.90	104.90	104.90	104.90	104.90	104.90	0.00	1,468.60

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

888,555.70	873,534.60	857,715.10	861,295.50	876,233.40	856,197.50	888,924.30	860,491.50	858,133.70	878,903.90	866,211.00	0.00	9,566,196.20

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	159,133.30	0.00	1,748,995.10

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	766,812.00	0.00	8,216,659.10

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

332,642.90	322,652.70	317,112.70	316,378.40	317,742.10	326,084.70	322,147.90	329,071.30	314,804.90	310,818.70	315,014.70	0.00	3,524,471.00

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	14,895.80	0.00	194,470.40

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	700,177.20	0.00	7,613,556.40

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	944.10	0.00	11,014.50

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	209.80	0.00	3,042.10

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	4,091.10	0.00	46,051.10

SUBTOTAL:

2,760,032.30

2,775,903.60	2,782,895.50	2,794,258.50	2,815,155.70	2,852,543.80	2,841,587.50	2,816,714.80	2,817,510.50	2,844,455.80	2,827,908.60	0.00	30,928,966.60

M
SUBTOTAL:

8720	SSI DISABLED FREEDO	524.50	524.50	419.60	314.70	314.70	314.70	419.60	419.60	419.60	524.50	629.40	0.00		4,825.40	
	524.50	524.50	419.60	314.70	314.70	314.70	419.60	419.60	419.60	524.50	629.40	0.00	4,825.40	

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	2,828,538.00	0.00	30,933,792.00	

TOTAL:

LTC HIB

For The Period Ending May 31, 2015

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

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

-5,106.60	0.00	0.00	426.00	0.00	0.00	0.00	0.00	0.00	407.00	224.00	0.00	-4,049.60

-6,887.80	5,613.00	0.00	0.00	0.00	0.00	1,259.00	814.00	0.00	0.00	6,512.00	0.00	7,310.20

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	257,050.80	0.00	2,736,224.50

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

-1,539.40	0.00	426.00	-852.00	426.00	-426.00	0.00	407.00	-407.00	0.00	0.00	0.00	-1,965.40

-10,177.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	284.90	0.00	-9,893.00

-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	12,739.70	0.00	86,840.10

2320	SSI BLIND WITH QMB	826.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	826.20

SUBTOTAL:

121,568.30

275,913.00	266,524.80	277,911.00	272,521.80	280,297.20	241,486.20	265,224.80	262,504.50	274,530.00	276,811.40	0.00	2,815,293.00

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	276,811.40	0.00	2,815,293.00		

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

For The Period Ending May 31, 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	2,151.38	0.00	13,483.40

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	4,538.54	0.00	87,948.14

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	4,028.63	0.00	44,198.72

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	2,643.08	0.00	15,362.69

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	794,590.11	0.00	11,336,390.01

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	1,308,124.16	0.00	22,090,496.44

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	1,961,912.53	0.00	36,550,870.79

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	381,921.46	0.00	6,831,816.56

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	677,097.52	0.00	10,869,155.21

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	911,897.19	0.00	11,329,092.09

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	3,947,049.11	0.00	55,987,924.36

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	1,194,234.93	0.00	15,427,858.45

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	2,442.00	0.00	35,962.69

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	1,130.04	0.00	8,328.80

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	-571.83	0.00	7,238.30

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	1,491.98	0.00	3,147.78

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

55,280.06	61,807.18	52,962.78	58,259.92	35,963.52	59,958.11	35,933.80	35,795.18	45,650.50	45,546.90	53,731.64	0.00	540,889.59

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	70,357.31	0.00	1,002,922.29

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	222,040.42	0.00	2,477,009.53

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

141,948.53	159,969.16	144,932.50	155,742.39	92,640.10	143,291.60	143,731.94	109,547.14	166,737.12	191,759.17	170,240.57	0.00	1,620,540.22

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	4,158,148.95	0.00	51,508,124.17

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	429,924.44	0.00	4,912,643.85

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	2,391.24	0.00	9,915.35

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	45,229.12	0.00	610,803.35

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	10,057.52	0.00	78,327.31

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	1,190,158.02	0.00	12,740,894.09

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	1,600,323.67	0.00	14,547,319.01

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	2,065,518.47	0.00	19,358,353.14

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	639,993.84	0.00	7,074,959.76

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	731,689.89	0.00	9,193,307.03

4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

158.10	59.40	571.42	179.57	146.34	1,431.61	-187.36	8.27	199.56	0.00	-45.51	0.00	2,521.40

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	206,858.10	0.00	2,750,617.44

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	902,972.74	0.00	10,756,684.41

-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	1,969.34	0.00	459.46

IT
SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	2,970.00	330.00	0.00	990.00	0.00	0.00	0.00	0.00	0.00	0.00	-316.00	0.00		3,974.00		
	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	23,695,924.60	0.00	309,829,539.83		

57,086.65	
136,250.05	
349,572.09	
193,474.49	
4,788.00	
81,005.88	
481,405.03	
297,981.66	
513,557.71	
5,770,886.67	
15,810,017.87	
9,103,092.03	
24,628.96	
846.53	
4,987.32	
36,681.61	
22,737.00	
167,664.27	
525,956.18	
2,085,476.27	
-330.00	
71,871.79	
827,381.23	
837,787.35	
37,404,806.64	

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	4,271.85	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	16,119.48	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	45,345.26	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

19,280.09	19,116.75	18,240.76	17,222.69	11,053.75	15,431.13	9,846.67	12,154.75	20,964.07	25,776.76	24,387.07	0.00

342.00	0.00	0.00	0.00	342.00	342.00	1,710.00	342.00	342.00	1,026.00	342.00	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	5,210.00	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	25,364.00	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	27,710.58	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	70,417.67	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	331,938.95	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	1,185,447.23	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	700,782.02	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	376.00	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	42.48	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	3,304.35	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	3,425.81	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

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	3,361.69	0.00

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	22,598.80	0.00

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	66,534.26	0.00

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	219,132.14	0.00

-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

7,548.42	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	12,061.74	0.00

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	76,038.98	0.00

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	93,549.35	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	2,937,761.71

0.00

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

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

0.00	
0.00	
0.00	
-316.00	
2,925.86	
-1,644.90	
14,756.13	
-316.00	

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

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	-316.00	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	-2,844.00	0.00

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	-4,108.00	0.00

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	-12,970.00	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	-316.00	0.00

SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	-20,554.00	0.00	15,405.09		

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

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	-316.00	0.00	11,589.88

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	-1,896.00	0.00	7,519.12

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	-18,116.00	0.00	23,434.63

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	-20,518.00	0.00	-12,115.82

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	-48,510.00	0.00	112,866.58

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

SUBTOTAL:

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	-89,356.00	0.00	145,639.02

8,384.47	
0.00	
72,127.10	
19,362.06	
120,728.01	
313,827.45	
3,253,984.32	
3,937,679.75	
12,247,735.07	
6,192.00	
2,398.79	
1,063.54	
11,861.01	
13,471.61	
84,494.69	
7,738.71	
2,362,696.84	
3,395,468.47	
38,332,990.50	
26,029,591.36	
53,854,324.72	
73,270.11	
572.34	

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	554.43	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	892.17	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	2,378.34	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	11,936.78	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	28,348.67	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	304,976.07	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	354,661.37	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	1,111,935.86	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	228.32	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	118.52	0.00

3706	ADULT <40% EXP MALE	1,792.92	1,968.09	297.17	182.40	627.67	192.00	112.63	0.00	406.44	2,117.11	4,164.58	0.00

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

1,067.23	420.38	-251.10	1,380.33	741.96	1,349.39	1,097.93	2,569.09	1,223.39	2,475.68	1,397.33	0.00

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	9,760.86	0.00

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 MALE	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	180,888.13	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	241,472.61	0.00

3716	ADULT <40% EXP MALE	3,847,800.35	3,546,062.74	4,041,892.63	3,442,949.46	3,052,156.77	3,352,667.69	3,181,190.42	3,262,614.68	4,342,455.20	3,578,583.42	2,684,617.14	0.00

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

2,702,957.26	2,499,001.62	2,930,369.65	2,323,636.33	2,219,259.83	2,273,036.74	1,984,703.79	2,115,723.72	2,656,035.32	2,343,784.27	1,981,082.83	0.00

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	4,389,476.12	0.00

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	2,760.00	0.00

3726	ADULT <40% EXP MALE	0.00	15.75	0.00	0.00	342.00	0.00	0.00	0.00	0.00	22.57	192.02	0.00

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

For The Period Ending May 31, 2015

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	750.80	859.07	0.00	0.00	1,609.87

0.00	1,026.00	0.00	569.61	193.95	342.00	17.60	1,026.00	684.00	59.40	342.00	0.00	4,260.56

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

SUBTOTAL:

14,288,592.20

13,293,822.90     15,303,619.55     12,461,534.03     12,212,840.75     12,845,446.82     11,112,103.12     12,213,130.22     15,485,335.05     13,627,401.56     11,312,184.15	0.00	144,156,010.35

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	12.32	0.00	3,081.08

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

696.00	0.00	1,710.00	342.00	0.00	2,394.00	0.00	0.00	0.00	0.00	0.00	0.00	5,142.00

15,345.28	11,628.43	8,100.42	10,133.07	1,752.05	4,453.59	7,582.29	3,898.85	5,012.67	4,024.10	4,254.61	0.00	76,185.36

735.29	3,671.34	5,409.63	1,978.28	869.70	342.00	99.22	403.75	612.48	1,382.74	503.97	0.00	16,008.40

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	2,426.00	0.00	45,435.21

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	10,075.54	0.00	93,325.34

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	167,478.59	0.00	1,747,629.40

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

130,991.21	153,945.73	161,583.42	119,051.66	120,153.83	182,779.87	141,743.79	143,163.76	214,682.56	247,674.01	264,254.95	0.00	1,880,024.79

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	599,821.36	0.00	6,062,363.81

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

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

SUBTOTAL:

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	1,048,827.34	0.00	9,938,591.30

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

4,638.00	2,394.00	1,710.00	1,368.00	1,026.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	11,478.00

220,130.89	222,012.81	266,413.75	194,465.10	218,511.10	269,032.43	147,392.76	188,647.69	240,154.55	204,076.50	172,100.60	0.00	2,342,938.18

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	71,967.93	0.00	865,409.39

4415	SOBRA 100-133% FEMA L

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	75,640.31	0.00	1,044,074.95

SUBTOTAL:

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	319,708.84	0.00	4,263,900.52

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	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	2,450.00	0.00	62,077.59

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	2,990.75	0.00	124,476.14

2,736.00	0.00	342.00	342.00	0.00	0.00	0.00	0.00	0.00	1,710.00	1,400.00	0.00	6,530.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,392.00	700.00	0.00	2,092.00

SUBTOTAL:

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	7,540.75	0.00	195,175.73

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

1,454.42	423.99	3,462.33	95.70	1,337.44	1,055.50	146.04	1,367.26	3,920.05	714.56	752.89	0.00	14,730.18

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	4,542.00	0.00	27,281.00

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

SUBTOTAL:

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	5,294.89	0.00	44,410.30

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	39,217,332.28	0.00	505,993,478.78	

TOTAL:

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

For The Period Ending May 31, 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	10,782.64	0.00	87,354.81

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	14,146.69	0.00	141,396.27

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	24,026.78	0.00	66,438.62

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	1,441.85	0.00	8,785.76

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	577,543.71	0.00	6,837,784.86

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	361,712.82	0.00	5,649,800.39

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	360,289.79	0.00	6,425,230.06

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	134,358.19	0.00	1,637,366.00

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	161,785.63	0.00	2,557,135.52

1016	TANF 21-44 MALE NON-	445,479.43	357,175.48	371,805.96	385,447.27	373,782.12	534,280.58	426,230.07	400,938.91	594,364.11	555,651.35	511,663.41	0.00	4,956,818.69

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	1,411,843.98	0.00	17,844,749.44

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	542,250.35	0.00	6,133,502.53

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	28,622.59	0.00	31,491.39

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	5.89	0.00	4,851.30

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	1,476.84	0.00	2,245.55

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

52,744.87	38,379.36	63,306.89	38,592.69	38,601.30	41,184.93	42,731.47	32,952.03	64,058.11	52,017.20	61,615.75	0.00	526,184.60

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	59,738.19	0.00	643,090.47

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	222,446.36	0.00	2,595,506.35

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

266,485.96	172,649.08	166,477.74	168,126.72	107,342.11	208,194.12	235,382.60	162,186.11	266,128.37	220,270.27	217,731.35	0.00	2,190,974.43

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	3,294,248.76	0.00	35,205,949.94

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	748,112.01	0.00	8,729,248.08

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	1,289.05	0.00	6,788.28

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	39,474.90	0.00	470,996.83

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	9,915.87	0.00	97,783.84

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	581,422.07	0.00	7,145,816.35

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	390,088.47	0.00	2,990,896.20

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	468,874.75	0.00	3,275,479.60

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	128,749.76	0.00	1,313,640.35

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	159,795.95	0.00	1,583,881.07

4325	SOBRA CHILD 14-20 FE	0.00	0.00	90.66	351.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	441.71

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

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

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	85,740.32	0.00	1,002,136.84

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	331,458.41	0.00	3,677,586.77

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

IT
SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	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	10,942,653.13	0.00	123,847,451.80		

143,700.80	
230,815.03	
650,716.01	
127,246.67	
1,979.01	
33,013.46	
75,470.82	
27,823.84	
103,381.64	
2,088,366.71	
3,366,378.14	
3,353,427.61	
22,219.74	
10,104.15	
4,419.35	
71,218.66	
33,138.54	
115,323.62	
445,735.39	
2,586,525.63	
0.00	
62,914.42	
361,153.04	
1,417,568.45	
15,332,640.73	

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	17,520.58	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	19,239.20	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	48,625.17	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

7,438.23	9,025.57	11,942.73	14,963.64	7,844.84	7,355.78	9,384.41	11,139.56	21,453.86	13,865.21	12,832.84	0.00

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	1,603.58	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	5,560.94	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	3,028.59	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	19,309.84	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	135,182.22	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	296,155.48	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	260,366.74	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	116.92	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	6,036.64	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	2,856.17	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	5,480.93	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

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	3,654.91	0.00

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	7,927.17	0.00

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	34,519.84	0.00

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	254,742.14	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

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	5,537.85	0.00

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	33,584.16	0.00

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	166,301.50	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	1,340,183.41

0.00

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13.20	0.00

-13.20	
-216.52	
60.62	
0.00	
213.51	
-1,968.97	
636.59	
-13.75	

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-216.52	0.00	0.00	0.00

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

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	118.58	26.76	0.00	0.00	68.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	-670.91	82.39	-177.32	128.06	68.17	-707.22	0.00	-17.03	5.34	0.00	-13.20	0.00	-1,301.72		

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

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	-812.36	0.00	49,479.56

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	-55.70	0.00	24,718.72

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	-170.68	0.00	17,645.64

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

SUBTOTAL:

12,870.75

42,748.13	12,694.35	6,495.04	639.13	23,304.93	189.64	-138.82	-184.71	352.67	-1,038.74	0.00	97,932.37

19,520.09	
0.00	
124,881.49	
4,537.07	
69,611.92	
73,124.99	
1,446,595.73	
958,081.23	
3,805,988.14	
2,103.95	
2,119.26	
0.00	
20,429.30	
24,435.21	
139,219.62	
1,722.33	
928,566.86	
762,711.02	
21,901,061.12	
9,394,745.65	
26,948,791.74	
27,664.34	
0.00	

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	1,562.37	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	5,832.57	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	312.70	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	4,102.84	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	9,785.72	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	224,686.37	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	105,658.54	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	400,137.07	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	712.98	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 MALE	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	1,506.15	0.00

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

1,699.84	857.70	202.77	2,310.82	176.50	4,795.70	3,424.87	4,184.32	3,735.99	1,561.63	1,485.07	0.00

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	13,695.85	0.00

19.51	59.79	399.85	769.60	317.75	328.51	-21.98	-15.53	0.00	0.00	-135.17	0.00

3714	ADULT <40% EXP MALE	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	80,113.25	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	52,911.19	0.00

3716	ADULT <40% EXP MALE	2,056,952.53	1,717,512.69	1,635,655.49	1,942,921.88	1,764,448.36	2,192,772.90	1,865,496.71	2,058,308.59	2,484,583.01	2,304,935.48	1,877,473.48	0.00

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

763,329.78	694,754.25	852,786.42	872,179.85	771,277.55	1,138,319.38	790,511.47	759,837.69	1,090,777.50	819,433.11	841,538.65	0.00

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	2,605,268.67	0.00

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	221.10	0.00

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

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

For The Period Ending May 31, 2015

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

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

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	4,782.10

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	155.65	0.00	14,269.58

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

SUBTOTAL:

5,669,460.82

4,764,474.08	5,331,290.31	5,835,977.65	5,346,772.57	6,966,584.87	5,778,047.00	5,964,232.49	7,914,825.09	6,876,272.81	6,227,025.05	0.00	66,674,962.74

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
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

140.82	0.00	46.31	0.00	0.00	91.02	0.00	0.00	0.00	0.00	0.00	0.00	278.15

20,470.96	14,484.59	7,064.47	7,393.77	1,680.78	5,096.67	2,303.85	179.83	24.69	2,285.74	2,329.75	0.00	63,315.10

0.00	824.23	603.22	0.00	1,297.92	0.00	0.00	204.26	183.55	144.59	103.28	0.00	3,361.05

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	655.14	0.00	4,632.30

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	1,014.81	0.00	25,825.32

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	76,517.79	0.00	631,759.78

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

15,483.34	24,987.66	67,374.92	31,854.35	20,317.81	34,921.96	26,304.11	33,178.90	45,931.02	58,112.53	96,007.29	0.00	454,473.89

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	225,094.87	0.00	2,071,306.00

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

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

SUBTOTAL:

165,883.05

171,322.54	295,061.18	258,195.44	196,449.93	344,920.04	249,166.02	302,106.19	450,166.10	423,568.77	401,722.93	0.00	3,258,562.19

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

255.50	0.00	7.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	263.07

14,205.19	14,325.32	18,387.82	24,979.21	36,364.33	32,560.15	20,253.76	29,575.06	55,625.35	25,028.34	27,758.72	0.00	299,063.25

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	8,871.63	0.00	118,240.75

4415	SOBRA 100-133% FEMA L

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	10,028.49	0.00	270,719.68

SUBTOTAL:

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	46,658.84	0.00	688,286.75

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71.19	0.00	0.00	71.19

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	13,826.97	0.00	162,574.74

0.00	0.00	127.34	100.17	0.00	0.00	0.00	0.00	0.00	894.96	1,354.75	0.00	2,477.22

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

SUBTOTAL:

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	15,181.72	0.00	166,504.46

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

2,168.55	5,501.70	880.57	1,409.51	1,509.54	1,639.81	887.05	1,751.87	3,064.18	1,408.95	3,134.93	0.00	23,356.66

22.57	0.00	0.00	381.74	0.00	174.86	84.58	0.00	31.43	887.07	353.38	0.00	1,935.63

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

SUBTOTAL:

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	3,488.31	0.00	25,557.45

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	18,975,861.45	0.00	210,090,596.77		

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

For The Period Ending May 31, 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
2110	SSI AGED NON-MEDICA
R

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

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

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

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

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

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

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

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

2310	SSI BLIND NON-MEDIC A

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

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

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
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

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

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

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

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

IT
SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

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

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

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&
1111	TANF EXPANDED <1 M
&F

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

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

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&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

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

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

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

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

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

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

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

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

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

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

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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

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	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

SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

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

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

SUBTOTAL:

0.00

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

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

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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 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

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

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

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

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

3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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 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

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

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

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

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

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

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

For The Period Ending May 31, 2015

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

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

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

SUBTOTAL:

0.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

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

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

3915	NEWLY ELIGIBLE FEMA L

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

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

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

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

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

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

SUBTOTAL:

0.00

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

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

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

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

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4415	SOBRA 100-133% FEMA L

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

SUBTOTAL:

0.00

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

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
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

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

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

SUBTOTAL:

0.00

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

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

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

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

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

SUBTOTAL:

0.00

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

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

TOTAL:

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

For The Period Ending May 31, 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	1,522.38	0.00	1,839.18

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	3,916.86	0.00	74,476.36

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	20,747.48	0.00	148,424.65

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	5,450.37	0.00	62,414.86

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	942.60	0.00	16,510.06

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	15,821.22	0.00	111,223.04

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	9,059.65	0.00	103,227.88

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	53,659.16	0.00	291,233.55

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	6,788.70	0.00	92,393.24

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
2110	SSI AGED NON-MEDICA
R

637.35	193.42	1,743.48	-72.49	2,408.61	193.66	-955.60	880.07	11,912.77	2,885.50	1,144.08	0.00	20,970.85

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	19,611.60	0.00	187,134.35

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	-944.11	0.00	5,979.75

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

1,445.44	827.70	195.47	2,076.72	3,265.80	496.16	427.63	546.76	218.12	2,378.37	4,660.27	0.00	16,538.44

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	252,336.79	0.00	964,343.80

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	3,852.26	0.00	41,953.28

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	96,172.07	0.00	331,054.70

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	15,940.03	0.00	183,573.57

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	11,958.19	0.00	135,080.47

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	11,328.65	0.00	105,746.29

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	3,777.02	0.00	64,580.06

4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

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

355.24	6,402.33	543.66	4,185.11	1,979.78	2,453.44	10,639.72	3,592.32	-1,517.75	6,668.41	4,046.11	0.00	39,348.37

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	16,605.41	0.00	134,424.92

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

IT
SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	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	558,396.79	0.00	3,134,572.77		

1,853.38	
1,097.00	
4,093.04	
85.66	
137.15	
2,377.09	
65.60	
3,531.78	
5,107.29	
89,945.51	
115,556.48	
117,388.47	
0.00	
0.00	
0.00	
968.83	
0.00	
14,369.08	
4,102.36	
16,951.41	
0.00	
6,023.68	
17,949.31	
9,666.10	
411,269.22	

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	177.12	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	218.90	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	230.75	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

0.00	0.00	0.00	0.00	0.00	0.00	12.33	0.00	73.33	0.00	0.00	0.00

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	55.05	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	8,844.78	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	6,106.34	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&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

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

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	493.78	0.00

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

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	2,196.76	0.00

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

221.18	1,442.53	26.49	170.03	81.86	21.80	77.60	1,261.94	747.67	1,195.03	777.55	0.00

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

504.00	504.00	0.00	151.88	1,131.21	302.92	729.60	595.67	991.91	1,887.59	2,867.32	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	21,968.35

0.00

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

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

0.00	
0.00	
0.00	
0.00	
-616.71	
0.00	
0.00	
0.00	

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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

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	-616.71	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	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

SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	-616.71	0.00	0.00	0.00	0.00	0.00	0.00	-616.71		

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

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	
519.09	
0.00	
5,346.16	
9,447.85	
233,319.90	
79,539.65	
451,769.12	
0.00	
2,068.08	
0.00	
-466.71	
-352.31	
6,163.31	
0.00	
46,988.97	
22,007.10	
794,310.81	
234,042.37	
838,090.84	
0.00	
0.00	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	231.08	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	-781.88	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	1,072.26	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	23,201.73	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	3,147.48	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	14,896.73	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	21.07	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 MALE	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
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

0.00	0.00	-352.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	-72.49	0.00	2,629.57	1,220.98	-171.35	0.00	654.80	1,203.84	0.00	697.96	0.00

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

3714	ADULT <40% EXP MALE	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	1,031.87	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	1,316.54	0.00

3716	ADULT <40% EXP MALE	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	70,316.63	0.00

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

15,464.69	7,575.62	11,004.31	18,345.03	15,707.90	25,521.33	61,116.83	26,314.24	22,945.85	21,493.32	8,553.25	0.00

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	98,059.38	0.00

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

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

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

For The Period Ending May 31, 2015

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

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

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

SUBTOTAL:

227,751.86

286,720.57	258,100.30	287,145.84	199,194.56	305,688.92	233,656.08	186,577.29	252,876.81	263,317.90	221,764.10	0.00	2,722,794.23

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

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

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

225.00	23.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.52

0.00	0.00	76.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.45

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

3915	NEWLY ELIGIBLE FEMA L

577.82	0.00	136.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	460.26	0.00	1,174.73

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	2,118.54	0.00	67,150.26

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

169.41	212.50	2,051.45	5,094.89	9,685.39	12,406.06	1,912.39	20,065.45	4,056.67	1,867.58	1,170.01	0.00	58,691.80

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	2,804.41	0.00	222,173.82

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

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

SUBTOTAL:

57,698.27

37,109.02	60,846.78	18,139.57	27,613.21	34,097.02	11,795.73	39,941.98	27,894.59	27,826.19	6,553.22	0.00	349,515.58

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

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

145.71	286.93	175.46	86.90	461.89	139.55	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	3,713.76	0.00	4,209.98

4415	SOBRA 100-133% FEMA L

798.96	84.38	662.74	231.12	54.53	0.00	123.06	163.98	0.00	3.02	2,641.89	0.00	4,763.68

SUBTOTAL:

944.67

371.31	838.20	318.02	516.42	139.55	449.43	869.08	1,231.02	364.03	6,355.65	0.00	12,397.38

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	0.00	0.00	0.00	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

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

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

SUBTOTAL:

0.00

0.00	63.08	0.00	5,650.43	4,681.60	0.00	0.00	256.94	0.00	0.00	0.00	10,652.05

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

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

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

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

SUBTOTAL:

0.00

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

TOTAL:	610,498.27	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	815,038.11	0.00	6,755,128.29		

IT

SUBTOTAL:	2

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	20,749.45	33,935.21	14,028.32	27,958.67	25,170.82	15,406.80	20,443.40	23,873.25	27,525.01	23,236.64	38,341.31	0.00		270,668.88		
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		14,028.3		27,958.67	25,170.82	15,406.80	20,443.40	23,873.25	28,119.93	23,236.64	38,341.31	0.00	271,263.80		

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	38,341.31	0.00	271,263.80	

TOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	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		0.0		0.00	0.00	0.00	349.92	0.00	202.46	0.00	0.00	0.00	552.38		

IT

SUBTOTAL:	0

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		

IT

SUBTOTAL:	9

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	206,280.04	288,775.58	184,962.59	308,199.09	179,270.46	211,109.78	313,044.03	295,514.04	357,924.75	206,373.85	317,749.58	0.00		2,869,203.79		
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		184,962.5		308,199.09	179,270.46	211,109.78	313,044.03	295,514.04	357,968.12	206,373.85	317,749.58	0.00	2,869,247.16		

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	317,749.58	0.00	2,869,247.16	

TOTAL:

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

For The Period Ending May 31, 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	658.71	0.00	8,221.23

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	311.12	0.00	6,976.95

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	502.60	0.00	31,401.17

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	152,538.94	0.00	928,430.37

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	23,207.31	0.00	399,155.42

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	15,863.45	0.00	378,202.73

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	1,179.48	0.00	107,588.76

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	27,017.36	0.00	246,112.35

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	32,891.24	0.00	508,193.57

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	96,803.42	0.00	2,189,366.29

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	15,852.27	0.00	484,868.15

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
2110	SSI AGED NON-MEDICA
R

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	12,269.01	0.00	96,362.09

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	2,416.69	0.00	72,704.36

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	13,008.54	0.00	130,625.13

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

13,662.86	42,533.24	8,606.75	8,165.79	2,835.72	7,637.69	12,933.01	9,303.59	37,881.99	6,896.20	2,140.90	0.00	152,597.74

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	238,920.02	0.00	3,325,291.75

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	39,096.19	0.00	440,759.76

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	1,320.17	0.00	63,850.62

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	42.42	0.00	4,800.04

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	29,883.45	0.00	753,664.17

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	29,491.71	0.00	246,823.29

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	18,618.62	0.00	234,879.45

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	10,202.20	0.00	215,628.71

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	10,411.29	0.00	136,058.54

4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	8.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.19

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

1,758.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,758.24

18,102.67	16,540.26	22,290.29	19,379.70	16,315.61	20,161.18	24,209.00	5,048.99	8,059.56	7,814.00	18,239.45	0.00	176,160.71

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	24,128.89	0.00	549,909.49

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

IT
SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	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	817,015.45	0.00	11,894,146.06		

4,285.30	
14,056.08	
23,098.13	
11,899.12	
0.00	
1,174.50	
5,336.27	
8,344.86	
32,574.57	
322,082.96	
574,935.92	
316,075.43	
251.28	
29.11	
16.17	
1,339.68	
149.98	
3,487.71	
53,225.51	
148,265.81	
0.00	
6,759.34	
10,604.49	
89,234.12	
1,627,226.34	

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	2,008.85	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	4,104.96	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

1,503.33	1,346.31	2,101.21	1,694.86	1,217.22	393.84	200.07	156.04	3,225.20	0.00	61.04	0.00

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

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	1,625.35	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	1,760.75	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	493.47	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	7,446.07	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	27,798.06	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	15,097.82	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	29.11	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	16.17	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	34.85	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2510	SSI BLIND EXPANDED
N
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

94.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55.53	0.00

794.63	64.31	296.56	488.33	532.96	174.38	789.58	51.29	77.04	58.67	159.96	0.00

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	597.32	0.00

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	9,694.13	0.00

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

92.70	1,634.66	153.11	633.37	245.75	775.39	126.95	1,623.11	57.02	1,297.34	119.94	0.00

209.07	879.14	542.12	152.63	484.69	1,690.72	559.20	1,042.61	1,486.78	3,497.18	60.35	0.00

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	7,319.62	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	78,483.35

0.00

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

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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

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	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

SUBTOTAL:

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

For The Period Ending May 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

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

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

SUBTOTAL:

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	
3,056.14	
248.95	
2,510.31	
69,361.68	
303,958.92	
209,317.68	
517,956.47	
0.00	
143.56	
0.00	
0.00	
137.97	
12,355.73	
463.46	
206,686.70	
80,445.87	
2,335,756.75	
1,128,499.53	
2,164,494.82	
0.00	
0.00	

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	151.20	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	843.06	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	2,759.30	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	24,656.09	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	17,789.55	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	29,117.35	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 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

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

0.00	0.00	30.31	0.00	0.00	0.00	0.00	0.00	0.00	107.66	0.00	0.00

2,451.54	2,205.17	837.47	2,507.14	242.63	29.18	68.64	0.00	24.55	1,971.97	2,017.44	0.00

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 MALE	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	3,165.25	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	6,834.48	0.00

3716	ADULT <40% EXP MALE	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	203,059.08	0.00

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

85,369.64	98,701.56	110,904.18	120,526.37	105,896.01	99,243.84	85,034.38	123,452.44	141,416.38	65,009.36	92,945.37	0.00

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	251,684.48	0.00

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

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

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

For The Period Ending May 31, 2015

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

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
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	119.13	1,433.19	0.00	0.00	0.00	0.00	577.08	47.97	79.99	0.00	2,257.36

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

SUBTOTAL:

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	635,102.64	0.00	7,039,026.01

3906	NEWLY ELIGIBLE MALE	225.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225.11

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

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

586.88	785.65	1,040.86	371.90	185.31	2,517.06	0.00	83.50	0.00	0.00	145.76	0.00	5,716.92

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	511.86	0.00	4,729.66

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	27.97	0.00	666.15

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	5,794.76	0.00	53,695.54

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

6,073.87	2,908.38	28,820.75	5,207.82	6,142.79	2,254.19	5,649.24	13,448.54	16,490.14	6,151.45	5,218.82	0.00	98,365.99

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	21,174.16	0.00	300,993.16

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

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

SUBTOTAL:

20,367.80

22,835.40	68,351.77	40,227.14	87,566.94	34,481.83	17,949.60	46,407.89	63,113.91	30,266.94	32,873.33	0.00	464,442.55

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

84.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84.06

1,505.68	1,455.19	1,299.50	10,273.42	8,846.56	3,004.47	1,235.06	800.55	2,231.45	921.76	1,190.52	0.00	32,764.16

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	864.84	0.00	21,692.56

4415	SOBRA 100-133% FEMA L

381.31	0.00	319.14	1,140.59	9,913.01	3,703.03	87.83	973.33	4,197.82	808.34	236.48	0.00	21,760.88

SUBTOTAL:

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	2,291.84	0.00	76,301.66

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	0.00	0.00	0.00	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	13.36	0.00	19,325.94

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

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

SUBTOTAL:

2,630.32

2,465.34	58.12	2,640.75	5,006.95	2,566.37	3,422.82	0.00	521.91	0.00	13.36	0.00	19,325.94

8700	SSI DISABLED FREEDO M
8710	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M

324.38	62.22	0.00	0.00	0.00	0.00	0.00	0.00	940.33	0.00	25.81	0.00	1,352.74

0.00	0.00	0.00	0.00	0.00	89.35	0.00	0.00	0.00	0.00	0.00	0.00	89.35

0.00	37.44	18.72	160.74	0.00	0.00	37.44	0.00	0.00	0.00	0.00	0.00	254.34

SUBTOTAL:

324.38

99.66	18.72	160.74	0.00	89.35	37.44	0.00	940.33	0.00	25.81	0.00	1,696.43

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	1,565,805.78	0.00	21,146,106.10		

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

For The Period Ending May 31, 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	342.00	0.00	8,316.56

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

182,999.78	206,203.74	177,774.65	192,246.43	141,311.29	189,450.03	164,492.17	156,930.78	276,365.47	174,489.71	192,260.21	0.00	2,054,524.26

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	20,078.30	0.00	380,431.19

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	188,851.48	0.00	1,959,016.05

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

45,131.68	36,659.49	44,022.63	49,795.83	32,822.35	35,765.73	29,162.27	29,998.86	44,471.22	38,050.86	50,342.40	0.00	436,223.32

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	631,997.42	0.00	8,255,023.89

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	71,067.10	0.00	778,867.74

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	8,622.00	0.00	122,887.11

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	228.11	0.00	4,246.50

SUBTOTAL:

1,471,411.01

1,318,771.80	1,330,018.52	1,331,659.90	1,080,438.73	1,320,460.85	1,057,080.49	1,110,695.29	1,559,885.97	1,255,831.32	1,163,789.02	0.00	14,000,042.90

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

0.00	43.89	51.65	121.44	0.00	0.00	0.00	0.00	154.92	0.00	21.87	0.00	393.77

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

SUBTOTAL:

0.00

43.89	51.65	121.44	0.00	0.00	0.00	0.00	154.92	0.00	21.87	0.00	393.77

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	1,163,810.89	0.00	14,000,436.67	

TOTAL:

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

For The Period Ending May 31, 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
2110	SSI AGED NON-MEDICA
R

2,664,791.67	2,286,017.04	2,299,939.18	2,502,189.39	2,230,289.96	2,506,926.63	2,180,726.34	2,080,624.01	2,842,635.18	2,229,654.11	2,197,498.61	0.00	26,021,292.12

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	166,452.49	0.00	1,775,830.84

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	2,778,620.95	0.00	32,806,774.82

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

466,608.06	464,804.54	438,058.71	500,388.76	427,476.48	524,802.68	397,076.96	457,472.85	483,961.70	451,340.31	415,090.55	0.00	5,027,081.60

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	1,757,046.27	0.00	19,943,065.70

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	632,762.89	0.00	6,893,351.13

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	5,736.56	0.00	89,079.47

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	5,419.27	0.00	78,345.36

SUBTOTAL:

8,958,286.43

7,902,754.78	8,007,612.46	8,777,861.74	8,031,960.94	9,082,328.52	7,897,484.60	7,653,612.67     10,057,354.72	8,310,070.50	7,958,627.59	0.00	92,637,954.95

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

0.00	4,543.62	2,285.20	2,174.88	2,122.56	0.00	4,582.80	1,656.24	1,800.96	2,058.24	1,716.54	0.00	22,941.04

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	1,447.20	0.00	25,627.22

SUBTOTAL:

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	3,163.74	0.00	48,568.26

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	7,961,791.33	0.00	92,686,523.21		

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

For The Period Ending May 31, 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
2110	SSI AGED NON-MEDICA
R

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	17,924.19	0.00	443,986.96

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	1,443.73	0.00	60,756.60

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	53.50	0.00	12,424.95

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

4,865.65	14,348.75	3,854.67	2,379.84	-342.84	1,804.64	7,701.35	341.45	6,288.05	10,326.44	13,858.32	0.00	65,426.32

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	14,693.66	0.00	245,209.11

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	2,272.45	0.00	27,654.16

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

2310	SSI BLIND NON-MEDIC A

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

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

SUBTOTAL:

91,973.31

85,468.58	96,995.06	115,919.51	32,254.23	109,999.38	38,691.76	68,874.53	143,467.16	21,568.73	50,245.85	0.00	855,458.10

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

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

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

SUBTOTAL:

0.00

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

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	50,245.85	0.00	855,458.10	

TOTAL:

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

For The Period Ending May 31, 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
2110	SSI AGED NON-MEDICA
R

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	13,583.80	0.00	275,390.03

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	16,909.46	0.00	194,277.44

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

6,702.65	5,212.13	1,788.76	1,718.52	2,251.53	2,380.39	398.09	1,198.76	4,744.74	2,086.82	11,866.37	0.00	40,348.76

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	81,035.68	0.00	667,909.97

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	4,657.47	0.00	69,474.34

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	47.97	0.00	1,309.53

SUBTOTAL:

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	128,100.75	0.00	1,258,660.85

8710	SSI DISABLED FREEDO M
8720	SSI DISABLED FREEDO
M

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

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

SUBTOTAL:

0.00

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

TOTAL:	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	128,100.75	0.00	1,258,660.85		

KidsCare - CAPITATION AMOUNTS

For The Period Ending May 31, 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	1,471.08	0.00	56,346.31

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	788.35	0.00	145,994.29

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	74,550.43	0.00	1,542,523.46

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	57,638.09	0.00	894,029.67

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	88,709.79	0.00	1,404,326.35

9960	KIDSCARE KICK PAYME N

0.00	6,046.14	0.00	0.00	0.00	6,216.14	0.00	0.00	0.00	0.00	0.00	0.00	12,262.28

SUBTOTAL:

317,921.81

319,265.24	311,916.90	324,341.71	320,128.32	1,129,266.34	313,733.76	285,768.59	278,712.97	231,268.98	223,157.74	0.00	4,055,482.36

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	223,157.74	0.00	4,055,482.36	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending May 31, 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	3.00	0.00	70.86

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	7.00	0.00	201.16

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	580.59	0.00	9,603.66

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	309.64	0.00	4,348.43

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	328.34	0.00	4,654.29

9960	KIDSCARE KICK PAYME N

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

SUBTOTAL:

1,943.71

1,914.65	1,901.03	1,887.94	1,851.82	1,835.67	1,808.76	1,638.91	1,594.33	1,275.01	1,228.57	0.00	18,880.40

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	1,228.57	0.00	18,880.40		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending May 31, 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	150.20	0.00	4,134.88

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	262.85	0.00	33,720.77

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	21,253.30	0.00	423,696.72

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	11,640.29	0.00	183,498.51

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	12,736.36	0.00	200,323.16

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	46,043.00	0.00	845,374.04

TOTAL:

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	46,043.00	0.00	845,374.04

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending May 31, 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	4.00	0.00	81.00

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	7.00	0.00	210.00

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	566.00	0.00	9,531.00

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	295.00	0.00	4,261.00

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	320.00	0.00	4,659.00

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	1,192.00	0.00	18,742.00

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	1,192.00	0.00	18,742.00		

SUBTOTAL:	6

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending May 31, 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	416.94	0.00		2,918.53		
	0.00	393.96		393.9		416.93	416.93	416.93	416.93	416.93	416.93	416.94	416.94	0.00	4,123.38		

0.00	393.96	393.96	416.93	416.93	416.93	416.93	416.93	416.93	416.94	416.94	0.00	4,123.38	

TOTAL:

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending May 31, 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	1.00	0.00		7.00		
	0.00	1.00		1.0		1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	10.00		

SUBTOTAL:	0

TOTAL:	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	10.00		

KidsCare - FEE FOR SERVICE

For The Period Ending May 31, 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	444.65	0.00	10,424.75

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	794.28	0.00	25,319.75

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	33.36	0.00	12,133.65

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	180.47	0.00	11,066.47

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	1,452.76	0.00	59,457.41

TOTAL:

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	1,452.76	0.00	59,457.41

KidsCare - REINSURANCE

For The Period Ending May 31, 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	4,287.27	0.00		-153,738.34		
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	31,753.83	0.00		228,267.09		
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		81,729.6		563.56	27,046.55	29,952.95	29,608.18	43,441.02	27,825.57	81,706.57	36,041.10	0.00	272,836.40		

SUBTOTAL:	0

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	36,041.10	0.00	272,836.40		

SUBTOTAL:

KidsCare - TRANSPLANT REINSURANCE

For The Period Ending May 31, 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:

BEHAVIORAL HEALTH - FEE FOR SERVICE (Claims processed by AHCCCS on behalf of DHS)

For The Period Ending May 31, 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	6.49	0.00	28.69	0.00	0.00	0.00	0.00	1,821.02	0.00	1,856.20

1007	TANF 21-44 FEMALE WI	747.24	661.12	228.01	837.12	0.00	0.00	0.00	45.14	0.00	0.00	0.00	0.00	2,518.63

1008	TANF 45-64 M & F WIT	0.00	2.65	0.00	0.00	31.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.12

1011	TANF <1 M & F NON-ME	540.62	678.25	152.17	1,460.68	22.25	1,106.52	301.27	1,013.23	1,828.11	1,479.06	404.38	0.00	8,986.54

1012	TANF 01-05 M & F NON	57,202.11	43,989.04	38,277.12	35,973.14	53,930.08	46,008.07	40,393.76	31,911.53	30,871.58	27,775.95	25,781.94	0.00	432,114.32

1013	TANF 06-13 M & F NON	1,427,876.54	1,124,921.20	1,193,818.68	920,396.12	893,686.34	1,099,014.36	860,111.12	849,757.39	986,485.03	644,639.66	584,181.24	0.00	10,584,887.68

1014	TANF 14-20 MALE NON-	224,741.03	162,852.04	273,863.57	228,865.81	149,619.99	231,726.03	159,851.55	142,882.17	214,731.93	190,771.91	160,015.78	0.00	2,139,921.81

1015	TANF 14-20 FEMALE N O

333,945.05	316,800.26	292,069.01	255,719.04	260,425.05	211,191.48	183,667.31	227,316.80	241,527.58	171,090.75	164,467.13	0.00	2,658,219.46

1016	TANF 21-44 MALE NON-	42,614.35	46,691.55	80,092.62	63,355.46	44,150.11	59,184.93	58,085.32	82,005.49	71,406.55	71,040.37	73,242.70	0.00	691,869.45

1017	TANF 21-44 FEMALE N O

283,824.51	240,248.55	256,716.86	271,467.83	243,366.63	277,990.69	288,371.95	246,111.34	349,836.04	251,389.85	300,423.28	0.00	3,009,747.53

1018	TANF 45-64 M & F NON	19,147.83	16,880.63	20,310.15	23,817.87	23,701.97	41,445.69	38,123.52	30,684.37	36,752.77	47,152.68	33,902.65	0.00	331,920.13

1027	TANF 21-44 FEMALE WI	5,032.80	3,690.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,723.52

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	403.42	0.00	403.42

1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.47	0.00	0.00	0.00	10.47

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

10,456.00	9,755.42	8,438.24	8,591.67	8,026.01	3,787.95	3,730.74	3,855.50	3,283.94	7,200.38	3,669.45	0.00	70,795.30

0.00	684.02	1,319.38	1,487.57	0.00	0.00	1,248.00	0.00	30.75	0.00	52.79	0.00	4,822.51

2120	SSI AGED WITH QMB	18,856.16	20,479.35	13,153.19	17,671.14	18,112.29	18,545.90	10,907.51	11,412.88	18,525.78	9,656.47	41,284.74	0.00	198,605.41

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

28,280.56	38,005.13	22,465.05	39,090.29	33,335.85	44,067.82	21,030.07	19,501.40	17,039.67	13,206.77	16,584.63	0.00	292,607.24

1,033,504.81	1,028,648.53	959,092.76	905,672.40	916,653.79	1,026,238.63	868,138.25	884,595.52	1,127,333.48	867,483.75	988,766.37	0.00	10,606,128.29

171,466.88	150,920.17	153,211.32	189,319.94	176,492.44	217,674.42	180,285.96	184,120.07	221,782.12	170,548.58	205,894.81	0.00	2,021,716.71

4,334.15	16,656.23	0.00	3,645.42	214.98	1,860.98	1,511.88	0.00	0.00	0.00	549.42	0.00	28,773.06

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	274.71	746.14	772.78	716.44	257.44	681.57	0.00	3,449.08

4311	SOBRA CHILD <1 M & F	333.67	46.44	26.71	2,353.09	85.00	669.75	214.62	798.90	660.19	3,477.28	13.82	0.00	8,679.47

4312	SOBRA CHILD 01-05 M	65,715.95	36,443.49	31,495.56	35,820.53	37,585.89	41,108.93	32,451.37	47,156.27	67,937.77	45,327.35	58,953.70	0.00	499,996.81

4313	SOBRA CHILD 06-13 M	729,889.24	574,606.43	514,625.72	527,679.86	493,878.49	726,366.06	518,221.27	547,691.92	705,205.56	691,114.41	870,797.56	0.00	6,900,076.52

4314	SOBRA CHILD 14-20 MA	301,780.12	299,416.97	177,388.91	274,827.10	200,018.96	226,808.61	327,719.43	197,908.61	284,142.30	239,526.20	390,405.77	0.00	2,919,942.98

4315	SOBRA CHILD 14-20 FE	512,671.40	360,643.38	308,967.71	266,959.77	280,753.35	305,315.64	253,821.98	239,099.56	317,113.74	242,882.39	271,772.19	0.00	3,360,001.11

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

6,166.49	3,139.55	3,247.50	6,815.52	11,353.30	5,499.57	1,822.70	1,374.34	3,794.86	3,152.14	7,149.19	0.00	53,515.16

11,556.79	8,952.71	18,481.50	11,989.46	15,454.09	15,920.09	9,968.34	17,620.43	10,886.35	9,390.18	10,540.54	0.00	140,760.48

1106	TANF EXPANDED 21-44	2,455.48	1,998.08	4,773.80	5,687.54	5,625.66	3,443.47	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	1,859.53	1,370.23	1,309.03	2,821.88	4,513.10	3,139.35	1,303.82	641.13	3,277.04	1,659.40	5,138.59	0.00	
1108	TANF EXPANDED 45-64	8.14	219.35	16.22	3,054.41	2,525.57	3,448.47	5,202.45	2,258.79	134.52	97.65	29.65	0.00	
1109	TANF EXPANDED 65+	0.00	688.84	166.58	63.52	65.00	301.76	0.00	1,707.57	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	159.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

5,290,684.30

4,505,813.83	4,367,441.74	4,093,823.32	3,860,898.33	4,601,835.52	3,860,724.06	3,767,635.64	4,711,903.01	3,708,563.57	4,211,760.09	0.00	46,981,083.41

23,984.03	
27,033.10	
16,995.22	
2,993.27	
159.89	

M&

BEHAVIORAL HEALTH - FEE FOR SERVICE (Claims processed by AHCCCS on behalf of DHS)

For The Period Ending May 31, 2015

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

1113	TANF EXPANDED 06-13	14,155.27	9,269.42	8,874.66	8,804.94	8,443.14	7,568.62	4,164.03	4,497.28	6,790.04	7,942.92	5,518.02	0.00	86,028.34

1114	TANF EXPANDED 14-20	10,149.39	6,183.98	7,179.06	6,139.28	7,784.79	12,603.41	7,844.60	6,770.68	4,856.36	5,247.18	1,930.15	0.00	76,688.88

1115	TANF EXPANDED 14-20	29,741.70	3,954.72	7,111.04	9,329.35	10,237.18	9,665.55	5,713.70	1,511.17	1,148.78	14,840.42	5,652.17	0.00	98,905.78

1116	TANF EXPANDED 21-44	25,922.15	14,762.16	17,423.23	15,527.53	18,766.73	18,277.54	32,687.93	14,536.82	18,519.50	10,178.45	9,654.37	0.00	196,256.41

1117	TANF EXPANDED 21-44	29,717.82	27,199.16	32,498.26	34,511.71	33,080.14	36,963.29	30,844.95	46,569.55	61,811.62	21,890.20	24,568.79	0.00	379,655.49

1118	TANF EXPANDED 45-64	27,338.91	31,508.69	37,008.26	8,195.50	4,756.99	12,213.16	11,084.54	13,931.39	8,721.88	11,365.67	4,989.02	0.00	171,114.01

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	86.65	15.56	0.00	0.00	0.00	0.00	0.00	0.00	102.21

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	498.80	334.40	214.71	0.00	1,047.91

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	1,629.00	4,080.17	1,628.86	2,867.44	5.26	0.00	0.00	0.00	10,210.73

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

1,697.97	1,704.50	1,592.67	2,310.13	427.51	650.88	388.83	491.82	533.13	133.63	53.85	0.00	9,984.92

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,996.97	504.70	0.00	3,501.67

5,892.48	3,890.12	4,957.52	8,471.62	9,580.29	10,549.19	8,121.15	5,979.61	5,937.60	6,130.80	5,917.40	0.00	75,427.78

22,478.38	26,354.34	21,514.11	23,528.46	16,201.62	23,759.64	26,759.98	23,614.72	25,490.47	16,909.53	22,571.83	0.00	249,183.08

0.00	0.00	75.74	0.00	1,083.61	457.12	448.18	571.86	1,321.57	0.00	0.00	0.00	3,958.08

13,485.73	20,355.49	23,762.56	23,071.80	19,972.53	15,532.02	15,750.01	13,333.96	21,476.79	12,077.71	21,265.05	0.00	200,083.65

22,003.07	21,978.92	15,572.95	10,406.96	6,447.95	7,404.30	9,033.51	14,365.76	34,206.98	20,622.76	30,460.21	0.00	192,503.37

SUBTOTAL:

206,906.02

171,438.00	183,995.58	161,924.63	151,227.46	170,073.50	160,976.54	153,649.55	194,730.34	132,427.69	138,468.51	0.00	1,825,817.82

2

SUBTOTAL:

3616	AHC CARE/MI MALE 21-	-2,520.92	0.00	0.00	0.00	350.01	42.24	0.00	0.00	0.00	0.00	0.00	0.00		-2,128.67	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	-1,069.73	0.00	0.00	0.00	0.00	0.00	0.00	91.71	0.00		-978.02	
3618	AHC CARE/MI M&F 45-6	19,060.16	0.00	-205.91	0.00	-96.95	-2.45	0.00	0.00	0.00	0.00	0.00	0.00		18,754.85	
	16,539.24	0.00	-205.91	-1,069.73	253.06	39.79	0.00	0.00	0.00	0.00	91.71	0.00	15,648.16	

14.15	
6,343.69	
3,434.07	
89,488.35	
65,373.41	
71,296.10	
27,756.28	
106.08	
12,157.36	
0.00	
434,004.59	
339,300.32	
4,608,736.04	
2,217,528.64	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.15	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	0.00	282.05	321.32	0.00	0.00	125.47	182.08	95.63	813.41	2,611.15	1,912.58	0.00

3515	ADULT 40-100% FEMAL E

0.00	0.00	421.69	0.00	127.04	1,040.86	426.77	844.34	573.37	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	5,786.55	5,268.96	3,803.24	4,830.27	4,790.52	7,498.57	11,297.67	6,970.74	5,892.36	20,662.80	12,686.67	0.00

3517	ADULT 40-100% FEMAL E

3,352.53	1,953.73	796.64	5,294.22	8,543.37	12,922.67	19,688.98	7,135.34	3,274.98	1,563.94	847.01	0.00

3518	ADULT 40-100% M&F 45	5,765.00	9,886.23	13,834.83	5,629.12	11,667.89	8,106.17	7,873.26	4,379.07	1,373.12	1,466.56	1,314.85	0.00

3706	ADULT <40% EXP MALE	196.98	4,194.00	4,697.28	5,913.28	5,871.60	5,871.60	1,011.54	0.00	0.00	0.00	0.00	0.00

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

25.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.72	0.00	10.02	0.00

0.00	0.00	265.46	833.17	124.40	0.00	227.66	0.00	4,791.36	5,473.74	441.57	0.00

0.00	0.00	1.69	0.00	0.00	-1.69	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	41,489.29	49,212.83	51,710.42	43,663.82	34,731.37	40,273.47	30,983.81	35,573.96	34,777.35	44,469.56	27,118.71	0.00

3715	ADULT <40% EXP FEM AL

41,519.35	39,734.39	42,445.53	38,565.58	23,603.56	34,374.00	24,829.05	21,136.29	38,705.97	21,985.75	12,400.85	0.00

3716	ADULT <40% EXP MALE	310,679.81	329,406.74	305,853.90	364,201.86	355,346.95	427,551.33	393,479.82	435,281.10	619,299.37	485,133.01	582,502.15	0.00

3717	ADULT <40% EXP FEM AL

157,223.92	171,803.46	163,551.66	213,487.28	172,909.05	233,157.46	208,916.50	206,782.70	282,176.33	185,793.92	221,726.36	0.00

BEHAVIORAL HEALTH - FEE FOR SERVICE (Claims processed by AHCCCS on behalf of DHS)

For The Period Ending May 31, 2015

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

3718	ADULT <40% EXP M&F
4
3728	ADULT <40% EXP M&F
4

184,028.00	188,401.10	152,232.42	213,937.71	209,471.24	283,229.95	240,613.11	245,821.25	263,280.34	214,906.21	262,557.51	0.00	2,458,478.84

0.00	0.00	0.00	0.00	0.00	4,449.12	5,203.99	0.00	1,388.95	0.00	100.85	0.00	11,142.91

SUBTOTAL:

750,066.77

800,143.49	739,936.08	896,356.31	827,186.99	1,058,598.98	944,734.24	964,034.57	1,256,417.63	984,066.64	1,123,619.13	0.00	10,345,160.83

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

0.00	0.00	0.00	0.00	0.00	376.03	0.00	0.00	0.00	0.00	0.00	0.00	376.03

0.00	2,691.92	63.52	0.00	0.00	0.00	58.08	0.00	0.00	0.00	0.00	0.00	2,813.52

3914	NEWLY ELIGIBLE MALE	1,282.54	2,739.22	2,130.98	1,810.12	2,838.56	3,219.44	4,419.63	4,078.32	2,268.38	0.00	0.00	0.00	24,787.19

3915	NEWLY ELIGIBLE FEMA L

4.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.82

3916	NEWLY ELIGIBLE MALE	2,191.44	1,224.94	118.25	1,491.02	1,397.44	8,704.33	2,050.48	4,444.87	16,230.51	8,058.05	8,140.75	0.00	54,052.08

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

14.92	4,460.64	1,816.73	2,046.98	2,890.49	1,629.71	1,935.88	2,488.91	-584.95	1,584.68	40.16	0.00	18,324.15

1,219.09	500.26	1,599.14	1,620.73	535.50	551.25	1,738.28	4,822.14	15,469.53	2,807.44	950.84	0.00	31,814.20

SUBTOTAL:

4,712.81

11,616.98	5,728.62	6,968.85	7,661.99	14,480.76	10,202.35	15,834.24	33,383.47	12,450.17	9,131.75	0.00	132,171.99

4413	SOBRA 100-133% M&F
6

56,228.66	51,963.29	36,141.57	29,918.83	25,387.11	17,860.99	17,923.82	15,074.20	24,393.72	12,601.29	29,823.48	0.00	317,316.96

4414	SOBRA 100-133% MALE	8,429.09	17,450.72	17,511.98	26,366.33	45,278.37	16,424.03	12,649.97	16,157.75	13,856.27	18,080.72	10,619.25	0.00	202,824.48

4415	SOBRA 100-133% FEMA L

7,716.01	20,533.31	4,962.49	9,942.32	6,300.66	12,586.68	13,714.66	5,603.88	8,472.43	13,041.66	21,277.90	0.00	124,152.00

8700	SSI DISABLED FREEDO	0.00	34.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.58	
	0.00	34.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.58	

SUBTOTAL:

72,373.76

89,947.32	58,616.04	66,227.48	76,966.14	46,871.70	44,288.45	36,835.83	46,722.42	43,723.67	61,720.63	0.00	644,293.44

M
SUBTOTAL:

TOTAL:	6,341,282.90	5,578,994.20	5,355,512.15	5,224,230.86	4,924,193.97	5,891,900.25	5,020,925.64	4,937,989.83	6,243,156.87	4,881,231.74	5,544,791.82	0.00	59,944,210.23		

SUBTOTAL:			4		
TOTAL:	105.09	64.65	1,266.24	0.00	59.96	42.12	36.38	220.19	0.00	69.81	0.00	0.00	1,864.44	

KidsCare - BEHAVIORAL HEALTH FEE FOR SERVICE (Claims processed by AHCCCS on behalf of DHS)

For The Period Ending May 31, 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	13.83	0.00	0.00	59.96	0.00	0.00	220.19	0.00	69.81	0.00	0.00		363.79		
6013	KIDS 6-13 M & F NON-	3.93	0.00	0.00	0.00	0.00	0.00	36.38	0.00	0.00	0.00	0.00	0.00		40.31		
6015	KIDS 14-19 FEMALE NO	101.16	50.82	1,266.24	0.00	0.00	42.12	0.00	0.00	0.00	0.00	0.00	0.00		1,460.34		
	105.09	64.65		1,266.2		0.00	59.96	42.12	36.38	220.19	0.00	69.81	0.00	0.00	1,864.44		

110007 DES-DD - CAP MEMBER MONTHS

For The Period Ending May 31, 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	2.00	0.00		22.00		
1010	TANF NON-MEDICARE	618.38	616.83	616.45	620.62	620.62	620.96	623.79	632.33	636.68	637.80	643.23	0.00		6,887.69		
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	1.00	0.00		14.00		
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	154.87	0.00		1,664.86		
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	4.00	0.00		52.00		
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	267.16	0.00		2,714.46		
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	1,725.09	0.00		19,272.97		
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	21,336.63	0.00		229,381.75		
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	0.03	0.00		7.44		
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	3,979.39	0.00		42,894.86		
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	14.00	0.00		162.38		
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	118.99	0.00		1,266.93		
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	24.80	0.00		292.73		
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	0.00		77.00		
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00		22.00		
8720	SSI DISABLED FREEDOM	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	3.00	3.00	0.00		27.00		
	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	28,283.19	0.00	304,766.60		
	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	28,283.19	0.00	304,766.60		

SUBTOTAL: TOTAL:

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending May 31, 2015

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL EPD
TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	378,800.20
81,832,334.90	377,975.63
91,563,188.35	376,641.36
82,730,279.25	377,090.04
83,774,273.60	376,452.78
93,279,309.59	372,298.89
84,421,747.15	368,910.84
83,617,697.83	374,105.76
96,221,860.48	371,853.88
84,003,373.04	368,450.62
85,358,376.28	367,636.38
97,645,032.06	0.00
0.00	4,110,216.38
964,447,472.53	
	82,211,135.10
90,441,057.34	91,941,163.98
90,874,990.67	83,106,920.61
91,356,447.37	84,151,363.64
91,810,801.83	93,655,762.37
92,142,171.96	84,794,046.04
93,945,839.51	83,986,608.67
93,016,958.34	96,595,966.24
93,363,074.13	84,375,226.92
94,258,277.93	85,726,826.90
94,721,707.64	98,012,668.44
94,988,031.75	0.00
0.00	968,557,688.91
1,020,919,358.47	
	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	94,988,031.75	0.00	1,020,919,358.47	
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	193,000,700.19	0.00	1,989,477,047.38	

EPD/DD FEE-FOR-SERVICE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	10,677,186.46
0.00	9,403,353.64
0.00	9,497,169.82
0.00	10,317,996.00
0.00	9,250,858.04
0.00	10,622,158.76
0.00	9,119,365.08
0.00	8,926,784.26
0.00	11,928,249.43
0.00	9,754,008.52
0.00	9,303,948.82
0.00	0.00
0.00	108,801,078.83
0.00	
	0.00	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	9,303,948.82	0.00	108,801,078.83	

EPD/DD REINSURANCE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	3,104,150.55
247,514.04	3,372,978.62
218,495.45	4,928,777.99
397,973.54	4,472,011.06
266,868.90	4,152,641.85
329,217.93	3,769,357.44
226,816.51	1,692,164.80
230,316.91	2,802,698.52
502,102.34	1,720,992.47
228,949.84	2,099,202.43
190,418.98	5,433,029.02
266,218.06	0.00
0.00	37,548,004.75
3,104,892.50	
	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	266,218.06	0.00	3,104,892.50	
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	5,699,247.08	0.00	40,652,897.25	

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	3,105,349.40	0.00	33,749,085.00	

Note to the ASR:
1- EPD reflects the Federal and County share for both acute and LTC services.
2- AHCCCS passes through only the Federal share to DES. Neither the Federal nor the Nonfederal dollars are included on the ASR summary (page 1) because both are included in the DES appropriation.

125

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending May 31, 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	13,247,812.80	0.00	147,189,082.97	
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	112,896.49	0.00	1,303,156.55	
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	3,242,070.30	0.00	31,598,468.63	
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	463,220.34	0.00	4,655,394.38	
	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	17,065,999.93	0.00	184,746,102.53	

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

TOTAL

Friday, June 26, 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	2,403,707.81	0.00	14,888,491.44	
	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	2,403,707.81	0.00	14,888,491.44	

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	32,882.60	0.00	624,406.49	
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	416.94	0.00	4,123.38	
	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	33,299.54	0.00	629,638.53	

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	19,503,007.28	0.00	200,264,232.50	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending May 31, 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	16,776.20	0.00	188,683.72	
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	160.73	0.00	1,883.92	
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	6,430.00	0.00	63,395.00	
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	1,111.00	0.00	11,292.00	
	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	24,477.93	0.00	265,254.64	

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

TOTAL

Friday, June 26, 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	41.63	0.00	667.90	
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	1.00	0.00	10.00	
	70.77	67.38	67.38	67.69	68.00	65.70	65.00	60.00	57.99	45.36	42.63	0.00	677.90	

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	24,520.56	0.00	265,932.54	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending May 31, 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	46,142,099.97	0.00	489,287,621.97	
	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	46,142,099.97	0.00	489,287,621.97	

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

TOTAL

Friday, June 26, 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	46,142,099.97	0.00	489,287,621.97	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending May 31, 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	19,012.97	0.00	202,952.43	
	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	19,012.97	0.00	202,952.43	

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

TOTAL

Friday, June 26, 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	19,012.97	0.00	202,952.43	

GRAND TOTAL