January 4, 2016

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 2016 Appropriation Status Report for the Period Ended November 30, 2015

Dear President Biggs and Speaker Gowan:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended November 30, 2015.

Status Summary – As part of the FY 2017 budget revision to the Governor’s Office of Strategic Planning and Budgeting, a FY 2016 rebase was prepared. AHCCCS is currently forecasting a FY 2016 Total Fund shortfall of $735.0 million. The shortfall is comprised of Federal Expenditure Authority ($671.7 million), Hospital Assessment Expenditure Authority ($34.4 million) and Prescription Drug Rebate Fund (PDRF) State Match ($28.9 million). The PDRF supplemental requirement is part of the Executive alternative to offset the 5% provider rate reduction. The Hospital Assessment shortfall represents the difference between the current assessment rate and the appropriated amount.

There are several issues this fiscal year that have the potential to affect the projected shortfall. They include:
Continued volatility in caseload growth and prior period expenditures.
Corrections of shifts between Traditional and Proposition 204 programs due to system generated eligibility misclassifications.
Ongoing implementation of the Medicare primary care physician parity program.
Implementation of the hospital presumptive eligibility program.
Potential Agency audit liabilities, which are detailed in the ASR.

AHCCCS intends to utilize surplus FY 2015 General Fund and Expenditure Authority for administrative adjustments of expenditures with dates of service prior to July 1, 2015. These administrative adjustments will reduce the projected Expenditure Authority shortfall.

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

The Honorable Andy Biggs
The Honorable David M. Gowan, Sr. January 4, 2016
Page 2

Given these program changes and issues, for purposes of this report, projected annual expenditures equal the FY 2016 appropriations.

Enrollment Update – November 2015 enrollment is 1,833,907 members, a 15,462 member increase over the prior month. Enrollment for December 2015 increased to 1,852,724 members, an 18,817 member increase.

Major December changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 9,483; Supplemental Security Income – increase of 834; Prop 204 Restoration - increase of 5,287; Adult Expansion - increase of 2,348; Medicare Cost Sharing
– increase of 57; and Federal Emergency Services - increase of 774.

Tobacco Funds Revenue Update –Tobacco tax collections through November 2015 are $1.6 million more than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2016 appropriations

If you have any questions about this report, please do not hesitate to call me at (602) 417-4111 or Jeffery Tegen at (602) 417-4705.

Sincerely,

Thomas J. Betlach Director

Enclosure

cc:      The Honorable Douglas A. Ducey, Governor
The Honorable Don Shooter, Chairman, Senate Appropriations Committee The Honorable Justin Olson, Chairman, House Appropriations Committee
The Honorable Nancy Barto, Chairman, Senate Health and Human Services Committee The Honorable Heather Carter, Chairman, House Health Committee
Lorenzo Romero, Director, Governor’s Office of Strategic Planning and Budgeting Richard Stavneak, Director, Joint Legislative Budget Committee

Appropriation Status Report (ASR)
Fiscal Year 2016
Through November 30, 2015

Prepared by: Division of Business and Finance

Appropriation Status Report
Table of Contents
APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 2016……………………………….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 2016 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2015
SUMMARY OF APPROPRIATED EXPENDITURES

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

AHCCCS Operating Lump Sum	$	77,975,400		$	32,790,500		$	28,837,718		$	3,952,782		$	77,975,400		$	-	
AHCCCS Prop 204 Administration	6,832,800		2,887,000		3,005,651		(118,651)		6,832,800		-	
DES Eligibility	54,874,500		23,089,200		22,493,280		595,921		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		16,171,300		4,087,628		12,083,672		38,358,700		-	
TOTAL ADMINISTRATION	178,041,400		74,938,000		58,424,277		16,513,723		178,041,400		-	

APPROPRIATIONS: ADMINISTRATION

Traditional Medicaid Services	3,439,758,600	1,460,509,900	1,564,832,873	(104,322,973)	3,439,758,600	-
Proposition 204 Services	2,507,700,600	985,530,800	980,983,018	4,547,782	2,507,700,600	-
ACA Adult Expansion	396,683,800	76,699,100	150,966,477	(74,267,377)	396,683,800	-
Children's Rehabilitative Services	234,866,700	92,948,900	95,797,082	(2,848,182)	234,866,700	-
KidsCare Services	6,295,200	2,596,400	745,368	1,851,032	6,295,200	-
ALTCS Services	1,386,588,900	575,112,200	552,606,700	22,505,500	1,386,588,900	-
Disproportionate Share Payments	5,087,100		-		-	-		5,087,100	- Rural Hospitals	22,650,000		-		-	-		22,650,000	- Voluntary Political Subdivision Programs	313,096,700	(13,403,600)	(13,403,558)	(42)	313,096,700	-

 	 	 	 	
TOTAL PROGRAMMATIC	8,312,727,600	3,179,993,700	3,332,527,959	(152,534,259)	8,312,727,600	-

TOTAL EXPENDITURES

$	8,490,769,000

$    3,254,931,700

$   3,390,952,236

$	(136,020,536)

$  8,490,769,000	$	-

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2015 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

Administrative Expenditures	
$	51,537,900	
$	21,585,900	
$	17,526,179	
4,059,721	
$	51,537,900	
$	-	
Proposition 204 - Administrative Expenditures	19,547,000	8,245,000	2,518,878	5,726,122	19,547,000	-	
Programmatic Expenditures Traditional Medicaid Services	
800,543,000	
332,610,000	
377,386,230	
(44,776,230)	
800,543,000	
-	
Proposition 204 Services	90,000,000	49,811,900	834,198	48,977,702	90,000,000	-	
Children's Rehabilitative Services	73,001,000	29,031,700	25,939,564	3,092,136	73,001,000	-	
KidsCare Services	338,000	269,900	(87,716)	357,616	338,000	-	
ALTCS Services	162,880,800	66,665,800	67,996,722	(1,330,922)	162,880,800	-	
DSH and Rural Hospitals	7,314,600	-	-	-	7,314,600	-
 	 	 	 	
TOTAL GF EXPENDITURES	1,205,162,300	508,220,200	492,114,054	16,106,146	1,205,162,300	-

Administrative Expenditures	
81,114,000	
34,211,400		
33,775,201		
436,199		
81,114,000		
-	
Proposition 204 - Administrative Expenditures	22,161,600	9,345,000		4,574,401		4,770,599		22,161,600		-	
Programmatic Expenditures											
Traditional Medicaid Services	2,271,941,100	974,526,400		1,002,139,451		(27,613,051)		2,271,941,100		-	
Proposition 204 Services	2,048,414,400	804,884,600		827,060,601		(22,176,001)		2,048,414,400		-	
ACA Adult Expansion	396,683,800	76,699,100		150,966,477		(74,267,377)		396,683,800		-	
Children's Rehabilitative Services	161,865,700	63,917,200		69,857,518		(5,940,318)		161,865,700		-	
KidsCare Services	5,587,200	2,170,900		833,084		1,337,816		5,587,200		-	
ALTCS Services and Nursing Facility Assessment	954,423,500	386,530,100		370,864,001		15,666,099		954,423,500		-	

Voluntary Political Subdivision Programs - See Note 5
TOTAL FEDERAL EXPENDITURES	214,151,100		(13,828,400)		(13,828,446)		46		214,151,100		-	
	6,176,764,900		2,338,456,300		2,446,242,289		(107,785,989)		6,176,764,900		-	

DSH and Rural Hospitals	20,422,500	-	-	-	20,422,500	-

Administrative Expenditures Proposition 204 - BNCF	3,482,900	1,468,300	-	1,468,300	3,482,900	- Programmatic Expenditures
Traditional Medicaid Services Acute Care	49,879,700		20,783,000		20,783,000		-		49,879,700		-	
ALTCS Services	249,234,600		102,009,000		101,391,331		617,669		249,234,600		-	
TOTAL COUNTY EXPENDITURES	302,597,200	124,260,300	122,174,331	2,085,969	302,597,200	-	

TOBACCO FUNDS

Programmatic Expenditures
Traditional Medicaid Services Acute Care - Medically Needy	31,180,000	13,404,500	15,590,000	(2,185,500)	31,180,000	-
Proposition 204 Services - Emergency Health Services	17,331,400	7,407,700	7,141,060	266,640	17,331,400	-
Proposition 204 Services - Proposition 204 Protection		36,396,000	15,647,100	18,198,000	(2,550,900)	36,396,000	- Proposition 204 Services - ATLSF	100,000,000		-		-		-	100,000,000	-
TOTAL TOBACCO EXPENDITURES

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures
Acute Care - Prescription Drug Rebate Program State Match Acute Care - Prescription Drug Rebate Program Federal Authority Long Term Care - Prescription Drug Rebate Program State Match
Long Term Care - Prescription Drug Rebate Program Federal Authority Proposition 204 Services - Hospital Assessment		184,907,400	36,459,300		40,929,060		(4,469,760)		184,907,400		-	
	OTHER											
		
198,000	
82,400		
29,618		
52,782		
198,000		
-	
		78,105,000	32,543,700		32,543,750		(50)		78,105,000		-	
		207,883,900	86,618,500		116,173,714		(29,555,214)		207,883,900		-	
		5,475,800	2,246,100		2,281,583		(35,483)		5,475,800		-	
		14,574,200	5,977,900		9,770,093		(3,792,193)		14,574,200		-	
		215,558,800	107,779,400		127,749,159		(19,969,759)		215,558,800		-	
Traditional Medicaid Services - TPL		194,700	-		195,043		(195,043)		194,700		-	
ALTCS Services - TPL		-	-		302,970		(302,970)		-		-	
ALTCS Services - Nursing Facility Assessment		-	11,683,300		-		11,683,300		-		-	
KidsCare Services Premiums		370,000	155,600		-		155,600		370,000		-	
Freedom to Work Premiums		31,200	23,800		21,684		2,116		31,200		-	
Voluntary Political Subdivision Programs - See Note 5		98,945,600	424,900		424,887		13		98,945,600		-	
TOTAL OTHER EXPENDITURES		621,337,200	247,535,600		289,492,502		(41,956,902)		621,337,200		-	
	TOTAL											

Administrative Expenditures		
178,041,400	
74,938,000		
58,424,277		
16,513,723		
178,041,400		
-	
Acute Care		6,926,138,700	2,604,881,500		2,779,921,259		(175,039,759)		6,926,138,700		-	
Long Term Care		1,386,588,900	575,112,200		552,606,700		22,505,500		1,386,588,900		-	
TOTAL EXPENDITURES	$	8,490,769,000	$	3,254,931,700		$	3,390,952,236		$	(136,020,536)		$	8,490,769,000		$	-	

BUDGET

BUDGET
YTD

RECEIPTS
YTD

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending November 30, 2015

GENERAL FUND:

FEDERAL:

COUNTY:

TOBACCO FUNDS:

OTHER:

TOTAL REVENUE

$

8,490,769,000

$

3,254,931,700

$

3,370,436,352

Traditional Medicaid Services & Administrative	$	932,396,500		$	383,227,600		$	420,851,973	
Proposition 204 Services & Administrative	109,547,000		58,056,900		3,353,075	
KidsCare Services	338,000		269,900		(87,716)	
ALTCS Services	 	162,880,800 			 	66,665,800 			 	67,996,722 		
TOTAL	1,205,162,300		508,220,200		492,114,055	

Acute & Administrative	5,216,754,200		1,949,755,300		2,048,671,402	
KidsCare Services	5,587,200		2,170,900		1,097,020	
ALTCS Services	 	954,423,500 			 	386,530,100 			 	376,901,975 		
TOTAL	6,176,764,900		2,338,456,300		2,426,670,397	

Acute & Administrative	53,362,600		22,251,300		20,493,606	
ALTCS Services	 	249,234,600 			 	102,009,000 			 	103,847,755 		
TOTAL	302,597,200		124,260,300		124,341,361	

Traditional Medicaid Services	31,180,000		13,404,500		15,590,000	
Proposition 204 Services	 	153,727,400 			 	23,054,800 			 	25,339,060 		
TOTAL	184,907,400		36,459,300		40,929,060	

Administrative	198,000		82,400		29,618	
Acute Care - Prescription Drug Rebate Program	285,988,900		119,162,200		148,717,464	
Long Term Care - Prescription Drug Rebate Program	20,050,000		8,224,000		12,051,677	
Hospital Assessment	215,558,800		107,779,400		124,345,291	
ALTCS - Nursing Facility Assessment	-		11,683,300		116,017	
Acute TPL - Note 1	194,700		-		195,043	
LTC TPL - Note 1	-		-		302,970	
KidsCare TPL - Note 1	-		-		20,942	
Member Premiums - CHIP	370,000		155,600		155,886	
Member Premiums - Freedom to Work	31,200		23,800		21,684	
Voluntary Political Subdivision - State Match	 	98,945,600 			 	424,900 			 	424,887 		
TOTAL	621,337,200		247,535,600		286,381,479	

 	

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2015

Note 1:	Third Party Liability Collections: Gross Collections:	November 2015		November 2014		July 1, 2015
November 30, 2015		July 1, 2014
November 30, 2014	
	Acute	$	191,384		$	417,633		$	1,756,645		$	2,467,244	
	LTC	218,824		270,299		1,342,044		1,578,504	
	KidsCare	98		1,239		104,447		3,412	
	Total TPL Collections	$	410,306		$	689,171		$	3,203,136		$	4,049,160	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	26,617		$	56,315		$	195,043		$	326,904	
LTC	50,641		60,435		302,970		369,848	
KidsCare	20		246		20,942		668	
Total Expenditure Offsets	$	77,278		$	116,996		$	518,955		$	697,420	

FY 16 Total

Note 2:    Authorized Positions	1,029.2
Actual Positions as of November 30, 2015	925.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2015

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2015	

$	2,853,728	
	Revenues	1,941,625	
	Transfers-In	 	229,340 		
	Total Revenues	 	2,170,965 		
	Expenditures	2,122,408	
	Transfers-out	 	920,066 		
	Total Expenditures	 	3,042,474 		
	Ending Balance November 30, 2015	$	1,982,220	

Of the $1,982,220 ending balance, $1,292,673 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through December 2015.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of November 30, 2015

Description		Amount		Type	

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

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2015

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of November 30, 2015 Expenditures

State Match	Federal	Total

DSH Voluntary

$	424,887	$

870,495	$

1,295,382

GME Voluntary	-	-	-

Safety Net Care Pool	-		(14,698,940)		(14,698,940)	
Total Voluntary Political Subdivision Program Expenditures	$	424,887		$	(13,828,446)		$	(13,403,558)	

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending November 30, 2015

TITLE XIX TRADITIONAL

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

TOTAL

CAPITATION - ACUTE	272,366,959	276,316,415	279,166,770	275,407,979	274,717,280	0	0	0	0	0	0	0	1,377,975,403	
CAPITATION - LTC	182,421,827	195,322,105	184,831,914	185,793,257	198,420,332	0	0	0	0	0	0	0	946,789,435	
MENTAL HEALTH - CHILD	24,739,142	24,849,877	25,557,281	28,336,540	28,517,836	0	0	0	0	0	0	0	132,000,675	
MENTAL HEALTH - ADULT	11,323,471	11,730,505	12,433,438	944,236	956,134	0	0	0	0	0	0	0	37,387,784	
MENTAL HEALTH - GENERAL	15,232,013	15,779,544	16,725,109	16,942,470	17,155,946	0	0	0	0	0	0	0	81,835,082	
MENTAL HEALTH - CMDP	14,633,559	14,896,415	14,987,440	15,967,464	16,435,700	0	0	0	0	0	0	0	76,920,578	
CHILDREN'S REHAB SERVICES	3,716,383	3,722,744	3,729,851	5,297,337	5,295,399	0	0	0	0	0	0	0	21,761,715	
FEE FOR SERVICE - ACUTE	39,309,584	42,687,182	52,163,025	35,355,326	39,335,094	0	0	0	0	0	0	0	208,850,212	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	607,419	638,824	0	0	0	0	0	0	0	3,265,875	
EMERGENCY SERVICES - FEDERAL	4,601,455	4,572,491	5,962,347	5,124,819	4,140,929	0	0	0	0	0	0	0	24,402,041	
FFS - FAMILY PLANNING	-39	0	0	0	0	0	0	0	0	0	0	0	-39	
FFS MEDICAID IN PUBLIC SCHOOLS	676,499	194,086	533,578	397,621	384,665	0	0	0	0	0	0	0	2,186,448	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	374,616	274,232	0	0	0	0	0	0	0	1,647,431	
INPATIENT INMATES FFS	94,140	163,355	30,952	166,197	96,395	0	0	0	0	0	0	0	551,038	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	33,509	11,088	0	0	0	0	0	0	0	152,336	
MOHAVE COUNTY INMATES FFS	0	177	0	4,575	0	0	0	0	0	0	0	0	4,752	
COCHISE COUNTY INMATES FFS	0	0	0	0	586	0	0	0	0	0	0	0	586	
PINAL COUNTY INMATES FFS	0	791	4,402	328	5,014	0	0	0	0	0	0	0	10,535	
PIMA COUNTY INMATES FFS	339	2,845	4,099	8,752	867	0	0	0	0	0	0	0	16,901	
FEE FOR SERVICE - LTC	8,618,281	9,030,245	12,244,181	8,955,714	9,411,357	0	0	0	0	0	0	0	48,259,778	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	21,120	18,430	0	0	0	0	0	0	0	121,225	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,303,186	520,396	1,333,715	799,779	799,536	0	0	0	0	0	0	0	4,756,612	
REINSURANCE - ACUTE	7,490,557	6,963,077	9,713,101	10,354,036	7,487,802	0	0	0	0	0	0	0	42,008,573	
REINSURANCE - LTC	4,045,763	3,839,634	5,041,535	4,350,748	5,856,334	0	0	0	0	0	0	0	23,134,014	
SMIB - ACUTE	9,829,585	10,084,385	10,344,498	10,630,380	10,758,366	0	0	0	0	0	0	0	51,647,214	
HIB - ACUTE	261,769	274,050	304,238	305,977	291,872	0	0	0	0	0	0	0	1,437,906	
Q1	2,399,485	1,983,017	1,927,946	1,981,086	1,974,022	0	0	0	0	0	0	0	10,265,555	
SMIB - LTC	2,846,826	2,859,916	2,858,311	2,859,099	2,866,769	0	0	0	0	0	0	0	14,290,920	
HIB - LTC	269,425	275,672	269,873	259,133	272,905	0	0	0	0	0	0	0	1,347,008	
	607,107,950	627,019,248	641,497,165	611,279,516	626,123,714	0	0	0	0	0	0	0	3,113,027,593	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending November 30, 2015

TITLE XIX PROP 204

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

TOTAL

CAPITATION - ACUTE	171,977,268	169,158,780	168,592,407	201,257,676	199,521,303	0	0	0	0	0	0	0	910,507,434	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	62,503	47,177	0	0	0	0	0	0	0	342,565	
MENTAL HEALTH - ADULT	14,130,226	13,753,412	13,745,030	1,449,862	1,458,767	0	0	0	0	0	0	0	44,537,296	
MENTAL HEALTH - GENERAL	19,007,580	18,500,700	18,489,426	26,014,924	26,174,705	0	0	0	0	0	0	0	108,187,335	
MENTAL HEALTH - CMDP	0	0	0	1,009	0	0	0	0	0	0	0	0	1,009	
CHILDREN'S REHAB SERVICES	13,342	14,176	13,759	16,233	15,769	0	0	0	0	0	0	0	73,279	
FEE FOR SERVICE - ACUTE	23,420,195	26,360,064	31,634,361	22,488,296	25,630,747	0	0	0	0	0	0	0	129,533,663	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	991,315	851,991	0	0	0	0	0	0	0	5,367,301	
EMERGENCY SERVICES - FEDERAL	1,615,009	1,756,056	2,298,814	2,324,017	1,395,634	0	0	0	0	0	0	0	9,389,530	
FFS MEDICAID IN PUBLIC SCHOOLS	5,786	3,204	5,139	1,380	897	0	0	0	0	0	0	0	16,406	
INPATIENT INMATES FFS	600,012	766,289	566,467	395,868	507,796	0	0	0	0	0	0	0	2,836,431	
MOHAVE COUNTY INMATES FFS	0	4,084	692	373	10,051	0	0	0	0	0	0	0	15,199	
YAVAPAI COUNTY INMATES FFS	306	0	166	9,252	485	0	0	0	0	0	0	0	10,209	
PINAL COUNTY INMATES FFS	8,167	-1,654	11,736	3,532	14,776	0	0	0	0	0	0	0	36,556	
PIMA COUNTY INMATES FFS	16,737	14,619	968	21,330	11,636	0	0	0	0	0	0	0	65,290	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	174,594	33,475	0	0	0	0	0	0	0	525,216	
COCONINO COUNTY INMATES FFS	152	3,842	0	274	1,126	0	0	0	0	0	0	0	5,394	
COCHISE COUNTY INMATES FFS	0	0	0	0	480	0	0	0	0	0	0	0	480	
REINSURANCE - ACUTE	3,024,281	3,235,285	3,273,260	5,216,265	4,459,353	0	0	0	0	0	0	0	19,208,445	
SMIB - ACUTE	5,190,825	5,190,446	5,117,460	5,152,132	4,954,096	0	0	0	0	0	0	0	25,604,958	
HIB - ACUTE	8,649	8,527	5,656	8,584	4,192	0	0	0	0	0	0	0	35,609	
	240,353,793	239,927,923	245,334,015	265,589,419	265,094,455	0	0	0	0	0	0	0	1,256,299,605	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending November 30, 2015

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE
TITLE XIX ACA ADULT EXPANSION

TOTAL

CAPITATION - ACUTE	22,690,376	23,251,291	24,201,251	29,417,656	29,997,586	0	0	0	0	0	0	0	129,558,160	
MENTAL HEALTH - CHILD	0	0	0	41	0	0	0	0	0	0	0	0	41	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	228,016	237,878	0	0	0	0	0	0	0	7,383,570	
MENTAL HEALTH - GENERAL	2,968,226	3,090,821	3,246,414	4,091,302	4,268,263	0	0	0	0	0	0	0	17,665,025	
CHILDREN'S REHAB SERVICES	417	417	417	0	0	0	0	0	0	0	0	0	1,251	
FEE FOR SERVICE - ACUTE	1,757,826	2,095,785	2,416,332	1,869,494	1,862,135	0	0	0	0	0	0	0	10,001,572	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	262,679	334,688	0	0	0	0	0	0	0	1,289,735	
EMERGENCY SERVICES - FEDERAL	1,701,575	1,999,988	3,176,831	2,397,434	1,935,178	0	0	0	0	0	0	0	11,211,005	
INPATIENT INMATES FFS	6,351	35,816	34,047	9,398	35,244	0	0	0	0	0	0	0	120,857	
MARICOPA CTY INMATES FFS	15,154	0	0	149	0	0	0	0	0	0	0	0	15,303	
REINSURANCE - ACUTE	276,372	479,010	344,794	397,029	359,861	0	0	0	0	0	0	0	1,857,066	
SMIB - ACUTE	1,469	734	839	629	839	0	0	0	0	0	0	0	4,511	
	31,784,937	33,467,076	36,150,580	38,673,829	39,031,673	0	0	0	0	0	0	0	179,108,095	
	879,246,680	900,414,248	922,981,760	915,542,763	930,249,842	0	0	0	0	0	0	0	4,548,435,293	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE

KidsCare - CAPITATION	183,782	170,409	173,186	164,735	157,227	0	0	0	0	0	0	0	849,339	
KidsCare - FEE FOR SERVICE	-819	774	436	1,805	404	0	0	0	0	0	0	0	2,601	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	36,831	35,192	0	0	0	0	0	0	0	179,326	
KidsCare - REINSURANCE	162	30,495	70,989	57,122	103,826	0	0	0	0	0	0	0	262,594	

220,533	237,043	279,141	260,493	296,650	0	0	0	0	0	0	0	1,293,860	

TOTAL TITLE XXI

879,467,213	900,651,004	923,260,901	915,803,257	930,546,492	0	0	0	0	0	0	0	4,549,728,866	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1003	TANF 06-13 M & F WIT	113.17	113.17	113.17	114.37	114.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		568.25		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	162.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.83		
1006	TANF 21-44 MALE WITH	91,470.48	100,935.93	114,056.53	29,730.44	30,795.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		366,989.31		
1007	TANF 21-44 FEMALE WI	262,969.81	321,024.00	366,691.13	93,778.32	95,564.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,140,027.77		
1008	TANF 45-64 M & F WIT	456,857.48	533,329.59	618,899.14	153,616.98	162,064.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,924,768.18		
1009	TANF 65+ M & F WITH	130,859.20	158,119.22	182,105.63	43,807.61	41,203.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		556,094.82		
100F	TANF 21-44 MALE WITH	3,124.94	3,371.26	1,066.32	1,235.50	433.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,231.11		
100G	TANF 21-44 FEMALE WI	6,088.86	5,158.50	4,029.73	604.18	1,064.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,945.83		
100H	TANF 44-64 M & F WIT	43,752.90	40,165.14	12,382.66	7,340.32	868.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,509.83		
100J	TANF 65+ M & F WITH	30,736.25	17,071.36	1,805.26	3,147.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,760.05		
1011	TANF <1 M & F NON-ME	7,317,911.15	7,330,064.00	6,810,085.94	6,752,430.01	6,885,407.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,095,899.06		
1012	TANF 01-05 M & F NON	5,120,069.24	4,255,241.15	3,820,804.71	3,463,337.50	3,013,110.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,672,562.99		
1013	TANF 06-13 M & F NON	8,517,151.93	7,122,208.02	6,407,880.79	5,781,174.88	4,987,581.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,815,996.92		
1014	TANF 14-20 MALE NON-	2,727,086.79	2,467,883.88	2,310,485.87	2,118,291.66	1,897,764.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,521,512.66		
1015	TANF 14-20 FEMALE N	5,165,143.02	4,749,211.72	4,482,122.34	3,898,517.39	3,521,357.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,816,351.82		
1016	TANF 21-44 MALE NON-	5,413,848.55	5,881,009.18	6,413,970.06	4,199,543.45	4,283,530.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,191,901.32		
1017	TANF 21-44 FEMALE N	26,519,446.98	27,563,602.69	29,211,296.32	21,814,659.48	21,700,333.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,809,339.38		
1018	TANF 45-64 M & F NON	11,340,403.80	12,200,886.15	13,314,078.59	8,505,687.29	8,526,844.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,887,900.10		
1019	TANF 65+ M & F NON-M	50,940.78	55,345.09	63,094.36	35,864.95	34,947.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,192.22		
101A	TANF < 1 M & F NON-M	1,483,647.90	1,229,135.61	596,433.59	1,591,704.20	1,242,886.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,143,808.20		
101B	TANF 01-05 M & F NON	18,930.19	10,452.99	13,969.51	21,291.05	8,127.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,771.66		
101C	TANF 06-13 M & F NON	13,827.52	10,991.93	10,596.95	24,089.70	7,386.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,892.23		
101D	TANF 14-20 MALE NON-	30,653.81	23,910.41	11,522.68	26,798.62	9,274.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,159.75		
101E	TANF 14-20 FEMALE N O	56,482.84	48,295.58	35,281.43	34,103.87	17,747.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,910.91		
101F	TANF 21-44 MALE NON-	441,372.83	443,539.24	240,851.96	193,781.66	93,373.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,412,919.32		
101G	TANF 21-44 FEMALE N O	967,547.84	939,350.71	551,924.22	458,482.24	314,016.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,231,321.33		
101H	TANF 44-64 M & F NON	673,153.96	695,670.20	390,666.92	248,353.01	134,308.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,142,152.33		
101J	TANF 65+ N & F NON-M	13,593.90	8,104.86	11,870.70	676.55	2,534.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,780.14		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	503.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503.59		
1026	TANF 21-44 MALE WITH	39,781.26	52,613.13	69,409.48	17,011.53	12,616.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,432.29		
1027	TANF 21-44 FEMALE WI	112,487.20	155,750.38	178,197.45	42,604.92	49,730.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		538,770.69		
1028	TANF 45-64 M & F WIT	142,957.26	219,266.01	262,802.70	39,010.80	49,106.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		713,143.41		
1029	TANF 65+ M & F WITH	53,811.16	84,861.43	103,507.94	16,738.86	19,102.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278,022.25		
102F	TANF 21-44 MALE WITH	0.00	349.97	22.18	283.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		655.45		
102G	TANF 21-44 FEMALE WI	894.71	245.67	322.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,462.82		
102H	TANF 44-64 M & F WIT	814.72	5,425.27	2,007.41	0.00	1,518.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,765.90		

O

O

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102J	TANF 65+ M & F WITH	958.54	944.87	0.00	2,333.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,237.35		
2100	SSI AGED WITH MEDIC A	646,891.69	640,426.15	626,324.88	741,218.85	763,396.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,418,257.65		
210Z	SSI AGED WITH MEDIC A	42,792.60	35,137.07	23,993.14	22,253.33	24,247.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148,423.48		
2110	SSI AGED NON-MEDICA R	4,841,984.49	4,755,477.85	4,841,046.00	5,319,754.55	5,244,733.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,002,996.38		
211Z	SSI AGED NON-MEDICA	168,114.98	120,300.70	81,292.69	107,483.51	100,740.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		577,932.12		
2120	SSI AGED WITH QMB	2,773,140.25	2,801,949.97	2,812,690.87	4,298,415.06	4,308,900.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,995,096.71		
212Z	SSI AGED WITH QMB P	5,569.66	5,916.01	9,571.88	5,721.66	6,731.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,510.71		
2200	SSI DISABLED WITH M E	1,438,779.65	1,356,642.89	1,368,850.54	1,750,088.66	1,712,310.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,626,672.10		
220Z	SSI DISABLED WITH M E	21,320.23	23,148.40	24,683.29	18,921.57	10,281.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,355.42		
2210	SSI DISABLED NON-ME D	55,077,622.81	54,829,218.00	54,812,398.76	59,204,588.11	59,278,100.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283,201,928.56		
221Z	SSI DISABLED NON-ME D	491,291.42	492,991.62	460,508.70	398,574.48	381,824.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,225,190.55		
2220	SSI DISABLED WITH Q M	10,386,804.88	10,418,005.20	10,514,240.11	14,112,652.81	14,189,750.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,621,453.86		
222Z	SSI DISABLED WITH Q M	5,921.17	7,380.90	10,401.43	3,840.12	2,524.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,068.61		
2300	SSI BLIND WITH MEDIC	4,363.55	4,060.83	3,780.74	6,282.61	6,337.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,825.21		
230Z	SSI BLIND WITH MEDIC	448.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448.85		
2310	SSI BLIND NON-MEDIC A	353,568.15	356,359.13	362,835.95	397,898.39	397,764.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,868,425.73		
231Z	SSI BLIND NON-MEDIC	3,440.09	12,852.23	5,876.17	7,201.16	2,280.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,650.46		
2320	SSI BLIND WITH QMB	44,041.31	43,688.31	44,085.09	52,049.43	51,728.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235,592.86		
232Z	SSI BLIND WITH QMB P	0.00	0.00	2.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.91		
4302	SOBRA CHILD 01-05 M	541.57	1,125.47	-453.71	224.19	224.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,661.71		
4303	SOBRA CHILD 06-13 M	227.07	227.07	276.11	244.30	1,116.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,090.82		
4304	SOBRA CHILD 14-20 MA	162.24	162.24	162.24	0.00	-162.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323.89		
4305	SOBRA CHILD 14-20 FE	789.59	840.59	831.97	868.03	704.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,034.53		
430B	SOBRA CHILD 01-05 M	49.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.61		
430C	SOBRA CHILD 06-13 M	0.00	0.00	95.88	47.55	77.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220.47		
430D	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		
430E	SOBRA CHILD 14-20 FE	0.00	120.83	193.23	-73.98	-119.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120.83		
4311	SOBRA CHILD <1 M & F	19,081,996.88	19,048,366.58	17,788,960.54	18,398,080.15	18,949,300.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,266,704.69		
4312	SOBRA CHILD 01-05 M	19,072,224.87	20,064,623.31	21,072,490.25	21,576,275.67	22,390,417.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,176,031.35		
4313	SOBRA CHILD 06-13 M	25,452,339.99	27,401,384.87	29,128,878.55	26,788,281.50	27,455,119.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,226,004.27		
4314	SOBRA CHILD 14-20 MA	8,607,044.24	8,948,118.85	9,523,338.23	8,708,264.72	8,805,134.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,591,900.27		
4315	SOBRA CHILD 14-20 FE	13,024,273.87	13,595,781.00	14,432,717.70	13,314,992.12	13,452,811.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,820,575.99		
431A	SOBRA CHILD < 1 M &	1,266,381.59	1,304,281.60	634,368.33	1,482,032.17	977,262.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,664,326.31		
431B	SOBRA CHILD 01-05 M	494,252.81	475,898.40	360,178.32	407,643.39	262,251.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,000,224.53		
431C	SOBRA CHILD 6-13 M&	634,059.19	670,453.45	453,423.37	439,439.88	292,079.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,489,454.98		
431D	SOBRA CHILD 14-20 MA	467,748.21	431,434.92	303,172.79	265,677.52	189,364.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,657,397.78		

R

P

A

F

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION		JULY		AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL 431E	SOBRA CHILD 14-20 FE	506,841.24	521,342.83	357,514.83	325,476.02		233,036.41		0.00		0.00		0.00		0.00	0.00	0.00	0.00	1,944,211.33
4321	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
4322	SOBRA CHILD 01-05 M	329.97	0.00	220.65	332.81	115.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	998.70
4323	SOBRA CHILD 06-13 M	755.82	0.00	107.48	558.29	399.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,821.05
4324	SOBRA CHILD 14-20 MA	623.74	0.00	162.24	137.86	272.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,196.12
4325	SOBRA CHILD 14-20 FE	490.95	259.91	523.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,274.26

5007	SOBRA PREG 21-44 FE
M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT
SUBTOTAL:

28,646.09	29,529.54	34,810.47	37,003.71	22,770.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	152,759.96

856.00	405.55	405.55	898.29	898.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,463.68

667.73	637.69	427.13	403.02	162.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,297.71

791.84	960.27	778.66	664.29	689.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,884.47

1,153,204.41	1,243,589.20	1,321,708.44	1,331,054.56	1,405,473.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,455,030.10

4,969,763.44	5,543,577.71	6,104,353.53	6,666,900.29	7,018,557.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,303,152.81

29,226.73	32,189.69	33,578.00	41,189.47	41,350.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	177,534.88

0.00	98.71	0.00	0.00	43.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142.38

77,023.42	77,726.43	48,097.14	49,640.39	42,451.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	294,938.78

331,612.75	308,457.61	239,213.41	224,480.35	178,215.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,281,979.46

3,630.96	10,740.73	531.17	334.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,237.41

2,329.77	2,829.66	4,481.72	4,273.54	4,730.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,644.84

0.00	2,426.39	2,426.39	2,242.66	2,242.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,338.10

218.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	218.29

-12.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-12.50

248,764,079.13  252,354,794.67  254,464,913.27  246,135,180.96  245,353,522.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,247,072,490.10

9910	TANF & SOBRA CHILDR E	3,483,562.65	3,047,996.25	2,907,424.24	2,225,583.72	2,475,483.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	66,760.99	67,334.84	73,848.44	60,848.38	72,108.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	253,912.66	175,567.47	201,893.70	182,160.74	179,014.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	12,465,299.69	13,765,854.41	14,897,401.05	13,552,095.42	13,016,280.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,269,535.99	17,056,752.97	18,080,567.43	16,020,688.26	15,742,887.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
14,140,050.66	
340,901.47	
992,549.11	
67,696,930.69	
83,170,431.93	

3100	TRANSPLANT OPTION 1	70.26	89.42	82.50	82.50	94.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION 1	94.74	75.58	0.00	0.00	4.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	165.00	165.00	82.50	82.50	99.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

419.28	
174.72	
594.00	

SUBTOTAL:

1106	TANF EXPANDED 21-44	167,462.38	144,030.22	123,318.86	348,239.33	330,998.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	599,045.66	537,386.92	489,127.06	1,038,594.89	978,957.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,023,600.25	911,053.14	848,021.18	1,766,284.56	1,717,007.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	274,415.40	245,636.00	232,837.24	502,261.74	493,090.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	3,682.62	630.49	1,486.57	3,392.63	3,061.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,114,049.28	
3,643,111.72	
6,265,966.72	
1,748,241.20	
12,253.58	

M&

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110G	TANF EXPANDED 21-44	520.84	324.33	2,552.22	7,103.54	4,282.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,782.95		
110H	TANF EXPANDED 45-64	161.40	385.93	27,647.67	33,347.53	20,685.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,227.97		
110J	TANF EXPANDED 65+
M&	0.00	1,210.32	15,631.07	6,020.54	4,765.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,627.60		
1111	TANF EXPANDED <1 M
&F	6,325.21	4,355.65	762.79	1,466.00	1,466.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,375.65		
1112	TANF EXPANDED 01-05	48,437.22	37,053.66	33,123.81	29,396.05	22,170.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,180.99		
1113	TANF EXPANDED 06-13	155,432.39	123,651.13	108,415.58	93,138.60	75,107.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		555,745.37		
1114	TANF EXPANDED 14-20	114,898.22	90,180.24	76,789.22	121,834.46	112,376.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		516,078.50		
1115	TANF EXPANDED 14-20	375,463.35	278,983.53	236,525.33	455,399.24	446,636.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,793,007.58		
1116	TANF EXPANDED 21-44	3,292,450.62	2,886,484.77	2,569,959.71	5,025,954.65	4,942,910.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,717,760.71		
1117	TANF EXPANDED 21-44	11,884,383.87	10,291,379.14	9,057,760.96	17,098,041.17	16,741,566.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,073,132.08		
1118	TANF EXPANDED 45-64	7,186,338.24	6,353,222.09	5,768,022.81	11,349,562.98	11,255,706.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,912,852.62		
1119	TANF EXPANDED 65+
M&	38,116.96	34,638.80	32,844.67	50,449.55	48,551.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204,600.99		
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-402.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-402.42		
111B	TANF EXPANDED 01-05	0.00	51.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.33		
111C	TANF EXPANDED 06-13	60.93	0.00	0.00	166.42	306.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		533.35		
111D	TANF EXPANDED 14-20	91.04	817.44	2,346.34	1,783.04	4,380.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,418.41		
111E	TANF EXPANDED 14-20	1,428.69	1,919.48	6,274.89	9,908.99	8,959.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,491.12		
111F	TANF EXPANDED 21-44	16,857.80	16,840.28	88,070.74	149,530.14	129,309.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		400,608.77		
111G	TANF EXPANDED 21-44	38,462.54	45,149.24	202,727.99	318,834.43	259,990.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		865,165.05		
111H	TANF EXPANDED 45-64	12,792.72	53,531.20	181,490.33	247,343.76	197,107.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		692,265.32		
111J	TANF EXPANDED 65+
M&	10,074.33	0.00	1,610.12	15,133.53	1,008.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,826.66		
1125	TANF EXPANDED 14-20	259.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.91		
1126	TANF EXPANDED 21-44	77,277.63	71,347.76	61,838.93	77,526.90	106,393.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394,384.91		
1127	TANF EXPANDED 21-44	214,717.61	193,927.68	179,884.44	245,571.04	327,309.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,161,410.65		
1128	TANF EXPANDED 45-64	242,994.86	222,897.30	210,610.65	289,864.60	387,477.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,353,844.90		
1129	TANF EXPANDED 65+
M&	89,535.41	77,417.22	73,153.41	82,720.03	108,728.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		431,554.30		
112F	TANF EXPANDED 21-44	0.00	0.00	406.00	246.72	273.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		925.96		
112G	TANF EXPANDED 21-44	0.00	681.07	726.03	964.10	648.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,019.77		
112H	TANF EXPANDED 45-64	10.59	0.00	1,235.44	3,753.28	2,524.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,523.82		
112J	TANF EXPANDED 65+
M&	0.00	0.00	6,378.93	344.31	4,119.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,842.57		
2400	SSI AGED EXPANDED WI	90,318.38	78,003.38	74,504.07	71,589.26	68,291.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382,706.76		
240Z	SSI AGED EXPANDED WI	28,495.79	37,821.60	22,409.28	21,024.30	14,619.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,370.93		
2410	SSI AGED EXPANDED NO	929,746.50	864,149.68	813,310.62	351,969.12	320,177.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,279,353.30		
241Z	SSI AGED EXPANDED NO	7,401.77	16,962.83	8,306.20	4,276.52	3,695.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,643.00		
2420	SSI AGED EXPANDED	5,235,551.09	5,187,661.49	5,133,746.28	4,943,310.23	4,730,309.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,230,578.67		
242Z	SSI AGED EXPANDED	7,997.68	5,766.54	4,987.33	5,330.17	2,179.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,261.22		

WI

WI

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION
2500

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
140.23	140.23	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

280.46

2510

2520

SSI BLIND EXPANDED
W
SSI BLIND EXPANDED
N
SSI BLIND EXPANDED
W
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E

1,458.65

124.99

1,458.65

124.99

1,458.65

124.99

755.69

130.02

755.69

130.02

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5,887.33

635.01

2600

159,975.75

157,902.91

154,039.57

218,895.60

207,386.21

0.00

0.00

0.00

0.00

0.00

0.00

0.00

898,200.04

260Z

17,956.66

21,077.50

16,146.29

10,542.62

5,850.05

0.00

0.00

0.00

0.00

0.00

0.00

0.00

71,573.12

2610

261Z

2,642,788.10

33,355.68

2,565,161.03

32,438.70

2,574,872.47

29,106.19

2,863,962.71

22,550.86

2,808,377.77

20,810.52

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

13,455,162.08

2620

7,540,307.86

7,645,491.81

7,856,549.93

10,670,749.62

10,778,061.56

0.00

0.00

0.00

0.00

0.00

0.00

0.00

138,261.95

44,491,160.78

262Z

6,428.48

5,511.39

8,031.41

4,310.82

1,836.82

0.00

0.00

0.00

0.00

0.00

0.00

0.00

26,118.92

SUBTOTAL:	42,577,206.07    39,244,718.86    37,338,771.85    58,563,716.52    57,700,500.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	235,424,913.46

9911	SB PAYMENT FOR TAN F	638,069.14	744,028.48	692,146.52	1,079,073.38	867,744.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI E	12,450.73	18,552.72	24,748.20	6,290.91	12,607.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	5,743.01	5,963.77	0.00	6,235.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	656,262.88	768,544.97	716,894.72	1,091,599.62	880,352.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4,021,062.33	
74,649.76	
17,942.11	
4,113,654.20	

SUBTOTAL:

3614	AHC CARE/MI MALE 14-	0.00	1,436.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	1,436.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
1,436.95

1,436.95

3506	ADULT 40-100% MALE 2	8,422.52	3,645.97	6,549.05	6,920.85	6,749.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	14,179.59	8,854.37	9,129.40	10,935.03	15,132.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	36,321.61	26,956.15	25,017.05	64,607.16	49,522.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	22,353.25	22,570.84	21,631.31	35,593.28	25,767.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	3,964.50	465.31	2,008.05	3,379.72	872.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	2,924.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	6,365.04	6,197.78	10,677.21	13,210.50	2,142.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	7,372.56	5,207.00	0.00	2,056.55	357.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	1,324,584.01	1,440,655.36	1,514,833.49	1,566,211.25	1,665,256.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	1,633,845.08	1,727,407.10	1,811,455.28	1,845,511.21	1,949,540.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	7,573,355.50	7,578,276.66	7,770,879.64	8,378,901.15	8,463,151.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	6,410,679.09	6,346,041.90	6,476,413.17	6,980,125.28	6,982,308.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	15,191,483.66	15,250,141.05	15,625,452.65	16,626,431.57	16,759,472.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	16,506.64	15,041.42	15,084.02	22,447.95	13,832.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	148,997.70	115,709.11	88,931.32	77,872.89	78,610.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	144,852.52	143,422.42	95,008.93	105,596.06	74,569.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	646,088.27	613,079.90	479,928.59	471,628.16	336,866.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL	458,558.32	429,699.96	368,800.73	356,601.53	246,284.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	1,204,084.30	1,016,417.29	728,945.34	784,761.29	597,289.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

32,288.23	
58,231.17	
202,424.09	
127,916.50	
10,689.69	
2,924.56	
38,592.98	
14,993.90	
7,511,540.55	
8,967,759.34	
39,764,564.60	
33,195,568.19	
79,452,981.40	
82,912.18	
510,121.62	
563,449.87	
2,547,591.91	
1,859,945.32	
4,331,497.22	

E

E

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015

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

351J	ADULT 40-100% M&F 65	27,457.81	15,740.35	20,203.21	13,703.32	28,147.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105,252.39	
3525	ADULT 40-100% FEMAL	351.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	351.97	
3526	E
ADULT 40-100% MALE 2	1,168.26	0.00	0.00	0.00	905.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,073.50	
3527	ADULT 40-100% FEMAL	668.80	1,504.94	0.00	366.57	441.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,981.41	
3528	E
ADULT 40-100% M&F 45	10,626.75	7,689.50	12,719.11	12,289.73	10,883.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
54,208.29	
3529	ADULT 40-100% M&F 65	2,416.71	4,002.70	1,585.00	5,981.76	4,387.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,374.11	
352G	ADULT 40-100% FEMAL	0.00	531.77	0.00	21.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	553.57	

352H	E
ADULT 40-100% M&F 45	
16.98	
1,224.13	
886.83	
72.11	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
2,200.05	
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	3,228.03	616.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,844.62	
3706	ADULT <40% EXP MALE	34,143.30	26,154.77	20,573.49	39,142.26	28,932.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148,946.33	
3707	ADULT <40% EXP FEM	12,691.88	18,567.70	11,647.93	10,314.66	6,489.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,712.03	

3708	AL
ADULT <40% EXP M&F	
47,370.84	
58,639.06	
54,729.62	
114,253.12	
92,664.47	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
367,657.11	
3709	4
ADULT <40% EXP M&F	8,255.13	8,986.58	12,316.96	18,221.48	9,722.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
57,502.77	
370F	6
ADULT <40% EXP MALE	3,590.13	5,678.35	4,459.00	2,315.61	2,138.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
18,181.11	
370G	ADULT <40% EXP FEM	824.34	1,262.96	35.10	1,823.55	2,665.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,611.39	
370H	AL
ADULT <40% EXP M&F	8,737.58	10,393.47	21,133.34	9,344.88	2,526.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
52,135.91	
370J	4
ADULT <40% EXP M&F	0.00	0.00	2,297.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,297.94	

3714	6
ADULT <40% EXP MALE	
4,383,132.32	
4,528,025.34	
4,668,083.27	
4,798,971.65	
4,966,868.66	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
23,345,081.24	
3715	ADULT <40% EXP FEM	3,752,637.27	3,863,233.89	3,962,050.58	4,047,408.69	4,164,982.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,790,313.40	

3716	AL
ADULT <40% EXP MALE	
27,106,086.04	
27,395,881.26	
28,559,100.18	
31,597,706.11	
31,781,110.59	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
146,439,884.18	
3717	ADULT <40% EXP FEM	16,530,344.45	16,579,394.61	17,156,912.82	19,193,803.19	19,394,362.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,854,817.40	

3718	AL
ADULT <40% EXP M&F	
33,539,387.24	
33,762,918.80	
34,763,411.03	
38,092,409.60	
38,325,239.72	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
178,483,366.39	
3719	4
ADULT <40% EXP M&F	36,205.17	36,567.62	42,431.28	59,561.30	45,300.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
220,065.64	
371D	6
ADULT <40% EXP MALE	392,849.93	382,830.27	238,138.75	208,431.92	203,147.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1,425,398.36	
371E	ADULT <40% EXP FEM	356,021.60	295,087.13	201,535.90	214,164.42	137,476.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,204,285.17	
371F	AL
ADULT <40% EXP MALE	2,852,336.09	2,763,526.13	1,988,245.68	1,937,830.92	1,404,623.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
10,946,561.83	
371G	ADULT <40% EXP FEM	1,605,524.56	1,472,687.76	1,073,635.38	1,106,222.16	812,781.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,070,851.61	

371H	AL
ADULT <40% EXP M&F	
2,523,268.04	
2,262,250.08	
1,652,940.26	
1,764,209.76	
1,371,358.12	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
9,574,026.26	
371J	4
ADULT <40% EXP M&F	2,019.24	1,369.87	8,989.45	9,843.47	14,388.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
36,610.31	

3724	6
ADULT <40% EXP MALE	
480.74	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
480.74	
3726	ADULT <40% EXP MALE	3,936.06	7,430.66	5,545.33	9,313.29	11,355.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,581.11	
3727	ADULT <40% EXP FEM	4,778.02	3,573.32	779.92	6,659.16	5,113.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,903.71	
3728	AL
ADULT <40% EXP M&F	17,960.52	5,138.97	16,090.90	8,323.68	7,311.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
54,825.63	
3729	4
ADULT <40% EXP M&F	1,616.38	0.00	362.34	1,703.88	1,306.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4,989.57	
372F	6
ADULT <40% EXP MALE	0.00	711.09	4,151.16	502.35	1,161.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6,525.66	
372G	ADULT <40% EXP FEM	598.25	1,319.88	2,540.22	0.00	720.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,179.21	
	AL														

SUBTOTAL:

22,454,160.88    23,042,703.84    23,851,867.00    29,013,956.22    29,589,138.68

0.00

0.00

0.00

0.00

0.00

0.00

0.00

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
372H	ADULT <40% EXP M&F 4	470.36	1,351.60	251.86	3,328.61	540.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,943.08		
	128,119,986.92	128,273,464.15	129,558,529.07	140,647,189.03	140,107,399.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		666,706,568.32		

SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	176,469.55	272,778.55	241,599.87	270,837.95	231,084.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	447,342.88	597,836.74	736,611.04	684,333.12	601,967.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	623,812.43	870,615.29	978,210.91	955,171.07	833,051.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,192,770.18	
3,068,090.95	
4,260,861.13	

A

3904	NEWLY ELIGIBLE MALE	0.00	55.96	346.93	367.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	2,243.33	4,164.05	5,522.85	5,309.15	5,518.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA	11,101.01	5,502.90	2,869.12	7,915.29	2,425.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3908	L
NEWLY ELIGIBLE M&F	
30,815.43	
20,891.02	
14,759.65	
37,342.86	
44,998.23	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3909	4
NEWLY ELIGIBLE M&F	
3,752.37	
6,340.48	
6,828.68	
14,529.93	
9,597.38	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

390D	6
NEWLY ELIGIBLE MALE	
0.00	
318.47	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
390F	NEWLY ELIGIBLE MALE	154.29	0.00	0.00	2,010.66	244.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA	558.35	584.83	0.00	417.38	411.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

390H	L
NEWLY ELIGIBLE M&F	
20,702.19	
14,075.84	
19,780.97	
33,511.35	
12,219.55	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

390J	4
NEWLY ELIGIBLE M&F	
3,743.08	
5,233.41	
11,173.35	
15,825.83	
6,081.31	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3914	6
NEWLY ELIGIBLE MALE	
520,790.75	
542,267.89	
590,928.22	
681,452.40	
726,387.85	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3915	NEWLY ELIGIBLE FEMA	601,783.26	669,009.91	701,931.63	809,407.48	873,776.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3916	L
NEWLY ELIGIBLE MALE	
5,010,046.71	
5,234,991.72	
5,512,159.07	
6,893,479.88	
7,146,162.82	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3917	NEWLY ELIGIBLE FEMA	6,457,501.35	6,891,154.05	7,326,735.48	9,254,679.43	9,714,688.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3918	L
NEWLY ELIGIBLE M&F	
7,992,989.32	
8,091,976.44	
8,244,535.29	
10,079,365.67	
10,259,563.30	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3919	4
NEWLY ELIGIBLE M&F	
13,274.71	
12,857.15	
12,513.51	
18,274.33	
14,084.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

391D	6
NEWLY ELIGIBLE MALE	
48,199.73	
37,609.47	
40,038.27	
20,046.88	
15,857.23	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
391E	NEWLY ELIGIBLE FEMA	52,151.67	50,095.35	33,023.96	35,335.57	22,995.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

391F	L
NEWLY ELIGIBLE MALE	
503,095.65	
399,419.06	
363,419.09	
317,691.28	
211,805.10	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
391G	NEWLY ELIGIBLE FEMA	575,662.05	557,633.73	466,745.78	408,568.59	242,094.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

391H	L
NEWLY ELIGIBLE M&F	
598,828.85	
481,913.67	
459,344.28	
364,265.20	
257,808.17	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

391J	4
NEWLY ELIGIBLE M&F	
3,178.08	
11,525.06	
33,951.68	
6,142.56	
16,607.25	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3926	6
NEWLY ELIGIBLE MALE	
282.13	
198.55	
587.36	
3,072.08	
383.64	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3927	NEWLY ELIGIBLE FEMA	0.00	3,064.18	3,059.32	744.64	384.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3928	L
NEWLY ELIGIBLE M&F	
1,925.68	
968.19	
772.82	
1,662.87	
3,871.37	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3929	4
NEWLY ELIGIBLE M&F	
598.20	
308.72	
649.48	
1,129.09	
384.46	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

392F	6
NEWLY ELIGIBLE MALE	
0.00	
81.24	
11.39	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
392H	NEWLY ELIGIBLE M&F	782.69	451.48	178.82	394.81	447.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

392J	4
NEWLY ELIGIBLE M&F
6	
0.00	
11.02	
0.00	
1,013.76	
341.50	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

 	
770.14	
22,757.53	
29,813.88	
148,807.19	
41,048.84	
318.47	
2,408.98	
1,972.21	
100,289.90	
42,056.98	
3,061,827.11	
3,655,908.42	
29,796,840.20	
39,644,758.47	
44,668,430.02	
71,004.10	
161,751.58	
193,601.60	
1,795,430.18	
2,250,705.11	
2,162,160.17	
71,404.63	
4,523.76	
7,252.18	
9,200.93	
3,069.95	
92.63	
2,255.18	
1,366.28	
127,951,826.62	

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9939	BIRTH SUPP PAYMENT N	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,606,333.39		
	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,606,333.39		

SUBTOTAL:

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	115.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	100.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	475.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F	227.07	113.90	227.80	1,524.18	1,263.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	2,472,060.61	2,222,646.29	2,028,673.87	5,518,655.29	5,786,559.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,124,482.78	1,019,075.04	944,477.21	2,115,166.99	2,156,414.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,627,175.04	1,485,905.55	1,372,014.41	3,133,836.80	3,215,261.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	16,933.27	18,946.08	66,346.90	88,725.94	53,097.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	21,389.49	17,226.07	66,017.92	64,560.80	48,242.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	15,755.99	20,553.56	83,770.13	68,104.17	69,588.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	162.83	119.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	5,278,024.25	4,784,466.49	4,561,528.24	10,991,313.12	11,330,662.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

115.08	
100.87	
475.25	
3,356.27	
18,028,595.40	
7,359,616.81	
10,834,193.35	
244,050.17	
217,436.97	
257,772.36	
282.24	
36,945,994.77	

1

SUBTOTAL:

239,868.86

239,868.86

9944	BIRTH SUPP PAYMENT	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

S

4517

4518

BC PATIENT FEMALE 2
1
BC PATIENT FEMALE 4
5
BC PATIENT FEMALE 6
5
BC PATIENT FEMALE 2
1
BC PATIENT FEMALE 4
5
CC PATIENT FEMALE 2
1
CC PATIENT FEMALE 4
5
CC PATIENT FEMALE 2
1
SB KICK PAYMENT FOR

6,031.34

112,672.67

6,350.82

110,350.85

6,499.88

110,314.38

8,177.94

108,889.84

8,370.90

103,615.29

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4519

273.27

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

451G

0.00

718.61

0.00

74.95

322.70

0.00

0.00

0.00

0.00

0.00

0.00

0.00

451H

4617

3,437.97

6,156.87

2,627.92

6,362.76

3,114.12

6,506.30

334.55

6,551.79

1,454.95

6,511.95

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4618

7,757.51

7,379.70

6,916.51

7,031.99

7,031.99

0.00

0.00

0.00

0.00

0.00

0.00

0.00

461G

0.00

323.65

0.00

217.69

443.57

0.00

0.00

0.00

0.00

0.00

0.00

0.00

9946

0.00

0.00

0.00

0.00

5,938.12

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SUBTOTAL:

136,329.63

134,114.31

133,351.19

131,278.75

133,689.47

0.00

0.00

0.00

0.00

0.00

0.00

0.00

35,430.88	
545,843.03	
273.27	
1,116.26	
10,969.51	
32,089.67	
36,117.70	
984.91	
5,938.12	
668,763.35	

8600	SSI BLIND FREEDOM/W O	119.15	119.15	119.15	1,518.09	1,518.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,387,627.33	1,409,227.99	1,427,434.60	1,601,635.36	1,588,056.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	14,851.04	13,861.37	11,262.22	8,619.47	2,040.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	257,066.42	281,571.85	279,236.21	280,748.11	281,893.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	43,575.80	38,994.92	27,502.94	20,641.47	11,801.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	165,188.17	161,572.52	163,088.68	196,297.59	193,686.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO	1,871.66	508.27	103.48	1,383.63	2,517.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,870,299.57	1,905,856.07	1,908,747.28	2,110,843.72	2,081,513.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3,393.63	
7,413,981.99	
50,634.34	
1,380,515.79	
142,516.79	
879,833.31	
6,384.05	
9,877,259.90	

M

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	467,034,603.84	468,726,485.92	471,960,427.06	506,083,311.72	504,236,168.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,418,040,996.98		

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1003	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1006	TANF 21-44 MALE WITH	297.30	350.67	391.93	80.61	84.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,205.36		
1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	172.66	178.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,343.85		
1008	TANF 45-64 M & F WIT	870.42	1,013.58	1,168.84	270.09	273.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,595.97		
1009	TANF 65+ M & F WITH	306.00	373.68	430.56	102.88	96.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,309.25		
100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	7.53	2.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.76		
100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	3.15	5.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.13		
100H	TANF 44-64 M & F WIT	97.51	98.86	32.85	17.79	2.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.10		
100J	TANF 65+ M & F WITH	73.60	39.19	4.37	7.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.64		
1011	TANF <1 M & F NON-ME	14,502.91	14,510.24	13,463.57	13,936.63	14,198.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,611.62		
1012	TANF 01-05 M & F NON	41,759.21	34,503.32	30,981.55	27,621.68	24,016.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,882.33		
1013	TANF 06-13 M & F NON	68,866.70	57,435.45	51,559.68	45,958.63	39,586.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		263,406.91		
1014	TANF 14-20 MALE NON-	15,523.91	13,919.00	12,939.58	11,807.22	10,522.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,712.25		
1015	TANF 14-20 FEMALE N	19,492.05	17,891.08	16,863.02	14,601.29	13,172.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,019.91		
1016	TANF 21-44 MALE NON-	32,422.89	35,110.56	38,554.07	24,200.36	24,611.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,899.12		
1017	TANF 21-44 FEMALE N	100,171.76	104,138.61	110,548.82	79,561.23	79,226.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		473,647.16		
1018	TANF 45-64 M & F NON	26,326.13	28,376.39	30,996.33	18,878.67	18,943.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,521.37		
1019	TANF 65+ M & F NON-M	122.25	133.13	152.05	81.72	80.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		569.93		
101A	TANF < 1 M & F NON-M	1,323.68	1,107.58	523.24	1,443.78	1,155.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,553.46		
101B	TANF 01-05 M & F NON	323.00	173.98	234.10	366.13	146.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,243.99		
101C	TANF 06-13 M & F NON	235.43	179.19	176.48	403.54	132.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,127.42		
101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	167.74	56.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		623.41		
101E	TANF 14-20 FEMALE N O	278.91	237.91	174.02	171.86	90.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		953.28		
101F	TANF 21-44 MALE NON-	2,653.94	2,660.54	1,444.98	1,220.10	625.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,605.40		
101G	TANF 21-44 FEMALE N O	4,819.02	4,659.58	2,737.74	2,315.36	1,601.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,133.16		
101H	TANF 44-64 M & F NON	1,604.09	1,643.02	919.13	633.40	373.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,173.18		
101J	TANF 65+ N & F NON-M	31.66	19.50	26.80	1.88	6.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86.26		
1021	TANF <1 M & F WITH Q	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		
1026	TANF 21-44 MALE WITH	136.90	188.45	227.64	39.06	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		629.05		
1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	69.00	73.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,041.07		
1028	TANF 45-64 M & F WIT	257.30	401.73	481.56	80.44	93.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,314.72		
1029	TANF 65+ M & F WITH	125.59	199.79	245.43	39.43	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		655.24		
102F	TANF 21-44 MALE WITH	0.00	2.12	0.13	1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.18		
102G	TANF 21-44 FEMALE WI	4.49	1.22	1.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.34		
102H	TANF 44-64 M & F WIT	1.88	12.13	4.43	0.00	3.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.39		

O

O

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102J	TANF 65+ M & F WITH	2.37	2.17	0.00	5.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.66		
2100	SSI AGED WITH MEDIC A	3,945.61	3,902.67	3,829.80	4,137.95	4,214.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,030.99		
210Z	SSI AGED WITH MEDIC A	450.53	377.60	249.36	270.80	307.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,655.78		
2110	SSI AGED NON-MEDICA R	5,996.37	5,885.71	5,990.17	6,174.44	6,096.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,143.31		
211Z	SSI AGED NON-MEDICA	323.02	229.89	155.90	195.56	189.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,094.13		
2120	SSI AGED WITH QMB	16,192.79	16,392.49	16,583.32	22,041.82	22,291.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,501.99		
212Z	SSI AGED WITH QMB P	60.27	61.77	97.36	67.89	76.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364.10		
2200	SSI DISABLED WITH M E	3,600.36	3,525.64	3,506.17	3,597.87	3,563.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,793.59		
220Z	SSI DISABLED WITH M E	236.76	251.22	272.95	225.46	135.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,122.15		
2210	SSI DISABLED NON-ME D	57,143.85	56,902.31	56,909.61	56,665.32	56,824.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,445.92		
221Z	SSI DISABLED NON-ME D	983.56	949.62	911.29	771.37	711.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,327.43		
2220	SSI DISABLED WITH Q M	24,588.70	24,755.94	24,980.93	25,099.07	25,302.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,726.79		
222Z	SSI DISABLED WITH Q M	62.38	77.46	109.31	43.36	32.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		324.79		
2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128.11		
230Z	SSI BLIND WITH MEDIC	4.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.45		
2310	SSI BLIND NON-MEDIC A	428.12	430.04	436.15	439.00	442.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,175.69		
231Z	SSI BLIND NON-MEDIC	8.02	26.80	11.45	13.31	4.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.37		
2320	SSI BLIND WITH QMB	207.48	205.10	207.96	204.24	202.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,026.87		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		
4302	SOBRA CHILD 01-05 M	5.00	3.99	2.01	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	2.12	4.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.10		
4304	SOBRA CHILD 14-20 MA	1.00	1.00	1.00	0.00	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4305	SOBRA CHILD 14-20 FE	1.00	1.19	1.13	1.25	0.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.19		
430B	SOBRA CHILD 01-05 M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
430C	SOBRA CHILD 06-13 M	0.00	0.00	1.56	0.87	1.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.89		
430D	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		
430E	SOBRA CHILD 14-20 FE	0.00	0.61	0.86	-0.25	-0.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.61		
4311	SOBRA CHILD <1 M & F	37,929.50	37,878.33	35,410.54	38,243.54	39,448.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188,910.73		
4312	SOBRA CHILD 01-05 M	150,215.05	158,567.13	166,797.13	169,987.40	176,662.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		822,229.53		
4313	SOBRA CHILD 06-13 M	200,525.14	216,198.75	230,401.99	209,630.58	214,915.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,071,672.14		
4314	SOBRA CHILD 14-20 MA	49,529.14	51,683.40	55,100.09	50,842.03	51,365.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258,520.38		
4315	SOBRA CHILD 14-20 FE	49,621.28	51,750.56	55,046.80	51,049.83	51,597.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259,066.34		
431A	SOBRA CHILD < 1 M &	1,144.43	1,199.85	596.85	1,439.14	966.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,346.97		
431B	SOBRA CHILD 01-05 M	7,397.32	7,233.01	5,425.60	5,749.99	4,037.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,843.71		
431C	SOBRA CHILD 6-13 M&	9,664.24	10,386.87	6,895.96	6,005.68	4,413.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,366.02		
431D	SOBRA CHILD 14-20 MA	2,729.60	2,547.00	1,740.21	1,587.56	1,149.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,753.37		

R

P

A

F

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 431E	SOBRA CHILD 14-20 FE	2,479.42	2,548.58		1,750.39		1,574.77		1,152.27		0.00		0.00		0.00		0.00	0.00	0.00	0.00	9,505.43
4321	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

4322	SOBRA CHILD 01-05 M	3.00	0.00	2.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00
4323	SOBRA CHILD 06-13 M	7.00	0.00	1.00	5.06	3.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.62
4324	SOBRA CHILD 14-20 MA	4.00	0.00	1.00	1.00	1.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.56

4325	SOBRA CHILD 14-20 FE	2.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

5007	SOBRA PREG 21-44 FE
M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
5510	SOBRA FPS FEMALE W
IT

44.60	44.25	49.08	47.32	34.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220.24

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

3.37	3.12	2.16	1.67	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.15

6.00	7.38	7.00	6.00	6.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32.58

4,442.88	4,822.40	5,139.99	5,199.98	5,482.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,087.80

19,288.96	21,436.17	23,639.77	25,479.28	26,864.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116,708.98

70.02	76.99	80.34	89.62	89.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	406.96

0.00	1.61	0.00	0.00	0.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.41

380.96	386.50	238.63	248.98	217.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,472.40

1,656.15	1,536.50	1,187.87	1,135.67	915.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,431.65

7.91	23.95	1.29	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.08

9.11	11.00	8.99	9.12	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.22

0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.87

-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.00

SUBTOTAL:

985,098.82

1,002,906.76	1,020,305.89	932,589.99	929,217.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,870,119.29

9910	TANF & SOBRA CHILDR E	571.00	500.00	476.00	365.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	11.00	11.00	12.00	10.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	42.00	29.00	33.00	30.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,053.00	2,266.00	2,452.00	2,223.00	2,141.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,677.00	2,806.00	2,973.00	2,628.00	2,589.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
2,319.00	
56.00	
163.00	
11,135.00	
13,673.00	

3100	TRANSPLANT OPTION 1	4.24	5.41	5.00	5.00	5.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION 1	5.74	4.58	0.00	0.00	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	9.98	9.99	5.00	5.00	5.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

25.38	
10.58	
35.96	

SUBTOTAL:

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	925.69	903.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	1,129.92	997.50	888.94	1,799.36	1,696.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,914.12	1,697.63	1,569.17	3,028.13	2,948.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	634.27	568.85	533.33	1,133.83	1,112.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	18.70	3.61	8.79	22.01	20.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,227.83	
6,512.21	
11,157.35	
3,982.30	
73.37	

M&

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110G	TANF EXPANDED 21-44	2.64	1.64	12.64	32.68	21.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.18		
110H	TANF EXPANDED 45-64	0.86	0.82	67.38	87.22	58.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215.03		
110J	TANF EXPANDED 65+
M&	0.00	2.64	37.58	16.71	13.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.69		
1111	TANF EXPANDED <1 M
&F	12.00	8.00	1.36	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.36		
1112	TANF EXPANDED 01-05	390.00	311.16	275.00	239.06	180.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,395.22		
1113	TANF EXPANDED 06-13	1,229.70	991.16	871.12	743.21	581.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,417.16		
1114	TANF EXPANDED 14-20	683.08	531.13	454.69	720.61	674.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,064.09		
1115	TANF EXPANDED 14-20	1,447.98	1,085.47	918.24	1,792.37	1,760.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,004.45		
1116	TANF EXPANDED 21-44	20,507.88	17,866.93	15,873.76	30,211.21	29,789.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,249.54		
1117	TANF EXPANDED 21-44	46,392.97	40,134.22	35,306.60	65,385.73	63,972.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,192.12		
1118	TANF EXPANDED 45-64	16,838.19	14,850.87	13,477.80	26,098.91	25,902.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,168.48		
1119	TANF EXPANDED 65+
M&	91.37	83.00	78.65	120.22	115.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		488.48		
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.35		
111B	TANF EXPANDED 01-05	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.83		
111C	TANF EXPANDED 06-13	1.00	0.00	0.00	2.80	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.80		
111D	TANF EXPANDED 14-20	0.54	5.28	14.31	10.92	28.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.32		
111E	TANF EXPANDED 14-20	7.24	9.73	31.24	50.14	45.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144.18		
111F	TANF EXPANDED 21-44	101.48	104.36	529.77	956.02	855.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,546.73		
111G	TANF EXPANDED 21-44	197.09	224.68	1,011.19	1,606.35	1,326.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,366.03		
111H	TANF EXPANDED 45-64	28.12	127.83	423.04	661.57	557.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,798.20		
111J	TANF EXPANDED 65+
M&	22.31	0.00	3.65	34.70	3.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.77		
1125	TANF EXPANDED 14-20	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1126	TANF EXPANDED 21-44	172.31	149.33	132.42	154.79	225.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		834.70		
1127	TANF EXPANDED 21-44	382.43	351.28	318.88	364.36	502.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,919.06		
1128	TANF EXPANDED 45-64	446.94	399.71	372.79	452.31	621.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,293.08		
1129	TANF EXPANDED 65+
M&	194.69	165.94	155.60	174.92	237.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928.82		
112F	TANF EXPANDED 21-44	0.00	0.00	2.56	1.63	1.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.05		
112G	TANF EXPANDED 21-44	0.00	3.44	3.22	4.87	3.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.85		
112H	TANF EXPANDED 45-64	0.03	0.00	2.92	11.24	7.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.64		
112J	TANF EXPANDED 65+
M&	0.00	0.00	16.30	1.06	10.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.10		
2400	SSI AGED EXPANDED WI	518.42	487.04	456.81	384.84	352.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,200.05		
240Z	SSI AGED EXPANDED WI	304.76	401.03	244.49	252.11	184.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,387.23		
2410	SSI AGED EXPANDED NO	1,134.27	1,056.52	991.15	391.57	359.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,933.19		
241Z	SSI AGED EXPANDED NO	13.94	39.82	16.61	7.34	6.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84.34		
2420	SSI AGED EXPANDED	26,853.34	26,842.37	26,813.66	21,188.36	20,913.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,611.02		
242Z	SSI AGED EXPANDED	86.51	60.16	53.24	60.10	29.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289.70		

WI

WI

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION
2500

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
1.00	1.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

2.00

2510

2520

SSI BLIND EXPANDED
W
SSI BLIND EXPANDED
N
SSI BLIND EXPANDED
W
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E

2.00

1.00

2.00

1.00

2.00

1.00

1.00

1.00

1.00

1.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8.00

5.00

2600

387.35

391.10

363.58

405.75

407.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,955.44

260Z

198.57

225.21

193.65

131.93

83.98

0.00

0.00

0.00

0.00

0.00

0.00

0.00

833.34

2610

261Z

2,800.72

66.87

2,719.35

64.13

2,722.76

55.86

2,696.85

42.68

2,637.63

36.03

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

13,577.31

2620

15,882.49

16,101.98

16,689.39

17,152.91

17,493.44

0.00

0.00

0.00

0.00

0.00

0.00

0.00

265.57

83,320.21

262Z

70.33

62.70

88.07

53.98

24.93

0.00

0.00

0.00

0.00

0.00

0.00

0.00

300.01

SUBTOTAL:	141,707.24	129,594.34	122,483.07	179,619.05	176,720.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	750,124.08

9911	SB PAYMENT FOR TAN F	105.00	122.00	113.00	177.00	141.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI E	2.00	3.00	4.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	108.00	126.00	117.00	179.00	143.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

658.00	
12.00	
3.00	
673.00	

SUBTOTAL:

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	
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

3506	ADULT 40-100% MALE 2	15.63	8.90	13.05	13.05	7.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	14.06	5.76	7.00	9.81	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	67.69	54.87	49.56	121.55	98.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	55.05	55.40	53.33	83.77	57.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	6.92	0.67	2.82	4.93	1.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	3.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	8.97	10.81	15.38	19.39	2.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	10.92	7.57	0.00	3.22	0.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	3,038.92	3,290.06	3,469.54	3,459.96	3,695.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	3,734.50	3,945.56	4,139.94	4,065.25	4,323.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	17,324.13	17,315.90	17,767.16	18,063.18	18,254.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	14,579.12	14,409.13	14,673.49	14,867.88	14,928.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	35,161.66	35,276.58	36,112.19	36,443.44	36,715.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	39.09	36.01	35.99	49.54	31.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	223.89	174.95	140.00	114.00	120.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	215.10	215.28	142.27	157.72	109.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	970.65	931.86	710.83	703.38	508.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL	687.03	645.80	559.94	543.04	370.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	1,789.29	1,532.58	1,097.36	1,161.58	880.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

58.35	
50.63	
391.80	
304.95	
16.83	
3.82	
57.41	
22.31	
16,954.16	
20,208.88	
88,724.83	
73,457.80	
179,709.53	
192.45	
773.61	
840.10	
3,825.41	
2,806.26	
6,460.83	

E

E

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015

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

351J	ADULT 40-100% M&F 65	40.88	22.67	29.32	20.45	46.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160.21	
3525	ADULT 40-100% FEMAL	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
3526	E
ADULT 40-100% MALE 2	3.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5.00	
3527	ADULT 40-100% FEMAL	1.41	3.21	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.62	
3528	E
ADULT 40-100% M&F 45	20.96	15.68	24.16	19.28	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
103.08	
3529	ADULT 40-100% M&F 65	6.00	10.00	4.00	14.03	10.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44.09	
352G	ADULT 40-100% FEMAL	0.00	0.77	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.80	

352H	E
ADULT 40-100% M&F 45	
0.03	
1.83	
1.26	
0.12	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3.24	
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	4.96	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.79	
3706	ADULT <40% EXP MALE	34.74	33.74	30.14	41.29	39.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	179.35	
3707	ADULT <40% EXP FEM	7.49	15.61	9.78	12.41	11.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.32	

3708	AL
ADULT <40% EXP M&F	
88.23	
98.60	
92.80	
188.88	
141.71	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
610.22	
3709	4
ADULT <40% EXP M&F	19.67	21.38	28.72	41.00	21.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
132.40	
370F	6
ADULT <40% EXP MALE	5.51	8.57	6.12	3.49	3.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
26.90	
370G	ADULT <40% EXP FEM	1.54	1.81	0.06	2.37	3.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.67	
370H	AL
ADULT <40% EXP M&F	14.58	15.74	30.56	13.97	3.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
78.41	
370J	4
ADULT <40% EXP M&F	0.00	0.00	2.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2.73	

3714	6
ADULT <40% EXP MALE	
9,839.70	
10,160.23	
10,470.29	
10,275.58	
10,661.47	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
51,407.27	
3715	ADULT <40% EXP FEM	8,418.28	8,667.97	8,908.49	8,752.70	9,023.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,771.40	

3716	AL
ADULT <40% EXP MALE	
58,247.03	
58,634.00	
61,113.02	
62,941.19	
63,352.21	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
304,287.45	
3717	ADULT <40% EXP FEM	34,827.18	34,929.63	36,183.66	37,298.36	37,725.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	180,964.38	

3718	AL
ADULT <40% EXP M&F	
72,820.34	
73,231.71	
75,412.07	
76,737.78	
77,207.05	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
375,408.95	
3719	4
ADULT <40% EXP M&F	80.88	80.74	94.53	128.19	96.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
480.56	
371D	6
ADULT <40% EXP MALE	580.76	572.41	352.26	309.50	300.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,115.19	
371E	ADULT <40% EXP FEM	519.38	449.84	305.73	319.68	204.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,799.20	
371F	AL
ADULT <40% EXP MALE	4,244.00	4,145.00	2,990.61	2,888.14	2,110.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
16,378.56	
371G	ADULT <40% EXP FEM	2,410.81	2,215.92	1,619.33	1,656.46	1,211.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,113.69	

371H	AL
ADULT <40% EXP M&F	
3,754.97	
3,389.75	
2,459.44	
2,612.62	
2,030.56	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
14,247.34	
371J	4
ADULT <40% EXP M&F	2.98	2.00	16.46	13.76	23.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
58.32	

3724	6
ADULT <40% EXP MALE	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1.00	
3726	ADULT <40% EXP MALE	9.00	8.05	8.35	11.73	10.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48.12	
3727	ADULT <40% EXP FEM	6.12	3.96	3.43	7.00	7.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.87	
3728	AL
ADULT <40% EXP M&F	23.78	6.39	19.82	15.21	14.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
79.40	
3729	4
ADULT <40% EXP M&F	4.00	0.00	1.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
12.00	
372F	6
ADULT <40% EXP MALE	0.00	0.86	5.62	0.82	1.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9.00	
372G	ADULT <40% EXP FEM	0.87	1.79	3.22	0.00	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.94	
	AL														

SUBTOTAL:

69,593.33

71,546.64

74,129.68

75,276.24

76,599.20

0.00

0.00

0.00

0.00

0.00

0.00

0.00

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
372H	ADULT <40% EXP M&F 4	0.77	1.95	0.36	4.98	0.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.86		
	273,979.51	274,669.50	279,217.19	284,229.49	284,415.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,396,511.29		

SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	29.00	45.00	40.00	44.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	74.00	98.00	121.00	112.00	98.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	103.00	143.00	161.00	156.00	136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

196.00	
503.00	
699.00	

A

3904	NEWLY ELIGIBLE MALE	0.00	0.16	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	6.92	5.18	4.00	8.20	10.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA	14.99	10.72	9.00	11.72	6.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3908	L
NEWLY ELIGIBLE M&F	
71.56	
53.47	
39.78	
80.22	
96.10	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3909	4
NEWLY ELIGIBLE M&F	
12.19	
19.97	
21.66	
39.05	
26.20	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

390D	6
NEWLY ELIGIBLE MALE	
0.00	
0.83	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
390F	NEWLY ELIGIBLE MALE	0.45	0.00	0.00	6.15	0.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA	1.83	2.06	0.00	1.25	1.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

390H	L
NEWLY ELIGIBLE M&F	
64.25	
40.88	
59.19	
97.73	
35.73	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

390J	4
NEWLY ELIGIBLE M&F	
10.96	
14.95	
34.33	
49.11	
17.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3914	6
NEWLY ELIGIBLE MALE	
1,606.89	
1,676.79	
1,806.88	
1,752.14	
1,876.50	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3915	NEWLY ELIGIBLE FEMA	1,867.46	2,072.53	2,181.57	2,102.93	2,272.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3916	L
NEWLY ELIGIBLE MALE	
15,590.65	
16,339.89	
17,228.33	
17,862.31	
18,493.39	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3917	NEWLY ELIGIBLE FEMA	20,086.40	21,456.04	22,844.42	23,906.19	25,104.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3918	L
NEWLY ELIGIBLE M&F	
24,879.24	
25,158.44	
25,656.88	
25,845.50	
26,301.97	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3919	4
NEWLY ELIGIBLE M&F	
43.11	
41.59	
40.65	
49.90	
38.52	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

391D	6
NEWLY ELIGIBLE MALE	
141.51	
112.48	
116.75	
61.70	
47.08	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
391E	NEWLY ELIGIBLE FEMA	153.51	153.08	97.96	106.98	67.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

391F	L
NEWLY ELIGIBLE MALE	
1,523.12	
1,206.66	
1,086.31	
945.80	
635.23	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
391G	NEWLY ELIGIBLE FEMA	1,726.49	1,680.05	1,394.47	1,209.37	730.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

391H	L
NEWLY ELIGIBLE M&F	
1,771.32	
1,458.13	
1,385.33	
1,103.78	
772.01	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

391J	4
NEWLY ELIGIBLE M&F	
8.86	
33.37	
111.19	
18.08	
52.44	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3926	6
NEWLY ELIGIBLE MALE	
1.00	
0.70	
1.96	
3.16	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3927	NEWLY ELIGIBLE FEMA	0.00	3.00	3.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3928	L
NEWLY ELIGIBLE M&F	
6.22	
3.11	
2.43	
4.57	
6.66	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3929	4
NEWLY ELIGIBLE M&F	
2.00	
0.96	
2.00	
3.03	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

392F	6
NEWLY ELIGIBLE MALE	
0.00	
0.29	
0.03	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
392H	NEWLY ELIGIBLE M&F	2.40	1.28	0.56	1.41	1.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

392J	4
NEWLY ELIGIBLE M&F
6	
0.00	
0.03	
0.00	
2.96	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

 	
2.16	
35.10	
52.96	
341.13	
119.07	
0.83	
7.20	
6.60	
297.78	
127.15	
8,719.20	
10,496.54	
85,514.57	
113,397.99	
127,842.03	
213.77	
479.52	
579.50	
5,397.12	
6,740.50	
6,490.57	
223.94	
7.82	
9.00	
22.99	
8.99	
0.32	
6.75	
3.99	
367,145.09	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9939	BIRTH SUPP PAYMENT N	39.00	34.00	57.00	67.00	67.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264.00		
	39.00	34.00	57.00	67.00	67.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264.00		

SUBTOTAL:

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F	2.00	1.00	2.00	7.38	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	20,103.69	18,080.37	16,565.93	44,553.71	46,675.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	6,535.04	5,919.99	5,497.23	12,583.32	12,880.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	6,240.09	5,678.68	5,237.34	12,115.93	12,426.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	288.14	323.40	1,091.93	1,531.67	968.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	126.41	106.24	394.18	409.63	316.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	81.96	103.18	421.32	344.01	343.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	1.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	33,377.33	30,212.86	29,209.93	71,548.32	73,618.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1.00	
0.67	
1.00	
17.38	
145,979.32	
43,416.22	
41,698.06	
4,204.00	
1,353.45	
1,293.72	
1.73	
237,966.55	

1

SUBTOTAL:

39.00

39.00

9944	BIRTH SUPP PAYMENT	8.00	13.00	3.00	3.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8.00	13.00	3.00	3.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

S

4517

4518

BC PATIENT FEMALE 2
1
BC PATIENT FEMALE 4
5
BC PATIENT FEMALE 6
5
BC PATIENT FEMALE 2
1
BC PATIENT FEMALE 4
5
CC PATIENT FEMALE 2
1
CC PATIENT FEMALE 4
5
CC PATIENT FEMALE 2
1
SB KICK PAYMENT FOR

23.96

251.91

25.35

246.16

26.00

245.84

27.58

240.06

28.33

227.69

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4519

0.77

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

451G

0.00

3.64

0.00

0.41

1.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

451H

4617

10.28

15.86

5.89

16.54

8.11

17.00

0.93

18.03

5.34

17.83

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

4618

18.00

17.00

16.00

16.00

16.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

461G

0.00

1.45

0.00

0.96

2.16

0.00

0.00

0.00

0.00

0.00

0.00

0.00

9946

0.00

0.00

0.00

0.00

1.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SUBTOTAL:

320.78

316.03

312.95

303.97

300.01

0.00

0.00

0.00

0.00

0.00

0.00

0.00

131.22	
1,211.66	
0.77	
5.71	
30.55	
85.26	
83.00	
4.57	
1.00	
1,553.74	

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,505.00	1,555.45	1,576.90	1,602.26	1,594.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	161.37	146.05	125.37	96.31	27.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	246.99	274.32	275.92	268.27	266.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	85.86	73.98	54.70	40.00	21.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	213.90	216.30	223.90	223.30	228.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO	20.61	6.41	1.03	15.63	27.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,234.73	2,273.51	2,258.82	2,246.77	2,166.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

5.00	
7,833.84	
556.50	
1,331.69	
276.53	
1,105.47	
71.54	
11,180.57	

M

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	1,509,256.72	1,514,651.63	1,531,233.53	1,548,851.83	1,545,990.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,649,984.57		

1000	TANF WITH MEDICARE	9,923.14	10,424.50	9,923.14	10,013.77	17,381.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,666.02	
1010	TANF NON-MEDICARE	2,246,124.76	2,243,143.25	2,252,388.63	2,282,295.84	2,283,614.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,307,567.31	
1020	TANF WITH QMB	3,414.03	3,414.03	3,414.03	3,433.17	3,433.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,108.43	
2100	SSI AGED WITH MEDIC	31,188,469.28	36,229,127.20	31,473,122.65	31,111,647.19	36,054,042.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166,056,409.19	
210Z	A
SSI AGED WITH MEDIC	707,295.55	628,872.62	699,533.74	841,652.65	651,630.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,528,985.27	
2110	A
SSI AGED NON-MEDICA	2,884,201.93	3,146,295.69	2,948,885.35	3,040,662.77	3,335,679.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
15,355,724.97	
211Z	R
SSI AGED NON-MEDICA	20,970.93	11,535.77	26,120.35	18,541.95	9,394.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
86,563.51	

2120	R
SSI AGED WITH QMB	
18,966,113.95	
22,019,693.90	
19,185,398.15	
19,009,038.07	
22,054,804.25	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
101,235,048.32	
212Z	SSI AGED WITH QMB P	27,811.67	8,720.78	31,076.14	21,591.82	10,487.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,687.50	

2200	P
SSI DISABLED WITH M	
13,803,406.37	
14,998,436.84	
13,783,997.15	
14,011,924.66	
15,406,736.15	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
72,004,501.17	
220Z	E
SSI DISABLED WITH M	40,564.67	63,879.36	93,590.05	124,380.26	73,436.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
395,851.01	

2210	E
SSI DISABLED NON-ME	
90,370,918.56	
92,527,644.78	
92,067,142.80	
93,105,599.36	
94,991,556.18	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
463,062,861.68	
221Z	D
SSI DISABLED NON-ME	66,459.25	35,301.18	25,164.71	27,841.86	30,576.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
185,343.10	
2220	D
SSI DISABLED WITH Q	21,237,804.05	22,510,241.65	21,355,507.04	21,308,948.47	22,578,485.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
108,990,986.27	
222Z	M
SSI DISABLED WITH Q	2,948.16	9,227.84	6,397.97	6,604.08	8,888.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
34,066.37	
2300	M
SSI BLIND WITH MEDIC	64,338.16	65,260.19	64,541.02	62,567.40	68,202.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
324,909.42	
2310	SSI BLIND NON-MEDIC	444,420.36	460,483.10	454,107.08	457,911.29	480,473.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,297,394.83	

2320	A
SSI BLIND WITH QMB	
130,315.90	
135,811.83	
130,342.85	
127,684.67	
131,086.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
655,242.05	

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

182,215,500.72  195,107,514.51  184,610,652.85  185,572,339.28  198,189,909.06

0.00

0.00

0.00

0.00

0.00

0.00

0.00

945,695,916.42

946,789,435.12

8700	SSI DISABLED FREEDO M	70,007.12	77,437.98	70,007.12	70,803.89	73,814.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	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	
8710	SSI DISABLED FREEDO M	113,605.70	118,717.57	126,429.56	130,091.75	134,898.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	2,876.81	-2,876.81	4,987.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	19,836.86	21,311.74	19,836.86	20,022.25	21,709.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	206,326.49	214,590.48	221,261.07	220,917.89	230,422.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

362,071.00	
0.00	
623,743.16	
4,987.53	
102,717.01	
1,093,518.70	

184,831,913.92	185,793,257.17	198,420,331.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

M

TOTAL:

182,421,827.21  195,322,104.99

1000	TANF WITH MEDICARE	3.00	3.00	3.00	3.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.00	
1010	TANF NON-MEDICARE	654.15	651.89	656.12	659.50	658.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,280.12	
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
2100	SSI AGED WITH MEDIC	11,288.11	11,289.28	11,378.95	11,358.29	11,326.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,641.22	
210Z	A
SSI AGED WITH MEDIC	717.21	639.08	710.00	851.48	668.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,586.45	
2110	A
SSI AGED NON-MEDICA	655.14	653.57	669.99	636.70	631.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,247.01	
211Z	R
SSI AGED NON-MEDICA	21.10	12.50	27.34	18.34	9.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
89.23	

2120	R
SSI AGED WITH QMB	
7,334.44	
7,374.82	
7,392.70	
7,402.32	
7,425.32	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
36,929.60	
212Z	SSI AGED WITH QMB P	27.75	9.33	32.14	22.04	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	102.26	

2200	P
SSI DISABLED WITH M	
4,540.03	
4,507.46	
4,531.49	
4,608.07	
4,649.47	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
22,836.52	
220Z	E
SSI DISABLED WITH M	40.61	63.99	95.38	125.93	77.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
403.56	

2210	E
SSI DISABLED NON-ME	
25,726.52	
25,794.02	
25,992.12	
25,925.40	
25,930.65	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
129,368.71	
221Z	D
SSI DISABLED NON-ME	68.02	35.27	25.38	30.27	31.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
190.66	
2220	D
SSI DISABLED WITH Q	6,765.32	6,778.39	6,816.99	6,805.73	6,791.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
33,958.14	
222Z	M
SSI DISABLED WITH Q	2.73	7.18	7.16	6.82	9.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
33.30	
2300	M
SSI BLIND WITH MEDIC	20.00	19.00	20.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
99.00	
2310	SSI BLIND NON-MEDIC	128.16	130.38	131.06	129.55	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	653.15	

2320	A
SSI BLIND WITH QMB	
42.00	
42.00	
42.00	
40.83	
40.30	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
207.13	

LONG TERM CARE MEMBER MONTHS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

58,035.29

58,012.16

58,532.82

58,645.27

58,422.52

0.00

0.00

0.00

0.00

0.00

0.00

0.00

291,648.06

291,931.05

TOTAL:

58,094.28

58,064.17

8700	SSI DISABLED FREEDO M	22.00	22.00	22.00	22.09	22.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	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	
8710	SSI DISABLED FREEDO M	27.09	25.91	26.96	27.00	25.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	2.90	-2.90	5.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	7.00	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	58.99	52.01	60.99	56.09	54.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

110.40	
0.00	
132.56	
5.03	
35.00	
282.99	

M

58,593.81	58,701.36	58,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending November 30, 2015
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1000	TANF WITH MEDICARE	37.55		37.55		37.55		41.42		41.42		0.00		0.00		0.00		0.00	0.00	0.00	0.00		195.49
1010	TANF NON-MEDICARE	6,001,729.15	5,085,321.40	4,606,746.65	4,559,389.34	4,008,130.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,261,317.10
1020	TANF WITH QMB	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41.42

2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
4320	SOBRA CHILD WITH Q
MB
5010	SOBRA PREGNANT WO
MAN

37.55	75.10	75.10	82.84	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	353.43

37.55	37.55	37.55	82.84	165.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	361.17

430,210.35	427,168.80	423,639.10	461,128.86	457,442.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,199,589.59

225.30	225.30	225.30	248.52	207.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,131.52

1,464.45	1,614.65	1,689.75	1,988.16	1,988.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,745.17

225.30	225.30	187.75	165.68	207.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,011.13

17,147,019.75    18,291,093.15     19,577,631.25     20,609,680.76     21,238,146.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,863,571.33

525.70	0.00	187.75	455.62	165.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,334.75

20,427.20	22,567.55	25,233.60	28,828.32	30,195.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127,251.85

SUBTOTAL:

23,601,939.85

23,828,366.35    24,635,691.35    25,662,133.78    25,736,772.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	123,464,903.95

1110	TANF EXPANDED FOR	92,861.15	74,837.15	64,811.30	62,295.68	46,970.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2610	FI
SSI DISABLED EXPAND	
37.55	
37.55	
37.55	
41.42	
41.42	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

92,898.70

74,874.70

64,848.85

62,337.10

47,011.70

0.00

0.00

0.00

0.00

0.00

0.00

0.00

341,775.56	
195.49	
341,971.05	

SUBTOTAL:

3510	ADULT 40-100% FOR FI	37.55	37.55	75.10	82.84	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	37.55	75.10	82.84	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	37.55	75.10	150.20	165.68	165.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

315.88	
278.33	
594.21	

SUBTOTAL:

41.42

41.42

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

132,343,281.85

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	41.42	41.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	1,137,201.75	1,021,510.20	921,589.65	2,674,365.14	2,781,021.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,137,201.75	1,021,510.20	921,589.65	2,674,406.56	2,781,063.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

82.84	
8,535,688.38	
8,535,771.22	

25,622,280.05	28,399,084.54	28,565,013.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

F

TOTAL:

24,832,077.85

24,924,826.35

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1000	TANF WITH MEDICARE		1.00		1.00		1.00		1.00		1.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00		5.00
1010	TANF NON-MEDICARE	159,833.00	135,428.00	122,683.00	110,077.00	96,768.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	624,789.00

1020	TANF WITH QMB	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

2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
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	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00

1.00	1.00	1.00	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00

11,457.00	11,376.00	11,282.00	11,133.00	11,044.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,292.00

6.00	6.00	6.00	6.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.00

39.00	43.00	45.00	48.00	48.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.00

6.00	6.00	5.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.00

456,645.00	487,113.00	521,375.00	497,578.00	512,751.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,475,462.00

14.00	0.00	5.00	11.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.00

544.00	601.00	672.00	696.00	729.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,242.00

SUBTOTAL:

628,547.00

634,577.00	656,077.00	619,559.00	621,361.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,160,121.00

1110	TANF EXPANDED FOR	2,473.00	1,993.00	1,726.00	1,504.00	1,134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2610	FI
SSI DISABLED EXPAND	
1.00	
1.00	
1.00	
1.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

2,474.00

1,994.00

1,727.00

1,505.00

1,135.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8,830.00	
5.00	
8,835.00	

SUBTOTAL:

3510	ADULT 40-100% FOR FI	1.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1.00	2.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

8.00	
7.00	
15.00	

SUBTOTAL:

1.00

1.00

3910	NEWLY ELIGIBLE FOR F	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

3,382,715.00

TOTAL:

661,307.00

663,777.00

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	30,285.00	27,204.00	24,543.00	64,567.00	67,142.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30,285.00	27,204.00	24,543.00	64,568.00	67,143.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2.00	
213,741.00	
213,743.00	

F

682,351.00	685,637.00	689,643.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1000	TANF WITH MEDICARE	67,083.83	80,473.34		92,942.96		1,873.88		1,880.20		0.00		0.00		0.00		0.00	0.00	0.00	0.00	244,254.21
1010	TANF NON-MEDICARE	6,077,917.65	6,393,201.43	6,925,613.32	441,979.72	444,046.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,282,758.48

1020	TANF WITH QMB	24,837.03	36,897.81	45,074.61	701.52	761.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,272.53

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

139,789.21	137,949.43	136,722.91	13,714.40	13,869.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	442,045.19

205,476.17	200,433.81	204,454.07	19,576.20	19,269.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	649,209.93

2120	SSI AGED WITH QMB	595,679.88	602,630.16	609,410.09	73,883.96	74,771.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,956,376.01

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

134,133.59	132,327.88	130,488.10	11,537.16	11,508.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419,995.45

1,422,763.20	1,422,831.34	1,426,408.69	116,724.08	117,773.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,506,500.51

832,159.75	837,747.23	844,561.23	70,060.36	70,610.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,655,138.77

2300	SSI BLIND WITH MEDIC	1,226.52	1,158.38	1,056.17	94.80	88.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,624.35

2310	SSI BLIND NON-MEDIC
A

14,820.45	14,650.10	14,547.89	1,295.60	1,311.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,625.44

2320	SSI BLIND WITH QMB	8,279.01	8,210.87	8,244.94	745.76	739.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,220.02

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

34.07	34.07	68.14	6.32	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145.76

834,544.65	810,661.58	852,976.52	73,251.96	73,425.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,644,860.47

68.14	34.07	34.07	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142.60

1,260.59	1,226.52	1,328.73	113.76	94.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,024.40

802,586.99	894,950.76	992,561.31	98,045.32	104,024.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,892,168.42

306.63	408.84	340.70	34.76	37.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,128.85

SUBTOTAL:

11,162,967.36

11,575,827.62    12,286,834.45	923,642.72	934,219.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,883,491.39

SUBTOTAL:

4,829,797.27	4,393,871.62	4,058,111.77

550,231.84

544,054.04

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1100	TANF EXPANDED FPR FI	141,594.92	125,002.83	112,124.37	20,394.64	19,800.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	3,052,160.95	2,639,368.83	2,306,811.56	405,740.84	398,852.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1120	FI
TANF EXPANDED FOR	
39,930.04	
35,535.01	
32,025.80	
3,239.00	
4,575.68	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2400	FI
SSI AGED EXPANDED	
14,990.80	
14,173.12	
13,662.07	
948.00	
913.24	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
39,725.62	
37,068.16	
34,887.68	
1,292.44	
1,166.04	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
952,256.50	
951,711.38	
949,360.55	
68,407.68	
67,696.68	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2500	WI
SSI BLIND EXPANDED	
0.00	
0.00	
0.00	
3.16	
3.16	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2510	W
SSI BLIND EXPANDED	
68.14	
68.14	
68.14	
3.16	
3.16	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2520	N
SSI BLIND EXPANDED	
34.07	
34.07	
34.07	
3.16	
3.16	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	W
SSI DISABLED EXPAND	
9,505.53	
9,335.18	
9,198.90	
850.04	
894.28	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
91,103.18	
87,900.60	
88,070.95	
6,955.16	
6,847.72	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
488,427.52	
493,674.30	
511,867.68	
42,394.56	
43,298.32	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
418,917.32	
8,802,934.22	
115,305.53	
44,687.23	
114,139.94	
2,989,432.79	
6.32	
210.74	
108.53	
29,783.93	
280,877.61	
1,579,662.38	
14,376,066.54	

3500	ADULT 40-100% FOR FI	4,974.22	4,326.89	3,849.91	688.88	530.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	2,568,639.51	2,579,984.82	2,658,856.87	246,432.60	250,894.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	1,056.17	919.89	919.89	97.96	113.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
14,370.78	
8,304,808.32	
3,107.67	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	4,463.17	4,667.59	4,769.80	774.20	609.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,284.64		
3710	AHC CARE EXPANDED FO	6,719,966.80	6,769,163.88	7,017,568.25	651,541.44	662,468.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,820,709.09		
3720	AHC CARE EXPANDED FO	1,328.73	476.98	953.96	94.80	94.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,949.27		
	9,300,428.60	9,359,540.05	9,686,918.68	899,629.88	914,712.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,161,229.77		

SUBTOTAL:

3900	NEWLY ELIGIBLE FOR	3,032.23	2,044.20	2,180.48	372.88	404.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3910	F
NEWLY ELIGIBLE FOR	
2,203,170.62	
2,295,500.32	
2,410,997.62	
227,614.80	
237,448.72	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3920	F
NEWLY ELIGIBLE FOR	
374.77	
170.35	
204.42	
28.44	
25.28	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2,206,577.62	2,297,714.87	2,413,382.52

228,016.12

237,878.48

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8,034.27	
7,374,732.08	
803.26	
7,383,569.61	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	103,709.08	95,634.49	86,469.66	15,683.08	17,019.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	103,709.08	95,634.49	86,469.66	15,686.24	17,022.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

318,516.07	
6.32	
318,522.39	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	9,471.46	9,301.11	9,267.04	837.40	799.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	1,192.45	1,158.38	1,124.31	104.28	104.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	10,663.91	10,459.49	10,391.35	941.68	903.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

29,676.49	
3,683.70	
33,360.19	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W	34.07	34.07	34.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	33,831.51	35,194.31	35,909.78	2,837.68	2,850.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	7,086.56	7,938.31	8,142.73	701.52	698.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	5,178.64	5,417.13	5,655.62	426.60	439.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	46,130.78	48,583.82	49,742.20	3,965.80	3,987.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

102.21	
110,623.60	
24,567.48	
17,117.23	
152,410.52	

O

SUBTOTAL:

89,308,650.41

27,660,274.62	27,781,631.96	28,591,850.63	2,622,114.28	2,652,778.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1000	TANF WITH MEDICARE	1,969.00	2,362.00		2,728.00		593.00		595.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	8,247.00
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	849,708.00

1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,598.00

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

4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,894.00

6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,208.00

2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100,102.00

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

3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,944.00

41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	199,597.00

24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	118,319.00

2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	159.00

2310	SSI BLIND NON-MEDIC
A

435.00	430.00	427.00	410.00	415.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,117.00

2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,196.00

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

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

24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119,742.00

2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

37.00	36.00	39.00	36.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178.00

23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,904.00

9.00	12.00	10.00	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.00

SUBTOTAL:

327,648.00

339,766.00	360,635.00	292,292.00	295,639.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,615,980.00

SUBTOTAL:

141,761.00

128,966.00

119,111.00

174,124.00

172,169.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1120	FI
TANF EXPANDED FOR	
1,172.00	
1,043.00	
940.00	
1,025.00	
1,448.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2400	FI
SSI AGED EXPANDED	
440.00	
416.00	
401.00	
300.00	
289.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
1,166.00	
1,088.00	
1,024.00	
409.00	
369.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
27,950.00	
27,934.00	
27,865.00	
21,648.00	
21,423.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2500	WI
SSI BLIND EXPANDED	
0.00	
0.00	
0.00	
1.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2510	W
SSI BLIND EXPANDED	
2.00	
2.00	
2.00	
1.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2520	N
SSI BLIND EXPANDED	
1.00	
1.00	
1.00	
1.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	W
SSI DISABLED EXPAND	
279.00	
274.00	
270.00	
269.00	
283.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
2,674.00	
2,580.00	
2,585.00	
2,201.00	
2,167.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
14,336.00	
14,490.00	
15,024.00	
13,416.00	
13,702.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
23,836.00	
489,380.00	
5,628.00	
1,846.00	
4,056.00	
126,820.00	
2.00	
8.00	
5.00	
1,375.00	
12,207.00	
70,968.00	
736,131.00	

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	75,393.00	75,726.00	78,041.00	77,985.00	79,397.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
772.00	
386,542.00	
152.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846.00		
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,017,725.00		
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141.00		
	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,406,178.00		

SUBTOTAL:

3900	NEWLY ELIGIBLE FOR	89.00	60.00	64.00	118.00	128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3910	F
NEWLY ELIGIBLE FOR	
64,666.00	
67,376.00	
70,766.00	
72,030.00	
75,142.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3920	F
NEWLY ELIGIBLE FOR	
11.00	
5.00	
6.00	
9.00	
8.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

64,766.00

67,441.00

70,836.00

72,157.00

75,278.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

459.00	
349,980.00	
39.00	
350,478.00	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

18,738.00	
2.00	
18,740.00	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	278.00	273.00	272.00	265.00	253.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	35.00	34.00	33.00	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,341.00	
168.00	
1,509.00	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	902.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	208.00	233.00	239.00	222.00	221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	152.00	159.00	166.00	135.00	139.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,354.00	1,426.00	1,460.00	1,255.00	1,262.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3.00	
4,880.00	
1,123.00	
751.00	
6,757.00	

O

4,135,773.00

TOTAL:

SUBTOTAL:

811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION		JULY		AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1000	TANF WITH MEDICARE	90,239.27	108,250.46	125,024.24	33,623.10		33,736.50		0.00		0.00		0.00		0.00	0.00	0.00	0.00	390,873.57
1010	TANF NON-MEDICARE	8,175,842.85	8,599,953.67	9,316,139.08	7,930,458.90	7,967,540.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,989,935.20

1020	TANF WITH QMB	33,410.07	49,633.89	60,633.09	12,587.40	13,664.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	169,929.15

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

188,040.49	185,565.67	183,915.79	246,078.00	248,856.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,052,456.25

276,400.73	269,617.89	275,025.83	351,256.50	345,756.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,518,057.55

2120	SSI AGED WITH QMB	801,291.72	810,641.04	819,761.21	1,325,702.70	1,341,635.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,099,032.07

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

180,432.71	178,003.72	175,528.90	207,011.70	206,501.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	947,478.43

1,913,860.80	1,913,952.46	1,918,764.61	2,094,384.60	2,113,209.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,954,171.47

1,119,397.75	1,126,913.87	1,136,079.87	1,257,095.70	1,266,961.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,906,448.69

2300	SSI BLIND WITH MEDIC	1,649.88	1,558.22	1,420.73	1,701.00	1,587.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,917.43

2310	SSI BLIND NON-MEDIC
A

19,936.05	19,706.90	19,569.41	23,247.00	23,530.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105,989.86

2320	SSI BLIND WITH QMB	11,136.69	11,045.03	11,090.86	13,381.20	13,267.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,921.58

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

45.83	45.83	91.66	113.40	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	353.42

1,122,605.85	1,090,479.02	1,147,399.88	1,314,362.70	1,317,481.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,992,328.65

91.66	45.83	45.83	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	296.72

1,695.71	1,649.88	1,787.37	2,041.20	1,701.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,875.16

1,079,617.31	1,203,862.44	1,335,165.39	1,759,230.90	1,866,507.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,244,383.34

412.47	549.96	458.30	623.70	680.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,724.83

SUBTOTAL:

15,016,107.84

15,571,475.78    16,527,902.05    16,572,956.40    16,762,731.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,451,173.37

SUBTOTAL:

6,496,906.63	5,910,511.78	5,458,857.13	9,872,830.80	9,761,982.30

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1100	TANF EXPANDED FPR FI	190,469.48	168,150.27	150,826.53	365,941.80	355,282.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	4,105,680.55	3,550,404.27	3,103,057.64	7,280,223.30	7,156,617.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1120	FI
TANF EXPANDED FOR	
53,712.76	
47,800.69	
43,080.20	
58,117.50	
82,101.60	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2400	FI
SSI AGED EXPANDED	
20,165.20	
19,065.28	
18,377.83	
17,010.00	
16,386.30	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
53,437.78	
49,863.04	
46,929.92	
23,190.30	
20,922.30	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
1,280,948.50	
1,280,215.22	
1,277,052.95	
1,227,441.60	
1,214,684.10	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2500	WI
SSI BLIND EXPANDED	
0.00	
0.00	
0.00	
56.70	
56.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2510	W
SSI BLIND EXPANDED	
91.66	
91.66	
91.66	
56.70	
56.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2520	N
SSI BLIND EXPANDED	
45.83	
45.83	
45.83	
56.70	
56.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	W
SSI DISABLED EXPAND	
12,786.57	
12,557.42	
12,374.10	
15,252.30	
16,046.10	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
122,549.42	
118,241.40	
118,470.55	
124,796.70	
122,868.90	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
657,018.88	
664,076.70	
688,549.92	
760,687.20	
776,903.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
1,230,670.28	
25,195,983.06	
284,812.75	
91,004.61	
194,343.34	
6,280,342.37	
113.40	
388.38	
250.89	
69,016.49	
606,926.97	
3,547,236.10	
37,501,088.64	

3500	ADULT 40-100% FOR FI	6,691.18	5,820.41	5,178.79	12,360.60	9,525.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	3,455,261.19	3,470,522.58	3,576,619.03	4,421,749.50	4,501,809.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	1,420.73	1,237.41	1,237.41	1,757.70	2,041.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
39,576.58	
19,425,962.20	
7,694.45	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	6,003.73	6,278.71	6,416.20	13,891.50	10,943.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,533.24		
3710	AHC CARE EXPANDED FO	9,039,509.20	9,105,687.72	9,439,834.25	11,690,632.80	11,886,701.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,162,365.37		
3720	AHC CARE EXPANDED FO	1,787.37	641.62	1,283.24	1,701.00	1,701.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,114.23		
	12,510,673.40	12,590,188.45	13,030,568.92	16,142,093.10	16,412,722.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,686,246.07		

SUBTOTAL:

3900	NEWLY ELIGIBLE FOR	4,078.87	2,749.80	2,933.12	6,690.60	7,257.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3910	F
NEWLY ELIGIBLE FOR	
2,963,642.78	
3,087,842.08	
3,243,205.78	
4,084,101.00	
4,260,551.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3920	F
NEWLY ELIGIBLE FOR	
504.13	
229.15	
274.98	
510.30	
453.60	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2,968,225.78	3,090,821.03	3,246,413.88	4,091,301.90	4,268,262.60

0.00

0.00

0.00

0.00

0.00

0.00

0.00

23,709.99	
17,639,343.04	
1,972.16	
17,665,025.19	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	139,506.52	128,644.81	116,316.54	281,402.10	305,386.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	139,506.52	128,644.81	116,316.54	281,458.80	305,442.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

971,256.17	
113.40	
971,369.57	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	12,740.74	12,511.59	12,465.76	15,025.50	14,345.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	1,604.05	1,558.22	1,512.39	1,871.10	1,871.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	14,344.79	14,069.81	13,978.15	16,896.60	16,216.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

67,088.69	
8,416.86	
75,505.55	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W	45.83	45.83	45.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	45,509.19	47,342.39	48,304.82	50,916.60	51,143.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	9,532.64	10,678.39	10,953.37	12,587.40	12,530.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	6,966.16	7,286.97	7,607.78	7,654.50	7,881.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	62,053.82	65,353.58	66,911.80	71,158.50	71,555.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

137.49	
243,216.40	
56,282.50	
37,396.71	
337,033.10	

O

SUBTOTAL:

207,687,441.49

37,207,818.78	37,371,065.24	38,460,948.47	47,048,696.10	47,598,912.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1000	TANF WITH MEDICARE	1,969.00	2,362.00		2,728.00		593.00		595.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	8,247.00
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	849,708.00

1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,598.00

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

4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,894.00

6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,208.00

2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100,102.00

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

3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,944.00

41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	199,597.00

24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	118,319.00

2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	159.00

2310	SSI BLIND NON-MEDIC
A

435.00	430.00	427.00	410.00	415.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,117.00

2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,196.00

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

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

24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119,742.00

2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

37.00	36.00	39.00	36.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178.00

23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,904.00

9.00	12.00	10.00	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.00

SUBTOTAL:

327,648.00

339,766.00	360,635.00	292,292.00	295,639.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,615,980.00

SUBTOTAL:

141,761.00

128,966.00

119,111.00

174,124.00

172,169.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1120	FI
TANF EXPANDED FOR	
1,172.00	
1,043.00	
940.00	
1,025.00	
1,448.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2400	FI
SSI AGED EXPANDED	
440.00	
416.00	
401.00	
300.00	
289.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
1,166.00	
1,088.00	
1,024.00	
409.00	
369.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
27,950.00	
27,934.00	
27,865.00	
21,648.00	
21,423.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2500	WI
SSI BLIND EXPANDED	
0.00	
0.00	
0.00	
1.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2510	W
SSI BLIND EXPANDED	
2.00	
2.00	
2.00	
1.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2520	N
SSI BLIND EXPANDED	
1.00	
1.00	
1.00	
1.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	W
SSI DISABLED EXPAND	
279.00	
274.00	
270.00	
269.00	
283.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
2,674.00	
2,580.00	
2,585.00	
2,201.00	
2,167.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
14,336.00	
14,490.00	
15,024.00	
13,416.00	
13,702.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
23,836.00	
489,380.00	
5,628.00	
1,846.00	
4,056.00	
126,820.00	
2.00	
8.00	
5.00	
1,375.00	
12,207.00	
70,968.00	
736,131.00	

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	75,393.00	75,726.00	78,041.00	77,985.00	79,397.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
772.00	
386,542.00	
152.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846.00		
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,017,725.00		
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141.00		
	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,406,178.00		

SUBTOTAL:

3900	NEWLY ELIGIBLE FOR	89.00	60.00	64.00	118.00	128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3910	F
NEWLY ELIGIBLE FOR	
64,666.00	
67,376.00	
70,766.00	
72,030.00	
75,142.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3920	F
NEWLY ELIGIBLE FOR	
11.00	
5.00	
6.00	
9.00	
8.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

64,766.00

67,441.00

70,836.00

72,157.00

75,278.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

459.00	
349,980.00	
39.00	
350,478.00	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

18,738.00	
2.00	
18,740.00	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	278.00	273.00	272.00	265.00	253.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	35.00	34.00	33.00	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,341.00	
168.00	
1,509.00	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	902.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	208.00	233.00	239.00	222.00	221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	152.00	159.00	166.00	135.00	139.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,354.00	1,426.00	1,460.00	1,255.00	1,262.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3.00	
4,880.00	
1,123.00	
751.00	
6,757.00	

O

4,135,773.00

TOTAL:

SUBTOTAL:

811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	912,101.24	848,941.48	773,707.06	781,066.62	725,564.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,041,380.87		
2210	SSI DISABLED NON-ME D	339,019.30	338,090.48	337,161.66	358,241.15	375,396.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,747,908.95		
2310	SSI BLIND NON-MEDIC A	928.82	928.82	928.82	1,009.13	1,009.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,804.72		
4310	SOBRA CHILD NON-ME DI	13,288,627.74	13,621,145.30	13,792,048.18	14,711,097.14	15,234,835.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,647,753.97		
5010	SOBRA PREGNANT WO	19,505.22	15,789.94	16,718.76	20,182.60	13,118.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,315.21		
SUBTOTAL:	14,560,182.32	14,824,896.02	14,920,564.48	15,871,596.64	16,349,924.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,527,163.72		

MAN

1,009.13

1,009.13

0.00	0.00	0.00	1,009.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	1,009.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3710	AHC CARE EXPANDED
FO
SUBTOTAL:

393,414.36

393,414.36

4410	SOBRA 100-133% FOR F	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

76,921,587.21

14,633,559.10	14,896,415.16	14,987,439.52	15,968,473.12	16,435,700.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	982.00	914.00	833.00	774.00	719.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,222.00		
2210	SSI DISABLED NON-ME D	365.00	364.00	363.00	355.00	372.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,819.00		
2310	SSI BLIND NON-MEDIC A	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4310	SOBRA CHILD NON-ME DI	14,307.00	14,665.00	14,849.00	14,578.00	15,097.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,496.00		
5010	SOBRA PREGNANT WO	21.00	17.00	18.00	20.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89.00		
SUBTOTAL:	15,676.00	15,961.00	16,064.00	15,728.00	16,202.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,631.00		

MAN

1.00

1.00

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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3710	AHC CARE EXPANDED
FO
SUBTOTAL:

408.00

408.00

80,040.00

TOTAL:

4410	SOBRA 100-133% FOR F	79.00	77.00	72.00	95.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	79.00	77.00	72.00	95.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

15,755.00	16,038.00	16,136.00	15,824.00	16,287.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,008.42	1,008.42	1,008.42	1,474.32	1,474.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,973.90		
1010	TANF NON-MEDICARE	133,111.44	130,590.39	131,598.81	194,610.24	194,610.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		784,521.12		
1011	TANF <1 M & F NON-ME	9,104.82	10,355.64	10,355.64	9,632.28	11,760.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,209.22		
1012	TANF 01-05 M & F NON	25,956.96	17,113.95	14,612.31	18,336.96	14,543.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,563.82		
1013	TANF 06-13 M & F NON	30,058.50	22,049.37	18,296.91	20,548.44	17,956.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,909.30		
1014	TANF 14-20 MALE NON-	8,513.34	6,845.58	6,098.97	5,921.88	5,921.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,301.65		
1015	TANF 14-20 FEMALE N	9,017.55	7,766.73	8,687.88	9,905.64	7,777.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,154.88		
1017	TANF 21-44 FEMALE N O	833.88	833.88	833.88	927.60	1,391.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,820.64		
2110	SSI AGED NON-MEDICA R	416.94	416.94	416.94	463.80	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,178.42		
2200	SSI DISABLED WITH M E	8,571.57	9,492.72	12,013.77	18,155.64	19,629.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,863.66		
2210	SSI DISABLED NON-ME D	3,071,131.98	3,075,185.07	3,070,908.99	4,422,630.00	4,413,676.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,053,532.60		
2220	SSI DISABLED WITH Q M	24,444.48	25,452.90	25,957.11	37,512.24	40,460.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,827.61		
2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	737.16	737.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,986.95		
2310	SSI BLIND NON-MEDIC A	27,624.87	28,129.08	27,624.87	39,640.80	39,831.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162,850.86		
4311	SOBRA CHILD <1 M & F	21,273.72	19,935.63	18,180.60	24,292.56	22,164.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,846.51		
4312	SOBRA CHILD 01-05 M	137,425.89	146,162.22	148,906.26	180,325.32	185,783.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		798,603.09		
4313	SOBRA CHILD 06-13 M	130,832.34	140,421.96	154,045.26	197,710.08	200,468.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		823,477.92		
4314	SOBRA CHILD 14-20 MA	30,970.02	33,141.99	36,060.57	45,851.52	45,578.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,602.26		
4315	SOBRA CHILD 14-20 FE	35,226.69	37,815.60	35,886.03	47,433.36	48,278.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204,639.72		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880.74		
5015	SOBRA PREG 14-20 FE M	3,005.85	2,588.91	2,171.97	2,592.36	3,056.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,415.25		
	3,709,033.47	3,715,811.19	3,724,586.34	5,279,166.00	5,275,563.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,704,160.12		

O

SUBTOTAL:

1113	TANF EXPANDED 06-13	416.94	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	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	416.94	416.94	416.94	463.80	463.80	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	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	833.88	416.94	416.94	927.60	927.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
416.94	
463.80	
2,178.42	
463.80	
3,522.96	

3514	ADULT 40-100% MALE 1	833.88	833.88	833.88	927.60	1,391.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	833.88	833.88	833.88	463.80	463.80	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	463.80	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	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	6,254.10	7,087.98	6,671.04	6,029.40	6,029.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	3,752.46	4,169.40	4,169.40	5,101.80	5,101.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	416.94	416.94	416.94	1,391.40	927.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	416.94	416.94	416.94	463.80	927.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,820.64	
3,429.24	
463.80	
463.80	
32,071.92	
22,294.86	
3,569.82	
2,642.22	

AL

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	12,508.20	13,759.02	13,342.08	15,305.40	14,841.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,756.30		

SUBTOTAL:

1,250.82

1,250.82

3915	NEWLY ELIGIBLE FEMA L	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	4,760.88	4,343.94	3,927.00	12,332.16	13,996.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,755.03	1,755.03	921.15	4,447.56	3,983.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	833.88	833.88	416.94	1,391.40	1,855.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	7,349.79	6,932.85	5,265.09	18,171.12	19,835.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

39,360.90	
12,862.53	
5,331.30	
57,554.73	

SUBTOTAL:

21,836,244.93

3,730,142.28	3,737,336.94	3,744,027.39	5,313,570.12	5,311,168.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1010	TANF NON-MEDICARE	264.00	259.00	261.00	264.00	264.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,312.00		
1011	TANF <1 M & F NON-ME	21.00	24.00	24.00	19.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111.00		
1012	TANF 01-05 M & F NON	61.00	40.00	34.00	36.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200.00		
1013	TANF 06-13 M & F NON	70.00	51.00	42.00	39.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236.00		
1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.00		
1015	TANF 14-20 FEMALE N	21.00	18.00	20.00	19.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93.00		
1017	TANF 21-44 FEMALE N O	2.00	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
2110	SSI AGED NON-MEDICA R	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2200	SSI DISABLED WITH M E	17.00	19.00	24.00	25.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112.00		
2210	SSI DISABLED NON-ME D	6,177.00	6,184.00	6,175.00	6,182.00	6,168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,886.00		
2220	SSI DISABLED WITH Q M	49.00	51.00	52.00	52.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2310	SSI BLIND NON-MEDIC A	56.00	57.00	56.00	56.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		282.00		
4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	40.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204.00		
4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	311.00	321.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,577.00		
4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	342.00	345.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,625.00		
4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	80.00	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381.00		
4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	84.00	87.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		413.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5015	SOBRA PREG 14-20 FE M	7.00	6.00	5.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
	7,546.00	7,561.00	7,581.00	7,572.00	7,566.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,826.00		

O

SUBTOTAL:

1113	TANF EXPANDED 06-13	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
1.00	
1.00	
5.00	
1.00	
8.00	

3514	ADULT 40-100% MALE 1	2.00	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	2.00	2.00	2.00	1.00	1.00	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	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	15.00	17.00	16.00	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	9.00	10.00	10.00	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1.00	1.00	1.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	1.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11.00	
8.00	
1.00	
1.00	
74.00	
51.00	
8.00	
6.00	

AL

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	30.00	33.00	32.00	33.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.00		

SUBTOTAL:

3.00

3.00

3915	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

38,121.00

TOTAL:

4413	SOBRA 100-133% M&F
6	11.00	10.00	9.00	26.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	4.00	4.00	2.00	9.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2.00	2.00	1.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	17.00	16.00	12.00	38.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

85.00	
27.00	
12.00	
124.00	

SUBTOTAL:

7,596.00	7,612.00	7,627.00	7,645.00	7,641.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		
	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		

SUBTOTAL:

1006	TANF 21-44 MALE WITH	13,748.51	11,706.46	23,270.89	8,748.57	7,149.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1007	TANF 21-44 FEMALE WI	17,026.44	13,867.21	25,370.63	22,346.09	17,592.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1008	TANF 45-64 M & F WIT	29,543.51	38,496.50	56,571.19	54,075.02	32,676.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1009	TANF 65+ M & F WITH	9,711.26	9,427.79	29,391.90	16,563.16	12,496.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1011	TANF <1 M & F NON-ME	1,290,959.10	1,245,523.04	1,285,302.05	905,574.17	963,537.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	1,257,382.93	1,081,951.02	933,354.82	539,709.66	757,662.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	1,882,318.21	1,589,351.98	1,841,982.47	862,977.79	1,029,797.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	349,688.37	397,522.68	308,438.57	514,200.50	224,937.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N O	618,162.51	955,347.31	724,128.67	410,827.38	435,390.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1016	TANF 21-44 MALE NON-	1,720,458.08	1,835,554.52	2,506,066.57	1,727,158.48	1,426,837.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1017	TANF 21-44 FEMALE N O	6,255,681.23	6,847,408.50	8,911,141.15	5,718,928.09	5,916,678.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1018	TANF 45-64 M & F NON	2,241,687.50	2,225,717.52	3,261,573.62	2,183,571.68	2,053,071.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1019	TANF 65+ M & F NON-M	10,320.41	9,670.04	10,279.84	5,969.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1026	TANF 21-44 MALE WITH	700.00	568.89	2,023.45	1,345.49	471.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1027	TANF 21-44 FEMALE WI	1,268.82	1,174.29	4,000.44	2,990.62	509.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1028	TANF 45-64 M & F WIT	6,682.12	19,778.64	18,075.17	3,448.75	7,147.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1029	TANF 65+ M & F WITH	5,507.74	3,496.54	5,763.29	2,613.98	4,407.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	167,284.72	163,478.22	201,904.18	127,579.30	163,117.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	125,205.47	128,787.96	211,507.53	151,466.88	159,319.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	326,875.26	398,974.35	518,146.67	350,297.01	301,912.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	306,269.94	461,879.30	527,481.62	417,867.71	349,136.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	8,070,657.42	8,785,140.60	10,377,505.66	6,855,292.97	7,625,934.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	1,017,428.75	1,228,462.25	1,678,808.77	1,093,787.83	1,003,545.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	2,615.94	1,503.84	1,485.61	614.91	454.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	117,830.33	100,119.21	107,909.34	69,161.53	71,428.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	16,751.49	16,898.33	16,514.76	11,295.59	10,808.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4311	SOBRA CHILD <1 M & F	2,174,749.48	2,074,877.06	2,217,875.37	1,618,780.76	2,184,782.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4312	SOBRA CHILD 01-05 M	2,763,871.20	2,834,483.06	3,569,126.85	2,468,077.70	3,433,325.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4313	SOBRA CHILD 06-13 M	3,762,824.46	4,361,436.75	6,065,640.01	3,546,216.84	4,651,190.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4314	SOBRA CHILD 14-20 MA	939,030.81	1,434,713.92	1,458,821.66	973,466.61	1,231,404.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4315	SOBRA CHILD 14-20 FE	1,301,099.71	1,480,601.04	1,858,178.99	1,598,217.67	1,508,100.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	700.00	700.00	0.00	21.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

64,624.04	
96,203.02	
211,362.50	
77,590.19	
5,690,895.44	
4,570,060.59	
7,206,428.42	
1,794,787.31	
3,143,856.32	
9,216,075.10	
33,649,837.38	
11,965,622.05	
36,939.29	
5,108.97	
9,944.02	
55,131.83	
21,788.91	
823,363.58	
776,287.13	
1,896,206.06	
2,062,634.68	
41,714,530.76	
6,022,032.95	
6,674.53	
466,448.82	
72,268.35	
700.00	
10,271,065.19	
15,068,884.68	
22,387,308.98	
6,037,437.84	
7,746,197.51	
1,421.79	

D

M

SUBTOTAL:

3,645,170.04	3,654,958.78	4,322,859.94	3,374,479.87	4,570,982.50

0.00

0.00

0.00

0.00

0.00

0.00

0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,357.53	1,572.17	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,629.70		
5015	SOBRA PREG 14-20 FE M	396,630.45	405,096.39	479,727.39	392,622.76	525,109.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,199,186.96		
5017	SOBRA PREG 21-44 FE M	1,708,550.06	2,049,753.34	2,625,202.28	1,982,900.83	2,364,318.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,730,725.07		
5018	SOBRA PREG 45-64 FE M	4,193.00	14,500.38	2,450.00	1,822.16	1,347.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,312.83		
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.47		
SUBTOTAL:	38,912,715.23	42,227,968.93	51,870,791.41	34,642,089.66	38,477,020.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,130,585.26		

M

1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	10,284.15	10,175.29	17,463.56	6,713.81	6,727.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	22,395.39	24,471.89	35,137.04	29,098.84	37,436.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	62,335.76	91,660.22	84,344.30	47,375.02	62,250.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	23,910.19	20,501.26	32,963.26	25,925.52	28,936.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1111	M&
TANF EXPANDED <1 M	
0.00	
107.79	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

1112	&F
TANF EXPANDED 01-05	
5,732.86	
4,829.90	
1,724.46	
1,174.70	
2,883.38	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1113	TANF EXPANDED 06-13	30,078.23	19,474.68	25,336.13	9,267.93	12,274.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	15,858.70	9,308.99	5,711.38	9,618.73	16,742.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	28,001.63	22,720.99	43,056.85	16,406.84	35,978.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	362,417.96	353,624.60	512,350.28	353,039.43	652,149.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,288,260.07	1,258,732.85	1,300,199.98	1,114,194.80	1,720,889.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	704,691.67	705,276.22	792,023.29	747,280.96	1,128,424.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+	4.35	1,208.05	2,125.17	1,050.00	1,233.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1126	M&
TANF EXPANDED 21-44	
1,500.26	
3,544.35	
2,230.96	
1,605.60	
1,457.35	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1127	TANF EXPANDED 21-44	2,664.74	2,843.89	7,168.40	2,711.75	2,663.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	9,867.91	10,323.33	12,735.99	9,612.64	14,560.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+	7,716.84	9,382.71	9,968.24	4,051.32	6,051.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2400	M&
SSI AGED EXPANDED	
22,942.06	
38,024.62	
25,791.81	
23,668.51	
15,918.51	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
67,166.54	
76,848.41	
85,275.84	
56,641.92	
14,405.42	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
381,632.77	
433,733.65	
560,695.33	
355,819.68	
312,801.61	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	WI
SSI DISABLED EXPAND	
12,133.96	
14,195.83	
29,503.82	
33,613.80	
21,605.09	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
300,375.73	
232,843.02	
283,300.90	
217,797.74	
205,261.69	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
285,198.27	
311,126.24	
453,402.95	
307,810.33	
270,330.08	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
350.00	
51,364.34	
148,539.18	
347,965.61	
132,236.41	
107.79	
16,345.30	
96,431.83	
57,240.34	
146,164.65	
2,233,581.67	
6,682,277.44	
4,077,696.57	
5,621.13	
10,338.52	
18,052.57	
57,100.59	
37,171.06	
126,345.51	
300,338.13	
2,044,683.04	
111,052.50	
1,239,579.08	
1,627,867.87	
19,568,451.13	

3308	AHC CARE M&F 45-64 W	21.62	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	-95.91	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	-527.88	0.00	-316.00	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	-12,669.89	0.00	0.00	-883.27	-304.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
21.62	
-95.91	
-843.88	
-13,857.29	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	-13,272.06	0.00	-316.00	-883.27	-304.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14,775.46		

SUBTOTAL:

3410	MED ELIGIBILITY NON-	0.00	0.00	-99.09	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	60.75	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-	-2,238.34	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	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-23,081.14	-52.99	-475.87	-491.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,251.30	-100.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	48,625.18	0.00	1,316.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	22,658.87	-52.99	14,341.74	-591.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

-99.09	
60.75	
-2,238.34	
12,313.57	
-24,101.04	
478.22	
49,941.56	
36,355.63	

SUBTOTAL:

3506	ADULT 40-100% MALE 2	100.62	646.90	826.55	497.49	10.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	350.00	-297.96	350.00	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	4,048.26	5,152.04	8,303.45	2,673.83	5,233.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	1,136.72	650.66	2,304.18	777.55	2,786.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	28,154.57	16,919.86	20,598.17	29,661.34	27,712.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	63,740.82	68,857.24	154,389.86	65,722.76	76,922.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	595,422.82	648,844.84	749,505.91	775,688.96	602,174.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	448,531.84	490,065.88	644,008.43	391,103.49	455,793.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	1,779,103.67	1,877,742.95	2,130,964.95	1,387,795.56	1,631,187.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	700.00	1,114.00	4,797.69	17,145.46	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	74.88	136.07	0.61	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	101.17	60.44	121.84	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	380.98	90.66	380.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	5.04	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	254.18	187.24	2,147.85	720.29	183.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	3,196.60	2,984.95	5,735.57	5,555.83	3,319.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	20,398.58	29,175.88	21,993.36	25,199.18	23,133.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	662.62	898.69	1,365.10	1,918.68	573.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	222,884.44	394,365.52	460,111.11	290,538.55	301,852.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	310,676.54	280,914.28	359,791.31	268,309.43	294,507.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	5,628,508.71	6,879,358.31	8,226,675.54	5,692,613.38	6,424,354.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,131,984.98	3,612,847.61	4,415,525.36	3,018,805.67	3,263,582.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	7,505,601.56	8,385,725.63	10,052,601.97	7,135,426.84	7,938,678.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	20,526.57	6,525.97	34,180.45	3,932.97	6,156.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	166.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	-612.98	2,336.87	599.83	1,113.03	476.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,081.62	
402.04	
25,411.11	
7,655.61	
123,046.17	
429,633.20	
3,371,637.06	
2,429,502.86	
8,806,794.32	
24,457.15	
561.56	
283.45	
851.86	
64.44	
3,492.60	
20,792.30	
119,900.12	
5,418.86	
1,669,751.84	
1,514,198.79	
32,851,510.52	
17,442,746.61	
41,018,034.59	
71,322.92	
166.20	
3,913.66	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	19,765,638.49	22,705,157.72	27,297,474.93	19,115,291.56	21,060,068.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,943,631.46		

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	21.47	708.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	2,100.00	392.10	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	8,274.29	12,110.91	11,447.94	6,297.36	4,582.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	291.65	74.97	0.00	1,418.20	2,273.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	6,715.58	7,956.39	28,873.22	11,240.21	10,919.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	22,792.35	34,855.60	21,227.56	25,293.64	28,961.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	305,610.01	396,142.75	488,332.18	433,207.58	284,638.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	365,563.44	469,279.85	562,236.94	478,333.08	462,900.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	1,046,431.51	1,175,014.10	1,299,604.63	912,240.75	1,066,051.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	700.00	0.00	2,450.00	1,050.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	47.11	350.00	59.40	0.00	48.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,757,825.94	2,095,784.57	2,416,331.87	1,869,494.39	1,862,134.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2,130.05	
2,842.10	
42,712.84	
4,058.67	
65,705.17	
133,130.98	
1,907,931.40	
2,338,313.55	
5,499,342.24	
4,900.00	
504.76	
10,001,571.76	

4

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F	208,919.81	208,659.92	145,887.27	356,231.37	470,925.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4414	6
SOBRA 100-133% MALE	
89,702.86	
89,764.24	
51,754.79	
154,905.56	
148,369.44	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4415	SOBRA 100-133% FEMA	72,034.45	135,577.62	72,403.64	179,192.24	176,144.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	L													

 	
700.00	
1,390,624.18	
534,496.89	
635,352.24	
2,561,173.31	

SUBTOTAL:

370,657.12

434,001.78

270,045.70

690,329.17

796,139.54

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4517	BC PATIENT FEMALE 2 1	5,936.00	6,300.97	5,519.97	999.09	457.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	1,513.47	2,898.87	2,896.09	4,542.74	42,584.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	8,655.21	1,050.00	485.19	7,330.09	-18.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	4,085.95	1,050.00	2,131.49	2,168.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	20,190.63	11,299.84	11,032.74	15,039.98	43,023.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

19,213.41	
54,435.25	
17,502.18	
9,435.50	
100,586.34	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	3,861.91	11,145.71	10,454.38	6,107.64	5,084.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	2,100.00	2,528.61	332.93	1,759.52	13,816.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8720	M
SSI DISABLED FREEDO	
59.40	
237.60	
367.94	
0.00	
10.26	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	M													

6,021.31

13,911.92

11,155.25

7,867.16

18,911.44

0.00

0.00

0.00

0.00

0.00

0.00

0.00

36,653.95	
20,537.93	
675.20	
57,867.08	

SUBTOTAL:

348,385,159.88

64,487,605.57	71,142,743.92	86,213,717.58	59,713,116.53	66,827,976.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2015

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

1006	TANF 21-44 MALE WITH	0.00	79.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79.15	
1008	TANF 45-64 M & F WIT	0.00	0.00	64.35	0.00	208.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	272.70	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	1,311.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,311.75	
1011	TANF <1 M & F NON-ME	439.67	11,488.16	5,242.20	3,484.30	7,484.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,139.01	
1012	TANF 01-05 M & F NON	1,999.68	0.00	6,173.64	0.00	177.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,350.35	
1013	TANF 06-13 M & F NON	0.00	0.00	-29.23	37.11	314.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	322.67	
1014	TANF 14-20 MALE NON-	1,639.96	371.56	1,298.43	1,214.10	4,020.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,544.34	
1015	TANF 14-20 FEMALE N	10,367.88	4,369.23	19,961.56	6,311.54	3,726.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,736.27	
1016	O
TANF 21-44 MALE NON-	27,978.02	35,547.13	51,358.56	38,612.37	40,905.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
194,401.08	
1017	TANF 21-44 FEMALE N	85,071.84	122,995.47	128,349.71	151,849.80	85,693.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	573,960.69	
1018	O
TANF 45-64 M & F NON	19,601.63	63,726.19	20,776.67	18,549.31	28,491.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
151,145.47	
2100	SSI AGED WITH MEDIC	4,288.93	2,161.00	6,039.80	3,610.04	6,310.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,409.81	
2110	A
SSI AGED NON-MEDICA	16,932.19	33,017.03	46,637.60	18,239.09	16,129.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
130,954.98	
2120	R
SSI AGED WITH QMB	0.00	807.00	131.79	1,379.48	288.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,607.24	
2200	SSI DISABLED WITH M	488.66	1,617.07	3,610.05	1,642.17	3,477.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,835.15	
2210	E
SSI DISABLED NON-ME	39,007.48	95,497.11	23,513.88	6,329.44	33,843.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
198,191.02	
2220	D
SSI DISABLED WITH Q	0.00	1,277.10	1,336.18	934.55	209.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,757.54	

2310	M
SSI BLIND NON-MEDIC	
0.00	
0.00	
0.00	
812.46	
700.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,512.46	
4311	A
SOBRA CHILD <1 M & F	117,403.64	23,297.12	59,254.42	35,673.44	67,380.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
303,009.45	
4312	SOBRA CHILD 01-05 M	64,184.72	52,686.05	65,786.94	66,664.94	55,185.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	304,508.12	
4313	SOBRA CHILD 06-13 M	34,405.76	34,320.87	47,228.07	40,773.76	40,430.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	197,159.16	
4314	SOBRA CHILD 14-20 MA	34,112.02	13,654.57	40,427.51	19,191.40	55,948.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	163,333.56	
4315	SOBRA CHILD 14-20 FE	25,544.79	41,450.78	33,073.65	31,045.68	27,206.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	158,321.13	
5007	SOBRA PREG 21-44 FE	1,316.92	-622.54	620.43	373.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,687.82	
5015	M
SOBRA PREG 14-20 FE	17,081.33	30,674.40	30,351.24	28,628.36	24,395.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
131,131.06	
5017	M
SOBRA PREG 21-44 FE	77,766.50	80,269.95	104,810.09	109,667.47	114,599.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
487,113.69	
5018	M
SOBRA PREG 45-64 FE	0.00	28.27	0.00	0.00	-28.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	

8040	M SLMB	
6,944.53	
49.41	
807.03	
-83.03	
73.45	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
7,791.39	
8050	QI1	959.34	1,438.39	130.47	132.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,660.21	

SUBTOTAL:

587,535.49

650,200.47	696,955.04	585,072.80	618,483.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,138,247.27

1106	TANF EXPANDED 21-44	0.00	93.33	88.81	2,077.39	12.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	264.36	294.74	124.24	62.89	255.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	773.33	420.71	6,906.69	1,311.67	883.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	515.10	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	1,224.74	4,420.72	764.15	3,746.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
2,271.86	
1,001.27	
10,296.35	
515.10	
10,156.08	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1116	TANF EXPANDED 21-44	13,694.50	13,902.95		27,807.18	11,482.37		18,513.51		0.00		0.00		0.00		0.00	0.00	0.00	0.00	85,400.51
1117	TANF EXPANDED 21-44	31,143.56	46,456.94	70,887.40	33,885.09	33,000.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215,373.09

1118	TANF EXPANDED 45-64	29,015.56	33,956.75	60,010.71	18,273.86	33,687.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	174,943.90

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

2,377.90	12,618.70	12,271.07	5,527.40	15,781.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,576.13

979.32	10,480.42	0.00	3,960.00	1,445.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,865.14

550.98	1,286.23	328.44	378.82	327.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,871.58

2,818.70	1,835.75	7,785.00	2,326.61	1,030.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,796.85

3,572.35	3,805.02	18,910.75	13,966.80	2,598.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,853.26

260.03	91.97	253.43	619.21	133.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,358.06

SUBTOTAL:

87,190.43

129,664.23	206,137.87	97,618.58	107,668.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	628,279.18

3508

3514

ADULT 40-100% M&F 45

ADULT 40-100% MALE 1

39.84

7,354.73

0.00

2,210.13

636.68

9,226.86

0.00

10,267.58

6.87

8,018.15

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3515

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

4,053.85

7,409.16

13,107.92

8,412.79

4,417.22

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3516

22,487.77

47,727.87

38,141.10

50,616.29

39,471.83

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3517

3518

ADULT 40-100% FEMAL
E
ADULT 40-100% M&F 45

32,478.15

115,109.31

34,588.71

85,155.48

42,476.30

173,866.91

26,676.78

145,967.88

23,987.36

74,682.01

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3519

ADULT 40-100% M&F 65

0.00

83.25

1,075.63

243.08

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3527

3708

ADULT 40-100% FEMAL
E
ADULT <40% EXP MALE

ADULT <40% EXP FEM AL
ADULT <40% EXP M&F
4
ADULT <40% EXP MALE

35.04

0.00

128.60

309.42

104.58

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3706

3707

1,587.28

947.85

0.00

0.00

57.02

377.50

0.00

1,293.45

0.00

265.02

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

350.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3714

-3,202.73

15,501.02

18,183.71

10,358.26

16,379.49

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3715

3716

ADULT <40% EXP FEM
AL
ADULT <40% EXP MALE

8,301.75

167,516.26

16,458.77

204,690.38

17,720.35

358,830.19

17,356.78

199,648.63

22,093.55

205,387.98

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3717

ADULT <40% EXP FEM
AL
ADULT <40% EXP M&F
4
ADULT <40% EXP MALE

161,052.04

116,919.92

123,724.40

87,699.35

97,976.52

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3718

492,428.69

286,192.87

473,719.11

334,168.08

251,532.72

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3726

0.00

0.00

2,252.43

677.92

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SUBTOTAL:

1,010,189.83

816,937.56	1,273,874.71

893,696.29

744,323.30

0.00

0.00

0.00

0.00

0.00

0.00

0.00

683.39	
37,077.45	
37,400.94	
198,444.86	
160,207.30	
594,781.59	
1,401.96	
577.64	
1,644.30	
2,883.82	
350.00	
57,219.75	
81,931.20	
1,136,073.44	
587,372.23	
1,838,041.47	
2,930.35	
4,739,021.69	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	76.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	125.54	0.00	50.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	90.99	700.00	234.31	0.00	276.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	654.68	234.01	6,077.75	2,071.23	3,663.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	4,655.16	13,237.05	2,758.11	1,970.89	1,064.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	33,428.04	33,670.17	77,463.51	55,695.29	104,128.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA	33,130.96	36,088.32	65,921.67	74,500.38	52,468.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

76.00	
175.69	
1,301.94	
12,701.49	
23,685.69	
304,385.37	
262,110.04	

L

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3918	NEWLY ELIGIBLE M&F 4	88,508.51	131,570.76	163,768.01	128,365.27	173,085.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		685,298.53		
	160,593.88	215,500.31	316,273.51	262,679.06	334,687.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,289,734.75		

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	4,059.93	12,186.74	21,110.23	15,342.31	11,795.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	5,335.47	2,393.38	14,375.66	2,342.66	3,270.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	867.96	4,065.21	16,099.57	3,552.16	3,166.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	10,263.36	18,645.33	51,585.46	21,237.13	18,232.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

64,494.84	
27,718.15	
27,750.96	
119,963.95	

SUBTOTAL:

2,070.14

2,070.14

4518	BC PATIENT FEMALE 4	0.00	0.00	0.00	124.56	1,945.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	124.56	1,945.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

5
SUBTOTAL:

9,922,910.39

TOTAL:

8700	SSI DISABLED FREEDO M	141.21	1,493.16	2,014.03	306.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	137.00	661.16	678.06	162.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	141.21	1,630.16	2,675.19	984.37	162.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3,954.71	
1,638.70	
5,593.41	

SUBTOTAL:

1,855,914.20	1,832,578.06	2,547,501.78	1,861,412.79	1,825,503.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

FAMILY PLANNING SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.37		
	-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.37		

SUBTOTAL:

-39.37

-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1011	TANF <1 M & F NON-ME		0.00		455.46		3,231.96		0.00		2,515.08		0.00		0.00		0.00		0.00	0.00	0.00	0.00	6,202.50
1012	TANF 01-05 M & F NON	3,325.77	8,684.64	18,795.85	24,960.25	9,691.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,458.14

1013	TANF 06-13 M & F NON	54,626.02	34,912.76	80,372.41	58,900.82	34,549.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	263,361.86

1014	TANF 14-20 MALE NON-	65,319.99	60,239.51	137,076.35	98,293.54	77,609.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	438,539.20

1015	TANF 14-20 FEMALE N
O

458,200.55	295,670.00	478,042.95	469,964.35	337,229.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,039,107.27

1016	TANF 21-44 MALE NON-	60,888.08	100,933.93	31,723.66	82,988.49	117,876.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	394,410.60

1017	TANF 21-44 FEMALE N
O

2,670,623.86	2,730,005.88	3,324,170.96	2,879,155.76	2,469,546.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,073,503.11

1018	TANF 45-64 M & F NON	115,318.65	114,094.17	197,992.93	147,100.97	130,195.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	704,702.29

1019	TANF 65+ M & F NON-M	974.37	580.16	36,530.93	189.47	5,569.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,844.34

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

1,028.00	1,134.36	2,508.08	3,684.44	9,408.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,763.37

767,030.64	976,118.47	1,135,999.12	1,013,075.24	667,723.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,559,946.49

2120	SSI AGED WITH QMB	0.00	1,247.40	0.00	491.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,738.45

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

15,487.16	14,895.52	19,590.18	15,828.97	7,325.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,127.18

388,846.01	233,518.99	496,312.04	330,185.22	270,923.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,719,785.42

0.00	0.00	0.00	0.00	764.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	764.97

-213.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-213.81

SUBTOTAL:

4,601,455.29

4,572,491.25	5,962,347.42	5,124,818.57	4,140,928.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,402,041.38

1106	TANF EXPANDED 21-44	942.36	1,534.47	1,505.09	822.46	57.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	926.52	718.33	594.32	890.41	738.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	2,965.50	1,071.83	1,199.19	627.92	4,088.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	312.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	1,190.91	3,724.52	4,105.86	9,094.01	4,525.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	10,061.00	21,034.78	16,389.70	20,183.82	22,986.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	354,391.46	305,914.64	598,525.42	505,905.51	304,707.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	755,978.61	983,459.10	1,040,015.43	1,183,824.04	701,830.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	334,689.08	312,771.14	498,580.17	493,587.41	273,748.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	5,837.82	4,006.70	13,397.27	6,670.37	1,703.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	3,738.85	228.58	31.65	378.59	28.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	91,019.49	40,318.46	59,658.59	49,583.24	58,225.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	698.31	742.38	385.05	49.30	660.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	34,997.13	35,849.69	53,494.32	45,988.82	18,108.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,597,437.04	1,711,374.62	2,288,194.10	2,317,605.90	1,391,409.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4,861.68	
3,868.37	
9,952.76	
312.04	
22,640.92	
90,655.92	
2,069,444.30	
4,665,107.67	
1,913,376.27	
31,616.11	
4,405.99	
298,804.95	
2,535.82	
188,438.06	
9,306,020.86	

SUBTOTAL:

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	11.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	631.64	303.33	2,007.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	0.00	3,220.32	764.56	0.00	470.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11.67	
2,942.57	
4,455.78	

E

FEDERAL EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	363.70	744.09	123.30	1,408.45	277.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,917.22		
3708	ADULT <40% EXP M&F 4	0.00	83.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.87		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	96.03	153.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.92		
3715	ADULT <40% EXP FEM AL	0.00	689.22	934.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,623.28		
3716	ADULT <40% EXP MALE	3,173.56	985.83	1,307.20	1,210.89	1,112.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,790.44		
3717	ADULT <40% EXP FEM AL	7,385.92	3,761.60	4,166.17	795.15	144.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,253.21		
3718	ADULT <40% EXP M&F	6,017.10	34,892.69	1,317.28	2,900.81	2,053.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,181.61		
	17,571.92	44,680.95	10,620.17	6,411.33	4,225.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,509.57		

4
SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	61.58	57.52	40.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	3,134.87	5,350.82	1,445.22	2,455.88	3,337.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	294.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	22,970.43	28,098.00	35,654.89	64,365.00	22,203.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	30,691.94	32,607.21	67,119.06	43,281.81	32,340.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	433,489.69	517,176.26	860,044.12	689,690.10	619,841.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	300,086.49	238,508.95	403,994.50	295,796.76	356,891.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	894,595.81	1,176,047.32	1,802,982.03	1,288,816.29	895,641.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	15,863.94	1,457.81	4,116.70	11,314.92	4,086.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	46.58	46.58	718.50	666.40	737.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	695.06	694.80	694.15	694.28	57.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,701,574.81	1,999,987.75	3,176,830.75	2,397,433.76	1,935,178.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

160.01	
15,724.59	
294.80	
173,292.06	
206,040.05	
3,120,241.79	
1,595,278.49	
6,058,082.68	
36,840.04	
2,215.24	
2,835.59	
11,211,005.34	

4

45,002,577.15

TOTAL:

SUBTOTAL:

7,918,039.06	8,328,534.57	11,437,992.44	9,846,269.56	7,471,741.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

QMB - FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,647,430.99		
	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,647,430.99		

SUBTOTAL:

1,647,430.99

293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

1017	TANF 21-44 FEMALE N	3,227.31	2,397.42	0.00	5,425.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,050.65	

2100	O
SSI AGED WITH MEDIC	
15,412.32	
89,978.84	
21,245.35	
45,417.87	
26,065.20	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
198,119.58	
2110	A
SSI AGED NON-MEDICA	61,148.18	60,953.07	9,698.95	112,583.05	49,546.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
293,929.91	
2120	R
SSI AGED WITH QMB	1,093.55	171.15	0.00	0.00	6,269.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
7,534.11	
2200	SSI DISABLED WITH M	4,280.93	0.00	0.00	0.00	121.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,402.35	
2210	E
SSI DISABLED NON-ME	0.00	806.03	7.57	2,769.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,583.26	
2220	D
SSI DISABLED WITH Q	5,933.83	6,506.08	0.00	0.00	13,921.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
26,361.78	

5017	M
SOBRA PREG 21-44 FE	
3,043.51	
2,377.80	
0.00	
0.00	
470.90	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
5,892.21	
8020	M
QMB ONLY	0.00	164.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
164.38	

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

94,139.63

163,354.77

30,951.87

166,196.50

96,395.46

0.00

0.00

0.00

0.00

0.00

0.00

0.00

551,038.23

1116	TANF EXPANDED 21-44	0.00	0.00	4,142.44	100.05	690.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	10,918.19	376.34	0.00	992.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	10,918.19	376.34	4,142.44	1,092.26	690.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4,932.55	
12,286.74	
17,219.29	

SUBTOTAL:

3516	ADULT 40-100% MALE 2	276.08	465.25	113.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	2,286.61	1,389.07	109,186.74	177.18	2,034.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	0.00	0.00	0.00	15.96	311.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3708	AL
ADULT <40% EXP M&F	
48,908.37	
28,993.62	
20,991.36	
10,383.16	
30,269.24	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3714	4
ADULT <40% EXP MALE	
0.00	
108.35	
23,795.80	
2,084.65	
249.30	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3716	ADULT <40% EXP MALE	282,960.57	239,237.96	160,049.34	141,590.13	133,394.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	8,006.01	55,446.91	23,944.21	15,778.68	10,519.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
235,458.94	
434,500.79	
215,685.56	
224,311.09	
328,728.18	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
1,495.64	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3726	6
ADULT <40% EXP MALE	
73.01	
0.00	
-57.05	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3728	ADULT <40% EXP M&F	9,628.14	5,770.49	8,615.35	434.96	1,598.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	4													

589,093.37

765,912.44

562,324.39

394,775.81

507,105.56

0.00

0.00

0.00

0.00

0.00

0.00

0.00

854.41	
115,074.17	
327.64	
139,545.75	
26,238.10	
957,232.48	
113,695.03	
1,438,684.56	
1,495.64	
15.96	
26,047.83	
2,819,211.57	

SUBTOTAL:

3,508,325.68

TOTAL:

3916	NEWLY ELIGIBLE MALE	352.61	16,903.27	22,673.32	2,578.16	12,349.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	5,998.76	18,912.57	11,373.57	6,819.98	22,894.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	6,351.37	35,815.84	34,046.89	9,398.14	35,244.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

54,857.11	
65,999.48	
120,856.59	

SUBTOTAL:

700,502.56	965,459.39	631,465.59	571,462.71	639,435.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

COCHISE COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	586.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		586.31		
	0.00	0.00	0.00	0.00	586.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		586.31		

SUBTOTAL:

479.53

479.53

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	479.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	479.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

1,065.84

0.00	0.00	0.00	0.00	1,065.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	3,842.02	0.00	0.00	7.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,849.39		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	274.42	1,118.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,393.13		
3718	ADULT <40% EXP M&F 4	151.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151.74		
	151.74	3,842.02	0.00	274.42	1,126.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,394.26		

SUBTOTAL:

TOTAL:	151.74	3,842.02	0.00	274.42	1,126.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,394.26		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1014	TANF 14-20 MALE NON-		0.00		0.00		7,504.65		0.00		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	7,504.65
1016	TANF 21-44 MALE NON-	2,440.29	3,129.66	300.47	366.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,237.12

1017	TANF 21-44 FEMALE N
O
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
5007	SOBRA PREG 21-44 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

0.00	2,041.21	946.05	3,936.64	9,915.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,839.43

0.00	10,751.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,751.39

18,422.83	10,195.76	34,766.80	17,317.71	168.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,871.97

15.35	3,019.90	3,735.46	357.86	-36.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,092.41

0.00	0.00	0.00	2,411.86	836.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,248.59

0.00	0.00	0.00	3,666.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,666.59

0.00	5,306.85	4,658.33	5,451.17	203.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,619.75

SUBTOTAL:

20,878.47

34,444.77	51,911.76	33,508.53	11,088.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151,831.90

1116	TANF EXPANDED 21-44	3,673.93	0.00	0.00	0.00	465.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	14,172.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	411.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	2,757.38	5,096.64	0.00	70.22	894.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,603.73	5,096.64	0.00	70.22	1,771.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4,139.40	
14,172.42	
411.22	
8,818.99	
27,542.03	

E

3516	ADULT 40-100% MALE 2	0.00	0.00	4,010.58	2,822.80	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	16,799.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	83.10	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	1,298.03	229.50	228.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	69,878.66	66,286.32	10,893.65	95,669.19	16,280.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	5,251.56	3,256.51	2,374.79	13,269.40	9,235.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	49,207.81	47,104.83	15,084.95	62,449.62	5,959.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	124,338.03	133,446.71	33,662.00	174,523.61	31,703.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

6,833.38	
16,799.05	
83.10	
1,755.99	
259,008.80	
33,387.45	
179,806.49	
497,674.26	

SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	149.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	15,153.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	15,153.54	0.00	0.00	149.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

149.02	
15,153.54	
15,302.56	

SUBTOTAL:

503.71

503.71

8720	SSI DISABLED FREEDO M	0.00	0.00	503.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	503.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

692,854.46

180,973.77	172,988.12	86,077.47	208,251.38	44,563.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	52.80	0.00	7.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.78		
2210	SSI DISABLED NON-ME D	327.15	591.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918.52		
5017	SOBRA PREG 21-44 FE M	11.66	2,253.21	4,046.52	8,752.09	858.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,922.18		
	338.81	2,844.58	4,099.32	8,752.09	866.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,901.48		

SUBTOTAL:

1116	TANF EXPANDED 21-44	435.29	0.00	0.00	91.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	112.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	548.25	0.00	0.00	91.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
526.42	
112.96	
639.38	

82,191.51

TOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	17.50	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	79.49	98.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	13,355.83	4,487.44	0.00	6,733.15	1,783.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	55.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	2,778.01	10,131.21	950.60	14,425.99	9,754.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	16,189.14	14,618.65	968.10	21,238.63	11,636.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

17.50	
177.73	
26,359.93	
55.30	
38,040.19	
64,650.65	

SUBTOTAL:

17,076.20	17,463.23	5,067.42	30,081.85	12,502.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	4,241.75	0.00	467.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,708.75		
2200	SSI DISABLED WITH M E	0.00	630.38	160.15	327.76	4,219.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,337.70		
2210	SSI DISABLED NON-ME D	0.00	160.89	0.00	0.00	327.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		488.65		
	0.00	791.27	4,401.90	327.76	5,014.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,535.10		

SUBTOTAL:

3716	ADULT <40% EXP MALE	7.98	1,430.76	0.00	0.00	250.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	144.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
8,014.50	
-3,085.25	
11,735.79	
3,531.90	
14,525.08	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

8,166.82

-1,654.49

11,735.79

3,531.90

14,775.65

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,689.31	
144.34	
34,722.02	
36,555.67	

4
SUBTOTAL:

47,090.77

8,166.82	-863.22	16,137.69	3,859.66	19,789.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	9,251.66	323.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,575.55		
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	160.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.89		
3716	ADULT <40% EXP MALE	306.05	0.00	166.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		472.31		
	306.05	0.00	166.26	9,251.66	484.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,208.75		

SUBTOTAL:

TOTAL:	306.05	0.00	166.26	9,251.66	484.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,208.75		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME D	0.00	177.03	0.00	4,575.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,752.19		
	0.00	177.03	0.00	4,575.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,752.19		

SUBTOTAL:

556.20

556.20

2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	556.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	556.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

3716	ADULT <40% EXP MALE	0.00	673.35	580.79	372.54	6,342.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	3,152.09	110.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	0.00	258.61	0.00	0.00	3,152.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	4,084.05	691.59	372.54	9,494.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

7,968.94	
3,262.89	
3,410.70	
14,642.53	

4
SUBTOTAL:

19,950.92

0.00	4,261.08	691.59	4,947.70	10,050.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

1010	TANF NON-MEDICARE	0.00	350.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	
2100	SSI AGED WITH MEDIC	1,867,476.11	2,106,357.37	3,001,652.11	2,153,315.25	2,357,150.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,485,951.51	
2110	A
SSI AGED NON-MEDICA	177,147.26	101,345.13	299,519.40	157,341.85	107,732.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
843,086.32	
2120	R
SSI AGED WITH QMB	2,867,399.51	2,877,254.51	4,110,836.71	2,939,351.28	3,113,372.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
15,908,214.33	
2200	SSI DISABLED WITH M	543,524.04	474,214.50	724,208.95	536,644.76	552,216.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,830,808.59	
2210	E
SSI DISABLED NON-ME	2,493,153.38	2,750,175.45	3,099,509.74	2,474,403.45	2,586,712.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
13,403,954.48	
2220	D
SSI DISABLED WITH Q	639,532.10	693,460.39	974,750.74	671,858.25	672,467.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,652,069.08	

2300	M
SSI BLIND WITH MEDIC	
74.93	
0.00	
59.40	
59.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
193.73	
2310	SSI BLIND NON-MEDIC	22,797.15	14,440.58	16,725.82	12,338.81	12,877.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,179.88	

2320	A
SSI BLIND WITH QMB	
5,463.78	
7,778.92	
7,725.25	
5,362.02	
6,671.36	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
33,001.33	

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

8,616,568.26	9,025,376.85     12,234,988.12	8,951,025.07	9,409,200.95

0.00

0.00

0.00

0.00

0.00

0.00

0.00

48,237,159.25

48,259,778.01

TOTAL:

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,044.41	2,637.12	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,712.52	4,868.22	9,193.05	4,689.12	2,155.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

9,658.40	
12,960.36	
22,618.76	

SUBTOTAL:

8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

121,224.74

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	4,497.83	12,645.58	24,804.14	14,473.36	13,002.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,423.40		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	399.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399.80		
2120	SSI AGED WITH QMB	0.00	83.04	41.43	0.00	81.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206.05		
2200	SSI DISABLED WITH M E	572.87	1,912.10	6,455.92	314.42	3,785.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,040.68		
2210	SSI DISABLED NON-ME	10,415.23	19,351.87	894.64	5,932.66	1,560.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,154.81		
SUBTOTAL:	15,485.93	33,992.59	32,196.13	21,120.24	18,429.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,224.74		

32,196.13	21,120.24	18,429.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

D

TOTAL:

15,485.93

33,992.59

1012	TANF 01-05 M & F NON	44,618.60	15,435.03	41,858.69	18,932.81	15,467.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136,312.17	
1013	TANF 06-13 M & F NON	101,743.02	26,444.15	55,447.66	40,252.23	32,584.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	256,471.97	
1014	TANF 14-20 MALE NON-	8,473.78	2,483.13	8,146.57	6,639.55	4,375.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,118.98	
1015	TANF 14-20 FEMALE N	3,292.00	1,194.76	3,063.63	2,548.02	1,886.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,984.66	
2120	O
SSI AGED WITH QMB	0.00	0.00	69.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
69.53	
2200	SSI DISABLED WITH M	33.88	103.18	181.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	318.20	
2210	E
SSI DISABLED NON-ME	252,041.30	84,309.59	219,296.65	140,342.61	148,906.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
844,896.29	

2220	D
SSI DISABLED WITH Q	
0.00	
0.00	
0.00	
23.96	
10.53	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
34.49	
2300	M
SSI BLIND WITH MEDIC	158.70	63.48	0.00	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
238.05	
2310	SSI BLIND NON-MEDIC	2,989.18	538.14	1,847.47	1,001.22	903.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,279.65	
2320	A
SSI BLIND WITH QMB	0.00	333.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
333.30	
4305	SOBRA CHILD 14-20 FE	32.20	0.00	0.00	0.00	28.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60.50	
4312	SOBRA CHILD 01-05 M	74,849.31	21,849.59	69,541.43	41,184.72	40,971.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248,396.94	
4313	SOBRA CHILD 06-13 M	138,639.38	30,827.76	103,590.12	109,202.16	99,584.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	481,843.50	
4314	SOBRA CHILD 14-20 MA	12,134.57	3,360.74	12,303.21	9,010.79	9,606.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,415.59	
4315	SOBRA CHILD 14-20 FE	3,881.60	1,365.86	4,314.96	4,418.98	4,272.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,254.37	

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

642,887.52

188,308.71

519,661.06

373,572.92

358,597.98

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,083,028.19

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	84.66	8.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	2,228.51	2,807.73	3,254.21	1,018.60	620.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	31.33	0.00	213.25	29.47	14.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	135.37	38.36	7.30	96.39	7.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	210.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,732.49	3,154.87	3,999.21	1,229.12	650.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,052.69	
9,929.77	
288.65	
284.72	
210.61	
11,766.44	

SUBTOTAL:

3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	95.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	12.33	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	6.83	27.28	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	1,726.70	9.31	990.53	137.29	119.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	1,319.96	0.00	149.20	14.00	31.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,053.49	48.92	1,139.73	151.29	246.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

95.69	
12.33	
34.11	
2,983.28	
1,514.23	
4,639.64	

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	25,022.12	4,486.95	12,154.90	21,398.13	23,398.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	8,073.76	649.78	1,470.80	1,731.37	1,992.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	515.37	640.27	290.86	918.34	676.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	33,611.25	5,777.00	13,916.56	24,047.84	26,066.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

86,460.13	
13,918.64	
3,040.84	
103,419.61	

SUBTOTAL:

TOTAL:	682,284.75	197,289.50	538,716.56	399,001.17	385,561.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,202,853.88		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1000	TANF WITH MEDICARE	831.19		0.00		115.74		154.36		496.51		0.00		0.00		0.00		0.00	0.00	0.00	0.00	1,597.80
1010	TANF NON-MEDICARE	40,868.65	24,234.06	48,725.89	26,485.58	29,892.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	170,206.60

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

2,871.13	789.16	3,394.59	1,281.47	667.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,004.20

1,249,307.80	489,106.70	1,265,880.28	765,381.38	758,689.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,528,365.47

2,114.42	-248.86	3,650.67	2,135.30	1,672.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,323.82

7,193.15	6,514.48	11,947.59	4,341.28	8,117.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,114.22

SUBTOTAL:

1,303,186.34

520,395.54	1,333,714.76	799,779.37	799,536.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,756,612.11

4,756,612.11

1,303,186.34	520,395.54	1,333,714.76	799,779.37	799,536.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE REINSURANCE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	98.96	0.00	0.01	17,434.82	-9,013.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,520.38		
1011	TANF <1 M & F NON-ME	741,618.20	275,323.86	870,817.73	584,132.79	463,642.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,935,535.15		
1012	TANF 01-05 M & F NON	59,967.01	17,049.65	46,379.51	20,619.83	151,913.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295,929.04		
1013	TANF 06-13 M & F NON	184,625.99	341,772.36	71,256.85	294,266.28	103,622.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		995,543.53		
1014	TANF 14-20 MALE NON-	12,269.60	19,354.41	57,649.19	33,553.81	369.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,196.87		
1015	TANF 14-20 FEMALE N O	18,361.96	12,714.48	18,838.21	15,383.78	25,213.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,511.45		
1016	TANF 21-44 MALE NON-	161,649.37	-21,881.23	40,292.26	305,406.83	277,743.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		763,210.72		
1017	TANF 21-44 FEMALE N O	127,936.47	159,048.89	395,075.50	504,125.42	255,419.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,441,605.47		
1018	TANF 45-64 M & F NON	84,129.25	65,348.37	87,293.71	207,392.12	65,634.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		509,797.55		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	6,170.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,170.15		
2100	SSI AGED WITH MEDIC A	624.78	33,070.16	362.69	24,212.27	12,180.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,450.62		
2110	SSI AGED NON-MEDICA R	67,861.38	195,769.67	82,798.86	187,110.03	156,837.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		690,377.37		
2200	SSI DISABLED WITH M E	43,874.36	10,496.70	3,907.51	14,759.66	36,550.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,588.28		
2210	SSI DISABLED NON-ME D	4,045,297.65	3,940,603.94	4,946,163.58	5,434,310.93	4,089,111.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,455,487.44		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	79,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,766.51		
2310	SSI BLIND NON-MEDIC A	40,412.86	2,873.76	1,068.77	-75,896.96	5,691.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-25,850.08		
4311	SOBRA CHILD <1 M & F	929,626.36	754,864.21	1,574,042.96	1,471,872.89	543,338.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,273,745.16		
4312	SOBRA CHILD 01-05 M	114,463.42	359,348.65	667,111.14	108,235.95	362,899.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,612,058.30		
4313	SOBRA CHILD 06-13 M	239,870.36	136,192.59	249,120.95	-32,500.15	196,513.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		789,196.90		
4314	SOBRA CHILD 14-20 MA	115,773.80	89,801.77	118,016.08	142,705.87	117,629.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		583,926.97		
4315	SOBRA CHILD 14-20 FE	14,027.07	63,132.41	6,858.73	138,256.42	16,264.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238,539.28		
5015	SOBRA PREG 14-20 FE M	0.00	9,507.28	408.56	4,728.20	1,067.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,711.74		
5017	SOBRA PREG 21-44 FE M	8,128.10	28,115.83	25,201.81	42,704.14	18,481.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,631.86		
	7,010,616.95	6,492,507.76	9,262,664.61	9,522,581.44	6,897,279.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,185,650.66		

SUBTOTAL:

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	329.59	0.01	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	-8.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	505.48	6,432.42	-7.13	0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	33,363.51	116,852.15	141,491.01	71,614.65	61,788.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	89,055.47	57,583.74	113,446.53	118,004.81	32,641.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	124,365.77	99,058.09	67,841.45	378,310.42	118,897.22	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	2,446.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	-18.11	42.85	43.82	25.93	10.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	14,090.33	42,829.44	49,706.82	46,616.48	7,100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND	35,356.98	19,953.70	40,311.53	39,071.56	75,248.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	20,284.70	72,266.71	62,393.79	63,319.22	126,966.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,512.50	
-8.67	
6,930.78	
425,110.26	
410,731.65	
788,472.95	
2,446.74	
104.80	
160,343.07	
209,942.16	
345,230.88	

E

E

ACUTE REINSURANCE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	316,711.60	410,028.71	481,700.77	717,276.86	425,099.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,350,817.12		

SUBTOTAL:

3316	AHC CARE MALE 21-44	22.30	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	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	742.92	2,889.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	765.22	2,889.03	0.00	0.00	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
22.30	
1,477.43	
3,631.95	
5,131.68	

3410	MED ELIGIBILITY NON-	0.00	0.00	-5,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	9,760.41	0.00	0.00	3,581.25	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	1,239.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	28,195.73	-1,579.93	-5,079.21	0.00	-1,327.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	37,956.14	-1,579.93	-10,803.56	3,581.25	-88.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

-5,724.35	
13,341.66	
1,239.38	
20,208.79	
29,065.48	

SUBTOTAL:

3508	ADULT 40-100% M&F 45	-1,247.11	6.67	2.28	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	90,377.57	23.98	303.56	10,582.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	9,715.08	0.00	14,961.01	39,148.26	53,075.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	42,038.64	132,978.87	147,952.07	213,702.36	158,020.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	69,797.48	154,862.63	143,383.48	95,096.25	34,812.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	414,839.94	278,819.33	311,265.46	367,780.84	470,498.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	2,767.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	37,973.29	1,282.59	21,727.75	-1,549.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	150,958.00	173,540.11	140,658.64	168,686.95	205,746.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	103,135.79	82,987.17	49,364.34	70,131.79	15,205.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	502,179.54	650,833.61	591,737.89	1,117,820.73	788,610.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	256,435.90	98,701.30	250,260.17	399,461.42	410,941.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	1,083,021.23	1,159,557.65	1,128,258.45	2,023,672.20	1,885,371.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	1,152.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,668,847.78	2,823,947.50	2,802,363.03	4,495,407.23	4,032,864.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

-1,238.16	
101,288.09	
116,899.49	
694,692.03	
497,952.37	
1,843,204.45	
2,767.51	
59,433.90	
839,589.97	
320,824.17	
3,651,182.74	
1,415,800.64	
7,279,880.62	
1,152.60	
16,823,430.42	

6

3908	NEWLY ELIGIBLE M&F 4	75,258.45	0.00	21,217.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,356.93	0.00	0.00	19,045.28	10,843.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	34,179.36	117,409.93	42,037.03	103,240.00	152,204.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	-833.32	13,544.41	28,948.15	38,254.97	33,953.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	163,410.54	348,055.35	252,590.82	236,488.95	162,860.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	276,371.96	479,009.69	344,793.74	397,029.20	359,861.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

96,476.19	
34,245.59	
449,070.70	
113,867.39	
1,163,405.90	
1,857,065.77	

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	19,844.57	10,180.96	21,606.21	141,092.28	121,073.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	451,101.89	451,107.67	426,127.94	679,863.69	468,911.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	188.17	9,280.96	106.64	4,451.52	-2,057.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

313,797.26	
2,477,112.63	
11,969.62	

L

ACUTE REINSURANCE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	471,134.63	470,569.59	447,840.79	825,407.49	587,927.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,802,879.51		

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	6,209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	855.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	6,209.80	0.00	0.00	855.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

6,209.80	
855.98	
7,065.78	

SUBTOTAL:

12,977.19

12,977.19

63,074,083.61

TOTAL:

8710	SSI DISABLED FREEDO	2,595.44	0.00	2,595.44	5,190.88	2,595.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,595.44	0.00	2,595.44	5,190.88	2,595.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

M

10,791,209.52	10,677,372.35	13,331,154.82	15,967,330.33	12,307,016.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

LONG TERM CARE REINSURANCE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	43.57	0.00	34,024.05	4,013.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,081.16		
2100	SSI AGED WITH MEDIC A	327,108.06	281,473.61	410,214.64	182,410.50	337,086.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,538,293.80		
2110	SSI AGED NON-MEDICA R	218,322.47	133,627.59	139,813.52	145,656.58	216,314.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		853,734.50		
2200	SSI DISABLED WITH M E	644,979.13	626,909.22	541,936.81	444,452.89	492,010.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,750,288.95		
2210	SSI DISABLED NON-ME	2,840,717.50	2,796,391.98	3,888,127.51	3,540,048.52	4,792,282.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,857,567.93		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	61.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.17		
2310	SSI BLIND NON-MEDIC	2,067.18	829.15	61,461.10	4,145.13	12,606.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,109.54		
	4,033,194.34	3,839,275.12	5,041,553.58	4,350,737.67	5,854,376.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,119,137.05		

D

A

8710	SSI DISABLED FREEDO M	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	5,856,334.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

	14,877.06	
SUBTOTAL:	14,877.06	

TOTAL:	23,134,014.11	

ACUTE SMIB
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

9,808,185.80    10,062,146.60    10,322,154.00    10,606,357.70    10,735,182.80

0.00

0.00

0.00

0.00

0.00

0.00

0.00

51,534,026.90

1000	TANF WITH MEDICARE	194,274.80	239,591.60	285,013.30	307,878.00	71,122.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,097,879.90	
1010	TANF NON-MEDICARE	419.60	314.70	419.60	419.60	839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,412.70	
1020	TANF WITH QMB	59,218.50	89,224.80	136,060.20	153,998.10	21,979.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	460,480.60	
2100	SSI AGED WITH MEDIC	55,177.40	57,030.30	58,179.30	62,320.40	92,112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	324,819.40	
2110	A
SSI AGED NON-MEDICA	390,962.30	405,066.70	409,640.00	406,988.40	406,802.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,019,459.60	
2120	R
SSI AGED WITH QMB	1,817,089.90	1,837,723.90	1,860,966.00	1,885,790.10	2,434,377.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9,835,947.30	
2200	SSI DISABLED WITH M	156,570.80	143,157.80	137,314.10	138,468.00	135,216.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	710,726.80	

2210	E
SSI DISABLED NON-ME	
332,008.50	
338,302.50	
334,945.70	
338,302.50	
337,253.50	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,680,812.70	
2220	D
SSI DISABLED WITH Q	2,831,922.00	2,873,883.50	2,914,800.20	2,923,716.10	2,934,708.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
14,479,029.80	

2300	M
SSI BLIND WITH MEDIC	
419.60	
419.60	
314.70	
314.70	
314.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,783.30	
2310	SSI BLIND NON-MEDIC	3,251.90	3,356.80	3,042.10	2,937.20	2,937.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,525.20	

2320	A
SSI BLIND WITH QMB	
25,071.10	
24,336.80	
25,910.30	
25,805.40	
26,015.20	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
127,138.80	
4300	SOBRA CHILD WITH ME	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524.50	
4320	D
SOBRA CHILD WITH Q	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
524.50	
5000	MB
SOBRA PREGNANT WO	1,363.70	1,363.70	1,153.90	944.10	629.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5,454.80	
5020	MAN
SOBRA PREGNANT WO	944.10	839.20	1,153.90	944.10	1,363.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5,245.00	
8000	MAN
SMIB ONLY NOT ELIGIB	0.00	0.00	-209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
-209.80	
8020	QMB ONLY	543,517.80	550,391.10	561,940.30	555,491.40	568,562.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,779,903.40	
8040	SLMB	3,389,057.50	3,504,045.60	3,489,229.70	3,653,533.40	3,562,064.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,597,930.90	
8888	SMIB ONLY NOT ELIGIB	-52,359.80	-26,959.30	-20,035.90	-24,127.00	-7,238.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-130,720.10	
9999	SMIB ONLY NOT ELIGIB	59,066.30	19,847.50	122,106.60	172,423.40	145,913.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	519,357.60	

1100	TANF EXPANDED FPR FI	470,376.20	412,891.00	362,329.20	338,157.10	689,298.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	209.80	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1120	FI
TANF EXPANDED FOR	
128,342.70	
125,775.10	
114,341.00	
103,116.70	
130,285.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2400	FI
SSI AGED EXPANDED	
3,042.10	
1,468.60	
1,253.90	
419.60	
209.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
524.50	
524.50	
524.50	
419.60	
314.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
2,928,537.00	
2,921,828.60	
2,878,145.10	
2,887,841.00	
2,295,255.90	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2520	WI
SSI BLIND EXPANDED	
104.90	
104.90	
104.90	
104.90	
104.90	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	W
SSI DISABLED EXPAND	
-419.60	
209.80	
314.70	
-104.90	
314.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
1,653,183.80	
1,727,813.10	
1,756,040.70	
1,816,932.70	
1,829,709.50	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
2,273,052.00	
629.40	
601,861.30	
6,394.00	
2,307.80	
13,911,607.60	
524.50	
314.70	
8,783,679.80	
25,580,371.10	

SUBTOTAL:

5,183,901.40	5,190,720.50	5,113,158.90	5,146,991.60	4,945,598.70

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3520	ADULT 40-100% FOR FI	3,147.00	-1,743.30	3,147.00	3,356.80	4,930.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	3,776.40	1,468.60	1,153.90	1,783.30	3,566.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	6,923.40	-274.70	4,300.90	5,140.10	8,496.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

12,837.80	
11,748.80	
24,586.60	

SUBTOTAL:

ACUTE SMIB
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR F	1,468.60	734.30	839.20	629.40	839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,510.70		
	1,468.60	734.30	839.20	629.40	839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,510.70		

SUBTOTAL:

113,187.10

113,187.10

TOTAL:

77,256,682.40

8720	SSI DISABLED FREEDO M	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

15,021,878.80	15,275,565.50	15,462,796.70	15,783,140.90	15,713,300.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

ACUTE HIB
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	407.00	-407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	2,442.00	-814.00	0.00	-557.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,070.50		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	1,221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,221.00		
2120	SSI AGED WITH QMB	173,720.20	179,916.50	193,518.70	197,193.80	189,836.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		934,186.00		
2220	SSI DISABLED WITH Q	88,616.20	96,125.80	110,636.10	112,246.10	100,161.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507,785.30		
2320	SSI BLIND WITH QMB	407.00	407.00	407.00	407.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,035.00		
8000	SMIB ONLY NOT ELIGIB	0.00	0.00	0.00	-887.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-887.30		
8020	QMB ONLY	4,988.10	2,953.10	3,645.00	5,761.40	4,133.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,481.00		
9999	SMIB ONLY NOT ELIGIB	-8,404.70	-4,538.50	-4,375.40	-7,780.00	-3,887.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-28,985.60		
	261,768.80	274,049.90	304,238.40	305,976.50	291,872.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,437,905.90		

M

SUBTOTAL:

35,609.20

35,609.20

2420	SSI AGED EXPANDED WI	8,649.20	8,527.10	5,656.40	8,584.10	4,192.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	8,649.20	8,527.10	5,656.40	8,584.10	4,192.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

1,473,515.10

270,418.00	282,577.00	309,894.80	314,560.60	296,064.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

10,265,555.40

TOTAL:

Q1
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,434,626.70	1,985,923.60	1,946,933.20	1,994,198.00	1,976,010.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,337,691.60		
9999	SMIB ONLY NOT ELIGIB	-35,141.50	-2,907.10	-18,986.90	-13,112.50	-1,988.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-72,136.20		
	2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,265,555.40		

SUBTOTAL:

2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

LTC SMIB
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	524.50	419.60	419.60	419.60	419.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,202.90		
1020	TANF WITH QMB	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.50		
2100	SSI AGED WITH MEDIC A	874,183.40	870,946.20	868,154.40	873,399.40	856,670.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,343,353.70		
2110	SSI AGED NON-MEDICA R	155,566.70	157,769.60	157,769.60	157,664.70	161,336.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		790,106.80		
2120	SSI AGED WITH QMB	764,559.10	761,981.70	777,780.80	770,483.50	771,637.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,846,442.50		
2200	SSI DISABLED WITH M E	319,840.10	329,595.80	321,623.40	322,567.50	334,134.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,627,761.60		
2210	SSI DISABLED NON-ME	15,630.10	25,513.40	17,308.50	18,147.70	26,318.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,918.30		
2220	SSI DISABLED WITH Q M	710,227.60	707,605.10	709,170.10	710,332.50	709,958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,547,293.30		
2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	839.20	839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,091.10		
2310	SSI BLIND NON-MEDIC A	209.80	104.90	209.80	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		734.30		
2320	SSI BLIND WITH QMB	4,300.90	4,510.70	4,405.80	4,405.80	4,615.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,238.80		
	2,846,091.20	2,859,286.20	2,857,681.20	2,858,469.70	2,866,139.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,287,667.80		

D

SUBTOTAL:

3,251.90

3,251.90

8720	SSI DISABLED FREEDO M	734.30	629.40	629.40	629.40	629.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	734.30	629.40	629.40	629.40	629.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

14,290,919.70

2,846,825.50	2,859,915.60	2,858,310.60	2,859,099.10	2,866,768.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

1,347,007.60

TOTAL:

269,424.80

275,671.80

LTC HIB
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	1,628.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,628.00		
2110	SSI AGED NON-MEDICA R	407.00	0.00	1,221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,628.00		
2120	SSI AGED WITH QMB	256,094.80	261,120.80	256,136.10	250,816.60	258,578.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,282,746.40		
2200	SSI DISABLED WITH M E	0.00	407.00	0.00	407.00	-407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		407.00		
2220	SSI DISABLED WITH Q	12,923.00	14,144.00	12,516.00	7,909.20	13,106.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,598.20		
SUBTOTAL:	269,424.80	275,671.80	269,873.10	259,132.80	272,905.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,347,007.60		

M

269,873.10	259,132.80	272,905.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	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:

1006	TANF 21-44 MALE WITH	1,467.46	3,014.86	4,778.75	2,265.53	988.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1007	TANF 21-44 FEMALE WI	4,007.77	5,488.43	7,854.61	6,151.20	4,092.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1008	TANF 45-64 M & F WIT	8,300.31	14,284.07	22,892.61	20,087.85	12,197.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1009	TANF 65+ M & F WITH	4,262.82	6,279.98	9,729.78	6,523.30	6,273.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1011	TANF <1 M & F NON-ME	706,541.50	682,073.88	661,237.30	404,783.59	599,501.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	969,410.73	801,705.50	673,128.09	375,548.29	575,579.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	1,633,637.26	1,349,156.15	1,576,752.74	664,270.88	879,050.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	262,704.72	279,116.04	271,658.86	463,703.61	191,251.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N O	478,631.67	795,039.67	607,159.78	297,693.87	324,099.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1016	TANF 21-44 MALE NON-	1,118,523.79	1,179,594.23	1,675,989.50	1,029,311.82	1,020,453.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1017	TANF 21-44 FEMALE N O	4,416,969.19	4,825,798.89	6,329,680.67	3,816,257.90	4,234,828.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1018	TANF 45-64 M & F NON	1,478,215.20	1,497,596.26	2,105,951.76	1,291,244.17	1,313,943.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1019	TANF 65+ M & F NON-M	5,703.98	4,317.50	4,221.17	3,150.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1026	TANF 21-44 MALE WITH	700.00	210.84	544.76	130.83	419.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1027	TANF 21-44 FEMALE WI	855.92	822.87	1,936.87	1,147.97	426.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1028	TANF 45-64 M & F WIT	3,634.52	8,293.46	6,324.26	2,792.64	3,162.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1029	TANF 65+ M & F WITH	2,256.22	1,398.03	4,606.47	1,605.11	1,827.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	51,457.56	41,686.19	96,120.74	33,984.56	29,250.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	60,414.26	72,757.77	86,289.46	47,067.16	74,476.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	145,603.01	196,624.00	255,370.13	143,751.63	126,739.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	118,193.79	139,630.47	151,342.90	119,909.21	78,796.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	3,959,038.86	4,322,461.60	5,500,714.34	3,203,783.82	4,183,126.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	327,062.97	435,664.94	615,950.69	349,244.88	330,111.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	1,289.05	551.00	712.94	606.14	408.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	50,186.61	38,392.80	56,042.79	39,540.77	41,693.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	3,801.09	7,726.54	6,797.06	2,292.59	3,643.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4311	SOBRA CHILD <1 M & F	1,574,251.07	1,423,643.90	1,543,846.70	1,024,305.43	1,429,503.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4312	SOBRA CHILD 01-05 M	2,244,228.98	2,250,185.12	2,701,838.18	1,843,748.57	2,742,656.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4313	SOBRA CHILD 06-13 M	3,142,386.43	3,632,568.25	5,087,632.31	2,636,227.61	3,879,239.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4314	SOBRA CHILD 14-20 MA	747,001.51	1,133,294.81	1,132,611.39	698,721.56	879,239.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4315	SOBRA CHILD 14-20 FE	984,792.86	1,180,701.71	1,436,210.29	1,243,516.66	1,117,437.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	700.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,515.43	
27,594.40	
77,762.83	
33,069.19	
3,054,137.71	
3,395,371.95	
6,102,867.50	
1,468,434.63	
2,502,624.84	
6,023,872.56	
23,623,535.47	
7,686,950.59	
18,092.65	
2,006.10	
5,189.95	
24,207.48	
11,693.13	
252,499.19	
341,005.00	
868,088.75	
607,872.84	
21,169,125.28	
2,058,034.70	
3,567.96	
225,856.76	
24,260.95	
700.00	
6,995,551.05	
11,782,657.20	
18,378,054.25	
4,590,868.42	
5,962,658.63	
1,400.00	

D

M

SUBTOTAL:

2,315,297.75	2,332,941.48	2,684,900.21	1,978,313.15	3,078,986.62

0.00

0.00

0.00

0.00

0.00

0.00

0.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	350.00	350.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,400.00		
5015	SOBRA PREG 14-20 FE M	237,999.22	275,437.95	329,140.16	268,427.33	331,831.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,442,835.79		
5017	SOBRA PREG 21-44 FE M	1,131,352.11	1,456,601.24	1,697,144.79	1,250,264.34	1,615,075.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,150,437.87		
5018	SOBRA PREG 45-64 FE M	4,193.00	1,958.21	2,450.00	1,400.00	974.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,975.99		
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.47		
SUBTOTAL:	25,879,075.44	28,064,777.16	34,666,425.32	21,293,810.82	26,033,700.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,937,789.51		

M

1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	2,193.53	4,316.53	6,771.33	2,886.65	2,350.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	3,881.00	7,550.93	10,740.46	8,070.42	13,935.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	17,862.89	29,601.36	33,234.71	16,412.58	23,674.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	11,589.10	11,907.56	11,276.99	10,530.63	13,763.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1111	M&
TANF EXPANDED <1 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	

1112	&F
TANF EXPANDED 01-05	
5,250.00	
4,248.00	
1,409.52	
1,050.00	
2,799.61	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1113	TANF EXPANDED 06-13	26,366.06	18,797.44	23,244.19	7,174.88	11,102.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	8,195.40	8,023.36	4,043.91	8,114.99	7,921.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	25,647.40	20,633.17	39,263.74	13,550.27	27,645.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	278,711.63	257,235.68	319,438.15	250,318.04	486,697.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,001,394.14	971,890.27	1,008,971.33	811,845.95	1,363,608.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	498,055.24	489,955.39	559,480.77	459,352.65	784,932.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+	0.00	0.00	2,125.17	1,050.00	1,233.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1126	M&
TANF EXPANDED 21-44	
460.06	
495.48	
1,008.03	
215.52	
525.49	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1127	TANF EXPANDED 21-44	1,085.12	2,207.71	3,464.62	1,332.43	1,918.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	2,666.83	4,370.29	2,032.68	1,945.34	2,866.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+	3,939.78	7,378.95	8,307.81	2,632.75	3,304.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2400	M&
SSI AGED EXPANDED	
15,824.15	
18,656.13	
11,154.82	
10,621.62	
8,971.28	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
44,953.28	
27,103.71	
42,572.30	
50,664.46	
11,766.38	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
165,461.94	
213,135.45	
288,519.65	
144,543.45	
123,666.38	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	WI
SSI DISABLED EXPAND	
6,769.93	
6,974.26	
11,598.68	
8,264.20	
12,953.02	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
109,481.97	
123,966.21	
147,456.41	
74,149.48	
84,743.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
85,508.30	
104,493.60	
148,434.94	
93,586.84	
88,605.26	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
350.00	
18,518.24	
44,178.40	
120,786.39	
59,067.28	
0.00	
14,757.13	
86,685.02	
36,299.38	
126,739.69	
1,592,401.39	
5,157,710.30	
2,791,776.68	
4,408.73	
2,704.58	
10,008.37	
13,882.07	
25,563.76	
65,228.00	
177,060.13	
935,326.87	
46,560.09	
539,797.77	
520,628.94	
12,390,439.21	

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	
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	-316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
0.00	
0.00	
-316.00	
0.00	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	-316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-316.00		

SUBTOTAL:

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	-52.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-52.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
0.00	
0.00	
-52.99	
0.00	
0.00	
-52.99	

SUBTOTAL:

3506	ADULT 40-100% MALE 2	85.05	386.37	826.55	497.49	10.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	350.00	-297.96	350.00	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	645.75	4,143.44	2,194.34	1,695.56	2,704.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	1,136.72	452.79	2,304.18	777.55	2,583.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	26,346.12	11,086.99	17,886.95	21,098.49	19,893.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	39,467.46	45,163.63	63,499.13	36,273.42	42,314.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	304,613.42	425,982.76	423,158.47	436,649.78	341,541.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	316,477.56	364,737.12	475,335.36	280,789.77	334,025.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	1,086,597.94	1,026,522.27	1,319,334.30	853,672.09	1,010,881.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	700.00	1,114.00	3,500.00	17,145.46	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	74.88	61.40	75.28	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	59.40	0.00	61.40	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	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	5.04	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	357.00	187.24	1,790.82	720.29	61.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	1,396.64	1,663.61	3,351.85	967.89	729.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	4,997.35	11,572.19	10,426.98	9,426.39	9,118.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	550.16	545.25	1,197.56	1,260.00	0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	165,528.85	261,775.93	267,888.88	187,172.51	179,844.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	208,336.04	216,013.15	264,710.67	163,391.21	226,208.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	3,029,287.38	3,988,308.94	4,654,737.86	3,315,942.24	3,506,890.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,927,561.48	2,317,641.88	3,111,066.30	1,949,322.89	2,217,906.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	4,322,313.67	5,015,624.62	5,861,943.16	3,932,359.26	4,603,664.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	1,400.00	4,739.20	2,450.00	1,017.76	4,900.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	476.33	0.00	700.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,805.52	
402.04	
11,383.34	
7,254.26	
96,312.49	
226,718.51	
1,931,946.26	
1,771,365.51	
5,297,008.12	
23,159.46	
561.56	
120.80	
350.00	
64.44	
3,116.75	
8,109.83	
45,541.13	
3,552.98	
1,062,210.65	
1,078,659.62	
18,495,167.25	
11,523,498.90	
23,735,904.81	
14,506.96	
0.00	
1,526.33	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	11,438,207.99	13,697,919.67	16,488,135.56	11,210,955.33	12,505,028.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,340,247.52		

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	0.00	708.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	2,100.00	392.10	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	5,768.03	7,449.33	2,569.39	3,983.75	3,579.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	291.65	74.97	0.00	1,418.20	2,100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	5,286.80	5,739.88	17,778.96	7,700.00	8,066.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	18,281.55	30,911.29	16,130.09	20,252.28	19,679.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	196,798.09	227,258.24	311,425.56	279,292.12	170,395.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	271,360.04	317,416.51	433,678.80	355,651.52	362,225.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	680,980.32	652,498.60	813,465.56	599,685.22	649,560.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	700.00	0.00	2,450.00	1,050.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	350.00	59.40	0.00	48.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,180,866.48	1,241,698.82	1,599,657.76	1,269,425.19	1,217,414.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2,108.58	
2,842.10	
23,350.16	
3,884.82	
44,571.84	
105,255.02	
1,185,169.73	
1,740,332.76	
3,396,190.22	
4,900.00	
457.65	
6,509,062.88	

4

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F	189,176.92	189,687.05	133,832.64	285,206.25	405,616.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4414	6
SOBRA 100-133% MALE	
79,176.44	
75,187.22	
48,308.80	
129,174.03	
108,710.33	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4415	SOBRA 100-133% FEMA	64,105.03	76,235.87	69,956.78	127,357.54	132,904.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	L													

 	
700.00	
1,203,519.29	
440,556.82	
470,559.60	
2,115,335.71	

SUBTOTAL:

332,458.39

341,110.14

252,098.22

541,737.82

647,931.14

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4517	BC PATIENT FEMALE 2 1	5,936.00	4,286.25	3,859.52	1,400.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	1,109.40	2,490.00	2,861.40	2,835.67	37,424.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	350.00	1,050.00	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	4,085.95	1,050.00	708.87	2,109.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	11,481.35	8,876.25	7,429.79	6,345.22	37,774.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

15,481.77	
46,720.48	
1,750.00	
7,954.37	
71,906.62	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	209.72	5,846.12	5,390.39	2,833.23	2,964.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	2,100.00	350.00	238.44	1,759.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8720	M
SSI DISABLED FREEDO	
59.40	
237.60	
163.68	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	M													

2,369.12

6,433.72

5,792.51

4,592.75

2,964.70

0.00

0.00

0.00

0.00

0.00

0.00

0.00

17,244.16	
4,447.96	
460.68	
22,152.80	

SUBTOTAL:

222,386,565.26

41,159,756.52	45,693,704.25	55,704,123.37	36,305,180.28	43,523,800.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	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:

1006	TANF 21-44 MALE WITH	12,234.63	8,503.24	18,275.63	6,381.31	5,844.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1007	TANF 21-44 FEMALE WI	12,732.53	6,507.68	17,412.00	15,691.14	13,500.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1008	TANF 45-64 M & F WIT	20,039.18	23,077.50	31,215.80	33,021.35	18,951.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1009	TANF 65+ M & F WITH	5,432.47	3,081.30	19,647.16	10,039.86	6,222.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1011	TANF <1 M & F NON-ME	567,248.47	532,325.46	584,585.71	313,406.39	331,234.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	268,055.89	267,958.17	247,550.22	145,229.43	177,888.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	241,026.07	231,615.87	249,245.17	192,348.16	143,246.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	82,531.85	114,669.34	34,788.77	49,531.89	31,882.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N O	132,827.40	149,313.25	111,126.28	104,486.80	105,368.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1016	TANF 21-44 MALE NON-	562,279.40	623,087.17	772,207.19	586,447.11	387,037.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1017	TANF 21-44 FEMALE N O	1,689,259.97	1,841,435.05	2,361,373.34	1,715,630.63	1,561,254.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1018	TANF 45-64 M & F NON	717,249.74	673,156.71	1,111,242.66	847,305.45	703,072.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1019	TANF 65+ M & F NON-M	4,366.70	5,352.54	6,058.67	2,819.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1026	TANF 21-44 MALE WITH	0.00	358.05	1,478.69	1,214.66	51.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1027	TANF 21-44 FEMALE WI	412.90	351.42	2,063.57	1,842.65	83.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1028	TANF 45-64 M & F WIT	3,047.60	9,471.40	10,036.97	633.37	3,837.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1029	TANF 65+ M & F WITH	3,251.52	2,098.51	1,156.82	1,008.87	2,580.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	106,798.55	110,945.57	91,003.61	88,139.93	128,224.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	64,152.89	46,997.31	91,231.24	102,587.31	66,008.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	175,558.22	197,043.69	252,769.74	198,249.01	171,594.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	166,567.65	317,497.47	346,091.63	291,180.02	264,676.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	3,771,166.39	3,833,723.81	4,457,896.20	3,339,155.66	3,222,228.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	655,176.74	747,126.30	1,013,047.49	712,906.83	646,672.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	1,326.89	422.13	772.67	8.77	45.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	66,376.71	61,383.92	49,169.33	28,967.10	28,750.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	12,727.94	8,978.40	9,598.98	8,794.19	7,071.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4304	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	
4311	SOBRA CHILD <1 M & F	497,249.77	602,823.96	598,332.57	520,995.09	499,154.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4312	SOBRA CHILD 01-05 M	458,185.52	543,964.72	797,467.83	578,583.31	636,762.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4313	SOBRA CHILD 06-13 M	547,894.44	679,833.89	916,035.21	861,311.80	719,678.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4314	SOBRA CHILD 14-20 MA	142,589.40	263,389.36	296,159.45	260,211.19	332,884.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4315	SOBRA CHILD 14-20 FE	302,021.91	271,458.30	384,496.73	294,852.74	340,518.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	21.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

51,239.64	
65,843.61	
126,305.06	
44,423.56	
2,328,800.83	
1,106,682.04	
1,057,482.20	
313,404.60	
603,122.59	
2,931,058.45	
9,168,953.10	
4,052,026.56	
18,596.91	
3,102.87	
4,754.07	
27,026.42	
10,095.78	
525,112.00	
370,977.31	
995,214.76	
1,386,012.88	
18,624,170.94	
3,774,929.47	
2,575.86	
234,647.58	
47,171.09	
0.00	
2,718,555.80	
3,014,963.89	
3,724,753.99	
1,295,233.77	
1,593,348.55	
21.79	

D

M

SUBTOTAL:

1,175,224.23	1,233,590.49	1,416,332.84	1,198,668.24	1,343,866.61

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 November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,007.53	1,222.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,229.70		
5015	SOBRA PREG 14-20 FE M	134,500.45	112,857.97	124,462.39	103,103.31	163,088.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		638,012.91		
5017	SOBRA PREG 21-44 FE M	505,008.76	490,355.70	786,301.26	601,673.87	660,195.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,043,534.97		
5018	SOBRA PREG 45-64 FE M	0.00	12,542.17	0.00	422.16	372.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,336.84		
5027	SOBRA PREG 21-44 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		
SUBTOTAL:	11,929,298.55	12,793,707.33	15,798,308.51	12,019,402.53	11,380,005.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,920,722.39		

M

1104	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	
1106	TANF EXPANDED 21-44	8,090.62	5,444.07	10,692.23	3,827.16	6,983.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	17,273.14	16,429.02	21,924.74	19,870.38	22,886.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	42,647.41	59,814.53	50,487.40	30,333.33	36,325.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	11,071.23	8,539.97	21,023.04	15,362.85	14,717.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1111	M&
TANF EXPANDED <1 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	

1112	&F
TANF EXPANDED 01-05	
394.14	
374.54	
145.54	
124.70	
83.77	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1113	TANF EXPANDED 06-13	3,697.17	677.24	2,091.94	2,093.05	1,172.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	6,680.00	533.05	1,187.06	1,282.18	3,112.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	2,354.23	2,087.82	3,793.11	2,856.57	8,261.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	76,478.73	84,826.03	112,645.22	98,803.74	144,505.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	248,164.67	258,823.73	251,229.71	263,654.55	303,030.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	195,427.93	197,298.94	217,067.90	273,091.81	329,142.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+	4.35	149.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1126	M&
TANF EXPANDED 21-44	
867.04	
2,844.83	
954.60	
1,390.08	
826.35	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1127	TANF EXPANDED 21-44	1,490.53	614.49	3,655.77	1,321.14	723.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	6,588.12	5,873.05	9,500.81	7,667.30	11,046.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+	3,777.06	2,003.76	1,660.43	1,418.57	2,747.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2400	M&
SSI AGED EXPANDED	
6,604.72	
20,310.29	
10,390.12	
10,974.13	
5,525.57	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
21,709.26	
49,550.80	
38,796.40	
5,977.46	
2,279.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
212,432.79	
214,996.21	
262,436.77	
205,237.08	
184,165.63	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	WI
SSI DISABLED EXPAND	
4,806.76	
6,477.98	
17,263.02	
20,022.37	
7,260.02	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
109,739.51	
100,550.95	
88,862.91	
27,616.73	
84,045.66	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
194,924.82	
195,369.54	
290,524.12	
205,743.06	
175,024.36	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
0.00	
35,037.77	
98,383.85	
219,608.40	
70,714.85	
0.00	
1,122.69	
9,731.81	
12,795.28	
19,353.02	
517,259.27	
1,324,902.68	
1,212,029.33	
154.00	
6,882.90	
7,805.54	
40,675.68	
11,607.30	
53,804.83	
118,312.92	
1,079,268.48	
55,830.15	
410,815.76	
1,061,585.90	
6,367,682.41	

3308	AHC CARE M&F 45-64 W	21.62	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	-40.77	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	-527.88	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	-12,669.89	0.00	0.00	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
21.62	
-40.77	
-527.88	
-13,553.16	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	-13,216.92	0.00	0.00	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14,100.19		

SUBTOTAL:

3410	MED ELIGIBILITY NON-	0.00	0.00	-99.09	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	60.75	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-	-2,238.34	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	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-24,077.78	0.00	-475.87	-491.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,335.41	-100.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	-7,509.71	0.00	1,439.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	-34,472.66	0.00	14,549.19	-591.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

-99.09	
60.75	
-2,238.34	
12,313.57	
-25,044.69	
562.33	
-6,069.99	
-20,515.46	

SUBTOTAL:

3506	ADULT 40-100% MALE 2	15.57	260.53	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	3,307.43	1,008.60	3,349.43	978.27	2,423.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	154.04	0.00	0.00	181.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	1,808.45	2,617.50	2,711.22	4,567.35	7,355.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	19,931.75	23,276.12	89,687.54	28,119.86	34,486.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	229,346.72	174,196.94	211,562.10	277,900.40	210,627.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	109,841.40	105,802.51	150,353.68	93,953.55	100,102.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	610,123.29	776,775.68	695,783.33	458,809.96	501,750.13	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	1,297.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	74.67	-74.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	41.77	60.44	60.44	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	380.98	90.66	30.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	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	
3706	ADULT <40% EXP MALE	-113.08	0.00	357.03	0.00	121.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	1,799.96	1,321.34	2,383.72	4,587.94	2,342.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	13,612.17	16,184.28	11,638.87	15,449.12	13,966.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	112.46	353.44	167.54	658.68	573.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	49,424.42	117,557.97	171,586.96	99,739.77	114,797.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	91,002.56	63,238.93	77,507.54	92,547.18	64,786.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	2,375,248.97	2,548,511.24	3,291,598.46	2,203,928.16	2,372,006.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,081,236.95	1,138,344.74	1,153,915.66	971,417.23	957,390.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	2,866,722.75	3,197,371.03	3,873,212.13	2,943,218.44	3,088,403.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	19,126.57	1,786.77	31,730.45	2,915.21	1,256.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	166.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	-612.98	600.54	599.83	413.03	126.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

276.10	
0.00	
11,067.39	
335.70	
19,060.14	
195,501.67	
1,103,633.78	
560,053.15	
3,043,242.39	
1,297.69	
0.00	
162.65	
501.86	
0.00	
365.59	
12,435.85	
70,851.09	
1,865.88	
553,107.06	
389,082.32	
12,791,293.53	
5,302,304.65	
15,968,927.82	
56,815.96	
166.20	
1,127.33	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	7,472,143.33	8,169,422.64	9,769,959.27	7,199,220.14	7,472,730.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,083,475.80		

SUBTOTAL:

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	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	1,878.61	4,565.59	8,493.20	2,313.61	1,002.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	173.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,428.78	2,216.51	11,094.26	2,843.03	2,853.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	4,206.93	3,731.02	4,932.18	4,863.26	5,664.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	104,385.56	160,195.48	159,710.74	140,347.56	108,373.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	89,440.86	139,303.63	118,586.92	109,708.96	85,587.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	273,456.06	265,129.06	405,070.04	269,867.19	392,397.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	474,843.91	575,141.29	707,887.34	529,943.61	596,053.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
18,253.69	
173.85	
20,436.15	
23,398.31	
673,013.13	
542,627.83	
1,605,920.06	
0.00	
47.11	
2,883,870.13	

4

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F	18,822.56	18,033.29	11,971.57	66,627.29	61,087.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4414	6
SOBRA 100-133% MALE	
10,518.44	
14,508.22	
3,138.31	
25,481.01	
34,844.73	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4415	SOBRA 100-133% FEMA	7,170.95	59,145.25	2,446.86	47,194.94	40,459.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	L													

 	
0.00	
176,541.75	
88,490.71	
156,417.21	
421,449.67	

SUBTOTAL:

36,511.95

91,686.76

17,556.74

139,303.24

136,390.98

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4517	BC PATIENT FEMALE 2 1	0.00	2,014.72	1,660.45	-400.91	457.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	393.90	393.23	34.69	1,707.07	5,144.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	4,917.91	0.00	344.62	7,470.66	-368.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	1,422.62	58.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	5,311.81	2,407.95	3,462.38	8,835.33	5,233.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3,731.64	
7,673.32	
12,364.88	
1,481.13	
25,250.97	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	3,652.19	5,276.89	5,063.99	2,938.66	1,991.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	0.00	0.00	94.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8720	M
SSI DISABLED FREEDO	
0.00	
0.00	
204.26	
0.00	
10.26	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	M													

3,652.19

5,276.89

5,362.74

2,938.66

2,002.06

0.00

0.00

0.00

0.00

0.00

0.00

0.00

113,687,068.26

TOTAL:

18,923.53	
94.49	
214.52	
19,232.54	

SUBTOTAL:

21,049,296.39	22,871,233.35	27,733,419.01	21,096,836.49	20,936,283.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	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:

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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
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	
1026	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	
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	
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	
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	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED 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	
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	
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	
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	
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	
4304	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	
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	
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	
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	
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	
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	
5007	SOBRA PREG 21-44 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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

D

M

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 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		
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		

M

1104	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	
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+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1111	M&
TANF EXPANDED <1 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	

1112	&F
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+	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	M&
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+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2400	M&
SSI AGED 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	

2410	WI
SSI AGED 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	

2420	NO
SSI AGED 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	

2600	WI
SSI DISABLED EXPAND	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	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	

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	
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	

 	
0.00	
0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 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		

SUBTOTAL:

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	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	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	
3526	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	
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	
3705	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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 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		

SUBTOTAL:

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	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE 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	
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	
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	
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	
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	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

4

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% 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	

4414	6
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	
4415	SOBRA 100-133% FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	L													

 	
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

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8720	M
SSI DISABLED FREEDO	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	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	

SUBTOTAL:

0.00

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

TOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		
	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		

SUBTOTAL:

1006	TANF 21-44 MALE WITH	0.00	0.00	50.39	0.00	86.53	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	
1008	TANF 45-64 M & F WIT	240.08	144.26	129.07	239.42	1,322.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1009	TANF 65+ M & F WITH	0.00	0.00	14.96	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	3,067.29	5,821.79	9,178.88	8,561.96	12,073.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	3,377.40	2,687.30	4,007.35	587.92	319.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	1,218.15	1,408.01	1,681.43	1,359.63	422.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	3,194.76	243.36	468.28	188.25	8.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N O	3,183.01	6,546.81	822.11	544.54	1,469.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1016	TANF 21-44 MALE NON-	15,380.38	5,438.43	12,392.42	22,983.79	9,608.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1017	TANF 21-44 FEMALE N O	26,675.44	30,189.68	21,923.51	32,698.97	13,500.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1018	TANF 45-64 M & F NON	1,585.03	20,476.42	7,032.33	4,217.25	3,765.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1019	TANF 65+ M & F NON-M	249.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1026	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	
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	
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	14.61	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	
2100	SSI AGED WITH MEDIC A	241.77	1,611.38	1,217.37	578.23	1,624.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	371.10	7,188.56	32,792.94	1,605.68	18,626.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	74.34	-102.87	2,258.84	-33.63	42.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	274.99	1,222.09	2,462.28	265.65	1,191.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	25,287.18	285,986.08	63,667.08	20,539.73	10,339.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	3,344.91	11,090.04	4,388.06	4,281.31	7,564.03	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	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	2,306.72	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	
4304	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	
4311	SOBRA CHILD <1 M & F	3,804.18	13,609.55	4,737.03	2,907.42	3,992.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4312	SOBRA CHILD 01-05 M	23,471.36	22,204.78	19,576.43	13,090.77	16,949.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4313	SOBRA CHILD 06-13 M	51,607.75	20,148.09	23,759.65	14,546.67	8,196.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4314	SOBRA CHILD 14-20 MA	12,529.17	16,769.02	21,002.41	3,957.63	8,758.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4315	SOBRA CHILD 14-20 FE	6,477.83	5,659.71	11,307.97	10,537.18	17,755.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 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	

136.92	
0.00	
2,075.55	
14.96	
38,703.12	
10,979.39	
6,090.06	
4,103.58	
12,566.10	
65,803.59	
124,987.92	
37,076.07	
249.73	
0.00	
0.00	
14.61	
0.00	
5,273.49	
60,585.17	
2,239.40	
5,416.02	
405,819.22	
30,668.35	
0.00	
2,306.72	
0.00	
0.00	
29,050.28	
95,292.83	
118,258.28	
63,016.66	
51,737.83	
0.00	

D

M

SUBTOTAL:

71,791.87

5,686.71

75,118.85

16,413.39

46,695.06

0.00

0.00

0.00

0.00

0.00

0.00

0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	4,547.68	626.35	7,875.28	1,288.69	1,480.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,818.21		
5017	SOBRA PREG 21-44 FE M	21,818.94	29,403.82	43,513.99	31,655.97	15,933.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,326.62		
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		
5027	SOBRA PREG 21-44 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		
SUBTOTAL:	212,022.47	488,372.66	298,566.78	176,603.03	155,045.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,330,610.68		

M

1104	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	
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	26.99	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	6.07	0.00	161.42	40.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	21.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1111	M&
TANF EXPANDED <1 M	
0.00	
107.79	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

1112	&F
TANF EXPANDED 01-05	
88.72	
207.36	
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	983.30	246.21	480.41	221.56	5,436.61	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	17.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	207.41	1,374.65	40,600.36	101.94	919.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	9,469.13	1,756.74	6,608.45	12,403.21	910.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	3,509.12	2,951.74	93.10	450.62	340.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 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	

1126	M&
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+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2400	M&
SSI AGED EXPANDED	
338.53	
-1,011.94	
2,895.49	
1,827.68	
233.88	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED 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	

2420	NO
SSI AGED EXPANDED	
199.65	
0.00	
129.18	
-72.61	
-17.74	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	WI
SSI DISABLED EXPAND	
386.96	
48.09	
143.85	
158.57	
1,284.03	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
56,129.73	
0.00	
20,969.96	
0.00	
35,888.67	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
479.32	
0.00	
3,171.06	
1,161.00	
1,618.58	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
0.00	
0.00	
26.99	
208.10	
21.69	
107.79	
296.08	
0.00	
7,368.09	
17.95	
43,204.18	
31,148.15	
7,344.92	
0.00	
0.00	
0.00	
0.00	
0.00	
4,283.64	
0.00	
238.48	
2,021.50	
112,988.36	
6,429.96	
215,705.88	

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	
3316	AHC CARE MALE 21-44	-55.14	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	-304.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
0.00	
-55.14	
0.00	
-304.13	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	-55.14	0.00	0.00	0.00	-304.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-359.27		

SUBTOTAL:

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	996.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	56,134.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	57,131.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
0.00	
0.00	
996.64	
0.00	
56,134.89	
57,131.53	

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	95.08	0.00	205.82	0.00	0.11	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	3,995.50	462.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	3,430.56	332.79	0.00	0.00	75.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	29,537.65	17,618.83	16,528.87	11,291.25	21,952.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	9,918.88	16,192.67	4,216.11	6,873.78	4,424.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	17,006.11	11,808.33	29,317.11	13,080.91	41,130.07	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	
3526	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	
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	
3705	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	
3706	ADULT <40% EXP MALE	10.26	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	47.77	159.41	-72.49	153.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP 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	
3714	ADULT <40% EXP MALE	638.33	2,949.89	655.77	55.09	1,044.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	6,886.22	1,333.58	986.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	87,516.94	137,213.09	59,107.89	86,557.14	76,793.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	28,711.56	30,380.42	62,265.11	20,947.83	13,043.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	73,759.29	34,317.41	75,461.37	91,305.45	36,478.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
301.01	
0.00	
4,458.17	
3,839.29	
96,928.79	
41,625.79	
112,342.53	
0.00	
0.00	
0.00	
0.00	
0.00	
10.26	
0.00	
287.97	
0.00	
5,343.50	
9,206.15	
447,188.92	
155,348.08	
311,321.97	
0.00	
0.00	
0.00	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	257,558.65	252,306.42	248,671.91	234,260.23	195,405.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,188,202.43		

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	21.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE 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	
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	
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	
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	
3916	NEWLY ELIGIBLE MALE	2,177.20	3,667.10	6,736.60	8,363.47	683.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	2,187.81	6,610.07	2,102.47	1,988.35	1,659.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	40,072.00	12,789.89	57,847.40	7,387.87	-635.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
	44,437.01	23,067.06	66,686.47	17,761.16	1,707.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

21.47	
0.00	
0.00	
0.00	
0.00	
0.00	
21,627.52	
14,548.14	
117,462.02	
0.00	
0.00	
153,659.15	

4

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F	0.00	332.82	31.19	1,392.55	1,273.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4414	6
SOBRA 100-133% MALE	
7.98	
68.80	
0.00	
61.55	
126.58	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4415	SOBRA 100-133% FEMA	169.44	0.00	0.00	636.29	424.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	L													

 	
0.00	
3,030.31	
264.91	
1,230.44	
4,525.66	

SUBTOTAL:

177.42

401.62

31.19

2,090.39

1,825.04

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	3,387.30	0.00	140.57	-140.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,387.30	0.00	140.57	-140.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
3,387.30	
0.00	
3,387.30	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	61.65	36.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	0.00	2,178.61	0.00	0.00	13,816.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8720	M
SSI DISABLED FREEDO	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	M													

0.00

2,178.61

0.00

61.65

13,853.68

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,968,670.67

TOTAL:

98.46	
15,995.48	
0.00	
16,093.94	

SUBTOTAL:

646,451.11	771,726.45	689,215.77	447,049.28	414,228.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,199.96		
	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,199.96		

SUBTOTAL:

140,199.96

22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

54.51

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	0.00	0.00	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.51		
	0.00	0.00	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.51		

SUBTOTAL:

0.00	0.00	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,506,898.15		
	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,506,898.15		

SUBTOTAL:

1,506,898.15

270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	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:

1006	TANF 21-44 MALE WITH	46.42	188.36	166.12	101.73	229.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1007	TANF 21-44 FEMALE WI	286.14	1,871.10	104.02	503.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1008	TANF 45-64 M & F WIT	963.94	990.67	2,333.71	726.40	204.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1009	TANF 65+ M & F WITH	15.97	66.51	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	14,101.84	25,301.91	30,300.16	178,822.23	20,727.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	16,538.91	9,600.05	8,669.16	18,344.02	3,875.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	6,436.73	7,171.95	14,303.13	4,999.12	7,077.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	1,257.04	3,493.94	1,522.66	776.75	1,794.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N O	3,520.43	4,447.58	5,020.50	8,102.17	4,452.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1016	TANF 21-44 MALE NON-	24,274.51	27,434.69	45,477.46	88,415.76	9,738.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1017	TANF 21-44 FEMALE N O	122,776.63	149,984.88	198,163.63	154,340.59	107,095.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1018	TANF 45-64 M & F NON	44,637.53	34,488.13	37,346.87	40,804.81	32,291.49	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	
1026	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	
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	
1028	TANF 45-64 M & F WIT	0.00	2,013.78	1,713.94	22.74	132.86	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	
2100	SSI AGED WITH MEDIC A	8,786.84	9,235.08	13,562.46	4,876.58	4,017.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	267.22	1,844.32	1,193.89	206.73	207.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	5,639.69	5,409.53	7,747.96	8,330.00	3,535.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	21,233.51	3,529.27	27,584.81	6,512.83	4,472.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	231,778.99	342,969.11	271,027.04	176,793.76	210,239.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	31,844.13	34,580.97	45,422.53	27,354.81	19,197.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	0.00	530.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	1,267.01	342.49	390.50	653.66	984.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	222.46	193.39	118.72	208.81	92.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4304	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	
4311	SOBRA CHILD <1 M & F	99,444.46	34,799.65	70,959.07	70,572.82	252,132.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4312	SOBRA CHILD 01-05 M	37,985.34	18,128.44	50,244.41	32,655.05	36,957.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4313	SOBRA CHILD 06-13 M	20,935.84	28,886.52	38,212.84	34,130.76	44,076.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4314	SOBRA CHILD 14-20 MA	36,910.73	21,260.73	9,048.41	10,576.23	10,522.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4315	SOBRA CHILD 14-20 FE	7,807.11	22,781.32	26,164.00	49,311.09	32,388.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 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	

732.05	
2,765.01	
5,219.06	
82.48	
269,253.78	
57,027.21	
39,988.66	
8,844.50	
25,542.79	
195,340.50	
732,360.89	
189,568.83	
0.00	
0.00	
0.00	
3,883.32	
0.00	
40,478.90	
3,719.65	
30,663.15	
63,332.94	
1,232,808.32	
158,400.43	
530.71	
3,637.76	
836.31	
0.00	
527,908.06	
175,970.76	
166,242.46	
88,318.99	
138,452.50	
0.00	

D

M

SUBTOTAL:

71,468.19

82,740.10

146,508.04

66,063.09

101,434.21

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 November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	19,583.10	16,174.12	18,249.56	19,803.43	28,709.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,520.05		
5017	SOBRA PREG 21-44 FE M	50,370.25	73,392.58	98,242.24	99,306.65	73,113.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394,425.61		
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		
5027	SOBRA PREG 21-44 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		
SUBTOTAL:	808,932.77	881,111.78	1,023,289.80	1,037,253.28	908,268.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,658,855.68		

M

1104	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	
1106	TANF EXPANDED 21-44	0.00	414.69	0.00	0.00	-2,606.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	1,241.25	491.94	2,444.85	1,158.04	613.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,825.46	2,238.26	622.19	467.69	2,209.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	1,249.86	53.73	663.23	32.04	433.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1111	M&
TANF EXPANDED <1 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	

1112	&F
TANF EXPANDED 01-05	
0.00	
0.00	
169.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1113	TANF EXPANDED 06-13	15.00	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	506.37	0.00	0.00	271.22	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	53.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	7,020.19	10,188.24	39,666.55	3,815.71	20,026.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	29,232.13	26,262.11	33,390.49	26,291.09	53,340.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	7,699.38	15,070.15	15,381.52	14,385.88	14,008.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+	0.00	1,058.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1126	M&
TANF EXPANDED 21-44	
173.16	
204.04	
268.33	
0.00	
105.51	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1127	TANF EXPANDED 21-44	89.09	21.69	48.01	58.18	21.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	612.96	79.99	1,202.50	0.00	647.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 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	

2400	M&
SSI AGED EXPANDED	
174.66	
70.14	
1,351.38	
245.08	
1,187.78	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
504.00	
193.90	
3,907.14	
0.00	
360.04	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
3,538.39	
5,601.99	
9,609.73	
6,111.76	
4,987.34	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	WI
SSI DISABLED EXPAND	
170.31	
695.50	
498.27	
5,168.66	
108.02	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2610	E
SSI DISABLED EXPAND	
13,636.52	
8,325.86	
26,011.62	
1,009.53	
583.66	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
4,285.83	
11,263.10	
11,272.83	
7,319.43	
5,081.88	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
0.00	
-2,191.67	
5,949.94	
7,362.72	
2,432.59	
0.00	
169.40	
15.00	
777.59	
53.99	
80,716.83	
168,516.31	
66,545.64	
1,058.40	
751.04	
238.66	
2,542.84	
0.00	
3,029.04	
4,965.08	
29,849.21	
6,640.76	
49,567.19	
39,223.07	
468,213.63	

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	
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	

 	
0.00	
0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending November 30, 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		

SUBTOTAL:

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	-84.11	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	-123.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	-207.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
0.00	
0.00	
0.00	
-84.11	
-123.34	
-207.45	

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	2,553.86	0.00	105.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	43.83	0.00	0.00	21.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	3,215.37	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	911.05	84.70	1,203.19	1,329.48	45.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	31,925.03	31,046.31	93,315.47	49,847.53	28,052.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	12,294.00	3,333.58	14,103.28	9,486.39	17,241.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	65,376.33	62,636.67	86,530.21	62,232.60	77,425.47	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	
3526	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	
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	
3705	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	
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	0.00	0.00	0.00	0.00	246.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	1,741.29	1,260.00	0.00	170.39	48.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP 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	
3714	ADULT <40% EXP MALE	7,292.84	12,081.73	19,979.50	3,571.18	6,165.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	4,451.72	328.62	16,586.75	12,371.04	3,512.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	136,455.42	205,325.04	266,134.03	102,321.13	255,550.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	94,474.99	126,480.57	88,278.29	77,117.72	75,243.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	181,612.85	129,721.57	241,985.31	168,543.69	210,132.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	1,260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
2,659.37	
65.65	
3,215.37	
3,573.73	
234,187.23	
56,458.41	
354,201.28	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
246.62	
3,219.93	
0.00	
49,090.63	
37,250.70	
965,786.31	
461,594.98	
931,995.99	
0.00	
0.00	
1,260.00	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	536,535.52	576,817.99	830,669.89	486,991.15	673,791.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,104,806.20		

SUBTOTAL:

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	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	627.65	95.99	385.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	697.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	303.87	213.29	165.29	178.10	3,617.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	2,249.16	5,021.93	10,459.28	5,204.43	5,186.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	2,574.73	5,949.64	7,868.75	10,984.25	13,427.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	51,923.13	16,392.55	23,221.63	35,300.47	24,728.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
	57,678.54	27,673.40	42,100.30	52,364.43	46,958.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
1,108.99	
0.00	
697.18	
4,477.65	
28,121.02	
40,804.82	
151,565.94	
0.00	
0.00	
226,775.60	

4

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F	920.33	606.76	51.87	3,005.28	2,948.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4414	6
SOBRA 100-133% MALE	
0.00	
0.00	
307.68	
188.97	
4,687.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4415	SOBRA 100-133% FEMA	589.03	196.50	0.00	4,003.47	2,355.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	L													

 	
0.00	
7,532.83	
5,184.45	
7,144.99	
19,862.27	

SUBTOTAL:

1,509.36

803.26

359.55

7,197.72

9,992.38

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	10.17	15.64	0.00	0.00	15.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
	10.17	15.64	0.00	0.00	15.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
41.45	
0.00	
0.00	
41.45	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	0.00	22.70	0.00	274.10	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8720	M
SSI DISABLED FREEDO	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	M													

0.00

22.70

0.00

274.10

91.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8,478,735.18

TOTAL:

387.80	
0.00	
0.00	
387.80	

SUBTOTAL:

1,476,134.55	1,569,184.87	2,042,720.13	1,650,143.77	1,740,551.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1010	TANF NON-MEDICARE	0.00	350.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	
2100	SSI AGED WITH MEDIC	106,605.75	138,772.37	243,060.06	109,396.22	86,575.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	684,409.49	
2110	A
SSI AGED NON-MEDICA	26,434.90	13,763.26	31,784.99	27,506.02	11,008.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110,497.18	
2120	R
SSI AGED WITH QMB	121,926.99	174,038.05	225,195.50	122,450.70	94,459.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
738,070.28	
2200	SSI DISABLED WITH M	45,476.20	32,686.17	56,715.55	29,618.96	25,027.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	189,524.79	
2210	E
SSI DISABLED NON-ME	688,624.66	871,046.82	795,795.36	508,232.84	646,246.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,509,945.94	
2220	D
SSI DISABLED WITH Q	48,687.58	68,819.71	112,495.22	51,083.18	51,662.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
332,748.46	

2300	M
SSI BLIND WITH MEDIC	
74.93	
0.00	
59.40	
59.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
193.73	
2310	SSI BLIND NON-MEDIC	8,400.00	7,019.66	6,650.00	5,950.00	2,407.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,427.47	

2320	A
SSI BLIND WITH QMB	
431.94	
428.25	
416.46	
71.62	
789.22	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
2,137.49	

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY	AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

1,046,662.95	1,306,924.29	1,472,172.54

854,718.94

918,176.11

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5,598,654.83

8710	SSI DISABLED FREEDO M	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

106.88	
0.00	
106.88	

SUBTOTAL:

5,598,761.71

1,046,662.95	1,306,924.29	1,472,179.89	854,718.94	918,275.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	1,685,117.40	1,915,799.87	2,681,450.39	1,999,482.31	2,206,654.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,488,504.35	
2110	A
SSI AGED NON-MEDICA	134,210.18	86,635.19	183,540.43	121,497.09	95,581.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
621,464.38	
2120	R
SSI AGED WITH QMB	2,732,315.87	2,691,509.27	3,869,487.21	2,806,461.70	3,006,316.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
15,106,090.95	
2200	SSI DISABLED WITH M	484,829.08	429,355.23	623,488.25	496,865.31	514,028.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,548,566.08	
2210	E
SSI DISABLED NON-ME	1,738,486.52	1,802,598.11	2,237,418.61	1,856,867.73	1,821,700.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9,457,071.37	
2220	D
SSI DISABLED WITH Q	585,872.48	620,560.01	851,203.88	615,551.90	612,586.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,285,774.63	

2300	M
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	7,740.32	7,420.92	10,075.82	6,388.81	10,469.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,095.58	

2320	A
SSI BLIND WITH QMB	
4,994.88	
7,132.53	
7,260.58	
5,253.26	
5,833.93	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
30,475.18	

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

7,373,566.73	7,561,011.13     10,463,925.17	7,908,368.11	8,273,171.38

0.00

0.00

0.00

0.00

0.00

0.00

0.00

41,580,042.52

41,602,554.40

TOTAL:

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,037.06	2,637.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,712.52	4,868.22	9,185.70	4,689.12	2,056.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

9,551.52	
12,960.36	
22,511.88	

SUBTOTAL:

7,375,279.25	7,565,879.35	10,473,110.87	7,913,057.23	8,275,227.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	57,961.58	35,627.77	43,341.81	22,249.92	35,336.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194,517.62	
2110	A
SSI AGED NON-MEDICA	16,433.83	946.68	83,538.56	8,338.74	936.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110,194.31	
2120	R
SSI AGED WITH QMB	443.59	1,507.61	18.05	566.68	28.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,564.39	
2200	SSI DISABLED WITH M	11,220.75	6,502.00	26,013.79	7,482.95	9,714.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,933.68	
2210	E
SSI DISABLED NON-ME	26,834.51	19,004.26	28,589.63	10,783.29	71,004.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
156,216.01	
2220	D
SSI DISABLED WITH Q	2,359.28	722.71	6,308.23	1,497.53	1,372.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
12,260.73	

2300	M
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	6,656.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,656.83	

2320	A
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	

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

121,910.37

64,311.03

187,810.07

50,919.11

118,392.99

0.00

0.00

0.00

0.00

0.00

0.00

0.00

543,343.57

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

543,343.57

121,910.37	64,311.03	187,810.07	50,919.11	118,392.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	17,791.38	16,157.36	33,799.85	22,186.80	28,584.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	118,520.05	
2110	A
SSI AGED NON-MEDICA	68.35	0.00	655.42	0.00	206.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
930.45	
2120	R
SSI AGED WITH QMB	12,713.06	10,199.58	16,135.95	9,872.20	12,567.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
61,488.71	
2200	SSI DISABLED WITH M	1,998.01	5,671.10	17,991.36	2,677.54	3,446.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,784.04	
2210	E
SSI DISABLED NON-ME	39,207.69	57,526.26	37,706.14	98,519.59	47,761.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
280,721.16	
2220	D
SSI DISABLED WITH Q	2,612.76	3,357.96	4,743.41	3,725.64	6,845.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
21,285.26	

2300	M
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	0.00	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	A
SSI BLIND WITH QMB	
36.96	
218.14	
48.21	
37.14	
48.21	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
388.66	

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending November 30, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

74,428.21

93,130.40

111,080.34

137,018.91

99,460.47

0.00

0.00

0.00

0.00

0.00

0.00

0.00

515,118.33

515,118.33

TOTAL:

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

KidsCare - CAPITATION AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	1,007.22	1,007.22	833.38	959.01	959.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,765.84		
6012	KIDS 1-5 M & F NON-M	220.96	220.96	220.96	223.26	223.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,109.40		
6013	KIDS 6-13 M & F NON-	58,022.76	55,071.22	54,144.19	51,905.62	50,587.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269,731.20		
6014	KIDS 14-19 MALE NON-	49,755.46	44,451.13	44,464.06	45,078.81	41,422.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225,171.84		
6015	KIDS 14-19 FEMALE NO	74,775.69	69,658.38	67,362.69	66,568.43	64,034.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342,400.14		
9960	KIDSCARE KICK PAYME N	0.00	0.00	6,160.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,160.56		
	183,782.09	170,408.91	173,185.84	164,735.13	157,227.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		849,338.98		

SUBTOTAL:

849,338.98

183,782.09	170,408.91	173,185.84	164,735.13	157,227.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

4,556.11

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	2.00	2.00	1.66	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.66		
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
6013	KIDS 6-13 M & F NON-	456.25	434.86	420.34	395.88	383.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,091.22		
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	242.85	218.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,193.47		
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	240.85	230.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,250.76		
9960	KIDSCARE KICK PAYME N	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		
	993.61	932.52	910.22	883.58	836.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,556.11		

SUBTOTAL:

993.61	932.52	910.22	883.58	836.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	75.10	75.10	37.55	82.84	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		353.43		
6012	KIDS 1-5 M & F NON-M	75.10	75.10	75.10	82.84	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390.98		
6013	KIDS 6-13 M & F NON-	16,709.75	16,146.50	15,620.80	15,698.18	15,532.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,707.73		
6014	KIDS 14-19 MALE NON-	9,776.08	8,979.83	9,075.34	10,574.10	9,401.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,806.43		
6015	KIDS 14-19 FEMALE NO	10,772.21	10,088.61	9,721.39	10,393.14	10,092.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,067.69		
SUBTOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179,326.26		

TOTAL:

37,408.24

179,326.26

34,530.18	36,831.10	35,191.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

35,365.14

4,441.00

TOTAL:

968.00

918.00

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	2.00	2.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
6013	KIDS 6-13 M & F NON-	445.00	430.00	416.00	379.00	375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,045.00		
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	235.00	210.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,152.00		
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	231.00	223.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,225.00		
SUBTOTAL:	968.00	918.00	894.00	849.00	812.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,441.00		

894.00	849.00	812.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

KidsCare - FEE FOR SERVICE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	-357.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-357.10		
6013	KIDS 6-13 M & F NON-	364.77	362.20	318.01	1,505.26	72.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,623.12		
6014	KIDS 14-19 MALE NON-	-652.26	85.01	0.00	96.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-471.05		
6015	KIDS 14-19 FEMALE NO	-174.33	326.70	118.31	203.32	331.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		805.61		
	-818.92	773.91	436.32	1,804.78	404.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,600.58		

SUBTOTAL:

2,600.58

-818.92	773.91	436.32	1,804.78	404.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - REINSURANCE
For The Period Ending November 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6013	KIDS 6-13 M & F NON-	161.54	203.93	36,712.84	0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,078.32		
6014	KIDS 14-19 MALE NON-	0.00	29,016.36	29,093.10	36,857.22	90,654.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,620.81		
6015	KIDS 14-19 FEMALE NO	0.00	1,274.86	5,182.91	20,265.16	13,172.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,895.29		
	161.54	30,495.15	70,988.85	57,122.39	103,826.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,594.42		

SUBTOTAL:

TOTAL:	161.54	30,495.15	70,988.85	57,122.39	103,826.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	262,594.42		

6

00

110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending October 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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			12.00		
1010	TANF NON-MEDICARE	643.15	641.57	646.12	649.50	648.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00			3,228.80		
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			5.00		
2100	SSI AGED WITH MEDICA	151.70	154.89	157.99	163.43	165.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00			793.60		
2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.19	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			24.19		
2120	SSI AGED WITH QMB	272.31	272.62	271.31	271.53	273.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1,361.24		
2200	SSI DISABLED WITH ME	1,753.65	1,745.73	1,754.42	1,769.90	1,793.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00			8,816.89		
2210	SSI DISABLED NON-MED	21,475.15	21,538.50	21,702.85	21,678.83	21,721.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00			108,116.39		
221Z	SSI DISABLED NON-MED	0.03	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			0.06		
2220	SSI DISABLED WITH QM	3,977.48	3,986.67	4,014.73	4,014.04	4,014.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00			20,007.84		
222Z	SSI DISABLED WITH QM	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1.00		
2300	SSI BLIND WITH MEDIC	13.00	13.00	13.00	14.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			67.00		
2310	SSI BLIND NON-MEDICA	111.00	112.38	114.06	111.81	116.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			565.25		
2320	SSI BLIND WITH QMB	28.00	29.00	28.00	28.00	27.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00			140.30		
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			35.00		
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			10.00		
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			15.00		
	28,445.47
28,445.47	28,515.36
28,515.36	28,722.48
28,722.48	28,721.26
28,721.2	28,794.99		0.00
0.00	0.00	0.00
0.00	0.00	0.00
0.	0.00	0.00		143,199.56		
					28,794.99		0.00		0.00		0.00	0.00		143,199.56		

SUBTOTAL: TOTAL:

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

EPD/DD  CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	370,741.89	366,197.37	369,544.65	371,342.65	369,390.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,847,217.32	
EPD	84,945,196.47	97,607,756.74	86,404,566.22	86,818,575.78	99,193,232.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	454,969,327.79	
TOTAL AHCCCS LTC	85,315,938.36	97,973,954.11	86,774,110.87	87,189,918.43	99,562,623.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	456,816,545.11	
DES/DD	97,105,888.85	97,348,150.88	98,057,803.05	98,603,338.74	98,857,708.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	489,972,890.01	
TOTAL DES LTC	97,105,888.85	97,348,150.88	98,057,803.05	98,603,338.74	98,857,708.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	489,972,890.01	
TOTAL LTC - CAP	182,421,827.21	195,322,104.99	184,831,913.92	185,793,257.17	198,420,331.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	946,789,435.12	

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	
	8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,259,778.01	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,259,778.01	

EPD/DD REINSURANCE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	3,670,305.62	3,513,547.75	4,248,800.50	3,640,983.44	5,239,547.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,313,184.67	
	375,457.62	326,085.82	792,734.80	709,764.46	616,786.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,820,829.44	
	375,457.62	326,085.82	792,734.80	709,764.46	616,786.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,820,829.44	
TOTAL LTC - REIN	4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	5,856,334.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,134,014.11	

EPD/DD  SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	3,116,250.30	3,135,587.40	3,128,183.70	3,118,231.90	3,139,674.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,637,927.30	

Note to the ASR:
EPD reflects the Federal and County share for both acute and LTC services.
AHCCCS passes through only the Federal share to DES. Neither the Federal nor the Nonfederal dollars are included on the ASR summary (page 1) because both are included in the DES appropriation.

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending November 30, 2015

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

TOTAL

Monday, December 28, 2015

010115	CRS FULLY INTEGRATED PLAN - CAP	13,474,971.60	13,492,632.75	13,576,771.54	13,943,462.74	13,889,830.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,377,669.49	
010145	CRS ACUTE SEMI INTEGRATED - CAP	122,251.86	115,316.41	116,070.08	130,768.30	127,797.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	612,203.83	
999125	CRS SEMI INTEGRATED PLAN - CAP	3,253,162.92	3,256,188.18	3,258,709.23	4,767,213.72	4,765,739.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,301,013.45	
999135	CRS ONLY PLAN - CAP	476,979.36	481,148.76	485,318.16	546,356.40	545,428.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,535,231.48	
	17,327,365.74	17,345,286.10	17,436,869.01	19,387,801.16	19,328,796.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	90,826,118.25	

Subtotal

999155	CRS REINSURANCE ONLY	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,498,921.98	
	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,498,921.98	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC CAP	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136,952.90	
	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136,952.90	

Subtotal

19,545,976.24	18,869,023.14	19,332,548.29	21,423,030.67	20,291,414.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,461,993.13	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending November 30, 2015

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

TOTAL

Monday, December 28, 2015

010115	CRS FULLY INTEGRATED PLAN - MM	17,063.13	17,085.46	17,193.00	17,270.81	17,202.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,814.77	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	168.21	164.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	836.05	
999125	CRS SEMI INTEGRATED PLAN - MM	6,452.00	6,458.00	6,463.00	6,467.00	6,465.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,305.00	
999135	CRS ONLY PLAN - MM	1,144.00	1,154.00	1,164.00	1,178.00	1,176.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,816.00	
	24,833.16	24,861.60	24,985.24	25,084.02	25,007.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	124,771.82	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC MM	36.87	32.00	33.00	34.99	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	171.86	
	36.87	32.00	33.00	34.99	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	171.86	

Subtotal

24,870.03	24,893.60	25,018.24	25,119.01	25,042.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	124,943.68	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS
For the Period Ending November 30, 2015

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

TOTAL

Monday, December 28, 2015

010700	HEALTH CHOICE INTEGRATED - CAP	0.00	0.00	-1,518.09	8,509,580.12	8,451,274.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,959,336.06	
010725	CENPATICO INTEGRATED - CAP	0.00	0.00	18,507.72	21,037,755.17	20,895,096.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,951,359.34	
078999	MERCY MARICOPA INTEGRATED - CAP	47,152,827.77	47,326,614.65	47,809,819.28	44,365,579.73	44,294,160.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	230,949,001.44	
	47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	289,859,696.84	

Subtotal

47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	289,859,696.84	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS
For the Period Ending November 30, 2015

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

TOTAL

Monday, December 28, 2015

010700	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	-1.00	5,604.33	5,566.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,169.51	
010725	CENPATICO INTEGRATED - MM	0.00	0.00	12.00	13,638.68	13,546.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,197.59	
078999	MERCY MARICOPA INTEGRATED - MM	19,430.16	19,501.43	19,702.99	19,787.96	19,758.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,181.35	
	19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136,548.45	

Subtotal

19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136,548.45	

GRAND TOTAL