October 26, 2015

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

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

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

SUBJECT: FY 2016 Appropriation Status Report for the Period Ended September 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 September 30, 2015.

Status Summary – As part of the FY 2017 budget request 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 $639.8 million. The shortfall is comprised of Federal Expenditure Authority ($610.9 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.

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.
Potentially significant Medicare Part B premium increase.
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.

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

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. October 26, 2015
Page 2

Enrollment Update – September 2015 enrollment is 1,803,005 members, a 47,631 member increase over the prior month. Enrollment for October 2015 increased to 1,818,445 members, a 15,440 member increase.

Major October changes by eligibility category include: 1931 for Families and   Children/SOBRA
– increase of 5,305; Supplemental Security Income – increase of 370; Prop 204 Restoration - increase of 5,478; Adult Expansion - increase of 1,818; Medicare Cost Sharing – increase of 566; and Federal Emergency Services - increase of 1,726.

Tobacco Funds Revenue Update –Tobacco tax collections through September 2015 are $1.0 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 September 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 September 30, 2015
SUMMARY OF APPROPRIATED EXPENDITURES	
			(A)		(B)		(A) - (B)					
			EXPENDITURE						PROJECTED			
	ANNUAL		PLAN		EXPENDITURES		VARIANCE		ANNUAL		ANNUALIZED	
	APPROPRIATION		YTD		YTD		YTD		EXPENDITURES		VARIANCE	

APPROPRIATIONS:												
ADMINISTRATION												
AHCCCS Operating Lump Sum	$	77,975,400		$	17,028,124		$	17,028,124		$	-		$	77,975,400		$	-	
AHCCCS Prop 204 Administration	6,832,800		1,785,751		1,785,751		-		6,832,800		-	
DES Eligibility	54,874,500		12,400,906		12,400,906		-		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		2,075,308		2,075,308		-		38,358,700		-	
TOTAL ADMINISTRATION	178,041,400		33,290,089		33,290,089		-		178,041,400		-	

Traditional Medicaid Services	3,639,258,600	947,468,349	947,468,349	-	3,639,258,600	-	
Proposition 204 Services	2,507,700,600	575,977,405	575,977,405	-	2,507,700,600	-	
ACA Adult Expansion	197,183,800	81,679,715	81,679,715	-	197,183,800	-	
Children's Rehabilitative Services	234,866,700	57,619,111	57,619,111	-	234,866,700	-	
KidsCare Services	6,295,200	748,640	748,640	-	6,295,200	-	
ALTCS Services	1,386,588,900	327,518,117	327,518,117	-	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		(12,845,615)	(12,845,615)	-	313,096,700		-	
TOTAL PROGRAMMATIC	8,312,727,600		 	 	
1,978,165,722	1,978,165,722	-	8,312,727,600		-	

TOTAL EXPENDITURES

$	8,490,769,000

$    2,011,455,811

$   2,011,455,811	$

-	$  8,490,769,000	$	-

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

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

Administrative Expenditures	

$	51,537,900		

$	10,461,381		

$	10,461,381		

-	$	51,537,900		

$	-	
Proposition 204 - Administrative Expenditures	19,547,000		1,450,303		1,450,303		-	19,547,000		-	
Programmatic Expenditures										
Traditional Medicaid Services	800,543,000		238,869,999		238,869,999		-	800,543,000		-	
Proposition 204 Services	90,000,000		9,394,463		9,394,463		-	90,000,000		-	
Children's Rehabilitative Services	73,001,000		17,561,185		17,561,185		-	73,001,000		-	
KidsCare Services	338,000		233,444		233,444		-	338,000		-	
ALTCS Services	162,880,800		40,720,200		40,720,200		-	162,880,800		-	
DSH and Rural Hospitals	7,314,600	-	-	-	7,314,600	-	
TOTAL GF EXPENDITURES	1,205,162,300	318,690,974	318,690,974	-	1,205,162,300	-	

Administrative Expenditures	
81,114,000	
18,943,568	
18,943,568	
-	81,114,000	
-	
Proposition 204 - Administrative Expenditures	22,161,600	2,410,756	2,410,756	-	22,161,600	-	
Programmatic Expenditures						
Traditional Medicaid Services	2,471,441,100	608,547,564	608,547,564	-	2,471,441,100	-	
Proposition 204 Services	2,048,414,400	485,054,880	485,054,880	-	2,048,414,400	-	
ACA Adult Expansion	197,183,800	81,679,715	81,679,715	-	197,183,800	-	
Children's Rehabilitative Services	161,865,700	40,057,927	40,057,927	-	161,865,700	-	
KidsCare Services	5,587,200	515,196	515,196	-	5,587,200	-	
ALTCS Services and Nursing Facility Assessment	954,423,500	219,350,269	219,350,269	-	954,423,500	-	
DSH and Rural Hospitals	20,422,500		-	-	-	20,422,500		-		
Voluntary Political Subdivision Programs - See Note 5	214,151,100		(13,452,950)	(13,452,950)	-	214,151,100		-		
TOTAL FEDERAL EXPENDITURES	6,176,764,900		 	 	
1,443,106,924	1,443,106,924	-	6,176,764,900		-		
Administrative Expenditures Proposition 204 - BNCF	3,482,900		-	-	-	3,482,900		-		
Programmatic Expenditures							
Traditional Medicaid Services Acute Care	49,879,700		12,469,925	12,469,925	-	49,879,700		-		
ALTCS Services	249,234,600		61,033,429	61,033,429	-	249,234,600		-		
TOTAL COUNTY EXPENDITURES	302,597,200		 	 	
73,503,354	73,503,354	-	302,597,200		-		
	TOBACCO FUNDS						
Programmatic Expenditures							
Traditional Medicaid Services Acute Care - Medically Needy		31,180,000	7,795,000	7,795,000	-	31,180,000	-	
Proposition 204 Services - Emergency Health Services		17,331,400	4,208,266	4,208,266	-	17,331,400	-	
Proposition 204 Services - Proposition 204 Protection		36,396,000	9,099,000	9,099,000	-	36,396,000	-	
Proposition 204 Services - ATLSF
TOTAL TOBACCO EXPENDITURES

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	100,000,000

184,907,400

OTHER

198,000	-	-	-	100,000,000	-
 	 	 	
21,102,266	21,102,266	-	184,907,400	-

24,082	24,082	-	198,000	-	
Acute Care - Prescription Drug Rebate Program State Match		78,105,000	19,526,250		19,526,250		-	78,105,000		-	
Acute Care - Prescription Drug Rebate Program Federal Authority		207,883,900	60,109,479		60,109,479		-	207,883,900		-	
Long Term Care - Prescription Drug Rebate Program State Match		5,475,800	1,368,950		1,368,950		-	5,475,800		-	
Long Term Care - Prescription Drug Rebate Program Federal Authority		14,574,200	4,832,618		4,832,618		-	14,574,200		-	
Proposition 204 Services - Hospital Assessment		215,558,800	68,220,796		68,220,796		-	215,558,800		-	
Traditional Medicaid Services - TPL		194,700	136,662		136,662		-	194,700		-	
ALTCS Services - TPL		-	207,634		207,634		-	-		-	
ALTCS Services - Nursing Facility Assessment		-	5,017		5,017		-	-		-	
KidsCare Services Premiums		370,000	-		-		-	370,000		-	
Freedom to Work Premiums		31,200	13,471		13,471		-	31,200		-	
Voluntary Political Subdivision Programs - See Note 5		98,945,600	607,335		607,335		-	98,945,600		-	
TOTAL OTHER EXPENDITURES		621,337,200	155,052,293		155,052,293		
-	621,337,200		-	
	TOTAL									

Administrative Expenditures		
178,041,400	
33,290,089		
33,290,089		
-	178,041,400		
-	
Acute Care		6,926,138,700	1,650,647,605		1,650,647,605		-	6,926,138,700		-	
Long Term Care		1,386,588,900	327,518,117		327,518,117		-	1,386,588,900		-	
TOTAL EXPENDITURES	$	8,490,769,000	$	2,011,455,811		$	2,011,455,811		$	-	$	8,490,769,000		$	-	

		 	

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

BUDGET

BUDGET
YTD

RECEIPTS
YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	932,396,500		$	266,892,564		$	266,892,564	
Proposition 204 Services & Administrative	109,547,000		10,844,766		10,844,766	
KidsCare Services	338,000		233,444		233,444	
ALTCS Services	 	162,880,800			 	40,720,200			 	40,720,200		
TOTAL	1,205,162,300		318,690,974		318,690,974	

FEDERAL:
Acute & Administrative	5,216,754,200		1,223,241,459		1,205,094,075	
KidsCare Services	5,587,200		515,196		486,314	
ALTCS Services	 	954,423,500			 	219,350,269			 	225,406,163		
TOTAL	6,176,764,900		1,443,106,924		1,430,986,552	

COUNTY:						
Acute & Administrative	53,362,600		12,469,925		11,686,838	
ALTCS Services	 	249,234,600			 	61,033,429			 	62,308,653		
TOTAL	302,597,200		73,503,354		73,995,491	

TOBACCO FUNDS:						
Traditional Medicaid Services	31,180,000		7,795,000		7,795,000	
Proposition 204 Services	 	153,727,400			 	13,307,266			 	13,307,266		
TOTAL	184,907,400		21,102,266		21,102,266	

OTHER:						
Administrative	198,000		24,082		24,082	
Acute Care - Prescription Drug Rebate Program	285,988,900		79,635,729		79,635,729	
Long Term Care - Prescription Drug Rebate Program	20,050,000		6,201,568		6,201,568	
Hospital Assessment	215,558,800		68,220,796		62,589,997	
ALTCS - Nursing Facility Assessment	-		5,017		55,405	
Acute TPL - Note 1	194,700		136,662		136,662	
LTC TPL - Note 1	-		207,634		207,634	
KidsCare TPL - Note 1	-		-		20,853	
Member Premiums - CHIP	370,000		-		99,673	
Member Premiums - Freedom to Work	31,200		13,471		13,471	
Voluntary Political Subdivision - State Match	 	98,945,600			 	607,335			 	8,288,023		
TOTAL	621,337,200		155,052,293		157,273,096	

TOTAL REVENUE

$	8,490,769,000

$	2,011,455,811

$	2,002,048,379

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2015	
Note 1:	Third Party Liability Collections:	September 2015		September 2014		July 1, 2015		July 1, 2014	
	Gross Collections:					September 30, 2015		September 30, 2014	
	Acute	$	427,291		$	465,921		$	1,247,725		$	1,525,697	
	LTC	317,202		327,779		905,933		1,130,377	
	KidsCare	466		1,322		103,981		2,140	
	Total TPL Collections	$	744,959		$	795,022		$	2,257,640		$	2,658,214	

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

Acute

$	31,857	$

77,698	$

136,662	$

206,119

LTC	74,192	77,961	207,634	264,998
KidsCare	88	258	20,853	417

Total Expenditure Offsets

$	106,137	$

155,917	$

365,149	$

471,534

FY 16 Total

Note 2:    Authorized Positions	1,029.2
Actual Positions as of September 30, 2015	912.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2015	

$	2,853,728	
	Revenues	914,693	
	Transfers-In	 	137,535		
	Total Revenues	 	1,052,229		
	Expenditures Transfers-out
Total Expenditures	1,291,455
 	-	
 	1,291,455		
	Ending Balance September 30, 2015	  $	2,614,502		

Of the $2,614,502 ending balance, $1,096,694 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through October 2015.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of September 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 September 30, 2015

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of September 30, 2015 Expenditures

State Match	Federal	Total

DSH Voluntary

$	607,335	$

1,245,990	$

1,853,325

GME Voluntary	-	-	-
Safety Net Care Pool	-		(14,698,940)		(14,698,940)	
Total Voluntary Political Subdivision Program Expenditures	$	607,335		$	(13,452,950)		$	(12,845,615)	

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending September 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	0	0	0	0	0	0	0	0	0	827,850,144	
CAPITATION - LTC	182,421,827	195,322,105	184,831,914	0	0	0	0	0	0	0	0	0	562,575,846	
MENTAL HEALTH - CHILD	24,739,142	24,849,877	25,557,281	0	0	0	0	0	0	0	0	0	75,146,299	
MENTAL HEALTH - ADULT	11,323,471	11,730,505	12,433,438	0	0	0	0	0	0	0	0	0	35,487,414	
MENTAL HEALTH - GENERAL	15,232,013	15,779,544	16,725,109	0	0	0	0	0	0	0	0	0	47,736,665	
MENTAL HEALTH - CMDP	14,633,559	14,896,415	14,987,440	0	0	0	0	0	0	0	0	0	44,517,414	
CHILDREN'S REHAB SERVICES	3,716,383	3,722,744	3,729,851	0	0	0	0	0	0	0	0	0	11,168,979	
FEE FOR SERVICE - ACUTE	39,309,584	42,687,182	52,163,025	0	0	0	0	0	0	0	0	0	134,159,792	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	0	0	0	0	0	0	0	0	0	2,019,632	
EMERGENCY SERVICES - FEDERAL	4,601,455	4,572,491	5,962,347	0	0	0	0	0	0	0	0	0	15,136,294	
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	0	0	0	0	0	0	0	0	0	1,404,162	
INPATIENT INMATES FFS	94,140	163,355	30,952	0	0	0	0	0	0	0	0	0	288,446	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	0	0	0	0	0	0	0	0	0	998,584	
PIMA COUNTY INMATES FFS	339	2,845	4,099	0	0	0	0	0	0	0	0	0	7,283	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	0	0	0	0	0	0	0	0	0	107,739	
PINAL COUNTY INMATES FFS	0	791	4,402	0	0	0	0	0	0	0	0	0	5,193	
FEE FOR SERVICE - LTC	8,618,281	9,030,245	12,244,181	0	0	0	0	0	0	0	0	0	29,892,707	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	0	0	0	0	0	0	0	0	0	81,675	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,303,186	520,396	1,333,715	0	0	0	0	0	0	0	0	0	3,157,297	
REINSURANCE - ACUTE	7,490,557	6,963,077	9,713,101	0	0	0	0	0	0	0	0	0	24,166,735	
REINSURANCE - LTC	4,045,763	3,839,634	5,041,535	0	0	0	0	0	0	0	0	0	12,926,932	
SMIB - ACUTE	9,829,585	10,084,385	10,344,498	0	0	0	0	0	0	0	0	0	30,258,469	
HIB - ACUTE	261,769	274,050	304,238	0	0	0	0	0	0	0	0	0	840,057	
Q1	2,399,485	1,983,017	1,927,946	0	0	0	0	0	0	0	0	0	6,310,448	
SMIB - LTC	2,846,826	2,859,916	2,858,311	0	0	0	0	0	0	0	0	0	8,565,052	
HIB - LTC	269,425	275,672	269,873	0	0	0	0	0	0	0	0	0	814,970	
SUBTOTAL	607,107,950	627,019,071	641,497,165	0	0	0	0	0	0	0	0	0	1,875,624,186	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending September 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	0	0	0	0	0	0	0	0	0	509,728,455	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	0	0	0	0	0	0	0	0	0	232,885	
MENTAL HEALTH - ADULT	14,130,226	13,753,412	13,745,030	0	0	0	0	0	0	0	0	0	41,628,668	
MENTAL HEALTH - GENERAL	19,007,580	18,500,700	18,489,426	0	0	0	0	0	0	0	0	0	55,997,706	
CHILDREN'S REHAB SERVICES	13,342	14,176	13,759	0	0	0	0	0	0	0	0	0	41,277	
FEE FOR SERVICE - ACUTE	23,420,195	26,360,064	31,634,361	0	0	0	0	0	0	0	0	0	81,414,619	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	0	0	0	0	0	0	0	0	0	3,523,995	
EMERGENCY SERVICES - FEDERAL	1,615,009	1,756,056	2,298,814	0	0	0	0	0	0	0	0	0	5,669,879	
FFS MEDICAID IN PUBLIC SCHOOLS	5,786	3,204	5,139	0	0	0	0	0	0	0	0	0	14,129	
INPATIENT INMATES FFS	600,012	766,289	566,467	0	0	0	0	0	0	0	0	0	1,932,767	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	0	0	0	0	0	0	0	0	0	317,147	
YAVAPAI COUNTY INMATES FFS	306	0	166	0	0	0	0	0	0	0	0	0	472	
PINAL COUNTY INMATES FFS	8,167	-1,654	11,736	0	0	0	0	0	0	0	0	0	18,248	
PIMA COUNTY INMATES FFS	16,737	14,619	968	0	0	0	0	0	0	0	0	0	32,324	
COCONINO COUNTY INMATES FFS	152	3,842	0	0	0	0	0	0	0	0	0	0	3,994	
REINSURANCE - ACUTE	3,024,281	3,235,285	3,273,260	0	0	0	0	0	0	0	0	0	9,532,826	
SMIB - ACUTE	5,190,825	5,190,446	5,117,460	0	0	0	0	0	0	0	0	0	15,498,730	
HIB - ACUTE	8,649	8,527	5,656	0	0	0	0	0	0	0	0	0	22,833	
SUBTOTAL	240,353,793	239,923,839	245,333,323	0	0	0	0	0	0	0	0	0	725,610,955	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending September 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	0	0	0	0	0	0	0	0	0	70,142,918	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	0	0	0	0	0	0	0	0	0	6,917,675	
MENTAL HEALTH - GENERAL	2,968,226	3,090,821	3,246,414	0	0	0	0	0	0	0	0	0	9,305,461	
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	0	0	0	0	0	0	0	0	0	6,269,942	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	0	0	0	0	0	0	0	0	0	692,368	
EMERGENCY SERVICES - FEDERAL	1,701,575	1,999,988	3,176,831	0	0	0	0	0	0	0	0	0	6,878,393	
INPATIENT INMATES FFS	6,351	35,816	34,047	0	0	0	0	0	0	0	0	0	76,214	
MARICOPA CTY INMATES FFS	15,154	0	0	0	0	0	0	0	0	0	0	0	15,154	
REINSURANCE - ACUTE	276,372	479,010	344,794	0	0	0	0	0	0	0	0	0	1,100,175	
SMIB - ACUTE	1,469	734	839	0	0	0	0	0	0	0	0	0	3,042	
	31,784,937	33,467,076	36,150,580	0	0	0	0	0	0	0	0	0	101,402,593	
	879,246,680	900,409,987	922,981,068	0	0	0	0	0	0	0	0	0	2,702,637,735	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
KidsCare - CAPITATION	183,782	170,409	173,186	0	0	0	0	0	0	0	0	0	527,377	
KidsCare - FEE FOR SERVICE	-819	774	436	0	0	0	0	0	0	0	0	0	391	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	0	0	0	0	0	0	0	0	0	107,304	
KidsCare - REINSURANCE	162	30,495	70,989	0	0	0	0	0	0	0	0	0	101,646	

220,533	237,043	279,141	0	0	0	0	0	0	0	0	0	736,717	

TOTAL TITLE XXI

879,467,213	900,646,743	923,260,209	0	0	0	0	0	0	0	0	0	2,703,374,165	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339.51		
1006	TANF 21-44 MALE WITH	91,470.48	100,935.93	114,056.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306,462.94		
1007	TANF 21-44 FEMALE WI	262,969.81	321,024.00	366,691.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		950,684.94		
1008	TANF 45-64 M & F WIT	456,857.48	533,329.59	618,899.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,609,086.21		
1009	TANF 65+ M & F WITH	130,859.20	158,119.22	182,105.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,084.05		
100F	TANF 21-44 MALE WITH	3,124.94	3,371.26	1,066.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,562.52		
100G	TANF 21-44 FEMALE WI	6,088.86	5,158.50	4,029.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,277.09		
100H	TANF 44-64 M & F WIT	43,752.90	40,165.14	12,382.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,300.70		
100J	TANF 65+ M & F WITH	30,736.25	17,071.36	1,805.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,612.87		
1011	TANF <1 M & F NON-ME	7,317,911.15	7,330,064.00	6,810,085.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,458,061.09		
1012	TANF 01-05 M & F NON	5,120,069.24	4,255,241.15	3,820,804.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,196,115.10		
1013	TANF 06-13 M & F NON	8,517,151.93	7,122,208.02	6,407,880.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,047,240.74		
1014	TANF 14-20 MALE NON-	2,727,086.79	2,467,883.88	2,310,485.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,505,456.54		
1015	TANF 14-20 FEMALE N O	5,165,143.02	4,749,211.72	4,482,122.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,396,477.08		
1016	TANF 21-44 MALE NON-	5,413,848.55	5,881,009.18	6,413,970.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,708,827.79		
1017	TANF 21-44 FEMALE N O	26,519,446.98	27,563,602.69	29,211,296.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,294,345.99		
1018	TANF 45-64 M & F NON	11,340,403.80	12,200,886.15	13,314,078.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,855,368.54		
1019	TANF 65+ M & F NON-M	50,940.78	55,345.09	63,094.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,380.23		
101A	TANF < 1 M & F NON-M	1,483,647.90	1,229,135.61	596,433.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,309,217.10		
101B	TANF 01-05 M & F NON	18,930.19	10,452.99	13,969.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,352.69		
101C	TANF 06-13 M & F NON	13,827.52	10,991.93	10,596.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,416.40		
101D	TANF 14-20 MALE NON-	30,653.81	23,910.41	11,522.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,086.90		
101E	TANF 14-20 FEMALE N O	56,482.84	48,295.58	35,281.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,059.85		
101F	TANF 21-44 MALE NON-	441,372.83	443,539.24	240,851.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,125,764.03		
101G	TANF 21-44 FEMALE N O	967,547.84	939,350.71	551,924.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,458,822.77		
101H	TANF 44-64 M & F NON	673,153.96	695,670.20	390,666.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,759,491.08		
101J	TANF 65+ N & F NON-M	13,593.90	8,104.86	11,870.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,569.46		
1026	TANF 21-44 MALE WITH	39,781.26	52,613.13	69,409.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,803.87		
1027	TANF 21-44 FEMALE WI	112,487.20	155,750.38	178,197.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446,435.03		
1028	TANF 45-64 M & F WIT	142,957.26	219,266.01	262,802.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		625,025.97		
1029	TANF 65+ M & F WITH	53,811.16	84,861.43	103,507.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242,180.53		
102F	TANF 21-44 MALE WITH	0.00	349.97	22.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		372.15		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,247.40		
102J	TANF 65+ M & F WITH	958.54	944.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,903.41		
2100	SSI AGED WITH MEDIC A	646,891.69	640,426.15	626,324.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,913,642.72		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	42,792.60	35,137.07	23,993.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,922.81		
2110	SSI AGED NON-MEDIC AR	4,841,984.49	4,755,477.85	4,841,046.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,438,508.34		
211Z	SSI AGED NON-MEDIC AR	168,114.98	120,300.70	81,292.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		369,708.37		
2120	SSI AGED WITH QMB	2,773,140.25	2,801,949.97	2,812,690.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,387,781.09		
212Z	SSI AGED WITH QMB P P	5,569.66	5,916.01	9,571.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,057.55		
2200	SSI DISABLED WITH M E	1,438,779.65	1,356,642.89	1,368,850.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,164,273.08		
220Z	SSI DISABLED WITH M E	21,320.23	23,148.40	24,683.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,151.92		
2210	SSI DISABLED NON-ME D	55,077,622.81	54,829,218.00	54,812,398.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164,719,239.57		
221Z	SSI DISABLED NON-ME D	491,291.42	492,991.62	460,508.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,444,791.74		
2220	SSI DISABLED WITH Q M	10,386,804.88	10,418,005.20	10,514,240.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,319,050.19		
222Z	SSI DISABLED WITH Q M	5,921.17	7,380.90	10,401.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,703.50		
2300	SSI BLIND WITH MEDIC	4,363.55	4,060.83	3,780.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,205.12		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,072,763.23		
231Z	SSI BLIND NON-MEDIC A	3,440.09	12,852.23	5,876.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,168.49		
2320	SSI BLIND WITH QMB	44,041.31	43,688.31	44,085.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,814.71		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,213.33		
4303	SOBRA CHILD 06-13 M	227.07	227.07	276.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		730.25		
4304	SOBRA CHILD 14-20 MA	162.24	162.24	162.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		486.72		
4305	SOBRA CHILD 14-20 FE	789.59	840.59	831.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,462.15		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.88		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.06		
4311	SOBRA CHILD <1 M & F	19,081,996.88	19,048,366.58	17,788,960.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,919,324.00		
4312	SOBRA CHILD 01-05 M	19,072,224.87	20,064,623.31	21,072,490.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,209,338.43		
4313	SOBRA CHILD 06-13 M	25,452,339.99	27,401,384.87	29,128,878.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,982,603.41		
4314	SOBRA CHILD 14-20 MA	8,607,044.24	8,948,118.85	9,523,338.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,078,501.32		
4315	SOBRA CHILD 14-20 FE	13,024,273.87	13,595,781.00	14,432,717.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,052,772.57		
431A	SOBRA CHILD < 1 M &	1,266,381.59	1,304,281.60	634,368.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,205,031.52		
431B	SOBRA CHILD 01-05 M	494,252.81	475,898.40	360,178.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,330,329.53		
431C	SOBRA CHILD 6-13 M& F	634,059.19	670,453.45	453,423.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,757,936.01		
431D	SOBRA CHILD 14-20 MA	467,748.21	431,434.92	303,172.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,202,355.92		
431E	SOBRA CHILD 14-20 FE	506,841.24	521,342.83	357,514.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,385,698.90		
4322	SOBRA CHILD 01-05 M	329.97	0.00	220.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		550.62		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4323	SOBRA CHILD 06-13 M	755.82	0.00	107.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		863.30		
4324	SOBRA CHILD 14-20 MA	623.74	0.00	162.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785.98		
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	28,646.09	29,529.54	34,810.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,986.10		
5008	SOBRA PREG 45-64 FE M	856.00	405.55	405.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,667.10		
500G	SOBRA PREG 21-44 FE M	667.73	637.69	427.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,732.55		
5013	SOBRA PREG 09-13 FE M	791.84	960.27	778.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,530.77		
5015	SOBRA PREG 14-20 FE M	1,153,204.41	1,243,589.20	1,321,708.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,718,502.05		
5017	SOBRA PREG 21-44 FE M	4,969,763.44	5,543,577.71	6,104,353.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,617,694.68		
5018	SOBRA PREG 45-64 FE M	29,226.73	32,189.69	33,578.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,994.42		
501C	SOBRA PREG 09-13 FE M	0.00	98.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98.71		
501E	SOBRA PREG 14-20 FE M	77,023.42	77,726.43	48,097.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202,846.99		
501G	SOBRA PREG 21-44 FE M	331,612.75	308,457.61	239,213.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		879,283.77		
501H	SOBRA PREG 45-64 FE M	3,630.96	10,740.73	531.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,902.86		
5027	SOBRA PREG 21-44 FE M	2,329.77	2,829.66	4,481.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,641.15		
5028	SOBRA PREG 45-64 FE M	0.00	2,426.39	2,426.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,852.78		
502G	SOBRA PREG 21-44 FE M	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		
5510	SOBRA FPS FEMALE W IT	-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		
SUBTOTAL:	248,764,079.13	252,354,794.67	254,464,913.2	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		755,583,787.07		

9910	TANF & SOBRA CHILDR E	3,483,562.65	3,047,996.25	2,907,424.24	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	253,912.66	175,567.47	201,893.70	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,269,535.99	17,056,752.97	18,080,567.4	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,438,983.14	
207,944.27	
631,373.83	
41,128,555.15	
51,406,856.39	

3100	TRANSPLANT OPTION 1	70.26	89.42	82.50	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	165.00	165.00	82.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
242.18	
170.32	
412.50	

1106	TANF EXPANDED 21-44	167,462.38	144,030.22	123,318.86	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	274,415.40	245,636.00	232,837.24	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	520.84	324.33	2,552.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	161.40	385.93	27,647.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+
M&	0.00	1,210.32	15,631.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
434,811.46	
1,625,559.64	
2,782,674.57	
752,888.64	
5,799.68	
3,397.39	
28,195.00	
16,841.39	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1111	TANF EXPANDED <1 M
&F	6,325.21	4,355.65	762.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,443.65		
1112	TANF EXPANDED 01-05	48,437.22	37,053.66	33,123.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,614.69		
1113	TANF EXPANDED 06-13	155,432.39	123,651.13	108,415.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		387,499.10		
1114	TANF EXPANDED 14-20	114,898.22	90,180.24	76,789.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281,867.68		
1115	TANF EXPANDED 14-20	375,463.35	278,983.53	236,525.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		890,972.21		
1116	TANF EXPANDED 21-44	3,292,450.62	2,886,484.77	2,569,959.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,748,895.10		
1117	TANF EXPANDED 21-44	11,884,383.87	10,291,379.14	9,057,760.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,233,523.97		
1118	TANF EXPANDED 45-64	7,186,338.24	6,353,222.09	5,768,022.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,307,583.14		
1119	TANF EXPANDED 65+
M&	38,116.96	34,638.80	32,844.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,600.43		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.93		
111D	TANF EXPANDED 14-20	91.04	817.44	2,346.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,254.82		
111E	TANF EXPANDED 14-20	1,428.69	1,919.48	6,274.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,623.06		
111F	TANF EXPANDED 21-44	16,857.80	16,840.28	88,070.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,768.82		
111G	TANF EXPANDED 21-44	38,462.54	45,149.24	202,727.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,339.77		
111H	TANF EXPANDED 45-64	12,792.72	53,531.20	181,490.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,814.25		
111J	TANF EXPANDED 65+
M&	10,074.33	0.00	1,610.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,684.45		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,464.32		
1127	TANF EXPANDED 21-44	214,717.61	193,927.68	179,884.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		588,529.73		
1128	TANF EXPANDED 45-64	242,994.86	222,897.30	210,610.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		676,502.81		
1129	TANF EXPANDED 65+
M&	89,535.41	77,417.22	73,153.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,106.04		
112F	TANF EXPANDED 21-44	0.00	0.00	406.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406.00		
112G	TANF EXPANDED 21-44	0.00	681.07	726.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,407.10		
112H	TANF EXPANDED 45-64	10.59	0.00	1,235.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,246.03		
112J	TANF EXPANDED 65+
M&	0.00	0.00	6,378.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,378.93		
2400	SSI AGED EXPANDED WI	90,318.38	78,003.38	74,504.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242,825.83		
240Z	SSI AGED EXPANDED WI	28,495.79	37,821.60	22,409.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,726.67		
2410	SSI AGED EXPANDED NO	929,746.50	864,149.68	813,310.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,607,206.80		
241Z	SSI AGED EXPANDED NO	7,401.77	16,962.83	8,306.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,670.80		
2420	SSI AGED EXPANDED WI	5,235,551.09	5,187,661.49	5,133,746.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,556,958.86		
242Z	SSI AGED EXPANDED WI	7,997.68	5,766.54	4,987.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,751.55		
2510	SSI BLIND EXPANDED N	1,458.65	1,458.65	1,458.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,375.95		
2520	SSI BLIND EXPANDED W	124.99	124.99	124.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		374.97		
2600	SSI DISABLED EXPAND E	159,975.75	157,902.91	154,039.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,918.23		

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
260Z	SSI DISABLED EXPAND E	17,956.66	21,077.50	16,146.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,180.45	
2610	SSI DISABLED EXPAND E	2,642,788.10	2,565,161.03	2,574,872.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,782,821.60	
261Z	SSI DISABLED EXPAND E	33,355.68	32,438.70	29,106.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94,900.57	
2620	SSI DISABLED EXPAND E	7,540,307.86	7,645,491.81	7,856,549.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,042,349.60	
262Z	SSI DISABLED EXPAND E	6,428.48	5,511.39	8,031.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,971.28	
SUBTOTAL	:	42,577,206.07	39,244,718.86	37,338,771.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119,160,696.78	

9911	SB PAYMENT FOR TAN F	638,069.14	744,028.48	692,146.52	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	656,262.88	768,544.97	716,894.7	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,074,244.14	
55,751.65	
11,706.78	
2,141,702.57	

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	0.00	0.00	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	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	36,321.61	26,956.15	25,017.05	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	22,353.25	22,570.84	21,631.31	0.00	0.00	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	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,633,845.08	1,727,407.10	1,811,455.28	0.00	0.00	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	0.00	0.00	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	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	15,191,483.66	15,250,141.05	15,625,452.65	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	16,506.64	15,041.42	15,084.02	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	458,558.32	429,699.96	368,800.73	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	27,457.81	15,740.35	20,203.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3525	ADULT 40-100% FEMAL E	351.97	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	1,168.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	668.80	1,504.94	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	10,626.75	7,689.50	12,719.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
18,617.54	
32,163.36	
88,294.81	
66,555.40	
6,437.86	
23,240.03	
12,579.56	
4,280,072.86	
5,172,707.46	
22,922,511.80	
19,233,134.16	
46,067,077.36	
46,632.08	
353,638.13	
383,283.87	
1,739,096.76	
1,257,059.01	
2,949,446.93	
63,401.37	
351.97	
1,168.26	
2,173.74	
31,035.36	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3529	ADULT 40-100% M&F 65	2,416.71	4,002.70	1,585.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,004.41		
352G	ADULT 40-100% FEMAL E	0.00	531.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		531.77		
352H	ADULT 40-100% M&F 45	16.98	1,224.13	886.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,127.94		
3706	ADULT <40% EXP MAL E	34,143.30	26,154.77	20,573.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,871.56		
3707	ADULT <40% EXP FEM AL	12,691.88	18,567.70	11,647.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,907.51		
3708	ADULT <40% EXP M&F 4	47,370.84	58,639.06	54,729.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,739.52		
3709	ADULT <40% EXP M&F 6	8,255.13	8,986.58	12,316.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,558.67		
370F	ADULT <40% EXP MAL E	3,590.13	5,678.35	4,459.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,727.48		
370G	ADULT <40% EXP FEM AL	824.34	1,262.96	35.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,122.40		
370H	ADULT <40% EXP M&F 4	8,737.58	10,393.47	21,133.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,264.39		
370J	ADULT <40% EXP M&F 6	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	ADULT <40% EXP MAL E	4,383,132.32	4,528,025.34	4,668,083.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,579,240.93		
3715	ADULT <40% EXP FEM AL	3,752,637.27	3,863,233.89	3,962,050.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,577,921.74		
3716	ADULT <40% EXP MAL E	27,106,086.04	27,395,881.26	28,559,100.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,061,067.48		
3717	ADULT <40% EXP FEM AL	16,530,344.45	16,579,394.61	17,156,912.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,266,651.88		
3718	ADULT <40% EXP M&F 4	33,539,387.24	33,762,918.80	34,763,411.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,065,717.07		
3719	ADULT <40% EXP M&F 6	36,205.17	36,567.62	42,431.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,204.07		
371D	ADULT <40% EXP MAL E	392,849.93	382,830.27	238,138.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,013,818.95		
371E	ADULT <40% EXP FEM AL	356,021.60	295,087.13	201,535.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852,644.63		
371F	ADULT <40% EXP MAL E	2,852,336.09	2,763,526.13	1,988,245.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,604,107.90		
371G	ADULT <40% EXP FEM AL	1,605,524.56	1,472,687.76	1,073,635.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,151,847.70		
371H	ADULT <40% EXP M&F 4	2,523,268.04	2,262,250.08	1,652,940.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,438,458.38		
371J	ADULT <40% EXP M&F 6	2,019.24	1,369.87	8,989.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,378.56		
3724	ADULT <40% EXP MAL E	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 MAL E	3,936.06	7,430.66	5,545.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,912.05		
3727	ADULT <40% EXP FEM AL	4,778.02	3,573.32	779.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,131.26		
3728	ADULT <40% EXP M&F 4	17,960.52	5,138.97	16,090.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,190.39		
3729	ADULT <40% EXP M&F 6	1,616.38	0.00	362.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,978.72		
372F	ADULT <40% EXP MAL E	0.00	711.09	4,151.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,862.25		
372G	ADULT <40% EXP FEM AL	598.25	1,319.88	2,540.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,458.35		
372H	ADULT <40% EXP M&F 4	470.36	1,351.60	251.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,073.82		
SUBTOTAL:	128,119,986.92	128,273,464.15	129,558,529.0	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		385,951,980.14		

9935	BIRTH SUPP PAYMENT A	176,469.55	272,778.55	241,599.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT A	447,342.88	597,836.74	736,611.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	623,812.43	870,615.29	978,210.9	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
690,847.97	
1,781,790.66	
2,472,638.63	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3904	NEWLY ELIGIBLE MALE	0.00	55.96	346.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		402.89		
3906	NEWLY ELIGIBLE MALE	2,243.33	4,164.05	5,522.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,930.23		
3907	NEWLY ELIGIBLE FEMA L	11,101.01	5,502.90	2,869.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,473.03		
3908	NEWLY ELIGIBLE M&F 4	30,815.43	20,891.02	14,759.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,466.10		
3909	NEWLY ELIGIBLE M&F 6	3,752.37	6,340.48	6,828.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,921.53		
390D	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		318.47		
390F	NEWLY ELIGIBLE MALE	154.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154.29		
390G	NEWLY ELIGIBLE FEMA L	558.35	584.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,143.18		
390H	NEWLY ELIGIBLE M&F 4	20,702.19	14,075.84	19,780.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,559.00		
390J	NEWLY ELIGIBLE M&F 6	3,743.08	5,233.41	11,173.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,149.84		
3914	NEWLY ELIGIBLE MALE	520,790.75	542,267.89	590,928.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,653,986.86		
3915	NEWLY ELIGIBLE FEMA L	601,783.26	669,009.91	701,931.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,972,724.80		
3916	NEWLY ELIGIBLE MALE	5,010,046.71	5,234,991.72	5,512,159.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,757,197.50		
3917	NEWLY ELIGIBLE FEMA L	6,457,501.35	6,891,154.05	7,326,735.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,675,390.88		
3918	NEWLY ELIGIBLE M&F 4	7,992,989.32	8,091,976.44	8,244,535.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,329,501.05		
3919	NEWLY ELIGIBLE M&F 6	13,274.71	12,857.15	12,513.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,645.37		
391D	NEWLY ELIGIBLE MALE	48,199.73	37,609.47	40,038.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,847.47		
391E	NEWLY ELIGIBLE FEMA L	52,151.67	50,095.35	33,023.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,270.98		
391F	NEWLY ELIGIBLE MALE	503,095.65	399,419.06	363,419.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,265,933.80		
391G	NEWLY ELIGIBLE FEMA L	575,662.05	557,633.73	466,745.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,600,041.56		
391H	NEWLY ELIGIBLE M&F 4	598,828.85	481,913.67	459,344.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,540,086.80		
391J	NEWLY ELIGIBLE M&F 6	3,178.08	11,525.06	33,951.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,654.82		
3926	NEWLY ELIGIBLE MALE	282.13	198.55	587.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,068.04		
3927	NEWLY ELIGIBLE FEMA L	0.00	3,064.18	3,059.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,123.50		
3928	NEWLY ELIGIBLE M&F 4	1,925.68	968.19	772.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,666.69		
3929	NEWLY ELIGIBLE M&F 6	598.20	308.72	649.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,556.40		
392F	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		92.63		
392H	NEWLY ELIGIBLE M&F 4	782.69	451.48	178.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,412.99		
392J	NEWLY ELIGIBLE M&F 6	0.00	11.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.02		
SUBTOTAL:	22,454,160.88	23,042,703.84	23,851,867.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,348,731.72		

9939	BIRTH SUPP PAYMENT N	236,215.30	208,587.25	349,383.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	236,215.30	208,587.25	349,383.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
794,186.41

794,186.41

4412	SOBRA 100-133% M&F
1	227.07	113.90	227.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	2,472,060.61	2,222,646.29	2,028,673.87	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
568.77	
6,723,380.77	
3,088,035.03	

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

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4415	SOBRA 100-133% FEM	1,627,175.04	1,485,905.55	1,372,014.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,485,095.00	
	AL														
441C	SOBRA 100-133% M&F	16,933.27	18,946.08	66,346.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	102,226.25	
	6														
441D	SOBRA 100-133% MALE	21,389.49	17,226.07	66,017.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104,633.48	
441E	SOBRA 100-133% FEM	15,755.99	20,553.56	83,770.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	120,079.68	

SUBT	AL
OTAL:	
5,278,024.25	
4,784,466.49	
4,561,528.24	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
14,624,018.98	

9944	BIRTH SUPP PAYMENT S	48,525.79	80,265.10	17,579.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	48,525.79	80,265.10	17,579.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
146,370.63

146,370.63

4517	BC PATIENT FEMALE 2 1	6,031.34	6,350.82	6,499.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	112,672.67	110,350.85	110,314.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	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	BC PATIENT FEMALE 2 1	0.00	718.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	3,437.97	2,627.92	3,114.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	6,156.87	6,362.76	6,506.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	7,757.51	7,379.70	6,916.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	323.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	136,329.63	134,114.31	133,351.1	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
18,882.04	
333,337.90	
273.27	
718.61	
9,180.01	
19,025.93	
22,053.72	
323.65	
403,795.13	

8600	SSI BLIND FREEDOM/W O	119.15	119.15	119.15	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	1,871.66	508.27	103.48	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
357.45	
4,224,289.92	
39,974.63	
817,874.48	
110,073.66	
489,849.37	
2,483.41	
5,684,902.92	

1,407,721,516.82

467,034,603.84	468,726,485.92	471,960,427.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1006	TANF 21-44 MALE WITH	297.30	350.67	391.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,039.90		
1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,992.67		
1008	TANF 45-64 M & F WIT	870.42	1,013.58	1,168.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,052.84		
1009	TANF 65+ M & F WITH	306.00	373.68	430.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,110.24		
100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.29		
100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.53		
100H	TANF 44-64 M & F WIT	97.51	98.86	32.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229.22		
100J	TANF 65+ M & F WITH	73.60	39.19	4.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117.16		
1011	TANF <1 M & F NON-ME	14,502.91	14,510.24	13,463.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,476.72		
1012	TANF 01-05 M & F NON	41,759.21	34,503.32	30,981.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,244.08		
1013	TANF 06-13 M & F NON	68,866.70	57,435.45	51,559.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,861.83		
1014	TANF 14-20 MALE NON-	15,523.91	13,919.00	12,939.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,382.49		
1015	TANF 14-20 FEMALE N O	19,492.05	17,891.08	16,863.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,246.15		
1016	TANF 21-44 MALE NON-	32,422.89	35,110.56	38,554.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,087.52		
1017	TANF 21-44 FEMALE N O	100,171.76	104,138.61	110,548.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,859.19		
1018	TANF 45-64 M & F NON	26,326.13	28,376.39	30,996.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,698.85		
1019	TANF 65+ M & F NON-M	122.25	133.13	152.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		407.43		
101A	TANF < 1 M & F NON-M	1,323.68	1,107.58	523.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,954.50		
101B	TANF 01-05 M & F NON	323.00	173.98	234.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		731.08		
101C	TANF 06-13 M & F NON	235.43	179.19	176.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		591.10		
101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		398.73		
101E	TANF 14-20 FEMALE N O	278.91	237.91	174.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		690.84		
101F	TANF 21-44 MALE NON-	2,653.94	2,660.54	1,444.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,759.46		
101G	TANF 21-44 FEMALE N O	4,819.02	4,659.58	2,737.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,216.34		
101H	TANF 44-64 M & F NON	1,604.09	1,643.02	919.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,166.24		
101J	TANF 65+ N & F NON-M	31.66	19.50	26.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.96		
1026	TANF 21-44 MALE WITH	136.90	188.45	227.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		552.99		
1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		898.99		
1028	TANF 45-64 M & F WIT	257.30	401.73	481.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,140.59		
1029	TANF 65+ M & F WITH	125.59	199.79	245.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		570.81		
102F	TANF 21-44 MALE WITH	0.00	2.12	0.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.25		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.44		
102J	TANF 65+ M & F WITH	2.37	2.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.54		
2100	SSI AGED WITH MEDIC A	3,945.61	3,902.67	3,829.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,678.08		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	450.53	377.60	249.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,077.49		
2110	SSI AGED NON-MEDIC AR	5,996.37	5,885.71	5,990.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,872.25		
211Z	SSI AGED NON-MEDIC AR	323.02	229.89	155.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		708.81		
2120	SSI AGED WITH QMB	16,192.79	16,392.49	16,583.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,168.60		
212Z	SSI AGED WITH QMB P P	60.27	61.77	97.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		219.40		
2200	SSI DISABLED WITH M E	3,600.36	3,525.64	3,506.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,632.17		
220Z	SSI DISABLED WITH M E	236.76	251.22	272.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		760.93		
2210	SSI DISABLED NON-ME D	57,143.85	56,902.31	56,909.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,955.77		
221Z	SSI DISABLED NON-ME D	983.56	949.62	911.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,844.47		
2220	SSI DISABLED WITH Q M	24,588.70	24,755.94	24,980.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,325.57		
222Z	SSI DISABLED WITH Q M	62.38	77.46	109.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.15		
2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.11		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,294.31		
231Z	SSI BLIND NON-MEDIC A	8.02	26.80	11.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46.27		
2320	SSI BLIND WITH QMB	207.48	205.10	207.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		620.54		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.43		
4304	SOBRA CHILD 14-20 MA	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4305	SOBRA CHILD 14-20 FE	1.00	1.19	1.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.32		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.56		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.47		
4311	SOBRA CHILD <1 M & F	37,929.50	37,878.33	35,410.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,218.37		
4312	SOBRA CHILD 01-05 M	150,215.05	158,567.13	166,797.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		475,579.31		
4313	SOBRA CHILD 06-13 M	200,525.14	216,198.75	230,401.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		647,125.88		
4314	SOBRA CHILD 14-20 MA	49,529.14	51,683.40	55,100.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,312.63		
4315	SOBRA CHILD 14-20 FE	49,621.28	51,750.56	55,046.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,418.64		
431A	SOBRA CHILD < 1 M &	1,144.43	1,199.85	596.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,941.13		
431B	SOBRA CHILD 01-05 M	7,397.32	7,233.01	5,425.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,055.93		
431C	SOBRA CHILD 6-13 M& F	9,664.24	10,386.87	6,895.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,947.07		
431D	SOBRA CHILD 14-20 MA	2,729.60	2,547.00	1,740.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,016.81		
431E	SOBRA CHILD 14-20 FE	2,479.42	2,548.58	1,750.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,778.39		
4322	SOBRA CHILD 01-05 M	3.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4323	SOBRA CHILD 06-13 M	7.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
4324	SOBRA CHILD 14-20 MA	4.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
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	44.60	44.25	49.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137.93		
5008	SOBRA PREG 45-64 FE M	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
500G	SOBRA PREG 21-44 FE M	3.37	3.12	2.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.65		
5013	SOBRA PREG 09-13 FE M	6.00	7.38	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.38		
5015	SOBRA PREG 14-20 FE M	4,442.88	4,822.40	5,139.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,405.27		
5017	SOBRA PREG 21-44 FE M	19,288.96	21,436.17	23,639.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,364.90		
5018	SOBRA PREG 45-64 FE M	70.02	76.99	80.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.35		
501C	SOBRA PREG 09-13 FE M	0.00	1.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.61		
501E	SOBRA PREG 14-20 FE M	380.96	386.50	238.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,006.09		
501G	SOBRA PREG 21-44 FE M	1,656.15	1,536.50	1,187.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,380.52		
501H	SOBRA PREG 45-64 FE M	7.91	23.95	1.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.15		
5027	SOBRA PREG 21-44 FE M	9.11	11.00	8.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.10		
5028	SOBRA PREG 45-64 FE M	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
502G	SOBRA PREG 21-44 FE M	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		
5510	SOBRA FPS FEMALE W IT	-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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,008,311.47		

9910	TANF & SOBRA CHILDR E	571.00	500.00	476.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	42.00	29.00	33.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,677.00	2,806.00	2,973.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,547.00	
34.00	
104.00	
6,771.00	
8,456.00	

3100	TRANSPLANT OPTION 1	4.24	5.41	5.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9.98	9.99	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14.65	
10.32	
24.97	

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	634.27	568.85	533.33	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	2.64	1.64	12.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	0.86	0.82	67.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+
M&	0.00	2.64	37.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,398.91

3,016.36

5,180.92

1,736.45

31.10

16.92

69.06

40.22

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1111	TANF EXPANDED <1 M
&F	12.00	8.00	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.36		
1112	TANF EXPANDED 01-05	390.00	311.16	275.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		976.16		
1113	TANF EXPANDED 06-13	1,229.70	991.16	871.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,091.98		
1114	TANF EXPANDED 14-20	683.08	531.13	454.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,668.90		
1115	TANF EXPANDED 14-20	1,447.98	1,085.47	918.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,451.69		
1116	TANF EXPANDED 21-44	20,507.88	17,866.93	15,873.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,248.57		
1117	TANF EXPANDED 21-44	46,392.97	40,134.22	35,306.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,833.79		
1118	TANF EXPANDED 45-64	16,838.19	14,850.87	13,477.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,166.86		
1119	TANF EXPANDED 65+
M&	91.37	83.00	78.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253.02		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
111D	TANF EXPANDED 14-20	0.54	5.28	14.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.13		
111E	TANF EXPANDED 14-20	7.24	9.73	31.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.21		
111F	TANF EXPANDED 21-44	101.48	104.36	529.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		735.61		
111G	TANF EXPANDED 21-44	197.09	224.68	1,011.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,432.96		
111H	TANF EXPANDED 45-64	28.12	127.83	423.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		578.99		
111J	TANF EXPANDED 65+
M&	22.31	0.00	3.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.96		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454.06		
1127	TANF EXPANDED 21-44	382.43	351.28	318.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052.59		
1128	TANF EXPANDED 45-64	446.94	399.71	372.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,219.44		
1129	TANF EXPANDED 65+
M&	194.69	165.94	155.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		516.23		
112F	TANF EXPANDED 21-44	0.00	0.00	2.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.56		
112G	TANF EXPANDED 21-44	0.00	3.44	3.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.66		
112H	TANF EXPANDED 45-64	0.03	0.00	2.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.95		
112J	TANF EXPANDED 65+
M&	0.00	0.00	16.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.30		
2400	SSI AGED EXPANDED WI	518.42	487.04	456.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,462.27		
240Z	SSI AGED EXPANDED WI	304.76	401.03	244.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		950.28		
2410	SSI AGED EXPANDED NO	1,134.27	1,056.52	991.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,181.94		
241Z	SSI AGED EXPANDED NO	13.94	39.82	16.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.37		
2420	SSI AGED EXPANDED WI	26,853.34	26,842.37	26,813.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,509.37		
242Z	SSI AGED EXPANDED WI	86.51	60.16	53.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.91		
2510	SSI BLIND EXPANDED N	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2520	SSI BLIND EXPANDED 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		3.00		
2600	SSI DISABLED EXPAND E	387.35	391.10	363.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,142.03		

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
260Z	SSI DISABLED EXPAND E	198.57	225.21	193.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	617.43	
2610	SSI DISABLED EXPAND E	2,800.72	2,719.35	2,722.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,242.83	
261Z	SSI DISABLED EXPAND E	66.87	64.13	55.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	186.86	
2620	SSI DISABLED EXPAND E	15,882.49	16,101.98	16,689.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,673.86	
262Z	SSI DISABLED EXPAND E	70.33	62.70	88.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	221.10	
SUBTOTAL	:	141,707.24	129,594.34	122,483.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	393,784.65	

9911	SB PAYMENT FOR TAN F	105.00	122.00	113.00	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	108.00	126.00	117.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
340.00	
9.00	
2.00	
351.00	

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	
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	0.00	0.00	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	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	67.69	54.87	49.56	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	55.05	55.40	53.33	0.00	0.00	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	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	3,734.50	3,945.56	4,139.94	0.00	0.00	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	0.00	0.00	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	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	35,161.66	35,276.58	36,112.19	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	39.09	36.01	35.99	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	687.03	645.80	559.94	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	40.88	22.67	29.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3525	ADULT 40-100% FEMAL E	1.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	1.41	3.21	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	20.96	15.68	24.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
37.58	
26.82	
172.12	
163.78	
10.41	
35.16	
18.49	
9,798.52	
11,820.00	
52,407.19	
43,661.74	
106,550.43	
111.09	
538.84	
572.65	
2,613.34	
1,892.77	
4,419.23	
92.87	
1.00	
3.00	
4.62	
60.80	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3529	ADULT 40-100% M&F 65	6.00	10.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
352G	ADULT 40-100% FEMAL E	0.00	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.77		
352H	ADULT 40-100% M&F 45	0.03	1.83	1.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.12		
3706	ADULT <40% EXP MAL E	34.74	33.74	30.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98.62		
3707	ADULT <40% EXP FEM AL	7.49	15.61	9.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.88		
3708	ADULT <40% EXP M&F 4	88.23	98.60	92.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		279.63		
3709	ADULT <40% EXP M&F 6	19.67	21.38	28.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.77		
370F	ADULT <40% EXP MAL E	5.51	8.57	6.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.20		
370G	ADULT <40% EXP FEM AL	1.54	1.81	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.41		
370H	ADULT <40% EXP M&F 4	14.58	15.74	30.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.88		
370J	ADULT <40% EXP M&F 6	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	ADULT <40% EXP MAL E	9,839.70	10,160.23	10,470.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,470.22		
3715	ADULT <40% EXP FEM AL	8,418.28	8,667.97	8,908.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,994.74		
3716	ADULT <40% EXP MAL E	58,247.03	58,634.00	61,113.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,994.05		
3717	ADULT <40% EXP FEM AL	34,827.18	34,929.63	36,183.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,940.47		
3718	ADULT <40% EXP M&F 4	72,820.34	73,231.71	75,412.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221,464.12		
3719	ADULT <40% EXP M&F 6	80.88	80.74	94.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256.15		
371D	ADULT <40% EXP MAL E	580.76	572.41	352.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,505.43		
371E	ADULT <40% EXP FEM AL	519.38	449.84	305.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,274.95		
371F	ADULT <40% EXP MAL E	4,244.00	4,145.00	2,990.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,379.61		
371G	ADULT <40% EXP FEM AL	2,410.81	2,215.92	1,619.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,246.06		
371H	ADULT <40% EXP M&F 4	3,754.97	3,389.75	2,459.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,604.16		
371J	ADULT <40% EXP M&F 6	2.98	2.00	16.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.44		
3724	ADULT <40% EXP MAL E	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 MAL E	9.00	8.05	8.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.40		
3727	ADULT <40% EXP FEM AL	6.12	3.96	3.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.51		
3728	ADULT <40% EXP M&F 4	23.78	6.39	19.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.99		
3729	ADULT <40% EXP M&F 6	4.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
372F	ADULT <40% EXP MAL E	0.00	0.86	5.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.48		
372G	ADULT <40% EXP FEM AL	0.87	1.79	3.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.88		
372H	ADULT <40% EXP M&F 4	0.77	1.95	0.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.08		
SUBTOTAL:	273,979.51	274,669.50	279,217.1	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		827,866.20		

9935	BIRTH SUPP PAYMENT A	29.00	45.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT A	74.00	98.00	121.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	103.00	143.00	161.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
114.00

293.00

407.00

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3904	NEWLY ELIGIBLE MALE	0.00	0.16	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.16		
3906	NEWLY ELIGIBLE MALE	6.92	5.18	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.10		
3907	NEWLY ELIGIBLE FEMA L	14.99	10.72	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.71		
3908	NEWLY ELIGIBLE M&F 4	71.56	53.47	39.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.81		
3909	NEWLY ELIGIBLE M&F 6	12.19	19.97	21.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.82		
390D	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		0.83		
390F	NEWLY ELIGIBLE MALE	0.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.45		
390G	NEWLY ELIGIBLE FEMA L	1.83	2.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.89		
390H	NEWLY ELIGIBLE M&F 4	64.25	40.88	59.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.32		
390J	NEWLY ELIGIBLE M&F 6	10.96	14.95	34.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.24		
3914	NEWLY ELIGIBLE MALE	1,606.89	1,676.79	1,806.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,090.56		
3915	NEWLY ELIGIBLE FEMA L	1,867.46	2,072.53	2,181.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,121.56		
3916	NEWLY ELIGIBLE MALE	15,590.65	16,339.89	17,228.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,158.87		
3917	NEWLY ELIGIBLE FEMA L	20,086.40	21,456.04	22,844.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,386.86		
3918	NEWLY ELIGIBLE M&F 4	24,879.24	25,158.44	25,656.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,694.56		
3919	NEWLY ELIGIBLE M&F 6	43.11	41.59	40.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125.35		
391D	NEWLY ELIGIBLE MALE	141.51	112.48	116.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370.74		
391E	NEWLY ELIGIBLE FEMA L	153.51	153.08	97.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		404.55		
391F	NEWLY ELIGIBLE MALE	1,523.12	1,206.66	1,086.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,816.09		
391G	NEWLY ELIGIBLE FEMA L	1,726.49	1,680.05	1,394.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,801.01		
391H	NEWLY ELIGIBLE M&F 4	1,771.32	1,458.13	1,385.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,614.78		
391J	NEWLY ELIGIBLE M&F 6	8.86	33.37	111.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153.42		
3926	NEWLY ELIGIBLE MALE	1.00	0.70	1.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.66		
3927	NEWLY ELIGIBLE FEMA L	0.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
3928	NEWLY ELIGIBLE M&F 4	6.22	3.11	2.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.76		
3929	NEWLY ELIGIBLE M&F 6	2.00	0.96	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.96		
392F	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		0.32		
392H	NEWLY ELIGIBLE M&F 4	2.40	1.28	0.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.24		
392J	NEWLY ELIGIBLE M&F 6	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		
SUBTOTAL:	69,593.33	71,546.64	74,129.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,269.65		

9939	BIRTH SUPP PAYMENT N	39.00	34.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39.00	34.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
130.00

130.00

4412	SOBRA 100-133% M&F
1	2.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	20,103.69	18,080.37	16,565.93	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5.00	
54,749.99	
17,952.26	

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

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4415	SOBRA 100-133% FEM	6,240.09	5,678.68	5,237.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,156.11	
	AL														
441C	SOBRA 100-133% M&F	288.14	323.40	1,091.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,703.47	
	6														
441D	SOBRA 100-133% MALE	126.41	106.24	394.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	626.83	
441E	SOBRA 100-133% FEM	81.96	103.18	421.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	606.46	

SUBT	AL
OTAL:	
33,377.33	
30,212.86	
29,209.93	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
92,800.12	

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

 
24.00

24.00

4517	BC PATIENT FEMALE 2 1	23.96	25.35	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	251.91	246.16	245.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	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	BC PATIENT FEMALE 2 1	0.00	3.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	10.28	5.89	8.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	15.86	16.54	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	18.00	17.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	1.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	320.78	316.03	312.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
75.31	
743.91	
0.77	
3.64	
24.28	
49.40	
51.00	
1.45	
949.76	

8600	SSI BLIND FREEDOM/W O	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	1,505.00	1,555.45	1,576.90	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	20.61	6.41	1.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,234.73	2,273.51	2,258.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
4,637.35	
432.79	
797.23	
214.54	
654.10	
28.05	
6,767.06	

TOTAL:	1,509,256.72	1,514,651.63	1,531,233.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,555,141.88		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	9,923.14	10,424.50	9,923.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,270.78		
1010	TANF NON-MEDICARE	2,246,124.76	2,243,143.25	2,252,388.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,741,656.64		
1020	TANF WITH QMB	3,414.03	3,414.03	3,414.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,242.09		
2100	SSI AGED WITH MEDIC A	31,188,469.28	36,229,127.20	31,473,122.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,890,719.13		
210Z	SSI AGED WITH MEDIC A	707,295.55	628,872.62	699,533.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,035,701.91		
2110	SSI AGED NON-MEDIC AR	2,884,201.93	3,146,295.69	2,948,885.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,979,382.97		
211Z	SSI AGED NON-MEDIC AR	20,970.93	11,535.77	26,120.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,627.05		
2120	SSI AGED WITH QMB	18,966,113.95	22,019,693.90	19,185,398.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,171,206.00		
212Z	SSI AGED WITH QMB P P	27,811.67	8,720.78	31,076.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,608.59		
2200	SSI DISABLED WITH M E	13,803,406.37	14,998,436.84	13,783,997.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,585,840.36		
220Z	SSI DISABLED WITH M E	40,564.67	63,879.36	93,590.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198,034.08		
2210	SSI DISABLED NON-ME D	90,370,918.56	92,527,644.78	92,067,142.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,965,706.14		
221Z	SSI DISABLED NON-ME D	66,459.25	35,301.18	25,164.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,925.14		
2220	SSI DISABLED WITH Q M	21,237,804.05	22,510,241.65	21,355,507.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,103,552.74		
222Z	SSI DISABLED WITH Q M	2,948.16	9,227.84	6,397.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,573.97		
2300	SSI BLIND WITH MEDIC	64,338.16	65,260.19	64,541.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194,139.37		
2310	SSI BLIND NON-MEDIC A	444,420.36	460,483.10	454,107.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,359,010.54		
2320	SSI BLIND WITH QMB	130,315.90	135,811.83	130,342.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		396,470.58		
SUBTOTAL:	182,215,500.72	195,107,514.51	184,610,652.8	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		561,933,668.08		
	
217,452.22	
	0.00	
	358,752.83	
	4,987.53	
	60,985.46	
	642,178.04	
TOTAL:		182,421,827.21	195,322,104.99	184,831,913.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		562,575,846.12	

8700	SSI DISABLED FREEDO M	70,007.12	77,437.98	70,007.12	0.00	0.00	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	0.00	0.00	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 M	19,836.86	21,311.74	19,836.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	206,326.49	214,590.48	221,261.0	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

LONG TERM CARE MEMBER MONTHS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1010	TANF NON-MEDICARE	654.15	651.89	656.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,962.16		
1020	TANF WITH QMB	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2100	SSI AGED WITH MEDIC A	11,288.11	11,289.28	11,378.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,956.34		
210Z	SSI AGED WITH MEDIC A	717.21	639.08	710.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,066.29		
2110	SSI AGED NON-MEDIC AR	655.14	653.57	669.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,978.70		
211Z	SSI AGED NON-MEDIC AR	21.10	12.50	27.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.94		
2120	SSI AGED WITH QMB	7,334.44	7,374.82	7,392.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,101.96		
212Z	SSI AGED WITH QMB P P	27.75	9.33	32.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.22		
2200	SSI DISABLED WITH M E	4,540.03	4,507.46	4,531.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,578.98		
220Z	SSI DISABLED WITH M E	40.61	63.99	95.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.98		
2210	SSI DISABLED NON-ME D	25,726.52	25,794.02	25,992.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,512.66		
221Z	SSI DISABLED NON-ME D	68.02	35.27	25.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128.67		
2220	SSI DISABLED WITH Q M	6,765.32	6,778.39	6,816.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,360.70		
222Z	SSI DISABLED WITH Q M	2.73	7.18	7.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.07		
2300	SSI BLIND WITH MEDIC	20.00	19.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.00		
2310	SSI BLIND NON-MEDIC A	128.16	130.38	131.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		389.60		
2320	SSI BLIND WITH QMB	42.00	42.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126.00		
SUBTOTAL:	58,035.29	58,012.16	58,532.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,580.27		

8700	SSI DISABLED FREEDO M	22.00	22.00	22.00	0.00	0.00	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	0.00	0.00	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 M	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	58.99	52.01	60.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
66.00

0.00

79.96

5.03

21.00

171.99

TOTAL:	58,094.28	58,064.17	58,593.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,752.26		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112.65		
1010	TANF NON-MEDICARE	6,001,729.15	5,085,321.40	4,606,746.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,693,797.20		
2110	SSI AGED NON-MEDIC AR	37.55	75.10	75.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		187.75		
2200	SSI DISABLED WITH M E	37.55	37.55	37.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112.65		
2210	SSI DISABLED NON-ME D	430,210.35	427,168.80	423,639.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,281,018.25		
2220	SSI DISABLED WITH Q M	225.30	225.30	225.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		675.90		
2310	SSI BLIND NON-MEDIC A	1,464.45	1,614.65	1,689.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,768.85		
4300	SOBRA CHILD WITH M ED	225.30	225.30	187.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		638.35		
4310	SOBRA CHILD NON-ME DI	17,147,019.75	18,291,093.15	19,577,631.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,015,744.15		
4320	SOBRA CHILD WITH Q MB	525.70	0.00	187.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		713.45		
5010	SOBRA PREGNANT WO MAN	20,427.20	22,567.55	25,233.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,228.35		
SUBTOTAL:	23,601,939.85	23,828,366.35	24,635,691.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,065,997.55		

1110	TANF EXPANDED FOR FI	92,861.15	74,837.15	64,811.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	37.55	37.55	37.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	92,898.70	74,874.70	64,848.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
232,509.60	
112.65	
232,622.25	

3510	ADULT 40-100% FOR FI	37.55	37.55	75.10	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	37.55	75.10	150.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
150.20	
112.65	
262.85	

4410	SOBRA 100-133% FOR F	1,137,201.75	1,021,510.20	921,589.65	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,080,301.60

3,080,301.60

75,379,184.25

24,832,077.85	24,924,826.35	25,622,280.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1010	TANF NON-MEDICARE	159,833.00	135,428.00	122,683.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417,944.00		
2110	SSI AGED NON-MEDIC AR	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2200	SSI DISABLED WITH M E	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2210	SSI DISABLED NON-ME D	11,457.00	11,376.00	11,282.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,115.00		
2220	SSI DISABLED WITH Q M	6.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
2310	SSI BLIND NON-MEDIC A	39.00	43.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.00		
4300	SOBRA CHILD WITH M ED	6.00	6.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
4310	SOBRA CHILD NON-ME DI	456,645.00	487,113.00	521,375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,465,133.00		
4320	SOBRA CHILD WITH Q MB	14.00	0.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
5010	SOBRA PREGNANT WO MAN	544.00	601.00	672.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,817.00		
SUBTOTAL:	628,547.00	634,577.00	656,077.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,919,201.00		

1110	TANF EXPANDED FOR FI	2,473.00	1,993.00	1,726.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	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:	2,474.00	1,994.00	1,727.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,192.00

3.00

6,195.00

3510	ADULT 40-100% FOR FI	1.00	1.00	2.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1.00	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4.00	
3.00	
7.00	

4410	SOBRA 100-133% FOR F	30,285.00	27,204.00	24,543.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30,285.00	27,204.00	24,543.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
82,032.00

82,032.00

TOTAL:	661,307.00	663,777.00	682,351.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,007,435.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,500.13		
1010	TANF NON-MEDICARE	6,077,917.65	6,393,201.43	6,925,613.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,396,732.40		
1020	TANF WITH QMB	24,837.03	36,897.81	45,074.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,809.45		
2100	SSI AGED WITH MEDIC A	139,789.21	137,949.43	136,722.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414,461.55		
2110	SSI AGED NON-MEDIC AR	205,476.17	200,433.81	204,454.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		610,364.05		
2120	SSI AGED WITH QMB	595,679.88	602,630.16	609,410.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,807,720.13		
2200	SSI DISABLED WITH M E	134,133.59	132,327.88	130,488.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		396,949.57		
2210	SSI DISABLED NON-ME D	1,422,763.20	1,422,831.34	1,426,408.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,272,003.23		
2220	SSI DISABLED WITH Q M	832,159.75	837,747.23	844,561.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,514,468.21		
2300	SSI BLIND WITH MEDIC	1,226.52	1,158.38	1,056.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,441.07		
2310	SSI BLIND NON-MEDIC A	14,820.45	14,650.10	14,547.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,018.44		
2320	SSI BLIND WITH QMB	8,279.01	8,210.87	8,244.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,734.82		
4300	SOBRA CHILD WITH M ED	34.07	34.07	68.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.28		
4310	SOBRA CHILD NON-ME DI	834,544.65	810,661.58	852,976.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,498,182.75		
4320	SOBRA CHILD WITH Q MB	68.14	34.07	34.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.28		
5000	SOBRA PREGNANT WO MAN	1,260.59	1,226.52	1,328.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,815.84		
5010	SOBRA PREGNANT WO MAN	802,586.99	894,950.76	992,561.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,690,099.06		
5020	SOBRA PREGNANT WO MAN	306.63	408.84	340.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,056.17		
SUBTOTAL:	11,162,967.36	11,575,827.62	12,286,834.4	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,025,629.43		

1100	TANF EXPANDED FPR FI	141,594.92	125,002.83	112,124.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	3,052,160.95	2,639,368.83	2,306,811.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	39,930.04	35,535.01	32,025.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	14,990.80	14,173.12	13,662.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	39,725.62	37,068.16	34,887.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	952,256.50	951,711.38	949,360.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	68.14	68.14	68.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED 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	
2600	SSI DISABLED EXPAND E	9,505.53	9,335.18	9,198.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	91,103.18	87,900.60	88,070.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	488,427.52	493,674.30	511,867.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,829,797.27	4,393,871.62	4,058,111.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
378,722.12	
7,998,341.34	
107,490.85	
42,825.99	
111,681.46	
2,853,328.43	
204.42	
102.21	
28,039.61	
267,074.73	
1,493,969.50	
13,281,780.66	

3500	ADULT 40-100% FOR FI	4,974.22	4,326.89	3,849.91	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	4,463.17	4,667.59	4,769.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,151.02	
7,807,481.20	
2,895.95	
13,900.56	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3710	AHC CARE EXPANDED FO	6,719,966.80	6,769,163.88	7,017,568.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,506,698.93	
3720	AHC CARE EXPANDED FO	1,328.73	476.98	953.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,759.67	
SUBTOTAL	:	9,300,428.60	9,359,540.05	9,686,918.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,346,887.33	

3900	NEWLY ELIGIBLE FOR F	3,032.23	2,044.20	2,180.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	2,203,170.62	2,295,500.32	2,410,997.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	374.77	170.35	204.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,206,577.62	2,297,714.87	2,413,382.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,256.91	
6,909,668.56	
749.54	
6,917,675.01	

4410	SOBRA 100-133% FOR F	103,709.08	95,634.49	86,469.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	103,709.08	95,634.49	86,469.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
285,813.23

285,813.23

4510	BC PATIENT FOR FINA N	9,471.46	9,301.11	9,267.04	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,663.91	10,459.49	10,391.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
28,039.61	
3,475.14	
31,514.75	

8600	SSI BLIND FREEDOM/W O	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	46,130.78	48,583.82	49,742.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
102.21	
104,935.60	
23,167.60	
16,251.39	
144,456.80	

84,033,757.21

27,660,274.62	27,781,631.96	28,591,850.63	0.00	0.00	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 September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,059.00		
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		569,320.00		
1020	TANF WITH QMB	729.00	1,083.00	1,323.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,135.00		
2100	SSI AGED WITH MEDIC A	4,103.00	4,049.00	4,013.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,165.00		
2110	SSI AGED NON-MEDIC AR	6,031.00	5,883.00	6,001.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,915.00		
2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,059.00		
2200	SSI DISABLED WITH M E	3,937.00	3,884.00	3,830.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,651.00		
2210	SSI DISABLED NON-ME D	41,760.00	41,762.00	41,867.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,389.00		
2220	SSI DISABLED WITH Q M	24,425.00	24,589.00	24,789.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,803.00		
2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101.00		
2310	SSI BLIND NON-MEDIC A	435.00	430.00	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,292.00		
2320	SSI BLIND WITH QMB	243.00	241.00	242.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		726.00		
4300	SOBRA CHILD WITH M ED	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4310	SOBRA CHILD NON-ME DI	24,495.00	23,794.00	25,036.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,325.00		
4320	SOBRA CHILD WITH Q MB	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
5000	SOBRA PREGNANT WO MAN	37.00	36.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112.00		
5010	SOBRA PREGNANT WO MAN	23,557.00	26,268.00	29,133.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,958.00		
5020	SOBRA PREGNANT WO MAN	9.00	12.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00		
SUBTOTAL:	327,648.00	339,766.00	360,635.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,028,049.00		

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	89,585.00	77,469.00	67,708.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	1,172.00	1,043.00	940.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	440.00	416.00	401.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	1,166.00	1,088.00	1,024.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	27,950.00	27,934.00	27,865.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED 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	
2600	SSI DISABLED EXPAND E	279.00	274.00	270.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	2,674.00	2,580.00	2,585.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	14,336.00	14,490.00	15,024.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	141,761.00	128,966.00	119,111.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,116.00	
234,762.00	
3,155.00	
1,257.00	
3,278.00	
83,749.00	
6.00	
3.00	
823.00	
7,839.00	
43,850.00	
389,838.00	

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
386.00	
229,160.00	
85.00	
408.00	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	601,899.00	
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81.00	
SUBTOTAL	:	272,980.00	274,715.00	284,324.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	832,019.00	

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	64,666.00	67,376.00	70,766.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	11.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	64,766.00	67,441.00	70,836.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
213.00	
202,808.00	
22.00	
203,043.00	

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,044.00	2,807.00	2,538.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,389.00

8,389.00

4510	BC PATIENT FOR FINA N	278.00	273.00	272.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	313.00	307.00	305.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
823.00	
102.00	
925.00	

8600	SSI BLIND FREEDOM/W O	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,354.00	1,426.00	1,460.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
3,080.00	
680.00	
477.00	
4,240.00	

TOTAL:	811,866.00	815,428.00	839,209.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,466,503.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323,513.97		
1010	TANF NON-MEDICARE	8,175,842.85	8,599,953.67	9,316,139.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,091,935.60		
1020	TANF WITH QMB	33,410.07	49,633.89	60,633.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,677.05		
2100	SSI AGED WITH MEDIC A	188,040.49	185,565.67	183,915.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557,521.95		
2110	SSI AGED NON-MEDIC AR	276,400.73	269,617.89	275,025.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		821,044.45		
2120	SSI AGED WITH QMB	801,291.72	810,641.04	819,761.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,431,693.97		
2200	SSI DISABLED WITH M E	180,432.71	178,003.72	175,528.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		533,965.33		
2210	SSI DISABLED NON-ME D	1,913,860.80	1,913,952.46	1,918,764.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,746,577.87		
2220	SSI DISABLED WITH Q M	1,119,397.75	1,126,913.87	1,136,079.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,382,391.49		
2300	SSI BLIND WITH MEDIC	1,649.88	1,558.22	1,420.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,628.83		
2310	SSI BLIND NON-MEDIC A	19,936.05	19,706.90	19,569.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,212.36		
2320	SSI BLIND WITH QMB	11,136.69	11,045.03	11,090.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,272.58		
4300	SOBRA CHILD WITH M ED	45.83	45.83	91.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183.32		
4310	SOBRA CHILD NON-ME DI	1,122,605.85	1,090,479.02	1,147,399.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,360,484.75		
4320	SOBRA CHILD WITH Q MB	91.66	45.83	45.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183.32		
5000	SOBRA PREGNANT WO MAN	1,695.71	1,649.88	1,787.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,132.96		
5010	SOBRA PREGNANT WO MAN	1,079,617.31	1,203,862.44	1,335,165.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,618,645.14		
5020	SOBRA PREGNANT WO MAN	412.47	549.96	458.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,420.73		
SUBTOTAL:	15,016,107.84	15,571,475.78	16,527,902.0	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,115,485.67		

1100	TANF EXPANDED FPR FI	190,469.48	168,150.27	150,826.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	4,105,680.55	3,550,404.27	3,103,057.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	53,712.76	47,800.69	43,080.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	20,165.20	19,065.28	18,377.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	53,437.78	49,863.04	46,929.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	1,280,948.50	1,280,215.22	1,277,052.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	91.66	91.66	91.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED 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	
2600	SSI DISABLED EXPAND E	12,786.57	12,557.42	12,374.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	122,549.42	118,241.40	118,470.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	657,018.88	664,076.70	688,549.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,496,906.63	5,910,511.78	5,458,857.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
509,446.28	
10,759,142.46	
144,593.65	
57,608.31	
150,230.74	
3,838,216.67	
274.98	
137.49	
37,718.09	
359,261.37	
2,009,645.50	
17,866,275.54	

3500	ADULT 40-100% FOR FI	6,691.18	5,820.41	5,178.79	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	6,003.73	6,278.71	6,416.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
17,690.38	
10,502,402.80	
3,895.55	
18,698.64	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3710	AHC CARE EXPANDED FO	9,039,509.20	9,105,687.72	9,439,834.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,585,031.17	
3720	AHC CARE EXPANDED FO	1,787.37	641.62	1,283.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,712.23	
SUBTOTAL	:	12,510,673.40	12,590,188.45	13,030,568.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,131,430.77	

3900	NEWLY ELIGIBLE FOR F	4,078.87	2,749.80	2,933.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	2,963,642.78	3,087,842.08	3,243,205.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	504.13	229.15	274.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,968,225.78	3,090,821.03	3,246,413.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,761.79	
9,294,690.64	
1,008.26	
9,305,460.69	

4410	SOBRA 100-133% FOR F	139,506.52	128,644.81	116,316.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	139,506.52	128,644.81	116,316.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
384,467.87

384,467.87

4510	BC PATIENT FOR FINA N	12,740.74	12,511.59	12,465.76	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,344.79	14,069.81	13,978.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
37,718.09	
4,674.66	
42,392.75	

8600	SSI BLIND FREEDOM/W O	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	62,053.82	65,353.58	66,911.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
137.49	
141,156.40	
31,164.40	
21,860.91	
194,319.20	

113,039,832.49

37,207,818.78	37,371,065.24	38,460,948.47	0.00	0.00	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 September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,059.00		
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		569,320.00		
1020	TANF WITH QMB	729.00	1,083.00	1,323.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,135.00		
2100	SSI AGED WITH MEDIC A	4,103.00	4,049.00	4,013.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,165.00		
2110	SSI AGED NON-MEDIC AR	6,031.00	5,883.00	6,001.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,915.00		
2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,059.00		
2200	SSI DISABLED WITH M E	3,937.00	3,884.00	3,830.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,651.00		
2210	SSI DISABLED NON-ME D	41,760.00	41,762.00	41,867.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,389.00		
2220	SSI DISABLED WITH Q M	24,425.00	24,589.00	24,789.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,803.00		
2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101.00		
2310	SSI BLIND NON-MEDIC A	435.00	430.00	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,292.00		
2320	SSI BLIND WITH QMB	243.00	241.00	242.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		726.00		
4300	SOBRA CHILD WITH M ED	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4310	SOBRA CHILD NON-ME DI	24,495.00	23,794.00	25,036.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,325.00		
4320	SOBRA CHILD WITH Q MB	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
5000	SOBRA PREGNANT WO MAN	37.00	36.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112.00		
5010	SOBRA PREGNANT WO MAN	23,557.00	26,268.00	29,133.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,958.00		
5020	SOBRA PREGNANT WO MAN	9.00	12.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00		
SUBTOTAL:	327,648.00	339,766.00	360,635.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,028,049.00		

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	89,585.00	77,469.00	67,708.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	1,172.00	1,043.00	940.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	440.00	416.00	401.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	1,166.00	1,088.00	1,024.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	27,950.00	27,934.00	27,865.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED 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	
2600	SSI DISABLED EXPAND E	279.00	274.00	270.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	2,674.00	2,580.00	2,585.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	14,336.00	14,490.00	15,024.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	141,761.00	128,966.00	119,111.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,116.00	
234,762.00	
3,155.00	
1,257.00	
3,278.00	
83,749.00	
6.00	
3.00	
823.00	
7,839.00	
43,850.00	
389,838.00	

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
386.00	
229,160.00	
85.00	
408.00	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	601,899.00	
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81.00	
SUBTOTAL	:	272,980.00	274,715.00	284,324.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	832,019.00	

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	64,666.00	67,376.00	70,766.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	11.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	64,766.00	67,441.00	70,836.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
213.00	
202,808.00	
22.00	
203,043.00	

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,044.00	2,807.00	2,538.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,389.00

8,389.00

4510	BC PATIENT FOR FINA N	278.00	273.00	272.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	313.00	307.00	305.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
823.00	
102.00	
925.00	

8600	SSI BLIND FREEDOM/W O	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,354.00	1,426.00	1,460.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
3,080.00	
680.00	
477.00	
4,240.00	

TOTAL:	811,866.00	815,428.00	839,209.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,466,503.00		

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,534,749.78	
2210	SSI DISABLED NON-ME	339,019.30	338,090.48	337,161.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,014,271.44	
	D														
2310	SSI BLIND NON-MEDIC	928.82	928.82	928.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,786.46	
	A														
4310	SOBRA CHILD NON-ME	13,288,627.74	13,621,145.30	13,792,048.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,701,821.22	
	DI														
5010	SOBRA PREGNANT WO	19,505.22	15,789.94	16,718.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,013.92	
	MAN														
SUBTOTAL:	14,560,182.32	14,824,896.02	14,920,564.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,305,642.82	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending September 30, 2015

211,770.96

211,770.96

73,376.78	71,519.14	66,875.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
73,376.78	71,519.14	66,875.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4410	SOBRA 100-133% FOR
F
SUBTOTAL:

44,517,413.78

14,633,559.10	14,896,415.16	14,987,439.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,729.00	
2210	SSI DISABLED NON-ME	365.00	364.00	363.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,092.00	
	D														
2310	SSI BLIND NON-MEDIC	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	
	A														
4310	SOBRA CHILD NON-ME	14,307.00	14,665.00	14,849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,821.00	
	DI														
5010	SOBRA PREGNANT WO	21.00	17.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.00	
	MAN														
SUBTOTAL:	15,676.00	15,961.00	16,064.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,701.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending September 30, 2015

228.00

228.00

79.00	77.00	72.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
79.00	77.00	72.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4410	SOBRA 100-133% FOR
F
SUBTOTAL:

TOTAL:	15,755.00	16,038.00	16,136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,929.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,025.26		
1010	TANF NON-MEDICARE	133,111.44	130,590.39	131,598.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395,300.64		
1011	TANF <1 M & F NON-ME	9,104.82	10,355.64	10,355.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,816.10		
1012	TANF 01-05 M & F NON	25,956.96	17,113.95	14,612.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,683.22		
1013	TANF 06-13 M & F NON	30,058.50	22,049.37	18,296.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,404.78		
1014	TANF 14-20 MALE NON-	8,513.34	6,845.58	6,098.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,457.89		
1015	TANF 14-20 FEMALE N O	9,017.55	7,766.73	8,687.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,472.16		
1017	TANF 21-44 FEMALE N O	833.88	833.88	833.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,501.64		
2110	SSI AGED NON-MEDIC AR	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,250.82		
2200	SSI DISABLED WITH M E	8,571.57	9,492.72	12,013.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,078.06		
2210	SSI DISABLED NON-ME D	3,071,131.98	3,075,185.07	3,070,908.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,217,226.04		
2220	SSI DISABLED WITH Q M	24,444.48	25,452.90	25,957.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,854.49		
2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,512.63		
2310	SSI BLIND NON-MEDIC A	27,624.87	28,129.08	27,624.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,378.82		
4311	SOBRA CHILD <1 M & F	21,273.72	19,935.63	18,180.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,389.95		
4312	SOBRA CHILD 01-05 M	137,425.89	146,162.22	148,906.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		432,494.37		
4313	SOBRA CHILD 06-13 M	130,832.34	140,421.96	154,045.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425,299.56		
4314	SOBRA CHILD 14-20 MA	30,970.02	33,141.99	36,060.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,172.58		
4315	SOBRA CHILD 14-20 FE	35,226.69	37,815.60	35,886.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,928.32		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		416.94		
5015	SOBRA PREG 14-20 FE M	3,005.85	2,588.91	2,171.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,766.73		
SUBTOTAL:	3,709,033.47	3,715,811.19	3,724,586.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,149,431.00		

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	
1116	TANF EXPANDED 21-44	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:	833.88	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
416.94

1,250.82

1,667.76

3514	ADULT 40-100% MALE
1	833.88	833.88	833.88	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	6,254.10	7,087.98	6,671.04	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	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:	12,508.20	13,759.02	13,342.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,501.64	
2,501.64	
20,013.12	
12,091.26	
1,250.82	
1,250.82	
39,609.30	

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	
SUBTOTAL:	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,250.82

1,250.82

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	4,760.88	4,343.94	3,927.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,031.82		
4414	SOBRA 100-133% MALE	1,755.03	1,755.03	921.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,431.21		
4415	SOBRA 100-133% FEM AL	833.88	833.88	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,084.70		
SUBTOTAL:	7,349.79	6,932.85	5,265.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,547.73		

TOTAL:

3,730,142.28

3,737,336.94	3,744,027.39

0.00

0.00	0.00	0.00	0.00

0.00

0.00

0.00

0.00

11,211,506.61

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1010	TANF NON-MEDICARE	264.00	259.00	261.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		784.00		
1011	TANF <1 M & F NON-ME	21.00	24.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.00		
1012	TANF 01-05 M & F NON	61.00	40.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.00		
1013	TANF 06-13 M & F NON	70.00	51.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163.00		
1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.00		
1015	TANF 14-20 FEMALE N O	21.00	18.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.00		
1017	TANF 21-44 FEMALE N O	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2110	SSI AGED NON-MEDIC AR	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2200	SSI DISABLED WITH M E	17.00	19.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.00		
2210	SSI DISABLED NON-ME D	6,177.00	6,184.00	6,175.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,536.00		
2220	SSI DISABLED WITH Q M	49.00	51.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2310	SSI BLIND NON-MEDIC A	56.00	57.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169.00		
4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128.00		
4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		945.00		
4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938.00		
4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221.00		
4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242.00		
5013	SOBRA PREG 09-13 FE M	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		
5015	SOBRA PREG 14-20 FE M	7.00	6.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
SUBTOTAL:	7,546.00	7,561.00	7,581.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,688.00		

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	
1116	TANF EXPANDED 21-44	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:	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00

3.00

4.00

3514	ADULT 40-100% MALE
1	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	15.00	17.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	9.00	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	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:	30.00	33.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
6.00	
48.00	
29.00	
3.00	
3.00	
95.00	

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	
SUBTOTAL:	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00

3.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	11.00	10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
4414	SOBRA 100-133% MALE	4.00	4.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
4415	SOBRA 100-133% FEM AL	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
SUBTOTAL:	17.00	16.0	0	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		

TOTAL:	7,596.00	7,612.00	7,627.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,835.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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	
SUBTOTAL	:	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	

1006	TANF 21-44 MALE WITH	13,748.51	11,706.46	23,270.89	0.00	0.00	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	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	29,543.51	38,496.50	56,571.19	0.00	0.00	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	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	1,290,959.10	1,245,523.04	1,285,302.05	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	1,257,382.93	1,081,951.02	933,354.82	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	1,882,318.21	1,589,351.98	1,841,982.47	0.00	0.00	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	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	618,162.51	955,347.31	724,128.67	0.00	0.00	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	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	6,255,681.23	6,847,408.50	8,911,141.15	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	2,241,687.50	2,225,717.52	3,261,573.62	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	10,320.41	9,670.04	10,279.84	0.00	0.00	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	0.00	0.00	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	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	6,682.12	19,778.64	18,075.17	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	125,205.47	128,787.96	211,507.53	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	8,070,657.42	8,785,140.60	10,377,505.66	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE M	0.00	700.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
48,725.86	
56,264.28	
124,611.20	
48,530.95	
3,821,784.19	
3,272,688.77	
5,313,652.66	
1,055,649.62	
2,297,638.49	
6,062,079.17	
22,014,230.88	
7,728,978.64	
30,270.29	
3,292.34	
6,443.55	
44,535.93	
14,767.57	
532,667.12	
465,500.96	
1,243,996.28	
1,295,630.86	
27,233,303.68	
3,924,699.77	
5,605.39	
325,858.88	
50,164.58	
700.00	
6,467,501.91	
9,167,481.11	
14,189,901.22	
3,832,566.39	
4,639,879.74	
1,400.00	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,357.53	
5015	SOBRA PREG 14-20 FE M	396,630.45	405,096.39	479,727.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,281,454.23	
5017	SOBRA PREG 21-44 FE M	1,708,550.06	2,049,753.34	2,625,202.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,383,505.68	
5018	SOBRA PREG 45-64 FE M	4,193.00	14,500.38	2,450.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,143.38	
5027	SOBRA PREG 21-44 FE M	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133,011,475.57	

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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	23,910.19	20,501.26	32,963.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	107.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	5,732.86	4,829.90	1,724.46	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	4.35	1,208.05	2,125.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	1,500.26	3,544.35	2,230.96	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	7,716.84	9,382.71	9,968.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	22,942.06	38,024.62	25,791.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	67,166.54	76,848.41	85,275.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	381,632.77	433,733.65	560,695.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	12,133.96	14,195.83	29,503.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	300,375.73	232,843.02	283,300.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	285,198.27	311,126.24	453,402.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,645,170.04	3,654,958.78	4,322,859.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
350.00	
37,923.00	
82,004.32	
238,340.28	
77,374.71	
107.79	
12,287.22	
74,889.04	
30,879.07	
93,779.47	
1,228,392.84	
3,847,192.90	
2,201,991.18	
3,337.57	
7,275.57	
12,677.03	
32,927.23	
27,067.79	
86,758.49	
229,290.79	
1,376,061.75	
55,833.61	
816,519.65	
1,049,727.46	
11,622,988.76	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
21.62	
-95.91	
-843.88	
-12,669.89	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	-13,272.06	0.00	-316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-13,588.06		

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	0.00	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	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	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	
SUBTOTAL:	22,658.87	-52.99	14,341.74	0.00	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	
-23,610.00	
579.17	
49,941.56	
36,947.62	

3506	ADULT 40-100% MALE
2	100.62	646.90	826.55	0.00	0.00	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	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	1,136.72	650.66	2,304.18	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	63,740.82	68,857.24	154,389.86	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	448,531.84	490,065.88	644,008.43	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	1,779,103.67	1,877,742.95	2,130,964.95	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	700.00	1,114.00	4,797.69	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	74.88	136.07	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	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	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	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 MAL E	254.18	187.24	2,147.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	3,196.60	2,984.95	5,735.57	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	20,398.58	29,175.88	21,993.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	662.62	898.69	1,365.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	222,884.44	394,365.52	460,111.11	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	5,628,508.71	6,879,358.31	8,226,675.54	0.00	0.00	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	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	7,505,601.56	8,385,725.63	10,052,601.97	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	20,526.57	6,525.97	34,180.45	0.00	0.00	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 4	-612.98	2,336.87	599.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,574.07	
402.04	
17,503.75	
4,091.56	
65,672.60	
286,987.92	
1,993,773.57	
1,582,606.15	
5,787,811.57	
6,611.69	
210.95	
283.45	
380.98	
64.44	
2,589.27	
11,917.12	
71,567.82	
2,926.41	
1,077,361.07	
951,382.13	
20,734,542.56	
11,160,357.95	
25,943,929.16	
61,232.99	
166.20	
2,323.72	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	19,765,638.49	22,705,157.72	27,297,474.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,768,271.14		

3906	NEWLY ELIGIBLE MALE	1,400.00	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	2,100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	8,274.29	12,110.91	11,447.94	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	350.00	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,757,825.94	2,095,784.57	2,416,331.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,400.00	
2,100.00	
31,833.14	
366.62	
43,545.19	
78,875.51	
1,190,084.94	
1,397,080.23	
3,521,050.24	
3,150.00	
456.51	
6,269,942.38	

4413	SOBRA 100-133% M&F
6	208,919.81	208,659.92	145,887.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	89,702.86	89,764.24	51,754.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	72,034.45	135,577.62	72,403.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	370,657.12	434,001.78	270,045.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
563,467.00	
231,221.89	
280,015.71	
1,074,704.60	

4517	BC PATIENT FEMALE 2 1	5,936.00	6,300.97	5,519.97	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	2,131.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,190.63	11,299.84	11,032.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
17,756.94	
7,308.43	
10,190.40	
7,267.44	
42,523.21	

8700	SSI DISABLED FREEDO M	3,861.91	11,145.71	10,454.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	2,100.00	2,528.61	332.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	59.40	237.60	367.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,021.31	13,911.92	11,155.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,462.00	
4,961.54	
664.94	
31,088.48	

64,487,605.57     71,142,743.92    86,213,717.58

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

221,844,067.07

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.35		
1011	TANF <1 M & F NON-ME	439.67	11,488.16	5,242.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,170.03		
1012	TANF 01-05 M & F NON	1,999.68	0.00	6,173.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,173.32		
1013	TANF 06-13 M & F NON	0.00	0.00	-29.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-29.23		
1014	TANF 14-20 MALE NON-	1,639.96	371.56	1,298.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,309.95		
1015	TANF 14-20 FEMALE N O	10,367.88	4,369.23	19,961.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,698.67		
1016	TANF 21-44 MALE NON-	27,978.02	35,547.13	51,358.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,883.71		
1017	TANF 21-44 FEMALE N O	85,071.84	122,995.47	128,349.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		336,417.02		
1018	TANF 45-64 M & F NON	19,601.63	63,726.19	20,776.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,104.49		
2100	SSI AGED WITH MEDIC A	4,288.93	2,161.00	6,039.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,489.73		
2110	SSI AGED NON-MEDIC AR	16,932.19	33,017.03	46,637.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,586.82		
2120	SSI AGED WITH QMB	0.00	807.00	131.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938.79		
2200	SSI DISABLED WITH M E	488.66	1,617.07	3,610.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,715.78		
2210	SSI DISABLED NON-ME D	39,007.48	95,497.11	23,513.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,018.47		
2220	SSI DISABLED WITH Q M	0.00	1,277.10	1,336.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,613.28		
4311	SOBRA CHILD <1 M & F	117,403.64	23,297.12	59,254.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,955.18		
4312	SOBRA CHILD 01-05 M	64,184.72	52,686.05	65,786.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,657.71		
4313	SOBRA CHILD 06-13 M	34,405.76	34,320.87	47,228.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,954.70		
4314	SOBRA CHILD 14-20 MA	34,112.02	13,654.57	40,427.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,194.10		
4315	SOBRA CHILD 14-20 FE	25,544.79	41,450.78	33,073.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,069.22		
5007	SOBRA PREG 21-44 FE M	1,316.92	-622.54	620.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,314.81		
5015	SOBRA PREG 14-20 FE M	17,081.33	30,674.40	30,351.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,106.97		
5017	SOBRA PREG 21-44 FE M	77,766.50	80,269.95	104,810.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,846.54		
5018	SOBRA PREG 45-64 FE M	0.00	28.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.27		
8040	SLMB	6,944.53	49.41	807.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,800.97		
8050	QI1	959.34	1,438.39	130.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,528.20		
SUBTOTAL:	587,535.49	650,200.47	696,955.0	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,934,691.00		

1106	TANF EXPANDED 21-44	0.00	93.33	88.81	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	13,694.50	13,902.95	27,807.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	31,143.56	46,456.94	70,887.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
182.14

683.34

8,100.73

515.10

6,409.61

55,404.63

148,487.90

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	29,015.56	33,956.75	60,010.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,983.02	
2400	SSI AGED EXPANDED WI	2,377.90	12,618.70	12,271.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,267.67	
2410	SSI AGED EXPANDED NO	979.32	10,480.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,459.74	
2420	SSI AGED EXPANDED WI	550.98	1,286.23	328.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,165.65	
2600	SSI DISABLED EXPAND E	2,818.70	1,835.75	7,785.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,439.45	
2610	SSI DISABLED EXPAND E	3,572.35	3,805.02	18,910.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,288.12	
2620	SSI DISABLED EXPAND E	260.03	91.97	253.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	605.43	
SUBTOTAL	:	87,190.43	129,664.23	206,137.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	422,992.53	

3508	ADULT 40-100% M&F 45	39.84	0.00	636.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	7,354.73	2,210.13	9,226.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	4,053.85	7,409.16	13,107.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	22,487.77	47,727.87	38,141.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	32,478.15	34,588.71	42,476.30	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	115,109.31	85,155.48	173,866.91	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	35.04	0.00	128.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	1,587.28	0.00	57.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	947.85	0.00	377.50	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	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	-3,202.73	15,501.02	18,183.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	8,301.75	16,458.77	17,720.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	167,516.26	204,690.38	358,830.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	161,052.04	116,919.92	123,724.40	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	492,428.69	286,192.87	473,719.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL E	0.00	0.00	2,252.43	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
676.52	
18,791.72	
24,570.93	
108,356.74	
109,543.16	
374,131.70	
1,158.88	
163.64	
1,644.30	
1,325.35	
350.00	
30,482.00	
42,480.87	
731,036.83	
401,696.36	
1,252,340.67	
2,252.43	
3,101,002.10	

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	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	33,130.96	36,088.32	65,921.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	88,508.51	131,570.76	163,768.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	160,593.88	215,500.31	316,273.5	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
175.69	
1,025.30	
6,966.44	
20,650.32	
144,561.72	
135,140.95	
383,847.28	
692,367.70	

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

4413	SOBRA 100-133% M&F
6

4,059.93	12,186.74	21,110.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,356.90

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

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4414	SOBRA 100-133% MALE	5,335.47	2,393.38	14,375.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,104.51	
4415

SUBT	SOBRA 100-133% FEM AL
OTAL:	867.96

10,263.36	4,065.21

18,645.33	16,099.57

51,585.46	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	21,032.74

80,494.15	

8700	SSI DISABLED FREEDO M	141.21	1,493.16	2,014.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	137.00	661.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	141.21	1,630.16	2,675.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,648.40	
798.16	
4,446.56	

TOTAL:	1,855,914.20	1,832,578.06	2,547,501.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,235,994.04		

FAMILY PLANNING SERVICES
For The Period Ending September 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		
SUBTOTAL:	-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

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,687.42		
1012	TANF 01-05 M & F NON	3,325.77	8,684.64	18,795.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,806.26		
1013	TANF 06-13 M & F NON	54,626.02	34,912.76	80,372.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,911.19		
1014	TANF 14-20 MALE NON-	65,319.99	60,239.51	137,076.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,635.85		
1015	TANF 14-20 FEMALE N O	458,200.55	295,670.00	478,042.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,231,913.50		
1016	TANF 21-44 MALE NON-	60,888.08	100,933.93	31,723.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,545.67		
1017	TANF 21-44 FEMALE N O	2,670,623.86	2,730,005.88	3,324,170.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,724,800.70		
1018	TANF 45-64 M & F NON	115,318.65	114,094.17	197,992.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427,405.75		
1019	TANF 65+ M & F NON-M	974.37	580.16	36,530.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,085.46		
2100	SSI AGED WITH MEDIC A	1,028.00	1,134.36	2,508.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,670.44		
2110	SSI AGED NON-MEDIC AR	767,030.64	976,118.47	1,135,999.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,879,148.23		
2120	SSI AGED WITH QMB	0.00	1,247.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,247.40		
2200	SSI DISABLED WITH M E	15,487.16	14,895.52	19,590.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,972.86		
2210	SSI DISABLED NON-ME D	388,846.01	233,518.99	496,312.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,118,677.04		
2310	SSI BLIND NON-MEDIC A	-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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,136,293.96		

1106	TANF EXPANDED 21-44	942.36	1,534.47	1,505.09	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,597,437.04	1,711,374.62	2,288,194.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,981.92	
2,239.17	
5,236.52	
312.04	
9,021.29	
47,485.48	
1,258,831.52	
2,779,453.14	
1,146,040.39	
23,241.79	
3,999.08	
190,996.54	
1,825.74	
124,341.14	
5,597,005.76	

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 E	0.00	3,220.32	764.56	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	363.70	744.09	123.30	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	83.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,942.57	
3,984.88	
1,231.09	
83.87	

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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 MAL E	3,173.56	985.83	1,307.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,466.59	
3717	ADULT <40% EXP FEM AL	7,385.92	3,761.60	4,166.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,313.69	
3718	ADULT <40% EXP M&F 4	6,017.10	34,892.69	1,317.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,227.07	
SUBTOTAL	:	17,571.92	44,680.95	10,620.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,873.04	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	61.58	0.00	0.00	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	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	894,595.81	1,176,047.32	1,802,982.03	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,701,574.81	1,999,987.75	3,176,830.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
61.58	
9,930.91	
86,723.32	
130,418.21	
1,810,710.07	
942,589.94	
3,873,625.16	
21,438.45	
811.66	
2,084.01	
6,878,393.31	

TOTAL:	7,918,039.06	8,328,534.57	11,437,992.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,684,566.07		

QMB - FEE FOR SERVICE
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	998,583.60	
SUBTOTAL:	293,436.77	211,412.30	493,734.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	998,583.60	
														
TOTAL:	293,436.77	211,412.30	493,734.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	998,583.60	

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending September 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	3,227.31	2,397.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,624.73		
2100	SSI AGED WITH MEDIC A	15,412.32	89,978.84	21,245.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,636.51		
2110	SSI AGED NON-MEDIC AR	61,148.18	60,953.07	9,698.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,800.20		
2120	SSI AGED WITH QMB	1,093.55	171.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,264.70		
2200	SSI DISABLED WITH M E	4,280.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,280.93		
2210	SSI DISABLED NON-ME D	0.00	806.03	7.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		813.60		
2220	SSI DISABLED WITH Q M	5,933.83	6,506.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,439.91		
5017	SOBRA PREG 21-44 FE M	3,043.51	2,377.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,421.31		
8020	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		
SUBTOTAL:	94,139.63	163,354.77	30,951.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		288,446.27		

1116	TANF EXPANDED 21-44	0.00	0.00	4,142.44	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,918.19	376.34	4,142.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,142.44	
11,294.53	
15,436.97	

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 MAL E	2,286.61	1,389.07	109,186.74	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	48,908.37	28,993.62	20,991.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	108.35	23,795.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	282,960.57	239,237.96	160,049.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	8,006.01	55,446.91	23,944.21	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	235,458.94	434,500.79	215,685.56	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	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	ADULT <40% EXP MAL E	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 4	9,628.14	5,770.49	8,615.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	589,093.37	765,912.44	562,324.3	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
854.41	
112,862.42	
98,893.35	
23,904.15	
682,247.87	
87,397.13	
885,645.29	
1,495.64	
15.96	
24,013.98	
1,917,330.20	

3916	NEWLY ELIGIBLE MALE	352.61	16,903.27	22,673.32	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,351.37	35,815.84	34,046.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
39,929.20	
36,284.90	
76,214.10	

TOTAL:	700,502.56	965,459.39	631,465.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,297,427.54		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MAL E	0.00	3,842.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,842.02		
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		
SUBTOTAL:	151.74	3,842.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,993.76		

3,993.76

151.74	3,842.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,870.42	
1017	TANF 21-44 FEMALE N O	0.00	2,041.21	946.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,987.26	
2200	SSI DISABLED WITH M E	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	
2210	SSI DISABLED NON-ME D	18,422.83	10,195.76	34,766.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,385.39	
2220	SSI DISABLED WITH Q M	15.35	3,019.90	3,735.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,770.71	
5017	SOBRA PREG 21-44 FE M	0.00	5,306.85	4,658.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,965.18	
SUBTOTAL	:	20,878.47	34,444.77	51,911.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,235.00	

1116	TANF EXPANDED 21-44	3,673.93	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	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	
2620	SSI DISABLED EXPAND E	2,757.38	5,096.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,603.73	5,096.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,673.93	
14,172.42	
7,854.02	
25,700.37	

3516	ADULT 40-100% MALE
2	0.00	0.00	4,010.58	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	16,799.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	1,298.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	69,878.66	66,286.32	10,893.65	0.00	0.00	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	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	49,207.81	47,104.83	15,084.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	124,338.03	133,446.71	33,662.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,010.58	
16,799.05	
1,298.03	
147,058.63	
10,882.86	
111,397.59	
291,446.74	

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	
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	
SUBTOTAL:	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	

 
0.00	
15,153.54	
15,153.54	

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	
SUBTOTAL:	0.00	0.00	503.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
503.71

503.71

TOTAL:	180,973.77	172,988.12	86,077.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		440,039.36		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2015

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	
3716	ADULT <40% EXP MAL E	13,355.83	4,487.44	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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,189.14	14,618.65	968.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52.80	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,311.39	
SUBTOTAL	:	338.81	2,844.58	4,099.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,282.71	

1116	TANF EXPANDED 21-44	435.29	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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
435.29	
112.96	
548.25	

	
17.50	
	17,843.27	
	55.30	
	13,859.82	
	31,775.89	
																
TOTAL:		17,076.20	17,463.23	5,067.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,606.85	

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2015

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,241.75	
2200	SSI DISABLED WITH M E	0.00	630.38	160.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	790.53	
2210	SSI DISABLED NON-ME D	0.00	160.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	160.89	
SUBTOTAL	:	0.00	791.27	4,401.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,193.17	

3716	ADULT <40% EXP MAL E	7.98	1,430.76	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	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	ADULT <40% EXP M&F 4	8,014.50	-3,085.25	11,735.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,166.82	-1,654.49	11,735.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,438.74	
144.34	
16,665.04	
18,248.12	

TOTAL:	8,166.82	-863.22	16,137.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,441.29		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MAL E	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		
SUBTOTAL:	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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

472.31

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350.00		
2100	SSI AGED WITH MEDIC A	1,867,476.11	2,106,357.37	3,001,652.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,975,485.59		
2110	SSI AGED NON-MEDIC AR	177,147.26	101,345.13	299,519.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		578,011.79		
2120	SSI AGED WITH QMB	2,867,399.51	2,877,254.51	4,110,836.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,855,490.73		
2200	SSI DISABLED WITH M E	543,524.04	474,214.50	724,208.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,741,947.49		
2210	SSI DISABLED NON-ME D	2,493,153.38	2,750,175.45	3,099,509.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,342,838.57		
2220	SSI DISABLED WITH Q M	639,532.10	693,460.39	974,750.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,307,743.23		
2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134.33		
2310	SSI BLIND NON-MEDIC A	22,797.15	14,440.58	16,725.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,963.55		
2320	SSI BLIND WITH QMB	5,463.78	7,778.92	7,725.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,967.95		
SUBTOTAL:	8,616,568.26	9,025,376.85	12,234,988.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,876,933.23		

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,044.41	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,712.52	4,868.22	9,193.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,921.75	
8,852.04	
15,773.79	

TOTAL:	8,618,280.78	9,030,245.07	12,244,181.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,892,707.02		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,947.55		
2120	SSI AGED WITH QMB	0.00	83.04	41.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.47		
2200	SSI DISABLED WITH M E	572.87	1,912.10	6,455.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,940.89		
2210	SSI DISABLED NON-ME D	10,415.23	19,351.87	894.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,661.74		
SUBTOTAL:	15,485.93	33,992.59	32,196.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,674.65		

81,674.65

15,485.93	33,992.59	32,196.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	44,618.60	15,435.03	41,858.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,912.32		
1013	TANF 06-13 M & F NON	101,743.02	26,444.15	55,447.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183,634.83		
1014	TANF 14-20 MALE NON-	8,473.78	2,483.13	8,146.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,103.48		
1015	TANF 14-20 FEMALE N O	3,292.00	1,194.76	3,063.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,550.39		
2120	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 E	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	SSI DISABLED NON-ME D	252,041.30	84,309.59	219,296.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		555,647.54		
2300	SSI BLIND WITH MEDIC	158.70	63.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222.18		
2310	SSI BLIND NON-MEDIC A	2,989.18	538.14	1,847.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,374.79		
2320	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.20		
4312	SOBRA CHILD 01-05 M	74,849.31	21,849.59	69,541.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,240.33		
4313	SOBRA CHILD 06-13 M	138,639.38	30,827.76	103,590.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273,057.26		
4314	SOBRA CHILD 14-20 MA	12,134.57	3,360.74	12,303.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,798.52		
4315	SOBRA CHILD 14-20 FE	3,881.60	1,365.86	4,314.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,562.42		
SUBTOTAL:	642,887.52	188,308.71	519,661.0	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,350,857.29		

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	
SUBTOTAL:	2,732.49	3,154.87	3,999.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
959.90	
8,290.45	
244.58	
181.03	
210.61	
9,886.57	

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 MAL E	1,726.70	9.31	990.53	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,053.49	48.92	1,139.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12.33	
34.11	
2,726.54	
1,469.16	
4,242.14	

4413	SOBRA 100-133% M&F
6	25,022.12	4,486.95	12,154.90	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	515.37	640.27	290.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	33,611.25	5,777.00	13,916.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
41,663.97	
10,194.34	
1,446.50	
53,304.81	

682,284.75

197,289.50

TOTAL:

538,716.56

0.00

0.00

0.00

0.00

0.00

1,418,290.81

0.00

0.00

0.00	0.00

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	831.19	0.00	115.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	946.93	
1010	TANF NON-MEDICARE	40,868.65	24,234.06	48,725.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	113,828.60	
2200	SSI DISABLED WITH M E	2,871.13	789.16	3,394.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,054.88	
2210	SSI DISABLED NON-ME D	1,249,307.80	489,106.70	1,265,880.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,004,294.78	
2220	SSI DISABLED WITH Q M	2,114.42	-248.86	3,650.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,516.23	
2310	SSI BLIND NON-MEDIC A	7,193.15	6,514.48	11,947.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,655.22	
SUBTOTAL	:	1,303,186.34	520,395.54	1,333,714.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,157,296.64	
															
TOTAL:		1,303,186.34	520,395.54	1,333,714.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,157,296.64	

ACUTE REINSURANCE
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98.97		
1011	TANF <1 M & F NON-ME	741,618.20	275,323.86	870,817.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,887,759.79		
1012	TANF 01-05 M & F NON	59,967.01	17,049.65	46,379.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,396.17		
1013	TANF 06-13 M & F NON	184,625.99	341,772.36	71,256.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		597,655.20		
1014	TANF 14-20 MALE NON-	12,269.60	19,354.41	57,649.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,273.20		
1015	TANF 14-20 FEMALE N O	18,361.96	12,714.48	18,838.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,914.65		
1016	TANF 21-44 MALE NON-	161,649.37	-21,881.23	40,292.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,060.40		
1017	TANF 21-44 FEMALE N O	127,936.47	159,048.89	395,075.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		682,060.86		
1018	TANF 45-64 M & F NON	84,129.25	65,348.37	87,293.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236,771.33		
2100	SSI AGED WITH MEDIC A	624.78	33,070.16	362.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,057.63		
2110	SSI AGED NON-MEDIC AR	67,861.38	195,769.67	82,798.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		346,429.91		
2200	SSI DISABLED WITH M E	43,874.36	10,496.70	3,907.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,278.57		
2210	SSI DISABLED NON-ME D	4,045,297.65	3,940,603.94	4,946,163.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,932,065.17		
2310	SSI BLIND NON-MEDIC A	40,412.86	2,873.76	1,068.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,355.39		
4311	SOBRA CHILD <1 M & F	929,626.36	754,864.21	1,574,042.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,258,533.53		
4312	SOBRA CHILD 01-05 M	114,463.42	359,348.65	667,111.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,140,923.21		
4313	SOBRA CHILD 06-13 M	239,870.36	136,192.59	249,120.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		625,183.90		
4314	SOBRA CHILD 14-20 MA	115,773.80	89,801.77	118,016.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323,591.65		
4315	SOBRA CHILD 14-20 FE	14,027.07	63,132.41	6,858.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,018.21		
5015	SOBRA PREG 14-20 FE M	0.00	9,507.28	408.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,915.84		
5017	SOBRA PREG 21-44 FE M	8,128.10	28,115.83	25,201.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,445.74		
SUBTOTAL:	7,010,616.95	6,492,507.76	9,262,664.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,765,789.32		

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	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	505.48	6,432.42	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	35,356.98	19,953.70	40,311.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	20,284.70	72,266.71	62,393.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	316,711.60	410,028.71	481,700.7	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,182.90	
6,937.90	
291,706.67	
260,085.74	
291,265.31	
68.56	
106,626.59	
95,622.21	
154,945.20	
1,208,441.08	

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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22.30	
3,631.95	
3,654.25	

ACUTE REINSURANCE
For The Period Ending September 30, 2015

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3410	MED ELIGIBILITY NON-	0.00	0.00	-5,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-5,724.35	
3616	AHC CARE/MI MALE 21-	9,760.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,760.41	
3618	AHC CARE/MI M&F 45-6	28,195.73	-1,579.93	-5,079.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,536.59	

SUBTOTAL:	
37,956.14	
-1,579.93	
-10,803.56	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
25,572.65	

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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	414,839.94	278,819.33	311,265.46	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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	150,958.00	173,540.11	140,658.64	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	502,179.54	650,833.61	591,737.89	0.00	0.00	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	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	1,083,021.23	1,159,557.65	1,128,258.45	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-1,238.16	
90,401.55	
24,676.09	
322,969.58	
368,043.59	
1,004,924.73	
2,767.51	
60,983.63	
465,156.75	
235,487.30	
1,744,751.04	
605,397.37	
3,370,837.33	
8,295,158.31	

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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	276,371.96	479,009.69	344,793.7	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
96,476.19	
4,356.93	
193,626.32	
41,659.24	
764,056.71	
1,100,175.39	

4413	SOBRA 100-133% M&F
6	19,844.57	10,180.96	21,606.21	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	188.17	9,280.96	106.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	471,134.63	470,569.59	447,840.7	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
51,631.74	
1,328,337.50	
9,575.77	
1,389,545.01	

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	
SUBTOTAL:	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	

 
6,209.80

6,209.80

8710	SSI DISABLED FREEDO M	2,595.44	0.00	2,595.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,595.44	0.00	2,595.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,190.88

5,190.88

TOTAL:	10,791,209.52	10,677,372.35	13,331,154.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,799,736.69		

LONG TERM CARE REINSURANCE
For The Period Ending September 30, 2015

8710	SSI DISABLED FREEDO M	12,568.90	358.45	-18.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,568.90	358.45	-18.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:	4,033,194.34	3,839,275.12	5,041,553.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,914,023.04	
															
														12,909.07	
														12,909.07	
															
TOTAL:	4,045,763.24	3,839,633.57	5,041,535.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,926,932.11	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43.57	
2100	SSI AGED WITH MEDIC	327,108.06	281,473.61	410,214.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,018,796.31	
	A														
2110	SSI AGED NON-MEDIC	218,322.47	133,627.59	139,813.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	491,763.58	
	AR														
2200	SSI DISABLED WITH M	644,979.13	626,909.22	541,936.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,813,825.16	
	E														
2210	SSI DISABLED NON-ME	2,840,717.50	2,796,391.98	3,888,127.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,525,236.99	
	D														
2310	SSI BLIND NON-MEDIC	2,067.18	829.15	61,461.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,357.43	
	A														

ACUTE SMIB
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	194,274.80	239,591.60	285,013.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		718,879.70		
1010	TANF NON-MEDICARE	419.60	314.70	419.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,153.90		
1020	TANF WITH QMB	59,218.50	89,224.80	136,060.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,503.50		
2100	SSI AGED WITH MEDIC A	55,177.40	57,030.30	58,179.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,387.00		
2110	SSI AGED NON-MEDIC AR	390,962.30	405,066.70	409,640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,205,669.00		
2120	SSI AGED WITH QMB	1,817,089.90	1,837,723.90	1,860,966.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,515,779.80		
2200	SSI DISABLED WITH M E	156,570.80	143,157.80	137,314.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		437,042.70		
2210	SSI DISABLED NON-ME D	332,008.50	338,302.50	334,945.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,005,256.70		
2220	SSI DISABLED WITH Q M	2,831,922.00	2,873,883.50	2,914,800.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,620,605.70		
2300	SSI BLIND WITH MEDIC	419.60	419.60	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,153.90		
2310	SSI BLIND NON-MEDIC A	3,251.90	3,356.80	3,042.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,650.80		
2320	SSI BLIND WITH QMB	25,071.10	24,336.80	25,910.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,318.20		
4300	SOBRA CHILD WITH M ED	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.70		
4320	SOBRA CHILD WITH Q MB	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.70		
5000	SOBRA PREGNANT WO MAN	1,363.70	1,363.70	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,881.30		
5020	SOBRA PREGNANT WO MAN	944.10	839.20	1,153.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,937.20		
8000	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,655,849.20		
8040	SLMB	3,389,057.50	3,504,045.60	3,489,229.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,382,332.80		
8888	SMIB ONLY NOT ELIGIB	-52,359.80	-26,959.30	-20,035.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-99,355.00		
9999	SMIB ONLY NOT ELIGIB	59,066.30	19,847.50	122,106.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,020.40		
SUBTOTAL:	9,808,185.80	10,062,146.60	10,322,154.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,192,486.40		

1100	TANF EXPANDED FPR FI	470,376.20	412,891.00	362,329.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	209.80	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	128,342.70	125,775.10	114,341.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	3,042.10	1,468.60	1,253.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	524.50	524.50	524.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,928,537.00	2,921,828.60	2,878,145.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	-419.60	209.80	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,653,183.80	1,727,813.10	1,756,040.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,183,901.40	5,190,720.50	5,113,158.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,245,596.40	
419.60	
368,458.80	
5,764.60	
1,573.50	
8,728,510.70	
314.70	
104.90	
5,137,037.60	
15,487,780.80	

3520	ADULT 40-100% FOR FI	3,147.00	-1,743.30	3,147.00	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,923.40	-274.70	4,300.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,550.70	
6,398.90	
10,949.60	

ACUTE SMIB
For The Period Ending September 30, 2015

8720	SSI DISABLED FREEDO M	21,399.60	22,238.80	22,343.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	21,399.60	22,238.80	22,343.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,042.10	
SUBTOTAL:	1,468.60	734.30	839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,042.10	
														
													65,982.10	
													65,982.10	
TOTAL:	15,021,878.80	15,275,565.50	15,462,796.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,760,241.00		

ACUTE HIB
For The Period Ending September 30, 2015

2420	SSI AGED EXPANDED WI	8,649.20	8,527.10	5,656.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,649.20	8,527.10	5,656.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:	261,768.80	274,049.90	304,238.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		840,057.10	
															
														22,832.70	
														22,832.70	
															
TOTAL:	270,418.00	282,577.00	309,894.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		862,889.80	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	407.00	
2100	SSI AGED WITH MEDIC	2,442.00	-814.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,628.00	
	A														
2120	SSI AGED WITH QMB	173,720.20	179,916.50	193,518.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	547,155.40	
2220	SSI DISABLED WITH Q	88,616.20	96,125.80	110,636.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295,378.10	
	M														
2320	SSI BLIND WITH QMB	407.00	407.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,221.00	
8020	QMB ONLY	4,988.10	2,953.10	3,645.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,586.20	
9999	SMIB ONLY NOT ELIGIB	-8,404.70	-4,538.50	-4,375.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-17,318.60	

Q1
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,367,483.50	
9999	SMIB ONLY NOT ELIGIB	-35,141.50	-2,907.10	-18,986.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-57,035.50	

SUBTOTAL:	
2,399,485.20	
1,983,016.50	
1,927,946.30	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
6,310,448.00	

TOTAL:	2,399,485.20	1,983,016.50	1,927,946.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,310,448.00		

LTC SMIB
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,363.70		
1020	TANF WITH QMB	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.70		
2100	SSI AGED WITH MEDIC A	874,183.40	870,946.20	868,154.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,613,284.00		
2110	SSI AGED NON-MEDIC AR	155,566.70	157,769.60	157,769.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,105.90		
2120	SSI AGED WITH QMB	764,559.10	761,981.70	777,780.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,304,321.60		
2200	SSI DISABLED WITH M E	319,840.10	329,595.80	321,623.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		971,059.30		
2210	SSI DISABLED NON-ME D	15,630.10	25,513.40	17,308.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,452.00		
2220	SSI DISABLED WITH Q M	710,227.60	707,605.10	709,170.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,127,002.80		
2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,412.70		
2310	SSI BLIND NON-MEDIC A	209.80	104.90	209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.50		
2320	SSI BLIND WITH QMB	4,300.90	4,510.70	4,405.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,217.40		
SUBTOTAL:	2,846,091.20	2,859,286.20	2,857,681.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,563,058.60		

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

 
1,993.10

1,993.10

8,565,051.70

2,846,825.50	2,859,915.60	2,858,310.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending September 30, 2015

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2110	SSI AGED NON-MEDIC AR	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	773,351.70	
2200	SSI DISABLED WITH M E	0.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	407.00	
2220	SSI DISABLED WITH Q M	12,923.00	14,144.00	12,516.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,583.00	
SUBTOTAL	:	269,424.80	275,671.80	269,873.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	814,969.70	

TOTAL:	269,424.80	275,671.80	269,873.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		814,969.70		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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	
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	

1006	TANF 21-44 MALE WITH	1,467.46	3,014.86	4,778.75	0.00	0.00	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	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	8,300.31	14,284.07	22,892.61	0.00	0.00	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	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	706,541.50	682,073.88	661,237.30	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	969,410.73	801,705.50	673,128.09	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	1,633,637.26	1,349,156.15	1,576,752.74	0.00	0.00	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	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	478,631.67	795,039.67	607,159.78	0.00	0.00	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	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	4,416,969.19	4,825,798.89	6,329,680.67	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	1,478,215.20	1,497,596.26	2,105,951.76	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	5,703.98	4,317.50	4,221.17	0.00	0.00	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	0.00	0.00	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	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	3,634.52	8,293.46	6,324.26	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	60,414.26	72,757.77	86,289.46	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	3,959,038.86	4,322,461.60	5,500,714.34	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE M	0.00	700.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,261.07	
17,350.81	
45,476.99	
20,272.58	
2,049,852.68	
2,444,244.32	
4,559,546.15	
813,479.62	
1,880,831.12	
3,974,107.52	
15,572,448.75	
5,081,763.22	
14,242.65	
1,455.60	
3,615.66	
18,252.24	
8,260.72	
189,264.49	
219,461.49	
597,597.14	
409,167.16	
13,782,214.80	
1,378,678.60	
2,552.99	
144,622.20	
18,324.69	
700.00	
4,541,741.67	
7,196,252.28	
11,862,586.99	
3,012,907.71	
3,601,704.86	
1,400.00	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	350.00	
5015	SOBRA PREG 14-20 FE M	237,999.22	275,437.95	329,140.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	842,577.33	
5017	SOBRA PREG 21-44 FE M	1,131,352.11	1,456,601.24	1,697,144.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,285,098.14	
5018	SOBRA PREG 45-64 FE M	4,193.00	1,958.21	2,450.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,601.21	
5027	SOBRA PREG 21-44 FE M	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,610,277.92	

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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	11,589.10	11,907.56	11,276.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	5,250.00	4,248.00	1,409.52	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	2,125.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	460.06	495.48	1,008.03	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	3,939.78	7,378.95	8,307.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	15,824.15	18,656.13	11,154.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	44,953.28	27,103.71	42,572.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	165,461.94	213,135.45	288,519.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	6,769.93	6,974.26	11,598.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	109,481.97	123,966.21	147,456.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	85,508.30	104,493.60	148,434.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,315,297.75	2,332,941.48	2,684,900.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
350.00	
13,281.39	
22,172.39	
80,698.96	
34,773.65	
0.00	
10,907.52	
68,407.69	
20,262.67	
85,544.31	
855,385.46	
2,982,255.74	
1,547,491.40	
2,125.17	
1,963.57	
6,757.45	
9,069.80	
19,626.54	
45,635.10	
114,629.29	
667,117.04	
25,342.87	
380,904.59	
338,436.84	
7,333,139.44	

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 September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	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		

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	
SUBTOTAL:	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	

3506	ADULT 40-100% MALE
2	85.05	386.37	826.55	0.00	0.00	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	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	1,136.72	452.79	2,304.18	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	39,467.46	45,163.63	63,499.13	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	316,477.56	364,737.12	475,335.36	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	1,086,597.94	1,026,522.27	1,319,334.30	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	700.00	1,114.00	3,500.00	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	74.88	61.40	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	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	0.00	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 MAL E	357.00	187.24	1,790.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	1,396.64	1,663.61	3,351.85	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	4,997.35	11,572.19	10,426.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	550.16	545.25	1,197.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	165,528.85	261,775.93	267,888.88	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	3,029,287.38	3,988,308.94	4,654,737.86	0.00	0.00	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	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	4,322,313.67	5,015,624.62	5,861,943.16	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	1,400.00	4,739.20	2,450.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	476.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,297.97	
402.04	
6,983.53	
3,893.69	
55,320.06	
148,130.22	
1,153,754.65	
1,156,550.04	
3,432,454.51	
5,314.00	
136.28	
120.80	
0.00	
64.44	
2,335.06	
6,412.10	
26,996.52	
2,292.97	
695,193.66	
689,059.86	
11,672,334.18	
7,356,269.66	
15,199,881.45	
8,589.20	
0.00	
476.33	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	11,438,207.99	13,697,919.67	16,488,135.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,624,263.22		

3906	NEWLY ELIGIBLE MALE	1,400.00	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	2,100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	5,768.03	7,449.33	2,569.39	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	350.00	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,180,866.48	1,241,698.82	1,599,657.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,400.00	
2,100.00	
15,786.75	
366.62	
28,805.64	
65,322.93	
735,481.89	
1,022,455.35	
2,146,944.48	
3,150.00	
409.40	
4,022,223.06	

4413	SOBRA 100-133% M&F
6	189,176.92	189,687.05	133,832.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	79,176.44	75,187.22	48,308.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	64,105.03	76,235.87	69,956.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	332,458.39	341,110.14	252,098.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
512,696.61	
202,672.46	
210,297.68	
925,666.75	

4517	BC PATIENT FEMALE 2 1	5,936.00	4,286.25	3,859.52	0.00	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	0.00	0.00	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	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,481.35	8,876.25	7,429.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14,081.77	
6,460.80	
1,400.00	
5,844.82	
27,787.39	

8700	SSI DISABLED FREEDO M	209.72	5,846.12	5,390.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	2,100.00	350.00	238.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	59.40	237.60	163.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,369.12	6,433.72	5,792.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,446.23	
2,688.44	
460.68	
14,595.35	

41,159,756.52     45,693,704.25    55,704,123.37

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

142,557,584.14

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2015

RATE COD	E	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	
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	

1006	TANF 21-44 MALE WITH	12,234.63	8,503.24	18,275.63	0.00	0.00	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	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	20,039.18	23,077.50	31,215.80	0.00	0.00	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	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	567,248.47	532,325.46	584,585.71	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	268,055.89	267,958.17	247,550.22	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	241,026.07	231,615.87	249,245.17	0.00	0.00	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	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	132,827.40	149,313.25	111,126.28	0.00	0.00	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	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	1,689,259.97	1,841,435.05	2,361,373.34	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	717,249.74	673,156.71	1,111,242.66	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	4,366.70	5,352.54	6,058.67	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	358.05	1,478.69	0.00	0.00	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	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	3,047.60	9,471.40	10,036.97	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	64,152.89	46,997.31	91,231.24	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	3,771,166.39	3,833,723.81	4,457,896.20	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	497,249.77	602,823.96	598,332.57	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
39,013.50	
36,652.21	
74,332.48	
28,160.93	
1,684,159.64	
783,564.28	
721,887.11	
231,989.96	
393,266.93	
1,957,573.76	
5,892,068.36	
2,501,649.11	
15,777.91	
1,836.74	
2,827.89	
22,555.97	
6,506.85	
308,747.73	
202,381.44	
625,371.65	
830,156.75	
12,062,786.40	
2,415,350.53	
2,521.69	
176,929.96	
31,305.32	
0.00	
1,698,406.30	
1,799,618.07	
2,143,763.54	
702,138.21	
957,976.94	
0.00	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2015

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,007.53	
5015	SOBRA PREG 14-20 FE M	134,500.45	112,857.97	124,462.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	371,820.81	
5017	SOBRA PREG 21-44 FE M	505,008.76	490,355.70	786,301.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,781,665.72	
5018	SOBRA PREG 45-64 FE M	0.00	12,542.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,542.17	
5027	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	
SUBTOTAL	:	11,929,298.55	12,793,707.33	15,798,308.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,521,314.39	

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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	11,071.23	8,539.97	21,023.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	394.14	374.54	145.54	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	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	TANF EXPANDED 21-44	867.04	2,844.83	954.60	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	3,777.06	2,003.76	1,660.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	6,604.72	20,310.29	10,390.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	21,709.26	49,550.80	38,796.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	212,432.79	214,996.21	262,436.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	4,806.76	6,477.98	17,263.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	109,739.51	100,550.95	88,862.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	194,924.82	195,369.54	290,524.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,175,224.23	1,233,590.49	1,416,332.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
24,226.92	
55,626.90	
152,949.34	
40,634.24	
0.00	
914.22	
6,466.35	
8,400.11	
8,235.16	
273,949.98	
758,218.11	
609,794.77	
154.00	
4,666.47	
5,760.79	
21,961.98	
7,441.25	
37,305.13	
110,056.46	
689,865.77	
28,547.76	
299,153.37	
680,818.48	
3,825,147.56	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
21.62	
-40.77	
-527.88	
-12,669.89	

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

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	0.00	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	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	-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	
SUBTOTAL:	-34,472.66	0.00	14,549.19	0.00	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	
-24,553.65	
663.28	
-6,069.99	
-19,923.47	

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	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	154.04	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	1,808.45	2,617.50	2,711.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	19,931.75	23,276.12	89,687.54	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	109,841.40	105,802.51	150,353.68	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	610,123.29	776,775.68	695,783.33	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	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	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	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	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 MAL E	-113.08	0.00	357.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	1,799.96	1,321.34	2,383.72	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	13,612.17	16,184.28	11,638.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	112.46	353.44	167.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	49,424.42	117,557.97	171,586.96	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	2,375,248.97	2,548,511.24	3,291,598.46	0.00	0.00	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	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	2,866,722.75	3,197,371.03	3,873,212.13	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	19,126.57	1,786.77	31,730.45	0.00	0.00	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 4	-612.98	600.54	599.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
276.10	
0.00	
7,665.46	
154.04	
7,137.17	
132,895.41	
615,105.76	
365,997.59	
2,082,682.30	
1,297.69	
74.67	
162.65	
380.98	
0.00	
243.95	
5,505.02	
41,435.32	
633.44	
338,569.35	
231,749.03	
8,215,358.67	
3,373,497.35	
9,937,305.91	
52,643.79	
166.20	
587.39	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	7,472,143.33	8,169,422.64	9,769,959.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,411,525.24		

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 4	1,878.61	4,565.59	8,493.20	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	1,428.78	2,216.51	11,094.26	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	474,843.91	575,141.29	707,887.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

14,937.40

0.00

14,739.55

12,870.13

424,291.78

347,331.41

943,655.16

0.00

47.11

1,757,872.54

4413	SOBRA 100-133% M&F
6	18,822.56	18,033.29	11,971.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	10,518.44	14,508.22	3,138.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	7,170.95	59,145.25	2,446.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36,511.95	91,686.76	17,556.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
48,827.42	
28,164.97	
68,763.06	
145,755.45	

4517	BC PATIENT FEMALE 2 1	0.00	2,014.72	1,660.45	0.00	0.00	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	0.00	0.00	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	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	1,422.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,311.81	2,407.95	3,462.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,675.17	
821.82	
5,262.53	
1,422.62	
11,182.14	

8700	SSI DISABLED FREEDO M	3,652.19	5,276.89	5,063.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	94.49	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	204.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,652.19	5,276.89	5,362.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,993.07	
94.49	
204.26	
14,291.82	

TOTAL:	21,049,296.39	22,871,233.35	27,733,419.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,653,948.75		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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	
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	

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-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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 D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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 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	
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	

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+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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 MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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 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	
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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	

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 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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

TOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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	
SUBTOTAL	:	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	

1006	TANF 21-44 MALE WITH	0.00	0.00	50.39	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	240.08	144.26	129.07	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	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	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	3,377.40	2,687.30	4,007.35	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	1,218.15	1,408.01	1,681.43	0.00	0.00	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	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	3,183.01	6,546.81	822.11	0.00	0.00	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	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	26,675.44	30,189.68	21,923.51	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	1,585.03	20,476.42	7,032.33	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	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	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	241.77	1,611.38	1,217.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	371.10	7,188.56	32,792.94	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	25,287.18	285,986.08	63,667.08	0.00	0.00	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	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	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
50.39	
0.00	
513.41	
14.96	
18,067.96	
10,072.05	
4,307.59	
3,906.40	
10,551.93	
33,211.23	
78,788.63	
29,093.78	
249.73	
0.00	
0.00	
0.00	
0.00	
3,070.52	
40,352.60	
2,230.31	
3,959.36	
374,940.34	
18,823.01	
0.00	
2,306.72	
0.00	
0.00	
22,150.76	
65,252.57	
95,515.49	
50,300.60	
23,445.51	
0.00	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,049.31	
5017	SOBRA PREG 21-44 FE M	21,818.94	29,403.82	43,513.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94,736.75	
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 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	
SUBTOTAL	:	212,022.47	488,372.66	298,566.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	998,961.91	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	107.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	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	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	207.41	1,374.65	40,600.36	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	338.53	-1,011.94	2,895.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	199.65	0.00	129.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	386.96	48.09	143.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	56,129.73	0.00	20,969.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	479.32	0.00	3,171.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	71,791.87	5,686.71	75,118.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
26.99	
6.07	
0.00	
107.79	
296.08	
0.00	
1,709.92	
0.00	
42,182.42	
17,834.32	
6,553.96	
0.00	
0.00	
0.00	
0.00	
0.00	
2,222.08	
0.00	
328.83	
578.90	
77,099.69	
3,650.38	
152,597.43	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
-55.14	
0.00	
0.00	

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

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	
SUBTOTAL:	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	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	3,430.56	332.79	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	29,537.65	17,618.83	16,528.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	9,918.88	16,192.67	4,216.11	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	17,006.11	11,808.33	29,317.11	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 MAL E	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 AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	47.77	159.41	-72.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	638.33	2,949.89	655.77	0.00	0.00	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 MAL E	87,516.94	137,213.09	59,107.89	0.00	0.00	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	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	73,759.29	34,317.41	75,461.37	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 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	
300.90	
0.00	
0.00	
3,763.35	
63,685.35	
30,327.66	
58,131.55	
0.00	
0.00	
0.00	
0.00	
0.00	
10.26	
0.00	
134.69	
0.00	
4,243.99	
9,206.15	
283,837.92	
121,357.09	
183,538.07	
0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	257,558.65	252,306.42	248,671.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		758,536.98		

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 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	
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	0.00	0.00	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	0.00	0.00	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	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	
SUBTOTAL:	44,437.01	23,067.06	66,686.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

0.00

0.00

0.00

0.00

12,580.90

10,900.35

110,709.29

0.00

0.00

134,190.54

4413	SOBRA 100-133% M&F
6	0.00	332.82	31.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	7.98	68.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	169.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	177.42	401.62	31.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
364.01	
76.78	
169.44	
610.23	

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	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	
SUBTOTAL:	3,387.30	0.00	140.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
3,527.87	
0.00	
3,527.87	

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 M	0.00	2,178.61	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	
SUBTOTAL:	0.00	2,178.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
2,178.61	
0.00	
2,178.61	

TOTAL:	646,451.11	771,726.45	689,215.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,107,393.33		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,666.49		
SUBTOTAL:	22,473.97	26,318.0	47,874.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,666.49		

96,666.49

22,473.97	26,318.07	47,874.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending September 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		
SUBTOTAL:	0.00	0.0	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.51		

TOTAL:	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		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901,721.71		
SUBTOTAL:	270,941.80	185,031.5	0	445,748.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901,721.71		

901,721.71

270,941.80	185,031.50	445,748.41	0.00	0.00	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 September 30, 2015

RATE COD	E	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	
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	

1006	TANF 21-44 MALE WITH	46.42	188.36	166.12	0.00	0.00	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	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	963.94	990.67	2,333.71	0.00	0.00	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	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	16,538.91	9,600.05	8,669.16	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	6,436.73	7,171.95	14,303.13	0.00	0.00	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	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	3,520.43	4,447.58	5,020.50	0.00	0.00	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	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	122,776.63	149,984.88	198,163.63	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	44,637.53	34,488.13	37,346.87	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	2,013.78	1,713.94	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	8,786.84	9,235.08	13,562.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	267.22	1,844.32	1,193.89	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	231,778.99	342,969.11	271,027.04	0.00	0.00	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	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	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	0.00	0.00	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	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	99,444.46	34,799.65	70,959.07	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
400.90	
2,261.26	
4,288.32	
82.48	
69,703.91	
34,808.12	
27,911.81	
6,273.64	
12,988.51	
97,186.66	
470,925.14	
116,472.53	
0.00	
0.00	
0.00	
3,727.72	
0.00	
31,584.38	
3,305.43	
18,797.18	
52,347.59	
845,775.14	
111,847.63	
530.71	
2,000.00	
534.57	
0.00	
205,203.18	
106,358.19	
88,035.20	
67,219.87	
56,752.43	
0.00	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2015

RATE COD	E	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,006.78	
5017	SOBRA PREG 21-44 FE M	50,370.25	73,392.58	98,242.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	222,005.07	
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 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	
SUBTOTAL	:	808,932.77	881,111.78	1,023,289.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,713,334.35	

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	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	1,249.86	53.73	663.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	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	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	7,020.19	10,188.24	39,666.55	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	1,058.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	173.16	204.04	268.33	0.00	0.00	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	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	174.66	70.14	1,351.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	504.00	193.90	3,907.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	3,538.39	5,601.99	9,609.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	170.31	695.50	498.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	13,636.52	8,325.86	26,011.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	4,285.83	11,263.10	11,272.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	71,468.19	82,740.10	146,508.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
414.69	
4,178.04	
4,685.91	
1,966.82	
0.00	
169.40	
15.00	
506.37	
0.00	
56,874.98	
88,884.73	
38,151.05	
1,058.40	
645.53	
158.79	
1,895.45	
0.00	
1,596.18	
4,605.04	
18,750.11	
1,364.08	
47,974.00	
26,821.76	
300,716.33	

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 September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		

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	
SUBTOTAL:	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	

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	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	43.83	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	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 E	911.05	84.70	1,203.19	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	12,294.00	3,333.58	14,103.28	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	65,376.33	62,636.67	86,530.21	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 MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	1,741.29	1,260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	7,292.84	12,081.73	19,979.50	0.00	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	136,455.42	205,325.04	266,134.03	0.00	0.00	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	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	181,612.85	129,721.57	241,985.31	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 4	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	
2,553.86	
43.83	
3,215.37	
2,198.94	
156,286.81	
29,730.86	
214,543.21	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3,001.29	
0.00	
39,354.07	
21,367.09	
607,914.49	
309,233.85	
553,319.73	
0.00	
0.00	
1,260.00	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	536,535.52	576,817.99	830,669.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,944,023.40		

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 4	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	0.00	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	0.00	0.00	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	0.00	0.00	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	0.00	0.00	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	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	
SUBTOTAL:	57,678.54	27,673.40	42,100.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

1,108.99

0.00

0.00

682.45

17,730.37

16,393.12

91,537.31

0.00

0.00

127,452.24

4413	SOBRA 100-133% M&F
6	920.33	606.76	51.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	307.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	589.03	196.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,509.36	803.26	359.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,578.96	
307.68	
785.53	
2,672.17	

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	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	
SUBTOTAL:	10.17	15.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
25.81	
0.00	
0.00	
25.81	

8700	SSI DISABLED FREEDO M	0.00	22.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	0.00	22.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22.70	
0.00	
0.00	
22.70	

TOTAL:	1,476,134.55	1,569,184.87	2,042,720.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,088,039.55		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350.00		
2100	SSI AGED WITH MEDIC A	106,605.75	138,772.37	243,060.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		488,438.18		
2110	SSI AGED NON-MEDIC AR	26,434.90	13,763.26	31,784.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,983.15		
2120	SSI AGED WITH QMB	121,926.99	174,038.05	225,195.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521,160.54		
2200	SSI DISABLED WITH M E	45,476.20	32,686.17	56,715.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,877.92		
2210	SSI DISABLED NON-ME D	688,624.66	871,046.82	795,795.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,355,466.84		
2220	SSI DISABLED WITH Q M	48,687.58	68,819.71	112,495.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230,002.51		
2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134.33		
2310	SSI BLIND NON-MEDIC A	8,400.00	7,019.66	6,650.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,069.66		
2320	SSI BLIND WITH QMB	431.94	428.25	416.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,276.65		
SUBTOTAL:	1,046,662.95	1,306,924.29	1,472,172.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,825,759.78		

8710	SSI DISABLED FREEDO M	0.00	0.00	7.35	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	
SUBTOTAL:	0.00	0.00	7.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7.35	
0.00	
7.35	

3,825,767.13

1,046,662.95	1,306,924.29	1,472,179.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	1,685,117.40	1,915,799.87	2,681,450.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,282,367.66		
2110	SSI AGED NON-MEDIC AR	134,210.18	86,635.19	183,540.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		404,385.80		
2120	SSI AGED WITH QMB	2,732,315.87	2,691,509.27	3,869,487.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,293,312.35		
2200	SSI DISABLED WITH M E	484,829.08	429,355.23	623,488.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,537,672.56		
2210	SSI DISABLED NON-ME D	1,738,486.52	1,802,598.11	2,237,418.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,778,503.24		
2220	SSI DISABLED WITH Q M	585,872.48	620,560.01	851,203.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,057,636.37		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	7,740.32	7,420.92	10,075.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,237.06		
2320	SSI BLIND WITH QMB	4,994.88	7,132.53	7,260.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,387.99		
SUBTOTAL:	7,373,566.73	7,561,011.13	10,463,925.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,398,503.03		

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,037.06	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,712.52	4,868.22	9,185.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,914.40	
8,852.04	
15,766.44	

TOTAL:	7,375,279.25	7,565,879.35	10,473,110.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,414,269.47		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	57,961.58	35,627.77	43,341.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,931.16		
2110	SSI AGED NON-MEDIC AR	16,433.83	946.68	83,538.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,919.07		
2120	SSI AGED WITH QMB	443.59	1,507.61	18.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,969.25		
2200	SSI DISABLED WITH M E	11,220.75	6,502.00	26,013.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,736.54		
2210	SSI DISABLED NON-ME D	26,834.51	19,004.26	28,589.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,428.40		
2220	SSI DISABLED WITH Q M	2,359.28	722.71	6,308.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,390.22		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	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	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	121,910.37	64,311.03	187,810.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		374,031.47		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	

374,031.47

121,910.37	64,311.03	187,810.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending September 30, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	17,791.38	16,157.36	33,799.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,748.59		
2110	SSI AGED NON-MEDIC AR	68.35	0.00	655.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		723.77		
2120	SSI AGED WITH QMB	12,713.06	10,199.58	16,135.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,048.59		
2200	SSI DISABLED WITH M E	1,998.01	5,671.10	17,991.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,660.47		
2210	SSI DISABLED NON-ME D	39,207.69	57,526.26	37,706.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,440.09		
2220	SSI DISABLED WITH Q M	2,612.76	3,357.96	4,743.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,714.13		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	36.96	218.14	48.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		303.31		
SUBTOTAL:	74,428.21	93,130.40	111,080.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278,638.95		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	

TOTAL:	74,428.21	93,130.40	111,080.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278,638.95		

KidsCare - CAPITATION AMOUNTS
For The Period Ending September 30, 2015

SUBTOTAL:	183,782.09	170,408.91	173,185.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		527,376.84	
															
TOTAL:	183,782.09	170,408.91	173,185.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		527,376.84	

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	1,007.22	1,007.22	833.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,847.82	
	C														
6012	KIDS 1-5 M & F NON-M	220.96	220.96	220.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	662.88	
6013	KIDS 6-13 M & F NON-	58,022.76	55,071.22	54,144.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	167,238.17	
6014	KIDS 14-19 MALE NON-	49,755.46	44,451.13	44,464.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138,670.65	
6015	KIDS 14-19 FEMALE NO	74,775.69	69,658.38	67,362.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	211,796.76	
9960	KIDSCARE KICK PAYM	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	
	EN														

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2015

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	2.00	2.00	1.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.66	
	C														
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
6013	KIDS 6-13 M & F NON-	456.25	434.86	420.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,311.45	
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	732.46	
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	779.78	
9960	KIDSCARE KICK PAYM	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	

SUBT	EN
OTAL:	
993.61	
932.52	
910.22	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
2,836.35	

TOTAL:	993.61	932.52	910.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,836.35		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending September 30, 2015

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	75.10	75.10	37.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	187.75	
	C														
6012	KIDS 1-5 M & F NON-M	75.10	75.10	75.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225.30	
6013	KIDS 6-13 M & F NON-	16,709.75	16,146.50	15,620.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,477.05	
6014	KIDS 14-19 MALE NON-	9,776.08	8,979.83	9,075.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,831.25	
6015	KIDS 14-19 FEMALE NO	10,772.21	10,088.61	9,721.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,582.21	
SUBTOTAL:	37,408.24	35,365.14	34,530.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,303.56	
TOTAL:	37,408.24	35,365.14	34,530.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,303.56	

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
6013	KIDS 6-13 M & F NON-	445.00	430.00	416.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,291.00		
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		707.00		
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		771.00		
SUBTOTAL:	968.00	918.00	894.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,780.00		

TOTAL:	968.00	918.00	894.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,780.00		

KidsCare - FEE FOR SERVICE
For The Period Ending September 30, 2015

SUBTOTAL:	-818.92	773.91	436.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.31	
															
TOTAL:	-818.92	773.91	436.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.31	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,044.98	
6014	KIDS 14-19 MALE NON-	-652.26	85.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-567.25	
6015	KIDS 14-19 FEMALE NO	-174.33	326.70	118.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270.68	

KidsCare - REINSURANCE
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,078.31	
6014	KIDS 14-19 MALE NON-	0.00	29,016.36	29,093.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,109.46	
6015	KIDS 14-19 FEMALE NO	0.00	1,274.86	5,182.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,457.77	

SUBTOTAL:	
161.54	
30,495.15	
70,988.85	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
101,645.54	

TOTAL:	161.54	30,495.15	70,988.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,645.54		

00

00

85,683.31

85,683.31

6.00

1,930.84

3.00

464.58

15.00

816.24

5,253.80

64,716.50

0.03

11,978.88

1.00

39.00

337.44

85.00

21.00

6.00

9.00

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	643.15	641.57	646.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	151.70	154.89	157.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	272.31	272.62	271.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH ME	1,753.65	1,745.73	1,754.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-MED	21,475.15	21,538.50	21,702.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
221Z	SSI DISABLED NON-MED	0.03	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 QM	3,977.48	3,986.67	4,014.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
2300	SSI BLIND WITH MEDIC	13.00	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	111.00	112.38	114.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	28.00	29.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,445.47	28,515.36	28,722.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL:	28,445.47	28,515.36	28,722.48	0.	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	

ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM
EPD/DD EXPENDITURES
For the Period Ending September 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,106,483.91	
EPD	84,945,196.47	97,607,756.74	86,404,566.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	268,957,519.43	
TOTAL AHCCCS LTC	85,315,938.36	97,973,954.11	86,774,110.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270,064,003.34	
DES/DD	97,105,888.85	97,348,150.88	98,057,803.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	292,511,842.78	
TOTAL DES LTC	97,105,888.85	97,348,150.88	98,057,803.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	292,511,842.78	
TOTAL LTC - CAP	182,421,827.21	195,322,104.99	184,831,913.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	562,575,846.12	

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
0.00	9,030,245.07
0.00	12,244,181.17
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	29,892,707.02
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	
TOTAL LTC - FFS	8,618,280.78	9,030,245.07	12,244,181.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,892,707.02	

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
375,457.62	3,513,547.75
326,085.82	4,248,800.50
792,734.80	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	11,432,653.87
1,494,278.24	
	375,457.62	326,085.82	792,734.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,494,278.24	
TOTAL LTC - REIN	4,045,763.24	3,839,633.57	5,041,535.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,926,932.11	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,380,021.40	

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.

Wednesday, October 21, 2015

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending September 30, 2015

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

010115	CRS FULLY INTEGRATED PLAN - CAP	13,474,971.60	13,492,632.75	13,576,771.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,544,375.89	
010145	CRS ACUTE SEMI INTEGRATED - CAP	122,251.86	115,316.41	116,070.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	353,638.35	
999125	CRS SEMI INTEGRATED PLAN - CAP	3,253,162.92	3,256,188.18	3,258,709.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,768,060.33	
999135	CRS ONLY PLAN - CAP	476,979.36	481,148.76	485,318.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,443,446.28	
Subtotal	17,327,365.74	17,345,286.10	17,436,869.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,109,520.85	

999155	CRS REINSURANCE ONLY	2,189,497.55	1,498,470.16	1,869,622.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,557,590.52	
Subtotal	2,189,497.55	1,498,470.16	1,869,622.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,557,590.52	

010115	CRS FULLY INTEGRATED PLAN - KC CAP	29,112.95	25,266.88	26,056.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,436.30	
Subtotal	29,112.95	25,266.88	26,056.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,436.30	

19,545,976.24	18,869,023.14	19,332,548.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,747,547.67	

GRAND TOTAL

Wednesday, October 21, 2015

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending September 30, 2015

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

010115	CRS FULLY INTEGRATED PLAN - MM	17,063.13	17,085.46	17,193.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,341.59	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	503.41	
999125	CRS SEMI INTEGRATED PLAN - MM	6,452.00	6,458.00	6,463.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,373.00	
999135	CRS ONLY PLAN - MM	1,144.00	1,154.00	1,164.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,462.00	
Subtotal	24,833.16	24,861.60	24,985.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,680.00	

010115	CRS FULLY INTEGRATED PLAN - KC MM	36.87	32.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101.87	
Subtotal	36.87	32.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101.87	

24,870.03	24,893.60	25,018.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,781.87	

GRAND TOTAL

Wednesday, October 21, 2015

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS
For the Period Ending September 30, 2015

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

078999	MERCY MARICOPA INTEGRATED - CAP	47,152,827.77	47,326,614.65	47,809,819.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,289,261.70	
Subtotal	47,152,827.77	47,326,614.65	47,809,819.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,289,261.70	

47,152,827.77	47,326,614.65	47,809,819.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,289,261.70	

GRAND TOTAL

Wednesday, October 21, 2015

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS
For the Period Ending September 30, 2015

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

078999	MERCY MARICOPA INTEGRATED - MM	19,430.16	19,501.43	19,702.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,634.58	
Subtotal	19,430.16	19,501.43	19,702.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,634.58	

19,430.16	19,501.43	19,702.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,634.58	

GRAND TOTAL