November 25, 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 October 31, 2015

Dear President Biggs and Speaker Gowan:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended October 31, 2015.

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

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

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

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. November 25, 2015
Page 2

Enrollment Update – October 2015 enrollment is 1,818,445 members, a 15,440 member increase over the prior month. Enrollment for November 2015 increased to 1,833,907 members,  a 15,462 member increase.

Major November changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 5,554; Supplemental Security Income – increase of 535; Prop  204 Restoration - increase of 4,512; Adult Expansion - increase of 3,134; Medicare Cost Sharing
– increase of 457; and Federal Emergency Services - increase of 1,176.

Tobacco Funds Revenue Update –Tobacco tax collections through October 2015 are $5.3 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 October 31, 2015

Prepared by: Division of Business and Finance

Appropriation Status Report
Table of Contents
APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 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 October 31, 2015
SUMMARY OF APPROPRIATED EXPENDITURES

	

ANNUAL APPROPRIATION		(A)      EXPENDITURE PLAN
YTD		(B)

EXPENDITURES YTD		(A) - (B)

VARIANCE YTD		
PROJECTED ANNUAL EXPENDITURES		

ANNUALIZED VARIANCE		

APPROPRIATIONS:													
ADMINISTRATION													
AHCCCS Operating Lump Sum	$	77,975,400		$	26,643,600		$	24,026,145		$	2,617,455		$	77,975,400		$	-		
AHCCCS Prop 204 Administration	6,832,800		2,342,300		2,384,333		(42,033)		6,832,800		-		
DES Eligibility	54,874,500		18,741,000		22,493,280		(3,752,280)		54,874,500		-		
DES Prop 204 Eligibility	38,358,700		13,163,500		4,087,628		9,075,872		38,358,700		-		
TOTAL ADMINISTRATION	178,041,400		60,890,400		52,991,386		7,899,014		178,041,400		-		

Traditional Medicaid Services	3,639,258,600	1,169,468,200	1,234,970,336	(65,502,136)	3,639,258,600	-	
Proposition 204 Services	2,507,700,600	774,910,300	771,944,072	2,966,228	2,507,700,600	-	
ACA Adult Expansion	197,183,800	59,251,900	114,261,465	(55,009,565)	197,183,800	-	
Children's Rehabilitative Services	234,866,700	73,237,300	75,537,948	(2,300,648)	234,866,700	-	
KidsCare Services	6,295,200	2,041,800	681,754	1,360,046	6,295,200	-	
ALTCS Services	1,386,588,900	447,618,100	433,777,805	13,840,295	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		(12,845,600)	(12,845,615)	15	313,096,700		-	
TOTAL PROGRAMMATIC	8,312,727,600		 	 	
2,513,682,000	2,618,327,765	(104,645,765)	8,312,727,600		-	

TOTAL EXPENDITURES

$	8,490,769,000

$    2,574,572,400

$   2,671,319,151

$	(96,746,751)

$  8,490,769,000	$	-

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 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		

$	17,536,600		

$	15,829,733		

1,706,867		

$	51,537,900		

$	-	
Proposition 204 - Administrative Expenditures	19,547,000		6,709,900		2,270,191		4,439,710		19,547,000		-	
Programmatic Expenditures												
Traditional Medicaid Services	800,543,000		268,161,500		302,254,009		(34,092,509)		800,543,000		-	
Proposition 204 Services	90,000,000		69,618,900		32,427,405		37,191,495		90,000,000		-	
Children's Rehabilitative Services	73,001,000		22,925,000		20,256,411		2,668,589		73,001,000		-	
KidsCare Services	338,000		238,600		4,574		234,026		338,000		-	
ALTCS Services	162,880,800		53,179,300		54,349,234		(1,169,934)		162,880,800		-	
DSH and Rural Hospitals	7,314,600	-	-	-	7,314,600	-	
TOTAL GF EXPENDITURES	1,205,162,300	438,369,800	427,391,558	10,978,242	1,205,162,300	-	

Administrative Expenditures	
81,114,000	
27,781,800	
30,662,841	
(2,881,041)	
81,114,000	
-	
Proposition 204 - Administrative Expenditures	22,161,600	7,600,700	4,201,770	3,398,930	22,161,600	-	
Programmatic Expenditures							
Traditional Medicaid Services	2,471,441,100	778,620,000	807,096,112	(28,476,112)	2,471,441,100	-	
Proposition 204 Services	2,048,414,400	632,977,500	650,155,760	(17,178,260)	2,048,414,400	-	
ACA Adult Expansion	197,183,800	59,251,900	114,261,465	(55,009,565)	197,183,800	-	
Children's Rehabilitative Services	161,865,700	50,312,300	55,281,537	(4,969,237)	161,865,700	-	
KidsCare Services	5,587,200	1,677,200	677,180	1,000,020	5,587,200	-	
ALTCS Services and Nursing Facility Assessment	954,423,500	300,664,400	294,657,229	6,007,171	954,423,500	-	
DSH and Rural Hospitals	20,422,500	-	-	-	20,422,500	-	
Voluntary Political Subdivision Programs - See Note 5	214,151,100		(13,452,900)		(13,452,950)		50		214,151,100		-		
TOTAL FEDERAL EXPENDITURES	6,176,764,900		1,845,432,900		1,943,540,944		(98,108,044)		6,176,764,900		-		

Administrative Expenditures Proposition 204 - BNCF	3,482,900	1,195,200	-	1,195,200	3,482,900	- Programmatic Expenditures

249,234,600		81,372,500		77,349,290		4,023,210		249,234,600		-	
302,597,200		99,194,100		93,975,690		5,218,410		302,597,200		-	

Traditional Medicaid Services Acute Care	49,879,700	16,626,400	16,626,400	-	49,879,700	- ALTCS Services
TOTAL COUNTY EXPENDITURES

TOBACCO FUNDS

Programmatic Expenditures
Traditional Medicaid Services Acute Care - Medically Needy	31,180,000	10,711,600	15,213,003	(4,501,403)	31,180,000	-
Proposition 204 Services - Emergency Health Services	17,331,400	5,920,500	6,196,979	(276,479)	17,331,400	-
Proposition 204 Services - Proposition 204 Protection		36,396,000	12,503,700	16,625,957	(4,122,257)	36,396,000	- Proposition 204 Services - ATLSF	100,000,000		-		-		-	100,000,000	-

TOTAL TOBACCO EXPENDITURES	184,907,400	29,135,800		38,035,939		(8,900,139)		184,907,400		-		
OTHER												
Administrative Expenditures Prescription Drug Rebate Program	
198,000	
66,200		
26,850		
39,350		
198,000		
-		
Programmatic Expenditures	
Acute Care - Prescription Drug Rebate Program State Match		78,105,000	26,034,900		26,035,000		(100)		78,105,000		-	
Acute Care - Prescription Drug Rebate Program Federal Authority		207,883,900	69,294,800		67,560,003		1,734,797		207,883,900		-	
Long Term Care - Prescription Drug Rebate Program State Match		5,475,800	1,791,700		1,825,267		(33,567)		5,475,800		-	
Long Term Care - Prescription Drug Rebate Program Federal Authority		14,574,200	4,768,600		5,344,456		(575,856)		14,574,200		-	
Proposition 204 Services - Hospital Assessment		215,558,800	53,889,700		66,537,971		(12,648,271)		215,558,800		-	
Traditional Medicaid Services - TPL		194,700	-		168,426		(168,426)		194,700		-	
ALTCS Services - TPL		-	-		252,329		(252,329)		-		-	
ALTCS Services - Nursing Facility Assessment		-	5,841,600		-		5,841,600		-		-	
KidsCare Services Premiums		370,000	126,000		-		126,000		370,000		-	
Freedom to Work Premiums		31,200	19,000		17,384		1,616		31,200		-	
Voluntary Political Subdivision Programs - See Note 5		98,945,600	607,300		607,335		(35)		98,945,600		-	
TOTAL OTHER EXPENDITURES		621,337,200	162,439,800		168,375,020		(5,935,220)		621,337,200		-	
	TOTAL											

Administrative Expenditures		
178,041,400	
60,890,400		
52,991,386		
7,899,014		
178,041,400		
-	
Acute Care		6,926,138,700	2,066,063,900		2,184,549,961		(118,486,061)		6,926,138,700		-	
Long Term Care		1,386,588,900	447,618,100		433,777,804		13,840,296		1,386,588,900		-	
TOTAL EXPENDITURES	$	8,490,769,000	$	2,574,572,400		$	2,671,319,150		$	(96,746,750)		$	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 October 31, 2015

BUDGET

BUDGET
YTD

RECEIPTS
YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	932,396,500		$	308,623,100		$	338,340,154	
Proposition 204 Services & Administrative	109,547,000		76,328,800		34,697,595	
KidsCare Services	338,000		238,600		4,574	
ALTCS Services	 	162,880,800			 	53,179,300			 	54,349,234		
TOTAL	1,205,162,300		438,369,800		427,391,558	

FEDERAL:
Acute & Administrative	5,216,754,200		1,543,091,300		1,657,781,788	
KidsCare Services	5,587,200		1,677,200		872,534	
ALTCS Services	 	954,423,500			 	300,664,400			 	295,509,542		
TOTAL	6,176,764,900		1,845,432,900		1,954,163,864	

COUNTY:						
Acute & Administrative	53,362,600		17,821,600		14,560,009	
ALTCS Services	 	249,234,600			 	81,372,500			 	83,078,204		
TOTAL	302,597,200		99,194,100		97,638,213	

TOBACCO FUNDS:						
Traditional Medicaid Services	31,180,000		10,711,600		15,213,003	
Proposition 204 Services	 	153,727,400			 	18,424,200			 	22,822,936		
TOTAL	184,907,400		29,135,800		38,035,939	

OTHER:						
Administrative	198,000		66,200		26,850	
Acute Care - Prescription Drug Rebate Program	285,988,900		95,329,700		93,595,003	
Long Term Care - Prescription Drug Rebate Program	20,050,000		6,560,300		7,169,722	
Hospital Assessment	215,558,800		53,889,700		62,679,680	
ALTCS - Nursing Facility Assessment	-		5,841,600		63,632	
Acute TPL - Note 1	194,700		-		168,426	
LTC TPL - Note 1	-		-		252,329	
KidsCare TPL - Note 1	-		-		20,922	
Member Premiums - CHIP	370,000		126,000		130,487	
Member Premiums - Freedom to Work	31,200		19,000		17,384	
Voluntary Political Subdivision - State Match	 	98,945,600			 	607,300			 	607,335		
TOTAL	621,337,200		162,439,800		164,731,769	

TOTAL REVENUE

$	8,490,769,000

$	2,574,572,400

$	2,681,961,343

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 2015	
Note 1:	Third Party Liability Collections:	October 2015		October 2014		July 1, 2015		July 1, 2014	
	Gross Collections:					October 31, 2015		October 31, 2014	
	Acute	$	317,535		$	523,914		$	1,565,261		$	2,049,611	
	LTC	217,287		177,829		1,123,220		1,308,205	
	KidsCare	368		33		104,349		2,173	
	Total TPL Collections	$	535,190		$	701,776		$	2,792,830		$	3,359,989	

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

Acute

$	31,764	$

64,469	$

168,426	$

270,588

LTC	44,695	44,414	252,329	309,413
KidsCare	69	5	20,922	422

Total Expenditure Offsets

$	76,528	$

108,888	$

441,677	$

580,423

FY 16 Total
Note 2:    Authorized Positions	1,029.2
Actual Positions as of October 31, 2015	912.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 2015

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2015	

$	2,853,728	
	Revenues	1,443,081	
	Transfers-In	 	181,936		
	Total Revenues	 	1,625,017		
	Expenditures	1,862,985	
	Transfers-out	 	920,066		
	Total Expenditures	 	2,783,051		
	Ending Balance October 31, 2015	  $	1,695,694		

Of the $1,695,694 ending balance, $1,053,551 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through November 2015.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of October 31, 2015

Description		Amount		Type	

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

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 2015

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of October 31, 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 October 31, 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	273,495,684	0	0	0	0	0	0	0	0	1,101,345,828	
CAPITATION - LTC	182,421,827	195,322,105	184,831,914	185,508,503	0	0	0	0	0	0	0	0	748,084,349	
MENTAL HEALTH - CHILD	24,739,142	24,849,877	25,557,281	28,336,540	0	0	0	0	0	0	0	0	103,482,839	
MENTAL HEALTH - ADULT	11,323,471	11,730,505	12,433,438	944,236	0	0	0	0	0	0	0	0	36,431,651	
MENTAL HEALTH - GENERAL	15,232,013	15,779,544	16,725,109	16,942,470	0	0	0	0	0	0	0	0	64,679,136	
MENTAL HEALTH - CMDP	14,633,559	14,896,415	14,987,440	15,967,464	0	0	0	0	0	0	0	0	60,484,878	
CHILDREN'S REHAB SERVICES	3,716,383	3,722,744	3,729,851	5,297,337	0	0	0	0	0	0	0	0	16,466,316	
FEE FOR SERVICE - ACUTE	39,309,584	42,687,182	52,163,025	35,355,326	0	0	0	0	0	0	0	0	169,515,118	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	607,419	0	0	0	0	0	0	0	0	2,627,051	
EMERGENCY SERVICES - FEDERAL	4,601,455	4,572,491	5,962,347	5,124,819	0	0	0	0	0	0	0	0	20,261,113	
FFS - FAMILY PLANNING	-39	0	0	0	0	0	0	0	0	0	0	0	-39	
FFS MEDICAID IN PUBLIC SCHOOLS	676,499	194,086	533,578	397,621	0	0	0	0	0	0	0	0	1,801,783	
INPATIENT INMATES FFS	94,140	163,355	30,952	166,197	0	0	0	0	0	0	0	0	454,643	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	374,616	0	0	0	0	0	0	0	0	1,373,199	
MOHAVE COUNTY INMATES FFS	0	177	0	4,575	0	0	0	0	0	0	0	0	4,752	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	33,509	0	0	0	0	0	0	0	0	141,247	
PINAL COUNTY INMATES FFS	0	791	4,402	328	0	0	0	0	0	0	0	0	5,521	
PIMA COUNTY INMATES FFS	339	2,845	4,099	8,752	0	0	0	0	0	0	0	0	16,035	
FEE FOR SERVICE - LTC	8,618,281	9,030,245	12,244,181	8,955,714	0	0	0	0	0	0	0	0	38,848,421	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	21,120	0	0	0	0	0	0	0	0	102,795	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,303,186	520,396	1,333,715	799,779	0	0	0	0	0	0	0	0	3,957,076	
REINSURANCE - ACUTE	7,490,557	6,963,077	9,713,101	10,354,036	0	0	0	0	0	0	0	0	34,520,771	
REINSURANCE - LTC	4,045,763	3,839,634	5,041,535	4,350,748	0	0	0	0	0	0	0	0	17,277,680	
SMIB - ACUTE	9,829,585	10,084,385	10,344,498	10,630,380	0	0	0	0	0	0	0	0	40,888,848	
HIB - ACUTE	261,769	274,050	304,238	305,977	0	0	0	0	0	0	0	0	1,146,034	
Q1	2,399,485	1,983,017	1,927,946	1,981,086	0	0	0	0	0	0	0	0	8,291,534	
SMIB - LTC	2,846,826	2,859,916	2,858,311	2,859,099	0	0	0	0	0	0	0	0	11,424,151	
HIB - LTC	269,425	275,672	269,873	259,133	0	0	0	0	0	0	0	0	1,074,103	
SUBTOTAL	607,107,950	627,019,248	641,497,165	609,082,467	0	0	0	0	0	0	0	0	2,484,706,830	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending October 31, 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	199,655,262	0	0	0	0	0	0	0	0	709,383,717	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	62,503	0	0	0	0	0	0	0	0	295,388	
MENTAL HEALTH - ADULT	14,130,226	13,753,412	13,745,030	1,449,862	0	0	0	0	0	0	0	0	43,078,530	
MENTAL HEALTH - GENERAL	19,007,580	18,500,700	18,489,426	26,014,924	0	0	0	0	0	0	0	0	82,012,630	
MENTAL HEALTH - CMDP	0	0	0	1,009	0	0	0	0	0	0	0	0	1,009	
CHILDREN'S REHAB SERVICES	13,342	14,176	13,759	16,233	0	0	0	0	0	0	0	0	57,510	
FEE FOR SERVICE - ACUTE	23,420,195	26,360,064	31,634,361	22,488,296	0	0	0	0	0	0	0	0	103,902,916	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	991,315	0	0	0	0	0	0	0	0	4,515,310	
EMERGENCY SERVICES - FEDERAL	1,615,009	1,756,056	2,298,814	2,324,017	0	0	0	0	0	0	0	0	7,993,896	
FFS MEDICAID IN PUBLIC SCHOOLS	5,786	3,204	5,139	1,380	0	0	0	0	0	0	0	0	15,509	
INPATIENT INMATES FFS	600,012	766,289	566,467	395,868	0	0	0	0	0	0	0	0	2,328,635	
MOHAVE COUNTY INMATES FFS	0	4,084	692	373	0	0	0	0	0	0	0	0	5,148	
YAVAPAI COUNTY INMATES FFS	306	0	166	9,252	0	0	0	0	0	0	0	0	9,724	
PINAL COUNTY INMATES FFS	8,167	-1,654	11,736	3,532	0	0	0	0	0	0	0	0	21,780	
PIMA COUNTY INMATES FFS	16,737	14,619	968	21,330	0	0	0	0	0	0	0	0	53,654	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	174,594	0	0	0	0	0	0	0	0	491,741	
COCONINO COUNTY INMATES FFS	152	3,842	0	274	0	0	0	0	0	0	0	0	4,268	
REINSURANCE - ACUTE	3,024,281	3,235,285	3,273,260	5,216,265	0	0	0	0	0	0	0	0	14,749,092	
SMIB - ACUTE	5,190,825	5,190,446	5,117,460	5,152,132	0	0	0	0	0	0	0	0	20,650,862	
HIB - ACUTE	8,649	8,527	5,656	8,584	0	0	0	0	0	0	0	0	31,417	
SUBTOTAL	240,353,793	239,927,923	245,334,015	263,987,005	0	0	0	0	0	0	0	0	989,602,735	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending October 31, 2015

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

TOTAL

CAPITATION - ACUTE	22,690,376	23,251,291	24,201,251	29,184,931	0	0	0	0	0	0	0	0	99,327,849	
MENTAL HEALTH - CHILD	0	0	0	41	0	0	0	0	0	0	0	0	41	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	228,016	0	0	0	0	0	0	0	0	7,145,691	
MENTAL HEALTH - GENERAL	2,968,226	3,090,821	3,246,414	4,091,302	0	0	0	0	0	0	0	0	13,396,763	
CHILDREN'S REHAB SERVICES	417	417	417	0	0	0	0	0	0	0	0	0	1,251	
FEE FOR SERVICE - ACUTE	1,757,826	2,095,785	2,416,332	1,869,494	0	0	0	0	0	0	0	0	8,139,437	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	262,679	0	0	0	0	0	0	0	0	955,047	
EMERGENCY SERVICES - FEDERAL	1,701,575	1,999,988	3,176,831	2,397,434	0	0	0	0	0	0	0	0	9,275,827	
INPATIENT INMATES FFS	6,351	35,816	34,047	9,398	0	0	0	0	0	0	0	0	85,612	
MARICOPA CTY INMATES FFS	15,154	0	0	149	0	0	0	0	0	0	0	0	15,303	
REINSURANCE - ACUTE	276,372	479,010	344,794	397,029	0	0	0	0	0	0	0	0	1,497,205	
SMIB - ACUTE	1,469	734	839	629	0	0	0	0	0	0	0	0	3,672	
	31,784,937	33,467,076	36,150,580	38,441,103	0	0	0	0	0	0	0	0	139,843,697	
	879,246,680	900,414,248	922,981,760	911,510,575	0	0	0	0	0	0	0	0	3,614,153,262	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
KidsCare - CAPITATION	183,782	170,409	173,186	164,735	0	0	0	0	0	0	0	0	692,112	
KidsCare - FEE FOR SERVICE	-819	774	436	1,805	0	0	0	0	0	0	0	0	2,196	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	36,831	0	0	0	0	0	0	0	0	144,135	
KidsCare - REINSURANCE	162	30,495	70,989	57,122	0	0	0	0	0	0	0	0	158,768	

220,533	237,043	279,141	260,493	0	0	0	0	0	0	0	0	997,211	

TOTAL TITLE XXI

879,467,213	900,651,004	923,260,901	911,771,068	0	0	0	0	0	0	0	0	3,615,150,186	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1003	TANF 06-13 M & F WIT	113.17	113.17	113.17	114.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453.88		
1006	TANF 21-44 MALE WITH	91,470.48	100,935.93	114,056.53	29,730.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		336,193.38		
1007	TANF 21-44 FEMALE WI	262,969.81	321,024.00	366,691.13	93,534.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,044,219.23		
1008	TANF 45-64 M & F WIT	456,857.48	533,329.59	618,899.14	152,612.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,761,699.13		
1009	TANF 65+ M & F WITH	130,859.20	158,119.22	182,105.63	43,807.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		514,891.66		
100F	TANF 21-44 MALE WITH	3,124.94	3,371.26	1,066.32	1,179.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,741.89		
100G	TANF 21-44 FEMALE WI	6,088.86	5,158.50	4,029.73	173.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,450.39		
100H	TANF 44-64 M & F WIT	43,752.90	40,165.14	12,382.66	6,486.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,786.91		
100J	TANF 65+ M & F WITH	30,736.25	17,071.36	1,805.26	3,147.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,760.05		
1011	TANF <1 M & F NON-ME	7,317,911.15	7,330,064.00	6,810,085.94	6,723,220.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,181,281.83		
1012	TANF 01-05 M & F NON	5,120,069.24	4,255,241.15	3,820,804.71	3,461,570.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,657,685.42		
1013	TANF 06-13 M & F NON	8,517,151.93	7,122,208.02	6,407,880.79	5,780,890.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,828,131.54		
1014	TANF 14-20 MALE NON-	2,727,086.79	2,467,883.88	2,310,485.87	2,117,042.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,622,499.44		
1015	TANF 14-20 FEMALE N O	5,165,143.02	4,749,211.72	4,482,122.34	3,895,890.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,292,367.62		
1016	TANF 21-44 MALE NON-	5,413,848.55	5,881,009.18	6,413,970.06	4,187,649.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,896,477.14		
1017	TANF 21-44 FEMALE N O	26,519,446.98	27,563,602.69	29,211,296.32	21,767,623.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,061,969.37		
1018	TANF 45-64 M & F NON	11,340,403.80	12,200,886.15	13,314,078.59	8,494,598.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,349,967.34		
1019	TANF 65+ M & F NON-M	50,940.78	55,345.09	63,094.36	34,977.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204,357.57		
101A	TANF < 1 M & F NON-M	1,483,647.90	1,229,135.61	596,433.59	1,485,874.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,795,091.89		
101B	TANF 01-05 M & F NON	18,930.19	10,452.99	13,969.51	19,674.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,026.83		
101C	TANF 06-13 M & F NON	13,827.52	10,991.93	10,596.95	23,802.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,218.60		
101D	TANF 14-20 MALE NON-	30,653.81	23,910.41	11,522.68	25,214.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,301.32		
101E	TANF 14-20 FEMALE N O	56,482.84	48,295.58	35,281.43	32,120.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172,180.09		
101F	TANF 21-44 MALE NON-	441,372.83	443,539.24	240,851.96	183,068.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,308,832.85		
101G	TANF 21-44 FEMALE N	967,547.84	939,350.71	551,924.22	422,374.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,881,197.25		
101H	TANF 44-64 M & F NON	673,153.96	695,670.20	390,666.92	232,596.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,992,087.20		
101J	TANF 65+ N & F NON-M	13,593.90	8,104.86	11,870.70	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,911.46		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	503.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503.59		
1026	TANF 21-44 MALE WITH	39,781.26	52,613.13	69,409.48	16,856.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178,660.04		
1027	TANF 21-44 FEMALE WI	112,487.20	155,750.38	178,197.45	42,604.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		489,039.95		
1028	TANF 45-64 M & F WIT	142,957.26	219,266.01	262,802.70	39,010.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		664,036.77		
1029	TANF 65+ M & F WITH	53,811.16	84,861.43	103,507.94	16,738.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258,919.39		
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	2,333.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,237.35		

O

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	646,891.69	640,426.15	626,324.88	736,756.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,650,398.74		
210Z	SSI AGED WITH MEDIC A	42,792.60	35,137.07	23,993.14	19,520.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,443.31		
2110	SSI AGED NON-MEDICA R	4,841,984.49	4,755,477.85	4,841,046.00	5,300,571.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,739,079.46		
211Z	SSI AGED NON-MEDICA R	168,114.98	120,300.70	81,292.69	94,411.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		464,120.02		
2120	SSI AGED WITH QMB	2,773,140.25	2,801,949.97	2,812,690.87	4,298,513.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,686,294.43		
212Z	SSI AGED WITH QMB P P	5,569.66	5,916.01	9,571.88	5,459.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,516.78		
2200	SSI DISABLED WITH M	1,438,779.65	1,356,642.89	1,368,850.54	1,743,295.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,907,568.31		
220Z	SSI DISABLED WITH M E	21,320.23	23,148.40	24,683.29	16,992.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,144.55		
2210	SSI DISABLED NON-ME D	55,077,622.81	54,829,218.00	54,812,398.76	59,179,887.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,899,127.34		
221Z	SSI DISABLED NON-ME D	491,291.42	492,991.62	460,508.70	368,493.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,813,284.77		
2220	SSI DISABLED WITH Q M	10,386,804.88	10,418,005.20	10,514,240.11	14,111,354.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,430,404.60		
222Z	SSI DISABLED WITH Q M	5,921.17	7,380.90	10,401.43	3,335.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,038.64		
2300	SSI BLIND WITH MEDIC	4,363.55	4,060.83	3,780.74	6,282.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,487.73		
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	353,568.15	356,359.13	362,835.95	397,658.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,470,421.24		
231Z	SSI BLIND NON-MEDIC A	3,440.09	12,852.23	5,876.17	7,201.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,369.65		
2320	SSI BLIND WITH QMB	44,041.31	43,688.31	44,085.09	52,328.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184,143.20		
232Z	SSI BLIND WITH QMB P	0.00	0.00	2.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.91		
4302	SOBRA CHILD 01-05 M	541.57	1,125.47	-453.71	224.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,437.52		
4303	SOBRA CHILD 06-13 M	227.07	227.07	276.11	244.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		974.55		
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	868.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,330.18		
430B	SOBRA CHILD 01-05 M	49.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.61		
430C	SOBRA CHILD 06-13 M	0.00	0.00	95.88	47.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143.43		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
430E	SOBRA CHILD 14-20 FE	0.00	120.83	193.23	-73.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240.08		
4311	SOBRA CHILD <1 M & F	19,081,996.88	19,048,366.58	17,788,960.54	18,259,206.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,178,530.15		
4312	SOBRA CHILD 01-05 M	19,072,224.87	20,064,623.31	21,072,490.25	21,509,414.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,718,753.29		
4313	SOBRA CHILD 06-13 M	25,452,339.99	27,401,384.87	29,128,878.55	26,727,722.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,710,326.32		
4314	SOBRA CHILD 14-20 MA	8,607,044.24	8,948,118.85	9,523,338.23	8,684,217.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,762,718.83		
4315	SOBRA CHILD 14-20 FE	13,024,273.87	13,595,781.00	14,432,717.70	13,281,591.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,334,363.68		
431A	SOBRA CHILD < 1 M &	1,266,381.59	1,304,281.60	634,368.33	1,369,018.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,574,049.80		
431B	SOBRA CHILD 01-05 M	494,252.81	475,898.40	360,178.32	372,613.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,702,943.33		
431C	SOBRA CHILD 6-13 M& F	634,059.19	670,453.45	453,423.37	408,409.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,166,345.39		
431D	SOBRA CHILD 14-20 MA	467,748.21	431,434.92	303,172.79	242,015.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,444,371.41		
431E	SOBRA CHILD 14-20 FE	506,841.24	521,342.83	357,514.83	290,170.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,675,868.92		

E

A

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4321	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4322	SOBRA CHILD 01-05 M	329.97	0.00	220.65	332.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	883.43	
4323	SOBRA CHILD 06-13 M	755.82	0.00	107.48	558.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,421.59	
4324	SOBRA CHILD 14-20 MA	623.74	0.00	162.24	137.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	923.84	
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	37,003.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	129,989.81	
5008	SOBRA PREG 45-64 FE	856.00	405.55	405.55	898.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,565.39	
500G	SOBRA PREG 21-44 FE M	667.73	637.69	427.13	403.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,135.57	
5013	SOBRA PREG 09-13 FE M	791.84	960.27	778.66	664.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,195.06	
5015	SOBRA PREG 14-20 FE M	1,153,204.41	1,243,589.20	1,321,708.44	1,322,370.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,040,872.66	
5017	SOBRA PREG 21-44 FE M	4,969,763.44	5,543,577.71	6,104,353.53	6,638,051.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,255,746.08	
5018	SOBRA PREG 45-64 FE M	29,226.73	32,189.69	33,578.00	40,765.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	135,760.20	
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	44,627.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	247,474.96	
501G	SOBRA PREG 21-44 FE	331,612.75	308,457.61	239,213.41	201,676.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,080,959.99	
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	2,329.77	2,829.66	4,481.72	4,273.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,914.69	
5028	SOBRA PREG 45-64 FE M	0.00	2,426.39	2,426.39	2,242.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,095.44	
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	-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	IT
:	
248,764,079.13	
252,354,794.67	
254,464,913.27	
245,119,121.74	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,000,702,908.81	

M

M

M

9910	TANF & SOBRA CHILDR E	3,483,562.65	3,047,996.25	2,907,424.24	2,122,336.87	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	55,170.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	253,912.66	175,567.47	201,893.70	175,925.41	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	12,834,264.22	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    15,187,696.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,561,320.01	
263,114.62	
807,299.24	
53,962,819.37	
66,594,553.24	

3100	TRANSPLANT OPTION	70.26	89.42	82.50	82.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION	94.74	75.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	165.00	165.00	82.50	82.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

324.68	
170.32	
495.00	

1

1
SUBTOTAL:

1106	TANF EXPANDED 21-44	167,462.38	144,030.22	123,318.86	348,201.94	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	1,038,005.28	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	1,764,074.45	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	500,349.50	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	3,251.38	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	6,738.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
783,013.40	
2,663,564.92	
4,546,749.02	
1,253,238.14	
9,051.06	
10,135.92	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110H	TANF EXPANDED 45-64	161.40	385.93	27,647.67	32,117.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,312.22		
110J	TANF EXPANDED 65+
M&	0.00	1,210.32	15,631.07	4,636.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,477.61		
1111	TANF EXPANDED <1 M
&F	6,325.21	4,355.65	762.79	1,466.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,909.65		
1112	TANF EXPANDED 01-05	48,437.22	37,053.66	33,123.81	29,396.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148,010.74		
1113	TANF EXPANDED 06-13	155,432.39	123,651.13	108,415.58	93,138.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480,637.70		
1114	TANF EXPANDED 14-20	114,898.22	90,180.24	76,789.22	121,498.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403,366.17		
1115	TANF EXPANDED 14-20	375,463.35	278,983.53	236,525.33	454,167.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,345,139.83		
1116	TANF EXPANDED 21-44	3,292,450.62	2,886,484.77	2,569,959.71	5,008,061.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,756,956.44		
1117	TANF EXPANDED 21-44	11,884,383.87	10,291,379.14	9,057,760.96	17,062,511.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,296,035.23		
1118	TANF EXPANDED 45-64	7,186,338.24	6,353,222.09	5,768,022.81	11,325,044.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,632,627.17		
1119	TANF EXPANDED 65+
M&	38,116.96	34,638.80	32,844.67	50,449.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,049.98		
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-402.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-402.42		
111B	TANF EXPANDED 01-05	0.00	51.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.33		
111C	TANF EXPANDED 06-13	60.93	0.00	0.00	166.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.35		
111D	TANF EXPANDED 14-20	91.04	817.44	2,346.34	1,517.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,771.88		
111E	TANF EXPANDED 14-20	1,428.69	1,919.48	6,274.89	6,791.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,414.71		
111F	TANF EXPANDED 21-44	16,857.80	16,840.28	88,070.74	132,572.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		254,341.47		
111G	TANF EXPANDED 21-44	38,462.54	45,149.24	202,727.99	290,121.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		576,461.05		
111H	TANF EXPANDED 45-64	12,792.72	53,531.20	181,490.33	221,190.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		469,004.77		
111J	TANF EXPANDED 65+
M&	10,074.33	0.00	1,610.12	15,133.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,817.98		
1125	TANF EXPANDED 14-20	259.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.91		
1126	TANF EXPANDED 21-44	77,277.63	71,347.76	61,838.93	77,686.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		288,150.67		
1127	TANF EXPANDED 21-44	214,717.61	193,927.68	179,884.44	240,941.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		829,470.77		
1128	TANF EXPANDED 45-64	242,994.86	222,897.30	210,610.65	291,431.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		967,934.47		
1129	TANF EXPANDED 65+	89,535.41	77,417.22	73,153.41	82,720.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322,826.07		
112F	TANF EXPANDED 21-44	0.00	0.00	406.00	246.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		652.72		
112G	TANF EXPANDED 21-44	0.00	681.07	726.03	964.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,371.20		
112H	TANF EXPANDED 45-64	10.59	0.00	1,235.44	3,753.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,999.31		
112J	TANF EXPANDED 65+
M&	0.00	0.00	6,378.93	344.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,723.24		
2400	SSI AGED EXPANDED WI	90,318.38	78,003.38	74,504.07	70,824.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		313,650.56		
240Z	SSI AGED EXPANDED WI	28,495.79	37,821.60	22,409.28	19,010.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,737.09		
2410	SSI AGED EXPANDED NO	929,746.50	864,149.68	813,310.62	351,969.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,959,175.92		
241Z	SSI AGED EXPANDED NO	7,401.77	16,962.83	8,306.20	4,276.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,947.32		
2420	SSI AGED EXPANDED WI	5,235,551.09	5,187,661.49	5,133,746.28	4,942,731.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,499,690.56		
242Z	SSI AGED EXPANDED	7,997.68	5,766.54	4,987.33	5,123.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,874.82		
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	140.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140.23		

M&

WI

W

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2510	SSI BLIND EXPANDED N	1,458.65	1,458.65	1,458.65	755.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,131.64	
2520	SSI BLIND EXPANDED W	124.99	124.99	124.99	130.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	504.99	
2600	SSI DISABLED EXPAND E	159,975.75	157,902.91	154,039.57	203,945.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	675,864.20	
260Z	SSI DISABLED EXPAND E	17,956.66	21,077.50	16,146.29	9,577.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,757.77	
2610	SSI DISABLED EXPAND	2,642,788.10	2,565,161.03	2,574,872.47	2,859,607.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,642,428.68	
261Z	SSI DISABLED EXPAND E	33,355.68	32,438.70	29,106.19	20,427.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115,328.53	
2620	SSI DISABLED EXPAND	7,540,307.86	7,645,491.81	7,856,549.93	10,671,220.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,713,570.53	
262Z	SSI DISABLED EXPAND E	6,428.48	5,511.39	8,031.41	2,774.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,745.58	
SUBTOTAL	:	42,577,206.07	39,244,718.86	37,338,771.85	58,371,203.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	177,531,900.10	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015

E

E

9911	SB PAYMENT FOR TAN F	638,069.14	744,028.48	692,146.52	1,048,619.27	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	6,290.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI	5,743.01	5,963.77	0.00	6,235.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	656,262.88	768,544.97	716,894.7	2	1,061,145.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,122,863.41	
62,042.56	
17,942.11	
3,202,848.08	

E
SUBTOTAL:

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

 
1,436.95

1,436.95

3506	ADULT 40-100% MALE 2	8,422.52	3,645.97	6,549.05	6,920.85	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	10,525.32	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	64,116.07	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	35,593.28	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	3,379.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1,264.42	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	10,932.16	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	2,056.55	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	1,559,483.07	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	1,839,553.60	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	8,354,693.83	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	6,962,315.85	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	16,587,909.35	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	22,447.95	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	62,981.28	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	96,368.08	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	428,940.00	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	325,592.33	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	700,892.30	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	12,306.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,538.39	
42,688.68	
152,410.88	
102,148.68	
9,817.58	
1,264.42	
34,172.19	
14,636.11	
5,839,555.93	
7,012,261.06	
31,277,205.63	
26,195,450.01	
62,654,986.71	
69,080.03	
416,619.41	
479,651.95	
2,168,036.76	
1,582,651.34	
3,650,339.23	
75,708.17	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015		
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL		
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		351.97		
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		1,168.26		
3527	ADULT 40-100% FEMAL E	668.80	1,504.94	0.00	366.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,540.31		
3528	ADULT 40-100% M&F 45	10,626.75	7,689.50	12,719.11	9,974.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,010.09		
3529	ADULT 40-100% M&F 65	2,416.71	4,002.70	1,585.00	5,538.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,543.26		
352G	ADULT 40-100% FEMAL E	0.00	531.77	0.00	21.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		553.57		
352H	ADULT 40-100% M&F 45	16.98	1,224.13	886.83	72.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,200.05		
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	2,538.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,538.60		
3706	ADULT <40% EXP MALE	34,143.30	26,154.77	20,573.49	37,500.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,372.01		
3707	ADULT <40% EXP FEM AL	12,691.88	18,567.70	11,647.93	7,542.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,450.42		
3708	ADULT <40% EXP M&F 4	47,370.84	58,639.06	54,729.62	114,253.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,992.64		
3709	ADULT <40% EXP M&F 6	8,255.13	8,986.58	12,316.96	18,221.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,780.15		
370F	ADULT <40% EXP MALE	3,590.13	5,678.35	4,459.00	2,315.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,043.09		
370G	ADULT <40% EXP FEM AL	824.34	1,262.96	35.10	1,157.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,279.50		
370H	ADULT <40% EXP M&F	8,737.58	10,393.47	21,133.34	9,344.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,609.27		
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 MALE	4,383,132.32	4,528,025.34	4,668,083.27	4,785,386.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,364,627.16		
3715	ADULT <40% EXP FEM AL	3,752,637.27	3,863,233.89	3,962,050.58	4,032,547.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,610,469.11		
3716	ADULT <40% EXP MALE	27,106,086.04	27,395,881.26	28,559,100.18	31,411,912.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,472,979.91		
3717	ADULT <40% EXP FEM AL	16,530,344.45	16,579,394.61	17,156,912.82	19,100,210.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,366,862.86		
3718	ADULT <40% EXP M&F 4	33,539,387.24	33,762,918.80	34,763,411.03	37,968,625.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,034,342.74		
3719	ADULT <40% EXP M&F 6	36,205.17	36,567.62	42,431.28	59,561.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,765.37		
371D	ADULT <40% EXP MALE	392,849.93	382,830.27	238,138.75	180,523.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,194,342.21		
371E	ADULT <40% EXP FEM AL	356,021.60	295,087.13	201,535.90	193,797.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,046,442.28		
371F	ADULT <40% EXP MALE	2,852,336.09	2,763,526.13	1,988,245.68	1,692,735.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,296,843.86		
371G	ADULT <40% EXP FEM AL	1,605,524.56	1,472,687.76	1,073,635.38	1,002,260.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,154,107.98		
371H	ADULT <40% EXP M&F	2,523,268.04	2,262,250.08	1,652,940.26	1,581,086.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,019,545.04		
371J	ADULT <40% EXP M&F 6	2,019.24	1,369.87	8,989.45	9,843.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,222.03		
3724	ADULT <40% EXP MALE	480.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480.74		
3726	ADULT <40% EXP MALE	3,936.06	7,430.66	5,545.33	9,313.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,225.34		
3727	ADULT <40% EXP FEM AL	4,778.02	3,573.32	779.92	6,659.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,790.42		
3728	ADULT <40% EXP M&F 4	17,960.52	5,138.97	16,090.90	7,367.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,558.05		
3729	ADULT <40% EXP M&F 6	1,616.38	0.00	362.34	1,703.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,682.60		
372F	ADULT <40% EXP MALE	0.00	711.09	4,151.16	502.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,364.60		
372G	ADULT <40% EXP FEM	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	470.36	1,351.60	251.86	43.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,117.42		

4

4

AL

4

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	128,119,986.92	128,273,464.15	129,558,529.07	139,341,202.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		525,293,182.36		

9935	BIRTH SUPP PAYMENT A	176,469.55	272,778.55	241,599.87	252,056.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	447,342.88	597,836.74	736,611.04	629,654.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	623,812.43	870,615.29	978,210.9	1	881,710.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

942,904.28	
2,411,445.31	
3,354,349.59	

A
SUBTOTAL:

3904	NEWLY ELIGIBLE MALE	0.00	55.96	346.93	367.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	2,243.33	4,164.05	5,522.85	5,309.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA	11,101.01	5,502.90	2,869.12	7,915.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	30,815.43	20,891.02	14,759.65	33,850.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	3,752.37	6,340.48	6,828.68	14,179.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
390F	NEWLY ELIGIBLE MALE	154.29	0.00	0.00	2,010.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	558.35	584.83	0.00	417.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	20,702.19	14,075.84	19,780.97	27,402.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	3,743.08	5,233.41	11,173.35	13,298.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	520,790.75	542,267.89	590,928.22	678,315.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	601,783.26	669,009.91	701,931.63	805,543.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	5,010,046.71	5,234,991.72	5,512,159.07	6,867,251.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	6,457,501.35	6,891,154.05	7,326,735.48	9,228,406.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	7,992,989.32	8,091,976.44	8,244,535.29	10,044,074.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	13,274.71	12,857.15	12,513.51	17,877.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	48,199.73	37,609.47	40,038.27	17,562.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	52,151.67	50,095.35	33,023.96	31,218.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	503,095.65	399,419.06	363,419.09	291,238.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	575,662.05	557,633.73	466,745.78	382,350.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F	598,828.85	481,913.67	459,344.28	322,384.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	3,178.08	11,525.06	33,951.68	2,053.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	282.13	198.55	587.36	3,072.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	0.00	3,064.18	3,059.32	744.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	1,925.68	968.19	772.82	1,662.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	598.20	308.72	649.48	732.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
392H	NEWLY ELIGIBLE M&F 4	782.69	451.48	178.82	394.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392J	NEWLY ELIGIBLE M&F	0.00	11.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	22,454,160.88	23,042,703.84	23,851,867.0	28,799,634.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

770.14	
17,239.38	
27,388.32	
100,316.41	
31,101.34	
318.47	
2,164.95	
1,560.56	
81,961.03	
33,448.25	
2,332,302.09	
2,778,268.27	
22,624,449.12	
29,903,797.16	
34,373,575.39	
56,523.27	
143,410.32	
166,489.30	
1,557,172.64	
1,982,392.50	
1,862,471.06	
50,708.18	
4,140.12	
6,868.14	
5,329.56	
2,288.63	
92.63	
1,807.80	
11.02	
98,148,366.05	

L

4

6
SUBTOTAL:

9939	BIRTH SUPP PAYMENT
N

236,215.30	208,587.25	349,383.86	385,296.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,179,483.04

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	236,215.30	208,587.25	349,383.86	385,296.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,179,483.04		

4404	SOBRA 100-133% MALE	0.00	0.00	0.00	100.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	475.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F	227.07	113.90	227.80	1,524.18	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	5,501,505.61	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	2,107,717.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,627,175.04	1,485,905.55	1,372,014.41	3,127,884.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	16,933.27	18,946.08	66,346.90	81,011.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	21,389.49	17,226.07	66,017.92	56,782.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	15,755.99	20,553.56	83,770.13	62,878.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	162.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,278,024.25	4,784,466.49	4,561,528.24	10,940,043.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

100.87	
475.25	
2,092.95	
12,224,886.38	
5,195,753.00	
7,612,979.35	
183,237.85	
161,415.66	
182,958.66	
162.83	
25,564,062.80	

1

164,962.48

164,962.48

9944	BIRTH SUPP PAYMENT	48,525.79	80,265.10	17,579.74	18,591.85	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	18,591.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

S

441,718.93

273.27

793.56

9,180.01

25,315.59

29,085.71

323.65

27,059.98

533,750.70

4517	BC PATIENT FEMALE 2 1	6,031.34	6,350.82	6,499.88	8,177.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	112,672.67	110,350.85	110,314.38	108,381.03	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	74.95	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	6,289.66	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	7,031.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2	0.00	323.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	136,329.63	134,114.31	133,351.1	9	129,955.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5

1
SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	119.15	119.15	119.15	1,518.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO	1,387,627.33	1,409,227.99	1,427,434.60	1,599,281.31	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	5,903.72	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	278,232.85	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	18,846.99	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	196,159.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO	1,871.66	508.27	103.48	249.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,870,299.57	1,905,856.07	1,908,747.28	2,100,191.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,875.54	
5,823,571.23	
45,878.35	
1,096,107.33	
128,920.65	
686,008.64	
2,732.96	
7,785,094.70	

M

M
SUBTOTAL:

1,910,057,393.90

467,034,603.84	468,726,485.92	471,960,427.06	502,335,877.08	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 October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1003	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1006	TANF 21-44 MALE WITH	297.30	350.67	391.93	80.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,120.51		
1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	171.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,164.27		
1008	TANF 45-64 M & F WIT	870.42	1,013.58	1,168.84	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,320.84		
1009	TANF 65+ M & F WITH	306.00	373.68	430.56	102.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,213.12		
100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	7.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.47		
100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.40		
100H	TANF 44-64 M & F WIT	97.51	98.86	32.85	15.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244.86		
100J	TANF 65+ M & F WITH	73.60	39.19	4.37	7.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.64		
1011	TANF <1 M & F NON-ME	14,502.91	14,510.24	13,463.57	13,876.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,353.67		
1012	TANF 01-05 M & F NON	41,759.21	34,503.32	30,981.55	27,611.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,855.73		
1013	TANF 06-13 M & F NON	68,866.70	57,435.45	51,559.68	45,956.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,818.05		
1014	TANF 14-20 MALE NON-	15,523.91	13,919.00	12,939.58	11,799.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,181.52		
1015	TANF 14-20 FEMALE N O	19,492.05	17,891.08	16,863.02	14,590.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,837.12		
1016	TANF 21-44 MALE NON-	32,422.89	35,110.56	38,554.07	24,138.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,225.66		
1017	TANF 21-44 FEMALE N O	100,171.76	104,138.61	110,548.82	79,377.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394,237.03		
1018	TANF 45-64 M & F NON	26,326.13	28,376.39	30,996.33	18,850.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,549.10		
1019	TANF 65+ M & F NON-M	122.25	133.13	152.05	79.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		487.06		
101A	TANF < 1 M & F NON-M	1,323.68	1,107.58	523.24	1,347.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,301.54		
101B	TANF 01-05 M & F NON	323.00	173.98	234.10	339.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,070.10		
101C	TANF 06-13 M & F NON	235.43	179.19	176.48	398.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989.75		
101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	157.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		556.70		
101E	TANF 14-20 FEMALE N O	278.91	237.91	174.02	162.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		853.05		
101F	TANF 21-44 MALE NON-	2,653.94	2,660.54	1,444.98	1,147.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,906.50		
101G	TANF 21-44 FEMALE N	4,819.02	4,659.58	2,737.74	2,130.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,346.60		
101H	TANF 44-64 M & F NON	1,604.09	1,643.02	919.13	591.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,758.05		
101J	TANF 65+ N & F NON-M	31.66	19.50	26.80	0.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.91		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1026	TANF 21-44 MALE WITH	136.90	188.45	227.64	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590.99		
1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		967.99		
1028	TANF 45-64 M & F WIT	257.30	401.73	481.56	80.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,221.03		
1029	TANF 65+ M & F WITH	125.59	199.79	245.43	39.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		610.24		
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	5.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.66		

O

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	3,945.61	3,902.67	3,829.80	4,108.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,786.61		
210Z	SSI AGED WITH MEDIC A	450.53	377.60	249.36	234.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,311.78		
2110	SSI AGED NON-MEDICA R	5,996.37	5,885.71	5,990.17	6,151.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,023.87		
211Z	SSI AGED NON-MEDICA R	323.02	229.89	155.90	172.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		881.34		
2120	SSI AGED WITH QMB	16,192.79	16,392.49	16,583.32	22,043.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,211.78		
212Z	SSI AGED WITH QMB P P	60.27	61.77	97.36	64.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.42		
2200	SSI DISABLED WITH M	3,600.36	3,525.64	3,506.17	3,583.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,215.37		
220Z	SSI DISABLED WITH M E	236.76	251.22	272.95	200.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		961.07		
2210	SSI DISABLED NON-ME D	57,143.85	56,902.31	56,909.61	56,638.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227,594.10		
221Z	SSI DISABLED NON-ME D	983.56	949.62	911.29	712.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,557.31		
2220	SSI DISABLED WITH Q M	24,588.70	24,755.94	24,980.93	25,101.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,427.12		
222Z	SSI DISABLED WITH Q M	62.38	77.46	109.31	37.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286.56		
2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.11		
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	428.12	430.04	436.15	439.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,733.33		
231Z	SSI BLIND NON-MEDIC A	8.02	26.80	11.45	13.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.58		
2320	SSI BLIND WITH QMB	207.48	205.10	207.96	205.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		826.20		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		
4302	SOBRA CHILD 01-05 M	5.00	3.99	2.01	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	2.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.55		
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	1.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.57		
430B	SOBRA CHILD 01-05 M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
430C	SOBRA CHILD 06-13 M	0.00	0.00	1.56	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.43		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
430E	SOBRA CHILD 14-20 FE	0.00	0.61	0.86	-0.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.22		
4311	SOBRA CHILD <1 M & F	37,929.50	37,878.33	35,410.54	37,957.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,176.16		
4312	SOBRA CHILD 01-05 M	150,215.05	158,567.13	166,797.13	169,515.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		645,094.39		
4313	SOBRA CHILD 06-13 M	200,525.14	216,198.75	230,401.99	209,151.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		856,277.84		
4314	SOBRA CHILD 14-20 MA	49,529.14	51,683.40	55,100.09	50,706.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,018.96		
4315	SOBRA CHILD 14-20 FE	49,621.28	51,750.56	55,046.80	50,918.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,337.09		
431A	SOBRA CHILD < 1 M &	1,144.43	1,199.85	596.85	1,327.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,268.93		
431B	SOBRA CHILD 01-05 M	7,397.32	7,233.01	5,425.60	5,140.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,196.54		
431C	SOBRA CHILD 6-13 M& F	9,664.24	10,386.87	6,895.96	5,455.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,402.60		
431D	SOBRA CHILD 14-20 MA	2,729.60	2,547.00	1,740.21	1,433.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,449.83		
431E	SOBRA CHILD 14-20 FE	2,479.42	2,548.58	1,750.39	1,396.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,174.99		

E

A

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4321	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4322	SOBRA CHILD 01-05 M	3.00	0.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00	
4323	SOBRA CHILD 06-13 M	7.00	0.00	1.00	5.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.06	
4324	SOBRA CHILD 14-20 MA	4.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
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	47.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	185.25	
5008	SOBRA PREG 45-64 FE	2.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
500G	SOBRA PREG 21-44 FE M	3.37	3.12	2.16	1.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.32	
5013	SOBRA PREG 09-13 FE M	6.00	7.38	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.38	
5015	SOBRA PREG 14-20 FE M	4,442.88	4,822.40	5,139.99	5,166.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,572.04	
5017	SOBRA PREG 21-44 FE M	19,288.96	21,436.17	23,639.77	25,361.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,726.20	
5018	SOBRA PREG 45-64 FE M	70.02	76.99	80.34	88.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	315.91	
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	223.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,229.20	
501G	SOBRA PREG 21-44 FE	1,656.15	1,536.50	1,187.87	1,018.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,399.33	
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	9.11	11.00	8.99	9.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38.22	
5028	SOBRA PREG 45-64 FE M	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	
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	928,118.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,936,429.86	

M

M

M

9910	TANF & SOBRA CHILDR E	571.00	500.00	476.00	348.00	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	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	42.00	29.00	33.00	29.00	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	2,106.00	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	2,492.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,895.00	
43.00	
133.00	
8,877.00	
10,948.00	

3100	TRANSPLANT OPTION	4.24	5.41	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION	5.74	4.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	9.98	9.99	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

19.65	
10.32	
29.97	

1

1
SUBTOTAL:

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	925.76	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	1,797.27	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	3,022.89	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	1,129.71	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	21.05	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	30.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,324.67

4,813.63

8,203.81

2,866.16

52.15

47.71

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110H	TANF EXPANDED 45-64	0.86	0.82	67.38	83.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152.99		
110J	TANF EXPANDED 65+
M&	0.00	2.64	37.58	12.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.07		
1111	TANF EXPANDED <1 M
&F	12.00	8.00	1.36	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.36		
1112	TANF EXPANDED 01-05	390.00	311.16	275.00	239.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,215.22		
1113	TANF EXPANDED 06-13	1,229.70	991.16	871.12	743.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,835.19		
1114	TANF EXPANDED 14-20	683.08	531.13	454.69	718.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,387.42		
1115	TANF EXPANDED 14-20	1,447.98	1,085.47	918.24	1,787.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,238.85		
1116	TANF EXPANDED 21-44	20,507.88	17,866.93	15,873.76	30,103.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,351.58		
1117	TANF EXPANDED 21-44	46,392.97	40,134.22	35,306.60	65,247.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		187,080.84		
1118	TANF EXPANDED 45-64	16,838.19	14,850.87	13,477.80	26,040.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,207.57		
1119	TANF EXPANDED 65+
M&	91.37	83.00	78.65	120.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		373.24		
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.35		
111B	TANF EXPANDED 01-05	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.83		
111C	TANF EXPANDED 06-13	1.00	0.00	0.00	2.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.80		
111D	TANF EXPANDED 14-20	0.54	5.28	14.31	9.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.16		
111E	TANF EXPANDED 14-20	7.24	9.73	31.24	34.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.60		
111F	TANF EXPANDED 21-44	101.48	104.36	529.77	841.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,576.81		
111G	TANF EXPANDED 21-44	197.09	224.68	1,011.19	1,459.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,892.75		
111H	TANF EXPANDED 45-64	28.12	127.83	423.04	591.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,170.95		
111J	TANF EXPANDED 65+
M&	22.31	0.00	3.65	34.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.66		
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	155.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		609.92		
1127	TANF EXPANDED 21-44	382.43	351.28	318.88	362.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,414.89		
1128	TANF EXPANDED 45-64	446.94	399.71	372.79	453.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,672.79		
1129	TANF EXPANDED 65+	194.69	165.94	155.60	174.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		691.15		
112F	TANF EXPANDED 21-44	0.00	0.00	2.56	1.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.19		
112G	TANF EXPANDED 21-44	0.00	3.44	3.22	4.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.53		
112H	TANF EXPANDED 45-64	0.03	0.00	2.92	11.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.19		
112J	TANF EXPANDED 65+
M&	0.00	0.00	16.30	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.36		
2400	SSI AGED EXPANDED WI	518.42	487.04	456.81	366.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,828.53		
240Z	SSI AGED EXPANDED WI	304.76	401.03	244.49	222.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,173.25		
2410	SSI AGED EXPANDED NO	1,134.27	1,056.52	991.15	391.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,573.51		
241Z	SSI AGED EXPANDED NO	13.94	39.82	16.61	7.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.71		
2420	SSI AGED EXPANDED WI	26,853.34	26,842.37	26,813.66	21,185.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,694.61		
242Z	SSI AGED EXPANDED	86.51	60.16	53.24	57.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257.12		
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		

M&

WI

W

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2510	SSI BLIND EXPANDED	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00	
	N														
2520	SSI BLIND EXPANDED	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	
	W														
2600	SSI DISABLED EXPAND	387.35	391.10	363.58	383.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,525.97	
	E														
260Z	SSI DISABLED EXPAND	198.57	225.21	193.65	117.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	735.03	
	E														
2610	SSI DISABLED EXPAND	2,800.72	2,719.35	2,722.76	2,692.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,935.48	
	E														
261Z	SSI DISABLED EXPAND	66.87	64.13	55.86	38.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225.72	
	E														
2620	SSI DISABLED EXPAND	15,882.49	16,101.98	16,689.39	17,146.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,820.54	
	E														
262Z	SSI DISABLED EXPAND	70.33	62.70	88.07	37.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	258.28	

SUBT	E
OTAL:	
141,707.24	
129,594.34	
122,483.07	
178,815.79	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
572,600.44	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2015

512.00

10.00

3.00

525.00

9911	SB PAYMENT FOR TAN F	105.00	122.00	113.00	172.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	108.00	126.00	117.00	174.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

E
SUBTOTAL:

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

3506	ADULT 40-100% MALE 2	15.63	8.90	13.05	13.05	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	8.78	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	120.52	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	83.77	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	4.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1.86	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	16.43	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	3.22	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	3,444.39	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	4,051.63	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	18,007.17	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	14,833.72	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	36,351.73	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	49.54	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	92.65	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	144.37	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	639.87	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	496.68	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	1,034.78	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	18.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
50.63	
35.60	
292.64	
247.55	
15.34	
1.86	
51.59	
21.71	
13,242.91	
15,871.63	
70,414.36	
58,495.46	
142,902.16	
160.63	
631.49	
717.02	
3,253.21	
2,389.45	
5,454.01	
111.32	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2015		
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL		
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		1.00		
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		3.00		
3527	ADULT 40-100% FEMAL E	1.41	3.21	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.62		
3528	ADULT 40-100% M&F 45	20.96	15.68	24.16	18.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.05		
3529	ADULT 40-100% M&F 65	6.00	10.00	4.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
352G	ADULT 40-100% FEMAL E	0.00	0.77	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.80		
352H	ADULT 40-100% M&F 45	0.03	1.83	1.26	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.24		
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
3706	ADULT <40% EXP MALE	34.74	33.74	30.14	40.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.85		
3707	ADULT <40% EXP FEM AL	7.49	15.61	9.78	10.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.20		
3708	ADULT <40% EXP M&F 4	88.23	98.60	92.80	188.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		468.51		
3709	ADULT <40% EXP M&F 6	19.67	21.38	28.72	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.77		
370F	ADULT <40% EXP MALE	5.51	8.57	6.12	3.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.69		
370G	ADULT <40% EXP FEM AL	1.54	1.81	0.06	1.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.85		
370H	ADULT <40% EXP M&F	14.58	15.74	30.56	13.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.85		
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 MALE	9,839.70	10,160.23	10,470.29	10,245.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,715.76		
3715	ADULT <40% EXP FEM AL	8,418.28	8,667.97	8,908.49	8,723.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,718.41		
3716	ADULT <40% EXP MALE	58,247.03	58,634.00	61,113.02	62,551.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,545.17		
3717	ADULT <40% EXP FEM AL	34,827.18	34,929.63	36,183.66	37,122.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,062.84		
3718	ADULT <40% EXP M&F 4	72,820.34	73,231.71	75,412.07	76,470.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		297,935.02		
3719	ADULT <40% EXP M&F 6	80.88	80.74	94.53	128.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.34		
371D	ADULT <40% EXP MALE	580.76	572.41	352.26	267.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,773.36		
371E	ADULT <40% EXP FEM AL	519.38	449.84	305.73	289.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,564.52		
371F	ADULT <40% EXP MALE	4,244.00	4,145.00	2,990.61	2,525.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,905.04		
371G	ADULT <40% EXP FEM AL	2,410.81	2,215.92	1,619.33	1,499.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,745.97		
371H	ADULT <40% EXP M&F	3,754.97	3,389.75	2,459.44	2,341.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,945.31		
371J	ADULT <40% EXP M&F 6	2.98	2.00	16.46	13.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.20		
3724	ADULT <40% EXP MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3726	ADULT <40% EXP MALE	9.00	8.05	8.35	11.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.13		
3727	ADULT <40% EXP FEM AL	6.12	3.96	3.43	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.51		
3728	ADULT <40% EXP M&F 4	23.78	6.39	19.82	13.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.14		
3729	ADULT <40% EXP M&F 6	4.00	0.00	1.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
372F	ADULT <40% EXP MALE	0.00	0.86	5.62	0.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.30		
372G	ADULT <40% EXP FEM	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	0.77	1.95	0.36	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.14		

4

4

AL

4

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	273,979.51	274,669.50	279,217.19	281,969.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,109,835.77		

9935	BIRTH SUPP PAYMENT A	29.00	45.00	40.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	74.00	98.00	121.00	103.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	103.00	143.00	161.00	144.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

155.00	
396.00	
551.00	

A
SUBTOTAL:

3904	NEWLY ELIGIBLE MALE	0.00	0.16	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	6.92	5.18	4.00	8.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA	14.99	10.72	9.00	11.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	71.56	53.47	39.78	76.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	12.19	19.97	21.66	38.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
390F	NEWLY ELIGIBLE MALE	0.45	0.00	0.00	6.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1.83	2.06	0.00	1.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	64.25	40.88	59.19	80.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	10.96	14.95	34.33	40.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,606.89	1,676.79	1,806.88	1,743.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1,867.46	2,072.53	2,181.57	2,092.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	15,590.65	16,339.89	17,228.33	17,794.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	20,086.40	21,456.04	22,844.42	23,835.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	24,879.24	25,158.44	25,656.88	25,762.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	43.11	41.59	40.65	48.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	141.51	112.48	116.75	54.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	153.51	153.08	97.96	94.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	1,523.12	1,206.66	1,086.31	866.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	1,726.49	1,680.05	1,394.47	1,130.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F	1,771.32	1,458.13	1,385.33	982.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	8.86	33.37	111.19	6.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	1.00	0.70	1.96	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	0.00	3.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	6.22	3.11	2.43	4.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	2.00	0.96	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392F	NEWLY ELIGIBLE MALE	0.00	0.29	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	2.40	1.28	0.56	1.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392J	NEWLY ELIGIBLE M&F	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	69,593.33	71,546.64	74,129.68	74,687.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.16	
24.30	
46.43	
240.88	
91.84	
0.83	
6.60	
5.14	
245.20	
100.39	
6,834.32	
8,214.11	
66,953.34	
88,221.99	
101,456.76	
174.22	
424.86	
499.00	
4,682.55	
5,931.60	
5,596.87	
159.54	
6.82	
8.00	
16.33	
6.96	
0.32	
5.65	
0.03	
289,957.04	

L

4

6
SUBTOTAL:

9939	BIRTH SUPP PAYMENT
N

39.00	34.00	57.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194.00

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	39.00	34.00	57.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194.00		

4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F	2.00	1.00	2.00	7.38	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	44,424.55	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	12,544.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	6,240.09	5,678.68	5,237.34	12,092.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	288.14	323.40	1,091.93	1,389.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	126.41	106.24	394.18	358.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	81.96	103.18	421.32	317.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	33,377.33	30,212.86	29,209.93	71,136.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.67	
1.00	
12.38	
99,174.54	
30,497.14	
29,248.23	
3,092.91	
985.18	
923.48	
1.00	
163,936.53	

1

27.00

27.00

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

S

982.91

0.77

4.05

24.28

66.40

67.00

1.45

102.89

1,249.75

4517	BC PATIENT FEMALE 2 1	23.96	25.35	26.00	27.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	251.91	246.16	245.84	239.00	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	0.41	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	17.00	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	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2	0.00	1.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	320.78	316.03	312.95	299.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5

1
SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO	1,505.00	1,555.45	1,576.90	1,596.08	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	62.51	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	265.18	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	37.12	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	222.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO	20.61	6.41	1.03	2.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,234.73	2,273.51	2,258.82	2,186.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
6,233.43	
495.30	
1,062.41	
251.66	
876.37	
30.72	
8,953.89	

M

M
SUBTOTAL:

TOTAL:	1,509,256.72	1,514,651.63	1,531,233.53	1,540,096.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,095,238.25		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

1000	TANF WITH MEDICARE	9,923.14	10,424.50	9,923.14	10,013.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,284.55

1010	TANF NON-MEDICARE	2,246,124.76	2,243,143.25	2,252,388.63	2,282,295.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,023,952.48

1020	TANF WITH QMB	3,414.03	3,414.03	3,414.03	3,433.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,675.26

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

31,188,469.28     36,229,127.20     31,473,122.65     31,080,376.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	129,971,095.37

707,295.55	628,872.62	699,533.74	748,646.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,784,348.08

2,884,201.93	3,146,295.69	2,948,885.35	3,035,939.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,015,322.19

20,970.93	11,535.77	26,120.35	18,541.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77,169.00

2120	SSI AGED WITH QMB	18,966,113.95     22,019,693.90     19,185,398.15     19,011,404.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,182,610.49

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

27,811.67	8,720.78	31,076.14	19,646.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,254.93

13,803,406.37     14,998,436.84     13,783,997.15     14,000,797.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,586,637.71

40,564.67	63,879.36	93,590.05	105,382.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	303,416.54

90,370,918.56     92,527,644.78     92,067,142.80     92,988,149.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	367,953,856.06

66,459.25	35,301.18	25,164.71	24,126.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151,051.76

21,237,804.05     22,510,241.65     21,355,507.04     21,304,064.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	86,407,617.00

2,948.16	9,227.84	6,397.97	6,604.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,178.05

2300	SSI BLIND WITH MEDIC	64,338.16	65,260.19	64,541.02	62,567.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	256,706.77

2310	SSI BLIND NON-MEDIC
A

444,420.36	460,483.10	454,107.08	457,911.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,816,921.83

2320	SSI BLIND WITH QMB	130,315.90	135,811.83	130,342.85	127,684.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524,155.25

SUBTOTAL:	182,215,500.72   195,107,514.51   184,610,652.85   185,287,585.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	747,221,253.32

288,256.11

0.00

488,844.58

4,987.53

81,007.71

863,095.93

8700	SSI DISABLED FREEDO M	70,007.12	77,437.98	70,007.12	70,803.89	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	130,091.75	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	19,836.86	21,311.74	19,836.86	20,022.25	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	220,917.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

M

184,831,913.92  185,508,503.13

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

748,084,349.25

TOTAL:	182,421,827.21   195,322,104.99

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00	
1010	TANF NON-MEDICARE	654.15	651.89	656.12	659.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,621.66	
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	
2100	SSI AGED WITH MEDIC	11,288.11	11,289.28	11,378.95	11,348.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,304.55	
	A														
210Z	SSI AGED WITH MEDIC	717.21	639.08	710.00	757.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,823.92	
	A														
2110	SSI AGED NON-MEDICA	655.14	653.57	669.99	635.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,614.34	
	R														
211Z	SSI AGED NON-MEDICA	21.10	12.50	27.34	18.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79.28	
	R														
2120	SSI AGED WITH QMB	7,334.44	7,374.82	7,392.70	7,406.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,508.24	
212Z	SSI AGED WITH QMB P	27.75	9.33	32.14	20.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89.40	
	P														
2200	SSI DISABLED WITH M	4,540.03	4,507.46	4,531.49	4,604.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,183.01	
	E														
220Z	SSI DISABLED WITH M	40.61	63.99	95.38	107.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	307.27	
	E														
2210	SSI DISABLED NON-ME	25,726.52	25,794.02	25,992.12	25,893.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,405.88	
	D														
221Z	SSI DISABLED NON-ME	68.02	35.27	25.38	26.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	155.07	
	D														
2220	SSI DISABLED WITH Q	6,765.32	6,778.39	6,816.99	6,806.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,166.79	
	M														
222Z	SSI DISABLED WITH Q	2.73	7.18	7.16	6.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.89	
	M														
2300	SSI BLIND WITH MEDIC	20.00	19.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79.00	
2310	SSI BLIND NON-MEDIC	128.16	130.38	131.06	129.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	519.15	
	A														
2320	SSI BLIND WITH QMB	42.00	42.00	42.00	40.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166.83	

SUBTOTAL:	
58,035.29	
58,012.16	
58,532.82	
58,484.01	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
233,064.28	

LONG TERM CARE MEMBER MONTHS
For The Period Ending October 31, 2015

88.09

0.00

106.96

5.03

28.00

228.08

8700	SSI DISABLED FREEDO M	22.00	22.00	22.00	22.09	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	27.00	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	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	58.99	52.01	60.99	56.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

M

TOTAL:	58,094.28	58,064.17	58,593.81	58,540.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233,292.36		

E

M

1110	TANF EXPANDED FOR	92,861.15	74,837.15	64,811.30	62,295.68	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	41.42	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	62,337.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

294,805.28	
154.07	
294,959.35	

FI

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

233.04	
195.49	
428.53	

FO
SUBTOTAL:

41.42

41.42

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

F
SUBTOTAL:

25,622,280.05

0.00

0.00

0.00

0.00

0.00

28,399,084.54

0.00

0.00	0.00

103,778,268.79

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	1,137,201.75	1,021,510.20	921,589.65	2,674,365.14	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	921,589.6	5	2,674,406.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

41.42	
5,754,666.74	
5,754,708.16	

F

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	37.55	37.55	37.55	41.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154.07		
1010	TANF NON-MEDICARE	6,001,729.15	5,085,321.40	4,606,746.65	4,559,389.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,253,186.54		
1020	TANF WITH QMB	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.42		
2110	SSI AGED NON-MEDICA R	37.55	75.10	75.10	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270.59		
2200	SSI DISABLED WITH M	37.55	37.55	37.55	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195.49		
2210	SSI DISABLED NON-ME D	430,210.35	427,168.80	423,639.10	461,128.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,742,147.11		
2220	SSI DISABLED WITH Q	225.30	225.30	225.30	248.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		924.42		
2310	SSI BLIND NON-MEDIC A	1,464.45	1,614.65	1,689.75	1,988.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,757.01		
4300	SOBRA CHILD WITH ME D	225.30	225.30	187.75	165.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		804.03		
4310	SOBRA CHILD NON-ME DI	17,147,019.75	18,291,093.15	19,577,631.25	20,609,680.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,625,424.91		
4320	SOBRA CHILD WITH Q MB	525.70	0.00	187.75	455.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,169.07		
5010	SOBRA PREGNANT WO MAN	20,427.20	22,567.55	25,233.60	28,828.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,056.67		
SUBTOTAL:	23,601,939.85	23,828,366.35	24,635,691.35	25,662,133.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,728,131.33		

TOTAL:

24,832,077.85

24,924,826.35

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1010	TANF NON-MEDICARE	159,833.00	135,428.00	122,683.00	110,077.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		528,021.00		
1020	TANF WITH QMB	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2110	SSI AGED NON-MEDICA R	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2200	SSI DISABLED WITH M	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2210	SSI DISABLED NON-ME D	11,457.00	11,376.00	11,282.00	11,133.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,248.00		
2220	SSI DISABLED WITH Q	6.00	6.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
2310	SSI BLIND NON-MEDIC A	39.00	43.00	45.00	48.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.00		
4300	SOBRA CHILD WITH ME D	6.00	6.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
4310	SOBRA CHILD NON-ME DI	456,645.00	487,113.00	521,375.00	497,578.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,962,711.00		
4320	SOBRA CHILD WITH Q MB	14.00	0.00	5.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
5010	SOBRA PREGNANT WO MAN	544.00	601.00	672.00	696.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,513.00		
SUBTOTAL:	628,547.00	634,577.00	656,077.00	619,559.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,538,760.00		

E

M

1110	TANF EXPANDED FOR	2,473.00	1,993.00	1,726.00	1,504.00	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	1.00	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	1,505.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,696.00	
4.00	
7,700.00	

FI

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

6.00	
5.00	
11.00	

FO
SUBTOTAL:

1.00

1.00

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

F
SUBTOTAL:

1.00

146,599.00

146,600.00

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

F

TOTAL:	661,307.00	663,777.00	682,351.00	685,637.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,693,072.00		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	67,083.83	80,473.34	92,942.96	1,873.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	242,374.01	
1010	TANF NON-MEDICARE	6,077,917.65	6,393,201.43	6,925,613.32	441,979.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,838,712.12	
1020	TANF WITH QMB	24,837.03	36,897.81	45,074.61	701.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,510.97	
2100	SSI AGED WITH MEDIC A	139,789.21	137,949.43	136,722.91	13,714.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	428,175.95	
2110	SSI AGED NON-MEDICA	205,476.17	200,433.81	204,454.07	19,576.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	629,940.25	
2120	SSI AGED WITH QMB	595,679.88	602,630.16	609,410.09	73,883.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,881,604.09	
2200	SSI DISABLED WITH M	134,133.59	132,327.88	130,488.10	11,537.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	408,486.73	
2210	SSI DISABLED NON-ME D	1,422,763.20	1,422,831.34	1,426,408.69	116,724.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,388,727.31	
2220	SSI DISABLED WITH Q M	832,159.75	837,747.23	844,561.23	70,060.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,584,528.57	
2300	SSI BLIND WITH MEDIC	1,226.52	1,158.38	1,056.17	94.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,535.87	
2310	SSI BLIND NON-MEDIC A	14,820.45	14,650.10	14,547.89	1,295.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,314.04	
2320	SSI BLIND WITH QMB	8,279.01	8,210.87	8,244.94	745.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,480.58	
4300	SOBRA CHILD WITH ME D	34.07	34.07	68.14	6.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142.60	
4310	SOBRA CHILD NON-ME DI	834,544.65	810,661.58	852,976.52	73,251.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,571,434.71	
4320	SOBRA CHILD WITH Q	68.14	34.07	34.07	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139.44	
5000	SOBRA PREGNANT WO MAN	1,260.59	1,226.52	1,328.73	113.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,929.60	
5010	SOBRA PREGNANT WO	802,586.99	894,950.76	992,561.31	98,045.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,788,144.38	
5020	SOBRA PREGNANT WO MAN	306.63	408.84	340.70	34.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,090.93	
SUBTOTAL	:	11,162,967.36	11,575,827.62	12,286,834.45	923,642.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,949,272.15	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending October 31, 2015

R

E

MB

MAN

1100	TANF EXPANDED FPR FI	141,594.92	125,002.83	112,124.37	20,394.64	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	405,740.84	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	3,239.00	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	948.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	39,725.62	37,068.16	34,887.68	1,292.44	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	68,407.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	3.16	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	3.16	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	3.16	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	850.04	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	6,955.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	488,427.52	493,674.30	511,867.68	42,394.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	4,829,797.27	4,393,871.62	4,058,111.77	550,231.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

399,116.76	
8,404,082.18	
110,729.85	
43,773.99	
112,973.90	
2,921,736.11	
3.16	
207.58	
105.37	
28,889.65	
274,029.89	
1,536,364.06	
13,832,012.50	

NO

W

E
SUBTOTAL:

3500	ADULT 40-100% FOR FI	4,974.22	4,326.89	3,849.91	688.88	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	246,432.60	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	97.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,839.90	
8,053,913.80	
2,993.91	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	4,463.17	4,667.59	4,769.80	774.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,674.76	
3710	AHC CARE EXPANDED FO	6,719,966.80	6,769,163.88	7,017,568.25	651,541.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,158,240.37	
3720	AHC CARE EXPANDED FO	1,328.73	476.98	953.96	94.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,854.47	
SUBTOTAL	:	9,300,428.60	9,359,540.05	9,686,918.68	899,629.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,246,517.21	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending October 31, 2015

3900	NEWLY ELIGIBLE FOR F	3,032.23	2,044.20	2,180.48	372.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR	2,203,170.62	2,295,500.32	2,410,997.62	227,614.80	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	28.44	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	228,016.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,629.79	
7,137,283.36	
777.98	
7,145,691.13	

F

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

301,496.31	
3.16	
301,499.47	

F
SUBTOTAL:

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

28,877.01	
3,579.42	
32,456.43	

N
SUBTOTAL:

8600	SSI BLIND FREEDOM/W	34.07	34.07	34.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	33,831.51	35,194.31	35,909.78	2,837.68	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	701.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	5,178.64	5,417.13	5,655.62	426.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	46,130.78	48,583.82	49,742.20	3,965.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

102.21	
107,773.28	
23,869.12	
16,677.99	
148,422.60	

O

M
SUBTOTAL:

86,655,871.49

27,660,274.62	27,781,631.96	28,591,850.63	2,622,114.28	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	
1000	TANF WITH MEDICARE	1,969.00	2,362.00	2,728.00	593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,652.00	
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	709,187.00	
1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,357.00	
2100	SSI AGED WITH MEDIC A	4,103.00	4,049.00	4,013.00	4,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,505.00	
2110	SSI AGED NON-MEDICA	6,031.00	5,883.00	6,001.00	6,195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,110.00	
2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,440.00	
2200	SSI DISABLED WITH M	3,937.00	3,884.00	3,830.00	3,651.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,302.00	
2210	SSI DISABLED NON-ME D	41,760.00	41,762.00	41,867.00	36,938.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162,327.00	
2220	SSI DISABLED WITH Q M	24,425.00	24,589.00	24,789.00	22,171.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95,974.00	
2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	131.00	
2310	SSI BLIND NON-MEDIC A	435.00	430.00	427.00	410.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,702.00	
2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	962.00	
4300	SOBRA CHILD WITH ME D	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
4310	SOBRA CHILD NON-ME DI	24,495.00	23,794.00	25,036.00	23,181.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,506.00	
4320	SOBRA CHILD WITH Q	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
5000	SOBRA PREGNANT WO MAN	37.00	36.00	39.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148.00	
5010	SOBRA PREGNANT WO	23,557.00	26,268.00	29,133.00	31,027.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,985.00	
5020	SOBRA PREGNANT WO MAN	9.00	12.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00	
SUBTOTAL	:	327,648.00	339,766.00	360,635.00	292,292.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,320,341.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending October 31, 2015

R

E

MB

MAN

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	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	128,399.00	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	1,025.00	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	300.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	1,166.00	1,088.00	1,024.00	409.00	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	21,648.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	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	1.00	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	1.00	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	269.00	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	2,201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	14,336.00	14,490.00	15,024.00	13,416.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	141,761.00	128,966.00	119,111.0	0	174,124.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17,570.00	
363,161.00	
4,180.00	
1,557.00	
3,687.00	
105,397.00	
1.00	
7.00	
4.00	
1,092.00	
10,040.00	
57,266.00	
563,962.00	

NO

W

E
SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	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	77,985.00	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	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
604.00	
307,145.00	
116.00	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	653.00	
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	808,083.00	
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111.00	
SUBTOTAL	:	272,980.00	274,715.00	284,324.00	284,693.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,116,712.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending October 31, 2015

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR	64,666.00	67,376.00	70,766.00	72,030.00	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	9.00	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	72,157.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

331.00	
274,838.00	
31.00	
275,200.00	

F

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

13,352.00	
1.00	
13,353.00	

F
SUBTOTAL:

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

1,088.00	
135.00	
1,223.00	

N
SUBTOTAL:

8600	SSI BLIND FREEDOM/W	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	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	222.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	152.00	159.00	166.00	135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,354.00	1,426.00	1,460.00	1,255.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
3,978.00	
902.00	
612.00	
5,495.00	

O

M
SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,296,286.00		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	90,239.27	108,250.46	125,024.24	33,623.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	357,137.07	
1010	TANF NON-MEDICARE	8,175,842.85	8,599,953.67	9,316,139.08	7,930,458.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,022,394.50	
1020	TANF WITH QMB	33,410.07	49,633.89	60,633.09	12,587.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	156,264.45	
2100	SSI AGED WITH MEDIC A	188,040.49	185,565.67	183,915.79	246,078.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	803,599.95	
2110	SSI AGED NON-MEDICA	276,400.73	269,617.89	275,025.83	351,256.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,172,300.95	
2120	SSI AGED WITH QMB	801,291.72	810,641.04	819,761.21	1,325,702.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,757,396.67	
2200	SSI DISABLED WITH M	180,432.71	178,003.72	175,528.90	207,011.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	740,977.03	
2210	SSI DISABLED NON-ME D	1,913,860.80	1,913,952.46	1,918,764.61	2,094,384.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,840,962.47	
2220	SSI DISABLED WITH Q M	1,119,397.75	1,126,913.87	1,136,079.87	1,257,095.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,639,487.19	
2300	SSI BLIND WITH MEDIC	1,649.88	1,558.22	1,420.73	1,701.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,329.83	
2310	SSI BLIND NON-MEDIC A	19,936.05	19,706.90	19,569.41	23,247.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82,459.36	
2320	SSI BLIND WITH QMB	11,136.69	11,045.03	11,090.86	13,381.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,653.78	
4300	SOBRA CHILD WITH ME D	45.83	45.83	91.66	113.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	296.72	
4310	SOBRA CHILD NON-ME DI	1,122,605.85	1,090,479.02	1,147,399.88	1,314,362.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,674,847.45	
4320	SOBRA CHILD WITH Q	91.66	45.83	45.83	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	240.02	
5000	SOBRA PREGNANT WO MAN	1,695.71	1,649.88	1,787.37	2,041.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,174.16	
5010	SOBRA PREGNANT WO	1,079,617.31	1,203,862.44	1,335,165.39	1,759,230.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,377,876.04	
5020	SOBRA PREGNANT WO MAN	412.47	549.96	458.30	623.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,044.43	
SUBTOTAL	:	15,016,107.84	15,571,475.78	16,527,902.05	16,572,956.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,688,442.07	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending October 31, 2015

R

E

MB

MAN

1100	TANF EXPANDED FPR FI	190,469.48	168,150.27	150,826.53	365,941.80	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	7,280,223.30	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	58,117.50	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	17,010.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	53,437.78	49,863.04	46,929.92	23,190.30	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	1,227,441.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	56.70	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	56.70	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	56.70	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	15,252.30	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	124,796.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	657,018.88	664,076.70	688,549.92	760,687.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	6,496,906.63	5,910,511.78	5,458,857.13	9,872,830.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

875,388.08	
18,039,365.76	
202,711.15	
74,618.31	
173,421.04	
5,065,658.27	
56.70	
331.68	
194.19	
52,970.39	
484,058.07	
2,770,332.70	
27,739,106.34	

NO

W

E
SUBTOTAL:

3500	ADULT 40-100% FOR FI	6,691.18	5,820.41	5,178.79	12,360.60	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	4,421,749.50	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	1,757.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
30,050.98	
14,924,152.30	
5,653.25	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	6,003.73	6,278.71	6,416.20	13,891.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,590.14	
3710	AHC CARE EXPANDED FO	9,039,509.20	9,105,687.72	9,439,834.25	11,690,632.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,275,663.97	
3720	AHC CARE EXPANDED FO	1,787.37	641.62	1,283.24	1,701.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,413.23	
SUBTOTAL	:	12,510,673.40	12,590,188.45	13,030,568.92	16,142,093.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,273,523.87	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending October 31, 2015

3900	NEWLY ELIGIBLE FOR F	4,078.87	2,749.80	2,933.12	6,690.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR	2,963,642.78	3,087,842.08	3,243,205.78	4,084,101.00	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	510.30	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	4,091,301.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,452.39	
13,378,791.64	
1,518.56	
13,396,762.59	

F

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

665,869.97	
56.70	
665,926.67	

F
SUBTOTAL:

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

52,743.59	
6,545.76	
59,289.35	

N
SUBTOTAL:

8600	SSI BLIND FREEDOM/W	45.83	45.83	45.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	45,509.19	47,342.39	48,304.82	50,916.60	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	12,587.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	6,966.16	7,286.97	7,607.78	7,654.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	62,053.82	65,353.58	66,911.80	71,158.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

137.49	
192,073.00	
43,751.80	
29,515.41	
265,477.70	

O

M
SUBTOTAL:

160,088,528.59

37,207,818.78	37,371,065.24	38,460,948.47	47,048,696.10	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	
1000	TANF WITH MEDICARE	1,969.00	2,362.00	2,728.00	593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,652.00	
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	709,187.00	
1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,357.00	
2100	SSI AGED WITH MEDIC A	4,103.00	4,049.00	4,013.00	4,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,505.00	
2110	SSI AGED NON-MEDICA	6,031.00	5,883.00	6,001.00	6,195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,110.00	
2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,440.00	
2200	SSI DISABLED WITH M	3,937.00	3,884.00	3,830.00	3,651.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,302.00	
2210	SSI DISABLED NON-ME D	41,760.00	41,762.00	41,867.00	36,938.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162,327.00	
2220	SSI DISABLED WITH Q M	24,425.00	24,589.00	24,789.00	22,171.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95,974.00	
2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	131.00	
2310	SSI BLIND NON-MEDIC A	435.00	430.00	427.00	410.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,702.00	
2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	962.00	
4300	SOBRA CHILD WITH ME D	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
4310	SOBRA CHILD NON-ME DI	24,495.00	23,794.00	25,036.00	23,181.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,506.00	
4320	SOBRA CHILD WITH Q	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
5000	SOBRA PREGNANT WO MAN	37.00	36.00	39.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148.00	
5010	SOBRA PREGNANT WO	23,557.00	26,268.00	29,133.00	31,027.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,985.00	
5020	SOBRA PREGNANT WO MAN	9.00	12.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00	
SUBTOTAL	:	327,648.00	339,766.00	360,635.00	292,292.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,320,341.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending October 31, 2015

R

E

MB

MAN

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	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	128,399.00	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	1,025.00	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	300.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	1,166.00	1,088.00	1,024.00	409.00	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	21,648.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	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	1.00	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	1.00	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	269.00	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	2,201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	14,336.00	14,490.00	15,024.00	13,416.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	141,761.00	128,966.00	119,111.0	0	174,124.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17,570.00	
363,161.00	
4,180.00	
1,557.00	
3,687.00	
105,397.00	
1.00	
7.00	
4.00	
1,092.00	
10,040.00	
57,266.00	
563,962.00	

NO

W

E
SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	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	77,985.00	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	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
604.00	
307,145.00	
116.00	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	653.00	
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	808,083.00	
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111.00	
SUBTOTAL	:	272,980.00	274,715.00	284,324.00	284,693.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,116,712.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending October 31, 2015

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR	64,666.00	67,376.00	70,766.00	72,030.00	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	9.00	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	72,157.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

331.00	
274,838.00	
31.00	
275,200.00	

F

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

13,352.00	
1.00	
13,353.00	

F
SUBTOTAL:

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

1,088.00	
135.00	
1,223.00	

N
SUBTOTAL:

8600	SSI BLIND FREEDOM/W	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	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	222.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	152.00	159.00	166.00	135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,354.00	1,426.00	1,460.00	1,255.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
3,978.00	
902.00	
612.00	
5,495.00	

O

M
SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,296,286.00		

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	781,066.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,315,816.40	
2210	SSI DISABLED NON-ME	339,019.30	338,090.48	337,161.66	358,241.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,372,512.59	
	D														
2310	SSI BLIND NON-MEDIC	928.82	928.82	928.82	1,009.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,795.59	
	A														
4310	SOBRA CHILD NON-ME	13,288,627.74	13,621,145.30	13,792,048.18	14,711,097.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,412,918.36	
	DI														
5010	SOBRA PREGNANT WO	19,505.22	15,789.94	16,718.76	20,182.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,196.52	
	MAN														
SUBT	OTAL:	14,560,182.32	14,824,896.02	14,920,564.48	15,871,596.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,177,239.46	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending October 31, 2015

1,009.13

1,009.13

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

3710	AHC CARE EXPANDED
FO
SUBTOTAL:

307,638.31

307,638.31

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

F
SUBTOTAL:

60,485,886.90

14,633,559.10	14,896,415.16	14,987,439.52	15,968,473.12	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	774.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,503.00	
2210	SSI DISABLED NON-ME	365.00	364.00	363.00	355.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,447.00	
	D														
2310	SSI BLIND NON-MEDIC	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	
	A														
4310	SOBRA CHILD NON-ME	14,307.00	14,665.00	14,849.00	14,578.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,399.00	
	DI														
5010	SOBRA PREGNANT WO	21.00	17.00	18.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.00	
	MAN														
SUBT	OTAL:	15,676.00	15,961.00	16,064.00	15,728.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,429.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending October 31, 2015

1.00

1.00

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

3710	AHC CARE EXPANDED
FO
SUBTOTAL:

323.00

323.00

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

F
SUBTOTAL:

TOTAL:	15,755.00	16,038.00	16,136.00	15,824.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,753.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,008.42	1,008.42	1,008.42	1,474.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,499.58		
1010	TANF NON-MEDICARE	133,111.44	130,590.39	131,598.81	194,610.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589,910.88		
1011	TANF <1 M & F NON-ME	9,104.82	10,355.64	10,355.64	9,632.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,448.38		
1012	TANF 01-05 M & F NON	25,956.96	17,113.95	14,612.31	18,336.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,020.18		
1013	TANF 06-13 M & F NON	30,058.50	22,049.37	18,296.91	20,548.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,953.22		
1014	TANF 14-20 MALE NON-	8,513.34	6,845.58	6,098.97	5,921.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,379.77		
1015	TANF 14-20 FEMALE N	9,017.55	7,766.73	8,687.88	9,905.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,377.80		
1017	TANF 21-44 FEMALE N O	833.88	833.88	833.88	927.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,429.24		
2110	SSI AGED NON-MEDICA R	416.94	416.94	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,714.62		
2200	SSI DISABLED WITH M E	8,571.57	9,492.72	12,013.77	18,155.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,233.70		
2210	SSI DISABLED NON-ME D	3,071,131.98	3,075,185.07	3,070,908.99	4,422,630.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,639,856.04		
2220	SSI DISABLED WITH Q M	24,444.48	25,452.90	25,957.11	37,512.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,366.73		
2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	737.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,249.79		
2310	SSI BLIND NON-MEDIC A	27,624.87	28,129.08	27,624.87	39,640.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,019.62		
4311	SOBRA CHILD <1 M & F	21,273.72	19,935.63	18,180.60	24,292.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,682.51		
4312	SOBRA CHILD 01-05 M	137,425.89	146,162.22	148,906.26	180,325.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		612,819.69		
4313	SOBRA CHILD 06-13 M	130,832.34	140,421.96	154,045.26	197,710.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		623,009.64		
4314	SOBRA CHILD 14-20 MA	30,970.02	33,141.99	36,060.57	45,851.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,024.10		
4315	SOBRA CHILD 14-20 FE	35,226.69	37,815.60	35,886.03	47,433.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,361.68		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880.74		
5015	SOBRA PREG 14-20 FE M	3,005.85	2,588.91	2,171.97	2,592.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,359.09		
SUBTOTAL:	3,709,033.47	3,715,811.19	3,724,586.34	5,279,166.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,428,597.00		

O

1113	TANF EXPANDED 06-13	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	416.94	416.94	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	833.88	416.94	416.94	927.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
416.94	
463.80	
1,714.62	
2,595.36	

3514	ADULT 40-100% MALE 1	833.88	833.88	833.88	927.60	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	463.80	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	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	6,254.10	7,087.98	6,671.04	6,029.40	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	5,101.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	416.94	416.94	416.94	1,391.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	416.94	416.94	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	12,508.20	13,759.02	13,342.08	15,305.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,429.24	
2,965.44	
463.80	
463.80	
26,042.52	
17,193.06	
2,642.22	
1,714.62	
54,914.70	

AL
SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		1,250.82		
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		

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

 
25,363.98	
8,878.77	
3,476.10	
37,718.85	

16,525,076.73

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

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1010	TANF NON-MEDICARE	264.00	259.00	261.00	264.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,048.00		
1011	TANF <1 M & F NON-ME	21.00	24.00	24.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.00		
1012	TANF 01-05 M & F NON	61.00	40.00	34.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.00		
1013	TANF 06-13 M & F NON	70.00	51.00	42.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202.00		
1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
1015	TANF 14-20 FEMALE N	21.00	18.00	20.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.00		
1017	TANF 21-44 FEMALE N O	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2110	SSI AGED NON-MEDICA R	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2200	SSI DISABLED WITH M E	17.00	19.00	24.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.00		
2210	SSI DISABLED NON-ME D	6,177.00	6,184.00	6,175.00	6,182.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,718.00		
2220	SSI DISABLED WITH Q M	49.00	51.00	52.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2310	SSI BLIND NON-MEDIC A	56.00	57.00	56.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.00		
4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168.00		
4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	311.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,256.00		
4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,280.00		
4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		301.00		
4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		326.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5015	SOBRA PREG 14-20 FE M	7.00	6.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.00		
SUBTOTAL:	7,546.00	7,561.00	7,581.00	7,572.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,260.00		

O

1113	TANF EXPANDED 06-13	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
1.00	
4.00	
6.00	

3514	ADULT 40-100% MALE 1	2.00	2.00	2.00	2.00	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	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	15.00	17.00	16.00	13.00	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	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1.00	1.00	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	30.00	33.00	32.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8.00	
7.00	
1.00	
1.00	
61.00	
40.00	
6.00	
4.00	
128.00	

AL
SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		3.00		
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		

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

 
56.00	
19.00	
8.00	
83.00	

TOTAL:	7,596.00	7,612.00	7,627.00	7,645.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,480.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-286.63	
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	8,748.57	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	22,346.09	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	54,075.02	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	16,563.16	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	905,574.17	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	539,709.66	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	862,977.79	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	514,200.50	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	410,827.38	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	1,727,158.48	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	5,718,928.09	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	2,183,571.68	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	5,969.00	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	1,345.49	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	2,990.62	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	3,448.75	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	2,613.98	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	127,579.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	125,205.47	128,787.96	211,507.53	151,466.88	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	350,297.01	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	417,867.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	8,070,657.42	8,785,140.60	10,377,505.66	6,855,292.97	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	1,093,787.83	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	614.91	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	69,161.53	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	11,295.59	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	1,618,780.76	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	2,468,077.70	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	3,546,216.84	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	973,466.61	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	1,598,217.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	700.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

57,474.43	
78,610.37	
178,686.22	
65,094.11	
4,727,358.36	
3,812,398.43	
6,176,630.45	
1,569,850.12	
2,708,465.87	
7,789,237.65	
27,733,158.97	
9,912,550.32	
36,239.29	
4,637.83	
9,434.17	
47,984.68	
17,381.55	
660,246.42	
616,967.84	
1,594,293.29	
1,713,498.57	
34,088,596.65	
5,018,487.60	
6,220.30	
395,020.41	
61,460.17	
700.00	
8,086,282.67	
11,635,558.81	
17,736,118.06	
4,806,033.00	
6,238,097.41	
1,400.00	

D

M

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

M

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,357.53	1,572.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,929.70	
5015	SOBRA PREG 14-20 FE M	396,630.45	405,096.39	479,727.39	392,622.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,674,076.99	
5017	SOBRA PREG 21-44 FE M	1,708,550.06	2,049,753.34	2,625,202.28	1,982,900.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,366,406.51	
5018	SOBRA PREG 45-64 FE M	4,193.00	14,500.38	2,450.00	1,822.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,965.54	
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.47	
SUBTOTAL	:	38,912,715.23	42,227,968.93	51,870,791.41	34,642,089.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	167,653,565.23	

1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	10,284.15	10,175.29	17,463.56	6,713.81	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	29,098.84	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	47,375.02	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	25,925.52	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	1,174.70	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	9,267.93	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	9,618.73	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	16,406.84	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	353,039.43	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	1,114,194.80	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	747,280.96	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	1,050.00	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	1,605.60	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	2,711.75	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	9,612.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+	7,716.84	9,382.71	9,968.24	4,051.32	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	23,668.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	67,166.54	76,848.41	85,275.84	56,641.92	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	355,819.68	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	33,613.80	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	217,797.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	285,198.27	311,126.24	453,402.95	307,810.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,645,170.04	3,654,958.78	4,322,859.94	3,374,479.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

350.00	
44,636.81	
111,103.16	
285,715.30	
103,300.23	
107.79	
13,461.92	
84,156.97	
40,497.80	
110,186.31	
1,581,432.27	
4,961,387.70	
2,949,272.14	
4,387.57	
8,881.17	
15,388.78	
42,539.87	
31,119.11	
110,427.00	
285,932.71	
1,731,881.43	
89,447.41	
1,034,317.39	
1,357,537.79	
14,997,468.63	

M&

NO

E
SUBTOTAL:

3308	AHC CARE M&F 45-64 W	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-95.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	-527.88	0.00	-316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	-12,669.89	0.00	0.00	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
21.62	
-95.91	
-843.88	
-13,553.16	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14,471.33		

3410	MED ELIGIBILITY NON-	0.00	0.00	-99.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	60.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	-2,238.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-23,081.14	-52.99	-475.87	-491.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,251.30	-100.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	48,625.18	0.00	1,316.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	22,658.87	-52.99	14,341.74	-591.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

3506	ADULT 40-100% MALE 2	100.62	646.90	826.55	497.49	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	2,673.83	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	777.55	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	29,661.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	63,740.82	68,857.24	154,389.86	65,722.76	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	775,688.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	448,531.84	490,065.88	644,008.43	391,103.49	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	1,387,795.56	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	17,145.46	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	0.61	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	90.66	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 MALE	254.18	187.24	2,147.85	720.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	3,196.60	2,984.95	5,735.57	5,555.83	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	25,199.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	662.62	898.69	1,365.10	1,918.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	222,884.44	394,365.52	460,111.11	290,538.55	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	268,309.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	5,628,508.71	6,879,358.31	8,226,675.54	5,692,613.38	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	3,018,805.67	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	7,135,426.84	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	3,932.97	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	-612.98	2,336.87	599.83	1,113.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,071.56	
402.04	
20,177.58	
4,869.11	
95,333.94	
352,710.68	
2,769,462.53	
1,973,709.64	
7,175,607.13	
23,757.15	
211.56	
283.45	
471.64	
64.44	
3,309.56	
17,472.95	
96,767.00	
4,845.09	
1,367,899.62	
1,219,691.56	
26,427,155.94	
14,179,163.62	
33,079,356.00	
65,165.96	
166.20	
3,436.75	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	19,115,291.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,883,562.70		

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	21.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	2,100.00	392.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	8,274.29	12,110.91	11,447.94	6,297.36	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	1,418.20	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	11,240.21	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	25,293.64	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	433,207.58	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	478,333.08	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	912,240.75	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	1,050.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	47.11	350.00	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,757,825.94	2,095,784.57	2,416,331.87	1,869,494.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,421.47	
2,492.10	
38,130.50	
1,784.82	
54,785.40	
104,169.15	
1,623,292.52	
1,875,413.31	
4,433,290.99	
4,200.00	
456.51	
8,139,436.77	

4

4
SUBTOTAL:

4413	SOBRA 100-133% M&F
6	208,919.81	208,659.92	145,887.27	356,231.37	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	154,905.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	72,034.45	135,577.62	72,403.64	179,192.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	370,657.12	434,001.78	270,045.7	0	690,329.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
919,698.37	
386,127.45	
459,207.95	
1,765,033.77	

4517	BC PATIENT FEMALE 2 1	5,936.00	6,300.97	5,519.97	999.09	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	4,542.74	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	7,330.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	4,085.95	1,050.00	2,131.49	2,168.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	20,190.63	11,299.84	11,032.74	15,039.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18,756.03	
11,851.17	
17,520.49	
9,435.50	
57,563.19	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO	3,861.91	11,145.71	10,454.38	6,107.64	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	1,759.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	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	7,867.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

31,569.64	
6,721.06	
664.94	
38,955.64	

M

M

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

0.00

0.00

0.00

0.00

0.00

59,713,116.53

0.00

0.00	0.00

281,557,183.60

TOTAL:

1106	TANF EXPANDED 21-44	0.00	93.33	88.81	2,077.39	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	62.89	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	1,311.67	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	3,746.47	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	11,482.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:	587,535.49	650,200.47	696,955.04	585,072.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,519,763.80	
															
	2,259.53	
	746.23	
	9,412.40	
	515.10	
	10,156.08	
	66,887.00	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2015

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	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	3,484.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,654.33	
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	37.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.88	
1014	TANF 14-20 MALE NON-	1,639.96	371.56	1,298.43	1,214.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,524.05	
1015	TANF 14-20 FEMALE N	10,367.88	4,369.23	19,961.56	6,311.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,010.21	
	O														
1016	TANF 21-44 MALE NON-	27,978.02	35,547.13	51,358.56	38,612.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	153,496.08	
1017	TANF 21-44 FEMALE N	85,071.84	122,995.47	128,349.71	151,849.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	488,266.82	
	O														
1018	TANF 45-64 M & F NON	19,601.63	63,726.19	20,776.67	18,549.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,653.80	
2100	SSI AGED WITH MEDIC	4,288.93	2,161.00	6,039.80	3,610.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,099.77	
	A														
2110	SSI AGED NON-MEDICA	16,932.19	33,017.03	46,637.60	18,239.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	114,825.91	
	R														
2120	SSI AGED WITH QMB	0.00	807.00	131.79	1,379.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,318.27	
2200	SSI DISABLED WITH M	488.66	1,617.07	3,610.05	1,642.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,357.95	
	E														
2210	SSI DISABLED NON-ME	39,007.48	95,497.11	23,513.88	6,329.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	164,347.91	
	D														
2220	SSI DISABLED WITH Q	0.00	1,277.10	1,336.18	934.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,547.83	
	M														
2310	SSI BLIND NON-MEDIC	0.00	0.00	0.00	812.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	812.46	
	A														
4311	SOBRA CHILD <1 M & F	117,403.64	23,297.12	59,254.42	35,673.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	235,628.62	
4312	SOBRA CHILD 01-05 M	64,184.72	52,686.05	65,786.94	66,664.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	249,322.65	
4313	SOBRA CHILD 06-13 M	34,405.76	34,320.87	47,228.07	40,773.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	156,728.46	
4314	SOBRA CHILD 14-20 MA	34,112.02	13,654.57	40,427.51	19,191.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,385.50	
4315	SOBRA CHILD 14-20 FE	25,544.79	41,450.78	33,073.65	31,045.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	131,114.90	
5007	SOBRA PREG 21-44 FE	1,316.92	-622.54	620.43	373.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,687.82	
	M														
5015	SOBRA PREG 14-20 FE	17,081.33	30,674.40	30,351.24	28,628.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	106,735.33	
	M														
5017	SOBRA PREG 21-44 FE	77,766.50	80,269.95	104,810.09	109,667.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	372,514.01	
	M														
5018	SOBRA PREG 45-64 FE	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	
	M														
8040	SLMB	6,944.53	49.41	807.03	-83.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,717.94	
8050	QI1	959.34	1,438.39	130.47	132.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,660.21	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	31,143.56	46,456.94	70,887.40	33,885.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	182,372.99	
1118	TANF EXPANDED 45-64	29,015.56	33,956.75	60,010.71	18,273.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	141,256.88	
2400	SSI AGED EXPANDED WI	2,377.90	12,618.70	12,271.07	5,527.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,795.07	
2410	SSI AGED EXPANDED NO	979.32	10,480.42	0.00	3,960.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,419.74	
2420	SSI AGED EXPANDED	550.98	1,286.23	328.44	378.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,544.47	
2600	SSI DISABLED EXPAND E	2,818.70	1,835.75	7,785.00	2,326.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,766.06	
2610	SSI DISABLED EXPAND	3,572.35	3,805.02	18,910.75	13,966.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,254.92	
2620	SSI DISABLED EXPAND E	260.03	91.97	253.43	619.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,224.64	
SUBTOTAL	:	87,190.43	129,664.23	206,137.87	97,618.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	520,611.11	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2015

WI

E

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	10,267.58	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	8,412.79	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	50,616.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	32,478.15	34,588.71	42,476.30	26,676.78	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	145,967.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	83.25	1,075.63	243.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	35.04	0.00	128.60	309.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	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	1,293.45	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 MALE	-3,202.73	15,501.02	18,183.71	10,358.26	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	17,356.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	167,516.26	204,690.38	358,830.19	199,648.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	161,052.04	116,919.92	123,724.40	87,699.35	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	334,168.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	2,252.43	677.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,010,189.83	816,937.56	1,273,874.71	893,696.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

676.52	
29,059.30	
32,983.72	
158,973.03	
136,219.94	
520,099.58	
1,401.96	
473.06	
1,644.30	
2,618.80	
350.00	
40,840.26	
59,837.65	
930,685.46	
489,395.71	
1,586,508.75	
2,930.35	
3,994,698.39	

E

AL

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	76.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	125.54	0.00	50.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	90.99	700.00	234.31	0.00	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	2,071.23	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	1,970.89	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	55,695.29	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	74,500.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	88,508.51	131,570.76	163,768.01	128,365.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

76.00	
175.69	
1,025.30	
9,037.67	
22,621.21	
200,257.01	
209,641.33	
512,212.55	

4

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	160,593.88	215,500.31	316,273.51	262,679.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		955,046.76		

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

52,699.21	
24,447.17	
24,584.90	
101,731.28	

L

124.56

124.56

0.00	0.00	0.00	124.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	124.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4518	BC PATIENT FEMALE 4
5
SUBTOTAL:

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

3,954.71	
1,476.22	
5,430.93	

M
SUBTOTAL:

TOTAL:	1,855,914.20	1,832,578.06	2,547,501.78	1,861,412.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,097,406.83		

FAMILY PLANNING SERVICES
For The Period Ending October 31, 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 October 31, 2015

O

O

A

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	24,960.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,766.51	
1013	TANF 06-13 M & F NON	54,626.02	34,912.76	80,372.41	58,900.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	228,812.01	
1014	TANF 14-20 MALE NON-	65,319.99	60,239.51	137,076.35	98,293.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	360,929.39	
1015	TANF 14-20 FEMALE N	458,200.55	295,670.00	478,042.95	469,964.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,701,877.85	
1016	TANF 21-44 MALE NON-	60,888.08	100,933.93	31,723.66	82,988.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	276,534.16	
1017	TANF 21-44 FEMALE N	2,670,623.86	2,730,005.88	3,324,170.96	2,879,155.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,603,956.46	
1018	TANF 45-64 M & F NON	115,318.65	114,094.17	197,992.93	147,100.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	574,506.72	
1019	TANF 65+ M & F NON-M	974.37	580.16	36,530.93	189.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,274.93	
2100	SSI AGED WITH MEDIC A	1,028.00	1,134.36	2,508.08	3,684.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,354.88	
2110	SSI AGED NON-MEDICA R	767,030.64	976,118.47	1,135,999.12	1,013,075.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,892,223.47	
2120	SSI AGED WITH QMB	0.00	1,247.40	0.00	491.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,738.45	
2200	SSI DISABLED WITH M E	15,487.16	14,895.52	19,590.18	15,828.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,801.83	
2210	SSI DISABLED NON-ME D	388,846.01	233,518.99	496,312.04	330,185.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,448,862.26	
2310	SSI BLIND NON-MEDIC	-213.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-213.81	
SUBTOTAL	:	4,601,455.29	4,572,491.25	5,962,347.42	5,124,818.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,261,112.53	

1106	TANF EXPANDED 21-44	942.36	1,534.47	1,505.09	822.46	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	890.41	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	627.92	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	9,094.01	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	20,183.82	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	505,905.51	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	1,183,824.04	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	493,587.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+	5,837.82	4,006.70	13,397.27	6,670.37	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	378.59	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	49,583.24	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	49.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	34,997.13	35,849.69	53,494.32	45,988.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,597,437.04	1,711,374.62	2,288,194.10	2,317,605.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,804.38	
3,129.58	
5,864.44	
312.04	
18,115.30	
67,669.30	
1,764,737.03	
3,963,277.18	
1,639,627.80	
29,912.16	
4,377.67	
240,579.78	
1,875.04	
170,329.96	
7,914,611.66	

M&

E
SUBTOTAL:

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	1,408.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	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	
2,639.54	
83.87	

4

FEDERAL EMERGENCY SERVICES
For The Period Ending October 31, 2015

4

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	96.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96.03	
3715	ADULT <40% EXP FEM AL	0.00	689.22	934.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,623.28	
3716	ADULT <40% EXP MALE	3,173.56	985.83	1,307.20	1,210.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,677.48	
3717	ADULT <40% EXP FEM AL	7,385.92	3,761.60	4,166.17	795.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,108.84	
3718	ADULT <40% EXP M&F	6,017.10	34,892.69	1,317.28	2,900.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,127.88	
SUBTOTAL	:	17,571.92	44,680.95	10,620.17	6,411.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,284.37	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	61.58	57.52	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	2,455.88	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	294.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	22,970.43	28,098.00	35,654.89	64,365.00	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	43,281.81	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	689,690.10	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	295,796.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	894,595.81	1,176,047.32	1,802,982.03	1,288,816.29	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	11,314.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA	46.58	46.58	718.50	666.40	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	694.28	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	2,397,433.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

119.10	
12,386.79	
294.80	
151,088.32	
173,700.02	
2,500,400.17	
1,238,386.70	
5,162,441.45	
32,753.37	
1,478.06	
2,778.29	
9,275,827.07	

4

L

TOTAL:	7,918,039.06	8,328,534.57	11,437,992.44	9,846,269.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,530,835.63		

QMB - FEE FOR SERVICE
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	293,436.77	211,412.30	493,734.53	374,615.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,373,199.42	
SUBTOTAL:	293,436.77	211,412.30	493,734.53	374,615.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,373,199.42	
														
TOTAL:	293,436.77	211,412.30	493,734.53	374,615.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,373,199.42	

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	3,227.31	2,397.42	0.00	5,425.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,050.65		
2100	SSI AGED WITH MEDIC A	15,412.32	89,978.84	21,245.35	45,417.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172,054.38		
2110	SSI AGED NON-MEDICA R	61,148.18	60,953.07	9,698.95	112,583.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,383.25		
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	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	2,769.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,583.26		
2220	SSI DISABLED WITH Q	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	166,196.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454,642.77		

E

M

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

4,242.49	
12,286.74	
16,529.23	

E
SUBTOTAL:

3516	ADULT 40-100% MALE 2	276.08	465.25	113.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	2,286.61	1,389.07	109,186.74	177.18	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	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	48,908.37	28,993.62	20,991.36	10,383.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	108.35	23,795.80	2,084.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	282,960.57	239,237.96	160,049.34	141,590.13	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	15,778.68	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	224,311.09	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 MALE	73.01	0.00	-57.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	9,628.14	5,770.49	8,615.35	434.96	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	394,775.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

854.41	
113,039.60	
15.96	
109,276.51	
25,988.80	
823,838.00	
103,175.81	
1,109,956.38	
1,495.64	
15.96	
24,448.94	
2,312,106.01	

4

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

42,507.36	
43,104.88	
85,612.24	

4
SUBTOTAL:

TOTAL:	700,502.56	965,459.39	631,465.59	571,462.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,868,890.25		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	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		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	274.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274.42		
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	274.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,268.18		

TOTAL:

151.74

3,842.02	0.00

274.42

0.00	0.00	0.00	0.00

0.00

0.00

0.00

0.00

4,268.18

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	0.00	0.00	7,504.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,504.65		
1016	TANF 21-44 MALE NON-	2,440.29	3,129.66	300.47	366.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,237.12		
1017	TANF 21-44 FEMALE N O	0.00	2,041.21	946.05	3,936.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,923.90		
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	18,422.83	10,195.76	34,766.80	17,317.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,703.10		
2220	SSI DISABLED WITH Q M	15.35	3,019.90	3,735.46	357.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,128.57		
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	2,411.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,411.86		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	3,666.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,666.59		
5017	SOBRA PREG 21-44 FE M	0.00	5,306.85	4,658.33	5,451.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,416.35		
SUBTOTAL:	20,878.47	34,444.77	51,911.76	33,508.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,743.53		

D

M

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	2,757.38	5,096.64	0.00	70.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	20,603.73	5,096.64	0.00	70.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,673.93	
14,172.42	
7,924.24	
25,770.59	

E
SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	4,010.58	2,822.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	16,799.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	0.00	0.00	0.00	83.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	1,298.03	229.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	69,878.66	66,286.32	10,893.65	95,669.19	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	13,269.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	49,207.81	47,104.83	15,084.95	62,449.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	124,338.03	133,446.71	33,662.00	174,523.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,833.38	
16,799.05	
83.10	
1,527.53	
242,727.82	
24,152.26	
173,847.21	
465,970.35	

AL

4
SUBTOTAL:

149.02

15,153.54

15,302.56

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	149.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	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	149.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4

503.71

503.71

0.00	0.00	503.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
0.00	0.00	503.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8720	SSI DISABLED FREEDO	0
M
SUBTOTAL:

TOTAL:	180,973.77	172,988.12	86,077.47	208,251.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		648,290.74		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	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	8,752.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,063.48	
SUBTOTAL	:	338.81	2,844.58	4,099.32	8,752.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,034.80	

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

 
526.42	
112.96	
639.38	

3516	ADULT 40-100% MALE 2	0.00	0.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	79.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	13,355.83	4,487.44	0.00	6,733.15	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	2,778.01	10,131.21	950.60	14,425.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	16,189.14	14,618.65	968.10	21,238.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17.50	
79.49	
24,576.42	
55.30	
28,285.81	
53,014.52	

4
SUBTOTAL:

69,688.70

17,076.20	17,463.23	5,067.42	30,081.85	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	
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	327.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,118.29	
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	327.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,520.93	

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2015

3716	ADULT <40% EXP MALE	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	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	3,531.90	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	3,531.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,438.74	
144.34	
20,196.94	
21,780.02	

AL

TOTAL:	8,166.82	-863.22	16,137.69	3,859.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,300.95		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	9,251.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,251.66		
3716	ADULT <40% EXP MALE	306.05	0.00	166.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		472.31		
SUBTOTAL:	306.05	0.00	166.26	9,251.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,723.97		

9,723.97

306.05	0.00	166.26	9,251.66	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	
2210	SSI DISABLED NON-ME D	0.00	177.03	0.00	4,575.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,752.19	
SUBTOTAL	:	0.00	177.03	0.00	4,575.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,752.19	

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2015

3716	ADULT <40% EXP MALE	0.00	673.35	580.79	372.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	0.00	3,152.09	110.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	258.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	4,084.05	691.59	372.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,626.68	
3,262.89	
258.61	
5,148.18	

AL

TOTAL:	0.00	4,261.08	691.59	4,947.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,900.37		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending October 31, 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	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		700.00		
2100	SSI AGED WITH MEDIC A	1,867,476.11	2,106,357.37	3,001,652.11	2,153,315.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,128,800.84		
2110	SSI AGED NON-MEDICA R	177,147.26	101,345.13	299,519.40	157,341.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		735,353.64		
2120	SSI AGED WITH QMB	2,867,399.51	2,877,254.51	4,110,836.71	2,939,351.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,794,842.01		
2200	SSI DISABLED WITH M	543,524.04	474,214.50	724,208.95	536,644.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,278,592.25		
2210	SSI DISABLED NON-ME D	2,493,153.38	2,750,175.45	3,099,509.74	2,474,403.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,817,242.02		
2220	SSI DISABLED WITH Q	639,532.10	693,460.39	974,750.74	671,858.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,979,601.48		
2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193.73		
2310	SSI BLIND NON-MEDIC A	22,797.15	14,440.58	16,725.82	12,338.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,302.36		
2320	SSI BLIND WITH QMB	5,463.78	7,778.92	7,725.25	5,362.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,329.97		
SUBTOTAL:	8,616,568.26	9,025,376.85	12,234,988.12	8,951,025.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,827,958.30		

E

M

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

9,558.87	
10,904.04	
20,462.91	

M
SUBTOTAL:

38,848,421.21

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

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2015

D

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	4,497.83	12,645.58	24,804.14	14,473.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,420.91	
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	399.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	399.80	
2120	SSI AGED WITH QMB	0.00	83.04	41.43	0.00	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	314.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,255.31	
2210	SSI DISABLED NON-ME	10,415.23	19,351.87	894.64	5,932.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,594.40	
SUBTOTAL	:	15,485.93	33,992.59	32,196.13	21,120.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	102,794.89	

TOTAL:	15,485.93	33,992.59	32,196.13	21,120.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,794.89		

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	18,932.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	120,845.13	
1013	TANF 06-13 M & F NON	101,743.02	26,444.15	55,447.66	40,252.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223,887.06	
1014	TANF 14-20 MALE NON-	8,473.78	2,483.13	8,146.57	6,639.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,743.03	
1015	TANF 14-20 FEMALE N	3,292.00	1,194.76	3,063.63	2,548.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,098.41	
	O														
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	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	
	E														
2210	SSI DISABLED NON-ME	252,041.30	84,309.59	219,296.65	140,342.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	695,990.15	
	D														
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	23.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.96	
	M														
2300	SSI BLIND WITH MEDIC	158.70	63.48	0.00	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	238.05	
2310	SSI BLIND NON-MEDIC	2,989.18	538.14	1,847.47	1,001.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,376.01	
	A														
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	41,184.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	207,425.05	
4313	SOBRA CHILD 06-13 M	138,639.38	30,827.76	103,590.12	109,202.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	382,259.42	
4314	SOBRA CHILD 14-20 MA	12,134.57	3,360.74	12,303.21	9,010.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,809.31	
4315	SOBRA CHILD 14-20 FE	3,881.60	1,365.86	4,314.96	4,418.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,981.40	

SUBTOTAL:	
642,887.52	
188,308.71	
519,661.06	
373,572.92	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,724,430.21	

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending October 31, 2015

1,044.56

9,309.05

274.05

277.42

210.61

11,115.69

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	84.66	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	1,018.60	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	29.47	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	96.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	210.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,732.49	3,154.87	3,999.21	1,229.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

E
SUBTOTAL:

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	6.83	27.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	1,726.70	9.31	990.53	137.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM	1,319.96	0.00	149.20	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,053.49	48.92	1,139.73	151.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12.33	
34.11	
2,863.83	
1,483.16	
4,393.43	

AL

AL
SUBTOTAL:

4413	SOBRA 100-133% M&F
6	25,022.12	4,486.95	12,154.90	21,398.13	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	1,731.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	515.37	640.27	290.86	918.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	33,611.25	5,777.00	13,916.56	24,047.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

63,062.10	
11,925.71	
2,364.84	
77,352.65	

L
SUBTOTAL:

1,817,291.98

682,284.75	197,289.50	538,716.56	399,001.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending October 31, 2015

M

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	831.19	0.00	115.74	154.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,101.29	
1010	TANF NON-MEDICARE	40,868.65	24,234.06	48,725.89	26,485.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140,314.18	
2200	SSI DISABLED WITH M E	2,871.13	789.16	3,394.59	1,281.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,336.35	
2210	SSI DISABLED NON-ME D	1,249,307.80	489,106.70	1,265,880.28	765,381.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,769,676.16	
2220	SSI DISABLED WITH Q	2,114.42	-248.86	3,650.67	2,135.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,651.53	
2310	SSI BLIND NON-MEDIC A	7,193.15	6,514.48	11,947.59	4,341.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,996.50	
SUBTOTAL	:	1,303,186.34	520,395.54	1,333,714.76	799,779.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,957,076.01	

TOTAL:	1,303,186.34	520,395.54	1,333,714.76	799,779.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,957,076.01		

ACUTE REINSURANCE
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	98.96	0.00	0.01	17,434.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,533.79		
1011	TANF <1 M & F NON-ME	741,618.20	275,323.86	870,817.73	584,132.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,471,892.58		
1012	TANF 01-05 M & F NON	59,967.01	17,049.65	46,379.51	20,619.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,016.00		
1013	TANF 06-13 M & F NON	184,625.99	341,772.36	71,256.85	294,266.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		891,921.48		
1014	TANF 14-20 MALE NON-	12,269.60	19,354.41	57,649.19	33,553.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,827.01		
1015	TANF 14-20 FEMALE N O	18,361.96	12,714.48	18,838.21	15,383.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,298.43		
1016	TANF 21-44 MALE NON-	161,649.37	-21,881.23	40,292.26	305,406.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		485,467.23		
1017	TANF 21-44 FEMALE N O	127,936.47	159,048.89	395,075.50	504,125.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,186,186.28		
1018	TANF 45-64 M & F NON	84,129.25	65,348.37	87,293.71	207,392.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		444,163.45		
2100	SSI AGED WITH MEDIC A	624.78	33,070.16	362.69	24,212.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,269.90		
2110	SSI AGED NON-MEDICA R	67,861.38	195,769.67	82,798.86	187,110.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		533,539.94		
2200	SSI DISABLED WITH M E	43,874.36	10,496.70	3,907.51	14,759.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,038.23		
2210	SSI DISABLED NON-ME D	4,045,297.65	3,940,603.94	4,946,163.58	5,434,310.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,366,376.10		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	79,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,766.51		
2310	SSI BLIND NON-MEDIC	40,412.86	2,873.76	1,068.77	-75,896.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-31,541.57		
4311	SOBRA CHILD <1 M & F	929,626.36	754,864.21	1,574,042.96	1,471,872.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,730,406.42		
4312	SOBRA CHILD 01-05 M	114,463.42	359,348.65	667,111.14	108,235.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,249,159.16		
4313	SOBRA CHILD 06-13 M	239,870.36	136,192.59	249,120.95	-32,500.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		592,683.75		
4314	SOBRA CHILD 14-20 MA	115,773.80	89,801.77	118,016.08	142,705.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		466,297.52		
4315	SOBRA CHILD 14-20 FE	14,027.07	63,132.41	6,858.73	138,256.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,274.63		
5015	SOBRA PREG 14-20 FE M	0.00	9,507.28	408.56	4,728.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,644.04		
5017	SOBRA PREG 21-44 FE M	8,128.10	28,115.83	25,201.81	42,704.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,149.88		
SUBTOTAL:	7,010,616.95	6,492,507.76	9,262,664.61	9,522,581.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,288,370.76		

A

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	329.59	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	-8.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	505.48	6,432.42	-7.13	0.00	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	71,614.65	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	118,004.81	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	378,310.42	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	25.93	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	46,616.48	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	39,071.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	20,284.70	72,266.71	62,393.79	63,319.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	316,711.60	410,028.71	481,700.7	7	717,276.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,512.49	
-8.67	
6,930.77	
363,321.32	
378,090.55	
669,575.73	
94.49	
153,243.07	
134,693.77	
218,264.42	
1,925,717.94	

E
SUBTOTAL:

3316	AHC CARE MALE 21-44	22.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22.30

ACUTE REINSURANCE
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	3,631.95	
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	3,654.25	

3410	MED ELIGIBILITY NON-	0.00	0.00	-5,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	9,760.41	0.00	0.00	3,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	37,956.14	-1,579.93	-10,803.56	3,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-5,724.35	
13,341.66	
21,536.59	
29,153.90	

3508	ADULT 40-100% M&F 45	-1,247.11	6.67	2.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	90,377.57	23.98	303.56	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	39,148.26	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	213,702.36	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	95,096.25	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	367,780.84	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	-1,549.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	150,958.00	173,540.11	140,658.64	168,686.95	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	70,131.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	502,179.54	650,833.61	591,737.89	1,117,820.73	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	399,461.42	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	2,023,672.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	1,152.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,668,847.78	2,823,947.50	2,802,363.03	4,495,407.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-1,238.16	
90,705.11	
63,824.35	
536,671.94	
463,139.84	
1,372,705.57	
2,767.51	
59,433.90	
633,843.70	
305,619.09	
2,862,571.77	
1,004,858.79	
5,394,509.53	
1,152.60	
12,790,565.54	

6
SUBTOTAL:

3908	NEWLY ELIGIBLE M&F 4	75,258.45	0.00	21,217.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,356.93	0.00	0.00	19,045.28	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	103,240.00	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	38,254.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	163,410.54	348,055.35	252,590.82	236,488.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	276,371.96	479,009.69	344,793.7	4	397,029.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

96,476.19	
23,402.21	
296,866.32	
79,914.21	
1,000,545.66	
1,497,204.59	

4
SUBTOTAL:

4413	SOBRA 100-133% M&F
6	19,844.57	10,180.96	21,606.21	141,092.28	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	679,863.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	188.17	9,280.96	106.64	4,451.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	471,134.63	470,569.59	447,840.7	9	825,407.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

192,724.02	
2,008,201.19	
14,027.29	
2,214,952.50	

L
SUBTOTAL:

6,209.80

855.98

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

5

ACUTE REINSURANCE
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	6,209.80	0.00	0.00	855.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,065.78		

M														
10,381.76	
SUBTOTAL:														10,381.76	
TOTAL:	10,791,209.52	10,677,372.35	13,331,154.82	15,967,330.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,767,067.02	

8710	SSI DISABLED FREEDO	2,595.44	0.00	2,595.44	5,190.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,595.44	0.00	2,595.44	5,190.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

LONG TERM CARE REINSURANCE
For The Period Ending October 31, 2015

D

8710	SSI DISABLED FREEDO	12,568.90	358.45	-18.28	10.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	12,568.90	358.45	-18.28	10.23	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	
1010	TANF NON-MEDICARE	0.00	43.57	0.00	34,024.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,067.62	
2100	SSI AGED WITH MEDIC A	327,108.06	281,473.61	410,214.64	182,410.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,201,206.81	
2110	SSI AGED NON-MEDICA R	218,322.47	133,627.59	139,813.52	145,656.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	637,420.16	
2200	SSI DISABLED WITH M E	644,979.13	626,909.22	541,936.81	444,452.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,258,278.05	
2210	SSI DISABLED NON-ME	2,840,717.50	2,796,391.98	3,888,127.51	3,540,048.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,065,285.51	
2310	SSI BLIND NON-MEDIC A	2,067.18	829.15	61,461.10	4,145.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,502.56	
SUBTOTAL	:	4,033,194.34	3,839,275.12	5,041,553.58	4,350,737.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,264,760.71	

M													12,919.30	
SUBTOTAL	:													12,919.30	
TOTAL:	4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,277,680.01		

ACUTE SMIB
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	194,274.80	239,591.60	285,013.30	307,878.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,026,757.70	
1010	TANF NON-MEDICARE	419.60	314.70	419.60	419.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,573.50	
1020	TANF WITH QMB	59,218.50	89,224.80	136,060.20	153,998.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	438,501.60	
2100	SSI AGED WITH MEDIC A	55,177.40	57,030.30	58,179.30	62,320.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	232,707.40	
2110	SSI AGED NON-MEDICA	390,962.30	405,066.70	409,640.00	406,988.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,612,657.40	
2120	SSI AGED WITH QMB	1,817,089.90	1,837,723.90	1,860,966.00	1,885,790.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,401,569.90	
2200	SSI DISABLED WITH M	156,570.80	143,157.80	137,314.10	138,468.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	575,510.70	
2210	SSI DISABLED NON-ME D	332,008.50	338,302.50	334,945.70	338,302.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,343,559.20	
2220	SSI DISABLED WITH Q M	2,831,922.00	2,873,883.50	2,914,800.20	2,923,716.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,544,321.80	
2300	SSI BLIND WITH MEDIC	419.60	419.60	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,468.60	
2310	SSI BLIND NON-MEDIC A	3,251.90	3,356.80	3,042.10	2,937.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,588.00	
2320	SSI BLIND WITH QMB	25,071.10	24,336.80	25,910.30	25,805.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,123.60	
4300	SOBRA CHILD WITH ME D	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419.60	
4320	SOBRA CHILD WITH Q MB	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419.60	
5000	SOBRA PREGNANT WO	1,363.70	1,363.70	1,153.90	944.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,825.40	
5020	SOBRA PREGNANT WO MAN	944.10	839.20	1,153.90	944.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,881.30	
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	555,491.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,211,340.60	
8040	SLMB	3,389,057.50	3,504,045.60	3,489,229.70	3,653,533.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,035,866.20	
8888	SMIB ONLY NOT ELIGIB	-52,359.80	-26,959.30	-20,035.90	-24,127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-123,482.00	
9999	SMIB ONLY NOT ELIGIB	59,066.30	19,847.50	122,106.60	172,423.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	373,443.80	
SUBTOTAL	:	9,808,185.80	10,062,146.60	10,322,154.00	10,606,357.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,798,844.10	

R

E

MAN

1100	TANF EXPANDED FPR FI	470,376.20	412,891.00	362,329.20	338,157.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	209.80	104.90	104.90	104.90	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	103,116.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED	3,042.10	1,468.60	1,253.90	419.60	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	419.60	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	2,887,841.00	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	104.90	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	-104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	1,653,183.80	1,727,813.10	1,756,040.70	1,816,932.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	5,183,901.40	5,190,720.50	5,113,158.90	5,146,991.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,583,753.50	
524.50	
471,575.50	
6,184.20	
1,993.10	
11,616,351.70	
419.60	
0.00	
6,953,970.30	
20,634,772.40	

FI

WI

E
SUBTOTAL:

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

7,907.50	
8,182.20	
16,089.70	

FO
SUBTOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR
F	1,468.60	734.30	839.20	629.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,671.50	
SUBTOTAL:	1,468.60	734.30	839.20	629.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,671.50	

M													90,004.20	
SUBTOTAL:													90,004.20	

ACUTE SMIB
For The Period Ending October 31, 2015

61,543,381.90

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

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

TOTAL:

ACUTE HIB
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	407.00	-407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	2,442.00	-814.00	0.00	-557.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,070.50		
2120	SSI AGED WITH QMB	173,720.20	179,916.50	193,518.70	197,193.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		744,349.20		
2220	SSI DISABLED WITH Q M	88,616.20	96,125.80	110,636.10	112,246.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		407,624.20		
2320	SSI BLIND WITH QMB	407.00	407.00	407.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,628.00		
8000	SMIB ONLY NOT ELIGIB	0.00	0.00	0.00	-887.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-887.30		
8020	QMB ONLY	4,988.10	2,953.10	3,645.00	5,761.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,347.60		
9999	SMIB ONLY NOT ELIGIB	-8,404.70	-4,538.50	-4,375.40	-7,780.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-25,098.60		
SUBTOTAL:	261,768.80	274,049.90	304,238.4	0	305,976.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,146,033.60		

31,416.80

31,416.80

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

WI
SUBTOTAL:

270,418.00

282,577.00

TOTAL:

309,894.80

0.00

0.00

0.00

0.00

0.00

1,177,450.40

314,560.60

0.00

0.00	0.00

Q1
For The Period Ending October 31, 2015

SUBTOTAL:	2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,291,533.50	
															
TOTAL:	2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,291,533.50	

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,434,626.70	1,985,923.60	1,946,933.20	1,994,198.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,361,681.50	
9999	SMIB ONLY NOT ELIGIB	-35,141.50	-2,907.10	-18,986.90	-13,112.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-70,148.00	

LTC SMIB
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	524.50	419.60	419.60	419.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,783.30		
1020	TANF WITH QMB	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		419.60		
2100	SSI AGED WITH MEDIC A	874,183.40	870,946.20	868,154.40	873,399.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,486,683.40		
2110	SSI AGED NON-MEDICA R	155,566.70	157,769.60	157,769.60	157,664.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		628,770.60		
2120	SSI AGED WITH QMB	764,559.10	761,981.70	777,780.80	770,483.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,074,805.10		
2200	SSI DISABLED WITH M E	319,840.10	329,595.80	321,623.40	322,567.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,293,626.80		
2210	SSI DISABLED NON-ME	15,630.10	25,513.40	17,308.50	18,147.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,599.70		
2220	SSI DISABLED WITH Q M	710,227.60	707,605.10	709,170.10	710,332.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,837,335.30		
2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,251.90		
2310	SSI BLIND NON-MEDIC A	209.80	104.90	209.80	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		629.40		
2320	SSI BLIND WITH QMB	4,300.90	4,510.70	4,405.80	4,405.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,623.20		
SUBTOTAL:	2,846,091.20	2,859,286.20	2,857,681.20	2,858,469.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,421,528.30		

D

2,622.50

2,622.50

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

M
SUBTOTAL:

TOTAL:	2,846,825.50	2,859,915.60	2,858,310.60	2,859,099.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,424,150.80		

LTC HIB
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2110	SSI AGED NON-MEDICA R	407.00	0.00	1,221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,628.00	
2120	SSI AGED WITH QMB	256,094.80	261,120.80	256,136.10	250,816.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,024,168.30	
2200	SSI DISABLED WITH M E	0.00	407.00	0.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	814.00	
2220	SSI DISABLED WITH Q M	12,923.00	14,144.00	12,516.00	7,909.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,492.20	
SUBTOTAL	:	269,424.80	275,671.80	269,873.10	259,132.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,074,102.50	
															
TOTAL:		269,424.80	275,671.80	269,873.10	259,132.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,074,102.50	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	2,265.53	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	6,151.20	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	20,087.85	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	6,523.30	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	404,783.59	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	375,548.29	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	664,270.88	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	463,703.61	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	297,693.87	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	1,029,311.82	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	3,816,257.90	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	1,291,244.17	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	3,150.00	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	130.83	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	1,147.97	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	2,792.64	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	1,605.11	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	33,984.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	60,414.26	72,757.77	86,289.46	47,067.16	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	143,751.63	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	119,909.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	3,959,038.86	4,322,461.60	5,500,714.34	3,203,783.82	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	349,244.88	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	606.14	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	39,540.77	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	2,292.59	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	1,024,305.43	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	1,843,748.57	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	2,636,227.61	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	698,721.56	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	1,243,516.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	700.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,526.60	
23,502.01	
65,564.84	
26,795.88	
2,454,636.27	
2,819,792.61	
5,223,817.03	
1,277,183.23	
2,178,524.99	
5,003,419.34	
19,388,706.65	
6,373,007.39	
17,392.65	
1,586.43	
4,763.63	
21,044.88	
9,865.83	
223,249.05	
266,528.65	
741,348.77	
529,076.37	
16,985,998.62	
1,727,923.48	
3,159.13	
184,162.97	
20,617.28	
700.00	
5,566,047.10	
9,040,000.85	
14,498,814.60	
3,711,629.27	
4,845,221.52	
1,400.00	

D

M

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

M

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	350.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	
5015	SOBRA PREG 14-20 FE M	237,999.22	275,437.95	329,140.16	268,427.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,111,004.66	
5017	SOBRA PREG 21-44 FE M	1,131,352.11	1,456,601.24	1,697,144.79	1,250,264.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,535,362.48	
5018	SOBRA PREG 45-64 FE M	4,193.00	1,958.21	2,450.00	1,400.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,001.21	
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.47	
SUBTOTAL	:	25,879,075.44	28,064,777.16	34,666,425.32	21,293,810.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,904,088.74	

1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	2,193.53	4,316.53	6,771.33	2,886.65	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	8,070.42	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	16,412.58	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	10,530.63	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	1,050.00	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	7,174.88	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	8,114.99	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	13,550.27	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	250,318.04	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	811,845.95	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	459,352.65	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	1,050.00	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	215.52	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	1,332.43	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	1,945.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+	3,939.78	7,378.95	8,307.81	2,632.75	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	10,621.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	44,953.28	27,103.71	42,572.30	50,664.46	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	144,543.45	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	8,264.20	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	74,149.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	85,508.30	104,493.60	148,434.94	93,586.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,315,297.75	2,332,941.48	2,684,900.21	1,978,313.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

350.00	
16,168.04	
30,242.81	
97,111.54	
45,304.28	
0.00	
11,957.52	
75,582.57	
28,377.66	
99,094.58	
1,105,703.50	
3,794,101.69	
2,006,844.05	
3,175.17	
2,179.09	
8,089.88	
11,015.14	
22,259.29	
56,256.72	
165,293.75	
811,660.49	
33,607.07	
455,054.07	
432,023.68	
9,311,452.59	

M&

NO

E
SUBTOTAL:

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 October 31, 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	497.49	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	1,695.56	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	777.55	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	21,098.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	39,467.46	45,163.63	63,499.13	36,273.42	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	436,649.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	316,477.56	364,737.12	475,335.36	280,789.77	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	853,672.09	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	17,145.46	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	75.28	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 MALE	357.00	187.24	1,790.82	720.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	1,396.64	1,663.61	3,351.85	967.89	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	9,426.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	550.16	545.25	1,197.56	1,260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	165,528.85	261,775.93	267,888.88	187,172.51	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	163,391.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	3,029,287.38	3,988,308.94	4,654,737.86	3,315,942.24	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	1,949,322.89	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	3,932,359.26	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	1,017.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	476.33	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,795.46	
402.04	
8,679.09	
4,671.24	
76,418.55	
184,403.64	
1,590,404.43	
1,437,339.81	
4,286,126.60	
22,459.46	
211.56	
120.80	
0.00	
64.44	
3,055.35	
7,379.99	
36,422.91	
3,552.97	
882,366.17	
852,451.07	
14,988,276.42	
9,305,592.55	
19,132,240.71	
9,606.96	
0.00	
1,176.33	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	11,210,955.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,835,218.55		

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	392.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	5,768.03	7,449.33	2,569.39	3,983.75	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	1,418.20	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	7,700.00	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	20,252.28	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	279,292.12	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	355,651.52	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	599,685.22	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	1,050.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	0.00	350.00	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,180,866.48	1,241,698.82	1,599,657.76	1,269,425.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,400.00	
2,492.10	
19,770.50	
1,784.82	
36,505.64	
85,575.21	
1,014,774.01	
1,378,106.87	
2,746,629.70	
4,200.00	
409.40	
5,291,648.25	

4

4
SUBTOTAL:

4413	SOBRA 100-133% M&F
6	189,176.92	189,687.05	133,832.64	285,206.25	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	129,174.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	64,105.03	76,235.87	69,956.78	127,357.54	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	541,737.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
797,902.86	
331,846.49	
337,655.22	
1,467,404.57	

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

15,481.77	
9,296.47	
1,400.00	
7,954.37	
34,132.61	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO	209.72	5,846.12	5,390.39	2,833.23	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	1,759.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	59.40	237.60	163.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,369.12	6,433.72	5,792.51	4,592.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14,279.46	
4,447.96	
460.68	
19,188.10	

M

M

TOTAL:	41,159,756.52	45,693,704.25	55,704,123.37	36,305,180.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178,862,764.42		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	6,381.31	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	15,691.14	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	33,021.35	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	10,039.86	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	313,406.39	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	145,229.43	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	192,348.16	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	49,531.89	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	104,486.80	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	586,447.11	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	1,715,630.63	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	847,305.45	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	2,819.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1026	TANF 21-44 MALE WITH	0.00	358.05	1,478.69	1,214.66	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	1,842.65	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	633.37	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	1,008.87	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	88,139.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	64,152.89	46,997.31	91,231.24	102,587.31	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	198,249.01	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	291,180.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	3,771,166.39	3,833,723.81	4,457,896.20	3,339,155.66	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	712,906.83	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	8.77	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	28,967.10	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	8,794.19	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	520,995.09	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	578,583.31	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	861,311.80	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	260,211.19	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	294,852.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

45,394.81	
52,343.35	
107,353.83	
38,200.79	
1,997,566.03	
928,793.71	
914,235.27	
281,521.85	
497,753.73	
2,544,020.87	
7,607,698.99	
3,348,954.56	
18,596.91	
3,051.40	
4,670.54	
23,189.34	
7,515.72	
396,887.66	
304,968.75	
823,620.66	
1,121,336.77	
15,401,942.06	
3,128,257.36	
2,530.46	
205,897.06	
40,099.51	
0.00	
2,219,401.39	
2,378,201.38	
3,005,075.34	
962,349.40	
1,252,829.68	
0.00	

D

M

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2015

M

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,007.53	1,222.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,229.70	
5015	SOBRA PREG 14-20 FE M	134,500.45	112,857.97	124,462.39	103,103.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	474,924.12	
5017	SOBRA PREG 21-44 FE M	505,008.76	490,355.70	786,301.26	601,673.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,383,339.59	
5018	SOBRA PREG 45-64 FE M	0.00	12,542.17	0.00	422.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,964.33	
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	11,929,298.55	12,793,707.33	15,798,308.51	12,019,402.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,540,716.92	

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	8,090.62	5,444.07	10,692.23	3,827.16	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	19,870.38	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	30,333.33	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	15,362.85	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	124.70	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	2,093.05	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	1,282.18	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	2,856.57	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	98,803.74	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	263,654.55	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	273,091.81	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	1,390.08	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	1,321.14	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	7,667.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+	3,777.06	2,003.76	1,660.43	1,418.57	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	10,974.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	21,709.26	49,550.80	38,796.40	5,977.46	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	205,237.08	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	20,022.37	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	27,616.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	194,924.82	195,369.54	290,524.12	205,743.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,175,224.23	1,233,590.49	1,416,332.84	1,198,668.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
28,054.08	
75,497.28	
183,282.67	
55,997.09	
0.00	
1,038.92	
8,559.40	
9,682.29	
11,091.73	
372,753.72	
1,021,872.66	
882,886.58	
154.00	
6,056.55	
7,081.93	
29,629.28	
8,859.82	
48,279.26	
116,033.92	
895,102.85	
48,570.13	
326,770.10	
886,561.54	
5,023,815.80	

M&

NO

E
SUBTOTAL:

3308	AHC CARE M&F 45-64 W	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-40.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	-527.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	-12,669.89	0.00	0.00	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
21.62	
-40.77	
-527.88	
-13,553.16	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 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	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14,100.19		

3410	MED ELIGIBILITY NON-	0.00	0.00	-99.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	60.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	-2,238.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-24,077.78	0.00	-475.87	-491.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,335.41	-100.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	-7,509.71	0.00	1,439.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-34,472.66	0.00	14,549.19	-591.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

3506	ADULT 40-100% MALE 2	15.57	260.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	3,307.43	1,008.60	3,349.43	978.27	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	4,567.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	19,931.75	23,276.12	89,687.54	28,119.86	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	277,900.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	109,841.40	105,802.51	150,353.68	93,953.55	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	458,809.96	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	-74.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	41.77	60.44	60.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	380.98	90.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	-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	1,799.96	1,321.34	2,383.72	4,587.94	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	15,449.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	112.46	353.44	167.54	658.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	49,424.42	117,557.97	171,586.96	99,739.77	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	92,547.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	2,375,248.97	2,548,511.24	3,291,598.46	2,203,928.16	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	971,417.23	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	2,943,218.44	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	2,915.21	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	-612.98	600.54	599.83	413.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

276.10	
0.00	
8,643.73	
154.04	
11,704.52	
161,015.27	
893,006.16	
459,951.14	
2,541,492.26	
1,297.69	
0.00	
162.65	
471.64	
0.00	
243.95	
10,092.96	
56,884.44	
1,292.12	
438,309.12	
324,296.21	
10,419,286.83	
4,344,914.58	
12,880,524.35	
55,559.00	
166.20	
1,000.42	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 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	7,199,220.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,610,745.38		

0.00

0.00

17,251.01

0.00

17,582.58

17,733.39

564,639.34

457,040.37

1,213,522.35

0.00

47.11

2,287,816.15

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	1,878.61	4,565.59	8,493.20	2,313.61	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	2,843.03	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	4,863.26	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	140,347.56	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	109,708.96	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	269,867.19	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	47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	474,843.91	575,141.29	707,887.34	529,943.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4

4
SUBTOTAL:

4413	SOBRA 100-133% M&F
6	18,822.56	18,033.29	11,971.57	66,627.29	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	25,481.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	7,170.95	59,145.25	2,446.86	47,194.94	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	139,303.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
115,454.71	
53,645.98	
115,958.00	
285,058.69	

4517	BC PATIENT FEMALE 2 1	0.00	2,014.72	1,660.45	-400.91	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	1,707.07	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	7,470.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	0.00	0.00	1,422.62	58.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	5,311.81	2,407.95	3,462.38	8,835.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,274.26	
2,528.89	
12,733.19	
1,481.13	
20,017.47	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO	3,652.19	5,276.89	5,063.99	2,938.66	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	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	2,938.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,931.73	
94.49	
204.26	
17,230.48	

M

M

21,049,296.39     22,871,233.35    27,733,419.01

0.00

0.00

0.00

0.00

0.00

21,096,836.49

0.00

0.00	0.00

92,750,785.24

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

D

M

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

M

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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+	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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

M&

NO

E
SUBTOTAL:

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 October 31, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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		

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

4

4
SUBTOTAL:

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% 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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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	

M

M

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-286.63	
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	239.42	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	8,561.96	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	587.92	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	1,359.63	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	188.25	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	544.54	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	22,983.79	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	32,698.97	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	4,217.25	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	578.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	371.10	7,188.56	32,792.94	1,605.68	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	-33.63	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	265.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	25,287.18	285,986.08	63,667.08	20,539.73	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	4,281.31	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	2,907.42	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	13,090.77	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	14,546.67	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	3,957.63	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	10,537.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

50.39	
0.00	
752.83	
14.96	
26,629.92	
10,659.97	
5,667.22	
4,094.65	
11,096.47	
56,195.02	
111,487.60	
33,311.03	
249.73	
0.00	
0.00	
0.00	
0.00	
3,648.75	
41,958.28	
2,196.68	
4,225.01	
395,480.07	
23,104.32	
0.00	
2,306.72	
0.00	
0.00	
25,058.18	
78,343.34	
110,062.16	
54,258.23	
33,982.69	
0.00	

D

M

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015

M

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5015	SOBRA PREG 14-20 FE M	4,547.68	626.35	7,875.28	1,288.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,338.00	
5017	SOBRA PREG 21-44 FE M	21,818.94	29,403.82	43,513.99	31,655.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,392.72	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	212,022.47	488,372.66	298,566.78	176,603.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,175,564.94	

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	26.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	6.07	0.00	161.42	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	221.56	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	101.94	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	12,403.21	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	450.62	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+	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	1,827.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	199.65	0.00	129.18	-72.61	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	158.57	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	479.32	0.00	3,171.06	1,161.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	71,791.87	5,686.71	75,118.85	16,413.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
26.99	
167.49	
0.00	
107.79	
296.08	
0.00	
1,931.48	
0.00	
42,284.36	
30,237.53	
7,004.58	
0.00	
0.00	
0.00	
0.00	
0.00	
4,049.76	
0.00	
256.22	
737.47	
77,099.69	
4,811.38	
169,010.82	

M&

NO

E
SUBTOTAL:

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 October 31, 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	3,995.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	3,430.56	332.79	0.00	0.00	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	11,291.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	9,918.88	16,192.67	4,216.11	6,873.78	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	13,080.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	47.77	159.41	-72.49	153.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	638.33	2,949.89	655.77	55.09	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 MALE	87,516.94	137,213.09	59,107.89	86,557.14	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	20,947.83	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	91,305.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
300.90	
0.00	
3,995.50	
3,763.35	
74,976.60	
37,201.44	
71,212.46	
0.00	
0.00	
0.00	
0.00	
0.00	
10.26	
0.00	
287.97	
0.00	
4,299.08	
9,206.15	
370,395.06	
142,304.92	
274,843.52	
0.00	
0.00	
0.00	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	234,260.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		992,797.21		

21.47

0.00

0.00

0.00

0.00

0.00

20,944.37

12,888.70

118,097.16

0.00

0.00

151,951.70

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	21.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	2,177.20	3,667.10	6,736.60	8,363.47	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	1,988.35	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	7,387.87	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	44,437.01	23,067.06	66,686.47	17,761.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4

4
SUBTOTAL:

4413	SOBRA 100-133% M&F
6	0.00	332.82	31.19	1,392.55	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	61.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	169.44	0.00	0.00	636.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	177.42	401.62	31.19	2,090.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,756.56	
138.33	
805.73	
2,700.62	

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

0.00	
0.00	
3,387.30	
0.00	
3,387.30	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO	0.00	0.00	0.00	61.65	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	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	61.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

61.65	
2,178.61	
0.00	
2,240.26	

M

M

646,451.11

771,726.45

689,215.77

0.00

0.00

0.00

0.00

0.00

447,049.28

0.00

0.00	0.00

2,554,442.61

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	22,473.97	26,318.07	47,874.45	20,739.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117,406.02		
SUBTOTAL:	22,473.97	26,318.0	47,874.45	20,739.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117,406.02		

TOTAL:	22,473.97	26,318.07	47,874.45	20,739.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117,406.02		

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending October 31, 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		

54.51

0.00	0.00	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	270,941.80	185,031.50	445,748.41	353,754.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,255,476.62		
SUBTOTAL:	270,941.80	185,031.5	0	445,748.41	353,754.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,255,476.62		

TOTAL:	270,941.80	185,031.50	445,748.41	353,754.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,255,476.62		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM AT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	101.73	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	503.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1008	TANF 45-64 M & F WIT	963.94	990.67	2,333.71	726.40	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	178,822.23	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	18,344.02	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	4,999.12	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	776.75	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	8,102.17	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	88,415.76	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	154,340.59	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	40,804.81	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	22.74	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	4,876.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	267.22	1,844.32	1,193.89	206.73	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	8,330.00	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	6,512.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	231,778.99	342,969.11	271,027.04	176,793.76	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	27,354.81	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	653.66	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	208.81	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	70,572.82	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	32,655.05	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	34,130.76	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	10,576.23	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	49,311.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

502.63	
2,765.01	
5,014.72	
82.48	
248,526.14	
53,152.14	
32,910.93	
7,050.39	
21,090.68	
185,602.42	
625,265.73	
157,277.34	
0.00	
0.00	
0.00	
3,750.46	
0.00	
36,460.96	
3,512.16	
27,127.18	
58,860.42	
1,022,568.90	
139,202.44	
530.71	
2,653.66	
743.38	
0.00	
275,776.00	
139,013.24	
122,165.96	
77,796.10	
106,063.52	
0.00	

D

M

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2015

M

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5015	SOBRA PREG 14-20 FE M	19,583.10	16,174.12	18,249.56	19,803.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,810.21	
5017	SOBRA PREG 21-44 FE M	50,370.25	73,392.58	98,242.24	99,306.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	321,311.72	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	808,932.77	881,111.78	1,023,289.80	1,037,253.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,750,587.63	

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	1,158.04	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	467.69	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	32.04	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	3,815.71	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	26,291.09	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	14,385.88	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	58.18	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+	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	245.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	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	6,111.76	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	5,168.66	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	1,009.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	4,285.83	11,263.10	11,272.83	7,319.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	71,468.19	82,740.10	146,508.04	66,063.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
414.69	
5,336.08	
5,153.60	
1,998.86	
0.00	
169.40	
15.00	
506.37	
0.00	
60,690.69	
115,175.82	
52,536.93	
1,058.40	
645.53	
216.97	
1,895.45	
0.00	
1,841.26	
4,605.04	
24,861.87	
6,532.74	
48,983.53	
34,141.19	
366,779.42	

M&

NO

E
SUBTOTAL:

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 October 31, 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	911.05	84.70	1,203.19	1,329.48	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	49,847.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	12,294.00	3,333.58	14,103.28	9,486.39	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	62,232.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	1,741.29	1,260.00	0.00	170.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	7,292.84	12,081.73	19,979.50	3,571.18	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	12,371.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	136,455.42	205,325.04	266,134.03	102,321.13	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	77,117.72	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	168,543.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	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	
3,528.42	
206,134.34	
39,217.25	
276,775.81	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3,171.68	
0.00	
42,925.25	
33,738.13	
710,235.62	
386,351.57	
721,863.42	
0.00	
0.00	
1,260.00	

E

E

AL

6

4

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 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	486,991.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,431,014.55		

0.00

0.00

1,108.99

0.00

697.18

860.55

22,934.80

27,377.37

126,837.78

0.00

0.00

179,816.67

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	627.65	95.99	385.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	697.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	303.87	213.29	165.29	178.10	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	5,204.43	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	10,984.25	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	35,300.47	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	57,678.54	27,673.40	42,100.30	52,364.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4

4
SUBTOTAL:

4413	SOBRA 100-133% M&F
6	920.33	606.76	51.87	3,005.28	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	188.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	589.03	196.50	0.00	4,003.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,509.36	803.26	359.55	7,197.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,584.24	
496.65	
4,789.00	
9,869.89	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	10.17	15.64	0.00	0.00	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	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO	0.00	22.70	0.00	274.10	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	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	274.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

296.80	
0.00	
0.00	
296.80	

M

M

1,476,134.55	1,569,184.87	2,042,720.13

0.00

0.00

0.00

0.00

0.00

1,650,143.77

0.00

0.00	0.00

6,738,183.32

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 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	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		700.00		
2100	SSI AGED WITH MEDIC A	106,605.75	138,772.37	243,060.06	109,396.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		597,834.40		
2110	SSI AGED NON-MEDICA R	26,434.90	13,763.26	31,784.99	27,506.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,489.17		
2120	SSI AGED WITH QMB	121,926.99	174,038.05	225,195.50	122,450.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		643,611.24		
2200	SSI DISABLED WITH M	45,476.20	32,686.17	56,715.55	29,618.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164,496.88		
2210	SSI DISABLED NON-ME D	688,624.66	871,046.82	795,795.36	508,232.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,863,699.68		
2220	SSI DISABLED WITH Q	48,687.58	68,819.71	112,495.22	51,083.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281,085.69		
2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193.73		
2310	SSI BLIND NON-MEDIC A	8,400.00	7,019.66	6,650.00	5,950.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,019.66		
2320	SSI BLIND WITH QMB	431.94	428.25	416.46	71.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,348.27		
SUBTOTAL:	1,046,662.95	1,306,924.29	1,472,172.54	854,718.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,680,478.72		

E

M

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	7.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.35	
0.00	
7.35	

M
SUBTOTAL:

TOTAL:	1,046,662.95	1,306,924.29	1,472,179.89	854,718.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,680,486.07		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	1,685,117.40	1,915,799.87	2,681,450.39	1,999,482.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,281,849.97		
2110	SSI AGED NON-MEDICA R	134,210.18	86,635.19	183,540.43	121,497.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		525,882.89		
2120	SSI AGED WITH QMB	2,732,315.87	2,691,509.27	3,869,487.21	2,806,461.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,099,774.05		
2200	SSI DISABLED WITH M	484,829.08	429,355.23	623,488.25	496,865.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,034,537.87		
2210	SSI DISABLED NON-ME D	1,738,486.52	1,802,598.11	2,237,418.61	1,856,867.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,635,370.97		
2220	SSI DISABLED WITH Q	585,872.48	620,560.01	851,203.88	615,551.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,673,188.27		
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	6,388.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,625.87		
2320	SSI BLIND WITH QMB	4,994.88	7,132.53	7,260.58	5,253.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,641.25		
SUBTOTAL:	7,373,566.73	7,561,011.13	10,463,925.17	7,908,368.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,306,871.14		

E

M

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,037.06	2,637.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	1,712.52	2,990.88	4,148.64	2,052.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,712.52	4,868.22	9,185.70	4,689.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,551.52	
10,904.04	
20,455.56	

M
SUBTOTAL:

33,327,326.70

7,375,279.25	7,565,879.35	10,473,110.87	7,913,057.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	57,961.58	35,627.77	43,341.81	22,249.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,181.08		
2110	SSI AGED NON-MEDICA R	16,433.83	946.68	83,538.56	8,338.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,257.81		
2120	SSI AGED WITH QMB	443.59	1,507.61	18.05	566.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,535.93		
2200	SSI DISABLED WITH M	11,220.75	6,502.00	26,013.79	7,482.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,219.49		
2210	SSI DISABLED NON-ME D	26,834.51	19,004.26	28,589.63	10,783.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,211.69		
2220	SSI DISABLED WITH Q	2,359.28	722.71	6,308.23	1,497.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,887.75		
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	50,919.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		424,950.58		

E

M

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

0.00	
0.00	
0.00	

M
SUBTOTAL:

TOTAL:	121,910.37	64,311.03	187,810.07	50,919.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		424,950.58		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending October 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	17,791.38	16,157.36	33,799.85	22,186.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,935.39		
2110	SSI AGED NON-MEDICA R	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	9,872.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,920.79		
2200	SSI DISABLED WITH M	1,998.01	5,671.10	17,991.36	2,677.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,338.01		
2210	SSI DISABLED NON-ME D	39,207.69	57,526.26	37,706.14	98,519.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232,959.68		
2220	SSI DISABLED WITH Q	2,612.76	3,357.96	4,743.41	3,725.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,439.77		
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	37.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		340.45		
SUBTOTAL:	74,428.21	93,130.40	111,080.34	137,018.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415,657.86		

E

M

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

0.00	
0.00	
0.00	

M
SUBTOTAL:

415,657.86

74,428.21	93,130.40	111,080.34	137,018.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION AMOUNTS
For The Period Ending October 31, 2015

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	1,007.22	1,007.22	833.38	959.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,806.83	
6012	KIDS 1-5 M & F NON-M	220.96	220.96	220.96	223.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	886.14	
6013	KIDS 6-13 M & F NON-	58,022.76	55,071.22	54,144.19	51,905.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	219,143.79	
6014	KIDS 14-19 MALE NON-	49,755.46	44,451.13	44,464.06	45,078.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	183,749.46	
6015	KIDS 14-19 FEMALE NO	74,775.69	69,658.38	67,362.69	66,568.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	278,365.19	
9960	KIDSCARE KICK PAYME N	0.00	0.00	6,160.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,160.56	
SUBTOTAL	:	183,782.09	170,408.91	173,185.84	164,735.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	692,111.97	

TOTAL:	183,782.09	170,408.91	173,185.84	164,735.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		692,111.97		

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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.66	
	C														
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00	
6013	KIDS 6-13 M & F NON-	456.25	434.86	420.34	395.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,707.33	
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	242.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	975.31	
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	240.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,020.63	
9960	KIDSCARE KICK PAYME	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	N
OTAL:	
993.61	
932.52	
910.22	
883.58	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3,719.93	

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2015

3,719.93

993.61	932.52	910.22	883.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending October 31, 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	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270.59	
	C														
6012	KIDS 1-5 M & F NON-M	75.10	75.10	75.10	82.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	308.14	
6013	KIDS 6-13 M & F NON-	16,709.75	16,146.50	15,620.80	15,698.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,175.23	
6014	KIDS 14-19 MALE NON-	9,776.08	8,979.83	9,075.34	10,574.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,405.35	
6015	KIDS 14-19 FEMALE NO	10,772.21	10,088.61	9,721.39	10,393.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,975.35	

SUBTOTAL:	
37,408.24	
35,365.14	
34,530.18	
36,831.10	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
144,134.66	

TOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,134.66		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2015

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	2.00	2.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00	
	C														
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00	
6013	KIDS 6-13 M & F NON-	445.00	430.00	416.00	379.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,670.00	
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	235.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	942.00	
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	231.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,002.00	
SUBTOTAL:	968.00	918.00	894.00	849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,629.00	
TOTAL:	968.00	918.00	894.00	849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,629.00	

KidsCare - FEE FOR SERVICE
For The Period Ending October 31, 2015

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	-357.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-357.10	
6013	KIDS 6-13 M & F NON-	364.77	362.20	318.01	1,505.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,550.24	
6014	KIDS 14-19 MALE NON-	-652.26	85.01	0.00	96.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-471.05	
6015	KIDS 14-19 FEMALE NO	-174.33	326.70	118.31	203.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	474.00	

SUBTOTAL:	
-818.92	
773.91	
436.32	
1,804.78	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
2,196.09	

TOTAL:	-818.92	773.91	436.32	1,804.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,196.09		

KidsCare - REINSURANCE
For The Period Ending October 31, 2015

SUBTOTAL:	161.54	30,495.15	70,988.85	57,122.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,767.93	
															
TOTAL:	161.54	30,495.15	70,988.85	57,122.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,767.93	

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6013	KIDS 6-13 M & F NON-	161.54	203.93	36,712.84	0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,078.32	
6014	KIDS 14-19 MALE NON-	0.00	29,016.36	29,093.10	36,857.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94,966.68	
6015	KIDS 14-19 FEMALE NO	0.00	1,274.86	5,182.91	20,265.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,722.93	

6

00

114,375.57

114,375.57

8.00

2,580.34

4.00

628.01

20.19

1,087.77

7,024.96

86,364.96

0.06

15,993.03

1.00

53.00

449.25

113.00

28.00

8.00

12.00

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending October 31, 2015

RATE CODE

DESCRIPTION

JULY

AUGUST     SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	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	649.50	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	1.00	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	163.43	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	5.19	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	271.53	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	1,771.16	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	21,648.46	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	0.03	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	4,014.15	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	14.00	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	111.81	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	28.00	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	7.00	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	2.00	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	3.00	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	28,692.26	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	28,692.	2	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 October 31, 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	372,751.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,479,235.46	
EPD	84,945,196.47	97,607,756.74	86,404,566.22	86,631,891.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	355,589,411.22	
TOTAL AHCCCS LTC	85,315,938.36	97,973,954.11	86,774,110.87	87,004,643.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	357,068,646.68	
DES/DD	97,105,888.85	97,348,150.88	98,057,803.05	98,503,859.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	391,015,702.57	
TOTAL DES LTC	97,105,888.85	97,348,150.88	98,057,803.05	98,503,859.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	391,015,702.57	
TOTAL LTC - CAP	182,421,827.21	195,322,104.99	184,831,913.92	185,508,503.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	748,084,349.25	

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	8,955,714.19
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	38,848,421.21
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,848,421.21	

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	3,640,983.44
709,764.46	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	15,073,637.31
2,204,042.70	
	375,457.62	326,085.82	792,734.80	709,764.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,204,042.70	
TOTAL LTC - REIN	4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,277,680.01	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	3,116,250.30	3,135,587.40	3,128,183.70	3,118,231.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,498,253.30	

Note to the ASR:
EPD reflects the Federal and County share for both acute and LTC services.
AHCCCS passes through only the Federal share to DES. Neither the Federal nor the Nonfederal dollars are included on the ASR summary (page 1) because both are included in the DES appropriation.

Tuesday, November 17, 2015

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending October 31, 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	13,907,011.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,451,387.56	
010145	CRS ACUTE SEMI INTEGRATED - CAP	122,251.86	115,316.41	116,070.08	130,768.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	484,406.65	
999125	CRS SEMI INTEGRATED PLAN - CAP	3,253,162.92	3,256,188.18	3,258,709.23	4,767,213.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,535,274.05	
999135	CRS ONLY PLAN - CAP	476,979.36	481,148.76	485,318.16	546,356.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,989,802.68	
Subtotal	17,327,365.74	17,345,286.10	17,436,869.01	19,351,350.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71,460,870.94	

999155	CRS REINSURANCE ONLY	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,564,561.73	
Subtotal	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,564,561.73	

010115	CRS FULLY INTEGRATED PLAN - KC CAP	29,112.95	25,266.88	26,056.47	28,258.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,694.60	
Subtotal	29,112.95	25,266.88	26,056.47	28,258.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,694.60	

19,545,976.24	18,869,023.14	19,332,548.29	21,386,579.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,134,127.27	

GRAND TOTAL

Tuesday, November 17, 2015

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending October 31, 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	17,225.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,567.15	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	168.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	671.62	
999125	CRS SEMI INTEGRATED PLAN - MM	6,452.00	6,458.00	6,463.00	6,467.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,840.00	
999135	CRS ONLY PLAN - MM	1,144.00	1,154.00	1,164.00	1,178.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,640.00	
Subtotal	24,833.16	24,861.60	24,985.24	25,038.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,718.77	

010115	CRS FULLY INTEGRATED PLAN - KC MM	36.87	32.00	33.00	34.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136.86	
Subtotal	36.87	32.00	33.00	34.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136.86	

24,870.03	24,893.60	25,018.24	25,073.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,855.63	

GRAND TOTAL

Tuesday, November 17, 2015

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS
For the Period Ending October 31, 2015

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

010700	HEALTH CHOICE INTEGRATED - CAP	0.00	0.00	-1,518.09	8,498,463.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,496,945.70	
010725	CENPATICO INTEGRATED - CAP	0.00	0.00	18,507.72	21,015,217.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,033,725.30	
078999	MERCY MARICOPA INTEGRATED - CAP	47,152,827.77	47,326,614.65	47,809,819.28	44,302,303.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	186,591,564.70	
Subtotal	47,152,827.77	47,326,614.65	47,826,808.91	73,815,984.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216,122,235.70	

47,152,827.77	47,326,614.65	47,826,808.91	73,815,984.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216,122,235.70	

GRAND TOTAL

Tuesday, November 17, 2015

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS
For the Period Ending October 31, 2015

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

010700	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	-1.00	5,597.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,596.09	
010725	CENPATICO INTEGRATED - MM	0.00	0.00	12.00	13,624.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,636.21	
078999	MERCY MARICOPA INTEGRATED - MM	19,430.16	19,501.43	19,702.99	19,759.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	78,394.50	
Subtotal	19,430.16	19,501.43	19,713.99	38,981.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,626.80	

19,430.16	19,501.43	19,713.99	38,981.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,626.80	

GRAND TOTAL