:AHCCCS

Arizona Heolth  Care  Cost Containment System

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

January 27, 2016

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

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

SUBJECT:  FY 2016 Appropriation Status Report for the Period Ended December 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 December 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  $737.0  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 ($30.9 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.

In December, AHCCCS administratively adjusted $218.9 million Total Fund ofFiscal Year 2015 date of service expenditures back to the Fiscal Year 2015 appropriation.   These administrative adjustments  will reduce the projected Expenditure  Authority shortfall.   The line item detail for these transactions is included in Note 6 of this report.

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

The Honorable Andy Biggs
The Honorable David M. Gowan, Sr. January 27, 2015
Page 2

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

Enrollment  Update- December  2015  enrollment  is 1,852,724  members,  a 18,817  member increase over the prior month.  Enrollment for January 2016 decreased to 1,845,353 members, a
7,371 member decrease.

Major January changes by eligibility category include: 1931 for Families and Children/SOBRA­ decrease  of  860;  Supplemental  Security  Income  - increase  of  205;  Prop  204  Restoration  - decrease  of 2,098;  Adult Expansion  - increase  of 848;  Medicare  Cost Sharing - decrease  of
3,332; and Federal Emergency Services- decrease of2,186.

The January decrease was the first monthly decline in eleven months.  Over 50% of the decline was associated with the Qualified Individuals program which had been frozen in October due to federal funding concerns.   This program was reinstated on December 22nd and it is anticipated that many of these members will resume coverage in February.

Tobacco Funds  Revenue Update  -Tobacco  tax collections  through December 2015 are $2.7 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 December 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 December 31, 2015
SUMMARY OF APPROPRIATED EXPENDITURES

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

APPROPRIATIONS:

ADMINISTRATION

AHCCCS Operating Lump Sum	$	77,975,400		$	33,887,200		$	33,522,887		$	364,313		$	77,975,400		$	-	
AHCCCS Prop 204 Administration	8,565,300		3,362,400		4,100,533		(738,133)		8,565,300		-	
DES Eligibility	54,874,500		25,415,100		22,493,280		2,921,821		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		17,480,700		4,087,628		13,393,072		38,358,700		-	
TOTAL ADMINISTRATION	179,773,900		80,145,400		64,204,328		15,941,072		179,773,900		-	

Traditional Medicaid Services	3,439,053,700		1,656,181,400		1,845,751,888		(189,570,488)		3,439,053,700		-	
Proposition 204 Services	2,507,700,600		1,188,401,900		1,173,739,718		14,662,182		2,507,700,600		-	
ACA Adult Expansion	396,683,800		185,975,500		181,756,378		4,219,122		396,683,800		-	
Children's Rehabilitative Services	233,839,100		111,297,000		121,761,460		(10,464,460)		233,839,100		-	
KidsCare Services	6,295,200		3,080,600		993,376		2,087,224		6,295,200		-	
ALTCS Services	1,386,588,900		668,316,100		626,040,852		42,275,248		1,386,588,900		-	
Disproportionate Share Payments	5,087,100		-	-	-	5,087,100		-	
Rural Hospitals	22,650,000		-	5,245,950	(5,245,950)	22,650,000		-	
Voluntary Political Subdivision Programs	342,323,786		150,147,000	150,146,959	41	342,323,786		-	
TOTAL PROGRAMMATIC	8,340,222,186		3,963,399,500		4,105,436,580		(142,037,080)		8,340,222,186		-	

$	8,519,996,086		$    4,043,544,900		$   4,169,640,908		$	(126,096,008)		$  8,519,996,086		$	-	

TOTAL EXPENDITURES

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT For the Period Ending December 31, 2015
APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

Administrative  Expenditures	$ 	51,537,900		$ 	23,043,000		$ 	18,951,819		4,091,181		$ 	51,537,900		$ 	-	
Proposition 204 - Administrative  Expenditures	20,280,700		8,998,100		2,962,701		6,035,399		20,280,700		-	
Programmatic  Expenditures
Traditional Medicaid Services	
800,323,100		
381,519,800		
444,742,634		
(63,222,834)		
800,323,100		
-	
Proposition 204 Services	90,000,000		82,490,600		34,698,597		47,792,003		90,000,000		-	
Children's Rehabilitative  Services	72,487,200		34,681,900		35,138,308		(456,408)		72,487,200		-	
KidsCare Services	338,000		289,400		(16,019)		305,419		338,000		-	
ALTCS Services	162,880,800		78,305,100		81,440,400		(3,135,300)		162,880,800		-	
DSH and Rural Hospitals	7,314,600		-		1,630,441		(1,630,441)		7,314,600		-	
TOTAL GF EXPENDITURES	1,205,162,300		609,327,900		619,548,880		(10,220,980)		1,205,162,300		-	

Administrative  Expenditures 	81,114,000 	36,162,600 	37,031,962 	 (869,362) 	81,114,000 	- Proposition 204 - Administrative  Expenditures 	23,160,400 	10,257,800 	  5,225,460 	5,032,340 	23,160,400 	-

Programmatic  Expenditures
Traditional Medicaid Services 		2,271,456,100 	1,090,616,900 	1,172,305,785 	   (81,688,885) 	    2,271,456,100 	   - Proposition 204 Services 	2,048,414,400 	970,371,200 	990,878,398 	(20,507,198) 	2,048,414,400 	- ACA Adult Expansion 		396,683,800 	185,975,500 	181,756,378 	    4,219,122 	    396,683,800 	- Children's Rehabilitative  Services 		161,351,900 		76,615,100 	  86,623,152 	(10,008,052) 	    161,351,900 	- KidsCare Services 		    5,587,200 		 2,606,300 	    1,009,395 	    1,596,905 		5,587,200 	- ALTCS Services and Nursing Facility Assessment 		931,056,600 	448,863,200 	409,475,828 	 39,387,372 	    931,056,600 	- DSH and Rural Hospitals 		  20,422,500 			- 	    3,615,509 	  (3,615,509) 	      20,422,500 	- Voluntary Political Subdivision Programs - See Note 5 		233,761,591 		97,630,600 	  97,630,564 		36 	    233,761,591 	- TOTAL FEDERAL EXPENDITURES		6,173,008,491 	2,919,099,200 	2,985,552,430 	   (66,453,230) 	    6,173,008,491 	   -

Administrative  Expenditures  Proposition 204 - BNCF 	3,482,900 	1,587,200 	- 	1,587,200 	3,482,900 	- Programmatic  Expenditures

249,234,600		119,819,400		110,940,024		8,879,376		249,234,600		-	
302,597,200		146,346,200		135,879,624		10,466,576		302,597,200		-	

Traditional Medicaid Services Acute Care 	49,879,700 	24,939,600 	24,939,600 	- 	49,879,700 	- ALTCS Services
TOTAL COUNTY EXPENDITURES

Programmatic  Expenditures

TOBACCO FUNDS

Traditional Medicaid Services Acute Care - Medically Needy 	     31,180,000 	   16,081,800 		15,590,000 		491,800 		  31,180,000 	   - Proposition 204 Services - Emergency Health Services 	  17,331,400 	 8,988,400 	  8,665,700 	322,700 	  17,331,400 	- Proposition 204 Services - Proposition 204 Protection 	  36,396,000 	18,772,300 	18,198,000 	574,300 	  36,396,000 	- Proposition 204 Services - ATLSF 	100,000,000 		- 			- 			- 	100,000,000 	- TOTAL TOBACCO EXPENDITURES	   184,907,400 	   43,842,500 		42,453,700 	1,388,800 		184,907,400 	   -

Administrative  Expenditures

OTHER

Prescription Drug Rebate Program                                                                                                               198,000                                           96,700                                           32,386                                           64,314                                          198,000                                                  - Programmatic  Expenditures
Acute Care - Prescription Drug Rebate Program State Match 	     78,105,000 		   39,052,500 		39,052,500 			- 		  78,105,000 	   - Acute Care - Prescription Drug Rebate Program Federal Authority 	207,883,900 	103,942,200 	148,859,364 	(44,917,164) 	207,883,900 	- Long Term Care - Prescription Drug Rebate Program State Match 	    5,475,800 		 2,634,100 	    2,737,900 	     (103,800) 		 5,475,800 	- Long Term Care - Prescription Drug Rebate Program Federal Authority 	  14,574,200 		 7,011,000 	  12,367,640 	  (5,356,640) 	  14,574,200 	- Proposition 204 Services - Hospital Assessment 	215,558,800 	107,779,400 	121,299,024 	(13,519,624) 	215,558,800 	- Traditional Medicaid Services - TPL 		194,700 			      - 		  236,856 	     (236,856) 		    194,700 	- ALTCS Services - TPL 			- 			      - 		  361,752 	     (361,752) 			- 	- ALTCS Services - Nursing Facility Assessment 	  23,366,900 		11,683,300 	    8,717,309 	    2,965,991 	  23,366,900 	- KidsCare Services Premiums 		370,000 		     184,900 			- 	      184,900 		    370,000 	- Freedom to Work Premiums 		  31,200 			28,600 		    25,150 		3,450 		      31,200 	- Voluntary Political Subdivision Programs - See Note 5 	108,562,195 		52,516,400 	  52,516,395 			 5 	108,562,195 	- TOTAL OTHER  EXPENDITURES	   654,320,695 		 324,929,100 	   386,206,274 	   (61,277,174) 		654,320,695 	   -

TOTAL

Administrative  Expenditures                                                                                                                      179,773,900                                    80,145,400                                    64,204,328                                    15,941,072                                   179,773,900                                                  - Acute Care                                                                                                                                               6,953,633,286                               3,295,083,400                                3,479,395,728                                 (184,312,328)                               6,953,633,286                                                  - Long Term Care                                                                                                                                      1,386,588,900                                  668,316,100                                  626,040,852                                     42,275,248                                1,386,588,900                                                  -

TOTAL EXPENDITURES

$ 	8,519,996,086

$ 	4,043,544,900

$ 	4,169,640,908

$ 	(126,096,008)

$ 	8,519,996,086 	$ 	-

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE  AND OTHER COLLECTIONS RECEIVED  DETAIL SCHEDULE For the Period Ending December  31, 2015

BUDGET 	BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	931,662,800		$	439,244,700		$	500,463,202	
Proposition 204 Services & Administrative	110,280,700		91,488,700		37,661,297	
KidsCare Services	338,000		289,400		(16,019)	
ALTCS Services	162,880,800		78,305,100		81,440,400	
TOTAL	1,205,162,300		609,327,900		619,548,880	

FEDERAL:
Acute & Administrative	5,236,364,691		2,467,629,700		2,711,313,033	
KidsCare Services	5,587,200		2,606,300		1,579,899	
ALTCS Services	931,056,600		448,863,200		448,872,568	
TOTAL	6,173,008,491		2,919,099,200		3,161,765,500	

COUNTY:
Acute & Administrative	53,362,600		26,526,800		25,078,303	
ALTCS Services	249,234,600		119,819,400		124,617,306	
TOTAL	302,597,200		146,346,200		149,695,609	

TOBACCO FUNDS:
Traditional Medicaid Services	31,180,000		16,081,800		15,590,000	
Proposition 204 Services	153,727,400		27,760,700		26,863,700	
TOTAL	184,907,400		43,842,500		42,453,700	

OTHER:
Administrative	198,000	96,700	32,386	
Acute Care - Prescription Drug Rebate Program	285,988,900	142,994,700	187,911,864	
Long Term Care - Prescription Drug Rebate Program	20,050,000	9,645,100	15,105,540	
Hospital Assessment	215,558,800	107,779,400	123,069,573	
ALTCS - Nursing Facility Assessment	23,366,900	11,683,300	118,967	
Acute TPL - Note 1	194,700	-	236,856	
LTC TPL - Note 1	-	-	361,752	
KidsCare TPL - Note 1	-	-	20,942	
Member Premiums - CHIP	370,000	184,900	173,600	
Member Premiums - Freedom to Work	31,200	28,600	25,150	
Voluntary Political Subdivision - State Match	108,562,195	52,516,400	112,157,791
TOTAL	654,320,695	324,929,100	439,214,420

TOTAL REVENUE

$	8,519,996,086

$	4,043,544,900

$	4,412,678,109

Appropriation Status Report

Footnotes

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

Note 1:	Third Party Liability Collections: Gross Collections:	December 2015		December 2014		July 1, 2015
December 31, 2015		July 1, 2014
December 31, 2014	
	Acute	$ 	373,701		$ 	404,240		$ 	2,130,346		$ 	2,871,484	
	LTC	248,546		262,934		1,590,590		1,841,439	
	KidsCare	-		291		104,447		3,703	
	Total TPL Collections	$ 	622,247		$ 	667,465		$ 	3,825,383		$ 	4,716,626	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$ 	41,813		$ 	42,889		$ 	236,856		$ 	369,793	
LTC	58,782		64,054		361,752		433,902	
KidsCare	-		59		20,942		727	
Total Expenditure Offsets	$ 	100,595		$ 	107,002		$ 	619,550		$ 	804,422	

FY 16 Total
Note 2:    Authorized Positions 	1,029.2
Actual Positions as of December 31, 2015 	913.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2015	

$ 	2,853,728	
	Revenues	3,045,595	
	Transfers-In	 	275,126 		
	Total Revenues	 	3,320,721 		
	Expenditures	2,624,022	
	Transfers-out	 	920,066 		
	Total Expenditures	 	3,544,088 		

Ending Balance December 31, 2015

$ 	2,630,362

Of the $2,630,362 ending balance, $1,821,404 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through February 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities
As of December 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 December 31, 2015

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of December 31, 2015
Expenditures

State Match 	Federal 	Total

DSH Voluntary

$ 	607,333 	$

1,245,986 	$

1,853,319

GME Voluntary 	51,909,062 	111,083,518 	162,992,580
Safety Net Care Pool 	- 	(14,698,940) 	(14,698,940)

Total Voluntary Political Subdivision Program Expenditures

$ 	52,516,395 	$

97,630,564 	$

150,146,959

Note 6:

The following is a summary of $218,889,592 Total Fund ($39,394,210 General Fund and $9,525,344 Hospital Assessment Fund) administrative adjustment transactions processed through December 2015 that either pay for or transfer expenditures with dates of service prior to June 30, 2015.
.

FY 2015 YTD December 31, 2015
State Match	Expenditure	ALTCS	Total	
Funds	Authority Funds	Fund	Fund	

Traditional Medicaid Services

$ 	38,289,534 	$

83,762,109 	$

- 	$ 	122,051,643

Proposition 204 Services 	9,525,344 	35,416,308 	- 	44,941,652
ACA Adult Expansion 	- 	6,518,930 	- 	6,518,930
KidsCare - Children Services 	55,321 	345,660 	- 	400,981
Children's Rehabilitative Services 	1,049,356 	1,880,510 	- 	2,929,866
Long Term Care 	- 	42,046,521 	42,046,521

Total

$ 	48,919,554 	$

127,923,518 	$

42,046,521 	$

218,889,592

Appropriation Status Report

Caseload	and	Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending December 31, 2015

CAPITATION - ACUTE	272,366,959	276,316,415	279,166,770	275,407,979	274,717,280	320,143,231	0	0	0	0	0	0	1,698,118,633	
CAPITATION - LTC	182,421,827	195,322,105	184,831,914	185,793,257	198,420,332	189,494,790	0	0	0	0	0	0	1,136,284,225	
MENTAL HEALTH - CHILD	24,739,142	24,849,877	25,557,281	28,336,540	28,517,836	31,518,669	0	0	0	0	0	0	163,519,344	
MENTAL HEALTH - ADULT	11,323,471	11,730,505	12,433,438	944,236	956,134	1,949,346	0	0	0	0	0	0	39,337,131	
MENTAL HEALTH - GENERAL	15,232,013	15,779,544	16,725,109	16,942,470	17,155,946	15,591,227	0	0	0	0	0	0	97,426,309	
MENTAL HEALTH - CMDP	14,633,559	14,896,415	14,987,440	15,967,464	16,435,700	18,339,912	0	0	0	0	0	0	95,260,490	
CHILDREN'S REHAB SERVICES	3,716,383	3,722,744	3,729,851	5,297,337	5,295,399	5,319,974	0	0	0	0	0	0	27,081,689	
FEE FOR SERVICE - ACUTE	39,309,584	42,687,182	52,163,025	35,355,326	39,335,094	43,637,685	0	0	0	0	0	0	252,487,897	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	607,419	638,824	734,158	0	0	0	0	0	0	4,000,032	
EMERGENCY SERVICES - FEDERAL	4,601,455	4,572,491	5,962,347	5,124,819	4,140,929	5,688,268	0	0	0	0	0	0	30,090,310	
FFS - FAMILY PLANNING	-39	0	0	0	0	0	0	0	0	0	0	0	-39	
FFS MEDICAID IN PUBLIC SCHOOLS	676,499	194,086	533,578	397,621	384,665	756,763	0	0	0	0	0	0	2,943,210	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	374,616	274,232	543,181	0	0	0	0	0	0	2,190,612	
INPATIENT INMATES FFS	94,140	163,355	30,952	166,197	96,395	235,228	0	0	0	0	0	0	786,266	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	33,509	11,088	28,421	0	0	0	0	0	0	180,756	
MOHAVE COUNTY INMATES FFS	0	177	0	4,575	0	9,164	0	0	0	0	0	0	13,916	
COCHISE COUNTY INMATES FFS	0	0	0	0	586	0	0	0	0	0	0	0	586	
PINAL COUNTY INMATES FFS	0	791	4,402	328	5,014	5,310	0	0	0	0	0	0	15,845	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	0	8,608	0	0	0	0	0	0	8,608	
PIMA COUNTY INMATES FFS	339	2,845	4,099	8,752	867	3,962	0	0	0	0	0	0	20,863	
FEE FOR SERVICE - LTC	8,618,281	9,030,245	12,244,181	8,955,714	9,411,357	11,193,029	0	0	0	0	0	0	59,452,807	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	21,120	18,430	22,655	0	0	0	0	0	0	143,880	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,303,186	520,396	1,333,715	799,779	799,536	1,430,086	0	0	0	0	0	0	6,186,698	
REINSURANCE - ACUTE	7,490,557	6,963,077	9,713,101	10,354,036	7,487,802	9,748,571	0	0	0	0	0	0	51,757,144	
REINSURANCE - LTC	4,045,763	3,839,634	5,041,535	4,350,748	5,856,334	3,769,395	0	0	0	0	0	0	26,903,409	
SMIB - ACUTE	9,829,585	10,084,385	10,344,498	10,630,380	10,758,366	10,820,128	0	0	0	0	0	0	62,467,342	
HIB - ACUTE	261,769	274,050	304,238	305,977	291,872	302,007	0	0	0	0	0	0	1,739,913	
Q1	2,399,485	1,983,017	1,927,946	1,981,086	1,974,022	1,905,403	0	0	0	0	0	0	12,170,958	
SMIB - LTC	2,846,826	2,859,916	2,858,311	2,859,099	2,866,769	2,884,480	0	0	0	0	0	0	17,175,400	
HIB - LTC	269,425	275,672	269,873	259,133	272,905	271,807	0	0	0	0	0	0	1,618,815	
	607,107,950	627,019,248	641,497,165	611,279,516	626,123,714	676,355,457	0	0	0	0	0	0	3,789,383,051	

TITLE XIX TRADITIONAL

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

TOTAL

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending December 31, 2015

CAPITATION - ACUTE	171,977,268	169,158,780	168,592,407	201,257,676	199,521,303	234,643,481	0	0	0	0	0	0	1,145,150,915	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	62,503	47,177	60,406	0	0	0	0	0	0	402,971	
MENTAL HEALTH - ADULT	14,130,226	13,753,412	13,745,030	1,449,862	1,458,767	2,988,321	0	0	0	0	0	0	47,525,618	
MENTAL HEALTH - GENERAL	19,007,580	18,500,700	18,489,426	26,014,924	26,174,705	26,546,243	0	0	0	0	0	0	134,733,578	
MENTAL HEALTH - CMDP	0	0	0	1,009	0	0	0	0	0	0	0	0	1,009	
CHILDREN'S REHAB SERVICES	13,342	14,176	13,759	16,233	15,769	17,161	0	0	0	0	0	0	90,440	
FEE FOR SERVICE - ACUTE	23,420,195	26,360,064	31,634,361	22,488,296	25,630,747	29,732,231	0	0	0	0	0	0	159,265,893	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	991,315	851,991	752,086	0	0	0	0	0	0	6,119,387	
EMERGENCY SERVICES - FEDERAL	1,615,009	1,756,056	2,298,814	2,324,017	1,395,634	1,620,895	0	0	0	0	0	0	11,010,425	
FFS MEDICAID IN PUBLIC SCHOOLS	5,786	3,204	5,139	1,380	897	4,447	0	0	0	0	0	0	20,853	
INPATIENT INMATES FFS	600,012	766,289	566,467	395,868	507,796	802,928	0	0	0	0	0	0	3,639,359	
MOHAVE COUNTY INMATES FFS	0	4,084	692	373	10,051	15,369	0	0	0	0	0	0	30,568	
YAVAPAI COUNTY INMATES FFS	306	0	166	9,252	485	161	0	0	0	0	0	0	10,370	
PINAL COUNTY INMATES FFS	8,167	-1,654	11,736	3,532	14,776	12,078	0	0	0	0	0	0	48,634	
PIMA COUNTY INMATES FFS	16,737	14,619	968	21,330	11,636	5,547	0	0	0	0	0	0	70,837	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	174,594	33,475	165,593	0	0	0	0	0	0	690,809	
COCONINO COUNTY INMATES FFS	152	3,842	0	274	1,126	0	0	0	0	0	0	0	5,394	
COCHISE COUNTY INMATES FFS	0	0	0	0	480	210	0	0	0	0	0	0	689	
REINSURANCE - ACUTE	3,024,281	3,235,285	3,273,260	5,216,265	4,459,353	3,409,309	0	0	0	0	0	0	22,617,753	
SMIB - ACUTE	5,190,825	5,190,446	5,117,460	5,152,132	4,954,096	4,968,092	0	0	0	0	0	0	30,573,050	
HIB - ACUTE	8,649	8,527	5,656	8,584	4,192	4,192	0	0	0	0	0	0	39,802	
	240,353,793	239,927,923	245,334,015	265,589,419	265,094,455	305,748,749	0	0	0	0	0	0	1,562,048,354	

TITLE XIX PROP 204

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

TOTAL

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending December 31, 2015

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

TITLE XIX ACA ADULT EXPANSION

TOTAL

SUBTOTAL

TOTAL TITLE XIX

CAPITATION - ACUTE	22,690,376	23,251,291	24,201,251	29,417,656	29,997,586	33,374,958	0	0	0	0	0	0	162,933,118	
MENTAL HEALTH - CHILD	0	0	0	41	0	0	0	0	0	0	0	0	41	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	228,016	237,878	360,470	0	0	0	0	0	0	7,744,039	
MENTAL HEALTH - GENERAL	2,968,226	3,090,821	3,246,414	4,091,302	4,268,263	4,542,373	0	0	0	0	0	0	22,207,398	
CHILDREN'S REHAB SERVICES	417	417	417	0	0	0	0	0	0	0	0	0	1,251	
FEE FOR SERVICE - ACUTE	1,757,826	2,095,785	2,416,332	1,869,494	1,862,135	2,333,128	0	0	0	0	0	0	12,334,700	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	262,679	334,688	251,090	0	0	0	0	0	0	1,540,825	
EMERGENCY SERVICES - FEDERAL	1,701,575	1,999,988	3,176,831	2,397,434	1,935,178	2,586,750	0	0	0	0	0	0	13,797,756	
INPATIENT INMATES FFS	6,351	35,816	34,047	9,398	35,244	52,674	0	0	0	0	0	0	173,531	
MARICOPA CTY INMATES FFS	15,154	0	0	149	0	0	0	0	0	0	0	0	15,303	
REINSURANCE - ACUTE	276,372	479,010	344,794	397,029	359,861	225,309	0	0	0	0	0	0	2,082,375	
SMIB - ACUTE	1,469	734	839	629	839	944	0	0	0	0	0	0	5,455	
	31,784,937	33,467,076	36,150,580	38,673,829	39,031,673	43,727,697	0	0	0	0	0	0	222,835,791	
	879,246,680	900,414,248	922,981,760	915,542,763	930,249,842	1,025,831,903	0	0	0	0	0	0	5,574,267,196	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	183,782	170,409	173,186	164,735	157,227	237,286	0	0	0	0	0	0	1,086,625	
KidsCare - FEE FOR SERVICE	-819	774	436	1,805	404	335	0	0	0	0	0	0	2,935	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	36,831	35,192	42,452	0	0	0	0	0	0	221,778	
KidsCare - REINSURANCE	162	30,495	70,989	57,122	103,826	25,397	0	0	0	0	0	0	287,992	

220,533	237,043	279,141	260,493	296,650	305,470	0	0	0	0	0	0	1,599,330	

TOTAL TITLE XXI

879,467,213	900,651,004	923,260,901	915,803,257	930,546,492	1,026,137,373	0	0	0	0	0	0	5,575,866,239	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 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	114.37	156.60	0.00	0.00	0.00	0.00	0.00	0.00	724.85

1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	162.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162.83

1006	TANF 21-44 MALE WITH	91,470.48	100,935.93	114,056.53	29,730.44	30,795.93	37,326.41	0.00	0.00	0.00	0.00	0.00	0.00	404,315.72

1007	TANF 21-44 FEMALE WI	262,969.81	321,024.00	366,691.13	93,778.32	95,564.51	105,731.27	0.00	0.00	0.00	0.00	0.00	0.00	1,245,759.04

1008	TANF 45-64 M & F WIT	456,857.48	533,329.59	618,899.14	153,616.98	162,064.99	169,735.99	0.00	0.00	0.00	0.00	0.00	0.00	2,094,504.17

1009	TANF 65+ M & F WITH	130,859.20	158,119.22	182,105.63	43,807.61	41,203.16	47,386.45	0.00	0.00	0.00	0.00	0.00	0.00	603,481.27

100F	TANF 21-44 MALE WITH	3,124.94	3,371.26	1,066.32	1,235.50	433.09	661.05	0.00	0.00	0.00	0.00	0.00	0.00	9,892.16

100G	TANF 21-44 FEMALE WI	6,088.86	5,158.50	4,029.73	604.18	1,064.56	319.24	0.00	0.00	0.00	0.00	0.00	0.00	17,265.07

100H	TANF 44-64 M & F WIT	43,752.90	40,165.14	12,382.66	7,340.32	868.81	2,130.60	0.00	0.00	0.00	0.00	0.00	0.00	106,640.43

100J	TANF 65+ M & F WITH	30,736.25	17,071.36	1,805.26	3,147.18	0.00	462.01	0.00	0.00	0.00	0.00	0.00	0.00	53,222.06

1011	TANF <1 M & F NON-ME	7,317,911.15	7,330,064.00	6,810,085.94	6,752,430.01	6,885,407.96	8,466,719.03	0.00	0.00	0.00	0.00	0.00	0.00	43,562,618.09

1012	TANF 01-05 M & F NON	5,120,069.24	4,255,241.15	3,820,804.71	3,463,337.50	3,013,110.39	5,009,601.92	0.00	0.00	0.00	0.00	0.00	0.00	24,682,164.91

1013	TANF 06-13 M & F NON	8,517,151.93	7,122,208.02	6,407,880.79	5,781,174.88	4,987,581.30	8,074,775.17	0.00	0.00	0.00	0.00	0.00	0.00	40,890,772.09

1014	TANF 14-20 MALE NON-	2,727,086.79	2,467,883.88	2,310,485.87	2,118,291.66	1,897,764.46	2,753,277.98	0.00	0.00	0.00	0.00	0.00	0.00	14,274,790.64

1015	TANF 14-20 FEMALE N O

5,165,143.02	4,749,211.72	4,482,122.34	3,898,517.39	3,521,357.35	5,141,893.76	0.00	0.00	0.00	0.00	0.00	0.00	26,958,245.58

1016	TANF 21-44 MALE NON-	5,413,848.55	5,881,009.18	6,413,970.06	4,199,543.45	4,283,530.08	5,058,731.41	0.00	0.00	0.00	0.00	0.00	0.00	31,250,632.73

1017	TANF 21-44 FEMALE N O

26,519,446.98    27,563,602.69     29,211,296.32     21,814,659.48     21,700,333.91     26,925,638.23	0.00	0.00	0.00	0.00	0.00	0.00	153,734,977.61

1018	TANF 45-64 M & F NON	11,340,403.80    12,200,886.15     13,314,078.59	8,505,687.29	8,526,844.27     10,212,133.25	0.00	0.00	0.00	0.00	0.00	0.00	64,100,033.35

1019	TANF 65+ M & F NON-M	50,940.78	55,345.09	63,094.36	35,864.95	34,947.04	41,877.20	0.00	0.00	0.00	0.00	0.00	0.00	282,069.42

101A	TANF < 1 M & F NON-M	1,483,647.90	1,229,135.61	596,433.59	1,591,704.20	1,242,886.90	1,676,211.66	0.00	0.00	0.00	0.00	0.00	0.00	7,820,019.86

101B	TANF 01-05 M & F NON	18,930.19	10,452.99	13,969.51	21,291.05	8,127.92	12,350.65	0.00	0.00	0.00	0.00	0.00	0.00	85,122.31

101C	TANF 06-13 M & F NON	13,827.52	10,991.93	10,596.95	24,089.70	7,386.13	8,766.98	0.00	0.00	0.00	0.00	0.00	0.00	75,659.21

101D	TANF 14-20 MALE NON-	30,653.81	23,910.41	11,522.68	26,798.62	9,274.23	9,473.63	0.00	0.00	0.00	0.00	0.00	0.00	111,633.38

101E	TANF 14-20 FEMALE N O

56,482.84	48,295.58	35,281.43	34,103.87	17,747.19	20,677.74	0.00	0.00	0.00	0.00	0.00	0.00	212,588.65

101F	TANF 21-44 MALE NON-	441,372.83	443,539.24	240,851.96	193,781.66	93,373.63	102,481.77	0.00	0.00	0.00	0.00	0.00	0.00	1,515,401.09

101G	TANF 21-44 FEMALE N O

967,547.84	939,350.71	551,924.22	458,482.24	314,016.32	252,665.56	0.00	0.00	0.00	0.00	0.00	0.00	3,483,986.89

101H	TANF 44-64 M & F NON	673,153.96	695,670.20	390,666.92	248,353.01	134,308.24	118,016.10	0.00	0.00	0.00	0.00	0.00	0.00	2,260,168.43

101J	TANF 65+ N & F NON-M	13,593.90	8,104.86	11,870.70	676.55	2,534.13	4,132.50	0.00	0.00	0.00	0.00	0.00	0.00	40,912.64

1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	503.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	503.59

1026	TANF 21-44 MALE WITH	39,781.26	52,613.13	69,409.48	17,011.53	12,616.89	12,420.55	0.00	0.00	0.00	0.00	0.00	0.00	203,852.84

1027	TANF 21-44 FEMALE WI	112,487.20	155,750.38	178,197.45	42,604.92	49,730.74	52,435.62	0.00	0.00	0.00	0.00	0.00	0.00	591,206.31

1028	TANF 45-64 M & F WIT	142,957.26	219,266.01	262,802.70	39,010.80	49,106.64	59,623.01	0.00	0.00	0.00	0.00	0.00	0.00	772,766.42

1029	TANF 65+ M & F WITH	53,811.16	84,861.43	103,507.94	16,738.86	19,102.86	21,396.49	0.00	0.00	0.00	0.00	0.00	0.00	299,418.74

102F	TANF 21-44 MALE WITH	0.00	349.97	22.18	283.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	655.45

102G	TANF 21-44 FEMALE WI	894.71	245.67	322.44	0.00	0.00	395.42	0.00	0.00	0.00	0.00	0.00	0.00	1,858.24

102H	TANF 44-64 M & F WIT	814.72	5,425.27	2,007.41	0.00	1,518.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,765.90

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

102J	TANF 65+ M & F WITH	958.54	944.87	0.00	2,333.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,237.35

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

646,891.69	640,426.15	626,324.88	741,218.85	763,396.08	911,370.46	0.00	0.00	0.00	0.00	0.00	0.00	4,329,628.11

42,792.60	35,137.07	23,993.14	22,253.33	24,247.34	18,780.78	0.00	0.00	0.00	0.00	0.00	0.00	167,204.26

4,841,984.49	4,755,477.85	4,841,046.00	5,319,754.55	5,244,733.49	6,165,217.24	0.00	0.00	0.00	0.00	0.00	0.00	31,168,213.62

168,114.98	120,300.70	81,292.69	107,483.51	100,740.24	108,279.02	0.00	0.00	0.00	0.00	0.00	0.00	686,211.14

2120	SSI AGED WITH QMB	2,773,140.25	2,801,949.97	2,812,690.87	4,298,415.06	4,308,900.56	5,096,743.92	0.00	0.00	0.00	0.00	0.00	0.00	22,091,840.63

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

5,569.66	5,916.01	9,571.88	5,721.66	6,731.50	3,193.40	0.00	0.00	0.00	0.00	0.00	0.00	36,704.11

1,438,779.65	1,356,642.89	1,368,850.54	1,750,088.66	1,712,310.36	1,875,273.93	0.00	0.00	0.00	0.00	0.00	0.00	9,501,946.03

21,320.23	23,148.40	24,683.29	18,921.57	10,281.93	13,756.93	0.00	0.00	0.00	0.00	0.00	0.00	112,112.35

55,077,622.81    54,829,218.00     54,812,398.76     59,204,588.11     59,278,100.88     69,156,204.73	0.00	0.00	0.00	0.00	0.00	0.00	352,358,133.29

491,291.42	492,991.62	460,508.70	398,574.48	381,824.33	446,410.95	0.00	0.00	0.00	0.00	0.00	0.00	2,671,601.50

10,386,804.88    10,418,005.20     10,514,240.11     14,112,652.81     14,189,750.86     15,063,808.66	0.00	0.00	0.00	0.00	0.00	0.00	74,685,262.52

5,921.17	7,380.90	10,401.43	3,840.12	2,524.99	1,286.06	0.00	0.00	0.00	0.00	0.00	0.00	31,354.67

2300	SSI BLIND WITH MEDIC	4,363.55	4,060.83	3,780.74	6,282.61	6,337.48	8,054.88	0.00	0.00	0.00	0.00	0.00	0.00	32,880.09

230Z	SSI BLIND WITH MEDIC	448.85	0.00	0.00	0.00	0.00	1,400.03	0.00	0.00	0.00	0.00	0.00	0.00	1,848.88

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

353,568.15	356,359.13	362,835.95	397,898.39	397,764.11	482,931.13	0.00	0.00	0.00	0.00	0.00	0.00	2,351,356.86

3,440.09	12,852.23	5,876.17	7,201.16	2,280.81	13,964.20	0.00	0.00	0.00	0.00	0.00	0.00	45,614.66

2320	SSI BLIND WITH QMB	44,041.31	43,688.31	44,085.09	52,049.43	51,728.72	56,683.73	0.00	0.00	0.00	0.00	0.00	0.00	292,276.59

232Z	SSI BLIND WITH QMB P	0.00	0.00	2.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.91

4302	SOBRA CHILD 01-05 M	541.57	1,125.47	-453.71	224.19	224.19	260.25	0.00	0.00	0.00	0.00	0.00	0.00	1,921.96

4303	SOBRA CHILD 06-13 M	227.07	227.07	276.11	244.30	1,116.27	1,036.83	0.00	0.00	0.00	0.00	0.00	0.00	3,127.65

4304	SOBRA CHILD 14-20 MA	162.24	162.24	162.24	0.00	-162.83	198.38	0.00	0.00	0.00	0.00	0.00	0.00	522.27

4305	SOBRA CHILD 14-20 FE	789.59	840.59	831.97	868.03	704.35	1,568.24	0.00	0.00	0.00	0.00	0.00	0.00	5,602.77

430B	SOBRA CHILD 01-05 M	49.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.61

430C	SOBRA CHILD 06-13 M	0.00	0.00	95.88	47.55	77.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220.47

430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

430E	SOBRA CHILD 14-20 FE	0.00	120.83	193.23	-73.98	-119.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	120.83

4311	SOBRA CHILD <1 M & F     19,081,996.88    19,048,366.58     17,788,960.54     18,398,080.15     18,949,300.54     22,265,454.91	0.00	0.00	0.00	0.00	0.00	0.00	115,532,159.60

4312	SOBRA CHILD 01-05 M	19,072,224.87    20,064,623.31     21,072,490.25     21,576,275.67     22,390,417.25     25,716,755.92	0.00	0.00	0.00	0.00	0.00	0.00	129,892,787.27

4313	SOBRA CHILD 06-13 M	25,452,339.99    27,401,384.87     29,128,878.55     26,788,281.50     27,455,119.36     31,848,138.21	0.00	0.00	0.00	0.00	0.00	0.00	168,074,142.48

4314	SOBRA CHILD 14-20 MA	8,607,044.24	8,948,118.85	9,523,338.23	8,708,264.72	8,805,134.23     10,211,158.07	0.00	0.00	0.00	0.00	0.00	0.00	54,803,058.34

4315	SOBRA CHILD 14-20 FE     13,024,273.87    13,595,781.00     14,432,717.70     13,314,992.12     13,452,811.30     15,650,130.16	0.00	0.00	0.00	0.00	0.00	0.00	83,470,706.15

431A	SOBRA CHILD < 1 M &	1,266,381.59	1,304,281.60	634,368.33	1,482,032.17	977,262.62	1,052,793.73	0.00	0.00	0.00	0.00	0.00	0.00	6,717,120.04

431B	SOBRA CHILD 01-05 M	494,252.81	475,898.40	360,178.32	407,643.39	262,251.61	237,112.36	0.00	0.00	0.00	0.00	0.00	0.00	2,237,336.89

431C	SOBRA CHILD 6-13 M& F

634,059.19	670,453.45	453,423.37	439,439.88	292,079.09	261,690.28	0.00	0.00	0.00	0.00	0.00	0.00	2,751,145.26

431D	SOBRA CHILD 14-20 MA	467,748.21	431,434.92	303,172.79	265,677.52	189,364.34	175,616.37	0.00	0.00	0.00	0.00	0.00	0.00	1,833,014.15

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

431E	SOBRA CHILD 14-20 FE	506,841.24	521,342.83	357,514.83	325,476.02	233,036.41	214,906.87	0.00	0.00	0.00	0.00	0.00	0.00	2,159,118.20

4321	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4322	SOBRA CHILD 01-05 M	329.97	0.00	220.65	332.81	115.27	299.36	0.00	0.00	0.00	0.00	0.00	0.00	1,298.06

4323	SOBRA CHILD 06-13 M	755.82	0.00	107.48	558.29	399.46	1,577.25	0.00	0.00	0.00	0.00	0.00	0.00	3,398.30

4324	SOBRA CHILD 14-20 MA	623.74	0.00	162.24	137.86	272.28	450.17	0.00	0.00	0.00	0.00	0.00	0.00	1,646.29

4325	SOBRA CHILD 14-20 FE	490.95	259.91	523.40	0.00	0.00	1,031.53	0.00	0.00	0.00	0.00	0.00	0.00	2,305.79

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

9910	TANF & SOBRA CHILDR	3,483,562.65	3,047,996.25	2,907,424.24	2,225,583.72	2,475,483.80	2,596,110.50	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	66,760.99	67,334.84	73,848.44	60,848.38	72,108.82	36,734.16	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	253,912.66	175,567.47	201,893.70	182,160.74	179,014.54	233,459.31	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	12,465,299.69	13,765,854.41	14,897,401.05	13,552,095.42	13,016,280.12	12,455,320.03	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,269,535.99	17,056,752.97	18,080,567.43	16,020,688.26	15,742,887.28	15,321,624.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

28,646.09	29,529.54	34,810.47	37,003.71	22,770.15	24,460.37	0.00	0.00	0.00	0.00	0.00	0.00	177,220.33

856.00	405.55	405.55	898.29	898.29	1,365.91	0.00	0.00	0.00	0.00	0.00	0.00	4,829.59

667.73	637.69	427.13	403.02	162.14	432.77	0.00	0.00	0.00	0.00	0.00	0.00	2,730.48

791.84	960.27	778.66	664.29	689.41	1,113.84	0.00	0.00	0.00	0.00	0.00	0.00	4,998.31

1,153,204.41	1,243,589.20	1,321,708.44	1,331,054.56	1,405,473.49	1,347,623.02	0.00	0.00	0.00	0.00	0.00	0.00	7,802,653.12

4,969,763.44	5,543,577.71	6,104,353.53	6,666,900.29	7,018,557.84	6,609,761.00	0.00	0.00	0.00	0.00	0.00	0.00	36,912,913.81

29,226.73	32,189.69	33,578.00	41,189.47	41,350.99	43,398.65	0.00	0.00	0.00	0.00	0.00	0.00	220,933.53

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

77,023.42	77,726.43	48,097.14	49,640.39	42,451.40	40,717.75	0.00	0.00	0.00	0.00	0.00	0.00	335,656.53

331,612.75	308,457.61	239,213.41	224,480.35	178,215.34	172,143.31	0.00	0.00	0.00	0.00	0.00	0.00	1,454,122.77

3,630.96	10,740.73	531.17	334.55	0.00	588.34	0.00	0.00	0.00	0.00	0.00	0.00	15,825.75

2,329.77	2,829.66	4,481.72	4,273.54	4,730.15	7,022.63	0.00	0.00	0.00	0.00	0.00	0.00	25,667.47

0.00	2,426.39	2,426.39	2,242.66	2,242.66	2,242.66	0.00	0.00	0.00	0.00	0.00	0.00	11,580.76

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

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

248,764,079.13  252,354,794.67   254,464,913.27  246,135,180.96  245,353,522.07   289,714,014.44	0.00	0.00	0.00	0.00	0.00	0.00	1,536,786,504.54

16,736,161.16	
377,635.63	
1,226,008.42	
80,152,250.72	
98,492,055.93	

E

1

1

1106	TANF EXPANDED 21-44	167,462.38	144,030.22	123,318.86	348,239.33	330,998.49	327,182.94	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	599,045.66	537,386.92	489,127.06	1,038,594.89	978,957.19	997,700.97	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,023,600.25	911,053.14	848,021.18	1,766,284.56	1,717,007.59	1,892,880.81	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	274,415.40	245,636.00	232,837.24	502,261.74	493,090.82	555,678.60	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	3,682.62	630.49	1,486.57	3,392.63	3,061.27	1,445.35	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

518.28

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

174.72

693.00

1,441,232.22	
4,640,812.69	
8,158,847.53	
2,303,919.80	
13,698.93	

M&

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

110G	TANF EXPANDED 21-44	520.84	324.33	2,552.22	7,103.54	4,282.02	3,569.35	0.00	0.00	0.00	0.00	0.00	0.00	18,352.30

110H	TANF EXPANDED 45-64	161.40	385.93	27,647.67	33,347.53	20,685.44	12,573.42	0.00	0.00	0.00	0.00	0.00	0.00	94,801.39

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

0.00	1,210.32	15,631.07	6,020.54	4,765.67	5,751.71	0.00	0.00	0.00	0.00	0.00	0.00	33,379.31

6,325.21	4,355.65	762.79	1,466.00	1,466.00	6,164.56	0.00	0.00	0.00	0.00	0.00	0.00	20,540.21

1112	TANF EXPANDED 01-05	48,437.22	37,053.66	33,123.81	29,396.05	22,170.25	40,683.70	0.00	0.00	0.00	0.00	0.00	0.00	210,864.69

1113	TANF EXPANDED 06-13	155,432.39	123,651.13	108,415.58	93,138.60	75,107.67	137,286.25	0.00	0.00	0.00	0.00	0.00	0.00	693,031.62

1114	TANF EXPANDED 14-20	114,898.22	90,180.24	76,789.22	121,834.46	112,376.36	164,931.05	0.00	0.00	0.00	0.00	0.00	0.00	681,009.55

1115	TANF EXPANDED 14-20	375,463.35	278,983.53	236,525.33	455,399.24	446,636.13	633,180.29	0.00	0.00	0.00	0.00	0.00	0.00	2,426,187.87

1116	TANF EXPANDED 21-44	3,292,450.62	2,886,484.77	2,569,959.71	5,025,954.65	4,942,910.96	6,002,728.09	0.00	0.00	0.00	0.00	0.00	0.00	24,720,488.80

1117	TANF EXPANDED 21-44     11,884,383.87    10,291,379.14	9,057,760.96     17,098,041.17     16,741,566.94     20,819,880.91	0.00	0.00	0.00	0.00	0.00	0.00	85,893,012.99

1118	TANF EXPANDED 45-64	7,186,338.24	6,353,222.09	5,768,022.81     11,349,562.98     11,255,706.50     13,396,810.80	0.00	0.00	0.00	0.00	0.00	0.00	55,309,663.42

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

38,116.96	34,638.80	32,844.67	50,449.55	48,551.01	53,636.05	0.00	0.00	0.00	0.00	0.00	0.00	258,237.04

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	14.09	0.00	0.00	0.00	0.00	0.00	0.00	65.42

111C	TANF EXPANDED 06-13	60.93	0.00	0.00	166.42	306.00	60.93	0.00	0.00	0.00	0.00	0.00	0.00	594.28

111D	TANF EXPANDED 14-20	91.04	817.44	2,346.34	1,783.04	4,380.55	2,916.80	0.00	0.00	0.00	0.00	0.00	0.00	12,335.21

111E	TANF EXPANDED 14-20	1,428.69	1,919.48	6,274.89	9,908.99	8,959.07	6,718.54	0.00	0.00	0.00	0.00	0.00	0.00	35,209.66

111F	TANF EXPANDED 21-44	16,857.80	16,840.28	88,070.74	149,530.14	129,309.81	116,610.53	0.00	0.00	0.00	0.00	0.00	0.00	517,219.30

111G	TANF EXPANDED 21-44	38,462.54	45,149.24	202,727.99	318,834.43	259,990.85	218,979.50	0.00	0.00	0.00	0.00	0.00	0.00	1,084,144.55

111H	TANF EXPANDED 45-64	12,792.72	53,531.20	181,490.33	247,343.76	197,107.31	226,180.46	0.00	0.00	0.00	0.00	0.00	0.00	918,445.78

111J	TANF EXPANDED 65+ M&

10,074.33	0.00	1,610.12	15,133.53	1,008.68	2,764.06	0.00	0.00	0.00	0.00	0.00	0.00	30,590.72

1125	TANF EXPANDED 14-20	259.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.91

1126	TANF EXPANDED 21-44	77,277.63	71,347.76	61,838.93	77,526.90	106,393.69	141,787.79	0.00	0.00	0.00	0.00	0.00	0.00	536,172.70

1127	TANF EXPANDED 21-44	214,717.61	193,927.68	179,884.44	245,571.04	327,309.88	412,966.19	0.00	0.00	0.00	0.00	0.00	0.00	1,574,376.84

1128	TANF EXPANDED 45-64	242,994.86	222,897.30	210,610.65	289,864.60	387,477.49	506,704.18	0.00	0.00	0.00	0.00	0.00	0.00	1,860,549.08

1129	TANF EXPANDED 65+ M&

89,535.41	77,417.22	73,153.41	82,720.03	108,728.23	148,924.61	0.00	0.00	0.00	0.00	0.00	0.00	580,478.91

112F	TANF EXPANDED 21-44	0.00	0.00	406.00	246.72	273.24	148.50	0.00	0.00	0.00	0.00	0.00	0.00	1,074.46

112G	TANF EXPANDED 21-44	0.00	681.07	726.03	964.10	648.57	537.96	0.00	0.00	0.00	0.00	0.00	0.00	3,557.73

112H	TANF EXPANDED 45-64	10.59	0.00	1,235.44	3,753.28	2,524.51	3,261.62	0.00	0.00	0.00	0.00	0.00	0.00	10,785.44

112J	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
241Z	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
242Z	SSI AGED EXPANDED
WI

0.00	0.00	6,378.93	344.31	4,119.33	5,140.99	0.00	0.00	0.00	0.00	0.00	0.00	15,983.56

90,318.38	78,003.38	74,504.07	71,589.26	68,291.67	85,596.82	0.00	0.00	0.00	0.00	0.00	0.00	468,303.58

28,495.79	37,821.60	22,409.28	21,024.30	14,619.96	19,893.94	0.00	0.00	0.00	0.00	0.00	0.00	144,264.87

929,746.50	864,149.68	813,310.62	351,969.12	320,177.38	502,076.63	0.00	0.00	0.00	0.00	0.00	0.00	3,781,429.93

7,401.77	16,962.83	8,306.20	4,276.52	3,695.68	4,224.09	0.00	0.00	0.00	0.00	0.00	0.00	44,867.09

5,235,551.09	5,187,661.49	5,133,746.28	4,943,310.23	4,730,309.58	5,380,172.92	0.00	0.00	0.00	0.00	0.00	0.00	30,610,751.59

7,997.68	5,766.54	4,987.33	5,330.17	2,179.50	3,294.80	0.00	0.00	0.00	0.00	0.00	0.00	29,556.02

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

2500	SSI BLIND EXPANDED W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
260Z	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
261Z	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E

0.00	0.00	0.00	140.23	140.23	140.23	0.00	0.00	0.00	0.00	0.00	0.00	420.69

1,458.65	1,458.65	1,458.65	755.69	755.69	869.56	0.00	0.00	0.00	0.00	0.00	0.00	6,756.89

124.99	124.99	124.99	130.02	130.02	214.81	0.00	0.00	0.00	0.00	0.00	0.00	849.82

159,975.75	157,902.91	154,039.57	218,895.60	207,386.21	236,189.23	0.00	0.00	0.00	0.00	0.00	0.00	1,134,389.27

17,956.66	21,077.50	16,146.29	10,542.62	5,850.05	8,516.52	0.00	0.00	0.00	0.00	0.00	0.00	80,089.64

2,642,788.10	2,565,161.03	2,574,872.47	2,863,962.71	2,808,377.77	3,044,563.75	0.00	0.00	0.00	0.00	0.00	0.00	16,499,725.83

33,355.68	32,438.70	29,106.19	22,550.86	20,810.52	30,090.61	0.00	0.00	0.00	0.00	0.00	0.00	168,352.56

7,540,307.86	7,645,491.81	7,856,549.93     10,670,749.62     10,778,061.56     11,297,117.91	0.00	0.00	0.00	0.00	0.00	0.00	55,788,278.69

6,428.48	5,511.39	8,031.41	4,310.82	1,836.82	2,308.74	0.00	0.00	0.00	0.00	0.00	0.00	28,427.66

SUBTOTAL:

42,577,206.07

39,244,718.86    37,338,771.85    58,563,716.52    57,700,500.16     67,461,072.16	0.00	0.00	0.00	0.00	0.00	0.00	302,885,985.62

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

638,069.14	744,028.48	692,146.52	1,079,073.38	867,744.81	1,482,620.38	0.00	0.00	0.00	0.00	0.00	0.00

5,503,682.71	
87,305.62	
17,942.11	
5,608,930.44	

12,450.73	18,552.72	24,748.20	6,290.91	12,607.20	12,655.86	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

656,262.88

768,544.97	716,894.72	1,091,599.62	880,352.01	1,495,276.24	0.00	0.00	0.00	0.00	0.00	0.00

3614	AHC CARE/MI MALE 14-	0.00	1,436.95	0.00	0.00	0.00	149.14	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	125.06	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	1,436.95	0.00	0.00	0.00	274.20	0.00	0.00	0.00	0.00	0.00	0.00	

1,586.09

2
SUBTOTAL:

125.06

1,711.15

47,534.78	
67,564.31	
274,419.98	
145,752.87	
10,689.69	
3,382.37	
42,834.48	
22,677.54	
9,494,635.95	
11,314,559.45	
49,763,480.48	
41,538,581.58	
99,304,730.27	
103,282.21	
580,407.86	
643,790.06	
2,940,907.54	
2,196,724.02	

3506	ADULT 40-100% MALE 2	8,422.52	3,645.97	6,549.05	6,920.85	6,749.84	15,246.55	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

14,179.59	8,854.37	9,129.40	10,935.03	15,132.78	9,333.14	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	36,321.61	26,956.15	25,017.05	64,607.16	49,522.12	71,995.89	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	22,353.25	22,570.84	21,631.31	35,593.28	25,767.82	17,836.37	0.00	0.00	0.00	0.00	0.00	0.00

350F	ADULT 40-100% MALE 2	3,964.50	465.31	2,008.05	3,379.72	872.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350G	ADULT 40-100% FEMAL E

0.00	0.00	0.00	2,924.56	0.00	457.81	0.00	0.00	0.00	0.00	0.00	0.00

350H	ADULT 40-100% M&F 45	6,365.04	6,197.78	10,677.21	13,210.50	2,142.45	4,241.50	0.00	0.00	0.00	0.00	0.00	0.00

350J	ADULT 40-100% M&F 65	7,372.56	5,207.00	0.00	2,056.55	357.79	7,683.64	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	1,324,584.01	1,440,655.36	1,514,833.49	1,566,211.25	1,665,256.44	1,983,095.40	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	1,845,511.21	1,949,540.67	2,346,800.11	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	7,573,355.50	7,578,276.66	7,770,879.64	8,378,901.15	8,463,151.65	9,998,915.88	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

6,410,679.09	6,346,041.90	6,476,413.17	6,980,125.28	6,982,308.75	8,343,013.39	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45    15,191,483.66    15,250,141.05     15,625,452.65     16,626,431.57     16,759,472.47     19,851,748.87	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	16,506.64	15,041.42	15,084.02	22,447.95	13,832.15	20,370.03	0.00	0.00	0.00	0.00	0.00	0.00

351D	ADULT 40-100% MALE 1	148,997.70	115,709.11	88,931.32	77,872.89	78,610.60	70,286.24	0.00	0.00	0.00	0.00	0.00	0.00

351E	ADULT 40-100% FEMAL E

144,852.52	143,422.42	95,008.93	105,596.06	74,569.94	80,340.19	0.00	0.00	0.00	0.00	0.00	0.00

351F	ADULT 40-100% MALE 2	646,088.27	613,079.90	479,928.59	471,628.16	336,866.99	393,315.63	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	356,601.53	246,284.78	336,778.70	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

351H	ADULT 40-100% M&F 45	1,204,084.30	1,016,417.29	728,945.34	784,761.29	597,289.00	719,875.67	0.00	0.00	0.00	0.00	0.00	0.00	5,051,372.89

351J	ADULT 40-100% M&F 65	27,457.81	15,740.35	20,203.21	13,703.32	28,147.70	3,538.93	0.00	0.00	0.00	0.00	0.00	0.00	108,791.32

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	905.24	584.84	0.00	0.00	0.00	0.00	0.00	0.00	2,658.34

3527	ADULT 40-100% FEMAL E

668.80	1,504.94	0.00	366.57	441.10	2,105.01	0.00	0.00	0.00	0.00	0.00	0.00	5,086.42

3528	ADULT 40-100% M&F 45	10,626.75	7,689.50	12,719.11	12,289.73	10,883.20	14,832.86	0.00	0.00	0.00	0.00	0.00	0.00	69,041.15

3529	ADULT 40-100% M&F 65	2,416.71	4,002.70	1,585.00	5,981.76	4,387.94	5,346.12	0.00	0.00	0.00	0.00	0.00	0.00	23,720.23

352F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	162.24	0.00	0.00	0.00	0.00	0.00	0.00	162.24

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	1,096.69	0.00	0.00	0.00	0.00	0.00	0.00	3,296.74

352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	3,228.03	616.59	2,867.30	0.00	0.00	0.00	0.00	0.00	0.00	6,711.92

3705	ADULT <40% EXP FEM AL

0.00	0.00	0.00	0.00	0.00	170.51	0.00	0.00	0.00	0.00	0.00	0.00	170.51

3706	ADULT <40% EXP MALE	34,143.30	26,154.77	20,573.49	39,142.26	28,932.51	26,253.84	0.00	0.00	0.00	0.00	0.00	0.00	175,200.17

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

12,691.88	18,567.70	11,647.93	10,314.66	6,489.86	16,865.89	0.00	0.00	0.00	0.00	0.00	0.00	76,577.92

47,370.84	58,639.06	54,729.62	114,253.12	92,664.47	96,421.92	0.00	0.00	0.00	0.00	0.00	0.00	464,079.03

8,255.13	8,986.58	12,316.96	18,221.48	9,722.62	8,101.26	0.00	0.00	0.00	0.00	0.00	0.00	65,604.03

370F	ADULT <40% EXP MALE	3,590.13	5,678.35	4,459.00	2,315.61	2,138.02	952.88	0.00	0.00	0.00	0.00	0.00	0.00	19,133.99

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

824.34	1,262.96	35.10	1,823.55	2,665.44	784.80	0.00	0.00	0.00	0.00	0.00	0.00	7,396.19

8,737.58	10,393.47	21,133.34	9,344.88	2,526.64	10,099.78	0.00	0.00	0.00	0.00	0.00	0.00	62,235.69

0.00	0.00	2,297.94	0.00	0.00	1,394.62	0.00	0.00	0.00	0.00	0.00	0.00	3,692.56

3714	ADULT <40% EXP MALE	4,383,132.32	4,528,025.34	4,668,083.27	4,798,971.65	4,966,868.66	6,189,908.62	0.00	0.00	0.00	0.00	0.00	0.00	29,534,989.86

3715	ADULT <40% EXP FEM AL

3,752,637.27	3,863,233.89	3,962,050.58	4,047,408.69	4,164,982.97	5,281,436.90	0.00	0.00	0.00	0.00	0.00	0.00	25,071,750.30

3716	ADULT <40% EXP MALE    27,106,086.04    27,395,881.26     28,559,100.18     31,597,706.11     31,781,110.59     37,367,610.80	0.00	0.00	0.00	0.00	0.00	0.00	183,807,494.98

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

16,530,344.45    16,579,394.61     17,156,912.82     19,193,803.19     19,394,362.33     22,633,082.01	0.00	0.00	0.00	0.00	0.00	0.00	111,487,899.41

33,539,387.24    33,762,918.80     34,763,411.03     38,092,409.60     38,325,239.72     44,949,795.06	0.00	0.00	0.00	0.00	0.00	0.00	223,433,161.45

36,205.17	36,567.62	42,431.28	59,561.30	45,300.27	53,028.22	0.00	0.00	0.00	0.00	0.00	0.00	273,093.86

371D	ADULT <40% EXP MALE	392,849.93	382,830.27	238,138.75	208,431.92	203,147.49	168,025.82	0.00	0.00	0.00	0.00	0.00	0.00	1,593,424.18

371E	ADULT <40% EXP FEM AL

356,021.60	295,087.13	201,535.90	214,164.42	137,476.12	150,098.52	0.00	0.00	0.00	0.00	0.00	0.00	1,354,383.69

371F	ADULT <40% EXP MALE	2,852,336.09	2,763,526.13	1,988,245.68	1,937,830.92	1,404,623.01	1,451,140.09	0.00	0.00	0.00	0.00	0.00	0.00	12,397,701.92

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

1,605,524.56	1,472,687.76	1,073,635.38	1,106,222.16	812,781.75	770,176.01	0.00	0.00	0.00	0.00	0.00	0.00	6,841,027.62

2,523,268.04	2,262,250.08	1,652,940.26	1,764,209.76	1,371,358.12	1,382,321.33	0.00	0.00	0.00	0.00	0.00	0.00	10,956,347.59

2,019.24	1,369.87	8,989.45	9,843.47	14,388.28	6,204.26	0.00	0.00	0.00	0.00	0.00	0.00	42,814.57

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

3725	ADULT <40% EXP FEM AL

0.00	0.00	0.00	0.00	0.00	410.22	0.00	0.00	0.00	0.00	0.00	0.00	410.22

3726	ADULT <40% EXP MALE	3,936.06	7,430.66	5,545.33	9,313.29	11,355.77	10,447.01	0.00	0.00	0.00	0.00	0.00	0.00	48,028.12

3727	ADULT <40% EXP FEM AL

4,778.02	3,573.32	779.92	6,659.16	5,113.29	603.66	0.00	0.00	0.00	0.00	0.00	0.00	21,507.37

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

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

17,960.52	5,138.97	16,090.90	8,323.68	7,311.56	7,865.93	0.00	0.00	0.00	0.00	0.00	0.00	62,691.56

1,616.38	0.00	362.34	1,703.88	1,306.97	1,829.61	0.00	0.00	0.00	0.00	0.00	0.00	6,819.18

372F	ADULT <40% EXP MALE	0.00	711.09	4,151.16	502.35	1,161.06	464.34	0.00	0.00	0.00	0.00	0.00	0.00	6,990.00

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

598.25	1,319.88	2,540.22	0.00	720.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,179.21

470.36	1,351.60	251.86	3,328.61	540.65	828.41	0.00	0.00	0.00	0.00	0.00	0.00	6,771.49

0.00	0.00	0.00	0.00	0.00	67.48	0.00	0.00	0.00	0.00	0.00	0.00	67.48

128,119,986.92  128,273,464.15   129,558,529.07  140,647,189.03  140,107,399.15   164,888,258.80	0.00	0.00	0.00	0.00	0.00	0.00	831,594,827.12

A A
SUBTOTAL:

1,401,728.46

3,657,732.19

5,059,460.65

9935	BIRTH SUPP PAYMENT	176,469.55	272,778.55	241,599.87	270,837.95	231,084.26	208,958.28	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	447,342.88	597,836.74	736,611.04	684,333.12	601,967.17	589,641.24	0.00	0.00	0.00	0.00	0.00	0.00	
	623,812.43	870,615.29	978,210.91	955,171.07	833,051.43	798,599.52	0.00	0.00	0.00	0.00	0.00	0.00	

770.14	
32,076.03	
33,972.63	
209,137.73	
56,445.89	
318.47	
2,453.04	
3,059.01	
108,845.17	
49,718.20	
3,893,742.42	
4,663,599.14	
37,608,318.91	
50,312,443.25	
56,234,934.10	
86,520.69	
182,328.50	
225,617.84	
2,022,540.86	
2,506,637.69	
2,547,374.16	
73,575.23	
4,618.75	
7,636.22	
11,467.79	

3904	NEWLY ELIGIBLE MALE	0.00	55.96	346.93	367.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3906	NEWLY ELIGIBLE MALE	2,243.33	4,164.05	5,522.85	5,309.15	5,518.15	9,318.50	0.00	0.00	0.00	0.00	0.00	0.00

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

11,101.01	5,502.90	2,869.12	7,915.29	2,425.56	4,158.75	0.00	0.00	0.00	0.00	0.00	0.00

30,815.43	20,891.02	14,759.65	37,342.86	44,998.23	60,330.54	0.00	0.00	0.00	0.00	0.00	0.00

3,752.37	6,340.48	6,828.68	14,529.93	9,597.38	15,397.05	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	244.03	44.06	0.00	0.00	0.00	0.00	0.00	0.00

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

558.35	584.83	0.00	417.38	411.65	1,086.80	0.00	0.00	0.00	0.00	0.00	0.00

20,702.19	14,075.84	19,780.97	33,511.35	12,219.55	8,555.27	0.00	0.00	0.00	0.00	0.00	0.00

3,743.08	5,233.41	11,173.35	15,825.83	6,081.31	7,661.22	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	681,452.40	726,387.85	831,915.31	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	809,407.48	873,776.14	1,007,690.72	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	6,893,479.88	7,146,162.82	7,811,478.71	0.00	0.00	0.00	0.00	0.00	0.00

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

6,457,501.35	6,891,154.05	7,326,735.48	9,254,679.43	9,714,688.16     10,667,684.78	0.00	0.00	0.00	0.00	0.00	0.00

7,992,989.32	8,091,976.44	8,244,535.29     10,079,365.67     10,259,563.30     11,566,504.08	0.00	0.00	0.00	0.00	0.00	0.00

13,274.71	12,857.15	12,513.51	18,274.33	14,084.40	15,516.59	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	20,046.88	15,857.23	20,576.92	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	35,335.57	22,995.05	32,016.24	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	317,691.28	211,805.10	227,110.68	0.00	0.00	0.00	0.00	0.00	0.00

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

575,662.05	557,633.73	466,745.78	408,568.59	242,094.96	255,932.58	0.00	0.00	0.00	0.00	0.00	0.00

598,828.85	481,913.67	459,344.28	364,265.20	257,808.17	385,213.99	0.00	0.00	0.00	0.00	0.00	0.00

3,178.08	11,525.06	33,951.68	6,142.56	16,607.25	2,170.60	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	383.64	94.99	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	3,064.18	3,059.32	744.64	384.04	384.04	0.00	0.00	0.00	0.00	0.00	0.00

1,925.68	968.19	772.82	1,662.87	3,871.37	2,266.86	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

3929	NEWLY ELIGIBLE M&F
6

598.20	308.72	649.48	1,129.09	384.46	438.37	0.00	0.00	0.00	0.00	0.00	0.00	3,508.32

392F	NEWLY ELIGIBLE MALE	0.00	81.24	11.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92.63

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

782.69	451.48	178.82	394.81	447.38	452.69	0.00	0.00	0.00	0.00	0.00	0.00	2,707.87

0.00	11.02	0.00	1,013.76	341.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,366.28

SUBTOTAL:

22,454,160.88

23,042,703.84    23,851,867.00    29,013,956.22    29,589,138.68     32,934,000.34	0.00	0.00	0.00	0.00	0.00	0.00	160,885,826.96

9939	BIRTH SUPP PAYMENT	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	440,957.67	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	440,957.67	0.00	0.00	0.00	0.00	0.00	0.00	

2,047,291.06
N

115.08	
100.87	
475.25	
4,853.93	
24,521,344.66	
9,791,007.95	
14,478,177.75	
300,805.17	
257,752.41	
324,023.23	
282.24	
49,678,938.54	

2,047,291.06

4403	SOBRA 100-133% M&F
6

0.00	0.00	0.00	0.00	115.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4404	SOBRA 100-133% MALE	0.00	0.00	0.00	100.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	475.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

227.07	113.90	227.80	1,524.18	1,263.32	1,497.66	0.00	0.00	0.00	0.00	0.00	0.00

2,472,060.61	2,222,646.29	2,028,673.87	5,518,655.29	5,786,559.34	6,492,749.26	0.00	0.00	0.00	0.00	0.00	0.00

4414	SOBRA 100-133% MALE	1,124,482.78	1,019,075.04	944,477.21	2,115,166.99	2,156,414.79	2,431,391.14	0.00	0.00	0.00	0.00	0.00	0.00

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

1,627,175.04	1,485,905.55	1,372,014.41	3,133,836.80	3,215,261.55	3,643,984.40	0.00	0.00	0.00	0.00	0.00	0.00

16,933.27	18,946.08	66,346.90	88,725.94	53,097.98	56,755.00	0.00	0.00	0.00	0.00	0.00	0.00

441D	SOBRA 100-133% MALE	21,389.49	17,226.07	66,017.92	64,560.80	48,242.69	40,315.44	0.00	0.00	0.00	0.00	0.00	0.00

441E	SOBRA 100-133% FEMA L

15,755.99	20,553.56	83,770.13	68,104.17	69,588.51	66,250.87	0.00	0.00	0.00	0.00	0.00	0.00

4424	SOBRA 100-133% MALE	0.00	0.00	0.00	162.83	119.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

5,278,024.25

4,784,466.49	4,561,528.24    10,991,313.12    11,330,662.67     12,732,943.77	0.00	0.00	0.00	0.00	0.00	0.00

S
SUBTOTAL:

284,733.37

284,733.37

9944	BIRTH SUPP PAYMENT	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	44,864.51	0.00	0.00	0.00	0.00	0.00	0.00	
	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	44,864.51	0.00	0.00	0.00	0.00	0.00	0.00	

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

6,031.34	6,350.82	6,499.88	8,177.94	8,370.90	10,265.31	0.00	0.00	0.00	0.00	0.00	0.00

45,696.19	
667,338.17	
273.27	
1,179.68	
12,148.20	
39,872.93	
44,009.01	
1,269.76	
5,938.12	
817,725.33	

112,672.67	110,350.85	110,314.38	108,889.84	103,615.29	121,495.14	0.00	0.00	0.00	0.00	0.00	0.00

273.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	718.61	0.00	74.95	322.70	63.42	0.00	0.00	0.00	0.00	0.00	0.00

3,437.97	2,627.92	3,114.12	334.55	1,454.95	1,178.69	0.00	0.00	0.00	0.00	0.00	0.00

6,156.87	6,362.76	6,506.30	6,551.79	6,511.95	7,783.26	0.00	0.00	0.00	0.00	0.00	0.00

7,757.51	7,379.70	6,916.51	7,031.99	7,031.99	7,891.31	0.00	0.00	0.00	0.00	0.00	0.00

0.00	323.65	0.00	217.69	443.57	284.85	0.00	0.00	0.00	0.00	0.00	0.00

9946	SB KICK PAYMENT FOR	0.00	0.00	0.00	0.00	5,938.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

136,329.63

134,114.31	133,351.19	131,278.75	133,689.47	148,961.98	0.00	0.00	0.00	0.00	0.00	0.00

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M

119.15	119.15	119.15	1,518.09	1,518.09	1,560.36	0.00	0.00	0.00	0.00	0.00	0.00	4,953.99

1,387,627.33	1,409,227.99	1,427,434.60	1,601,635.36	1,588,056.71	1,637,025.33	0.00	0.00	0.00	0.00	0.00	0.00	9,051,007.32

14,851.04	13,861.37	11,262.22	8,619.47	2,040.24	6,583.34	0.00	0.00	0.00	0.00	0.00	0.00	57,217.68

ACUTE CAPITATION - AMOUNTS

For The Period Ending December 31, 2015

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

8710	SSI DISABLED FREEDO M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

257,066.42	281,571.85	279,236.21	280,748.11	281,893.20	315,011.51	0.00	0.00	0.00	0.00	0.00	0.00	1,695,527.30

43,575.80	38,994.92	27,502.94	20,641.47	11,801.66	14,268.11	0.00	0.00	0.00	0.00	0.00	0.00	156,784.90

165,188.17	161,572.52	163,088.68	196,297.59	193,686.35	206,157.70	0.00	0.00	0.00	0.00	0.00	0.00	1,085,991.01

1,871.66	508.27	103.48	1,383.63	2,517.01	116.45	0.00	0.00	0.00	0.00	0.00	0.00	6,500.50

467,034,603.84	468,726,485.92	471,960,427.06	506,083,311.72	504,236,168.44	588,161,669.43	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1,870,299.57

1,905,856.07	1,908,747.28	2,110,843.72	2,081,513.26	2,180,722.80	0.00	0.00	0.00	0.00	0.00	0.00	12,057,982.70

TOTAL:

3,006,202,666.41

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

1006	TANF 21-44 MALE WITH	297.30	350.67	391.93	80.61	84.85	84.84	0.00	0.00	0.00	0.00	0.00	0.00	1,290.20

1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	172.66	178.52	167.20	0.00	0.00	0.00	0.00	0.00	0.00	2,511.05

1008	TANF 45-64 M & F WIT	870.42	1,013.58	1,168.84	270.09	273.04	266.32	0.00	0.00	0.00	0.00	0.00	0.00	3,862.29

1009	TANF 65+ M & F WITH	306.00	373.68	430.56	102.88	96.13	94.11	0.00	0.00	0.00	0.00	0.00	0.00	1,403.36

100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	7.53	2.94	4.64	0.00	0.00	0.00	0.00	0.00	0.00	59.40

100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	3.15	5.45	1.70	0.00	0.00	0.00	0.00	0.00	0.00	83.83

100H	TANF 44-64 M & F WIT	97.51	98.86	32.85	17.79	2.09	6.52	0.00	0.00	0.00	0.00	0.00	0.00	255.62

100J	TANF 65+ M & F WITH	73.60	39.19	4.37	7.48	0.00	1.80	0.00	0.00	0.00	0.00	0.00	0.00	126.44

1011	TANF <1 M & F NON-ME	14,502.91	14,510.24	13,463.57	13,936.63	14,198.27	14,255.62	0.00	0.00	0.00	0.00	0.00	0.00	84,867.24

1012	TANF 01-05 M & F NON	41,759.21	34,503.32	30,981.55	27,621.68	24,016.57	21,015.49	0.00	0.00	0.00	0.00	0.00	0.00	179,897.82

1013	TANF 06-13 M & F NON	68,866.70	57,435.45	51,559.68	45,958.63	39,586.45	34,084.90	0.00	0.00	0.00	0.00	0.00	0.00	297,491.81

1014	TANF 14-20 MALE NON-	15,523.91	13,919.00	12,939.58	11,807.22	10,522.54	9,494.84	0.00	0.00	0.00	0.00	0.00	0.00	74,207.09

1015	TANF 14-20 FEMALE N O

19,492.05	17,891.08	16,863.02	14,601.29	13,172.47	12,413.27	0.00	0.00	0.00	0.00	0.00	0.00	94,433.18

1016	TANF 21-44 MALE NON-	32,422.89	35,110.56	38,554.07	24,200.36	24,611.24	24,737.70	0.00	0.00	0.00	0.00	0.00	0.00	179,636.82

1017	TANF 21-44 FEMALE N O

100,171.76	104,138.61	110,548.82	79,561.23	79,226.74	80,823.60	0.00	0.00	0.00	0.00	0.00	0.00	554,470.76

1018	TANF 45-64 M & F NON	26,326.13	28,376.39	30,996.33	18,878.67	18,943.85	19,065.54	0.00	0.00	0.00	0.00	0.00	0.00	142,586.91

1019	TANF 65+ M & F NON-M	122.25	133.13	152.05	81.72	80.78	86.25	0.00	0.00	0.00	0.00	0.00	0.00	656.18

101A	TANF < 1 M & F NON-M	1,323.68	1,107.58	523.24	1,443.78	1,155.18	1,583.78	0.00	0.00	0.00	0.00	0.00	0.00	7,137.24

101B	TANF 01-05 M & F NON	323.00	173.98	234.10	366.13	146.78	226.69	0.00	0.00	0.00	0.00	0.00	0.00	1,470.68

101C	TANF 06-13 M & F NON	235.43	179.19	176.48	403.54	132.78	155.26	0.00	0.00	0.00	0.00	0.00	0.00	1,282.68

101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	167.74	56.94	63.73	0.00	0.00	0.00	0.00	0.00	0.00	687.14

101E	TANF 14-20 FEMALE N O

278.91	237.91	174.02	171.86	90.58	105.20	0.00	0.00	0.00	0.00	0.00	0.00	1,058.48

101F	TANF 21-44 MALE NON-	2,653.94	2,660.54	1,444.98	1,220.10	625.84	687.22	0.00	0.00	0.00	0.00	0.00	0.00	9,292.62

101G	TANF 21-44 FEMALE N O

4,819.02	4,659.58	2,737.74	2,315.36	1,601.46	1,299.16	0.00	0.00	0.00	0.00	0.00	0.00	17,432.32

101H	TANF 44-64 M & F NON	1,604.09	1,643.02	919.13	633.40	373.54	344.59	0.00	0.00	0.00	0.00	0.00	0.00	5,517.77

101J	TANF 65+ N & F NON-M	31.66	19.50	26.80	1.88	6.42	11.98	0.00	0.00	0.00	0.00	0.00	0.00	98.24

1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

1026	TANF 21-44 MALE WITH	136.90	188.45	227.64	39.06	37.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	676.05

1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	69.00	73.08	74.70	0.00	0.00	0.00	0.00	0.00	0.00	1,115.77

1028	TANF 45-64 M & F WIT	257.30	401.73	481.56	80.44	93.69	103.67	0.00	0.00	0.00	0.00	0.00	0.00	1,418.39

1029	TANF 65+ M & F WITH	125.59	199.79	245.43	39.43	45.00	49.00	0.00	0.00	0.00	0.00	0.00	0.00	704.24

102F	TANF 21-44 MALE WITH	0.00	2.12	0.13	1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.18

102G	TANF 21-44 FEMALE WI	4.49	1.22	1.63	0.00	0.00	2.03	0.00	0.00	0.00	0.00	0.00	0.00	9.37

102H	TANF 44-64 M & F WIT	1.88	12.13	4.43	0.00	3.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.39

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

102J	TANF 65+ M & F WITH	2.37	2.17	0.00	5.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.66

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

3,945.61	3,902.67	3,829.80	4,137.95	4,214.96	4,351.14	0.00	0.00	0.00	0.00	0.00	0.00	24,382.13

450.53	377.60	249.36	270.80	307.49	245.67	0.00	0.00	0.00	0.00	0.00	0.00	1,901.45

5,996.37	5,885.71	5,990.17	6,174.44	6,096.62	6,036.50	0.00	0.00	0.00	0.00	0.00	0.00	36,179.81

323.02	229.89	155.90	195.56	189.76	186.20	0.00	0.00	0.00	0.00	0.00	0.00	1,280.33

2120	SSI AGED WITH QMB	16,192.79	16,392.49	16,583.32	22,041.82	22,291.57	22,559.16	0.00	0.00	0.00	0.00	0.00	0.00	116,061.15

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

60.27	61.77	97.36	67.89	76.81	46.22	0.00	0.00	0.00	0.00	0.00	0.00	410.32

3,600.36	3,525.64	3,506.17	3,597.87	3,563.55	3,628.56	0.00	0.00	0.00	0.00	0.00	0.00	21,422.15

236.76	251.22	272.95	225.46	135.76	177.56	0.00	0.00	0.00	0.00	0.00	0.00	1,299.71

57,143.85	56,902.31	56,909.61	56,665.32	56,824.83	57,068.09	0.00	0.00	0.00	0.00	0.00	0.00	341,514.01

983.56	949.62	911.29	771.37	711.59	807.44	0.00	0.00	0.00	0.00	0.00	0.00	5,134.87

24,588.70	24,755.94	24,980.93	25,099.07	25,302.15	25,461.39	0.00	0.00	0.00	0.00	0.00	0.00	150,188.18

62.38	77.46	109.31	43.36	32.28	18.33	0.00	0.00	0.00	0.00	0.00	0.00	343.12

2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	25.00	25.00	27.29	0.00	0.00	0.00	0.00	0.00	0.00	155.40

230Z	SSI BLIND WITH MEDIC	4.45	0.00	0.00	0.00	0.00	14.70	0.00	0.00	0.00	0.00	0.00	0.00	19.15

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

428.12	430.04	436.15	439.00	442.38	450.44	0.00	0.00	0.00	0.00	0.00	0.00	2,626.13

8.02	26.80	11.45	13.31	4.79	28.85	0.00	0.00	0.00	0.00	0.00	0.00	93.22

2320	SSI BLIND WITH QMB	207.48	205.10	207.96	204.24	202.09	202.70	0.00	0.00	0.00	0.00	0.00	0.00	1,229.57

232Z	SSI BLIND WITH QMB P	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03

4302	SOBRA CHILD 01-05 M	5.00	3.99	2.01	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	17.00

4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	2.12	4.55	3.00	0.00	0.00	0.00	0.00	0.00	0.00	16.10

4304	SOBRA CHILD 14-20 MA	1.00	1.00	1.00	0.00	-1.00	1.00	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	0.62	2.64	0.00	0.00	0.00	0.00	0.00	0.00	7.83

430B	SOBRA CHILD 01-05 M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

430C	SOBRA CHILD 06-13 M	0.00	0.00	1.56	0.87	1.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.89

430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

430E	SOBRA CHILD 14-20 FE	0.00	0.61	0.86	-0.25	-0.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.61

4311	SOBRA CHILD <1 M & F	37,929.50	37,878.33	35,410.54	38,243.54	39,448.82	39,665.68	0.00	0.00	0.00	0.00	0.00	0.00	228,576.41

4312	SOBRA CHILD 01-05 M	150,215.05	158,567.13	166,797.13	169,987.40	176,662.82	181,767.61	0.00	0.00	0.00	0.00	0.00	0.00	1,003,997.14

4313	SOBRA CHILD 06-13 M	200,525.14	216,198.75	230,401.99	209,630.58	214,915.68	221,919.10	0.00	0.00	0.00	0.00	0.00	0.00	1,293,591.24

4314	SOBRA CHILD 14-20 MA	49,529.14	51,683.40	55,100.09	50,842.03	51,365.72	52,500.23	0.00	0.00	0.00	0.00	0.00	0.00	311,020.61

4315	SOBRA CHILD 14-20 FE	49,621.28	51,750.56	55,046.80	51,049.83	51,597.87	52,976.70	0.00	0.00	0.00	0.00	0.00	0.00	312,043.04

431A	SOBRA CHILD < 1 M &	1,144.43	1,199.85	596.85	1,439.14	966.70	1,041.62	0.00	0.00	0.00	0.00	0.00	0.00	6,388.59

431B	SOBRA CHILD 01-05 M	7,397.32	7,233.01	5,425.60	5,749.99	4,037.79	3,714.84	0.00	0.00	0.00	0.00	0.00	0.00	33,558.55

431C	SOBRA CHILD 6-13 M& F

9,664.24	10,386.87	6,895.96	6,005.68	4,413.27	4,173.44	0.00	0.00	0.00	0.00	0.00	0.00	41,539.46

431D	SOBRA CHILD 14-20 MA	2,729.60	2,547.00	1,740.21	1,587.56	1,149.00	1,112.89	0.00	0.00	0.00	0.00	0.00	0.00	10,866.26

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

431E	SOBRA CHILD 14-20 FE	2,479.42	2,548.58	1,750.39	1,574.77	1,152.27	1,031.22	0.00	0.00	0.00	0.00	0.00	0.00	10,536.65

4321	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4322	SOBRA CHILD 01-05 M	3.00	0.00	2.00	3.00	1.00	2.67	0.00	0.00	0.00	0.00	0.00	0.00	11.67

4323	SOBRA CHILD 06-13 M	7.00	0.00	1.00	5.06	3.56	14.00	0.00	0.00	0.00	0.00	0.00	0.00	30.62

4324	SOBRA CHILD 14-20 MA	4.00	0.00	1.00	1.00	1.56	3.00	0.00	0.00	0.00	0.00	0.00	0.00	10.56

4325	SOBRA CHILD 14-20 FE	2.00	1.00	2.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00

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

44.60	44.25	49.08	47.32	34.99	31.66	0.00	0.00	0.00	0.00	0.00	0.00	251.90

2.00	1.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00

3.37	3.12	2.16	1.67	0.83	2.31	0.00	0.00	0.00	0.00	0.00	0.00	13.46

6.00	7.38	7.00	6.00	6.20	10.00	0.00	0.00	0.00	0.00	0.00	0.00	42.58

4,442.88	4,822.40	5,139.99	5,199.98	5,482.55	4,554.64	0.00	0.00	0.00	0.00	0.00	0.00	29,642.44

19,288.96	21,436.17	23,639.77	25,479.28	26,864.80	23,321.14	0.00	0.00	0.00	0.00	0.00	0.00	140,030.12

70.02	76.99	80.34	89.62	89.99	85.34	0.00	0.00	0.00	0.00	0.00	0.00	492.30

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

380.96	386.50	238.63	248.98	217.33	208.39	0.00	0.00	0.00	0.00	0.00	0.00	1,680.79

1,656.15	1,536.50	1,187.87	1,135.67	915.46	885.14	0.00	0.00	0.00	0.00	0.00	0.00	7,316.79

7.91	23.95	1.29	0.93	0.00	1.63	0.00	0.00	0.00	0.00	0.00	0.00	35.71

9.11	11.00	8.99	9.12	11.00	10.67	0.00	0.00	0.00	0.00	0.00	0.00	59.89

0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

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

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

9910	TANF & SOBRA CHILDR	571.00	500.00	476.00	365.00	407.00	424.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	11.00	11.00	12.00	10.00	12.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	42.00	29.00	33.00	30.00	29.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,053.00	2,266.00	2,452.00	2,223.00	2,141.00	2,045.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,677.00	2,806.00	2,973.00	2,628.00	2,589.00	2,513.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

985,098.82

1,002,906.76	1,020,305.89	932,589.99	929,217.83	931,717.15	0.00	0.00	0.00	0.00	0.00	0.00	5,801,836.44

2,743.00	
62.00	
201.00	
13,180.00	
16,186.00	

E

1

1

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	925.69	903.23	850.32	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	1,129.92	997.50	888.94	1,799.36	1,696.49	1,572.85	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,914.12	1,697.63	1,569.17	3,028.13	2,948.30	2,824.92	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	634.27	568.85	533.33	1,133.83	1,112.02	1,083.33	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	18.70	3.61	8.79	22.01	20.26	9.49	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

31.38

10.58

41.96

3100	TRANSPLANT OPTION	4.24	5.41	5.00	5.00	5.73	6.00	0.00	0.00	0.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION	5.74	4.58	0.00	0.00	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	9.98	9.99	5.00	5.00	5.99	6.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,078.15	
8,085.06	
13,982.27	
5,065.63	
82.86	

M&

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

110G	TANF EXPANDED 21-44	2.64	1.64	12.64	32.68	21.58	18.42	0.00	0.00	0.00	0.00	0.00	0.00	89.60

110H	TANF EXPANDED 45-64	0.86	0.82	67.38	87.22	58.75	32.60	0.00	0.00	0.00	0.00	0.00	0.00	247.63

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

0.00	2.64	37.58	16.71	13.76	16.71	0.00	0.00	0.00	0.00	0.00	0.00	87.40

12.00	8.00	1.36	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	30.36

1112	TANF EXPANDED 01-05	390.00	311.16	275.00	239.06	180.00	142.15	0.00	0.00	0.00	0.00	0.00	0.00	1,537.37

1113	TANF EXPANDED 06-13	1,229.70	991.16	871.12	743.21	581.97	473.00	0.00	0.00	0.00	0.00	0.00	0.00	4,890.16

1114	TANF EXPANDED 14-20	683.08	531.13	454.69	720.61	674.58	643.29	0.00	0.00	0.00	0.00	0.00	0.00	3,707.38

1115	TANF EXPANDED 14-20	1,447.98	1,085.47	918.24	1,792.37	1,760.39	1,912.79	0.00	0.00	0.00	0.00	0.00	0.00	8,917.24

1116	TANF EXPANDED 21-44	20,507.88	17,866.93	15,873.76	30,211.21	29,789.76	30,670.86	0.00	0.00	0.00	0.00	0.00	0.00	144,920.40

1117	TANF EXPANDED 21-44	46,392.97	40,134.22	35,306.60	65,385.73	63,972.60	67,465.10	0.00	0.00	0.00	0.00	0.00	0.00	318,657.22

1118	TANF EXPANDED 45-64	16,838.19	14,850.87	13,477.80	26,098.91	25,902.71	26,740.77	0.00	0.00	0.00	0.00	0.00	0.00	123,909.25

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

91.37	83.00	78.65	120.22	115.24	118.36	0.00	0.00	0.00	0.00	0.00	0.00	606.84

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	0.25	0.00	0.00	0.00	0.00	0.00	0.00	1.08

111C	TANF EXPANDED 06-13	1.00	0.00	0.00	2.80	5.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	9.80

111D	TANF EXPANDED 14-20	0.54	5.28	14.31	10.92	28.27	20.03	0.00	0.00	0.00	0.00	0.00	0.00	79.35

111E	TANF EXPANDED 14-20	7.24	9.73	31.24	50.14	45.83	34.70	0.00	0.00	0.00	0.00	0.00	0.00	178.88

111F	TANF EXPANDED 21-44	101.48	104.36	529.77	956.02	855.10	799.41	0.00	0.00	0.00	0.00	0.00	0.00	3,346.14

111G	TANF EXPANDED 21-44	197.09	224.68	1,011.19	1,606.35	1,326.72	1,130.55	0.00	0.00	0.00	0.00	0.00	0.00	5,496.58

111H	TANF EXPANDED 45-64	28.12	127.83	423.04	661.57	557.64	653.69	0.00	0.00	0.00	0.00	0.00	0.00	2,451.89

111J	TANF EXPANDED 65+ M&

22.31	0.00	3.65	34.70	3.11	8.54	0.00	0.00	0.00	0.00	0.00	0.00	72.31

1125	TANF EXPANDED 14-20	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

1126	TANF EXPANDED 21-44	172.31	149.33	132.42	154.79	225.85	292.60	0.00	0.00	0.00	0.00	0.00	0.00	1,127.30

1127	TANF EXPANDED 21-44	382.43	351.28	318.88	364.36	502.11	662.14	0.00	0.00	0.00	0.00	0.00	0.00	2,581.20

1128	TANF EXPANDED 45-64	446.94	399.71	372.79	452.31	621.33	801.19	0.00	0.00	0.00	0.00	0.00	0.00	3,094.27

1129	TANF EXPANDED 65+ M&

194.69	165.94	155.60	174.92	237.67	308.56	0.00	0.00	0.00	0.00	0.00	0.00	1,237.38

112F	TANF EXPANDED 21-44	0.00	0.00	2.56	1.63	1.86	1.03	0.00	0.00	0.00	0.00	0.00	0.00	7.08

112G	TANF EXPANDED 21-44	0.00	3.44	3.22	4.87	3.32	2.59	0.00	0.00	0.00	0.00	0.00	0.00	17.44

112H	TANF EXPANDED 45-64	0.03	0.00	2.92	11.24	7.45	9.77	0.00	0.00	0.00	0.00	0.00	0.00	31.41

112J	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
241Z	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
242Z	SSI AGED EXPANDED
WI

0.00	0.00	16.30	1.06	10.74	12.39	0.00	0.00	0.00	0.00	0.00	0.00	40.49

518.42	487.04	456.81	384.84	352.94	380.25	0.00	0.00	0.00	0.00	0.00	0.00	2,580.30

304.76	401.03	244.49	252.11	184.84	248.32	0.00	0.00	0.00	0.00	0.00	0.00	1,635.55

1,134.27	1,056.52	991.15	391.57	359.68	303.63	0.00	0.00	0.00	0.00	0.00	0.00	4,236.82

13.94	39.82	16.61	7.34	6.63	7.25	0.00	0.00	0.00	0.00	0.00	0.00	91.59

26,853.34	26,842.37	26,813.66	21,188.36	20,913.29	20,752.98	0.00	0.00	0.00	0.00	0.00	0.00	143,364.00

86.51	60.16	53.24	60.10	29.69	42.86	0.00	0.00	0.00	0.00	0.00	0.00	332.56

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

2500	SSI BLIND EXPANDED W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
260Z	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
261Z	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E

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

2.00	2.00	2.00	1.00	1.00	0.99	0.00	0.00	0.00	0.00	0.00	0.00	8.99

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

387.35	391.10	363.58	405.75	407.66	435.90	0.00	0.00	0.00	0.00	0.00	0.00	2,391.34

198.57	225.21	193.65	131.93	83.98	110.70	0.00	0.00	0.00	0.00	0.00	0.00	944.04

2,800.72	2,719.35	2,722.76	2,696.85	2,637.63	2,668.05	0.00	0.00	0.00	0.00	0.00	0.00	16,245.36

66.87	64.13	55.86	42.68	36.03	52.57	0.00	0.00	0.00	0.00	0.00	0.00	318.14

15,882.49	16,101.98	16,689.39	17,152.91	17,493.44	17,902.04	0.00	0.00	0.00	0.00	0.00	0.00	101,222.25

70.33	62.70	88.07	53.98	24.93	29.44	0.00	0.00	0.00	0.00	0.00	0.00	329.45

SUBTOTAL:

141,707.24

129,594.34	122,483.07	179,619.05	176,720.38	182,253.38	0.00	0.00	0.00	0.00	0.00	0.00	932,377.46

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

105.00	122.00	113.00	177.00	141.00	242.00	0.00	0.00	0.00	0.00	0.00	0.00

900.00	
14.00	
3.00	
917.00	

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

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

SUBTOTAL:

108.00

126.00	117.00	179.00	143.00	244.00	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	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	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
SUBTOTAL:

0.00

0.00

68.41	
57.88	
457.97	
337.37	
16.83	
4.49	
63.50	
36.63	
20,934.34	
24,838.29	
107,513.28	
88,682.64	
217,443.95	
235.24	
877.72	
958.82	
4,412.57	
3,307.52	

3506	ADULT 40-100% MALE 2	15.63	8.90	13.05	13.05	7.72	10.06	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

14.06	5.76	7.00	9.81	14.00	7.25	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	67.69	54.87	49.56	121.55	98.13	66.17	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	55.05	55.40	53.33	83.77	57.40	32.42	0.00	0.00	0.00	0.00	0.00	0.00

350F	ADULT 40-100% MALE 2	6.92	0.67	2.82	4.93	1.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00

350G	ADULT 40-100% FEMAL E

0.00	0.00	0.00	3.82	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00

350H	ADULT 40-100% M&F 45	8.97	10.81	15.38	19.39	2.86	6.09	0.00	0.00	0.00	0.00	0.00	0.00

350J	ADULT 40-100% M&F 65	10.92	7.57	0.00	3.22	0.60	14.32	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	3,038.92	3,290.06	3,469.54	3,459.96	3,695.68	3,980.18	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	4,065.25	4,323.63	4,629.41	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	17,324.13	17,315.90	17,767.16	18,063.18	18,254.46	18,788.45	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

14,579.12	14,409.13	14,673.49	14,867.88	14,928.18	15,224.84	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	35,161.66	35,276.58	36,112.19	36,443.44	36,715.66	37,734.42	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	39.09	36.01	35.99	49.54	31.82	42.79	0.00	0.00	0.00	0.00	0.00	0.00

351D	ADULT 40-100% MALE 1	223.89	174.95	140.00	114.00	120.77	104.11	0.00	0.00	0.00	0.00	0.00	0.00

351E	ADULT 40-100% FEMAL E

215.10	215.28	142.27	157.72	109.73	118.72	0.00	0.00	0.00	0.00	0.00	0.00

351F	ADULT 40-100% MALE 2	970.65	931.86	710.83	703.38	508.69	587.16	0.00	0.00	0.00	0.00	0.00	0.00

351G	ADULT 40-100% FEMAL E

687.03	645.80	559.94	543.04	370.45	501.26	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

351H	ADULT 40-100% M&F 45	1,789.29	1,532.58	1,097.36	1,161.58	880.02	1,063.97	0.00	0.00	0.00	0.00	0.00	0.00	7,524.80

351J	ADULT 40-100% M&F 65	40.88	22.67	29.32	20.45	46.89	6.12	0.00	0.00	0.00	0.00	0.00	0.00	166.33

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	2.00	0.70	0.00	0.00	0.00	0.00	0.00	0.00	5.70

3527	ADULT 40-100% FEMAL E

1.41	3.21	0.00	1.00	1.00	1.74	0.00	0.00	0.00	0.00	0.00	0.00	8.36

3528	ADULT 40-100% M&F 45	20.96	15.68	24.16	19.28	23.00	25.79	0.00	0.00	0.00	0.00	0.00	0.00	128.87

3529	ADULT 40-100% M&F 65	6.00	10.00	4.00	14.03	10.06	9.93	0.00	0.00	0.00	0.00	0.00	0.00	54.02

352F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.29	0.00	0.00	0.00	0.00	0.00	0.00	0.29

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	1.69	0.00	0.00	0.00	0.00	0.00	0.00	4.93

352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	4.96	0.83	4.06	0.00	0.00	0.00	0.00	0.00	0.00	9.85

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	0.00

3706	ADULT <40% EXP MALE	34.74	33.74	30.14	41.29	39.44	33.46	0.00	0.00	0.00	0.00	0.00	0.00	212.81

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

7.49	15.61	9.78	12.41	11.03	18.57	0.00	0.00	0.00	0.00	0.00	0.00	74.89

88.23	98.60	92.80	188.88	141.71	121.99	0.00	0.00	0.00	0.00	0.00	0.00	732.21

19.67	21.38	28.72	41.00	21.63	14.00	0.00	0.00	0.00	0.00	0.00	0.00	146.40

370F	ADULT <40% EXP MALE	5.51	8.57	6.12	3.49	3.21	1.63	0.00	0.00	0.00	0.00	0.00	0.00	28.53

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

1.54	1.81	0.06	2.37	3.89	1.15	0.00	0.00	0.00	0.00	0.00	0.00	10.82

14.58	15.74	30.56	13.97	3.56	15.01	0.00	0.00	0.00	0.00	0.00	0.00	93.42

0.00	0.00	2.73	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	4.73

3714	ADULT <40% EXP MALE	9,839.70	10,160.23	10,470.29	10,275.58	10,661.47	11,010.13	0.00	0.00	0.00	0.00	0.00	0.00	62,417.40

3715	ADULT <40% EXP FEM AL

8,418.28	8,667.97	8,908.49	8,752.70	9,023.96	9,365.22	0.00	0.00	0.00	0.00	0.00	0.00	53,136.62

3716	ADULT <40% EXP MALE	58,247.03	58,634.00	61,113.02	62,941.19	63,352.21	65,328.42	0.00	0.00	0.00	0.00	0.00	0.00	369,615.87

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

34,827.18	34,929.63	36,183.66	37,298.36	37,725.55	38,465.34	0.00	0.00	0.00	0.00	0.00	0.00	219,429.72

72,820.34	73,231.71	75,412.07	76,737.78	77,207.05	78,604.66	0.00	0.00	0.00	0.00	0.00	0.00	454,013.61

80.88	80.74	94.53	128.19	96.22	106.84	0.00	0.00	0.00	0.00	0.00	0.00	587.40

371D	ADULT <40% EXP MALE	580.76	572.41	352.26	309.50	300.26	253.18	0.00	0.00	0.00	0.00	0.00	0.00	2,368.37

371E	ADULT <40% EXP FEM AL

519.38	449.84	305.73	319.68	204.57	222.83	0.00	0.00	0.00	0.00	0.00	0.00	2,022.03

371F	ADULT <40% EXP MALE	4,244.00	4,145.00	2,990.61	2,888.14	2,110.81	2,171.83	0.00	0.00	0.00	0.00	0.00	0.00	18,550.39

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

2,410.81	2,215.92	1,619.33	1,656.46	1,211.17	1,143.52	0.00	0.00	0.00	0.00	0.00	0.00	10,257.21

3,754.97	3,389.75	2,459.44	2,612.62	2,030.56	2,040.85	0.00	0.00	0.00	0.00	0.00	0.00	16,288.19

2.98	2.00	16.46	13.76	23.12	9.87	0.00	0.00	0.00	0.00	0.00	0.00	68.19

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

3725	ADULT <40% EXP FEM AL

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

3726	ADULT <40% EXP MALE	9.00	8.05	8.35	11.73	10.99	8.74	0.00	0.00	0.00	0.00	0.00	0.00	56.86

3727	ADULT <40% EXP FEM AL

6.12	3.96	3.43	7.00	7.36	1.00	0.00	0.00	0.00	0.00	0.00	0.00	28.87

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

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

23.78	6.39	19.82	15.21	14.20	12.68	0.00	0.00	0.00	0.00	0.00	0.00	92.08

4.00	0.00	1.00	4.00	3.00	3.90	0.00	0.00	0.00	0.00	0.00	0.00	15.90

372F	ADULT <40% EXP MALE	0.00	0.86	5.62	0.82	1.70	0.54	0.00	0.00	0.00	0.00	0.00	0.00	9.54

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

0.87	1.79	3.22	0.00	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.94

0.77	1.95	0.36	4.98	0.80	1.22	0.00	0.00	0.00	0.00	0.00	0.00	10.08

0.00	0.00	0.00	0.00	0.00	0.09	0.00	0.00	0.00	0.00	0.00	0.00	0.09

SUBTOTAL:

273,979.51

274,669.50	279,217.19	284,229.49	284,415.60	291,922.28	0.00	0.00	0.00	0.00	0.00	0.00	1,688,433.57

A A
SUBTOTAL:

230.00

599.00

829.00

9935	BIRTH SUPP PAYMENT	29.00	45.00	40.00	44.00	38.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	74.00	98.00	121.00	112.00	98.00	96.00	0.00	0.00	0.00	0.00	0.00	0.00	
	103.00	143.00	161.00	156.00	136.00	130.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.16	
48.60	
59.37	
448.63	
150.54	
0.83	
7.32	
10.60	
325.92	
149.56	
10,750.43	
12,981.55	
104,525.68	
139,875.96	
154,801.47	
253.41	
540.21	
673.72	
6,082.84	
7,511.55	
7,627.61	
230.29	
7.82	
10.00	
28.37	

3904	NEWLY ELIGIBLE MALE	0.00	0.16	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3906	NEWLY ELIGIBLE MALE	6.92	5.18	4.00	8.20	10.80	13.50	0.00	0.00	0.00	0.00	0.00	0.00

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

14.99	10.72	9.00	11.72	6.53	6.41	0.00	0.00	0.00	0.00	0.00	0.00

71.56	53.47	39.78	80.22	96.10	107.50	0.00	0.00	0.00	0.00	0.00	0.00

12.19	19.97	21.66	39.05	26.20	31.47	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	0.60	0.12	0.00	0.00	0.00	0.00	0.00	0.00

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

1.83	2.06	0.00	1.25	1.46	4.00	0.00	0.00	0.00	0.00	0.00	0.00

64.25	40.88	59.19	97.73	35.73	28.14	0.00	0.00	0.00	0.00	0.00	0.00

10.96	14.95	34.33	49.11	17.80	22.41	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	1,752.14	1,876.50	2,031.23	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	2,102.93	2,272.05	2,485.01	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	17,862.31	18,493.39	19,011.11	0.00	0.00	0.00	0.00	0.00	0.00

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

20,086.40	21,456.04	22,844.42	23,906.19	25,104.94	26,477.97	0.00	0.00	0.00	0.00	0.00	0.00

24,879.24	25,158.44	25,656.88	25,845.50	26,301.97	26,959.44	0.00	0.00	0.00	0.00	0.00	0.00

43.11	41.59	40.65	49.90	38.52	39.64	0.00	0.00	0.00	0.00	0.00	0.00

391D	NEWLY ELIGIBLE MALE	141.51	112.48	116.75	61.70	47.08	60.69	0.00	0.00	0.00	0.00	0.00	0.00

391E	NEWLY ELIGIBLE FEMA L

153.51	153.08	97.96	106.98	67.97	94.22	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	945.80	635.23	685.72	0.00	0.00	0.00	0.00	0.00	0.00

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

1,726.49	1,680.05	1,394.47	1,209.37	730.12	771.05	0.00	0.00	0.00	0.00	0.00	0.00

1,771.32	1,458.13	1,385.33	1,103.78	772.01	1,137.04	0.00	0.00	0.00	0.00	0.00	0.00

8.86	33.37	111.19	18.08	52.44	6.35	0.00	0.00	0.00	0.00	0.00	0.00

3926	NEWLY ELIGIBLE MALE	1.00	0.70	1.96	3.16	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

6.22	3.11	2.43	4.57	6.66	5.38	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

3929	NEWLY ELIGIBLE M&F
6

2.00	0.96	2.00	3.03	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	9.99

392F	NEWLY ELIGIBLE MALE	0.00	0.29	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.32

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

2.40	1.28	0.56	1.41	1.10	1.60	0.00	0.00	0.00	0.00	0.00	0.00	8.35

0.00	0.03	0.00	2.96	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.99

SUBTOTAL:

69,593.33

71,546.64	74,129.68	75,276.24	76,599.20	79,982.00	0.00	0.00	0.00	0.00	0.00	0.00	447,127.09

9939	BIRTH SUPP PAYMENT	39.00	34.00	57.00	67.00	67.00	72.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39.00	34.00	57.00	67.00	67.00	72.00	0.00	0.00	0.00	0.00	0.00	0.00	

336.00
N

1.00	
0.67	
1.00	
21.38	
194,378.31	
56,497.50	
54,378.03	
5,255.32	
1,627.48	
1,630.54	
1.73	
313,792.96	

336.00

4403	SOBRA 100-133% M&F
6

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

4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

2.00	1.00	2.00	7.38	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00

20,103.69	18,080.37	16,565.93	44,553.71	46,675.62	48,398.99	0.00	0.00	0.00	0.00	0.00	0.00

4414	SOBRA 100-133% MALE	6,535.04	5,919.99	5,497.23	12,583.32	12,880.64	13,081.28	0.00	0.00	0.00	0.00	0.00	0.00

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

6,240.09	5,678.68	5,237.34	12,115.93	12,426.02	12,679.97	0.00	0.00	0.00	0.00	0.00	0.00

288.14	323.40	1,091.93	1,531.67	968.86	1,051.32	0.00	0.00	0.00	0.00	0.00	0.00

441D	SOBRA 100-133% MALE	126.41	106.24	394.18	409.63	316.99	274.03	0.00	0.00	0.00	0.00	0.00	0.00

441E	SOBRA 100-133% FEMA L

81.96	103.18	421.32	344.01	343.25	336.82	0.00	0.00	0.00	0.00	0.00	0.00

4424	SOBRA 100-133% MALE	0.00	0.00	0.00	1.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

33,377.33

30,212.86	29,209.93	71,548.32	73,618.11	75,826.41	0.00	0.00	0.00	0.00	0.00	0.00

S
SUBTOTAL:

47.00

47.00

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

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

23.96	25.35	26.00	27.58	28.33	27.64	0.00	0.00	0.00	0.00	0.00	0.00

158.86	
1,444.87	
0.77	
6.06	
34.31	
104.73	
98.00	
6.08	
1.00	
1,854.68	

251.91	246.16	245.84	240.06	227.69	233.21	0.00	0.00	0.00	0.00	0.00	0.00

0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	3.64	0.00	0.41	1.66	0.35	0.00	0.00	0.00	0.00	0.00	0.00

10.28	5.89	8.11	0.93	5.34	3.76	0.00	0.00	0.00	0.00	0.00	0.00

15.86	16.54	17.00	18.03	17.83	19.47	0.00	0.00	0.00	0.00	0.00	0.00

18.00	17.00	16.00	16.00	16.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	1.45	0.00	0.96	2.16	1.51	0.00	0.00	0.00	0.00	0.00	0.00

9946	SB KICK PAYMENT FOR	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

320.78

316.03	312.95	303.97	300.01	300.94	0.00	0.00	0.00	0.00	0.00	0.00

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M

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

1,505.00	1,555.45	1,576.90	1,602.26	1,594.23	1,632.59	0.00	0.00	0.00	0.00	0.00	0.00	9,466.43

161.37	146.05	125.37	96.31	27.40	81.11	0.00	0.00	0.00	0.00	0.00	0.00	637.61

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending December 31, 2015

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

8710	SSI DISABLED FREEDO M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

246.99	274.32	275.92	268.27	266.19	276.60	0.00	0.00	0.00	0.00	0.00	0.00	1,608.29

85.86	73.98	54.70	40.00	21.99	24.91	0.00	0.00	0.00	0.00	0.00	0.00	301.44

213.90	216.30	223.90	223.30	228.07	240.46	0.00	0.00	0.00	0.00	0.00	0.00	1,345.93

20.61	6.41	1.03	15.63	27.86	2.32	0.00	0.00	0.00	0.00	0.00	0.00	73.86

SUBTOTAL:

2,234.73

2,273.51	2,258.82	2,246.77	2,166.74	2,258.99	0.00	0.00	0.00	0.00	0.00	0.00	13,439.56

TOTAL:	1,509,256.72	1,514,651.63	1,531,233.53	1,548,851.83	1,545,990.86	1,567,234.15	0.00	0.00	0.00	0.00	0.00	0.00		9,217,218.72		

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending December 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	17,381.47	20,492.16	0.00	0.00	0.00	0.00	0.00	0.00	78,158.18

1010	TANF NON-MEDICARE	2,246,124.76	2,243,143.25	2,252,388.63	2,282,295.84	2,283,614.83	2,329,163.03	0.00	0.00	0.00	0.00	0.00	0.00	13,636,730.34

1020	TANF WITH QMB	3,414.03	3,414.03	3,414.03	3,433.17	3,433.17	6,955.78	0.00	0.00	0.00	0.00	0.00	0.00	24,064.21

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     31,111,647.19     36,054,042.87     31,251,390.90	0.00	0.00	0.00	0.00	0.00	0.00	197,307,800.09

707,295.55	628,872.62	699,533.74	841,652.65	651,630.71	655,378.83	0.00	0.00	0.00	0.00	0.00	0.00	4,184,364.10

2,884,201.93	3,146,295.69	2,948,885.35	3,040,662.77	3,335,679.23	3,064,203.17	0.00	0.00	0.00	0.00	0.00	0.00	18,419,928.14

20,970.93	11,535.77	26,120.35	18,541.95	9,394.51	31,592.71	0.00	0.00	0.00	0.00	0.00	0.00	118,156.22

2120	SSI AGED WITH QMB	18,966,113.95    22,019,693.90     19,185,398.15     19,009,038.07     22,054,804.25     19,343,191.23	0.00	0.00	0.00	0.00	0.00	0.00	120,578,239.55

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	21,591.82	10,487.09	22,572.09	0.00	0.00	0.00	0.00	0.00	0.00	122,259.59

13,803,406.37    14,998,436.84     13,783,997.15     14,011,924.66     15,406,736.15     14,474,404.40	0.00	0.00	0.00	0.00	0.00	0.00	86,478,905.57

40,564.67	63,879.36	93,590.05	124,380.26	73,436.67	93,117.27	0.00	0.00	0.00	0.00	0.00	0.00	488,968.28

90,370,918.56    92,527,644.78     92,067,142.80     93,105,599.36     94,991,556.18     95,562,212.27	0.00	0.00	0.00	0.00	0.00	0.00	558,625,073.95

66,459.25	35,301.18	25,164.71	27,841.86	30,576.10	26,054.92	0.00	0.00	0.00	0.00	0.00	0.00	211,398.02

21,237,804.05    22,510,241.65     21,355,507.04     21,308,948.47     22,578,485.06     21,707,039.85	0.00	0.00	0.00	0.00	0.00	0.00	130,698,026.12

2,948.16	9,227.84	6,397.97	6,604.08	8,888.32	7,078.53	0.00	0.00	0.00	0.00	0.00	0.00	41,144.90

2300	SSI BLIND WITH MEDIC	64,338.16	65,260.19	64,541.02	62,567.40	68,202.65	66,548.80	0.00	0.00	0.00	0.00	0.00	0.00	391,458.22

2310	SSI BLIND NON-MEDIC A

444,420.36	460,483.10	454,107.08	457,911.29	480,473.00	490,226.15	0.00	0.00	0.00	0.00	0.00	0.00	2,787,620.98

2320	SSI BLIND WITH QMB	130,315.90	135,811.83	130,342.85	127,684.67	131,086.80	129,801.65	0.00	0.00	0.00	0.00	0.00	0.00	785,043.70

SUBTOTAL:

182,215,500.72  195,107,514.51   184,610,652.85  185,572,339.28  198,189,909.06   189,281,423.74	0.00	0.00	0.00	0.00	0.00	0.00	1,134,977,340.16

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

70,007.12	77,437.98	70,007.12	70,803.89	73,814.89	71,344.62	0.00	0.00	0.00	0.00	0.00	0.00

433,415.62	
0.00	
745,302.56	
4,987.53	
123,179.49	
1,306,885.20	

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

113,605.70	118,717.57	126,429.56	130,091.75	134,898.58	121,559.40	0.00	0.00	0.00	0.00	0.00	0.00

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

19,836.86	21,311.74	19,836.86	20,022.25	21,709.30	20,462.48	0.00	0.00	0.00	0.00	0.00	0.00

184,831,913.92	185,793,257.17	198,420,331.83	189,494,790.24	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

206,326.49

214,590.48	221,261.07	220,917.89	230,422.77	213,366.50	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

182,421,827.21  195,322,104.99

1,136,284,225.36

LONG TERM CARE MEMBER MONTHS

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	3.00	3.00	3.00	3.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	23.00

1010	TANF NON-MEDICARE	654.15	651.89	656.12	659.50	658.46	656.64	0.00	0.00	0.00	0.00	0.00	0.00	3,936.76

1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00

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

11,288.11	11,289.28	11,378.95	11,358.29	11,326.59	11,312.02	0.00	0.00	0.00	0.00	0.00	0.00	67,953.24

717.21	639.08	710.00	851.48	668.68	671.96	0.00	0.00	0.00	0.00	0.00	0.00	4,258.41

655.14	653.57	669.99	636.70	631.61	621.54	0.00	0.00	0.00	0.00	0.00	0.00	3,868.55

21.10	12.50	27.34	18.34	9.95	32.31	0.00	0.00	0.00	0.00	0.00	0.00	121.54

2120	SSI AGED WITH QMB	7,334.44	7,374.82	7,392.70	7,402.32	7,425.32	7,463.15	0.00	0.00	0.00	0.00	0.00	0.00	44,392.75

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

27.75	9.33	32.14	22.04	11.00	24.17	0.00	0.00	0.00	0.00	0.00	0.00	126.43

4,540.03	4,507.46	4,531.49	4,608.07	4,649.47	4,686.29	0.00	0.00	0.00	0.00	0.00	0.00	27,522.81

40.61	63.99	95.38	125.93	77.65	98.95	0.00	0.00	0.00	0.00	0.00	0.00	502.51

25,726.52	25,794.02	25,992.12	25,925.40	25,930.65	25,960.83	0.00	0.00	0.00	0.00	0.00	0.00	155,329.54

68.02	35.27	25.38	30.27	31.72	24.91	0.00	0.00	0.00	0.00	0.00	0.00	215.57

6,765.32	6,778.39	6,816.99	6,805.73	6,791.71	6,794.82	0.00	0.00	0.00	0.00	0.00	0.00	40,752.96

2.73	7.18	7.16	6.82	9.41	7.33	0.00	0.00	0.00	0.00	0.00	0.00	40.63

2300	SSI BLIND WITH MEDIC	20.00	19.00	20.00	20.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	119.00

2310	SSI BLIND NON-MEDIC A

128.16	130.38	131.06	129.55	134.00	134.12	0.00	0.00	0.00	0.00	0.00	0.00	787.27

2320	SSI BLIND WITH QMB	42.00	42.00	42.00	40.83	40.30	40.96	0.00	0.00	0.00	0.00	0.00	0.00	248.09

SUBTOTAL:

58,035.29

58,012.16	58,532.82	58,645.27	58,422.52	58,558.00	0.00	0.00	0.00	0.00	0.00	0.00	350,206.06

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

22.00	22.00	22.00	22.09	22.31	23.00	0.00	0.00	0.00	0.00	0.00	0.00

133.40	
0.00	
157.56	
5.03	
42.09	
338.08	

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

27.09	25.91	26.96	27.00	25.60	25.00	0.00	0.00	0.00	0.00	0.00	0.00

2.90	-2.90	5.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

7.00	7.00	7.00	7.00	7.00	7.09	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

58.99

52.01	60.99	56.09	54.91	55.09	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	58,094.28	58,064.17	58,593.81	58,701.36	58,477.43	58,613.09	0.00	0.00	0.00	0.00	0.00	0.00		350,544.14		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending December 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	41.42	45.66	0.00	0.00	0.00	0.00	0.00	0.00	241.15

1010	TANF NON-MEDICARE	6,001,729.15	5,085,321.40	4,606,746.65	4,559,389.34	4,008,130.56	4,802,606.88	0.00	0.00	0.00	0.00	0.00	0.00	29,063,923.98

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	82.84	82.84	0.00	0.00	0.00	0.00	0.00	0.00	436.27

2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	0.00	0.00	41.42

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

37.55	37.55	37.55	82.84	165.68	174.16	0.00	0.00	0.00	0.00	0.00	0.00	535.33

430,210.35	427,168.80	423,639.10	461,128.86	457,442.48	503,226.44	0.00	0.00	0.00	0.00	0.00	0.00	2,702,816.03

225.30	225.30	225.30	248.52	207.10	241.02	0.00	0.00	0.00	0.00	0.00	0.00	1,372.54

1,464.45	1,614.65	1,689.75	1,988.16	1,988.16	2,162.00	0.00	0.00	0.00	0.00	0.00	0.00	10,907.17

225.30	225.30	187.75	165.68	207.10	335.60	0.00	0.00	0.00	0.00	0.00	0.00	1,346.73

17,147,019.75    18,291,093.15     19,577,631.25     20,609,680.76     21,238,146.42     23,190,384.24	0.00	0.00	0.00	0.00	0.00	0.00	120,053,955.57

525.70	0.00	187.75	455.62	165.68	869.82	0.00	0.00	0.00	0.00	0.00	0.00	2,204.57

20,427.20	22,567.55	25,233.60	28,828.32	30,195.18	26,234.24	0.00	0.00	0.00	0.00	0.00	0.00	153,486.09

SUBTOTAL:

23,601,939.85

23,828,366.35    24,635,691.35    25,662,133.78    25,736,772.62     28,526,404.32	0.00	0.00	0.00	0.00	0.00	0.00	151,991,308.27

1110	TANF EXPANDED FOR	92,861.15	74,837.15	64,811.30	62,295.68	46,970.28	60,148.88	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	37.55	37.55	37.55	41.42	41.42	49.90	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	47,011.70	60,198.78	0.00	0.00	0.00	0.00	0.00	0.00	

401,924.44
FI
245.39
E
402,169.83

3510	ADULT 40-100% FOR FI	37.55	37.55	75.10	82.84	82.84	41.42	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED	0.00	37.55	75.10	82.84	82.84	165.68	0.00	0.00	0.00	0.00	0.00	0.00	
	37.55	75.10	150.20	165.68	165.68	207.10	0.00	0.00	0.00	0.00	0.00	0.00	

357.30

FO
SUBTOTAL:

444.01

801.31

F
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 F

24,832,077.85	24,924,826.35	25,622,280.05	28,399,084.54	28,565,013.06	31,579,075.02	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

124.26

11,527,911.78

11,528,036.04

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	41.42	41.42	41.42	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	1,137,201.75	1,021,510.20	921,589.65	2,674,365.14	2,781,021.64	2,992,223.40	0.00	0.00	0.00	0.00	0.00	0.00	
	1,137,201.75	1,021,510.20	921,589.65	2,674,406.56	2,781,063.06	2,992,264.82	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

163,922,356.87

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending December 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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

1010	TANF NON-MEDICARE	159,833.00	135,428.00	122,683.00	110,077.00	96,768.00	85,240.00	0.00	0.00	0.00	0.00	0.00	0.00	710,029.00

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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00

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

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

1.00	1.00	1.00	2.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	13.00

11,457.00	11,376.00	11,282.00	11,133.00	11,044.00	10,970.00	0.00	0.00	0.00	0.00	0.00	0.00	67,262.00

6.00	6.00	6.00	6.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	34.00

39.00	43.00	45.00	48.00	48.00	48.00	0.00	0.00	0.00	0.00	0.00	0.00	271.00

6.00	6.00	5.00	4.00	5.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	34.00

456,645.00	487,113.00	521,375.00	497,578.00	512,751.00	529,324.00	0.00	0.00	0.00	0.00	0.00	0.00	3,004,786.00

14.00	0.00	5.00	11.00	4.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	55.00

544.00	601.00	672.00	696.00	729.00	600.00	0.00	0.00	0.00	0.00	0.00	0.00	3,842.00

SUBTOTAL:

628,547.00

634,577.00	656,077.00	619,559.00	621,361.00	626,224.00	0.00	0.00	0.00	0.00	0.00	0.00	3,786,345.00

1110	TANF EXPANDED FOR	2,473.00	1,993.00	1,726.00	1,504.00	1,134.00	904.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	1.00	1.00	1.00	1.00	1.00	1.00	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	1,135.00	905.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,734.00
FI
6.00
E
9,740.00

3510	ADULT 40-100% FOR FI	1.00	1.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED	0.00	1.00	2.00	2.00	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1.00	2.00	4.00	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	

9.00

FO
SUBTOTAL:

11.00

20.00

F

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	30,285.00	27,204.00	24,543.00	64,567.00	67,142.00	69,354.00	0.00	0.00	0.00	0.00	0.00	0.00	
	30,285.00	27,204.00	24,543.00	64,568.00	67,143.00	69,355.00	0.00	0.00	0.00	0.00	0.00	0.00	

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 F
SUBTOTAL:

3.00

283,095.00

283,098.00

TOTAL:	661,307.00	663,777.00	682,351.00	685,637.00	689,643.00	696,489.00	0.00	0.00	0.00	0.00	0.00	0.00		4,079,204.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	67,083.83	80,473.34	92,942.96	1,873.88	1,880.20	2,409.24	0.00	0.00	0.00	0.00	0.00	0.00	246,663.45

1010	TANF NON-MEDICARE	6,077,917.65	6,393,201.43	6,925,613.32	441,979.72	444,046.36	1,050,735.48	0.00	0.00	0.00	0.00	0.00	0.00	21,333,493.96

1020	TANF WITH QMB	24,837.03	36,897.81	45,074.61	701.52	761.56	220.68	0.00	0.00	0.00	0.00	0.00	0.00	108,493.21

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

139,789.21	137,949.43	136,722.91	13,714.40	13,869.24	19,412.00	0.00	0.00	0.00	0.00	0.00	0.00	461,457.19

205,476.17	200,433.81	204,454.07	19,576.20	19,269.68	42,553.12	0.00	0.00	0.00	0.00	0.00	0.00	691,763.05

2120	SSI AGED WITH QMB	595,679.88	602,630.16	609,410.09	73,883.96	74,771.92	96,621.20	0.00	0.00	0.00	0.00	0.00	0.00	2,052,997.21

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

134,133.59	132,327.88	130,488.10	11,537.16	11,508.72	20,634.20	0.00	0.00	0.00	0.00	0.00	0.00	440,629.65

1,422,763.20	1,422,831.34	1,426,408.69	116,724.08	117,773.20	279,823.24	0.00	0.00	0.00	0.00	0.00	0.00	4,786,323.75

832,159.75	837,747.23	844,561.23	70,060.36	70,610.20	107,153.96	0.00	0.00	0.00	0.00	0.00	0.00	2,762,292.73

2300	SSI BLIND WITH MEDIC	1,226.52	1,158.38	1,056.17	94.80	88.48	155.48	0.00	0.00	0.00	0.00	0.00	0.00	3,779.83

2310	SSI BLIND NON-MEDIC A

14,820.45	14,650.10	14,547.89	1,295.60	1,311.40	2,962.84	0.00	0.00	0.00	0.00	0.00	0.00	49,588.28

2320	SSI BLIND WITH QMB	8,279.01	8,210.87	8,244.94	745.76	739.44	1,094.24	0.00	0.00	0.00	0.00	0.00	0.00	27,314.26

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

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

834,544.65	810,661.58	852,976.52	73,251.96	73,425.76	148,481.52	0.00	0.00	0.00	0.00	0.00	0.00	2,793,341.99

68.14	34.07	34.07	3.16	3.16	3.88	0.00	0.00	0.00	0.00	0.00	0.00	146.48

1,260.59	1,226.52	1,328.73	113.76	94.80	188.68	0.00	0.00	0.00	0.00	0.00	0.00	4,213.08

802,586.99	894,950.76	992,561.31	98,045.32	104,024.04	141,289.04	0.00	0.00	0.00	0.00	0.00	0.00	3,033,457.46

306.63	408.84	340.70	34.76	37.92	22.56	0.00	0.00	0.00	0.00	0.00	0.00	1,151.41

SUBTOTAL:

11,162,967.36

11,575,827.62    12,286,834.45	923,642.72	934,219.24	1,913,761.36	0.00	0.00	0.00	0.00	0.00	0.00	38,797,252.75

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2500	SSI BLIND EXPANDED
W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

141,594.92	125,002.83	112,124.37	20,394.64	19,800.56	23,775.56	0.00	0.00	0.00	0.00	0.00	0.00

442,692.88	
9,678,884.94	
117,259.25	
46,642.87	
119,799.74	
3,080,405.91	
6.32	
221.66	
116.29	
31,796.17	
292,201.09	
1,615,393.74	
15,425,420.86	

3,052,160.95	2,639,368.83	2,306,811.56	405,740.84	398,852.04	875,950.72	0.00	0.00	0.00	0.00	0.00	0.00

39,930.04	35,535.01	32,025.80	3,239.00	4,575.68	1,953.72	0.00	0.00	0.00	0.00	0.00	0.00

14,990.80	14,173.12	13,662.07	948.00	913.24	1,955.64	0.00	0.00	0.00	0.00	0.00	0.00

39,725.62	37,068.16	34,887.68	1,292.44	1,166.04	5,659.80	0.00	0.00	0.00	0.00	0.00	0.00

952,256.50	951,711.38	949,360.55	68,407.68	67,696.68	90,973.12	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00

68.14	68.14	68.14	3.16	3.16	10.92	0.00	0.00	0.00	0.00	0.00	0.00

34.07	34.07	34.07	3.16	3.16	7.76	0.00	0.00	0.00	0.00	0.00	0.00

9,505.53	9,335.18	9,198.90	850.04	894.28	2,012.24	0.00	0.00	0.00	0.00	0.00	0.00

91,103.18	87,900.60	88,070.95	6,955.16	6,847.72	11,323.48	0.00	0.00	0.00	0.00	0.00	0.00

488,427.52	493,674.30	511,867.68	42,394.56	43,298.32	35,731.36	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

4,829,797.27

4,393,871.62	4,058,111.77	550,231.84	544,054.04	1,049,354.32	0.00	0.00	0.00	0.00	0.00	0.00

FO
SUBTOTAL:

11.64

11.64

3610	AHC CARE EXPANDED	0.00	0.00	0.00	0.00	0.00	11.64	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	11.64	0.00	0.00	0.00	0.00	0.00	0.00	

3500	ADULT 40-100% FOR FI	4,974.22	4,326.89	3,849.91	688.88	530.88	1,899.32	0.00	0.00	0.00	0.00	0.00	0.00	16,270.10

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending December 31, 2015

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

3510	ADULT 40-100% FOR FI	2,568,639.51	2,579,984.82	2,658,856.87	246,432.60	250,894.52	506,423.88	0.00	0.00	0.00	0.00	0.00	0.00	8,811,232.20

3520	ADULT 40-100% FOR FI	1,056.17	919.89	919.89	97.96	113.76	149.16	0.00	0.00	0.00	0.00	0.00	0.00	3,256.83

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

4,463.17	4,667.59	4,769.80	774.20	609.88	1,647.40	0.00	0.00	0.00	0.00	0.00	0.00	16,932.04

6,719,966.80	6,769,163.88	7,017,568.25	651,541.44	662,468.72	1,428,717.48	0.00	0.00	0.00	0.00	0.00	0.00	23,249,426.57

1,328.73	476.98	953.96	94.80	94.80	118.12	0.00	0.00	0.00	0.00	0.00	0.00	3,067.39

SUBTOTAL:

9,300,428.60

9,359,540.05	9,686,918.68	899,629.88	914,712.56	1,938,955.36	0.00	0.00	0.00	0.00	0.00	0.00	32,100,185.13

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

3,032.23	2,044.20	2,180.48	372.88	404.48	593.92	0.00	0.00	0.00	0.00	0.00	0.00

8,628.19	
7,734,589.36	
821.94	
7,744,039.49	

2,203,170.62	2,295,500.32	2,410,997.62	227,614.80	237,448.72	359,857.28	0.00	0.00	0.00	0.00	0.00	0.00

374.77	170.35	204.42	28.44	25.28	18.68	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	237,878.48	360,469.88	0.00	0.00	0.00	0.00	0.00	0.00

F F
SUBTOTAL:

346,370.31

6.32

346,376.63

4410	SOBRA 100-133% FOR	103,709.08	95,634.49	86,469.66	15,683.08	17,019.76	27,854.24	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	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	103,709.08	95,634.49	86,469.66	15,686.24	17,022.92	27,854.24	0.00	0.00	0.00	0.00	0.00	0.00	

N N
SUBTOTAL:

31,689.41

3,961.86

35,651.27

4510	BC PATIENT FOR FINA	9,471.46	9,301.11	9,267.04	837.40	799.48	2,012.92	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	104.28	278.16	0.00	0.00	0.00	0.00	0.00	0.00	
	10,663.91	10,459.49	10,391.35	941.68	903.76	2,291.08	0.00	0.00	0.00	0.00	0.00	0.00	

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

34.07	34.07	34.07	0.00	0.00	3.88	0.00	0.00	0.00	0.00	0.00	0.00

106.09	
114,209.12	
25,871.28	
17,663.59	
157,850.08	

33,831.51	35,194.31	35,909.78	2,837.68	2,850.32	3,585.52	0.00	0.00	0.00	0.00	0.00	0.00

7,086.56	7,938.31	8,142.73	701.52	698.36	1,303.80	0.00	0.00	0.00	0.00	0.00	0.00

5,178.64	5,417.13	5,655.62	426.60	439.24	546.36	0.00	0.00	0.00	0.00	0.00	0.00

27,660,274.62	27,781,631.96	28,591,850.63	2,622,114.28	2,652,778.92	5,298,137.44	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

46,130.78

48,583.82	49,742.20	3,965.80	3,987.92	5,439.56	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

94,606,787.85

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	0.00	0.00	0.00	0.00	0.00	0.00	8,312.00

1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	0.00	0.00	0.00	0.00	0.00	0.00	992,486.00

1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	3,631.00

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

4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	0.00	0.00	0.00	0.00	0.00	0.00	21,233.00

6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	0.00	0.00	0.00	0.00	0.00	0.00	35,827.00

2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	0.00	0.00	0.00	0.00	0.00	0.00	101,846.00

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

3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	0.00	0.00	0.00	0.00	0.00	0.00	19,768.00

41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	0.00	0.00	0.00	0.00	0.00	0.00	236,789.00

24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	0.00	0.00	0.00	0.00	0.00	0.00	121,229.00

2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	164.00

2310	SSI BLIND NON-MEDIC A

435.00	430.00	427.00	410.00	415.00	417.00	0.00	0.00	0.00	0.00	0.00	0.00	2,534.00

2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	1,239.00

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

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

24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	0.00	0.00	0.00	0.00	0.00	0.00	142,179.00

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

37.00	36.00	39.00	36.00	30.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	180.00

23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	0.00	0.00	0.00	0.00	0.00	0.00	170,944.00

9.00	12.00	10.00	11.00	12.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	55.00

SUBTOTAL:

327,648.00

339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	0.00	0.00	0.00	0.00	0.00	0.00	1,858,429.00

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2500	SSI BLIND EXPANDED
W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	0.00	0.00	0.00	0.00	0.00	0.00

24,274.00	
620,877.00	
5,776.00	
1,862.00	
4,327.00	
128,045.00	
2.00	
9.00	
5.00	
1,404.00	
14,301.00	
71,738.00	
872,620.00	

89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	131,497.00	0.00	0.00	0.00	0.00	0.00	0.00

1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	0.00	0.00	0.00	0.00	0.00	0.00

440.00	416.00	401.00	300.00	289.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00

1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	0.00	0.00	0.00	0.00	0.00	0.00

27,950.00	27,934.00	27,865.00	21,648.00	21,423.00	1,225.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

279.00	274.00	270.00	269.00	283.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00

2,674.00	2,580.00	2,585.00	2,201.00	2,167.00	2,094.00	0.00	0.00	0.00	0.00	0.00	0.00

14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

141,761.00

128,966.00	119,111.00	174,124.00	172,169.00	136,489.00	0.00	0.00	0.00	0.00	0.00	0.00

FO
SUBTOTAL:

0.00

0.00

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

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	780.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending December 31, 2015

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

3510	ADULT 40-100% FOR FI	75,393.00	75,726.00	78,041.00	77,985.00	79,397.00	81,218.00	0.00	0.00	0.00	0.00	0.00	0.00	467,760.00

3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	155.00

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

131.00	137.00	140.00	245.00	193.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	859.00

197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	213,189.00	0.00	0.00	0.00	0.00	0.00	0.00	1,230,914.00

39.00	14.00	28.00	30.00	30.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	144.00

SUBTOTAL:

272,980.00

274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	0.00	0.00	0.00	0.00	0.00	0.00	1,700,612.00

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

89.00	60.00	64.00	118.00	128.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00

464.00	
427,436.00	
40.00	
427,940.00	

64,666.00	67,376.00	70,766.00	72,030.00	75,142.00	77,456.00	0.00	0.00	0.00	0.00	0.00	0.00

11.00	5.00	6.00	9.00	8.00	1.00	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	75,278.00	77,462.00	0.00	0.00	0.00	0.00	0.00	0.00

F F
SUBTOTAL:

24,068.00

2.00

24,070.00

4410	SOBRA 100-133% FOR	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	5,330.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	0.00	0.00	0.00	0.00	0.00	0.00	

N N
SUBTOTAL:

1,590.00

202.00

1,792.00

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	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	33.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

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

3.00	
4,901.00	
1,333.00	
752.00	
6,989.00	

993.00	1,033.00	1,054.00	898.00	902.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00

208.00	233.00	239.00	222.00	221.00	210.00	0.00	0.00	0.00	0.00	0.00	0.00

152.00	159.00	166.00	135.00	139.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,354.00

1,426.00	1,460.00	1,255.00	1,262.00	232.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	0.00	0.00	0.00	0.00	0.00	0.00		4,892,452.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	90,239.27	108,250.46	125,024.24	33,623.10	33,736.50	6,548.22	0.00	0.00	0.00	0.00	0.00	0.00	397,421.79

1010	TANF NON-MEDICARE	8,175,842.85	8,599,953.67	9,316,139.08	7,930,458.90	7,967,540.70	8,874,318.60	0.00	0.00	0.00	0.00	0.00	0.00	50,864,253.80

1020	TANF WITH QMB	33,410.07	49,633.89	60,633.09	12,587.40	13,664.70	2,022.30	0.00	0.00	0.00	0.00	0.00	0.00	171,951.45

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

188,040.49	185,565.67	183,915.79	246,078.00	248,856.30	43,045.38	0.00	0.00	0.00	0.00	0.00	0.00	1,095,501.63

276,400.73	269,617.89	275,025.83	351,256.50	345,756.60	350,807.94	0.00	0.00	0.00	0.00	0.00	0.00	1,868,865.49

2120	SSI AGED WITH QMB	801,291.72	810,641.04	819,761.21	1,325,702.70	1,341,635.40	217,234.08	0.00	0.00	0.00	0.00	0.00	0.00	5,316,266.15

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

180,432.71	178,003.72	175,528.90	207,011.70	206,501.40	70,141.68	0.00	0.00	0.00	0.00	0.00	0.00	1,017,620.11

1,913,860.80	1,913,952.46	1,918,764.61	2,094,384.60	2,113,209.00	2,319,604.56	0.00	0.00	0.00	0.00	0.00	0.00	12,273,776.03

1,119,397.75	1,126,913.87	1,136,079.87	1,257,095.70	1,266,961.50	292,241.88	0.00	0.00	0.00	0.00	0.00	0.00	6,198,690.57

2300	SSI BLIND WITH MEDIC	1,649.88	1,558.22	1,420.73	1,701.00	1,587.60	464.94	0.00	0.00	0.00	0.00	0.00	0.00	8,382.37

2310	SSI BLIND NON-MEDIC A

19,936.05	19,706.90	19,569.41	23,247.00	23,530.50	25,780.86	0.00	0.00	0.00	0.00	0.00	0.00	131,770.72

2320	SSI BLIND WITH QMB	11,136.69	11,045.03	11,090.86	13,381.20	13,267.80	3,682.98	0.00	0.00	0.00	0.00	0.00	0.00	63,604.56

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

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

1,122,605.85	1,090,479.02	1,147,399.88	1,314,362.70	1,317,481.20	1,372,952.70	0.00	0.00	0.00	0.00	0.00	0.00	7,365,281.35

91.66	45.83	45.83	56.70	56.70	5.04	0.00	0.00	0.00	0.00	0.00	0.00	301.76

1,695.71	1,649.88	1,787.37	2,041.20	1,701.00	350.28	0.00	0.00	0.00	0.00	0.00	0.00	9,225.44

1,079,617.31	1,203,862.44	1,335,165.39	1,759,230.90	1,866,507.30	1,658,301.12	0.00	0.00	0.00	0.00	0.00	0.00	8,902,684.46

412.47	549.96	458.30	623.70	680.40	81.90	0.00	0.00	0.00	0.00	0.00	0.00	2,806.73

SUBTOTAL:

15,016,107.84

15,571,475.78    16,527,902.05    16,572,956.40    16,762,731.30     15,237,584.46	0.00	0.00	0.00	0.00	0.00	0.00	95,688,757.83

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2500	SSI BLIND EXPANDED
W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

190,469.48	168,150.27	150,826.53	365,941.80	355,282.20	53,920.44	0.00	0.00	0.00	0.00	0.00	0.00

1,284,590.72	
33,249,934.56	
295,134.67	
94,386.45	
215,948.56	
6,462,942.83	
113.40	
455.16	
260.97	
73,155.59	
731,770.29	
3,634,148.38	
46,042,841.58	

4,105,680.55	3,550,404.27	3,103,057.64	7,280,223.30	7,156,617.30	8,053,951.50	0.00	0.00	0.00	0.00	0.00	0.00

53,712.76	47,800.69	43,080.20	58,117.50	82,101.60	10,321.92	0.00	0.00	0.00	0.00	0.00	0.00

20,165.20	19,065.28	18,377.83	17,010.00	16,386.30	3,381.84	0.00	0.00	0.00	0.00	0.00	0.00

53,437.78	49,863.04	46,929.92	23,190.30	20,922.30	21,605.22	0.00	0.00	0.00	0.00	0.00	0.00

1,280,948.50	1,280,215.22	1,277,052.95	1,227,441.60	1,214,684.10	182,600.46	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00

91.66	91.66	91.66	56.70	56.70	66.78	0.00	0.00	0.00	0.00	0.00	0.00

45.83	45.83	45.83	56.70	56.70	10.08	0.00	0.00	0.00	0.00	0.00	0.00

12,786.57	12,557.42	12,374.10	15,252.30	16,046.10	4,139.10	0.00	0.00	0.00	0.00	0.00	0.00

122,549.42	118,241.40	118,470.55	124,796.70	122,868.90	124,843.32	0.00	0.00	0.00	0.00	0.00	0.00

657,018.88	664,076.70	688,549.92	760,687.20	776,903.40	86,912.28	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

6,496,906.63

5,910,511.78	5,458,857.13	9,872,830.80	9,761,982.30	8,541,752.94	0.00	0.00	0.00	0.00	0.00	0.00

FO
SUBTOTAL:

15.12

15.12

3610	AHC CARE EXPANDED	0.00	0.00	0.00	0.00	0.00	15.12	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	15.12	0.00	0.00	0.00	0.00	0.00	0.00	

3500	ADULT 40-100% FOR FI	6,691.18	5,820.41	5,178.79	12,360.60	9,525.60	2,887.92	0.00	0.00	0.00	0.00	0.00	0.00	42,464.50

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending December 31, 2015

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

3510	ADULT 40-100% FOR FI	3,455,261.19	3,470,522.58	3,576,619.03	4,421,749.50	4,501,809.90	4,929,510.60	0.00	0.00	0.00	0.00	0.00	0.00	24,355,472.80

3520	ADULT 40-100% FOR FI	1,420.73	1,237.41	1,237.41	1,757.70	2,041.20	351.54	0.00	0.00	0.00	0.00	0.00	0.00	8,045.99

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

6,003.73	6,278.71	6,416.20	13,891.50	10,943.10	2,823.66	0.00	0.00	0.00	0.00	0.00	0.00	46,356.90

9,039,509.20	9,105,687.72	9,439,834.25     11,690,632.80     11,886,701.40     13,068,590.22	0.00	0.00	0.00	0.00	0.00	0.00	64,230,955.59

1,787.37	641.62	1,283.24	1,701.00	1,701.00	311.22	0.00	0.00	0.00	0.00	0.00	0.00	7,425.45

SUBTOTAL:

12,510,673.40

12,590,188.45    13,030,568.92    16,142,093.10    16,412,722.20     18,004,475.16	0.00	0.00	0.00	0.00	0.00	0.00	88,690,721.23

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

4,078.87	2,749.80	2,933.12	6,690.60	7,257.60	1,034.46	0.00	0.00	0.00	0.00	0.00	0.00

24,744.45	
22,180,604.80	
2,049.02	
22,207,398.27	

2,963,642.78	3,087,842.08	3,243,205.78	4,084,101.00	4,260,551.40	4,541,261.76	0.00	0.00	0.00	0.00	0.00	0.00

504.13	229.15	274.98	510.30	453.60	76.86	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	4,268,262.60	4,542,373.08	0.00	0.00	0.00	0.00	0.00	0.00

F F
SUBTOTAL:

1,287,770.69

113.40

1,287,884.09

4410	SOBRA 100-133% FOR	139,506.52	128,644.81	116,316.54	281,402.10	305,386.20	316,514.52	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	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	139,506.52	128,644.81	116,316.54	281,458.80	305,442.90	316,514.52	0.00	0.00	0.00	0.00	0.00	0.00	

N N
SUBTOTAL:

82,799.63

10,566.42

93,366.05

4510	BC PATIENT FOR FINA	12,740.74	12,511.59	12,465.76	15,025.50	14,345.10	15,710.94	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	1,871.10	2,149.56	0.00	0.00	0.00	0.00	0.00	0.00	
	14,344.79	14,069.81	13,978.15	16,896.60	16,216.20	17,860.50	0.00	0.00	0.00	0.00	0.00	0.00	

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

45.83	45.83	45.83	0.00	0.00	5.04	0.00	0.00	0.00	0.00	0.00	0.00

142.53	
248,978.38	
69,021.10	
38,159.01	
356,301.02	

45,509.19	47,342.39	48,304.82	50,916.60	51,143.40	5,761.98	0.00	0.00	0.00	0.00	0.00	0.00

9,532.64	10,678.39	10,953.37	12,587.40	12,530.70	12,738.60	0.00	0.00	0.00	0.00	0.00	0.00

6,966.16	7,286.97	7,607.78	7,654.50	7,881.30	762.30	0.00	0.00	0.00	0.00	0.00	0.00

37,207,818.78	37,371,065.24	38,460,948.47	47,048,696.10	47,598,912.90	46,679,843.70	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

62,053.82

65,353.58	66,911.80	71,158.50	71,555.40	19,267.92	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

254,367,285.19

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	0.00	0.00	0.00	0.00	0.00	0.00	8,312.00

1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	0.00	0.00	0.00	0.00	0.00	0.00	992,486.00

1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	3,631.00

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

4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	0.00	0.00	0.00	0.00	0.00	0.00	21,233.00

6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	0.00	0.00	0.00	0.00	0.00	0.00	35,827.00

2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	0.00	0.00	0.00	0.00	0.00	0.00	101,846.00

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

3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	0.00	0.00	0.00	0.00	0.00	0.00	19,768.00

41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	0.00	0.00	0.00	0.00	0.00	0.00	236,789.00

24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	0.00	0.00	0.00	0.00	0.00	0.00	121,229.00

2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	164.00

2310	SSI BLIND NON-MEDIC A

435.00	430.00	427.00	410.00	415.00	417.00	0.00	0.00	0.00	0.00	0.00	0.00	2,534.00

2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	1,239.00

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

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

24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	0.00	0.00	0.00	0.00	0.00	0.00	142,179.00

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

37.00	36.00	39.00	36.00	30.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	180.00

23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	0.00	0.00	0.00	0.00	0.00	0.00	170,944.00

9.00	12.00	10.00	11.00	12.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	55.00

SUBTOTAL:

327,648.00

339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	0.00	0.00	0.00	0.00	0.00	0.00	1,858,429.00

1100	TANF EXPANDED FPR FI
1110	TANF EXPANDED FOR
FI
1120	TANF EXPANDED FOR
FI
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2500	SSI BLIND EXPANDED
W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	0.00	0.00	0.00	0.00	0.00	0.00

24,274.00	
620,877.00	
5,776.00	
1,862.00	
4,327.00	
128,045.00	
2.00	
9.00	
5.00	
1,404.00	
14,301.00	
71,738.00	
872,620.00	

89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	131,497.00	0.00	0.00	0.00	0.00	0.00	0.00

1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	0.00	0.00	0.00	0.00	0.00	0.00

440.00	416.00	401.00	300.00	289.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00

1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	0.00	0.00	0.00	0.00	0.00	0.00

27,950.00	27,934.00	27,865.00	21,648.00	21,423.00	1,225.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

279.00	274.00	270.00	269.00	283.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00

2,674.00	2,580.00	2,585.00	2,201.00	2,167.00	2,094.00	0.00	0.00	0.00	0.00	0.00	0.00

14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

141,761.00

128,966.00	119,111.00	174,124.00	172,169.00	136,489.00	0.00	0.00	0.00	0.00	0.00	0.00

FO
SUBTOTAL:

0.00

0.00

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

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	780.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending December 31, 2015

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

3510	ADULT 40-100% FOR FI	75,393.00	75,726.00	78,041.00	77,985.00	79,397.00	81,218.00	0.00	0.00	0.00	0.00	0.00	0.00	467,760.00

3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	155.00

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

131.00	137.00	140.00	245.00	193.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	859.00

197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	213,189.00	0.00	0.00	0.00	0.00	0.00	0.00	1,230,914.00

39.00	14.00	28.00	30.00	30.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	144.00

SUBTOTAL:

272,980.00

274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	0.00	0.00	0.00	0.00	0.00	0.00	1,700,612.00

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

89.00	60.00	64.00	118.00	128.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00

464.00	
427,436.00	
40.00	
427,940.00	

64,666.00	67,376.00	70,766.00	72,030.00	75,142.00	77,456.00	0.00	0.00	0.00	0.00	0.00	0.00

11.00	5.00	6.00	9.00	8.00	1.00	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	75,278.00	77,462.00	0.00	0.00	0.00	0.00	0.00	0.00

F F
SUBTOTAL:

24,068.00

2.00

24,070.00

4410	SOBRA 100-133% FOR	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	5,330.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	0.00	0.00	0.00	0.00	0.00	0.00	

N N
SUBTOTAL:

1,590.00

202.00

1,792.00

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	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	33.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

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

3.00	
4,901.00	
1,333.00	
752.00	
6,989.00	

993.00	1,033.00	1,054.00	898.00	902.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00

208.00	233.00	239.00	222.00	221.00	210.00	0.00	0.00	0.00	0.00	0.00	0.00

152.00	159.00	166.00	135.00	139.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,354.00

1,426.00	1,460.00	1,255.00	1,262.00	232.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	0.00	0.00	0.00	0.00	0.00	0.00		4,892,452.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending December 31, 2015

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

1010	TANF NON-MEDICARE	912,101.24	848,941.48	773,707.06	781,066.62	725,564.47	827,530.30	0.00	0.00	0.00	0.00	0.00	0.00	4,868,911.17

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

339,019.30	338,090.48	337,161.66	358,241.15	375,396.36	431,901.92	0.00	0.00	0.00	0.00	0.00	0.00	2,179,810.87

928.82	928.82	928.82	1,009.13	1,009.13	1,114.72	0.00	0.00	0.00	0.00	0.00	0.00	5,919.44

13,288,627.74    13,621,145.30     13,792,048.18     14,711,097.14     15,234,835.61     16,974,862.22	0.00	0.00	0.00	0.00	0.00	0.00	87,622,616.19

19,505.22	15,789.94	16,718.76	20,182.60	13,118.69	14,702.54	0.00	0.00	0.00	0.00	0.00	0.00	100,017.75

SUBTOTAL:

14,560,182.32

14,824,896.02    14,920,564.48    15,871,596.64    16,349,924.26     18,250,111.70	0.00	0.00	0.00	0.00	0.00	0.00	94,777,275.42

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:

1,009.13

1,009.13

F

14,633,559.10	14,896,415.16	14,987,439.52	15,968,473.12	16,435,700.31	18,339,912.22	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

483,214.88

483,214.88

4410	SOBRA 100-133% FOR	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	89,800.52	0.00	0.00	0.00	0.00	0.00	0.00	
	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	89,800.52	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

95,261,499.43

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending December 31, 2015

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

1010	TANF NON-MEDICARE	982.00	914.00	833.00	774.00	719.00	652.00	0.00	0.00	0.00	0.00	0.00	0.00	4,874.00

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

365.00	364.00	363.00	355.00	372.00	392.00	0.00	0.00	0.00	0.00	0.00	0.00	2,211.00

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

14,307.00	14,665.00	14,849.00	14,578.00	15,097.00	15,449.00	0.00	0.00	0.00	0.00	0.00	0.00	88,945.00

21.00	17.00	18.00	20.00	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	102.00

SUBTOTAL:

15,676.00

15,961.00	16,064.00	15,728.00	16,202.00	16,507.00	0.00	0.00	0.00	0.00	0.00	0.00	96,138.00

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

4410	SOBRA 100-133% FOR	79.00	77.00	72.00	95.00	85.00	87.00	0.00	0.00	0.00	0.00	0.00	0.00	
	79.00	77.00	72.00	95.00	85.00	87.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1.00

1.00

F
SUBTOTAL:

495.00

495.00

TOTAL:	15,755.00	16,038.00	16,136.00	15,824.00	16,287.00	16,594.00	0.00	0.00	0.00	0.00	0.00	0.00		96,634.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending December 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	1,474.32	1,474.32	0.00	0.00	0.00	0.00	0.00	0.00	7,448.22

1010	TANF NON-MEDICARE	133,111.44	130,590.39	131,598.81	194,610.24	194,610.24	193,135.92	0.00	0.00	0.00	0.00	0.00	0.00	977,657.04

1011	TANF <1 M & F NON-ME	9,104.82	10,355.64	10,355.64	9,632.28	11,760.84	10,286.52	0.00	0.00	0.00	0.00	0.00	0.00	61,495.74

1012	TANF 01-05 M & F NON	25,956.96	17,113.95	14,612.31	18,336.96	14,543.64	11,297.04	0.00	0.00	0.00	0.00	0.00	0.00	101,860.86

1013	TANF 06-13 M & F NON	30,058.50	22,049.37	18,296.91	20,548.44	17,956.08	13,425.60	0.00	0.00	0.00	0.00	0.00	0.00	122,334.90

1014	TANF 14-20 MALE NON-	8,513.34	6,845.58	6,098.97	5,921.88	5,921.88	4,530.48	0.00	0.00	0.00	0.00	0.00	0.00	37,832.13

1015	TANF 14-20 FEMALE N O

9,017.55	7,766.73	8,687.88	9,905.64	7,777.08	8,787.60	0.00	0.00	0.00	0.00	0.00	0.00	51,942.48

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	927.60	0.00	0.00	0.00	0.00	0.00	0.00	927.60

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

833.88	833.88	833.88	927.60	1,391.40	1,391.40	0.00	0.00	0.00	0.00	0.00	0.00	6,212.04

416.94	416.94	416.94	463.80	463.80	463.80	0.00	0.00	0.00	0.00	0.00	0.00	2,642.22

8,571.57	9,492.72	12,013.77	18,155.64	19,629.96	19,629.96	0.00	0.00	0.00	0.00	0.00	0.00	87,493.62

3,071,131.98	3,075,185.07	3,070,908.99	4,422,630.00	4,413,676.56	4,434,590.40	0.00	0.00	0.00	0.00	0.00	0.00	22,488,123.00

24,444.48	25,452.90	25,957.11	37,512.24	40,460.88	40,460.88	0.00	0.00	0.00	0.00	0.00	0.00	194,288.49

2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	737.16	737.16	737.16	0.00	0.00	0.00	0.00	0.00	0.00	3,724.11

2310	SSI BLIND NON-MEDIC A

27,624.87	28,129.08	27,624.87	39,640.80	39,831.24	39,094.08	0.00	0.00	0.00	0.00	0.00	0.00	201,944.94

4311	SOBRA CHILD <1 M & F	21,273.72	19,935.63	18,180.60	24,292.56	22,164.00	24,375.48	0.00	0.00	0.00	0.00	0.00	0.00	130,221.99

4312	SOBRA CHILD 01-05 M	137,425.89	146,162.22	148,906.26	180,325.32	185,783.40	191,871.12	0.00	0.00	0.00	0.00	0.00	0.00	990,474.21

4313	SOBRA CHILD 06-13 M	130,832.34	140,421.96	154,045.26	197,710.08	200,468.28	209,255.88	0.00	0.00	0.00	0.00	0.00	0.00	1,032,733.80

4314	SOBRA CHILD 14-20 MA	30,970.02	33,141.99	36,060.57	45,851.52	45,578.16	44,186.76	0.00	0.00	0.00	0.00	0.00	0.00	235,789.02

4315	SOBRA CHILD 14-20 FE	35,226.69	37,815.60	35,886.03	47,433.36	48,278.04	50,679.96	0.00	0.00	0.00	0.00	0.00	0.00	255,319.68

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 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

3,005.85	2,588.91	2,171.97	2,592.36	3,056.16	1,664.76	0.00	0.00	0.00	0.00	0.00	0.00	15,080.01

SUBTOTAL:

3,709,033.47

3,715,811.19	3,724,586.34	5,279,166.00	5,275,563.12	5,302,266.72	0.00	0.00	0.00	0.00	0.00	0.00	27,006,426.84

416.94	
927.60	
2,178.42	
463.80	
3,986.76	

SUBTOTAL:

1113	TANF EXPANDED 06-13	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	463.80	0.00	463.80	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	416.94	416.94	416.94	463.80	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	833.88	416.94	416.94	927.60	927.60	463.80	0.00	0.00	0.00	0.00	0.00	0.00	

6,212.04	
3,893.04	
927.60	
463.80	
38,101.32	
28,324.26	
4,497.42	

3514	ADULT 40-100% MALE 1	833.88	833.88	833.88	927.60	1,391.40	1,391.40	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

833.88	833.88	833.88	463.80	463.80	463.80	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	463.80	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

0.00	0.00	0.00	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	6,254.10	7,087.98	6,671.04	6,029.40	6,029.40	6,029.40	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

3,752.46	4,169.40	4,169.40	5,101.80	5,101.80	6,029.40	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	416.94	416.94	416.94	1,391.40	927.60	927.60	0.00	0.00	0.00	0.00	0.00	0.00

AL

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

SUBTOTAL:

L
SUBTOTAL:

1,250.82

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEM	416.94	416.94	416.94	463.80	927.60	1,391.40	0.00	0.00	0.00	0.00	0.00	0.00		4,033.62		
	12,508.20	13,759.02	13,342.08	15,305.40	14,841.60	16,696.80	0.00	0.00	0.00	0.00	0.00	0.00		86,453.10		

1,250.82

50,765.46	
17,310.09	
7,186.50	
75,262.05	

6

L

3,730,142.28	3,737,336.94	3,744,027.39	5,313,570.12	5,311,168.20	5,337,134.64	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4413	SOBRA 100-133% M&F	4,760.88	4,343.94	3,927.00	12,332.16	13,996.92	11,404.56	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,755.03	1,755.03	921.15	4,447.56	3,983.76	4,447.56	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	833.88	833.88	416.94	1,391.40	1,855.20	1,855.20	0.00	0.00	0.00	0.00	0.00	0.00	
	7,349.79	6,932.85	5,265.09	18,171.12	19,835.88	17,707.32	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

27,173,379.57

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00

1010	TANF NON-MEDICARE	264.00	259.00	261.00	264.00	264.00	262.00	0.00	0.00	0.00	0.00	0.00	0.00	1,574.00

1011	TANF <1 M & F NON-ME	21.00	24.00	24.00	19.00	23.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	132.00

1012	TANF 01-05 M & F NON	61.00	40.00	34.00	36.00	29.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	222.00

1013	TANF 06-13 M & F NON	70.00	51.00	42.00	39.00	34.00	26.00	0.00	0.00	0.00	0.00	0.00	0.00	262.00

1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	11.00	11.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	80.00

1015	TANF 14-20 FEMALE N O

21.00	18.00	20.00	19.00	15.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	109.00

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

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

2.00	2.00	2.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00

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

17.00	19.00	24.00	25.00	27.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	139.00

6,177.00	6,184.00	6,175.00	6,182.00	6,168.00	6,196.00	0.00	0.00	0.00	0.00	0.00	0.00	37,082.00

49.00	51.00	52.00	52.00	56.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	316.00

2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

2310	SSI BLIND NON-MEDIC A

56.00	57.00	56.00	56.00	57.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	338.00

4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	40.00	36.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	243.00

4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	311.00	321.00	330.00	0.00	0.00	0.00	0.00	0.00	0.00	1,907.00

4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	342.00	345.00	361.00	0.00	0.00	0.00	0.00	0.00	0.00	1,986.00

4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	80.00	80.00	77.00	0.00	0.00	0.00	0.00	0.00	0.00	458.00

4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	84.00	87.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00	504.00

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 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

7.00	6.00	5.00	5.00	6.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	32.00

SUBTOTAL:

7,546.00

7,561.00	7,581.00	7,572.00	7,566.00	7,600.00	0.00	0.00	0.00	0.00	0.00	0.00	45,426.00

1.00	
2.00	
5.00	
1.00	
9.00	

SUBTOTAL:

1113	TANF EXPANDED 06-13	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2.00	1.00	1.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	

14.00	
9.00	
2.00	
1.00	
87.00	
64.00	
10.00	

3514	ADULT 40-100% MALE 1	2.00	2.00	2.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

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

3517	ADULT 40-100% FEMAL E

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

3714	ADULT <40% EXP MALE	15.00	17.00	16.00	13.00	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

9.00	10.00	10.00	11.00	11.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	1.00	1.00	1.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00

AL

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

SUBTOTAL:

L

4413	SOBRA 100-133% M&F	11.00	10.00	9.00	26.00	29.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	4.00	4.00	2.00	9.00	8.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	2.00	2.00	1.00	3.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	
	17.00	16.00	12.00	38.00	41.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEM	1.00	1.00	1.00	1.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
	30.00	33.00	32.00	33.00	32.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00		196.00		

3.00

109.00	
36.00	
16.00	
161.00	

6

L
SUBTOTAL:

TOTAL:	7,596.00	7,612.00	7,627.00	7,645.00	7,641.00	7,674.00	0.00	0.00	0.00	0.00	0.00	0.00		45,795.00		

AT
SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		
	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		

79,084.04	
119,711.65	
237,801.85	
86,142.33	
6,709,688.73	
5,156,756.51	
7,979,991.61	
1,967,657.01	
3,650,464.89	
10,897,910.13	
39,853,071.97	
14,197,133.32	
44,471.02	
7,158.67	
13,659.41	
57,924.23	
26,872.94	
966,765.65	
913,317.49	
2,423,679.73	
2,560,530.15	
50,505,466.11	
7,570,507.28	
7,761.03	
559,063.05	
96,270.18	
700.00	
12,642,269.78	
19,180,826.81	
27,701,610.32	
7,430,805.46	
9,526,482.45	
2,307.66	

1006	TANF 21-44 MALE WITH	13,748.51	11,706.46	23,270.89	8,748.57	7,149.61	14,460.00	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	17,026.44	13,867.21	25,370.63	22,346.09	17,592.65	23,508.63	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	29,543.51	38,496.50	56,571.19	54,075.02	32,676.28	26,439.35	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	9,711.26	9,427.79	29,391.90	16,563.16	12,496.08	8,552.14	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	1,290,959.10	1,245,523.04	1,285,302.05	905,574.17	963,537.08	1,018,793.29	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	1,257,382.93	1,081,951.02	933,354.82	539,709.66	757,662.16	586,695.92	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	1,882,318.21	1,589,351.98	1,841,982.47	862,977.79	1,029,797.97	773,563.19	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	349,688.37	397,522.68	308,438.57	514,200.50	224,937.19	172,869.70	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

618,162.51	955,347.31	724,128.67	410,827.38	435,390.45	506,608.57	0.00	0.00	0.00	0.00	0.00	0.00

1016	TANF 21-44 MALE NON-	1,720,458.08	1,835,554.52	2,506,066.57	1,727,158.48	1,426,837.45	1,681,835.03	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

6,255,681.23	6,847,408.50	8,911,141.15	5,718,928.09	5,916,678.41	6,203,234.59	0.00	0.00	0.00	0.00	0.00	0.00

1018	TANF 45-64 M & F NON	2,241,687.50	2,225,717.52	3,261,573.62	2,183,571.68	2,053,071.73	2,231,511.27	0.00	0.00	0.00	0.00	0.00	0.00

1019	TANF 65+ M & F NON-M	10,320.41	9,670.04	10,279.84	5,969.00	700.00	7,531.73	0.00	0.00	0.00	0.00	0.00	0.00

1026	TANF 21-44 MALE WITH	700.00	568.89	2,023.45	1,345.49	471.14	2,049.70	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	1,268.82	1,174.29	4,000.44	2,990.62	509.85	3,715.39	0.00	0.00	0.00	0.00	0.00	0.00

1028	TANF 45-64 M & F WIT	6,682.12	19,778.64	18,075.17	3,448.75	7,147.15	2,792.40	0.00	0.00	0.00	0.00	0.00	0.00

1029	TANF 65+ M & F WITH	5,507.74	3,496.54	5,763.29	2,613.98	4,407.36	5,084.03	0.00	0.00	0.00	0.00	0.00	0.00

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

167,284.72	163,478.22	201,904.18	127,579.30	163,117.16	143,402.07	0.00	0.00	0.00	0.00	0.00	0.00

125,205.47	128,787.96	211,507.53	151,466.88	159,319.29	137,030.36	0.00	0.00	0.00	0.00	0.00	0.00

2120	SSI AGED WITH QMB	326,875.26	398,974.35	518,146.67	350,297.01	301,912.77	527,473.67	0.00	0.00	0.00	0.00	0.00	0.00

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

306,269.94	461,879.30	527,481.62	417,867.71	349,136.11	497,895.47	0.00	0.00	0.00	0.00	0.00	0.00

8,070,657.42	8,785,140.60     10,377,505.66	6,855,292.97	7,625,934.11	8,790,935.35	0.00	0.00	0.00	0.00	0.00	0.00

1,017,428.75	1,228,462.25	1,678,808.77	1,093,787.83	1,003,545.35	1,548,474.33	0.00	0.00	0.00	0.00	0.00	0.00

2300	SSI BLIND WITH MEDIC	2,615.94	1,503.84	1,485.61	614.91	454.23	1,086.50	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

117,830.33	100,119.21	107,909.34	69,161.53	71,428.41	92,614.23	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	16,751.49	16,898.33	16,514.76	11,295.59	10,808.18	24,001.83	0.00	0.00	0.00	0.00	0.00	0.00

4304	SOBRA CHILD 14-20 MA	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	2,174,749.48	2,074,877.06	2,217,875.37	1,618,780.76	2,184,782.52	2,371,204.59	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	2,763,871.20	2,834,483.06	3,569,126.85	2,468,077.70	3,433,325.87	4,111,942.13	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	3,762,824.46	4,361,436.75	6,065,640.01	3,546,216.84	4,651,190.92	5,314,301.34	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	939,030.81	1,434,713.92	1,458,821.66	973,466.61	1,231,404.84	1,393,367.62	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	1,301,099.71	1,480,601.04	1,858,178.99	1,598,217.67	1,508,100.10	1,780,284.94	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M

0.00	700.00	700.00	0.00	21.79	885.87	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2015

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M

0.00	0.00	4,357.53	1,572.17	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,629.70

396,630.45	405,096.39	479,727.39	392,622.76	525,109.97	463,461.69	0.00	0.00	0.00	0.00	0.00	0.00	2,662,648.65

1,708,550.06	2,049,753.34	2,625,202.28	1,982,900.83	2,364,318.56	2,224,181.36	0.00	0.00	0.00	0.00	0.00	0.00	12,954,906.43

4,193.00	14,500.38	2,450.00	1,822.16	1,347.29	4,635.72	0.00	0.00	0.00	0.00	0.00	0.00	28,948.55

0.00	0.00	12.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.47

SUBTOTAL:

38,912,715.23

42,227,968.93    51,870,791.41    34,642,089.66    38,477,020.03     42,696,424.00	0.00	0.00	0.00	0.00	0.00	0.00	248,827,009.26

3100	TRANSPLANT OPTION
1
SUBTOTAL:

85.42

85.42

0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	0.00	0.00	0.00	

350.00	
72,013.10	
202,651.01	
464,466.17	
176,301.17	
107.79	
17,476.83	
100,551.23	
73,069.64	
176,266.55	
2,966,209.52	
8,774,633.51	
5,477,134.69	
11,263.19	
20,558.72	
23,431.67	
84,704.64	
49,857.02	
146,125.18	
294,089.51	
2,447,524.77	
136,369.26	
1,434,871.21	
2,054,128.53	
25,204,154.91	

1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	10,284.15	10,175.29	17,463.56	6,713.81	6,727.53	20,648.76	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	22,395.39	24,471.89	35,137.04	29,098.84	37,436.02	54,111.83	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	62,335.76	91,660.22	84,344.30	47,375.02	62,250.31	116,500.56	0.00	0.00	0.00	0.00	0.00	0.00

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

23,910.19	20,501.26	32,963.26	25,925.52	28,936.18	44,064.76	0.00	0.00	0.00	0.00	0.00	0.00

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	2,883.38	1,131.53	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	30,078.23	19,474.68	25,336.13	9,267.93	12,274.86	4,119.40	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	15,858.70	9,308.99	5,711.38	9,618.73	16,742.54	15,829.30	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	28,001.63	22,720.99	43,056.85	16,406.84	35,978.34	30,101.90	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	362,417.96	353,624.60	512,350.28	353,039.43	652,149.40	732,627.85	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	1,288,260.07	1,258,732.85	1,300,199.98	1,114,194.80	1,720,889.74	2,092,356.07	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	704,691.67	705,276.22	792,023.29	747,280.96	1,128,424.43	1,399,438.12	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	1,233.56	5,642.06	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	1,457.35	10,220.20	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	2,664.74	2,843.89	7,168.40	2,711.75	2,663.79	5,379.10	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	9,867.91	10,323.33	12,735.99	9,612.64	14,560.72	27,604.05	0.00	0.00	0.00	0.00	0.00	0.00

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

7,716.84	9,382.71	9,968.24	4,051.32	6,051.95	12,685.96	0.00	0.00	0.00	0.00	0.00	0.00

22,942.06	38,024.62	25,791.81	23,668.51	15,918.51	19,779.67	0.00	0.00	0.00	0.00	0.00	0.00

67,166.54	76,848.41	85,275.84	56,641.92	14,405.42	-6,248.62	0.00	0.00	0.00	0.00	0.00	0.00

381,632.77	433,733.65	560,695.33	355,819.68	312,801.61	402,841.73	0.00	0.00	0.00	0.00	0.00	0.00

12,133.96	14,195.83	29,503.82	33,613.80	21,605.09	25,316.76	0.00	0.00	0.00	0.00	0.00	0.00

300,375.73	232,843.02	283,300.90	217,797.74	205,261.69	195,292.13	0.00	0.00	0.00	0.00	0.00	0.00

285,198.27	311,126.24	453,402.95	307,810.33	270,330.08	426,260.66	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

3,645,170.04

3,654,958.78	4,322,859.94	3,374,479.87	4,570,982.50	5,635,703.78	0.00	0.00	0.00	0.00	0.00	0.00

3308	AHC CARE M&F 45-64	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	

21.62
W
-95.91

4

SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3317	AHC CARE FEMALE 21-	-527.88	0.00	-316.00	0.00	0.00	-453.42	0.00	0.00	0.00	0.00	0.00	0.00		-1,297.30		
3318	AHC CARE M&F 45-64 N	-12,669.89	0.00	0.00	-883.27	-304.13	-3,862.00	0.00	0.00	0.00	0.00	0.00	0.00		-17,719.29		
	-13,272.06	0.00	-316.00	-883.27	-304.13	-4,315.42	0.00	0.00	0.00	0.00	0.00	0.00		-19,090.88		

-1,057.32	
-189.98	
60.75	
-2,238.34	
12,313.57	
-30,444.54	
-1,789.78	
42,642.08	
19,296.44	

1

2

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	-1,057.32	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	-99.09	0.00	0.00	-90.89	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	-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	-6,343.50	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	-672.13	0.00	1,251.30	-100.95	0.00	-2,268.00	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	-7,299.48	0.00	0.00	0.00	0.00	0.00	0.00	
	22,658.87	-52.99	14,341.74	-591.99	0.00	-17,059.19	0.00	0.00	0.00	0.00	0.00	0.00	

2,938.48	
402.04	
30,736.25	
10,312.37	
160,627.11	
494,671.58	
4,080,369.57	
2,884,139.71	
10,680,639.04	
26,907.15	
561.56	
346.29	
972.74	
64.44	
5,632.50	
32,035.32	
144,174.36	
5,640.17	
1,986,662.54	
1,867,830.01	
39,916,438.98	
21,380,891.30	
50,260,313.20	

3506	ADULT 40-100% MALE 2	100.62	646.90	826.55	497.49	10.06	856.86	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

350.00	-297.96	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	4,048.26	5,152.04	8,303.45	2,673.83	5,233.53	5,325.14	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	1,136.72	650.66	2,304.18	777.55	2,786.50	2,656.76	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	28,154.57	16,919.86	20,598.17	29,661.34	27,712.23	37,580.94	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

63,740.82	68,857.24	154,389.86	65,722.76	76,922.52	65,038.38	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	595,422.82	648,844.84	749,505.91	775,688.96	602,174.53	708,732.51	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

448,531.84	490,065.88	644,008.43	391,103.49	455,793.22	454,636.85	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	1,779,103.67	1,877,742.95	2,130,964.95	1,387,795.56	1,631,187.19	1,873,844.72	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	700.00	1,114.00	4,797.69	17,145.46	700.00	2,450.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	74.88	136.07	0.61	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	101.17	60.44	121.84	0.00	0.00	62.84	0.00	0.00	0.00	0.00	0.00	0.00

3529	ADULT 40-100% M&F 65	0.00	0.00	380.98	90.66	380.22	120.88	0.00	0.00	0.00	0.00	0.00	0.00

3705	ADULT <40% EXP FEM AL

0.00	5.04	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	254.18	187.24	2,147.85	720.29	183.04	2,139.90	0.00	0.00	0.00	0.00	0.00	0.00

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

3,196.60	2,984.95	5,735.57	5,555.83	3,319.35	11,243.02	0.00	0.00	0.00	0.00	0.00	0.00

20,398.58	29,175.88	21,993.36	25,199.18	23,133.12	24,274.24	0.00	0.00	0.00	0.00	0.00	0.00

662.62	898.69	1,365.10	1,918.68	573.77	221.31	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	222,884.44	394,365.52	460,111.11	290,538.55	301,852.22	316,910.70	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

310,676.54	280,914.28	359,791.31	268,309.43	294,507.23	353,631.22	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	5,628,508.71	6,879,358.31	8,226,675.54	5,692,613.38	6,424,354.58	7,064,928.46	0.00	0.00	0.00	0.00	0.00	0.00

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

3,131,984.98	3,612,847.61	4,415,525.36	3,018,805.67	3,263,582.99	3,938,144.69	0.00	0.00	0.00	0.00	0.00	0.00

7,505,601.56	8,385,725.63     10,052,601.97	7,135,426.84	7,938,678.59	9,242,278.61	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending December 31, 2015

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

3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

20,526.57	6,525.97	34,180.45	3,932.97	6,156.96	11,148.55	0.00	0.00	0.00	0.00	0.00	0.00	82,471.47

166.20	0.00	0.00	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	516.20

-612.98	2,336.87	599.83	1,113.03	476.91	1,324.77	0.00	0.00	0.00	0.00	0.00	0.00	5,238.43

SUBTOTAL:

19,765,638.49

22,705,157.72    27,297,474.93    19,115,291.56    21,060,068.76     24,117,901.35	0.00	0.00	0.00	0.00	0.00	0.00	134,061,532.81

2,534.34	
3,192.10	
56,967.25	
5,429.56	
83,193.95	
172,222.51	
2,398,771.04	
3,004,687.70	
6,601,936.73	
5,250.00	
514.83	
12,334,700.01	

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	21.47	708.58	404.29	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	2,100.00	392.10	350.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00

8,274.29	12,110.91	11,447.94	6,297.36	4,582.34	14,254.41	0.00	0.00	0.00	0.00	0.00	0.00

291.65	74.97	0.00	1,418.20	2,273.85	1,370.89	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	6,715.58	7,956.39	28,873.22	11,240.21	10,919.77	17,488.78	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

22,792.35	34,855.60	21,227.56	25,293.64	28,961.83	39,091.53	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	305,610.01	396,142.75	488,332.18	433,207.58	284,638.88	490,839.64	0.00	0.00	0.00	0.00	0.00	0.00

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

365,563.44	469,279.85	562,236.94	478,333.08	462,900.24	666,374.15	0.00	0.00	0.00	0.00	0.00	0.00

1,046,431.51	1,175,014.10	1,299,604.63	912,240.75	1,066,051.25	1,102,594.49	0.00	0.00	0.00	0.00	0.00	0.00

700.00	0.00	2,450.00	1,050.00	700.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00

47.11	350.00	59.40	0.00	48.25	10.07	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,757,825.94

2,095,784.57	2,416,331.87	1,869,494.39	1,862,134.99	2,333,128.25	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

700.00	
1,950,324.45	
689,232.11	
839,196.78	
3,479,453.34	

208,919.81	208,659.92	145,887.27	356,231.37	470,925.81	559,700.27	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	148,369.44	154,735.22	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	176,144.29	203,844.54	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

370,657.12

434,001.78	270,045.70	690,329.17	796,139.54	918,280.03	0.00	0.00	0.00	0.00	0.00	0.00

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

5,936.00	6,300.97	5,519.97	999.09	457.38	700.00	0.00	0.00	0.00	0.00	0.00	0.00

19,913.41	
64,055.67	
18,202.18	
9,435.50	
111,606.76	

1,513.47	2,898.87	2,896.09	4,542.74	42,584.08	9,620.42	0.00	0.00	0.00	0.00	0.00	0.00

8,655.21	1,050.00	485.19	7,330.09	-18.31	700.00	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

20,190.63

11,299.84	11,032.74	15,039.98	43,023.15	11,020.42	0.00	0.00	0.00	0.00	0.00	0.00

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

3,861.91	11,145.71	10,454.38	6,107.64	5,084.31	10,824.80	0.00	0.00	0.00	0.00	0.00	0.00

47,478.75	
21,587.93	
675.20	
69,741.88	

2,100.00	2,528.61	332.93	1,759.52	13,816.87	1,050.00	0.00	0.00	0.00	0.00	0.00	0.00

59.40	237.60	367.94	0.00	10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00

64,487,605.57	71,142,743.92	86,213,717.58	59,713,116.53	66,827,976.28	75,703,043.44	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	18,911.44	11,874.80	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

424,088,203.32

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

For The Period Ending December 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

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	12.47	0.00	0.00	0.00	0.00	0.00	0.00	12.47

1008	TANF 45-64 M & F WIT	0.00	0.00	64.35	0.00	208.35	57.88	0.00	0.00	0.00	0.00	0.00	0.00	330.58

1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	1,311.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,311.75

1011	TANF <1 M & F NON-ME	439.67	11,488.16	5,242.20	3,484.30	7,484.68	7,020.38	0.00	0.00	0.00	0.00	0.00	0.00	35,159.39

1012	TANF 01-05 M & F NON	1,999.68	0.00	6,173.64	0.00	177.03	57.31	0.00	0.00	0.00	0.00	0.00	0.00	8,407.66

1013	TANF 06-13 M & F NON	0.00	0.00	-29.23	37.11	314.79	409.90	0.00	0.00	0.00	0.00	0.00	0.00	732.57

1014	TANF 14-20 MALE NON-	1,639.96	371.56	1,298.43	1,214.10	4,020.29	977.96	0.00	0.00	0.00	0.00	0.00	0.00	9,522.30

1015	TANF 14-20 FEMALE N O

10,367.88	4,369.23	19,961.56	6,311.54	3,726.06	2,690.31	0.00	0.00	0.00	0.00	0.00	0.00	47,426.58

1016	TANF 21-44 MALE NON-	27,978.02	35,547.13	51,358.56	38,612.37	40,905.00	50,432.24	0.00	0.00	0.00	0.00	0.00	0.00	244,833.32

1017	TANF 21-44 FEMALE N O

85,071.84	122,995.47	128,349.71	151,849.80	85,693.87	133,933.74	0.00	0.00	0.00	0.00	0.00	0.00	707,894.43

1018	TANF 45-64 M & F NON	19,601.63	63,726.19	20,776.67	18,549.31	28,491.67	41,639.63	0.00	0.00	0.00	0.00	0.00	0.00	192,785.10

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

4,288.93	2,161.00	6,039.80	3,610.04	6,310.04	9,322.70	0.00	0.00	0.00	0.00	0.00	0.00	31,732.51

16,932.19	33,017.03	46,637.60	18,239.09	16,129.07	54,594.05	0.00	0.00	0.00	0.00	0.00	0.00	185,549.03

2120	SSI AGED WITH QMB	0.00	807.00	131.79	1,379.48	288.97	25.56	0.00	0.00	0.00	0.00	0.00	0.00	2,632.80

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

488.66	1,617.07	3,610.05	1,642.17	3,477.20	5,815.21	0.00	0.00	0.00	0.00	0.00	0.00	16,650.36

39,007.48	95,497.11	23,513.88	6,329.44	33,843.11	15,669.91	0.00	0.00	0.00	0.00	0.00	0.00	213,860.93

0.00	1,277.10	1,336.18	934.55	209.71	96.81	0.00	0.00	0.00	0.00	0.00	0.00	3,854.35

0.00	0.00	0.00	812.46	700.00	875.48	0.00	0.00	0.00	0.00	0.00	0.00	2,387.94

4311	SOBRA CHILD <1 M & F	117,403.64	23,297.12	59,254.42	35,673.44	67,380.83	113,499.55	0.00	0.00	0.00	0.00	0.00	0.00	416,509.00

4312	SOBRA CHILD 01-05 M	64,184.72	52,686.05	65,786.94	66,664.94	55,185.47	50,219.69	0.00	0.00	0.00	0.00	0.00	0.00	354,727.81

4313	SOBRA CHILD 06-13 M	34,405.76	34,320.87	47,228.07	40,773.76	40,430.70	52,470.13	0.00	0.00	0.00	0.00	0.00	0.00	249,629.29

4314	SOBRA CHILD 14-20 MA	34,112.02	13,654.57	40,427.51	19,191.40	55,948.06	42,767.75	0.00	0.00	0.00	0.00	0.00	0.00	206,101.31

4315	SOBRA CHILD 14-20 FE	25,544.79	41,450.78	33,073.65	31,045.68	27,206.23	30,313.34	0.00	0.00	0.00	0.00	0.00	0.00	188,634.47

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

1,316.92	-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

17,081.33	30,674.40	30,351.24	28,628.36	24,395.73	18,499.32	0.00	0.00	0.00	0.00	0.00	0.00	149,630.38

77,766.50	80,269.95	104,810.09	109,667.47	114,599.68	69,726.40	0.00	0.00	0.00	0.00	0.00	0.00	556,840.09

0.00	28.27	0.00	0.00	-28.27	1,541.56	0.00	0.00	0.00	0.00	0.00	0.00	1,541.56

8040	SLMB	6,944.53	49.41	807.03	-83.03	73.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,791.39

8050	QI1	959.34	1,438.39	130.47	132.01	0.00	31.17	0.00	0.00	0.00	0.00	0.00	0.00	2,691.38

SUBTOTAL:

587,535.49

2,271.86	
1,001.27	
11,986.75	
515.10	

650,200.47	696,955.04	585,072.80	618,483.47	702,700.45	0.00	0.00	0.00	0.00	0.00	0.00	3,840,947.72

1106	TANF EXPANDED 21-44	0.00	93.33	88.81	2,077.39	12.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	264.36	294.74	124.24	62.89	255.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	773.33	420.71	6,906.69	1,311.67	883.95	1,690.40	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	

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

For The Period Ending December 31, 2015

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

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	10,156.08

1116	TANF EXPANDED 21-44	13,694.50	13,902.95	27,807.18	11,482.37	18,513.51	10,877.18	0.00	0.00	0.00	0.00	0.00	0.00	96,277.69

1117	TANF EXPANDED 21-44	31,143.56	46,456.94	70,887.40	33,885.09	33,000.10	15,326.63	0.00	0.00	0.00	0.00	0.00	0.00	230,699.72

1118	TANF EXPANDED 45-64	29,015.56	33,956.75	60,010.71	18,273.86	33,687.02	21,583.85	0.00	0.00	0.00	0.00	0.00	0.00	196,527.75

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

2,377.90	12,618.70	12,271.07	5,527.40	15,781.06	14,405.54	0.00	0.00	0.00	0.00	0.00	0.00	62,981.67

979.32	10,480.42	0.00	3,960.00	1,445.40	-3,716.92	0.00	0.00	0.00	0.00	0.00	0.00	13,148.22

550.98	1,286.23	328.44	378.82	327.11	134.82	0.00	0.00	0.00	0.00	0.00	0.00	3,006.40

2,818.70	1,835.75	7,785.00	2,326.61	1,030.79	2,145.67	0.00	0.00	0.00	0.00	0.00	0.00	17,942.52

3,572.35	3,805.02	18,910.75	13,966.80	2,598.34	1,128.87	0.00	0.00	0.00	0.00	0.00	0.00	43,982.13

260.03	91.97	253.43	619.21	133.42	173.46	0.00	0.00	0.00	0.00	0.00	0.00	1,531.52

SUBTOTAL:

87,190.43

129,664.23	206,137.87	97,618.58	107,668.07	63,749.50	0.00	0.00	0.00	0.00	0.00	0.00	692,028.68

1,515.51	
38,133.48	
47,119.15	
245,140.06	
190,042.63	
672,971.77	
1,401.96	
661.55	
1,644.30	
2,883.82	
350.00	
60,468.86	
91,926.04	
1,318,878.02	
649,118.70	
2,102,171.89	
2,930.35	
5,427,358.09	

3508	ADULT 40-100% M&F 45	39.84	0.00	636.68	0.00	6.87	832.12	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	8,018.15	1,056.03	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	4,417.22	9,718.21	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	39,471.83	46,695.20	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

32,478.15	34,588.71	42,476.30	26,676.78	23,987.36	29,835.33	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	74,682.01	78,190.18	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	104.58	83.91	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
3708	ADULT <40% EXP M&F
4

947.85	0.00	377.50	1,293.45	265.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	-3,202.73	15,501.02	18,183.71	10,358.26	16,379.49	3,249.11	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	22,093.55	9,994.84	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	205,387.98	182,804.58	0.00	0.00	0.00	0.00	0.00	0.00

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

161,052.04	116,919.92	123,724.40	87,699.35	97,976.52	61,746.47	0.00	0.00	0.00	0.00	0.00	0.00

492,428.69	286,192.87	473,719.11	334,168.08	251,532.72	264,130.42	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	744,323.30	688,336.40	0.00	0.00	0.00	0.00	0.00	0.00

76.00	
175.69	
1,301.94	
13,009.18	
27,261.71	
363,079.28	

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
3908	NEWLY ELIGIBLE M&F
4

125.54	0.00	50.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

90.99	700.00	234.31	0.00	276.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	654.68	234.01	6,077.75	2,071.23	3,663.82	307.69	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

4,655.16	13,237.05	2,758.11	1,970.89	1,064.48	3,576.02	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	33,428.04	33,670.17	77,463.51	55,695.29	104,128.36	58,693.91	0.00	0.00	0.00	0.00	0.00	0.00

L

4

4413	SOBRA 100-133% M&F	4,059.93	12,186.74	21,110.23	15,342.31	11,795.63	23,287.90	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	5,335.47	2,393.38	14,375.66	2,342.66	3,270.98	1,893.85	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	3,166.06	6,247.80	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	18,232.67	31,429.55	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3917	NEWLY ELIGIBLE FEMA	33,130.96	36,088.32	65,921.67	74,500.38	52,468.71	45,771.22	0.00	0.00	0.00	0.00	0.00	0.00		307,881.26		
3918	NEWLY ELIGIBLE M&F	88,508.51	131,570.76	163,768.01	128,365.27	173,085.98	142,740.97	0.00	0.00	0.00	0.00	0.00	0.00		828,039.50		
	160,593.88	215,500.31	316,273.51	262,679.06	334,687.99	251,089.81	0.00	0.00	0.00	0.00	0.00	0.00		1,540,824.56		

87,782.74	
29,612.00	
33,998.76	
151,393.50	

6

L

5

8700	SSI DISABLED FREEDO	141.21	1,493.16	2,014.03	306.31	0.00	27.56	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	0.00	137.00	661.16	678.06	162.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	141.21	1,630.16	2,675.19	984.37	162.48	27.56	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

2,070.14

2,070.14

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

M M
SUBTOTAL:

3,982.27

1,638.70

5,620.97

TOTAL:	1,855,914.20	1,832,578.06	2,547,501.78	1,861,412.79	1,825,503.56	1,737,333.27	0.00	0.00	0.00	0.00	0.00	0.00		11,660,243.66		

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	

SUBTOTAL:

FAMILY PLANNING SERVICES

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

-39.37

FEDERAL EMERGENCY SERVICES

For The Period Ending December 31, 2015

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

1011	TANF <1 M & F NON-ME	0.00	455.46	3,231.96	0.00	2,515.08	1,013.45	0.00	0.00	0.00	0.00	0.00	0.00	7,215.95

1012	TANF 01-05 M & F NON	3,325.77	8,684.64	18,795.85	24,960.25	9,691.63	12,197.50	0.00	0.00	0.00	0.00	0.00	0.00	77,655.64

1013	TANF 06-13 M & F NON	54,626.02	34,912.76	80,372.41	58,900.82	34,549.85	51,854.16	0.00	0.00	0.00	0.00	0.00	0.00	315,216.02

1014	TANF 14-20 MALE NON-	65,319.99	60,239.51	137,076.35	98,293.54	77,609.81	159,897.23	0.00	0.00	0.00	0.00	0.00	0.00	598,436.43

1015	TANF 14-20 FEMALE N O

458,200.55	295,670.00	478,042.95	469,964.35	337,229.42	431,546.68	0.00	0.00	0.00	0.00	0.00	0.00	2,470,653.95

1016	TANF 21-44 MALE NON-	60,888.08	100,933.93	31,723.66	82,988.49	117,876.44	146,067.61	0.00	0.00	0.00	0.00	0.00	0.00	540,478.21

1017	TANF 21-44 FEMALE N O

2,670,623.86	2,730,005.88	3,324,170.96	2,879,155.76	2,469,546.65	3,202,404.78	0.00	0.00	0.00	0.00	0.00	0.00	17,275,907.89

1018	TANF 45-64 M & F NON	115,318.65	114,094.17	197,992.93	147,100.97	130,195.57	184,591.56	0.00	0.00	0.00	0.00	0.00	0.00	889,293.85

1019	TANF 65+ M & F NON-M	974.37	580.16	36,530.93	189.47	5,569.41	908.59	0.00	0.00	0.00	0.00	0.00	0.00	44,752.93

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

1,028.00	1,134.36	2,508.08	3,684.44	9,408.49	13,782.91	0.00	0.00	0.00	0.00	0.00	0.00	31,546.28

767,030.64	976,118.47	1,135,999.12	1,013,075.24	667,723.02	878,890.18	0.00	0.00	0.00	0.00	0.00	0.00	5,438,836.67

2120	SSI AGED WITH QMB	0.00	1,247.40	0.00	491.05	0.00	30.26	0.00	0.00	0.00	0.00	0.00	0.00	1,768.71

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

15,487.16	14,895.52	19,590.18	15,828.97	7,325.35	7,561.88	0.00	0.00	0.00	0.00	0.00	0.00	80,689.06

388,846.01	233,518.99	496,312.04	330,185.22	270,923.16	597,379.32	0.00	0.00	0.00	0.00	0.00	0.00	2,317,164.74

0.00	0.00	0.00	0.00	764.97	142.20	0.00	0.00	0.00	0.00	0.00	0.00	907.17

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

SUBTOTAL:

4,601,455.29

4,572,491.25	5,962,347.42	5,124,818.57	4,140,928.85	5,688,268.31	0.00	0.00	0.00	0.00	0.00	0.00	30,090,309.69

4,983.35	
4,097.55	
9,952.76	
107.93	
312.04	
22,640.92	
98,172.90	
2,460,705.96	
5,487,504.53	
2,213,504.49	
32,581.67	
4,898.31	
335,971.54	
3,233.50	
243,755.25	
10,922,422.70	

1106	TANF EXPANDED 21-44	942.36	1,534.47	1,505.09	822.46	57.30	121.67	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	926.52	718.33	594.32	890.41	738.79	229.18	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	2,965.50	1,071.83	1,199.19	627.92	4,088.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1109	TANF EXPANDED 65+ M&

0.00	0.00	0.00	0.00	0.00	107.93	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	0.00	0.00	312.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	1,190.91	3,724.52	4,105.86	9,094.01	4,525.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	10,061.00	21,034.78	16,389.70	20,183.82	22,986.62	7,516.98	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	354,391.46	305,914.64	598,525.42	505,905.51	304,707.27	391,261.66	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	755,978.61	983,459.10	1,040,015.43	1,183,824.04	701,830.49	822,396.86	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	334,689.08	312,771.14	498,580.17	493,587.41	273,748.47	300,128.22	0.00	0.00	0.00	0.00	0.00	0.00

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

5,837.82	4,006.70	13,397.27	6,670.37	1,703.95	965.56	0.00	0.00	0.00	0.00	0.00	0.00

3,738.85	228.58	31.65	378.59	28.32	492.32	0.00	0.00	0.00	0.00	0.00	0.00

91,019.49	40,318.46	59,658.59	49,583.24	58,225.17	37,166.59	0.00	0.00	0.00	0.00	0.00	0.00

698.31	742.38	385.05	49.30	660.78	697.68	0.00	0.00	0.00	0.00	0.00	0.00

34,997.13	35,849.69	53,494.32	45,988.82	18,108.10	55,317.19	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,597,437.04

1,711,374.62	2,288,194.10	2,317,605.90	1,391,409.20	1,616,401.84	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	11.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	631.64	303.33	2,007.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11.67

2,942.57

FEDERAL EMERGENCY SERVICES

For The Period Ending December 31, 2015

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

3517	ADULT 40-100% FEMAL E

0.00	3,220.32	764.56	0.00	470.90	2,523.03	0.00	0.00	0.00	0.00	0.00	0.00	6,978.81

3518	ADULT 40-100% M&F 45	363.70	744.09	123.30	1,408.45	277.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,917.22

3708	ADULT <40% EXP M&F
4

0.00	83.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83.87

3714	ADULT <40% EXP MALE	0.00	0.00	0.00	96.03	153.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	249.92

3715	ADULT <40% EXP FEM AL

0.00	689.22	934.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,623.28

3716	ADULT <40% EXP MALE	3,173.56	985.83	1,307.20	1,210.89	1,112.96	27.45	0.00	0.00	0.00	0.00	0.00	0.00	7,817.89

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

7,385.92	3,761.60	4,166.17	795.15	144.37	119.24	0.00	0.00	0.00	0.00	0.00	0.00	16,372.45

6,017.10	34,892.69	1,317.28	2,900.81	2,053.73	1,823.06	0.00	0.00	0.00	0.00	0.00	0.00	49,004.67

SUBTOTAL:

17,571.92

44,680.95	10,620.17	6,411.33	4,225.20	4,492.78	0.00	0.00	0.00	0.00	0.00	0.00	88,002.35

420.94	
23,226.43	
294.80	
230,089.55	
239,979.69	
3,855,428.49	
2,043,352.04	
7,352,715.80	
46,426.05	
2,928.94	
2,892.89	
13,797,755.62	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	61.58	57.52	40.91	260.93	0.00	0.00	0.00	0.00	0.00	0.00

3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

3,134.87	5,350.82	1,445.22	2,455.88	3,337.80	7,501.84	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	294.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	22,970.43	28,098.00	35,654.89	64,365.00	22,203.74	56,797.49	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

30,691.94	32,607.21	67,119.06	43,281.81	32,340.03	33,939.64	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	433,489.69	517,176.26	860,044.12	689,690.10	619,841.62	735,186.70	0.00	0.00	0.00	0.00	0.00	0.00

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

300,086.49	238,508.95	403,994.50	295,796.76	356,891.79	448,073.55	0.00	0.00	0.00	0.00	0.00	0.00

894,595.81	1,176,047.32	1,802,982.03	1,288,816.29	895,641.23	1,294,633.12	0.00	0.00	0.00	0.00	0.00	0.00

15,863.94	1,457.81	4,116.70	11,314.92	4,086.67	9,586.01	0.00	0.00	0.00	0.00	0.00	0.00

46.58	46.58	718.50	666.40	737.18	713.70	0.00	0.00	0.00	0.00	0.00	0.00

695.06	694.80	694.15	694.28	57.30	57.30	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	1,935,178.27	2,586,750.28	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	7,918,039.06	8,328,534.57	11,437,992.44	9,846,269.56	7,471,741.52	9,895,913.21	0.00	0.00	0.00	0.00	0.00	0.00		54,898,490.36		

293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

QMB - FEE FOR SERVICE

For The Period Ending December 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	274,231.57	543,181.05	0.00	0.00	0.00	0.00	0.00	0.00		2,190,612.04		
	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	0.00	0.00	0.00	0.00	0.00	0.00		2,190,612.04		

TOTAL:

2,190,612.04

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending December 31, 2015

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

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

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

15,412.32	89,978.84	21,245.35	45,417.87	26,065.20	121,503.30	0.00	0.00	0.00	0.00	0.00	0.00	319,622.88

61,148.18	60,953.07	9,698.95	112,583.05	49,546.66	80,506.33	0.00	0.00	0.00	0.00	0.00	0.00	374,436.24

2120	SSI AGED WITH QMB	1,093.55	171.15	0.00	0.00	6,269.41	192.50	0.00	0.00	0.00	0.00	0.00	0.00	7,726.61

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
5017	SOBRA PREG 21-44 FE
M

4,280.93	0.00	0.00	0.00	121.42	30,146.45	0.00	0.00	0.00	0.00	0.00	0.00	34,548.80

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

5,933.83	6,506.08	0.00	0.00	13,921.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,361.78

3,043.51	2,377.80	0.00	0.00	470.90	2,879.02	0.00	0.00	0.00	0.00	0.00	0.00	8,771.23

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	96,395.46	235,227.60	0.00	0.00	0.00	0.00	0.00	0.00	786,265.83

1116	TANF EXPANDED 21-44	0.00	0.00	4,142.44	100.05	690.06	17,222.60	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	690.06	17,222.60	0.00	0.00	0.00	0.00	0.00	0.00	

22,155.15

E
SUBTOTAL:

12,286.74

34,441.89

854.41	
120,499.61	
370.17	
191,090.23	
28,665.47	
1,184,947.82	
168,992.64	
1,881,361.39	
1,495.64	
15.96	
26,624.07	
3,604,917.41	

3516	ADULT 40-100% MALE 2	276.08	465.25	113.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	2,286.61	1,389.07	109,186.74	177.18	2,034.57	5,425.44	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	15.96	311.68	42.53	0.00	0.00	0.00	0.00	0.00	0.00

48,908.37	28,993.62	20,991.36	10,383.16	30,269.24	51,544.48	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	249.30	2,427.37	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	282,960.57	239,237.96	160,049.34	141,590.13	133,394.48	227,715.34	0.00	0.00	0.00	0.00	0.00	0.00

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

8,006.01	55,446.91	23,944.21	15,778.68	10,519.22	55,297.61	0.00	0.00	0.00	0.00	0.00	0.00

235,458.94	434,500.79	215,685.56	224,311.09	328,728.18	442,676.83	0.00	0.00	0.00	0.00	0.00	0.00

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	1,598.89	576.24	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

589,093.37

765,912.44	562,324.39	394,775.81	507,105.56	785,705.84	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	352.61	16,903.27	22,673.32	2,578.16	12,349.75	32,515.04	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	22,894.60	20,159.18	0.00	0.00	0.00	0.00	0.00	0.00	
	6,351.37	35,815.84	34,046.89	9,398.14	35,244.35	52,674.22	0.00	0.00	0.00	0.00	0.00	0.00	

87,372.15

4
SUBTOTAL:

86,158.66

173,530.81

TOTAL:	700,502.56	965,459.39	631,465.59	571,462.71	639,435.43	1,090,830.26	0.00	0.00	0.00	0.00	0.00	0.00		4,599,155.94		

COCHISE COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	586.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		586.31		
	0.00	0.00	0.00	0.00	586.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		586.31		

O

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	479.53	209.84	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	479.53	209.84	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	0.00	0.00	0.00	1,065.84	209.84	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

	689.37	
SUBTOTAL:	689.37	
TOTAL:	
1,275.68	

COCONINO COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 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	7.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,849.39		
3717	ADULT <40% EXP FEM	0.00	0.00	0.00	274.42	1,118.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,393.13		
3718	ADULT <40% EXP M&F	151.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151.74		
	151.74	3,842.02	0.00	274.42	1,126.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,394.26		

AL

4
SUBTOTAL:

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

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 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
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
5007	SOBRA PREG 21-44 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

0.00	2,041.21	946.05	3,936.64	9,915.53	3,263.60	0.00	0.00	0.00	0.00	0.00	0.00	20,103.03

0.00	10,751.39	0.00	0.00	0.00	288.16	0.00	0.00	0.00	0.00	0.00	0.00	11,039.55

18,422.83	10,195.76	34,766.80	17,317.71	168.87	5,679.57	0.00	0.00	0.00	0.00	0.00	0.00	86,551.54

15.35	3,019.90	3,735.46	357.86	-36.16	7,396.96	0.00	0.00	0.00	0.00	0.00	0.00	14,489.37

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

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

0.00	5,306.85	4,658.33	5,451.17	203.40	11,761.22	0.00	0.00	0.00	0.00	0.00	0.00	27,380.97

SUBTOTAL:

20,878.47

34,444.77	51,911.76	33,508.53	11,088.37	28,389.51	0.00	0.00	0.00	0.00	0.00	0.00	180,221.41

10,436.54	
14,172.42	
848.47	
419.49	
9,091.88	
34,968.80	

1116	TANF EXPANDED 21-44	3,673.93	0.00	0.00	0.00	465.47	6,297.14	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

2420	SSI AGED EXPANDED WI
2600	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	848.47	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	411.22	8.27	0.00	0.00	0.00	0.00	0.00	0.00

2,757.38	5,096.64	0.00	70.22	894.75	272.89	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

20,603.73

5,096.64	0.00	70.22	1,771.44	7,426.77	0.00	0.00	0.00	0.00	0.00	0.00

6,833.38	
21,678.22	
83.10	
16,565.81	
360,334.41	
51,593.98	
198,751.48	
655,840.38	

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	4,879.17	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP FEM AL

0.00	0.00	0.00	83.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	0.00	0.00	1,298.03	229.50	228.46	14,809.82	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	69,878.66	66,286.32	10,893.65	95,669.19	16,280.98	101,325.61	0.00	0.00	0.00	0.00	0.00	0.00

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

5,251.56	3,256.51	2,374.79	13,269.40	9,235.19	18,206.53	0.00	0.00	0.00	0.00	0.00	0.00

49,207.81	47,104.83	15,084.95	62,449.62	5,959.28	18,944.99	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

124,338.03

133,446.71	33,662.00	174,523.61	31,703.91	158,166.12	0.00	0.00	0.00	0.00	0.00	0.00

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	
	15,153.54	0.00	0.00	149.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

149.02

4
SUBTOTAL:

15,153.54

15,302.56

M

180,973.77	172,988.12	86,077.47	208,251.38	44,563.72	194,013.46	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

534.77

534.77

8720	SSI DISABLED FREEDO	0.00	0.00	503.71	0.00	0.00	31.06	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	503.71	0.00	0.00	31.06	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

886,867.92

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 2015

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

1015	TANF 14-20 FEMALE N O

0.00	0.00	0.00	0.00	0.00	2,192.24	0.00	0.00	0.00	0.00	0.00	0.00	2,192.24

1016	TANF 21-44 MALE NON-	0.00	0.00	52.80	0.00	7.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60.78

2210	SSI DISABLED NON-ME D
5017	SOBRA PREG 21-44 FE
M

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

11.66	2,253.21	4,046.52	8,752.09	858.70	1,769.51	0.00	0.00	0.00	0.00	0.00	0.00	17,691.69

SUBTOTAL:

338.81

2,844.58	4,099.32	8,752.09	866.68	3,961.75	0.00	0.00	0.00	0.00	0.00	0.00	20,863.23

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	
	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

SUBTOTAL:

639.38

17.50	
177.73	
26,723.68	
5,291.69	
37,987.41	
70,198.01	

3516	ADULT 40-100% MALE 2	0.00	0.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

0.00	0.00	0.00	79.49	98.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	13,355.83	4,487.44	0.00	6,733.15	1,783.51	363.75	0.00	0.00	0.00	0.00	0.00	0.00

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

55.30	0.00	0.00	0.00	0.00	5,236.39	0.00	0.00	0.00	0.00	0.00	0.00

2,778.01	10,131.21	950.60	14,425.99	9,754.38	-52.78	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

16,189.14

14,618.65	968.10	21,238.63	11,636.13	5,547.36	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	17,076.20	17,463.23	5,067.42	30,081.85	12,502.81	9,509.11	0.00	0.00	0.00	0.00	0.00	0.00		91,700.62		

E

D
SUBTOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 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	4,241.75	0.00	467.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,708.75		
2200	SSI DISABLED WITH M	0.00	630.38	160.15	327.76	4,219.41	5,242.80	0.00	0.00	0.00	0.00	0.00	0.00		10,580.50		
2210	SSI DISABLED NON-ME	0.00	160.89	0.00	0.00	327.76	67.24	0.00	0.00	0.00	0.00	0.00	0.00		555.89		
	0.00	791.27	4,401.90	327.76	5,014.17	5,310.04	0.00	0.00	0.00	0.00	0.00	0.00		15,845.14		

0.00	0.00	0.00	0.00	0.00	7,877.62	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	7,877.62	0.00	0.00	0.00	0.00	0.00	0.00	

1117	TANF EXPANDED 21-44

7,877.62

SUBTOTAL:

7,877.62

5,479.74	
144.34	
35,131.97	
40,756.05	

AL

4

8,166.82	-863.22	16,137.69	3,859.66	19,789.82	17,388.04	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3716	ADULT <40% EXP MALE	7.98	1,430.76	0.00	0.00	250.57	3,790.43	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	8,014.50	-3,085.25	11,735.79	3,531.90	14,525.08	409.95	0.00	0.00	0.00	0.00	0.00	0.00	
	8,166.82	-1,654.49	11,735.79	3,531.90	14,775.65	4,200.38	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

64,478.81

D

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	9,251.66	323.89	160.89	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	160.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
	306.05	0.00	166.26	9,251.66	484.78	160.89	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	8,608.34	0.00	0.00	0.00	0.00	0.00	0.00		8,608.34		
	0.00	0.00	0.00	0.00	0.00	8,608.34	0.00	0.00	0.00	0.00	0.00	0.00		8,608.34		

9,736.44	
160.89	
472.31	
10,369.64	

E

SUBTOTAL:

TOTAL:	306.05	0.00	166.26	9,251.66	484.78	8,769.23	0.00	0.00	0.00	0.00	0.00	0.00		18,977.98		

D
SUBTOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME	0.00	177.03	0.00	4,575.16	0.00	9,164.20	0.00	0.00	0.00	0.00	0.00	0.00		13,916.39		
	0.00	177.03	0.00	4,575.16	0.00	9,164.20	0.00	0.00	0.00	0.00	0.00	0.00		13,916.39		

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	12,006.76	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	556.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	556.20	12,006.76	0.00	0.00	0.00	0.00	0.00	0.00	

12,006.76

556.20
E

3716	ADULT <40% EXP MALE	0.00	673.35	580.79	372.54	6,342.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	0.00	3,152.09	110.80	0.00	0.00	3,362.36	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	0.00	258.61	0.00	0.00	3,152.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	4,084.05	691.59	372.54	9,494.35	3,362.36	0.00	0.00	0.00	0.00	0.00	0.00	

12,562.96

7,968.94	
6,625.25	
3,410.70	
18,004.89	

AL

4

0.00	4,261.08	691.59	4,947.70	10,050.55	24,533.32	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

TOTAL:

44,484.24

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD

For The Period Ending December 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
2110	SSI AGED NON-MEDICA
R

1,867,476.11	2,106,357.37	3,001,652.11	2,153,315.25	2,357,150.67	2,661,401.68	0.00	0.00	0.00	0.00	0.00	0.00	14,147,353.19

177,147.26	101,345.13	299,519.40	157,341.85	107,732.68	129,146.89	0.00	0.00	0.00	0.00	0.00	0.00	972,233.21

2120	SSI AGED WITH QMB	2,867,399.51	2,877,254.51	4,110,836.71	2,939,351.28	3,113,372.32	3,642,449.33	0.00	0.00	0.00	0.00	0.00	0.00	19,550,663.66

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

543,524.04	474,214.50	724,208.95	536,644.76	552,216.34	695,544.60	0.00	0.00	0.00	0.00	0.00	0.00	3,526,353.19

2,493,153.38	2,750,175.45	3,099,509.74	2,474,403.45	2,586,712.46	3,134,206.32	0.00	0.00	0.00	0.00	0.00	0.00	16,538,160.80

639,532.10	693,460.39	974,750.74	671,858.25	672,467.60	904,432.53	0.00	0.00	0.00	0.00	0.00	0.00	4,556,501.61

2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	59.40	0.00	32.09	0.00	0.00	0.00	0.00	0.00	0.00	225.82

2310	SSI BLIND NON-MEDIC A

22,797.15	14,440.58	16,725.82	12,338.81	12,877.52	11,687.97	0.00	0.00	0.00	0.00	0.00	0.00	90,867.85

2320	SSI BLIND WITH QMB	5,463.78	7,778.92	7,725.25	5,362.02	6,671.36	7,306.13	0.00	0.00	0.00	0.00	0.00	0.00	40,307.46

8710	SSI DISABLED FREEDO	0.00	1,877.34	5,044.41	2,637.12	99.53	2,709.12	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	2,056.32	4,112.64	0.00	0.00	0.00	0.00	0.00	0.00	
	1,712.52	4,868.22	9,193.05	4,689.12	2,155.85	6,821.76	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

8,616,568.26

9,025,376.85    12,234,988.12	8,951,025.07	9,409,200.95     11,186,207.54	0.00	0.00	0.00	0.00	0.00	0.00	59,423,366.79

M M
SUBTOTAL:

12,367.52

17,073.00

29,440.52

TOTAL:	8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	11,193,029.30	0.00	0.00	0.00	0.00	0.00	0.00		59,452,807.31		

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

For The Period Ending December 31, 2015

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

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

4,497.83	12,645.58	24,804.14	14,473.36	13,002.49	20,599.26	0.00	0.00	0.00	0.00	0.00	0.00	90,022.66

0.00	0.00	0.00	399.80	0.00	435.84	0.00	0.00	0.00	0.00	0.00	0.00	835.64

2120	SSI AGED WITH QMB	0.00	83.04	41.43	0.00	81.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206.05

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

572.87	1,912.10	6,455.92	314.42	3,785.37	2,357.90	0.00	0.00	0.00	0.00	0.00	0.00	15,398.58

10,415.23	19,351.87	894.64	5,932.66	1,560.41	-737.82	0.00	0.00	0.00	0.00	0.00	0.00	37,416.99

32,196.13	21,120.24	18,429.85	22,655.18	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

15,485.93

33,992.59	32,196.13	21,120.24	18,429.85	22,655.18	0.00	0.00	0.00	0.00	0.00	0.00	143,879.92

TOTAL:

15,485.93

33,992.59

143,879.92

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending December 31, 2015

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

1012	TANF 01-05 M & F NON	44,618.60	15,435.03	41,858.69	18,932.81	15,467.04	20,642.88	0.00	0.00	0.00	0.00	0.00	0.00	156,955.05

1013	TANF 06-13 M & F NON	101,743.02	26,444.15	55,447.66	40,252.23	32,584.91	57,732.47	0.00	0.00	0.00	0.00	0.00	0.00	314,204.44

1014	TANF 14-20 MALE NON-	8,473.78	2,483.13	8,146.57	6,639.55	4,375.95	7,509.81	0.00	0.00	0.00	0.00	0.00	0.00	37,628.79

1015	TANF 14-20 FEMALE N O

3,292.00	1,194.76	3,063.63	2,548.02	1,886.25	4,133.96	0.00	0.00	0.00	0.00	0.00	0.00	16,118.62

2120	SSI AGED WITH QMB	0.00	0.00	69.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69.53

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

33.88	103.18	181.14	0.00	0.00	1,721.70	0.00	0.00	0.00	0.00	0.00	0.00	2,039.90

252,041.30	84,309.59	219,296.65	140,342.61	148,906.14	260,843.16	0.00	0.00	0.00	0.00	0.00	0.00	1,105,739.45

0.00	0.00	0.00	23.96	10.53	188.39	0.00	0.00	0.00	0.00	0.00	0.00	222.88

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 A

2,989.18	538.14	1,847.47	1,001.22	903.64	1,360.84	0.00	0.00	0.00	0.00	0.00	0.00	8,640.49

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	28.30	14.24	0.00	0.00	0.00	0.00	0.00	0.00	74.74

4312	SOBRA CHILD 01-05 M	74,849.31	21,849.59	69,541.43	41,184.72	40,971.89	82,869.18	0.00	0.00	0.00	0.00	0.00	0.00	331,266.12

4313	SOBRA CHILD 06-13 M	138,639.38	30,827.76	103,590.12	109,202.16	99,584.08	228,223.73	0.00	0.00	0.00	0.00	0.00	0.00	710,067.23

4314	SOBRA CHILD 14-20 MA	12,134.57	3,360.74	12,303.21	9,010.79	9,606.28	18,550.26	0.00	0.00	0.00	0.00	0.00	0.00	64,965.85

4315	SOBRA CHILD 14-20 FE	3,881.60	1,365.86	4,314.96	4,418.98	4,272.97	8,147.04	0.00	0.00	0.00	0.00	0.00	0.00	26,401.41

5015	SOBRA PREG 14-20 FE M

0.00	0.00	0.00	0.00	0.00	98.89	0.00	0.00	0.00	0.00	0.00	0.00	98.89

SUBTOTAL:

642,887.52

188,308.71	519,661.06	373,572.92	358,597.98	692,036.55	0.00	0.00	0.00	0.00	0.00	0.00	2,775,064.74

1,285.12	
12,473.25	
428.75	
292.07	
210.61	
14,689.80	

E
SUBTOTAL:

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	84.66	8.13	232.43	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	2,228.51	2,807.73	3,254.21	1,018.60	620.72	2,543.48	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	31.33	0.00	213.25	29.47	14.60	140.10	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	135.37	38.36	7.30	96.39	7.30	7.35	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	650.75	2,923.36	0.00	0.00	0.00	0.00	0.00	0.00	

18.98	
123.64	
12.33	
34.11	
3,555.62	
1,562.31	
856.23	
6,163.22	

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	18.98	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

0.00	0.00	0.00	0.00	95.69	27.95	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	0.00	12.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP FEM AL

6.83	27.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	1,726.70	9.31	990.53	137.29	119.45	572.34	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

1,319.96	0.00	149.20	14.00	31.07	48.08	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	856.23	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

3,053.49

48.92	1,139.73	151.29	246.21	1,523.58	0.00	0.00	0.00	0.00	0.00	0.00

4413	SOBRA 100-133% M&F	25,022.12	4,486.95	12,154.90	21,398.13	23,398.03	58,170.12	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	8,073.76	649.78	1,470.80	1,731.37	1,992.93	4,038.41	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	676.00	2,517.58	0.00	0.00	0.00	0.00	0.00	0.00	

144,630.25
6
17,957.05

5,558.42
L

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	33,611.25	5,777.00	13,916.56	24,047.84	26,066.96	64,726.11	0.00	0.00	0.00	0.00	0.00	0.00		168,145.72		

SUBTOTAL:

TOTAL:	682,284.75	197,289.50	538,716.56	399,001.17	385,561.90	761,209.60	0.00	0.00	0.00	0.00	0.00	0.00		2,964,063.48		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	831.19	0.00	115.74	154.36	496.51	387.64	0.00	0.00	0.00	0.00	0.00	0.00	1,985.44

1010	TANF NON-MEDICARE	40,868.65	24,234.06	48,725.89	26,485.58	29,892.42	44,214.96	0.00	0.00	0.00	0.00	0.00	0.00	214,421.56

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

2,871.13	789.16	3,394.59	1,281.47	667.85	3,130.34	0.00	0.00	0.00	0.00	0.00	0.00	12,134.54

1,249,307.80	489,106.70	1,265,880.28	765,381.38	758,689.31	1,369,048.70	0.00	0.00	0.00	0.00	0.00	0.00	5,897,414.17

2,114.42	-248.86	3,650.67	2,135.30	1,672.29	3,246.71	0.00	0.00	0.00	0.00	0.00	0.00	12,570.53

7,193.15	6,514.48	11,947.59	4,341.28	8,117.72	10,057.63	0.00	0.00	0.00	0.00	0.00	0.00	48,171.85

1,303,186.34	520,395.54	1,333,714.76	799,779.37	799,536.10	1,430,085.98	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1,303,186.34

520,395.54	1,333,714.76	799,779.37	799,536.10	1,430,085.98	0.00	0.00	0.00	0.00	0.00	0.00	6,186,698.09

TOTAL:

6,186,698.09

ACUTE REINSURANCE

For The Period Ending December 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	-9,013.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,520.38

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	17,401.25	0.00	0.00	0.00	0.00	0.00	0.00	17,401.25

1011	TANF <1 M & F NON-ME	741,618.20	275,323.86	870,817.73	584,132.79	463,642.57	201,270.80	0.00	0.00	0.00	0.00	0.00	0.00	3,136,805.95

1012	TANF 01-05 M & F NON	59,967.01	17,049.65	46,379.51	20,619.83	151,913.04	119,032.86	0.00	0.00	0.00	0.00	0.00	0.00	414,961.90

1013	TANF 06-13 M & F NON	184,625.99	341,772.36	71,256.85	294,266.28	103,622.05	208,524.29	0.00	0.00	0.00	0.00	0.00	0.00	1,204,067.82

1014	TANF 14-20 MALE NON-	12,269.60	19,354.41	57,649.19	33,553.81	369.86	44,304.16	0.00	0.00	0.00	0.00	0.00	0.00	167,501.03

1015	TANF 14-20 FEMALE N O

18,361.96	12,714.48	18,838.21	15,383.78	25,213.02	121,039.33	0.00	0.00	0.00	0.00	0.00	0.00	211,550.78

1016	TANF 21-44 MALE NON-	161,649.37	-21,881.23	40,292.26	305,406.83	277,743.49	140,429.72	0.00	0.00	0.00	0.00	0.00	0.00	903,640.44

1017	TANF 21-44 FEMALE N O

127,936.47	159,048.89	395,075.50	504,125.42	255,419.19	305,860.33	0.00	0.00	0.00	0.00	0.00	0.00	1,747,465.80

1018	TANF 45-64 M & F NON	84,129.25	65,348.37	87,293.71	207,392.12	65,634.10	157,000.19	0.00	0.00	0.00	0.00	0.00	0.00	666,797.74

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	6,170.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,170.15

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

624.78	33,070.16	362.69	24,212.27	12,180.72	34,105.65	0.00	0.00	0.00	0.00	0.00	0.00	104,556.27

67,861.38	195,769.67	82,798.86	187,110.03	156,837.43	149,288.35	0.00	0.00	0.00	0.00	0.00	0.00	839,665.72

43,874.36	10,496.70	3,907.51	14,759.66	36,550.05	14,130.33	0.00	0.00	0.00	0.00	0.00	0.00	123,718.61

4,045,297.65	3,940,603.94	4,946,163.58	5,434,310.93	4,089,111.34	5,950,914.30	0.00	0.00	0.00	0.00	0.00	0.00	28,406,401.74

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	79,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,766.51

2310	SSI BLIND NON-MEDIC A

40,412.86	2,873.76	1,068.77	-75,896.96	5,691.49	32,166.80	0.00	0.00	0.00	0.00	0.00	0.00	6,316.72

4311	SOBRA CHILD <1 M & F	929,626.36	754,864.21	1,574,042.96	1,471,872.89	543,338.74	662,693.47	0.00	0.00	0.00	0.00	0.00	0.00	5,936,438.63

4312	SOBRA CHILD 01-05 M	114,463.42	359,348.65	667,111.14	108,235.95	362,899.14	277,105.60	0.00	0.00	0.00	0.00	0.00	0.00	1,889,163.90

4313	SOBRA CHILD 06-13 M	239,870.36	136,192.59	249,120.95	-32,500.15	196,513.15	581,907.40	0.00	0.00	0.00	0.00	0.00	0.00	1,371,104.30

4314	SOBRA CHILD 14-20 MA	115,773.80	89,801.77	118,016.08	142,705.87	117,629.45	-526,014.65	0.00	0.00	0.00	0.00	0.00	0.00	57,912.32

4315	SOBRA CHILD 14-20 FE	14,027.07	63,132.41	6,858.73	138,256.42	16,264.65	34,636.41	0.00	0.00	0.00	0.00	0.00	0.00	273,175.69

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

0.00	9,507.28	408.56	4,728.20	1,067.70	335.40	0.00	0.00	0.00	0.00	0.00	0.00	16,047.14

8,128.10	28,115.83	25,201.81	42,704.14	18,481.98	1,987.47	0.00	0.00	0.00	0.00	0.00	0.00	124,619.33

SUBTOTAL:

7,010,616.95

6,492,507.76	9,262,664.61	9,522,581.44	6,897,279.90	8,528,119.46	0.00	0.00	0.00	0.00	0.00	0.00	47,713,770.12

1,777.41	
-8.67	
6,930.78	
471,189.71	
471,900.58	
901,934.41	
2,446.74	
104.80	
155,201.95	
211,341.53	

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	329.59	0.01	264.91	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	-8.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	505.48	6,432.42	-7.13	0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	33,363.51	116,852.15	141,491.01	71,614.65	61,788.94	46,079.45	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	89,055.47	57,583.74	113,446.53	118,004.81	32,641.10	61,168.93	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	124,365.77	99,058.09	67,841.45	378,310.42	118,897.22	113,461.46	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	2,446.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00

-18.11	42.85	43.82	25.93	10.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00

14,090.33	42,829.44	49,706.82	46,616.48	7,100.00	-5,141.12	0.00	0.00	0.00	0.00	0.00	0.00

35,356.98	19,953.70	40,311.53	39,071.56	75,248.39	1,399.37	0.00	0.00	0.00	0.00	0.00	0.00

E

3316	AHC CARE MALE 21-44	22.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	742.92	2,889.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	765.22	2,889.03	0.00	0.00	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2610	SSI DISABLED EXPAND	20,284.70	72,266.71	62,393.79	63,319.22	126,966.46	50,917.39	0.00	0.00	0.00	0.00	0.00	0.00		396,148.27		
	316,711.60	410,028.71	481,700.77	717,276.86	425,099.18	268,150.39	0.00	0.00	0.00	0.00	0.00	0.00		2,618,967.51		

22.30	
1,477.43	
3,631.95	
5,131.68	

4

SUBTOTAL:

-5,724.35	
13,341.66	
1,239.38	
21,385.18	
30,241.87	

2

SUBTOTAL:

3410	MED ELIGIBILITY NON-	0.00	0.00	-5,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	9,760.41	0.00	0.00	3,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	1,239.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	28,195.73	-1,579.93	-5,079.21	0.00	-1,327.80	1,176.39	0.00	0.00	0.00	0.00	0.00	0.00	
	37,956.14	-1,579.93	-10,803.56	3,581.25	-88.42	1,176.39	0.00	0.00	0.00	0.00	0.00	0.00	

-1,238.16	
101,288.09	
116,899.49	
870,227.41	
648,888.29	
2,210,613.61	
2,767.51	
80,687.78	
887,325.52	
334,050.09	
4,401,548.20	
1,761,250.75	
8,547,067.80	
2,035.97	
19,963,412.35	

3508	ADULT 40-100% M&F 45	-1,247.11	6.67	2.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	0.00	90,377.57	23.98	303.56	10,582.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

9,715.08	0.00	14,961.01	39,148.26	53,075.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	42,038.64	132,978.87	147,952.07	213,702.36	158,020.09	175,535.38	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

69,797.48	154,862.63	143,383.48	95,096.25	34,812.53	150,935.92	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	414,839.94	278,819.33	311,265.46	367,780.84	470,498.88	367,409.16	0.00	0.00	0.00	0.00	0.00	0.00

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

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

37,973.29	1,282.59	21,727.75	-1,549.73	0.00	21,253.88	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	150,958.00	173,540.11	140,658.64	168,686.95	205,746.27	47,735.55	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

103,135.79	82,987.17	49,364.34	70,131.79	15,205.08	13,225.92	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	502,179.54	650,833.61	591,737.89	1,117,820.73	788,610.97	750,365.46	0.00	0.00	0.00	0.00	0.00	0.00

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

256,435.90	98,701.30	250,260.17	399,461.42	410,941.85	345,450.11	0.00	0.00	0.00	0.00	0.00	0.00

1,083,021.23	1,159,557.65	1,128,258.45	2,023,672.20	1,885,371.09	1,267,187.18	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	1,152.60	0.00	883.37	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

2,668,847.78

2,823,947.50	2,802,363.03	4,495,407.23	4,032,864.88	3,139,981.93	0.00	0.00	0.00	0.00	0.00	0.00

3908	NEWLY ELIGIBLE M&F
4

75,258.45	0.00	21,217.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	4,356.93	0.00	0.00	19,045.28	10,843.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

0.00	0.00	0.00	0.00	0.00	1,064.69	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	34,179.36	117,409.93	42,037.03	103,240.00	152,204.38	53,659.73	0.00	0.00	0.00	0.00	0.00	0.00

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

-833.32	13,544.41	28,948.15	38,254.97	33,953.18	7,099.39	0.00	0.00	0.00	0.00	0.00	0.00

163,410.54	348,055.35	252,590.82	236,488.95	162,860.24	163,485.29	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

276,371.96

479,009.69	344,793.74	397,029.20	359,861.18	225,309.10	0.00	0.00	0.00	0.00	0.00	0.00

96,476.19	
34,245.59	
1,064.69	
502,730.43	
120,966.78	
1,326,891.19	
2,082,374.87	

4413	SOBRA 100-133% M&F	19,844.57	10,180.96	21,606.21	141,092.28	121,073.24	36,860.81	0.00	0.00	0.00	0.00	0.00	0.00	

350,658.07
6

L

4517	BC PATIENT FEMALE 2	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	
	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	

SUBTOTAL:

1

5

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

SUBTOTAL:

6,209.80

ACUTE REINSURANCE

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4414	SOBRA 100-133% MALE	451,101.89	451,107.67	426,127.94	679,863.69	468,911.44	1,180,962.21	0.00	0.00	0.00	0.00	0.00	0.00		3,658,074.84		
4415	SOBRA 100-133% FEMA	188.17	9,280.96	106.64	4,451.52	-2,057.67	32.82	0.00	0.00	0.00	0.00	0.00	0.00		12,002.44		
	471,134.63	470,569.59	447,840.79	825,407.49	587,927.01	1,217,855.84	0.00	0.00	0.00	0.00	0.00	0.00		4,020,735.35		

855.98

7,065.78

M
SUBTOTAL:

15,572.63

15,572.63

TOTAL:	10,791,209.52	10,677,372.35	13,331,154.82	15,967,330.33	12,307,016.59	13,383,188.55	0.00	0.00	0.00	0.00	0.00	0.00		76,457,272.16		

LONG TERM CARE REINSURANCE

For The Period Ending December 31, 2015

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

1010	TANF NON-MEDICARE	0.00	43.57	0.00	34,024.05	4,013.54	40.56	0.00	0.00	0.00	0.00	0.00	0.00	38,121.72

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

327,108.06	281,473.61	410,214.64	182,410.50	337,086.99	210,136.17	0.00	0.00	0.00	0.00	0.00	0.00	1,748,429.97

218,322.47	133,627.59	139,813.52	145,656.58	216,314.34	137,105.95	0.00	0.00	0.00	0.00	0.00	0.00	990,840.45

644,979.13	626,909.22	541,936.81	444,452.89	492,010.90	679,427.76	0.00	0.00	0.00	0.00	0.00	0.00	3,429,716.71

2,840,717.50	2,796,391.98	3,888,127.51	3,540,048.52	4,792,282.42	2,737,929.54	0.00	0.00	0.00	0.00	0.00	0.00	20,595,497.47

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	61.17	91.91	0.00	0.00	0.00	0.00	0.00	0.00	153.08

2310	SSI BLIND NON-MEDIC A

2,067.18	829.15	61,461.10	4,145.13	12,606.98	4,663.25	0.00	0.00	0.00	0.00	0.00	0.00	85,772.79

SUBTOTAL:

4,033,194.34

3,839,275.12	5,041,553.58	4,350,737.67	5,854,376.34	3,769,395.14	0.00	0.00	0.00	0.00	0.00	0.00	26,888,532.19

M

4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	5,856,334.10	3,769,395.14	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

14,877.06

14,877.06

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

TOTAL:

26,903,409.25

ACUTE SMIB

For The Period Ending December 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	71,122.20	73,325.10	0.00	0.00	0.00	0.00	0.00	0.00	1,171,205.00

1010	TANF NON-MEDICARE	419.60	314.70	419.60	419.60	839.20	524.50	0.00	0.00	0.00	0.00	0.00	0.00	2,937.20

1020	TANF WITH QMB	59,218.50	89,224.80	136,060.20	153,998.10	21,979.00	27,224.00	0.00	0.00	0.00	0.00	0.00	0.00	487,704.60

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

55,177.40	57,030.30	58,179.30	62,320.40	92,112.00	76,322.10	0.00	0.00	0.00	0.00	0.00	0.00	401,141.50

390,962.30	405,066.70	409,640.00	406,988.40	406,802.20	436,932.40	0.00	0.00	0.00	0.00	0.00	0.00	2,456,392.00

2120	SSI AGED WITH QMB	1,817,089.90	1,837,723.90	1,860,966.00	1,885,790.10	2,434,377.40	2,464,358.80	0.00	0.00	0.00	0.00	0.00	0.00	12,300,306.10

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

156,570.80	143,157.80	137,314.10	138,468.00	135,216.10	127,558.40	0.00	0.00	0.00	0.00	0.00	0.00	838,285.20

332,008.50	338,302.50	334,945.70	338,302.50	337,253.50	333,791.80	0.00	0.00	0.00	0.00	0.00	0.00	2,014,604.50

2,831,922.00	2,873,883.50	2,914,800.20	2,923,716.10	2,934,708.00	2,924,607.70	0.00	0.00	0.00	0.00	0.00	0.00	17,403,637.50

2300	SSI BLIND WITH MEDIC	419.60	419.60	314.70	314.70	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00	2,098.00

2310	SSI BLIND NON-MEDIC A

3,251.90	3,356.80	3,042.10	2,937.20	2,937.20	2,832.30	0.00	0.00	0.00	0.00	0.00	0.00	18,357.50

2320	SSI BLIND WITH QMB	25,071.10	24,336.80	25,910.30	25,805.40	26,015.20	25,176.00	0.00	0.00	0.00	0.00	0.00	0.00	152,314.80

4300	SOBRA CHILD WITH ME D
4320	SOBRA CHILD WITH Q
MB
5000	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	629.40

104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524.50

1,363.70	1,363.70	1,153.90	944.10	629.40	419.60	0.00	0.00	0.00	0.00	0.00	0.00	5,874.40

944.10	839.20	1,153.90	944.10	1,363.70	1,049.00	0.00	0.00	0.00	0.00	0.00	0.00	6,294.00

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	568,562.80	566,367.00	0.00	0.00	0.00	0.00	0.00	0.00	3,346,270.40

8040	SLMB	3,389,057.50	3,504,045.60	3,489,229.70	3,653,533.40	3,562,064.70	3,558,489.40	0.00	0.00	0.00	0.00	0.00	0.00	21,156,420.30

8888	SMIB ONLY NOT ELIGIB	-52,359.80	-26,959.30	-20,035.90	-24,127.00	-7,238.10	-13,002.70	0.00	0.00	0.00	0.00	0.00	0.00	-143,722.80

9999	SMIB ONLY NOT ELIGIB	59,066.30	19,847.50	122,106.60	172,423.40	145,913.80	190,130.30	0.00	0.00	0.00	0.00	0.00	0.00	709,487.90

SUBTOTAL:

9,808,185.80

10,062,146.60    10,322,154.00    10,606,357.70    10,735,182.80     10,796,525.30	0.00	0.00	0.00	0.00	0.00	0.00	62,330,552.20

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

470,376.20	412,891.00	362,329.20	338,157.10	689,298.50	630,171.70	0.00	0.00	0.00	0.00	0.00	0.00

2,903,223.70	
734.30	
799,912.50	
6,708.70	
2,622.50	
16,180,183.10	
629.40	
524.50	
10,646,791.10	
30,541,329.80	

209.80	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00

128,342.70	125,775.10	114,341.00	103,116.70	130,285.80	198,051.20	0.00	0.00	0.00	0.00	0.00	0.00

3,042.10	1,468.60	1,253.90	419.60	209.80	314.70	0.00	0.00	0.00	0.00	0.00	0.00

524.50	524.50	524.50	419.60	314.70	314.70	0.00	0.00	0.00	0.00	0.00	0.00

2,928,537.00	2,921,828.60	2,878,145.10	2,887,841.00	2,295,255.90	2,268,575.50	0.00	0.00	0.00	0.00	0.00	0.00

104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00

-419.60	209.80	314.70	-104.90	314.70	209.80	0.00	0.00	0.00	0.00	0.00	0.00

1,653,183.80	1,727,813.10	1,756,040.70	1,816,932.70	1,829,709.50	1,863,111.30	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

5,183,901.40

5,190,720.50	5,113,158.90	5,146,991.60	4,945,598.70	4,960,958.70	0.00	0.00	0.00	0.00	0.00	0.00

3520	ADULT 40-100% FOR FI	3,147.00	-1,743.30	3,147.00	3,356.80	4,930.30	4,510.70	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	3,566.60	2,622.50	0.00	0.00	0.00	0.00	0.00	0.00	
	6,923.40	-274.70	4,300.90	5,140.10	8,496.90	7,133.20	0.00	0.00	0.00	0.00	0.00	0.00	

17,348.50

FO
SUBTOTAL:

14,371.30

31,719.80

F

8720	SSI DISABLED FREEDO	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	23,602.50	0.00	0.00	0.00	0.00	0.00	0.00	
	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	23,602.50	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

M
SUBTOTAL:

136,789.60

ACUTE SMIB

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR	1,468.60	734.30	839.20	629.40	839.20	944.10	0.00	0.00	0.00	0.00	0.00	0.00		5,454.80		
	1,468.60	734.30	839.20	629.40	839.20	944.10	0.00	0.00	0.00	0.00	0.00	0.00		5,454.80		

136,789.60

TOTAL:	15,021,878.80	15,275,565.50	15,462,796.70	15,783,140.90	15,713,300.50	15,789,163.80	0.00	0.00	0.00	0.00	0.00	0.00		93,045,846.20		

ACUTE HIB

For The Period Ending December 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
2110	SSI AGED NON-MEDICA
R

2,442.00	-814.00	0.00	-557.50	0.00	1,628.00	0.00	0.00	0.00	0.00	0.00	0.00	2,698.50

0.00	0.00	0.00	0.00	1,221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,221.00

2120	SSI AGED WITH QMB	173,720.20	179,916.50	193,518.70	197,193.80	189,836.80	195,941.80	0.00	0.00	0.00	0.00	0.00	0.00	1,130,127.80

2220	SSI DISABLED WITH Q M

88,616.20	96,125.80	110,636.10	112,246.10	100,161.10	107,121.10	0.00	0.00	0.00	0.00	0.00	0.00	614,906.40

2320	SSI BLIND WITH QMB	407.00	407.00	407.00	407.00	407.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	2,442.00

8000	SMIB ONLY NOT ELIGIB	0.00	0.00	0.00	-887.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-887.30

8020	QMB ONLY	4,988.10	2,953.10	3,645.00	5,761.40	4,133.40	3,726.40	0.00	0.00	0.00	0.00	0.00	0.00	25,207.40

9999	SMIB ONLY NOT ELIGIB	-8,404.70	-4,538.50	-4,375.40	-7,780.00	-3,887.00	-6,817.40	0.00	0.00	0.00	0.00	0.00	0.00	-35,803.00

SUBTOTAL:

261,768.80

274,049.90	304,238.40	305,976.50	291,872.30	302,006.90	0.00	0.00	0.00	0.00	0.00	0.00	1,739,912.80

WI

270,418.00	282,577.00	309,894.80	314,560.60	296,064.70	306,199.30	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

39,801.60

39,801.60

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

TOTAL:

1,779,714.40

Q1

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,434,626.70	1,985,923.60	1,946,933.20	1,994,198.00	1,976,010.10	1,905,772.20	0.00	0.00	0.00	0.00	0.00	0.00		12,243,463.80		
9999	SMIB ONLY NOT ELIGIB	-35,141.50	-2,907.10	-18,986.90	-13,112.50	-1,988.20	-369.60	0.00	0.00	0.00	0.00	0.00	0.00		-72,505.80		
	2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	1,905,402.60	0.00	0.00	0.00	0.00	0.00	0.00		12,170,958.00		

SUBTOTAL:

TOTAL:	2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	1,905,402.60	0.00	0.00	0.00	0.00	0.00	0.00		12,170,958.00		

LTC SMIB

For The Period Ending December 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	419.60	1,573.50	0.00	0.00	0.00	0.00	0.00	0.00	3,776.40

1020	TANF WITH QMB	104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	629.40

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

874,183.40	870,946.20	868,154.40	873,399.40	856,670.30	875,757.20	0.00	0.00	0.00	0.00	0.00	0.00	5,219,110.90

155,566.70	157,769.60	157,769.60	157,664.70	161,336.20	159,657.80	0.00	0.00	0.00	0.00	0.00	0.00	949,764.60

2120	SSI AGED WITH QMB	764,559.10	761,981.70	777,780.80	770,483.50	771,637.40	774,259.90	0.00	0.00	0.00	0.00	0.00	0.00	4,620,702.40

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

319,840.10	329,595.80	321,623.40	322,567.50	334,134.80	337,673.10	0.00	0.00	0.00	0.00	0.00	0.00	1,965,434.70

15,630.10	25,513.40	17,308.50	18,147.70	26,318.60	19,721.20	0.00	0.00	0.00	0.00	0.00	0.00	122,639.50

710,227.60	707,605.10	709,170.10	710,332.50	709,958.00	709,858.00	0.00	0.00	0.00	0.00	0.00	0.00	4,257,151.30

2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	839.20	839.20	839.20	0.00	0.00	0.00	0.00	0.00	0.00	4,930.30

2310	SSI BLIND NON-MEDIC A

209.80	104.90	209.80	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	839.20

2320	SSI BLIND WITH QMB	4,300.90	4,510.70	4,405.80	4,405.80	4,615.60	4,300.90	0.00	0.00	0.00	0.00	0.00	0.00	26,539.70

SUBTOTAL:

2,846,091.20

2,859,286.20	2,857,681.20	2,858,469.70	2,866,139.50	2,883,850.60	0.00	0.00	0.00	0.00	0.00	0.00	17,171,518.40

M

2,846,825.50	2,859,915.60	2,858,310.60	2,859,099.10	2,866,768.90	2,884,480.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3,881.30

3,881.30

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

TOTAL:

17,175,399.70

LTC HIB

For The Period Ending December 31, 2015

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

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

0.00	0.00	0.00	0.00	1,628.00	1,221.00	0.00	0.00	0.00	0.00	0.00	0.00	2,849.00

407.00	0.00	1,221.00	0.00	0.00	1,221.00	0.00	0.00	0.00	0.00	0.00	0.00	2,849.00

2120	SSI AGED WITH QMB	256,094.80	261,120.80	256,136.10	250,816.60	258,578.10	257,073.10	0.00	0.00	0.00	0.00	0.00	0.00	1,539,819.50

2200	SSI DISABLED WITH M E
2220	SSI DISABLED WITH Q
M

0.00	407.00	0.00	407.00	-407.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	814.00

12,923.00	14,144.00	12,516.00	7,909.20	13,106.00	11,885.00	0.00	0.00	0.00	0.00	0.00	0.00	72,483.20

SUBTOTAL:

269,424.80

275,671.80	269,873.10	259,132.80	272,905.10	271,807.10	0.00	0.00	0.00	0.00	0.00	0.00	1,618,814.70

TOTAL:	269,424.80	275,671.80	269,873.10	259,132.80	272,905.10	271,807.10	0.00	0.00	0.00	0.00	0.00	0.00		1,618,814.70		

AT
SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

11,364.51	
34,423.32	
85,118.24	
35,815.19	
3,645,746.39	
3,846,149.75	
6,757,360.99	
1,612,727.14	
2,882,967.27	
7,168,046.90	
28,092,908.37	
9,138,143.91	
18,442.65	
2,147.15	
5,408.78	
26,121.38	
12,452.05	
288,190.46	
409,328.34	
1,052,396.12	
726,671.32	
25,650,545.44	
2,491,931.95	
4,136.65	
281,097.62	
34,054.24	
700.00	
8,493,023.92	
14,799,391.21	
22,668,094.75	
5,680,225.69	
7,377,773.54	
1,400.00	

1006	TANF 21-44 MALE WITH	1,467.46	3,014.86	4,778.75	2,265.53	988.83	-1,150.92	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	4,007.77	5,488.43	7,854.61	6,151.20	4,092.39	6,828.92	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	8,300.31	14,284.07	22,892.61	20,087.85	12,197.99	7,355.41	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	4,262.82	6,279.98	9,729.78	6,523.30	6,273.31	2,746.00	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	706,541.50	682,073.88	661,237.30	404,783.59	599,501.44	591,608.68	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	969,410.73	801,705.50	673,128.09	375,548.29	575,579.34	450,777.80	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	1,633,637.26	1,349,156.15	1,576,752.74	664,270.88	879,050.47	654,493.49	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	262,704.72	279,116.04	271,658.86	463,703.61	191,251.40	144,292.51	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

478,631.67	795,039.67	607,159.78	297,693.87	324,099.85	380,342.43	0.00	0.00	0.00	0.00	0.00	0.00

1016	TANF 21-44 MALE NON-	1,118,523.79	1,179,594.23	1,675,989.50	1,029,311.82	1,020,453.22	1,144,174.34	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

4,416,969.19	4,825,798.89	6,329,680.67	3,816,257.90	4,234,828.82	4,469,372.90	0.00	0.00	0.00	0.00	0.00	0.00

1018	TANF 45-64 M & F NON	1,478,215.20	1,497,596.26	2,105,951.76	1,291,244.17	1,313,943.20	1,451,193.32	0.00	0.00	0.00	0.00	0.00	0.00

1019	TANF 65+ M & F NON-M	5,703.98	4,317.50	4,221.17	3,150.00	700.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00

1026	TANF 21-44 MALE WITH	700.00	210.84	544.76	130.83	419.67	141.05	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	855.92	822.87	1,936.87	1,147.97	426.32	218.83	0.00	0.00	0.00	0.00	0.00	0.00

1028	TANF 45-64 M & F WIT	3,634.52	8,293.46	6,324.26	2,792.64	3,162.60	1,913.90	0.00	0.00	0.00	0.00	0.00	0.00

1029	TANF 65+ M & F WITH	2,256.22	1,398.03	4,606.47	1,605.11	1,827.30	758.92	0.00	0.00	0.00	0.00	0.00	0.00

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

51,457.56	41,686.19	96,120.74	33,984.56	29,250.14	35,691.27	0.00	0.00	0.00	0.00	0.00	0.00

60,414.26	72,757.77	86,289.46	47,067.16	74,476.35	68,323.34	0.00	0.00	0.00	0.00	0.00	0.00

2120	SSI AGED WITH QMB	145,603.01	196,624.00	255,370.13	143,751.63	126,739.98	184,307.37	0.00	0.00	0.00	0.00	0.00	0.00

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

118,193.79	139,630.47	151,342.90	119,909.21	78,796.47	118,798.48	0.00	0.00	0.00	0.00	0.00	0.00

3,959,038.86	4,322,461.60	5,500,714.34	3,203,783.82	4,183,126.66	4,481,420.16	0.00	0.00	0.00	0.00	0.00	0.00

327,062.97	435,664.94	615,950.69	349,244.88	330,111.22	433,897.25	0.00	0.00	0.00	0.00	0.00	0.00

2300	SSI BLIND WITH MEDIC	1,289.05	551.00	712.94	606.14	408.83	568.69	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

50,186.61	38,392.80	56,042.79	39,540.77	41,693.79	55,240.86	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	3,801.09	7,726.54	6,797.06	2,292.59	3,643.67	9,793.29	0.00	0.00	0.00	0.00	0.00	0.00

4304	SOBRA CHILD 14-20 MA	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	1,574,251.07	1,423,643.90	1,543,846.70	1,024,305.43	1,429,503.95	1,497,472.87	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	2,244,228.98	2,250,185.12	2,701,838.18	1,843,748.57	2,742,656.35	3,016,734.01	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	3,142,386.43	3,632,568.25	5,087,632.31	2,636,227.61	3,879,239.65	4,290,040.50	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	747,001.51	1,133,294.81	1,132,611.39	698,721.56	879,239.15	1,089,357.27	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	984,792.86	1,180,701.71	1,436,210.29	1,243,516.66	1,117,437.11	1,415,114.91	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M

0.00	700.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

For The Period Ending December 31, 2015

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M

0.00	0.00	350.00	350.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,400.00

237,999.22	275,437.95	329,140.16	268,427.33	331,831.13	313,180.11	0.00	0.00	0.00	0.00	0.00	0.00	1,756,015.90

1,131,352.11	1,456,601.24	1,697,144.79	1,250,264.34	1,615,075.39	1,490,352.46	0.00	0.00	0.00	0.00	0.00	0.00	8,640,790.33

4,193.00	1,958.21	2,450.00	1,400.00	974.78	3,500.00	0.00	0.00	0.00	0.00	0.00	0.00	14,475.99

0.00	0.00	12.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.47

SUBTOTAL:

25,879,075.44

28,064,777.16    34,666,425.32    21,293,810.82    26,033,700.77     27,809,210.42	0.00	0.00	0.00	0.00	0.00	0.00	163,746,999.93

3100	TRANSPLANT OPTION
1
SUBTOTAL:

0.00

0.00

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

350.00	
22,755.48	
59,046.55	
148,135.58	
80,314.33	
0.00	
15,807.13	
90,265.34	
47,243.14	
151,819.26	
2,159,259.64	
6,800,842.00	
3,809,633.82	
9,740.26	
3,338.26	
12,703.56	
16,787.47	
29,383.86	
73,187.68	
189,399.88	
1,088,140.45	
55,798.68	
634,015.35	
624,484.69	
16,122,452.41	

1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	2,193.53	4,316.53	6,771.33	2,886.65	2,350.20	4,237.24	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	3,881.00	7,550.93	10,740.46	8,070.42	13,935.59	14,868.15	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	17,862.89	29,601.36	33,234.71	16,412.58	23,674.85	27,349.19	0.00	0.00	0.00	0.00	0.00	0.00

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

11,589.10	11,907.56	11,276.99	10,530.63	13,763.00	21,247.05	0.00	0.00	0.00	0.00	0.00	0.00

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

1112	TANF EXPANDED 01-05	5,250.00	4,248.00	1,409.52	1,050.00	2,799.61	1,050.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	26,366.06	18,797.44	23,244.19	7,174.88	11,102.45	3,580.32	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	8,195.40	8,023.36	4,043.91	8,114.99	7,921.72	10,943.76	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	25,647.40	20,633.17	39,263.74	13,550.27	27,645.11	25,079.57	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	278,711.63	257,235.68	319,438.15	250,318.04	486,697.89	566,858.25	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	1,001,394.14	971,890.27	1,008,971.33	811,845.95	1,363,608.61	1,643,131.70	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	498,055.24	489,955.39	559,480.77	459,352.65	784,932.63	1,017,857.14	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	1,233.56	5,331.53	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	525.49	633.68	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	1,085.12	2,207.71	3,464.62	1,332.43	1,918.49	2,695.19	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	2,666.83	4,370.29	2,032.68	1,945.34	2,866.93	2,905.40	0.00	0.00	0.00	0.00	0.00	0.00

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

3,939.78	7,378.95	8,307.81	2,632.75	3,304.47	3,820.10	0.00	0.00	0.00	0.00	0.00	0.00

15,824.15	18,656.13	11,154.82	10,621.62	8,971.28	7,959.68	0.00	0.00	0.00	0.00	0.00	0.00

44,953.28	27,103.71	42,572.30	50,664.46	11,766.38	12,339.75	0.00	0.00	0.00	0.00	0.00	0.00

165,461.94	213,135.45	288,519.65	144,543.45	123,666.38	152,813.58	0.00	0.00	0.00	0.00	0.00	0.00

6,769.93	6,974.26	11,598.68	8,264.20	12,953.02	9,238.59	0.00	0.00	0.00	0.00	0.00	0.00

109,481.97	123,966.21	147,456.41	74,149.48	84,743.70	94,217.58	0.00	0.00	0.00	0.00	0.00	0.00

85,508.30	104,493.60	148,434.94	93,586.84	88,605.26	103,855.75	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

2,315,297.75

2,332,941.48	2,684,900.21	1,978,313.15	3,078,986.62	3,732,013.20	0.00	0.00	0.00	0.00	0.00	0.00

3308	AHC CARE M&F 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	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00
W
0.00

4

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3317	AHC CARE FEMALE 21-	0.00	0.00	-316.00	0.00	0.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00		-646.00		
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	-3,862.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,862.00		
	0.00	0.00	-316.00	0.00	0.00	-4,192.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,508.00		

0.00	
0.00	
0.00	
0.00	
0.00	
-5,880.99	
-2,268.00	
-6,446.00	
-14,594.99	

1

2

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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	-5,828.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	-2,268.00	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	-6,446.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-52.99	0.00	0.00	0.00	-14,542.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,805.52	
402.04	
15,233.34	
9,824.09	
113,549.41	
278,408.98	
2,314,924.96	
2,104,672.64	
6,369,429.25	
25,609.46	
561.56	
120.80	
350.00	
64.44	
4,516.75	
8,859.60	
59,201.74	
3,588.39	
1,282,779.43	
1,341,439.45	
22,585,852.31	
14,288,652.02	
29,093,022.39	

3506	ADULT 40-100% MALE 2	85.05	386.37	826.55	497.49	10.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

350.00	-297.96	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3508	ADULT 40-100% M&F 45	645.75	4,143.44	2,194.34	1,695.56	2,704.25	3,850.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	1,136.72	452.79	2,304.18	777.55	2,583.02	2,569.83	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	26,346.12	11,086.99	17,886.95	21,098.49	19,893.94	17,236.92	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

39,467.46	45,163.63	63,499.13	36,273.42	42,314.87	51,690.47	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	304,613.42	425,982.76	423,158.47	436,649.78	341,541.83	382,978.70	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

316,477.56	364,737.12	475,335.36	280,789.77	334,025.70	333,307.13	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	1,086,597.94	1,026,522.27	1,319,334.30	853,672.09	1,010,881.52	1,072,421.13	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	700.00	1,114.00	3,500.00	17,145.46	700.00	2,450.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	74.88	61.40	75.28	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	59.40	0.00	61.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3705	ADULT <40% EXP FEM AL

0.00	5.04	59.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	357.00	187.24	1,790.82	720.29	61.40	1,400.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1,396.64	1,663.61	3,351.85	967.89	729.84	749.77	0.00	0.00	0.00	0.00	0.00	0.00

4,997.35	11,572.19	10,426.98	9,426.39	9,118.22	13,660.61	0.00	0.00	0.00	0.00	0.00	0.00

550.16	545.25	1,197.56	1,260.00	0.01	35.41	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	165,528.85	261,775.93	267,888.88	187,172.51	179,844.48	220,568.78	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

208,336.04	216,013.15	264,710.67	163,391.21	226,208.55	262,779.83	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	3,029,287.38	3,988,308.94	4,654,737.86	3,315,942.24	3,506,890.83	4,090,685.06	0.00	0.00	0.00	0.00	0.00	0.00

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

1,927,561.48	2,317,641.88	3,111,066.30	1,949,322.89	2,217,906.35	2,765,153.12	0.00	0.00	0.00	0.00	0.00	0.00

4,322,313.67	5,015,624.62	5,861,943.16	3,932,359.26	4,603,664.10	5,357,117.58	0.00	0.00	0.00	0.00	0.00	0.00

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

For The Period Ending December 31, 2015

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

3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

1,400.00	4,739.20	2,450.00	1,017.76	4,900.00	8,050.00	0.00	0.00	0.00	0.00	0.00	0.00	22,556.96

0.00	0.00	0.00	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	350.00

0.00	476.33	0.00	700.00	350.00	1,050.00	0.00	0.00	0.00	0.00	0.00	0.00	2,576.33

SUBTOTAL:

11,438,207.99

13,697,919.67    16,488,135.56    11,210,955.33    12,505,028.97     14,588,104.34	0.00	0.00	0.00	0.00	0.00	0.00	79,928,351.86

2,458.58	
3,192.10	
29,221.55	
5,081.82	
51,262.04	
141,601.99	
1,492,651.90	
2,242,117.55	
4,062,589.83	
5,250.00	
467.72	
8,035,895.08	

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	0.00	708.58	350.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	2,100.00	392.10	350.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00

5,768.03	7,449.33	2,569.39	3,983.75	3,579.66	5,871.39	0.00	0.00	0.00	0.00	0.00	0.00

291.65	74.97	0.00	1,418.20	2,100.00	1,197.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	5,286.80	5,739.88	17,778.96	7,700.00	8,066.20	6,690.20	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

18,281.55	30,911.29	16,130.09	20,252.28	19,679.81	36,346.97	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	196,798.09	227,258.24	311,425.56	279,292.12	170,395.72	307,482.17	0.00	0.00	0.00	0.00	0.00	0.00

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

271,360.04	317,416.51	433,678.80	355,651.52	362,225.89	501,784.79	0.00	0.00	0.00	0.00	0.00	0.00

680,980.32	652,498.60	813,465.56	599,685.22	649,560.52	666,399.61	0.00	0.00	0.00	0.00	0.00	0.00

700.00	0.00	2,450.00	1,050.00	700.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	350.00	59.40	0.00	48.25	10.07	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,180,866.48

1,241,698.82	1,599,657.76	1,269,425.19	1,217,414.63	1,526,832.20	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

700.00	
1,636,546.16	
566,023.59	
642,340.94	
2,845,610.69	

189,176.92	189,687.05	133,832.64	285,206.25	405,616.43	433,026.87	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	108,710.33	125,466.77	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	132,904.38	171,781.34	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	647,931.14	730,274.98	0.00	0.00	0.00	0.00	0.00	0.00

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

5,936.00	4,286.25	3,859.52	1,400.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00

16,181.77	
55,960.80	
2,450.00	
7,954.37	
82,546.94	

1,109.40	2,490.00	2,861.40	2,835.67	37,424.01	9,240.32	0.00	0.00	0.00	0.00	0.00	0.00

350.00	1,050.00	0.00	0.00	350.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

11,481.35

8,876.25	7,429.79	6,345.22	37,774.01	10,640.32	0.00	0.00	0.00	0.00	0.00	0.00

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

209.72	5,846.12	5,390.39	2,833.23	2,964.70	4,834.60	0.00	0.00	0.00	0.00	0.00	0.00

22,078.76	
5,497.96	
460.68	
28,037.40	

2,100.00	350.00	238.44	1,759.52	0.00	1,050.00	0.00	0.00	0.00	0.00	0.00	0.00

59.40	237.60	163.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

41,159,756.52	45,693,704.25	55,704,123.37	36,305,180.28	43,523,800.84	48,384,226.06	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	2,964.70	5,884.60	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

270,770,791.32

AT
SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

66,802.55	
82,523.32	
143,855.13	
49,960.53	
2,680,767.70	
1,216,941.43	
1,170,112.55	
340,009.79	
719,452.36	
3,424,558.84	
10,796,773.07	
4,780,848.01	
25,778.64	
5,011.52	
8,250.63	
27,889.13	
14,420.89	
628,769.60	
426,774.48	
1,325,354.26	
1,755,203.21	
22,767,257.90	
4,832,776.60	
3,093.67	
269,457.27	
61,309.41	
0.00	
3,508,088.56	
4,010,882.90	
4,635,938.82	
1,570,023.07	
1,928,143.80	
907.66	

1006	TANF 21-44 MALE WITH	12,234.63	8,503.24	18,275.63	6,381.31	5,844.83	15,562.91	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	12,732.53	6,507.68	17,412.00	15,691.14	13,500.26	16,679.71	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	20,039.18	23,077.50	31,215.80	33,021.35	18,951.23	17,550.07	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	5,432.47	3,081.30	19,647.16	10,039.86	6,222.77	5,536.97	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	567,248.47	532,325.46	584,585.71	313,406.39	331,234.80	351,966.87	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	268,055.89	267,958.17	247,550.22	145,229.43	177,888.33	110,259.39	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	241,026.07	231,615.87	249,245.17	192,348.16	143,246.93	112,630.35	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	82,531.85	114,669.34	34,788.77	49,531.89	31,882.75	26,605.19	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

132,827.40	149,313.25	111,126.28	104,486.80	105,368.86	116,329.77	0.00	0.00	0.00	0.00	0.00	0.00

1016	TANF 21-44 MALE NON-	562,279.40	623,087.17	772,207.19	586,447.11	387,037.58	493,500.39	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

1,689,259.97	1,841,435.05	2,361,373.34	1,715,630.63	1,561,254.11	1,627,819.97	0.00	0.00	0.00	0.00	0.00	0.00

1018	TANF 45-64 M & F NON	717,249.74	673,156.71	1,111,242.66	847,305.45	703,072.00	728,821.45	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	7,181.73	0.00	0.00	0.00	0.00	0.00	0.00

1026	TANF 21-44 MALE WITH	0.00	358.05	1,478.69	1,214.66	51.47	1,908.65	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	412.90	351.42	2,063.57	1,842.65	83.53	3,496.56	0.00	0.00	0.00	0.00	0.00	0.00

1028	TANF 45-64 M & F WIT	3,047.60	9,471.40	10,036.97	633.37	3,837.08	862.71	0.00	0.00	0.00	0.00	0.00	0.00

1029	TANF 65+ M & F WITH	3,251.52	2,098.51	1,156.82	1,008.87	2,580.06	4,325.11	0.00	0.00	0.00	0.00	0.00	0.00

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

106,798.55	110,945.57	91,003.61	88,139.93	128,224.34	103,657.60	0.00	0.00	0.00	0.00	0.00	0.00

64,152.89	46,997.31	91,231.24	102,587.31	66,008.56	55,797.17	0.00	0.00	0.00	0.00	0.00	0.00

2120	SSI AGED WITH QMB	175,558.22	197,043.69	252,769.74	198,249.01	171,594.10	330,139.50	0.00	0.00	0.00	0.00	0.00	0.00

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

166,567.65	317,497.47	346,091.63	291,180.02	264,676.11	369,190.33	0.00	0.00	0.00	0.00	0.00	0.00

3,771,166.39	3,833,723.81	4,457,896.20	3,339,155.66	3,222,228.88	4,143,086.96	0.00	0.00	0.00	0.00	0.00	0.00

655,176.74	747,126.30	1,013,047.49	712,906.83	646,672.11	1,057,847.13	0.00	0.00	0.00	0.00	0.00	0.00

2300	SSI BLIND WITH MEDIC	1,326.89	422.13	772.67	8.77	45.40	517.81	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

66,376.71	61,383.92	49,169.33	28,967.10	28,750.52	34,809.69	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	12,727.94	8,978.40	9,598.98	8,794.19	7,071.58	14,138.32	0.00	0.00	0.00	0.00	0.00	0.00

4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	497,249.77	602,823.96	598,332.57	520,995.09	499,154.41	789,532.76	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	458,185.52	543,964.72	797,467.83	578,583.31	636,762.51	995,919.01	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	547,894.44	679,833.89	916,035.21	861,311.80	719,678.65	911,184.83	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	142,589.40	263,389.36	296,159.45	260,211.19	332,884.37	274,789.30	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	302,021.91	271,458.30	384,496.73	294,852.74	340,518.87	334,795.25	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M

0.00	0.00	0.00	0.00	21.79	885.87	0.00	0.00	0.00	0.00	0.00	0.00

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

For The Period Ending December 31, 2015

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 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

134,500.45	112,857.97	124,462.39	103,103.31	163,088.79	110,109.08	0.00	0.00	0.00	0.00	0.00	0.00	748,121.99

505,008.76	490,355.70	786,301.26	601,673.87	660,195.38	611,434.78	0.00	0.00	0.00	0.00	0.00	0.00	3,654,969.75

0.00	12,542.17	0.00	422.16	372.51	1,135.72	0.00	0.00	0.00	0.00	0.00	0.00	14,472.56

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

SUBTOTAL:

11,929,298.55

12,793,707.33    15,798,308.51    12,019,402.53    11,380,005.47     13,780,008.91	0.00	0.00	0.00	0.00	0.00	0.00	77,700,731.30

3100	TRANSPLANT OPTION
1
SUBTOTAL:

0.00

0.00

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

0.00	
51,449.29	
135,578.59	
302,137.29	
92,202.50	
0.00	
1,204.22	
10,270.89	
17,192.01	
24,238.25	
670,853.29	
1,728,059.96	
1,571,908.51	
154.00	
16,074.86	
10,441.44	
63,709.60	
20,391.46	
65,388.05	
99,680.24	
1,316,745.89	
69,876.25	
497,686.30	
1,363,552.86	
8,128,795.75	

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	8,090.62	5,444.07	10,692.23	3,827.16	6,983.69	16,411.52	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	17,273.14	16,429.02	21,924.74	19,870.38	22,886.57	37,194.74	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	42,647.41	59,814.53	50,487.40	30,333.33	36,325.73	82,528.89	0.00	0.00	0.00	0.00	0.00	0.00

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

11,071.23	8,539.97	21,023.04	15,362.85	14,717.76	21,487.65	0.00	0.00	0.00	0.00	0.00	0.00

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

1112	TANF EXPANDED 01-05	394.14	374.54	145.54	124.70	83.77	81.53	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	3,697.17	677.24	2,091.94	2,093.05	1,172.41	539.08	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	6,680.00	533.05	1,187.06	1,282.18	3,112.99	4,396.73	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	2,354.23	2,087.82	3,793.11	2,856.57	8,261.29	4,885.23	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	76,478.73	84,826.03	112,645.22	98,803.74	144,505.55	153,594.02	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	248,164.67	258,823.73	251,229.71	263,654.55	303,030.02	403,157.28	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	195,427.93	197,298.94	217,067.90	273,091.81	329,142.75	359,879.18	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	826.35	9,191.96	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	1,490.53	614.49	3,655.77	1,321.14	723.61	2,635.90	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	6,588.12	5,873.05	9,500.81	7,667.30	11,046.40	23,033.92	0.00	0.00	0.00	0.00	0.00	0.00

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

3,777.06	2,003.76	1,660.43	1,418.57	2,747.48	8,784.16	0.00	0.00	0.00	0.00	0.00	0.00

6,604.72	20,310.29	10,390.12	10,974.13	5,525.57	11,583.22	0.00	0.00	0.00	0.00	0.00	0.00

21,709.26	49,550.80	38,796.40	5,977.46	2,279.00	-18,632.68	0.00	0.00	0.00	0.00	0.00	0.00

212,432.79	214,996.21	262,436.77	205,237.08	184,165.63	237,477.41	0.00	0.00	0.00	0.00	0.00	0.00

4,806.76	6,477.98	17,263.02	20,022.37	7,260.02	14,046.10	0.00	0.00	0.00	0.00	0.00	0.00

109,739.51	100,550.95	88,862.91	27,616.73	84,045.66	86,870.54	0.00	0.00	0.00	0.00	0.00	0.00

194,924.82	195,369.54	290,524.12	205,743.06	175,024.36	301,966.96	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,175,224.23

1,233,590.49	1,416,332.84	1,198,668.24	1,343,866.61	1,761,113.34	0.00	0.00	0.00	0.00	0.00	0.00

3308	AHC CARE M&F 45-64	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	

21.62
W
-40.77

4

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3317	AHC CARE FEMALE 21-	-527.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-527.88		
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		-13,553.16		
	-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		

-1,057.32	
-99.09	
60.75	
-2,238.34	
12,313.57	
-25,560.19	
562.33	
-6,923.47	
-22,941.76	

1

2

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	-1,057.32	0.00	0.00	0.00	0.00	0.00	0.00	
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	-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	-515.50	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	-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	-853.48	0.00	0.00	0.00	0.00	0.00	0.00	
	-34,472.66	0.00	14,549.19	-591.99	0.00	-2,426.30	0.00	0.00	0.00	0.00	0.00	0.00	

1,132.96	
0.00	
12,410.97	
335.70	
25,600.26	
207,716.47	
1,365,133.19	
673,540.52	
3,638,959.79	
1,297.69	
0.00	
225.49	
622.74	
0.00	
1,105.49	
18,814.98	
81,267.79	
2,051.78	
637,027.89	
472,954.13	
15,514,891.87	
6,351,070.23	
19,542,384.15	

3506	ADULT 40-100% MALE 2	15.57	260.53	0.00	0.00	0.00	856.86	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

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

3508	ADULT 40-100% M&F 45	3,307.43	1,008.60	3,349.43	978.27	2,423.66	1,343.58	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	154.04	0.00	0.00	181.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	1,808.45	2,617.50	2,711.22	4,567.35	7,355.62	6,540.12	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

19,931.75	23,276.12	89,687.54	28,119.86	34,486.40	12,214.80	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	229,346.72	174,196.94	211,562.10	277,900.40	210,627.62	261,499.41	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

109,841.40	105,802.51	150,353.68	93,953.55	100,102.01	113,487.37	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	610,123.29	776,775.68	695,783.33	458,809.96	501,750.13	595,717.40	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	62.84	0.00	0.00	0.00	0.00	0.00	0.00

3529	ADULT 40-100% M&F 65	0.00	0.00	380.98	90.66	30.22	120.88	0.00	0.00	0.00	0.00	0.00	0.00

3705	ADULT <40% EXP FEM AL

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

3706	ADULT <40% EXP MALE	-113.08	0.00	357.03	0.00	121.64	739.90	0.00	0.00	0.00	0.00	0.00	0.00

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

1,799.96	1,321.34	2,383.72	4,587.94	2,342.89	6,379.13	0.00	0.00	0.00	0.00	0.00	0.00

13,612.17	16,184.28	11,638.87	15,449.12	13,966.65	10,416.70	0.00	0.00	0.00	0.00	0.00	0.00

112.46	353.44	167.54	658.68	573.76	185.90	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	49,424.42	117,557.97	171,586.96	99,739.77	114,797.94	83,920.83	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

91,002.56	63,238.93	77,507.54	92,547.18	64,786.11	83,871.81	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	2,375,248.97	2,548,511.24	3,291,598.46	2,203,928.16	2,372,006.70	2,723,598.34	0.00	0.00	0.00	0.00	0.00	0.00

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

1,081,236.95	1,138,344.74	1,153,915.66	971,417.23	957,390.07	1,048,765.58	0.00	0.00	0.00	0.00	0.00	0.00

2,866,722.75	3,197,371.03	3,873,212.13	2,943,218.44	3,088,403.47	3,573,456.33	0.00	0.00	0.00	0.00	0.00	0.00

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

For The Period Ending December 31, 2015

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

3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

19,126.57	1,786.77	31,730.45	2,915.21	1,256.96	3,098.55	0.00	0.00	0.00	0.00	0.00	0.00	59,914.51

166.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166.20

-612.98	600.54	599.83	413.03	126.91	274.77	0.00	0.00	0.00	0.00	0.00	0.00	1,402.10

SUBTOTAL:

7,472,143.33

8,169,422.64	9,769,959.27	7,199,220.14	7,472,730.42	8,526,551.10	0.00	0.00	0.00	0.00	0.00	0.00	48,610,026.90

0.00	
0.00	
26,636.71	
347.74	
31,015.07	
26,142.87	
840,313.06	
682,144.64	
1,985,944.90	
0.00	
47.11	
3,592,592.10	

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
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

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

1,878.61	4,565.59	8,493.20	2,313.61	1,002.68	8,383.02	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	173.85	173.89	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	1,428.78	2,216.51	11,094.26	2,843.03	2,853.57	10,578.92	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

4,206.93	3,731.02	4,932.18	4,863.26	5,664.92	2,744.56	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	104,385.56	160,195.48	159,710.74	140,347.56	108,373.79	167,299.93	0.00	0.00	0.00	0.00	0.00	0.00

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

89,440.86	139,303.63	118,586.92	109,708.96	85,587.46	139,516.81	0.00	0.00	0.00	0.00	0.00	0.00

273,456.06	265,129.06	405,070.04	269,867.19	392,397.71	380,024.84	0.00	0.00	0.00	0.00	0.00	0.00

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

47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

474,843.91

575,141.29	707,887.34	529,943.61	596,053.98	708,721.97	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	
288,685.94	
116,624.26	
183,045.89	
588,356.09	

18,822.56	18,033.29	11,971.57	66,627.29	61,087.04	112,144.19	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	34,844.73	28,133.55	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	40,459.21	26,628.68	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	136,390.98	166,906.42	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	2,014.72	1,660.45	-400.91	457.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,731.64	
8,053.42	
12,364.88	
1,481.13	
25,631.07	

393.90	393.23	34.69	1,707.07	5,144.43	380.10	0.00	0.00	0.00	0.00	0.00	0.00

4,917.91	0.00	344.62	7,470.66	-368.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

5,311.81

2,407.95	3,462.38	8,835.33	5,233.50	380.10	0.00	0.00	0.00	0.00	0.00	0.00

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

3,652.19	5,276.89	5,063.99	2,938.66	1,991.80	5,632.26	0.00	0.00	0.00	0.00	0.00	0.00

24,555.79	
94.49	
214.52	
24,864.80	

0.00	0.00	94.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	204.26	0.00	10.26	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	2,002.06	5,632.26	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	21,049,296.39	22,871,233.35	27,733,419.01	21,096,836.49	20,936,283.02	24,946,887.80	0.00	0.00	0.00	0.00	0.00	0.00		138,633,956.06		

AT
SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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
2110	SSI AGED NON-MEDICA
R

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

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

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

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

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

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

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

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

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M

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

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

For The Period Ending December 31, 2015

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M

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

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

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

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

0.00	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

3100	TRANSPLANT OPTION
1
SUBTOTAL:

0.00

0.00

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

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

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

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

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1119	TANF EXPANDED 65+ M&

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

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

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

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

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

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

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

3308	AHC CARE M&F 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	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00
W
0.00

4

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3317	AHC CARE FEMALE 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		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

1

2

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

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

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

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

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

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

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3705	ADULT <40% EXP FEM AL

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

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

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

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

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

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

3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

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

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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 December 31, 2015

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

3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

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

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

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

SUBTOTAL:

0.00

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

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

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
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

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

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

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

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
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3928	NEWLY ELIGIBLE M&F
4

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

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

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

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

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

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

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

0.00	
0.00	
0.00	
0.00	
0.00	

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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

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

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

0.00	
0.00	
0.00	
0.00	
0.00	

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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

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

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

0.00	
0.00	
0.00	
0.00	

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

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

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

TOTAL:

0.00

AT
SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		
	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		

136.92	
0.00	
2,075.55	
284.13	
39,064.74	
20,021.83	
6,787.91	
5,755.05	
13,119.97	
81,174.00	
131,631.82	
39,515.00	
249.73	
0.00	
0.00	
14.61	
0.00	
7,400.46	
70,356.98	
4,914.60	
7,251.66	
424,961.71	
36,353.43	
0.00	
2,306.72	
0.00	
0.00	
42,576.85	
133,696.13	
165,491.82	
68,498.95	
59,649.85	
0.00	

1006	TANF 21-44 MALE WITH	0.00	0.00	50.39	0.00	86.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	240.08	144.26	129.07	239.42	1,322.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	0.00	0.00	14.96	0.00	0.00	269.17	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	3,067.29	5,821.79	9,178.88	8,561.96	12,073.20	361.62	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	3,377.40	2,687.30	4,007.35	587.92	319.42	9,042.44	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	1,218.15	1,408.01	1,681.43	1,359.63	422.84	697.85	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	3,194.76	243.36	468.28	188.25	8.93	1,651.47	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

3,183.01	6,546.81	822.11	544.54	1,469.63	553.87	0.00	0.00	0.00	0.00	0.00	0.00

1016	TANF 21-44 MALE NON-	15,380.38	5,438.43	12,392.42	22,983.79	9,608.57	15,370.41	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

26,675.44	30,189.68	21,923.51	32,698.97	13,500.32	6,643.90	0.00	0.00	0.00	0.00	0.00	0.00

1018	TANF 45-64 M & F NON	1,585.03	20,476.42	7,032.33	4,217.25	3,765.04	2,438.93	0.00	0.00	0.00	0.00	0.00	0.00

1019	TANF 65+ M & F NON-M	249.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	14.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

241.77	1,611.38	1,217.37	578.23	1,624.74	2,126.97	0.00	0.00	0.00	0.00	0.00	0.00

371.10	7,188.56	32,792.94	1,605.68	18,626.89	9,771.81	0.00	0.00	0.00	0.00	0.00	0.00

2120	SSI AGED WITH QMB	74.34	-102.87	2,258.84	-33.63	42.72	2,675.20	0.00	0.00	0.00	0.00	0.00	0.00

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

274.99	1,222.09	2,462.28	265.65	1,191.01	1,835.64	0.00	0.00	0.00	0.00	0.00	0.00

25,287.18	285,986.08	63,667.08	20,539.73	10,339.15	19,142.49	0.00	0.00	0.00	0.00	0.00	0.00

3,344.91	11,090.04	4,388.06	4,281.31	7,564.03	5,685.08	0.00	0.00	0.00	0.00	0.00	0.00

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

0.00	0.00	2,306.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	3,804.18	13,609.55	4,737.03	2,907.42	3,992.10	13,526.57	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	23,471.36	22,204.78	19,576.43	13,090.77	16,949.49	38,403.30	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	51,607.75	20,148.09	23,759.65	14,546.67	8,196.12	47,233.54	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	12,529.17	16,769.02	21,002.41	3,957.63	8,758.43	5,482.29	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	6,477.83	5,659.71	11,307.97	10,537.18	17,755.14	7,912.02	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M

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

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

For The Period Ending December 31, 2015

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M

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

4,547.68	626.35	7,875.28	1,288.69	1,480.21	1,333.79	0.00	0.00	0.00	0.00	0.00	0.00	17,152.00

21,818.94	29,403.82	43,513.99	31,655.97	15,933.90	13,446.16	0.00	0.00	0.00	0.00	0.00	0.00	155,772.78

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

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

SUBTOTAL:

212,022.47

488,372.66	298,566.78	176,603.03	155,045.74	205,604.52	0.00	0.00	0.00	0.00	0.00	0.00	1,536,215.20

3100	TRANSPLANT OPTION
1
SUBTOTAL:

85.42

85.42

0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
26.99	
208.10	
21.69	
107.79	
296.08	
0.00	
7,856.90	
155.05	
47,366.14	
44,861.03	
11,263.71	
0.00	
0.00	
0.00	
0.00	
0.00	
4,374.39	
0.00	
427.62	
3,973.32	
126,472.20	
6,785.96	
254,196.97	

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	0.00	0.00	26.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	0.00	6.07	0.00	161.42	40.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	21.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	5,436.61	488.81	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	17.95	137.10	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	207.41	1,374.65	40,600.36	101.94	919.82	4,161.96	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	9,469.13	1,756.74	6,608.45	12,403.21	910.62	13,712.88	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	3,509.12	2,951.74	93.10	450.62	340.34	3,918.79	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&

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

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

338.53	-1,011.94	2,895.49	1,827.68	233.88	90.75	0.00	0.00	0.00	0.00	0.00	0.00

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

199.65	0.00	129.18	-72.61	-17.74	189.14	0.00	0.00	0.00	0.00	0.00	0.00

386.96	48.09	143.85	158.57	1,284.03	1,951.82	0.00	0.00	0.00	0.00	0.00	0.00

56,129.73	0.00	20,969.96	0.00	35,888.67	13,483.84	0.00	0.00	0.00	0.00	0.00	0.00

479.32	0.00	3,171.06	1,161.00	1,618.58	356.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

71,791.87

5,686.71	75,118.85	16,413.39	46,695.06	38,491.09	0.00	0.00	0.00	0.00	0.00	0.00

3308	AHC CARE M&F 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	
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	

0.00
W
-55.14

4

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	0.00	-123.42	0.00	0.00	0.00	0.00	0.00	0.00		-123.42		
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	-304.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-304.13		
	-55.14	0.00	0.00	0.00	-304.13	-123.42	0.00	0.00	0.00	0.00	0.00	0.00		-482.69		

0.00	
-90.89	
0.00	
0.00	
0.00	
996.64	
0.00	
56,134.89	
57,040.64	

1

2

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	-90.89	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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	56,134.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	57,131.53	0.00	0.00	0.00	0.00	-90.89	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
301.01	
61.23	
5,039.99	
4,182.25	
121,199.86	
42,773.88	
134,408.95	
0.00	
0.00	
0.00	
0.00	
0.00	
10.26	
4,114.12	
344.99	
0.00	
6,164.53	
10,177.88	
535,996.09	
217,915.53	
349,915.31	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

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

3508	ADULT 40-100% M&F 45	95.08	0.00	205.82	0.00	0.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	61.23	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	3,995.50	462.67	581.82	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

3,430.56	332.79	0.00	0.00	75.94	342.96	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	29,537.65	17,618.83	16,528.87	11,291.25	21,952.19	24,271.07	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

9,918.88	16,192.67	4,216.11	6,873.78	4,424.35	1,148.09	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	17,006.11	11,808.33	29,317.11	13,080.91	41,130.07	22,066.42	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 AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

0.00	0.00	0.00	0.00	0.00	4,114.12	0.00	0.00	0.00	0.00	0.00	0.00

47.77	159.41	-72.49	153.28	0.00	57.02	0.00	0.00	0.00	0.00	0.00	0.00

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

3714	ADULT <40% EXP MALE	638.33	2,949.89	655.77	55.09	1,044.42	821.03	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	971.73	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	87,516.94	137,213.09	59,107.89	86,557.14	76,793.86	88,807.17	0.00	0.00	0.00	0.00	0.00	0.00

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

28,711.56	30,380.42	62,265.11	20,947.83	13,043.16	62,567.45	0.00	0.00	0.00	0.00	0.00	0.00

73,759.29	34,317.41	75,461.37	91,305.45	36,478.45	38,593.34	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 December 31, 2015

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

3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

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

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

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

SUBTOTAL:

257,558.65

252,306.42	248,671.91	234,260.23	195,405.22	244,403.45	0.00	0.00	0.00	0.00	0.00	0.00	1,432,605.88

75.76	
0.00	
0.00	
0.00	
219.66	
0.00	
30,602.18	
29,249.53	
123,151.66	
0.00	
0.00	
183,298.79	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	21.47	0.00	54.29	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	219.66	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

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

3916	NEWLY ELIGIBLE MALE	2,177.20	3,667.10	6,736.60	8,363.47	683.15	8,974.66	0.00	0.00	0.00	0.00	0.00	0.00

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

2,187.81	6,610.07	2,102.47	1,988.35	1,659.44	14,701.39	0.00	0.00	0.00	0.00	0.00	0.00

40,072.00	12,789.89	57,847.40	7,387.87	-635.14	5,689.64	0.00	0.00	0.00	0.00	0.00	0.00

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

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

SUBTOTAL:

44,437.01

23,067.06	66,686.47	17,761.16	1,707.45	29,639.64	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	
8,416.58	
334.70	
1,191.27	
9,942.55	

0.00	332.82	31.19	1,392.55	1,273.75	5,386.27	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	126.58	69.79	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	424.71	-39.17	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

177.42

401.62	31.19	2,090.39	1,825.04	5,416.89	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	
0.00	
3,387.30	
0.00	
3,387.30	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

3,387.30

0.00	140.57	-140.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	61.65	36.81	95.62	0.00	0.00	0.00	0.00	0.00	0.00

194.08	
15,995.48	
0.00	
16,189.56	

0.00	2,178.61	0.00	0.00	13,816.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	13,853.68	95.62	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	646,451.11	771,726.45	689,215.77	447,049.28	414,228.06	523,522.32	0.00	0.00	0.00	0.00	0.00	0.00		3,492,192.99		

IT

22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	0.00	0.00	0.00	0.00	0.00	0.00		171,372.30		
	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	0.00	0.00	0.00	0.00	0.00	0.00		171,372.30		

TOTAL:

171,372.30

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	0.00	0.00	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.51		
	0.00	0.00	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.51		

IT

SUBTOTAL:

TOTAL:	0.00	0.00	54.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.51		

IT

270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	0.00	0.00	0.00	0.00	0.00	0.00		2,018,849.81		
	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	0.00	0.00	0.00	0.00	0.00	0.00		2,018,849.81		

TOTAL:

2,018,849.81

AT
SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

780.06	
2,765.01	
6,752.93	
82.48	
344,109.90	
73,643.50	
45,730.16	
9,165.03	
34,925.29	
224,130.39	
831,758.71	
238,626.40	
0.00	
0.00	
0.00	
3,899.11	
0.00	
42,405.13	
6,857.69	
41,014.75	
71,403.96	
1,437,352.06	
209,445.30	
530.71	
6,201.44	
906.53	
0.00	
598,580.45	
236,856.57	
232,084.93	
112,057.75	
160,915.26	
0.00	

1006	TANF 21-44 MALE WITH	46.42	188.36	166.12	101.73	229.42	48.01	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	286.14	1,871.10	104.02	503.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	963.94	990.67	2,333.71	726.40	204.34	1,533.87	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	15.97	66.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	14,101.84	25,301.91	30,300.16	178,822.23	20,727.64	74,856.12	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	16,538.91	9,600.05	8,669.16	18,344.02	3,875.07	16,616.29	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	6,436.73	7,171.95	14,303.13	4,999.12	7,077.73	5,741.50	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	1,257.04	3,493.94	1,522.66	776.75	1,794.11	320.53	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

3,520.43	4,447.58	5,020.50	8,102.17	4,452.11	9,382.50	0.00	0.00	0.00	0.00	0.00	0.00

1016	TANF 21-44 MALE NON-	24,274.51	27,434.69	45,477.46	88,415.76	9,738.08	28,789.89	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

122,776.63	149,984.88	198,163.63	154,340.59	107,095.16	99,397.82	0.00	0.00	0.00	0.00	0.00	0.00

1018	TANF 45-64 M & F NON	44,637.53	34,488.13	37,346.87	40,804.81	32,291.49	49,057.57	0.00	0.00	0.00	0.00	0.00	0.00

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1028	TANF 45-64 M & F WIT	0.00	2,013.78	1,713.94	22.74	132.86	15.79	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
2110	SSI AGED NON-MEDICA
R

8,786.84	9,235.08	13,562.46	4,876.58	4,017.94	1,926.23	0.00	0.00	0.00	0.00	0.00	0.00

267.22	1,844.32	1,193.89	206.73	207.49	3,138.04	0.00	0.00	0.00	0.00	0.00	0.00

2120	SSI AGED WITH QMB	5,639.69	5,409.53	7,747.96	8,330.00	3,535.97	10,351.60	0.00	0.00	0.00	0.00	0.00	0.00

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

21,233.51	3,529.27	27,584.81	6,512.83	4,472.52	8,071.02	0.00	0.00	0.00	0.00	0.00	0.00

231,778.99	342,969.11	271,027.04	176,793.76	210,239.42	204,543.74	0.00	0.00	0.00	0.00	0.00	0.00

31,844.13	34,580.97	45,422.53	27,354.81	19,197.99	51,044.87	0.00	0.00	0.00	0.00	0.00	0.00

2300	SSI BLIND WITH MEDIC	0.00	530.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

1,267.01	342.49	390.50	653.66	984.10	2,563.68	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	222.46	193.39	118.72	208.81	92.93	70.22	0.00	0.00	0.00	0.00	0.00	0.00

4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4311	SOBRA CHILD <1 M & F	99,444.46	34,799.65	70,959.07	70,572.82	252,132.06	70,672.39	0.00	0.00	0.00	0.00	0.00	0.00

4312	SOBRA CHILD 01-05 M	37,985.34	18,128.44	50,244.41	32,655.05	36,957.52	60,885.81	0.00	0.00	0.00	0.00	0.00	0.00

4313	SOBRA CHILD 06-13 M	20,935.84	28,886.52	38,212.84	34,130.76	44,076.50	65,842.47	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	36,910.73	21,260.73	9,048.41	10,576.23	10,522.89	23,738.76	0.00	0.00	0.00	0.00	0.00	0.00

4315	SOBRA CHILD 14-20 FE	7,807.11	22,781.32	26,164.00	49,311.09	32,388.98	22,462.76	0.00	0.00	0.00	0.00	0.00	0.00

5007	SOBRA PREG 21-44 FE M

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

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

For The Period Ending December 31, 2015

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

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M

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

19,583.10	16,174.12	18,249.56	19,803.43	28,709.84	38,838.71	0.00	0.00	0.00	0.00	0.00	0.00	141,358.76

50,370.25	73,392.58	98,242.24	99,306.65	73,113.89	108,947.96	0.00	0.00	0.00	0.00	0.00	0.00	503,373.57

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

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

SUBTOTAL:

808,932.77

881,111.78	1,023,289.80	1,037,253.28	908,268.05	958,858.15	0.00	0.00	0.00	0.00	0.00	0.00	5,617,713.83

3100	TRANSPLANT OPTION
1
SUBTOTAL:

0.00

0.00

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

0.00	
-2,191.67	
7,998.88	
13,985.20	
3,762.65	
0.00	
169.40	
15.00	
777.59	
53.99	
88,730.45	
200,870.52	
84,328.65	
1,368.93	
1,145.60	
286.67	
4,207.57	
81.70	
3,175.06	
5,009.39	
42,210.81	
6,721.01	
50,287.36	
59,305.02	
572,299.78	

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1106	TANF EXPANDED 21-44	0.00	414.69	0.00	0.00	-2,606.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	1,241.25	491.94	2,444.85	1,158.04	613.86	2,048.94	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	1,825.46	2,238.26	622.19	467.69	2,209.12	6,622.48	0.00	0.00	0.00	0.00	0.00	0.00

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

1,249.86	53.73	663.23	32.04	433.73	1,330.06	0.00	0.00	0.00	0.00	0.00	0.00

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	271.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	53.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	7,020.19	10,188.24	39,666.55	3,815.71	20,026.14	8,013.62	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	29,232.13	26,262.11	33,390.49	26,291.09	53,340.49	32,354.21	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	7,699.38	15,070.15	15,381.52	14,385.88	14,008.71	17,783.01	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	310.53	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	105.51	394.56	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	89.09	21.69	48.01	58.18	21.69	48.01	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	612.96	79.99	1,202.50	0.00	647.39	1,664.73	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	0.00	81.70	0.00	0.00	0.00	0.00	0.00	0.00

174.66	70.14	1,351.38	245.08	1,187.78	146.02	0.00	0.00	0.00	0.00	0.00	0.00

504.00	193.90	3,907.14	0.00	360.04	44.31	0.00	0.00	0.00	0.00	0.00	0.00

3,538.39	5,601.99	9,609.73	6,111.76	4,987.34	12,361.60	0.00	0.00	0.00	0.00	0.00	0.00

170.31	695.50	498.27	5,168.66	108.02	80.25	0.00	0.00	0.00	0.00	0.00	0.00

13,636.52	8,325.86	26,011.62	1,009.53	583.66	720.17	0.00	0.00	0.00	0.00	0.00	0.00

4,285.83	11,263.10	11,272.83	7,319.43	5,081.88	20,081.95	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

71,468.19

82,740.10	146,508.04	66,063.09	101,434.21	104,086.15	0.00	0.00	0.00	0.00	0.00	0.00

3308	AHC CARE M&F 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	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00
W
0.00

4

SUBTOTAL:

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

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3317	AHC CARE FEMALE 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		
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	0.00	0.00	0.00	0.00	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	

1

2

SUBTOTAL:

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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	0.00	0.00	-84.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-123.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	-207.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
2,790.93	
91.35	
16,437.45	
4,363.88	
274,170.56	
63,152.67	
453,640.05	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
246.62	
3,359.84	
0.00	
60,690.69	
43,258.55	
1,127,624.20	
523,253.52	
1,205,107.35	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

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

3508	ADULT 40-100% M&F 45	0.00	0.00	2,553.86	0.00	105.51	131.56	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	43.83	0.00	0.00	21.82	25.70	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	13,222.08	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL E

911.05	84.70	1,203.19	1,329.48	45.31	790.15	0.00	0.00	0.00	0.00	0.00	0.00

3516	ADULT 40-100% MALE 2	31,925.03	31,046.31	93,315.47	49,847.53	28,052.89	39,983.33	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

12,294.00	3,333.58	14,103.28	9,486.39	17,241.16	6,694.26	0.00	0.00	0.00	0.00	0.00	0.00

3518	ADULT 40-100% M&F 45	65,376.33	62,636.67	86,530.21	62,232.60	77,425.47	99,438.77	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 AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6

0.00	0.00	0.00	0.00	246.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,741.29	1,260.00	0.00	170.39	48.25	139.91	0.00	0.00	0.00	0.00	0.00	0.00

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

3714	ADULT <40% EXP MALE	7,292.84	12,081.73	19,979.50	3,571.18	6,165.38	11,600.06	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

4,451.72	328.62	16,586.75	12,371.04	3,512.57	6,007.85	0.00	0.00	0.00	0.00	0.00	0.00

3716	ADULT <40% EXP MALE	136,455.42	205,325.04	266,134.03	102,321.13	255,550.69	161,837.89	0.00	0.00	0.00	0.00	0.00	0.00

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

94,474.99	126,480.57	88,278.29	77,117.72	75,243.41	61,658.54	0.00	0.00	0.00	0.00	0.00	0.00

181,612.85	129,721.57	241,985.31	168,543.69	210,132.57	273,111.36	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 December 31, 2015

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

3719	ADULT <40% EXP M&F
6
3727	ADULT <40% EXP FEM
AL
3728	ADULT <40% EXP M&F
4

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

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

0.00	1,260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,260.00

SUBTOTAL:

536,535.52

576,817.99	830,669.89	486,991.15	673,791.65	674,641.46	0.00	0.00	0.00	0.00	0.00	0.00	3,779,447.66

0.00	
0.00	
1,108.99	
0.00	
697.18	
4,477.65	
35,203.90	
51,175.98	
202,046.34	
0.00	
0.00	
294,710.04	

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
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6

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

627.65	95.99	385.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	697.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

303.87	213.29	165.29	178.10	3,617.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	2,249.16	5,021.93	10,459.28	5,204.43	5,186.22	7,082.88	0.00	0.00	0.00	0.00	0.00	0.00

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

2,574.73	5,949.64	7,868.75	10,984.25	13,427.45	10,371.16	0.00	0.00	0.00	0.00	0.00	0.00

51,923.13	16,392.55	23,221.63	35,300.47	24,728.16	50,480.40	0.00	0.00	0.00	0.00	0.00	0.00

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

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

SUBTOTAL:

57,678.54

27,673.40	42,100.30	52,364.43	46,958.93	67,934.44	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	
16,675.77	
6,249.56	
12,618.68	
35,544.01	

920.33	606.76	51.87	3,005.28	2,948.59	9,142.94	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	4,687.80	1,065.11	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	2,355.99	5,473.69	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,509.36

803.26	359.55	7,197.72	9,992.38	15,681.74	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	
41.45	
0.00	
0.00	
41.45	

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

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

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

SUBTOTAL:

10.17

15.64	0.00	0.00	15.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	22.70	0.00	274.10	91.00	262.32	0.00	0.00	0.00	0.00	0.00	0.00

650.12	
0.00	
0.00	
650.12	

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

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	91.00	262.32	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	1,476,134.55	1,569,184.87	2,042,720.13	1,650,143.77	1,740,551.86	1,821,464.26	0.00	0.00	0.00	0.00	0.00	0.00		10,300,199.44		

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

For The Period Ending December 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
2110	SSI AGED NON-MEDICA
R

106,605.75	138,772.37	243,060.06	109,396.22	86,575.09	110,463.52	0.00	0.00	0.00	0.00	0.00	0.00	794,873.01

26,434.90	13,763.26	31,784.99	27,506.02	11,008.01	20,476.11	0.00	0.00	0.00	0.00	0.00	0.00	130,973.29

2120	SSI AGED WITH QMB	121,926.99	174,038.05	225,195.50	122,450.70	94,459.04	143,149.01	0.00	0.00	0.00	0.00	0.00	0.00	881,219.29

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

45,476.20	32,686.17	56,715.55	29,618.96	25,027.91	41,363.82	0.00	0.00	0.00	0.00	0.00	0.00	230,888.61

688,624.66	871,046.82	795,795.36	508,232.84	646,246.26	763,839.63	0.00	0.00	0.00	0.00	0.00	0.00	4,273,785.57

48,687.58	68,819.71	112,495.22	51,083.18	51,662.77	56,329.19	0.00	0.00	0.00	0.00	0.00	0.00	389,077.65

2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	59.40	0.00	32.09	0.00	0.00	0.00	0.00	0.00	0.00	225.82

2310	SSI BLIND NON-MEDIC A

8,400.00	7,019.66	6,650.00	5,950.00	2,407.81	8,076.38	0.00	0.00	0.00	0.00	0.00	0.00	38,503.85

2320	SSI BLIND WITH QMB	431.94	428.25	416.46	71.62	789.22	833.02	0.00	0.00	0.00	0.00	0.00	0.00	2,970.51

SUBTOTAL:

1,046,662.95

1,306,924.29	1,472,172.54	854,718.94	918,176.11	1,144,562.77	0.00	0.00	0.00	0.00	0.00	0.00	6,743,217.60

M M

1,046,662.95	1,306,924.29	1,472,179.89	854,718.94	918,275.64	1,144,562.77	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

106.88

0.00

106.88

8710	SSI DISABLED FREEDO	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

6,743,324.48

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

For The Period Ending December 31, 2015

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

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1,685,117.40	1,915,799.87	2,681,450.39	1,999,482.31	2,206,654.38	2,521,199.26	0.00	0.00	0.00	0.00	0.00	0.00	13,009,703.61

134,210.18	86,635.19	183,540.43	121,497.09	95,581.49	106,014.38	0.00	0.00	0.00	0.00	0.00	0.00	727,478.76

2120	SSI AGED WITH QMB	2,732,315.87	2,691,509.27	3,869,487.21	2,806,461.70	3,006,316.90	3,483,453.49	0.00	0.00	0.00	0.00	0.00	0.00	18,589,544.44

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

484,829.08	429,355.23	623,488.25	496,865.31	514,028.21	644,163.05	0.00	0.00	0.00	0.00	0.00	0.00	3,192,729.13

1,738,486.52	1,802,598.11	2,237,418.61	1,856,867.73	1,821,700.40	2,248,380.45	0.00	0.00	0.00	0.00	0.00	0.00	11,705,451.82

585,872.48	620,560.01	851,203.88	615,551.90	612,586.36	832,248.41	0.00	0.00	0.00	0.00	0.00	0.00	4,118,023.04

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	10,469.71	3,611.59	0.00	0.00	0.00	0.00	0.00	0.00	45,707.17

2320	SSI BLIND WITH QMB	4,994.88	7,132.53	7,260.58	5,253.26	5,833.93	6,424.90	0.00	0.00	0.00	0.00	0.00	0.00	36,900.08

8710	SSI DISABLED FREEDO	0.00	1,877.34	5,037.06	2,637.12	0.00	2,709.12	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	2,056.32	4,112.64	0.00	0.00	0.00	0.00	0.00	0.00	
	1,712.52	4,868.22	9,185.70	4,689.12	2,056.32	6,821.76	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

7,373,566.73

7,561,011.13    10,463,925.17	7,908,368.11	8,273,171.38	9,845,495.53	0.00	0.00	0.00	0.00	0.00	0.00	51,425,538.05

M M
SUBTOTAL:

12,260.64

17,073.00

29,333.64

TOTAL:	7,375,279.25	7,565,879.35	10,473,110.87	7,913,057.23	8,275,227.70	9,852,317.29	0.00	0.00	0.00	0.00	0.00	0.00		51,454,871.69		

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

For The Period Ending December 31, 2015

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

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

57,961.58	35,627.77	43,341.81	22,249.92	35,336.54	18,733.95	0.00	0.00	0.00	0.00	0.00	0.00	213,251.57

16,433.83	946.68	83,538.56	8,338.74	936.50	2,605.51	0.00	0.00	0.00	0.00	0.00	0.00	112,799.82

2120	SSI AGED WITH QMB	443.59	1,507.61	18.05	566.68	28.46	76.41	0.00	0.00	0.00	0.00	0.00	0.00	2,640.80

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

11,220.75	6,502.00	26,013.79	7,482.95	9,714.19	1,405.20	0.00	0.00	0.00	0.00	0.00	0.00	62,338.88

26,834.51	19,004.26	28,589.63	10,783.29	71,004.32	45,428.28	0.00	0.00	0.00	0.00	0.00	0.00	201,644.29

2,359.28	722.71	6,308.23	1,497.53	1,372.98	2,162.54	0.00	0.00	0.00	0.00	0.00	0.00	14,423.27

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

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	118,392.99	70,411.89	0.00	0.00	0.00	0.00	0.00	0.00	613,755.46

M M

121,910.37	64,311.03	187,810.07	50,919.11	118,392.99	70,411.89	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

0.00

0.00

0.00

8710	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	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	

TOTAL:

613,755.46

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

For The Period Ending December 31, 2015

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

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

17,791.38	16,157.36	33,799.85	22,186.80	28,584.66	11,004.95	0.00	0.00	0.00	0.00	0.00	0.00	129,525.00

68.35	0.00	655.42	0.00	206.68	50.89	0.00	0.00	0.00	0.00	0.00	0.00	981.34

2120	SSI AGED WITH QMB	12,713.06	10,199.58	16,135.95	9,872.20	12,567.92	15,770.42	0.00	0.00	0.00	0.00	0.00	0.00	77,259.13

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

1,998.01	5,671.10	17,991.36	2,677.54	3,446.03	8,612.53	0.00	0.00	0.00	0.00	0.00	0.00	40,396.57

39,207.69	57,526.26	37,706.14	98,519.59	47,761.48	76,557.96	0.00	0.00	0.00	0.00	0.00	0.00	357,279.12

2,612.76	3,357.96	4,743.41	3,725.64	6,845.49	13,692.39	0.00	0.00	0.00	0.00	0.00	0.00	34,977.65

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	48.21	48.21	0.00	0.00	0.00	0.00	0.00	0.00	436.87

8710	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	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	

SUBTOTAL:

74,428.21

93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	0.00	0.00	0.00	0.00	0.00	0.00	640,855.68

M M
SUBTOTAL:

0.00

0.00

0.00

TOTAL:	74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	0.00	0.00	0.00	0.00	0.00	0.00		640,855.68		

C

N

183,782.09	170,408.91	173,185.84	164,735.13	157,227.01	237,286.25	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

KidsCare - CAPITATION AMOUNTS

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	1,007.22	1,007.22	833.38	959.01	959.01	2,143.00	0.00	0.00	0.00	0.00	0.00	0.00		6,908.84		
6012	KIDS 1-5 M & F NON-M	220.96	220.96	220.96	223.26	223.26	544.33	0.00	0.00	0.00	0.00	0.00	0.00		1,653.73		
6013	KIDS 6-13 M & F NON-	58,022.76	55,071.22	54,144.19	51,905.62	50,587.41	81,247.87	0.00	0.00	0.00	0.00	0.00	0.00		350,979.07		
6014	KIDS 14-19 MALE NON-	49,755.46	44,451.13	44,464.06	45,078.81	41,422.38	59,062.76	0.00	0.00	0.00	0.00	0.00	0.00		284,234.60		
6015	KIDS 14-19 FEMALE NO	74,775.69	69,658.38	67,362.69	66,568.43	64,034.95	94,288.29	0.00	0.00	0.00	0.00	0.00	0.00		436,688.43		
9960	KIDSCARE KICK PAYME	0.00	0.00	6,160.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,160.56		
	183,782.09	170,408.91	173,185.84	164,735.13	157,227.01	237,286.25	0.00	0.00	0.00	0.00	0.00	0.00		1,086,625.23		

TOTAL:

1,086,625.23

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending December 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	1.66	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		11.66		
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
6013	KIDS 6-13 M & F NON-	456.25	434.86	420.34	395.88	383.89	368.99	0.00	0.00	0.00	0.00	0.00	0.00		2,460.21		
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	242.85	218.16	218.83	0.00	0.00	0.00	0.00	0.00	0.00		1,412.30		
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	240.85	230.13	226.93	0.00	0.00	0.00	0.00	0.00	0.00		1,477.69		
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		
	993.61	932.52	910.22	883.58	836.18	816.75	0.00	0.00	0.00	0.00	0.00	0.00		5,372.86		

C

N
SUBTOTAL:

TOTAL:	993.61	932.52	910.22	883.58	836.18	816.75	0.00	0.00	0.00	0.00	0.00	0.00		5,372.86		

34,530.18	36,831.10	35,191.60	42,451.52	0.00	0.00	0.00	0.00	0.00	0.00	

C

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending December 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	82.84	125.24	0.00	0.00	0.00	0.00	0.00	0.00		478.67		
6012	KIDS 1-5 M & F NON-M	75.10	75.10	75.10	82.84	82.84	101.76	0.00	0.00	0.00	0.00	0.00	0.00		492.74		
6013	KIDS 6-13 M & F NON-	16,709.75	16,146.50	15,620.80	15,698.18	15,532.50	19,008.02	0.00	0.00	0.00	0.00	0.00	0.00		98,715.75		
6014	KIDS 14-19 MALE NON-	9,776.08	8,979.83	9,075.34	10,574.10	9,401.08	11,247.46	0.00	0.00	0.00	0.00	0.00	0.00		59,053.89		
6015	KIDS 14-19 FEMALE NO	10,772.21	10,088.61	9,721.39	10,393.14	10,092.34	11,969.04	0.00	0.00	0.00	0.00	0.00	0.00		63,036.73		
SUBTOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	42,451.52	0.00	0.00	0.00	0.00	0.00	0.00		221,777.78		

TOTAL:

37,408.24

35,365.14

221,777.78

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending December 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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
6013	KIDS 6-13 M & F NON-	445.00	430.00	416.00	379.00	375.00	359.00	0.00	0.00	0.00	0.00	0.00	0.00		2,404.00		
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	235.00	210.00	211.00	0.00	0.00	0.00	0.00	0.00	0.00		1,363.00		
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	231.00	223.00	220.00	0.00	0.00	0.00	0.00	0.00	0.00		1,445.00		
SUBTOTAL:	968.00	918.00	894.00	849.00	812.00	792.00	0.00	0.00	0.00	0.00	0.00	0.00		5,233.00		

C

TOTAL:	968.00	918.00	894.00	849.00	812.00	792.00	0.00	0.00	0.00	0.00	0.00	0.00		5,233.00		

-818.92	773.91	436.32	1,804.78	404.49	334.79	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

KidsCare - FEE FOR SERVICE

For The Period Ending December 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	72.88	323.60	0.00	0.00	0.00	0.00	0.00	0.00		2,946.72		
6014	KIDS 14-19 MALE NON-	-652.26	85.01	0.00	96.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-471.05		
6015	KIDS 14-19 FEMALE NO	-174.33	326.70	118.31	203.32	331.61	11.19	0.00	0.00	0.00	0.00	0.00	0.00		816.80		
	-818.92	773.91	436.32	1,804.78	404.49	334.79	0.00	0.00	0.00	0.00	0.00	0.00		2,935.37		

TOTAL:

2,935.37

KidsCare - REINSURANCE

For The Period Ending December 31, 2015	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6013	KIDS 6-13 M & F NON-	161.54	203.93	36,712.84	0.01	0.00	-0.01	0.00	0.00	0.00	0.00	0.00	0.00		37,078.31		
6014	KIDS 14-19 MALE NON-	0.00	29,016.36	29,093.10	36,857.22	90,654.13	25,128.40	0.00	0.00	0.00	0.00	0.00	0.00		210,749.21		
6015	KIDS 14-19 FEMALE NO	0.00	1,274.86	5,182.91	20,265.16	13,172.36	268.82	0.00	0.00	0.00	0.00	0.00	0.00		40,164.11		
	161.54	30,495.15	70,988.85	57,122.39	103,826.49	25,397.21	0.00	0.00	0.00	0.00	0.00	0.00		287,991.63		

SUBTOTAL:

TOTAL:	161.54	30,495.15	70,988.85	57,122.39	103,826.49	25,397.21	0.00	0.00	0.00	0.00	0.00	0.00		287,991.63		

110007

DES-DD - CAP MEMBER MONTHS

For The Period Ending December 31, 2015

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

1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	17.00

1010	TANF NON-MEDICARE	643.15	641.57	646.12	649.50	648.46	646.64	0.00	0.00	0.00	0.00	0.00	0.00	3,875.44

1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00

2100	SSI AGED WITH MEDICA	151.70	154.89	157.99	163.43	165.59	167.99	0.00	0.00	0.00	0.00	0.00	0.00	961.59

2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.19	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	28.19

2120	SSI AGED WITH QMB	272.31	272.62	271.31	271.53	273.47	273.79	0.00	0.00	0.00	0.00	0.00	0.00	1,635.03

2200	SSI DISABLED WITH ME	1,753.65	1,745.73	1,754.42	1,769.90	1,793.19	1,805.13	0.00	0.00	0.00	0.00	0.00	0.00	10,622.02

220Z	SSI DISABLED WITH ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2210	SSI DISABLED NON-MED	21,475.15	21,538.50	21,702.85	21,678.83	21,721.06	21,781.29	0.00	0.00	0.00	0.00	0.00	0.00	129,897.68

221Z	SSI DISABLED NON-MED	0.03	0.00	0.00	0.03	0.00	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.70

2220	SSI DISABLED WITH QM	3,977.48	3,986.67	4,014.73	4,014.04	4,014.92	4,011.64	0.00	0.00	0.00	0.00	0.00	0.00	24,019.48

222Z	SSI DISABLED WITH QM	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

2300	SSI BLIND WITH MEDIC	13.00	13.00	13.00	14.00	14.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	81.00

2310	SSI BLIND NON-MEDICA	111.00	112.38	114.06	111.81	116.00	115.00	0.00	0.00	0.00	0.00	0.00	0.00	680.25

2320	SSI BLIND WITH QMB	28.00	29.00	28.00	28.00	27.30	27.00	0.00	0.00	0.00	0.00	0.00	0.00	167.30

8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	42.00

8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00

8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	18.00

SUBTOTAL: TOTAL:

28,445.47

28,445.47

28,515.36	28,722.48	28,721.26	28,794.99	28,866.12	0.00	0.00

6

28,515.36	28,722.48	28,721.2	28,794.99	28,866.12	0.00	0.00

0.00	0.00	0.00

00

0.00	0.	0.00

0.00	172,065.68

0.00	172,065.68

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending December 31, 2015

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL EPD
TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	370,741.89
84,945,196.47	366,197.37
97,607,756.74	369,544.65
86,404,566.22	371,342.65
86,818,575.78	369,390.76
99,193,232.58	367,883.84
87,564,861.12	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	2,215,101.16
542,534,188.91	
	85,315,938.36
97,105,888.85	97,973,954.11
97,348,150.88	86,774,110.87
98,057,803.05	87,189,918.43
98,603,338.74	99,562,623.34
98,857,708.49	87,932,744.96
101,562,045.28	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	544,749,290.07
591,534,935.29	
	97,105,888.85	97,348,150.88	98,057,803.05	98,603,338.74	98,857,708.49	101,562,045.28	0.00	0.00	0.00	0.00	0.00	0.00	591,534,935.29	
TOTAL LTC - CAP	182,421,827.21	195,322,104.99	184,831,913.92	185,793,257.17	198,420,331.83	189,494,790.24	0.00	0.00	0.00	0.00	0.00	0.00	1,136,284,225.36	

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	9,411,356.80
0.00	11,193,029.30
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	59,452,807.31
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	11,193,029.30	0.00	0.00	0.00	0.00	0.00	0.00	59,452,807.31	

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	5,239,547.36
616,786.74	3,396,112.43
373,282.71	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	23,709,297.10
3,194,112.15	
	375,457.62	326,085.82	792,734.80	709,764.46	616,786.74	373,282.71	0.00	0.00	0.00	0.00	0.00	0.00	3,194,112.15	
TOTAL LTC - REIN	4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	5,856,334.10	3,769,395.14	0.00	0.00	0.00	0.00	0.00	0.00	26,903,409.25	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	3,116,250.30	3,135,587.40	3,128,183.70	3,118,231.90	3,139,674.00	3,156,287.10	0.00	0.00	0.00	0.00	0.00	0.00	18,794,214.40	

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

117

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending December 31, 2015

010115	CRS FULLY INTEGRATED PLAN - CAP	13,474,971.60	13,492,632.75	13,576,771.54	13,943,462.74	13,889,830.86	19,837,251.02	0.00	0.00	0.00	0.00	0.00	0.00	88,214,920.51	
010145	CRS ACUTE SEMI INTEGRATED - CAP	122,251.86	115,316.41	116,070.08	130,768.30	127,797.18	190,317.07	0.00	0.00	0.00	0.00	0.00	0.00	802,520.90	
999125	CRS SEMI INTEGRATED PLAN - CAP	3,253,162.92	3,256,188.18	3,258,709.23	4,767,213.72	4,765,739.40	4,794,488.64	0.00	0.00	0.00	0.00	0.00	0.00	24,095,502.09	
999135	CRS ONLY PLAN - CAP	476,979.36	481,148.76	485,318.16	546,356.40	545,428.80	542,646.00	0.00	0.00	0.00	0.00	0.00	0.00	3,077,877.48	
	17,327,365.74	17,345,286.10	17,436,869.01	19,387,801.16	19,328,796.24	25,364,702.73	0.00	0.00	0.00	0.00	0.00	0.00	116,190,820.98	

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

TOTAL

Wednesday, January 13, 2016

999155	CRS REINSURANCE ONLY	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	2,963,907.95	0.00	0.00	0.00	0.00	0.00	0.00	11,462,829.93	
	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	2,963,907.95	0.00	0.00	0.00	0.00	0.00	0.00	11,462,829.93	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC CAP	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	49,375.16	0.00	0.00	0.00	0.00	0.00	0.00	186,328.06	
	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	49,375.16	0.00	0.00	0.00	0.00	0.00	0.00	186,328.06	

Subtotal

Subtotal

19,545,976.24	18,869,023.14	19,332,548.29	21,423,030.67	20,291,414.79	28,377,985.84	0.00	0.00	0.00	0.00	0.00	0.00	127,839,978.97	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending December 31, 2015

010115	CRS FULLY INTEGRATED PLAN - MM	17,063.13	17,085.46	17,193.00	17,270.81	17,202.37	17,235.55	0.00	0.00	0.00	0.00	0.00	0.00	103,050.32	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	168.21	164.43	179.03	0.00	0.00	0.00	0.00	0.00	0.00	1,015.08	
999125	CRS SEMI INTEGRATED PLAN - MM	6,452.00	6,458.00	6,463.00	6,467.00	6,465.00	6,504.00	0.00	0.00	0.00	0.00	0.00	0.00	38,809.00	
999135	CRS ONLY PLAN - MM	1,144.00	1,154.00	1,164.00	1,178.00	1,176.00	1,170.00	0.00	0.00	0.00	0.00	0.00	0.00	6,986.00	
	24,833.16	24,861.60	24,985.24	25,084.02	25,007.80	25,088.58	0.00	0.00	0.00	0.00	0.00	0.00	149,860.40	

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

TOTAL

Wednesday, January 13, 2016

010115	CRS FULLY INTEGRATED PLAN - KC MM	36.87	32.00	33.00	34.99	35.00	32.93	0.00	0.00	0.00	0.00	0.00	0.00	204.79	
	36.87	32.00	33.00	34.99	35.00	32.93	0.00	0.00	0.00	0.00	0.00	0.00	204.79	

Subtotal

Subtotal

24,870.03	24,893.60	25,018.24	25,119.01	25,042.80	25,121.51	0.00	0.00	0.00	0.00	0.00	0.00	150,065.19	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending December 31, 2015

010700	HEALTH CHOICE INTEGRATED - CAP	0.00	0.00	-1,518.09	8,509,580.12	8,451,274.03	8,456,882.74	0.00	0.00	0.00	0.00	0.00	0.00	25,416,218.80	
010725	CENPATICO INTEGRATED - CAP	0.00	0.00	18,507.72	21,037,755.17	20,895,096.45	20,866,872.26	0.00	0.00	0.00	0.00	0.00	0.00	62,818,231.60	
078999	MERCY MARICOPA INTEGRATED - CAP	47,152,827.77	47,326,614.65	47,809,819.28	44,365,579.73	44,294,160.01	45,009,901.61	0.00	0.00	0.00	0.00	0.00	0.00	275,958,903.05	
	47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	74,333,656.61	0.00	0.00	0.00	0.00	0.00	0.00	364,193,353.45	

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

TOTAL

Wednesday, January 13, 2016

Subtotal

47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	74,333,656.61	0.00	0.00	0.00	0.00	0.00	0.00	364,193,353.45	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending December 31, 2015

010700	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	-1.00	5,604.33	5,566.18	5,569.66	0.00	0.00	0.00	0.00	0.00	0.00	16,739.17	
010725	CENPATICO INTEGRATED - MM	0.00	0.00	12.00	13,638.68	13,546.91	13,528.13	0.00	0.00	0.00	0.00	0.00	0.00	40,725.72	
078999	MERCY MARICOPA INTEGRATED - MM	19,430.16	19,501.43	19,702.99	19,787.96	19,758.81	20,068.81	0.00	0.00	0.00	0.00	0.00	0.00	118,250.16	
	19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,166.60	0.00	0.00	0.00	0.00	0.00	0.00	175,715.05	

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

TOTAL

Wednesday, January 13, 2016

Subtotal

19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,166.60	0.00	0.00	0.00	0.00	0.00	0.00	175,715.05	

GRAND TOTAL