February 26, 2016

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

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

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

SUBJECT:  FY 2016 Appropriation Status Report for the Period Ended January 31, 2016

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 January 31, 2016.

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 of Fiscal 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 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov

The Honorable Andy Biggs
The Honorable David M. Gowan, Sr. February 26, 2016
Page 2

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

Enrollment Update – January 2016 enrollment is 1,845,353 members, a 7,371 member decrease over the prior month. Enrollment for February 2016 increased to 1,845,530  members, an increase of 177 members.

Major February changes by eligibility category include: 1931 for Families and Children/SOBRA
– decrease of 5,905; Supplemental Security Income – increase of 141; Prop 204 Restoration – increase of 696; Adult Expansion - increase of 3,720; Medicare Cost Sharing – increase of 1,521; and Federal Emergency Services – increase of 138.

Note that the February 1st enrollment report indicated a decrease of 8,775; however, it was discovered that the February 1st enrollment was understated due to a timing issue in which 8,952 SOBRA newborns moved to SOBRA children during the period of time when the report  was run. As such, the report captured the decrease in the newborn category but did not reflect the increase in the child category.

Tobacco Funds Revenue Update –Tobacco tax collections through January 2016 are $4.7 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 January 31, 2016

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 January 31, 2016
SUMMARY OF APPROPRIATED EXPENDITURES

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

AHCCCS Operating Lump Sum	$	78,225,400		$	40,048,000		$	40,237,719		$	(189,719)		$	78,225,400		$	-	
AHCCCS Prop 204 Administration	8,565,300		4,144,400		5,209,979		(1,065,579)		8,565,300		-	
DES Eligibility	54,874,500		29,763,300		32,975,977		(3,212,677)		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		20,488,500		8,244,559		12,243,941		38,358,700		-	
TOTAL ADMINISTRATION	180,023,900		94,444,200		86,668,235		7,775,965		180,023,900		-	

APPROPRIATIONS: ADMINISTRATION

Traditional Medicaid Services	3,438,803,700	1,946,447,500	2,141,432,535	(194,985,035)	3,438,803,700	-
Proposition 204 Services	2,507,700,600	1,404,332,900	1,387,674,125	16,658,775	2,507,700,600	-
ACA Adult Expansion	396,683,800	221,040,300	216,665,550	4,374,750	396,683,800	-
Children's Rehabilitative Services	233,839,100	131,836,400	143,004,207	(11,167,807)	233,839,100	-
KidsCare Services	6,295,200	3,630,100	1,136,867	2,493,233	6,295,200	-
ALTCS Services	1,386,588,900	779,254,800	744,640,101	34,614,699	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	214,215,400	214,215,369	31	342,323,786	-

 	 	 	 	
TOTAL PROGRAMMATIC	8,339,972,186	4,700,757,400	4,854,014,704	(153,257,304)	8,339,972,186	-

TOTAL EXPENDITURES

$	8,519,996,086

$    4,795,201,600

$   4,940,682,939

$	(145,481,339)

$  8,519,996,086	$	-

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending January 31, 2016 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	
$	27,129,400	
$	24,754,397		
2,375,003		
$	51,537,900		
$	-	
Proposition 204 - Administrative Expenditures	20,280,700	10,633,500	4,295,780		6,337,720		20,280,700		-	
Programmatic Expenditures Traditional Medicaid Services	
800,323,100	
450,141,600	
510,403,657		
(60,262,057)		
800,323,100		
-	
Proposition 204 Services	90,000,000	118,098,200	60,111,323		57,986,877		90,000,000		-	
Children's Rehabilitative Services	72,487,200	41,051,100	42,049,488		(998,388)		72,487,200		-	
KidsCare Services	338,000	305,600	(22,852)		328,452		338,000		-	
ALTCS Services	162,880,800	92,045,300	95,013,800		(2,968,500)		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	739,404,700	738,236,033		1,168,667		1,205,162,300		-		

Administrative Expenditures	
81,114,000		
42,568,900	
48,385,132		
(5,816,232)		
81,114,000		
-	
Proposition 204 - Administrative Expenditures	23,160,400		12,139,100	7,417,309		4,721,791		23,160,400		-	
Programmatic Expenditures Traditional Medicaid Services	
2,271,456,100		
1,281,855,000	
1,360,200,662		
(78,345,662)		
2,271,456,100		
-	
Proposition 204 Services	2,048,414,400		1,146,546,900	1,170,130,394		(23,583,494)		2,048,414,400		-	
ACA Adult Expansion	396,683,800		221,040,300	216,665,550		4,374,750		396,683,800		-	
Children's Rehabilitative Services	161,351,900		90,785,300	100,954,719		(10,169,419)		161,351,900		-	
KidsCare Services	5,587,200		3,110,600	1,159,719		1,950,881		5,587,200		-	
ALTCS Services and Nursing Facility Assessment	931,056,600		523,339,200	488,853,790		34,485,410		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	141,287,100	141,287,060	40	233,761,591	-
 	 	 	 	
TOTAL FEDERAL EXPENDITURES	6,173,008,491	3,462,672,400	3,538,669,844	(75,997,444)	6,173,008,491	-

	
1,860,300		
1,741,450		
118,850		
3,482,900		
-	
Traditional Medicaid Services Acute Care		49,879,700		29,096,200		29,096,200		-		49,879,700		-	
ALTCS Services		249,234,600		140,844,100		130,793,914		10,050,186		249,234,600		-	
	171,800,600		161,631,564		10,169,036		302,597,200		-	
TOBACCO FUNDS										
Traditional Medicaid Services Acute Care - Medically Needy		31,180,000		18,494,100		22,611,908		(4,117,808)		31,180,000		-	
Proposition 204 Services - Emergency Health Services		17,331,400		10,320,300		10,490,672		(170,372)		17,331,400		-	
Proposition 204 Services - Proposition 204 Protection		36,396,000		21,588,100		25,642,711		(4,054,611)		36,396,000		-	

Administrative Expenditures Proposition 204 - BNCF	3,482,900 Programmatic Expenditures

TOTAL COUNTY EXPENDITURES	302,597,200

Programmatic Expenditures

Proposition 204 Services - ATLSF	100,000,000	-	-	-	100,000,000	-

	58,745,291		(8,342,791)		184,907,400		-	
	OTHER											

Prescription Drug Rebate Program	448,000	113,000		
74,168		
38,832		
448,000		
-	
									
Acute Care - Prescription Drug Rebate Program State Match		77,855,000	45,561,300		45,561,250		50		77,855,000		-	
Acute Care - Prescription Drug Rebate Program Federal Authority		207,883,900	121,265,900		173,268,385		(52,002,485)		207,883,900		-	
Long Term Care - Prescription Drug Rebate Program State Match		5,475,800	3,097,800		3,194,217		(96,417)		5,475,800		-	
Long Term Care - Prescription Drug Rebate Program Federal Authority		14,574,200	8,245,100		13,116,780		(4,871,680)		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	-		260,817		(260,817)		194,700		-	
ALTCS Services - TPL		-	-		413,874		(413,874)		-		-	

TOTAL TOBACCO EXPENDITURES	184,907,400	50,402,500

Administrative Expenditures

Programmatic Expenditures

ALTCS Services - Nursing Facility Assessment	23,366,900	11,683,300	13,253,727	(1,570,427)	23,366,900	-
KidsCare Services Premiums	370,000	213,900	-	213,900	370,000	-
Freedom to Work Premiums	31,200	33,400	29,656	3,744	31,200	-
Voluntary Political Subdivision Programs - See Note 5	108,562,195	72,928,300	72,928,309	(9)	108,562,195	-
 	 	 	 	
TOTAL OTHER  EXPENDITURES	654,320,695	370,921,400	443,400,206	(72,478,806)	654,320,695	-

	TOTAL		

Administrative Expenditures		
180,023,900	
94,444,200		
86,668,235		
7,775,965		
180,023,900		
-	
Acute Care		6,953,383,286	3,921,502,600		4,109,374,603		(187,872,003)		6,953,383,286		-	
Long Term Care		1,386,588,900	779,254,800		744,640,101		34,614,699		1,386,588,900		-	
TOTAL EXPENDITURES	$	8,519,996,086	$	4,795,201,600		$	4,940,682,938		$	(145,481,338)		$	8,519,996,086		$	-	

BUDGET

BUDGET
YTD

RECEIPTS
YTD

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

GENERAL FUND:

FEDERAL:

COUNTY:

TOBACCO FUNDS:

OTHER:

TOTAL REVENUE

$

8,519,996,086

$

4,795,201,600

$

5,170,872,445

Traditional Medicaid Services & Administrative	$	931,662,800		$	518,322,100		$	578,837,982	
Proposition 204 Services & Administrative	110,280,700		128,731,700		64,407,103	
KidsCare Services	338,000		305,600		(22,852)	
ALTCS Services	 	162,880,800 			 	92,045,300 			 	95,013,800 		
TOTAL	1,205,162,300		739,404,700		738,236,033	

Acute & Administrative	5,236,364,691		2,936,222,600		3,185,635,544	
KidsCare Services	5,587,200		3,110,600		1,784,478	
ALTCS Services	 	931,056,600 			 	523,339,200 			 	528,286,461 		
TOTAL	6,173,008,491		3,462,672,400		3,715,706,483	

Acute & Administrative	53,362,600		30,956,500		27,514,017	
ALTCS Services	 	249,234,600 			 	140,844,100 			 	145,386,857 		
TOTAL	302,597,200		171,800,600		172,900,874	

Traditional Medicaid Services	31,180,000		18,494,100		22,611,908	
Proposition 204 Services	 	153,727,400 			 	31,908,400 			 	36,133,383 		
TOTAL	184,907,400		50,402,500		58,745,291	

Administrative	448,000		113,000		74,168	
Acute Care - Prescription Drug Rebate Program	285,738,900		166,827,200		218,829,635	
Long Term Care - Prescription Drug Rebate Program	20,050,000		11,342,900		16,310,997	
Hospital Assessment	215,558,800		107,779,400		123,092,973	
ALTCS - Nursing Facility Assessment	23,366,900		11,683,300		119,335	
Acute TPL - Note 1	194,700		-		260,817	
LTC TPL - Note 1	-		-		413,874	
KidsCare TPL - Note 1	-		-		20,940	
Member Premiums - CHIP	370,000		213,900		198,807	
Member Premiums - Freedom to Work	31,200		33,400		29,656	
Voluntary Political Subdivision - State Match	 	108,562,195 			 	72,928,300 			 	125,932,563 		
TOTAL	654,320,695		370,921,400		485,283,764	

 	

Appropriation Status Report
Footnotes

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

Note 1:	Third Party Liability Collections: Gross Collections:	January 2016		January 2015		July 1, 2015
January 31, 2016		July 1, 2014
January 31, 2015	
	Acute	$	386,549		$	423,864		$	2,516,895		$	3,295,348	
	LTC	222,947		256,339		1,813,536		2,097,777	
	KidsCare	-		7,785		104,447		11,488	
	Total TPL Collections	$	609,496		$	687,988		$	4,434,878		$	5,404,613	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	23,962		$	65,045		$	260,817		$	434,838	
LTC	52,122		54,156		413,874		488,057	
KidsCare	(2)		1,483		20,940		2,210	
Total Expenditure Offsets	$	76,082		$	120,684		$	695,631		$	925,105	

FY 16 Total

Note 2:    Authorized Positions	1,029.2
Actual Positions as of January 31, 2016	913.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2015	

$	2,853,728	
	Revenues	3,120,180	
	Transfers-In	 	315,101 		
	Total Revenues	 	3,435,281 		
	Expenditures	3,402,836	
	Transfers-out	 	920,066 		
	Total Expenditures	 	4,322,902 		
	Ending Balance January 31, 2016	  $	1,966,108 		

Of the $1,966,108 ending balance, $1,043,550 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 January 31, 2016

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 January 31, 2016

Note 5:	Summary of Voluntary Political Subdivision Contribution Expenditures.			

As of January 31, 2016 Expenditures		
		State Match		Federal		Total	
	
DSH Voluntary	
$	607,333		
$	1,245,986		
$	1,853,319	
	GME Voluntary	52,396,919		111,158,965		163,555,884	
	Safety Net Care Pool	19,924,057		28,882,109		48,806,166	
	Total Voluntary Political Subdivision Program Expenditures	$	72,928,309		$	141,287,060		$	214,215,369	

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 January 31, 2016
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 January 31, 2016

TITLE XIX TRADITIONAL

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

TOTAL

CAPITATION - ACUTE	272,366,959	276,316,415	279,166,770	275,407,979	274,717,280	321,423,200	271,362,223	0	0	0	0	0	1,970,760,826	
CAPITATION - LTC	182,421,827	195,322,105	184,831,914	185,793,257	198,420,332	189,544,234	185,883,929	0	0	0	0	0	1,322,217,598	
MENTAL HEALTH - CHILD	24,739,142	24,849,877	25,557,281	28,336,540	28,517,836	31,518,669	28,859,923	0	0	0	0	0	192,379,268	
MENTAL HEALTH - ADULT	11,323,471	11,730,505	12,433,438	944,236	956,134	1,949,346	771,078	0	0	0	0	0	40,108,209	
MENTAL HEALTH - GENERAL	15,232,013	15,779,544	16,725,109	16,942,470	17,155,946	15,591,227	13,835,480	0	0	0	0	0	111,261,789	
MENTAL HEALTH - CMDP	14,633,559	14,896,415	14,987,440	15,967,464	16,435,700	18,339,912	17,026,041	0	0	0	0	0	112,286,532	
CHILDREN'S REHAB SERVICES	3,716,383	3,722,744	3,729,851	5,297,337	5,295,399	5,319,974	5,455,020	0	0	0	0	0	32,536,709	
FEE FOR SERVICE - ACUTE	39,309,584	42,687,182	52,163,025	35,355,326	39,335,094	43,637,685	33,373,888	0	0	0	0	0	285,861,784	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	607,419	638,824	734,158	723,075	0	0	0	0	0	4,723,107	
EMERGENCY SERVICES - FEDERAL	4,601,455	4,572,491	5,962,347	5,124,819	4,140,929	5,688,268	4,450,762	0	0	0	0	0	34,541,072	
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	450,088	0	0	0	0	0	3,393,299	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	374,616	274,232	543,181	277,299	0	0	0	0	0	2,467,911	
INPATIENT INMATES FFS	94,140	163,355	30,952	166,197	96,395	235,228	148,485	0	0	0	0	0	934,751	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	33,509	11,088	28,421	29,734	0	0	0	0	0	210,490	
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	57	0	0	0	0	0	643	
PINAL COUNTY INMATES FFS	0	791	4,402	328	5,014	5,310	6,835	0	0	0	0	0	22,680	
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	-72	0	0	0	0	0	20,791	
FEE FOR SERVICE - LTC	8,618,281	9,030,245	12,244,181	8,955,714	9,411,357	11,193,029	9,149,200	0	0	0	0	0	68,602,008	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	21,120	18,430	22,655	12,515	0	0	0	0	0	156,395	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,303,186	520,396	1,333,715	799,779	799,536	1,430,086	941,904	0	0	0	0	0	7,128,602	
REINSURANCE - ACUTE	7,490,557	6,963,077	9,713,101	10,354,036	7,487,802	9,748,571	2,985,446	0	0	0	0	0	54,742,590	
REINSURANCE - LTC	4,045,763	3,839,634	5,041,535	4,350,748	5,856,334	3,769,395	3,174,328	0	0	0	0	0	30,077,737	
SMIB - ACUTE	9,829,585	10,084,385	10,344,498	10,630,380	10,758,366	10,820,128	12,607,558	0	0	0	0	0	75,074,900	
HIB - ACUTE	261,769	274,050	304,238	305,977	291,872	302,007	303,696	0	0	0	0	0	2,043,609	
Q1	2,399,485	1,983,017	1,927,946	1,981,086	1,974,022	1,905,403	2,072,651	0	0	0	0	0	14,243,609	
SMIB - LTC	2,846,826	2,859,916	2,858,311	2,859,099	2,866,769	2,884,480	3,334,042	0	0	0	0	0	20,509,442	
HIB - LTC	269,425	275,672	269,873	259,133	272,905	271,807	270,456	0	0	0	0	0	1,889,271	
	607,107,950	627,019,248	641,497,165	611,279,516	626,123,714	677,684,870	597,505,643	0	0	0	0	0	4,388,218,107	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending January 31, 2016

TITLE XIX PROP 204

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

TOTAL

CAPITATION - ACUTE	171,977,268	169,158,780	168,592,407	201,257,676	199,521,303	235,448,237	205,650,359	0	0	0	0	0	1,351,606,031	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	62,503	47,177	60,406	28,621	0	0	0	0	0	431,592	
MENTAL HEALTH - ADULT	14,130,226	13,753,412	13,745,030	1,449,862	1,458,767	2,988,321	1,363,117	0	0	0	0	0	48,888,734	
MENTAL HEALTH - GENERAL	19,007,580	18,500,700	18,489,426	26,014,924	26,174,705	26,546,243	24,458,452	0	0	0	0	0	159,192,030	
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	18,131	0	0	0	0	0	108,570	
FEE FOR SERVICE - ACUTE	23,420,195	26,360,064	31,634,361	22,488,296	25,630,747	29,732,231	23,746,555	0	0	0	0	0	183,012,448	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	991,315	851,991	752,086	812,910	0	0	0	0	0	6,932,297	
EMERGENCY SERVICES - FEDERAL	1,615,009	1,756,056	2,298,814	2,324,017	1,395,634	1,620,895	1,262,081	0	0	0	0	0	12,272,506	
FEDERAL ESP CHRONIC SERVICES	0	0	0	0	0	0	381	0	0	0	0	0	381	
FFS MEDICAID IN PUBLIC SCHOOLS	5,786	3,204	5,139	1,380	897	4,447	3,240	0	0	0	0	0	24,093	
INPATIENT INMATES FFS	600,012	766,289	566,467	395,868	507,796	802,928	570,913	0	0	0	0	0	4,210,272	
MOHAVE COUNTY INMATES FFS	0	4,084	692	373	10,051	15,369	123	0	0	0	0	0	30,691	
YAVAPAI COUNTY INMATES FFS	306	0	166	9,252	485	161	990	0	0	0	0	0	11,360	
PINAL COUNTY INMATES FFS	8,167	-1,654	11,736	3,532	14,776	12,078	8,551	0	0	0	0	0	57,185	
PIMA COUNTY INMATES FFS	16,737	14,619	968	21,330	11,636	5,547	222	0	0	0	0	0	71,059	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	174,594	33,475	165,593	246,302	0	0	0	0	0	937,111	
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	2,974	0	0	0	0	0	3,663	
REINSURANCE - ACUTE	3,024,281	3,235,285	3,273,260	5,216,265	4,459,353	3,409,309	1,371,470	0	0	0	0	0	23,989,223	
SMIB - ACUTE	5,190,825	5,190,446	5,117,460	5,152,132	4,954,096	4,968,092	5,781,412	0	0	0	0	0	36,354,461	
HIB - ACUTE	8,649	8,527	5,656	8,584	4,192	4,192	4,233	0	0	0	0	0	44,035	
	240,353,793	239,927,923	245,334,015	265,589,419	265,094,455	306,553,506	265,331,036	0	0	0	0	0	1,828,184,146	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending January 31, 2016

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

TOTAL

CAPITATION - ACUTE	22,690,376	23,251,291	24,201,251	29,417,656	29,997,586	33,503,941	31,696,431	0	0	0	0	0	194,758,531	
MENTAL HEALTH - CHILD	0	0	0	41	0	0	41	0	0	0	0	0	83	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	228,016	237,878	360,470	247,498	0	0	0	0	0	7,991,537	
MENTAL HEALTH - GENERAL	2,968,226	3,090,821	3,246,414	4,091,302	4,268,263	4,542,373	4,440,857	0	0	0	0	0	26,648,256	
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	1,787,248	0	0	0	0	0	14,121,948	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	262,679	334,688	251,090	169,817	0	0	0	0	0	1,710,642	
EMERGENCY SERVICES - FEDERAL	1,701,575	1,999,988	3,176,831	2,397,434	1,935,178	2,586,750	2,498,424	0	0	0	0	0	16,296,180	
INPATIENT INMATES FFS	6,351	35,816	34,047	9,398	35,244	52,674	13,907	0	0	0	0	0	187,438	
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	150,630	0	0	0	0	0	2,233,005	
SMIB - ACUTE	1,469	734	839	629	839	944	1,847	0	0	0	0	0	7,302	
SUBTOTAL TOTAL TITLE XIX	31,784,937	33,467,076	36,150,580	38,673,829	39,031,673	43,856,679	41,006,701	0	0	0	0	0	263,971,475	
	879,246,680	900,414,248	922,981,760	915,542,763	930,249,842	1,028,095,055	903,843,380	0	0	0	0	0	6,480,373,728	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	183,782	170,409	173,186	164,735	157,227	237,286	145,036	0	0	0	0	0	1,231,661	
KidsCare - FEE FOR SERVICE	-819	774	436	1,805	404	335	15	0	0	0	0	0	2,951	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	36,831	35,192	42,452	32,067	0	0	0	0	0	253,845	
KidsCare - REINSURANCE	162	30,495	70,989	57,122	103,826	25,397	86	0	0	0	0	0	288,078	

220,533	237,043	279,141	260,493	296,650	305,470	177,205	0	0	0	0	0	1,776,535	

TOTAL TITLE XXI

879,467,213	900,651,004	923,260,901	915,803,257	930,546,492	1,028,400,525	904,020,585	0	0	0	0	0	6,482,149,976	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
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	114.91	0.00	0.00	0.00	0.00	0.00		839.76		
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	28,770.18	0.00	0.00	0.00	0.00	0.00		433,085.90		
1007	TANF 21-44 FEMALE WI	262,969.81	321,024.00	366,691.13	93,778.32	95,564.51	105,731.27	102,211.44	0.00	0.00	0.00	0.00	0.00		1,347,970.48		
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	168,805.46	0.00	0.00	0.00	0.00	0.00		2,263,309.63		
1009	TANF 65+ M & F WITH	130,859.20	158,119.22	182,105.63	43,807.61	41,203.16	47,386.45	36,764.90	0.00	0.00	0.00	0.00	0.00		640,246.17		
100F	TANF 21-44 MALE WITH	3,124.94	3,371.26	1,066.32	1,235.50	433.09	661.05	235.42	0.00	0.00	0.00	0.00	0.00		10,127.58		
100G	TANF 21-44 FEMALE WI	6,088.86	5,158.50	4,029.73	604.18	1,064.56	319.24	830.22	0.00	0.00	0.00	0.00	0.00		18,095.29		
100H	TANF 44-64 M & F WIT	43,752.90	40,165.14	12,382.66	7,340.32	868.81	2,130.60	4,966.65	0.00	0.00	0.00	0.00	0.00		111,607.08		
100J	TANF 65+ M & F WITH	30,736.25	17,071.36	1,805.26	3,147.18	0.00	462.01	329.45	0.00	0.00	0.00	0.00	0.00		53,551.51		
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	8,489,462.43	6,705,198.41	0.00	0.00	0.00	0.00	0.00		50,290,559.90		
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	5,011,473.07	2,389,877.98	0.00	0.00	0.00	0.00	0.00		27,073,914.04		
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	8,075,406.66	3,758,665.88	0.00	0.00	0.00	0.00	0.00		44,650,069.46		
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	2,755,592.87	1,558,570.22	0.00	0.00	0.00	0.00	0.00		15,835,675.75		
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	5,143,183.63	3,078,652.35	0.00	0.00	0.00	0.00	0.00		30,038,187.80		
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	5,063,491.42	4,343,235.61	0.00	0.00	0.00	0.00	0.00		35,598,628.35		
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	26,938,380.02	21,958,442.61	0.00	0.00	0.00	0.00	0.00		175,706,162.01		
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	10,220,186.73	8,658,377.98	0.00	0.00	0.00	0.00	0.00		72,766,464.81		
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	36,723.84	0.00	0.00	0.00	0.00	0.00		318,793.26		
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	1,748,319.94	1,410,545.03	0.00	0.00	0.00	0.00	0.00		9,302,673.17		
101B	TANF 01-05 M & F NON	18,930.19	10,452.99	13,969.51	21,291.05	8,127.92	12,666.37	13,738.01	0.00	0.00	0.00	0.00	0.00		99,176.04		
101C	TANF 06-13 M & F NON	13,827.52	10,991.93	10,596.95	24,089.70	7,386.13	8,920.56	11,015.60	0.00	0.00	0.00	0.00	0.00		86,828.39		
101D	TANF 14-20 MALE NON-	30,653.81	23,910.41	11,522.68	26,798.62	9,274.23	9,614.88	8,434.80	0.00	0.00	0.00	0.00	0.00		120,209.43		
101E	TANF 14-20 FEMALE N O	56,482.84	48,295.58	35,281.43	34,103.87	17,747.19	21,343.15	22,638.34	0.00	0.00	0.00	0.00	0.00		235,892.40		
101F	TANF 21-44 MALE NON-	441,372.83	443,539.24	240,851.96	193,781.66	93,373.63	105,684.74	106,107.39	0.00	0.00	0.00	0.00	0.00		1,624,711.45		
101G	TANF 21-44 FEMALE N O	967,547.84	939,350.71	551,924.22	458,482.24	314,016.32	266,567.51	305,275.97	0.00	0.00	0.00	0.00	0.00		3,803,164.81		
101H	TANF 44-64 M & F NON	673,153.96	695,670.20	390,666.92	248,353.01	134,308.24	126,224.28	153,889.31	0.00	0.00	0.00	0.00	0.00		2,422,265.92		
101J	TANF 65+ N & F NON-M	13,593.90	8,104.86	11,870.70	676.55	2,534.13	4,132.50	1,949.50	0.00	0.00	0.00	0.00	0.00		42,862.14		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	503.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503.59		
1026	TANF 21-44 MALE WITH	39,781.26	52,613.13	69,409.48	17,011.53	12,616.89	12,420.55	15,215.78	0.00	0.00	0.00	0.00	0.00		219,068.62		
1027	TANF 21-44 FEMALE WI	112,487.20	155,750.38	178,197.45	42,604.92	49,730.74	52,435.62	44,117.53	0.00	0.00	0.00	0.00	0.00		635,323.84		
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	50,856.10	0.00	0.00	0.00	0.00	0.00		823,622.52		
1029	TANF 65+ M & F WITH	53,811.16	84,861.43	103,507.94	16,738.86	19,102.86	21,396.49	20,442.35	0.00	0.00	0.00	0.00	0.00		319,861.09		
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	119.25	0.00	0.00	0.00	0.00	0.00		1,977.49		
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 January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102J	TANF 65+ M & F WITH	958.54	944.87	0.00	2,333.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,237.35		
2100	SSI AGED WITH MEDIC A	646,891.69	640,426.15	626,324.88	741,218.85	763,396.08	912,983.06	800,177.94	0.00	0.00	0.00	0.00	0.00		5,131,418.65		
210Z	SSI AGED WITH MEDIC A	42,792.60	35,137.07	23,993.14	22,253.33	24,247.34	19,520.95	19,495.37	0.00	0.00	0.00	0.00	0.00		187,439.80		
2110	SSI AGED NON-MEDIC AR	4,841,984.49	4,755,477.85	4,841,046.00	5,319,754.55	5,244,733.49	6,162,557.25	5,104,276.41	0.00	0.00	0.00	0.00	0.00		36,269,830.04		
211Z	SSI AGED NON-MEDIC AR	168,114.98	120,300.70	81,292.69	107,483.51	100,740.24	114,287.30	119,704.75	0.00	0.00	0.00	0.00	0.00		811,924.17		
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	5,095,008.46	4,363,995.06	0.00	0.00	0.00	0.00	0.00		26,454,100.23		
212Z	SSI AGED WITH QMB P P	5,569.66	5,916.01	9,571.88	5,721.66	6,731.50	3,193.40	5,058.59	0.00	0.00	0.00	0.00	0.00		41,762.70		
2200	SSI DISABLED WITH M E	1,438,779.65	1,356,642.89	1,368,850.54	1,750,088.66	1,712,310.36	1,880,846.57	1,729,865.54	0.00	0.00	0.00	0.00	0.00		11,237,384.21		
220Z	SSI DISABLED WITH M E	21,320.23	23,148.40	24,683.29	18,921.57	10,281.93	14,271.27	14,439.89	0.00	0.00	0.00	0.00	0.00		127,066.58		
2210	SSI DISABLED NON-ME D	55,077,622.81	54,829,218.00	54,812,398.76	59,204,588.11	59,278,100.88	69,163,873.56	59,481,048.89	0.00	0.00	0.00	0.00	0.00		411,846,851.01		
221Z	SSI DISABLED NON-ME D	491,291.42	492,991.62	460,508.70	398,574.48	381,824.33	470,632.81	438,715.10	0.00	0.00	0.00	0.00	0.00		3,134,538.46		
2220	SSI DISABLED WITH Q M	10,386,804.88	10,418,005.20	10,514,240.11	14,112,652.81	14,189,750.86	15,045,495.81	14,303,641.89	0.00	0.00	0.00	0.00	0.00		88,970,591.56		
222Z	SSI DISABLED WITH Q M	5,921.17	7,380.90	10,401.43	3,840.12	2,524.99	1,306.61	2,738.93	0.00	0.00	0.00	0.00	0.00		34,114.15		
2300	SSI BLIND WITH MEDIC	4,363.55	4,060.83	3,780.74	6,282.61	6,337.48	8,054.88	6,870.52	0.00	0.00	0.00	0.00	0.00		39,750.61		
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	353,568.15	356,359.13	362,835.95	397,898.39	397,764.11	482,839.14	417,031.99	0.00	0.00	0.00	0.00	0.00		2,768,296.86		
231Z	SSI BLIND NON-MEDIC A	3,440.09	12,852.23	5,876.17	7,201.16	2,280.81	13,964.20	7,166.70	0.00	0.00	0.00	0.00	0.00		52,781.36		
2320	SSI BLIND WITH QMB	44,041.31	43,688.31	44,085.09	52,049.43	51,728.72	56,683.73	49,268.31	0.00	0.00	0.00	0.00	0.00		341,544.90		
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	224.91	0.00	0.00	0.00	0.00	0.00		2,146.87		
4303	SOBRA CHILD 06-13 M	227.07	227.07	276.11	244.30	1,116.27	1,036.83	1,061.37	0.00	0.00	0.00	0.00	0.00		4,189.02		
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	1,896.27	0.00	0.00	0.00	0.00	0.00		7,499.04		
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	22,353,310.47	17,644,405.08	0.00	0.00	0.00	0.00	0.00		133,264,420.24		
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	25,747,478.39	23,497,937.91	0.00	0.00	0.00	0.00	0.00		153,421,447.65		
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	31,872,811.53	28,972,941.33	0.00	0.00	0.00	0.00	0.00		197,071,757.13		
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	10,221,259.84	9,174,817.99	0.00	0.00	0.00	0.00	0.00		63,987,978.10		
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	15,664,057.38	14,037,152.48	0.00	0.00	0.00	0.00	0.00		97,521,785.85		
431A	SOBRA CHILD < 1 M &	1,266,381.59	1,304,281.60	634,368.33	1,482,032.17	977,262.62	1,098,964.98	63,622.62	0.00	0.00	0.00	0.00	0.00		6,826,913.91		
431B	SOBRA CHILD 01-05 M	494,252.81	475,898.40	360,178.32	407,643.39	262,251.61	248,010.60	271,540.03	0.00	0.00	0.00	0.00	0.00		2,519,775.16		
431C	SOBRA CHILD 6-13 M& F	634,059.19	670,453.45	453,423.37	439,439.88	292,079.09	274,008.02	282,295.62	0.00	0.00	0.00	0.00	0.00		3,045,758.62		
431D	SOBRA CHILD 14-20 MA	467,748.21	431,434.92	303,172.79	265,677.52	189,364.34	182,262.95	177,918.24	0.00	0.00	0.00	0.00	0.00		2,017,578.97		

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
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	227,826.88	230,531.24	0.00	0.00	0.00	0.00	0.00		2,402,569.45		
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	411.36	0.00	0.00	0.00	0.00	0.00		3,809.66		
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	28,646.09	29,529.54	34,810.47	37,003.71	22,770.15	24,460.37	22,927.68	0.00	0.00	0.00	0.00	0.00		200,148.01		
5008	SOBRA PREG 45-64 FE M	856.00	405.55	405.55	898.29	898.29	1,365.91	898.29	0.00	0.00	0.00	0.00	0.00		5,727.88		
500G	SOBRA PREG 21-44 FE M	667.73	637.69	427.13	403.02	162.14	432.77	318.82	0.00	0.00	0.00	0.00	0.00		3,049.30		
5013	SOBRA PREG 09-13 FE M	791.84	960.27	778.66	664.29	689.41	1,113.84	900.22	0.00	0.00	0.00	0.00	0.00		5,898.53		
5015	SOBRA PREG 14-20 FE M	1,153,204.41	1,243,589.20	1,321,708.44	1,331,054.56	1,405,473.49	1,350,428.51	1,054,815.01	0.00	0.00	0.00	0.00	0.00		8,860,273.62		
5017	SOBRA PREG 21-44 FE M	4,969,763.44	5,543,577.71	6,104,353.53	6,666,900.29	7,018,557.84	6,624,611.50	5,287,100.31	0.00	0.00	0.00	0.00	0.00		42,214,864.62		
5018	SOBRA PREG 45-64 FE M	29,226.73	32,189.69	33,578.00	41,189.47	41,350.99	43,398.65	34,884.14	0.00	0.00	0.00	0.00	0.00		255,817.67		
501C	SOBRA PREG 09-13 FE M	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		
501E	SOBRA PREG 14-20 FE M	77,023.42	77,726.43	48,097.14	49,640.39	42,451.40	43,034.61	52,196.23	0.00	0.00	0.00	0.00	0.00		390,169.62		
501G	SOBRA PREG 21-44 FE M	331,612.75	308,457.61	239,213.41	224,480.35	178,215.34	181,213.77	209,298.69	0.00	0.00	0.00	0.00	0.00		1,672,491.92		
501H	SOBRA PREG 45-64 FE M	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		
5027	SOBRA PREG 21-44 FE M	2,329.77	2,829.66	4,481.72	4,273.54	4,730.15	7,022.63	4,272.15	0.00	0.00	0.00	0.00	0.00		29,939.62		
5028	SOBRA PREG 45-64 FE M	0.00	2,426.39	2,426.39	2,242.66	2,242.66	2,242.66	2,361.11	0.00	0.00	0.00	0.00	0.00		13,941.87		
502G	SOBRA PREG 21-44 FE M	218.29	0.00	0.00	0.00	0.00	0.00	169.46	0.00	0.00	0.00	0.00	0.00		387.75		
502H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	122.33	0.00	0.00	0.00	0.00	0.00		122.33		
5510	SOBRA FPS FEMALE W IT	-12.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-12.50		
	248,764,079.13	252,354,794.67	254,464,913.27	246,135,180.96	245,353,522.07	290,175,954.31	242,885,635.24	0.00	0.00	0.00	0.00	0.00		1,780,134,079.65		

SUBTOTAL:

9910	TANF & SOBRA CHILDR E	3,483,562.65	3,047,996.25	2,907,424.24	2,225,583.72	2,475,483.80	2,699,633.43	2,359,982.88	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	61,091.07	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	253,912.66	175,567.47	201,893.70	182,160.74	179,014.54	246,059.59	185,727.70	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	13,122,762.07	11,790,756.24	0.00	0.00	0.00	0.00	0.00	
	16,269,535.99	17,056,752.97	18,080,567.43	16,020,688.26	15,742,887.28	16,105,189.25	14,397,557.89	0.00	0.00	0.00	0.00	0.00	

19,199,666.97	
438,726.70	
1,424,336.40	
92,610,449.00	
113,673,179.07	

SUBTOTAL:

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

617.28	
174.72	
792.00	

SUBTOTAL:

1106	TANF EXPANDED 21-44	167,462.38	144,030.22	123,318.86	348,239.33	330,998.49	327,013.61	293,372.02	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	998,025.53	900,412.62	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	1,898,559.74	1,646,749.25	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	274,415.40	245,636.00	232,837.24	502,261.74	493,090.82	555,592.30	475,594.93	0.00	0.00	0.00	0.00	0.00	

 
1,734,434.91	
5,541,549.87	
9,811,275.71	
2,779,428.43	

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110F	TANF EXPANDED 21-44	3,682.62	630.49	1,486.57	3,392.63	3,061.27	1,445.35	1,532.16	0.00	0.00	0.00	0.00	0.00		15,231.09		
110G	TANF EXPANDED 21-44	520.84	324.33	2,552.22	7,103.54	4,282.02	3,757.64	4,112.14	0.00	0.00	0.00	0.00	0.00		22,652.73		
110H	TANF EXPANDED 45-64	161.40	385.93	27,647.67	33,347.53	20,685.44	12,573.42	14,788.08	0.00	0.00	0.00	0.00	0.00		109,589.47		
110J	TANF EXPANDED 65+
M&	0.00	1,210.32	15,631.07	6,020.54	4,765.67	5,992.18	6,238.92	0.00	0.00	0.00	0.00	0.00		39,858.70		
1111	TANF EXPANDED <1 M
&F	6,325.21	4,355.65	762.79	1,466.00	1,466.00	6,164.56	959.74	0.00	0.00	0.00	0.00	0.00		21,499.95		
1112	TANF EXPANDED 01-05	48,437.22	37,053.66	33,123.81	29,396.05	22,170.25	40,683.70	12,458.19	0.00	0.00	0.00	0.00	0.00		223,322.88		
1113	TANF EXPANDED 06-13	155,432.39	123,651.13	108,415.58	93,138.60	75,107.67	137,286.25	45,721.14	0.00	0.00	0.00	0.00	0.00		738,752.76		
1114	TANF EXPANDED 14-20	114,898.22	90,180.24	76,789.22	121,834.46	112,376.36	164,931.05	104,108.53	0.00	0.00	0.00	0.00	0.00		785,118.08		
1115	TANF EXPANDED 14-20	375,463.35	278,983.53	236,525.33	455,399.24	446,636.13	633,451.47	511,369.76	0.00	0.00	0.00	0.00	0.00		2,937,828.81		
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	6,009,674.15	5,107,974.70	0.00	0.00	0.00	0.00	0.00		29,835,409.56		
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	20,837,934.57	18,135,306.62	0.00	0.00	0.00	0.00	0.00		104,046,373.27		
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	13,412,203.34	11,705,309.17	0.00	0.00	0.00	0.00	0.00		67,030,365.13		
1119	TANF EXPANDED 65+
M&	38,116.96	34,638.80	32,844.67	50,449.55	48,551.01	54,580.40	49,262.22	0.00	0.00	0.00	0.00	0.00		308,443.61		
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-402.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-402.42		
111B	TANF EXPANDED 01-05	0.00	51.33	0.00	0.00	0.00	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	12.33	0.00	0.00	0.00	0.00	0.00		606.61		
111D	TANF EXPANDED 14-20	91.04	817.44	2,346.34	1,783.04	4,380.55	2,916.80	2,166.48	0.00	0.00	0.00	0.00	0.00		14,501.69		
111E	TANF EXPANDED 14-20	1,428.69	1,919.48	6,274.89	9,908.99	8,959.07	6,906.83	7,798.29	0.00	0.00	0.00	0.00	0.00		43,196.24		
111F	TANF EXPANDED 21-44	16,857.80	16,840.28	88,070.74	149,530.14	129,309.81	123,356.30	133,296.48	0.00	0.00	0.00	0.00	0.00		657,261.55		
111G	TANF EXPANDED 21-44	38,462.54	45,149.24	202,727.99	318,834.43	259,990.85	233,575.81	282,025.05	0.00	0.00	0.00	0.00	0.00		1,380,765.91		
111H	TANF EXPANDED 45-64	12,792.72	53,531.20	181,490.33	247,343.76	197,107.31	238,384.88	202,701.94	0.00	0.00	0.00	0.00	0.00		1,133,352.14		
111J	TANF EXPANDED 65+
M&	10,074.33	0.00	1,610.12	15,133.53	1,008.68	3,362.50	12,031.53	0.00	0.00	0.00	0.00	0.00		43,220.69		
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	142,497.14	0.00	0.00	0.00	0.00	0.00		678,669.84		
1127	TANF EXPANDED 21-44	214,717.61	193,927.68	179,884.44	245,571.04	327,309.88	412,966.19	430,483.37	0.00	0.00	0.00	0.00	0.00		2,004,860.21		
1128	TANF EXPANDED 45-64	242,994.86	222,897.30	210,610.65	289,864.60	387,477.49	506,717.56	500,993.90	0.00	0.00	0.00	0.00	0.00		2,361,556.36		
1129	TANF EXPANDED 65+
M&	89,535.41	77,417.22	73,153.41	82,720.03	108,728.23	148,924.61	151,914.73	0.00	0.00	0.00	0.00	0.00		732,393.64		
112F	TANF EXPANDED 21-44	0.00	0.00	406.00	246.72	273.24	148.50	1,391.61	0.00	0.00	0.00	0.00	0.00		2,466.07		
112G	TANF EXPANDED 21-44	0.00	681.07	726.03	964.10	648.57	537.96	1,154.70	0.00	0.00	0.00	0.00	0.00		4,712.43		
112H	TANF EXPANDED 45-64	10.59	0.00	1,235.44	3,753.28	2,524.51	3,607.70	638.24	0.00	0.00	0.00	0.00	0.00		11,769.76		
112J	TANF EXPANDED 65+
M&	0.00	0.00	6,378.93	344.31	4,119.33	5,140.99	1,028.83	0.00	0.00	0.00	0.00	0.00		17,012.39		
2400	SSI AGED EXPANDED WI	90,318.38	78,003.38	74,504.07	71,589.26	68,291.67	87,163.90	64,453.13	0.00	0.00	0.00	0.00	0.00		534,323.79		
240Z	SSI AGED EXPANDED WI	28,495.79	37,821.60	22,409.28	21,024.30	14,619.96	20,639.55	11,037.06	0.00	0.00	0.00	0.00	0.00		156,047.54		
2410	SSI AGED EXPANDED NO	929,746.50	864,149.68	813,310.62	351,969.12	320,177.38	502,076.63	219,435.89	0.00	0.00	0.00	0.00	0.00		4,000,865.82		
241Z	SSI AGED EXPANDED NO	7,401.77	16,962.83	8,306.20	4,276.52	3,695.68	4,224.09	1,447.14	0.00	0.00	0.00	0.00	0.00		46,314.23		
2420	SSI AGED EXPANDED WI	5,235,551.09	5,187,661.49	5,133,746.28	4,943,310.23	4,730,309.58	5,377,961.60	4,556,076.95	0.00	0.00	0.00	0.00	0.00		35,164,617.22		

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
242Z	SSI AGED EXPANDED WI	7,997.68	5,766.54	4,987.33	5,330.17	2,179.50	3,525.88	2,827.84	0.00	0.00	0.00	0.00	0.00		32,614.94		
2500	SSI BLIND EXPANDED W	0.00	0.00	0.00	140.23	140.23	140.23	140.23	0.00	0.00	0.00	0.00	0.00		560.92		
2510	SSI BLIND EXPANDED N	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		
2520	SSI BLIND EXPANDED W	124.99	124.99	124.99	130.02	130.02	214.81	130.02	0.00	0.00	0.00	0.00	0.00		979.84		
2600	SSI DISABLED EXPAND E	159,975.75	157,902.91	154,039.57	218,895.60	207,386.21	239,347.71	231,849.47	0.00	0.00	0.00	0.00	0.00		1,369,397.22		
260Z	SSI DISABLED EXPAND E	17,956.66	21,077.50	16,146.29	10,542.62	5,850.05	8,936.66	10,113.57	0.00	0.00	0.00	0.00	0.00		90,623.35		
2610	SSI DISABLED EXPAND E	2,642,788.10	2,565,161.03	2,574,872.47	2,863,962.71	2,808,377.77	3,045,057.86	2,747,705.93	0.00	0.00	0.00	0.00	0.00		19,247,925.87		
261Z	SSI DISABLED EXPAND E	33,355.68	32,438.70	29,106.19	22,550.86	20,810.52	30,567.23	19,261.47	0.00	0.00	0.00	0.00	0.00		188,090.65		
2620	SSI DISABLED EXPAND E	7,540,307.86	7,645,491.81	7,856,549.93	10,670,749.62	10,778,061.56	11,298,685.05	11,070,787.28	0.00	0.00	0.00	0.00	0.00		66,860,633.11		
262Z	SSI DISABLED EXPAND E	6,428.48	5,511.39	8,031.41	4,310.82	1,836.82	3,073.81	1,560.51	0.00	0.00	0.00	0.00	0.00		30,753.24		
	42,577,206.07	39,244,718.86	37,338,771.85	58,563,716.52	57,700,500.16	67,550,763.27	59,822,231.30	0.00	0.00	0.00	0.00	0.00		362,797,908.03		

SUBTOTAL:

9911	SB PAYMENT FOR TAN F	638,069.14	744,028.48	692,146.52	1,079,073.38	867,744.81	1,551,281.98	1,457,853.88	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI E	12,450.73	18,552.72	24,748.20	6,290.91	12,607.20	12,655.86	12,028.11	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	5,743.01	5,963.77	0.00	6,235.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	656,262.88	768,544.97	716,894.72	1,091,599.62	880,352.01	1,563,937.84	1,469,881.99	0.00	0.00	0.00	0.00	0.00	

 
7,030,198.19	
99,333.73	
17,942.11	
7,147,474.03	

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 2	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	
125.06	
1,711.15	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	8,422.52	3,645.97	6,549.05	6,920.85	6,749.84	15,246.55	5,143.30	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	5,542.92	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	74,441.74	47,502.86	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	11,672.15	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	5,432.06	4,183.93	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	7,661.84	1,332.88	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	1,984,883.57	1,872,667.57	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	2,348,680.27	2,176,541.43	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	10,011,398.23	8,761,850.23	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	8,356,713.50	7,184,025.95	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	19,876,479.58	17,359,739.78	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	12,054.26	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	74,037.41	91,239.55	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	82,977.04	119,502.32	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	413,200.04	403,697.51	0.00	0.00	0.00	0.00	0.00	

 
52,678.08	
73,107.23	
324,368.69	
157,425.02	
10,689.69	
3,382.37	
48,208.97	
23,988.62	
11,369,091.69	
13,492,981.04	
58,537,813.06	
48,736,307.64	
116,689,200.76	
115,336.47	
675,398.58	
765,929.23	
3,364,489.46	

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351G	ADULT 40-100% FEMAL E	458,558.32	429,699.96	368,800.73	356,601.53	246,284.78	355,331.06	338,219.87	0.00	0.00	0.00	0.00	0.00		2,553,496.25		
351H	ADULT 40-100% M&F 45	1,204,084.30	1,016,417.29	728,945.34	784,761.29	597,289.00	758,626.02	802,383.13	0.00	0.00	0.00	0.00	0.00		5,892,506.37		
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	12,732.65	0.00	0.00	0.00	0.00	0.00		121,523.97		
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	914.43	0.00	0.00	0.00	0.00	0.00		3,572.77		
3527	ADULT 40-100% FEMAL E	668.80	1,504.94	0.00	366.57	441.10	2,105.01	2,683.76	0.00	0.00	0.00	0.00	0.00		7,770.18		
3528	ADULT 40-100% M&F 45	10,626.75	7,689.50	12,719.11	12,289.73	10,883.20	14,398.75	12,861.10	0.00	0.00	0.00	0.00	0.00		81,468.14		
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	2,711.73	0.00	0.00	0.00	0.00	0.00		26,431.96		
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	1,002.81	0.00	0.00	0.00	0.00	0.00		4,299.55		
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	3,228.03	616.59	2,867.30	457.81	0.00	0.00	0.00	0.00	0.00		7,169.73		
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 MAL E	34,143.30	26,154.77	20,573.49	39,142.26	28,932.51	26,253.84	35,940.46	0.00	0.00	0.00	0.00	0.00		211,140.63		
3707	ADULT <40% EXP FEM AL	12,691.88	18,567.70	11,647.93	10,314.66	6,489.86	16,865.89	19,177.00	0.00	0.00	0.00	0.00	0.00		95,754.92		
3708	ADULT <40% EXP M&F 4	47,370.84	58,639.06	54,729.62	114,253.12	92,664.47	99,216.03	92,080.32	0.00	0.00	0.00	0.00	0.00		558,953.46		
3709	ADULT <40% EXP M&F 6	8,255.13	8,986.58	12,316.96	18,221.48	9,722.62	8,101.26	6,854.86	0.00	0.00	0.00	0.00	0.00		72,458.89		
370F	ADULT <40% EXP MAL E	3,590.13	5,678.35	4,459.00	2,315.61	2,138.02	952.88	3,315.80	0.00	0.00	0.00	0.00	0.00		22,449.79		
370G	ADULT <40% EXP FEM AL	824.34	1,262.96	35.10	1,823.55	2,665.44	784.80	3,403.18	0.00	0.00	0.00	0.00	0.00		10,799.37		
370H	ADULT <40% EXP M&F 4	8,737.58	10,393.47	21,133.34	9,344.88	2,526.64	10,753.79	5,476.93	0.00	0.00	0.00	0.00	0.00		68,366.63		
370J	ADULT <40% EXP M&F 6	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 MAL E	4,383,132.32	4,528,025.34	4,668,083.27	4,798,971.65	4,966,868.66	6,197,353.47	5,122,155.64	0.00	0.00	0.00	0.00	0.00		34,664,590.35		
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	5,285,430.48	4,388,863.77	0.00	0.00	0.00	0.00	0.00		29,464,607.65		
3716	ADULT <40% EXP MAL E	27,106,086.04	27,395,881.26	28,559,100.18	31,597,706.11	31,781,110.59	37,440,882.09	32,286,459.21	0.00	0.00	0.00	0.00	0.00		216,167,225.48		
3717	ADULT <40% EXP FEM AL	16,530,344.45	16,579,394.61	17,156,912.82	19,193,803.19	19,394,362.33	22,676,531.06	19,539,939.24	0.00	0.00	0.00	0.00	0.00		131,071,287.70		
3718	ADULT <40% EXP M&F 4	33,539,387.24	33,762,918.80	34,763,411.03	38,092,409.60	38,325,239.72	45,012,735.95	38,341,083.70	0.00	0.00	0.00	0.00	0.00		261,837,186.04		
3719	ADULT <40% EXP M&F 6	36,205.17	36,567.62	42,431.28	59,561.30	45,300.27	53,028.22	31,341.67	0.00	0.00	0.00	0.00	0.00		304,435.53		
371D	ADULT <40% EXP MAL E	392,849.93	382,830.27	238,138.75	208,431.92	203,147.49	183,401.52	184,039.62	0.00	0.00	0.00	0.00	0.00		1,792,839.50		
371E	ADULT <40% EXP FEM AL	356,021.60	295,087.13	201,535.90	214,164.42	137,476.12	155,663.63	164,778.45	0.00	0.00	0.00	0.00	0.00		1,524,727.25		
371F	ADULT <40% EXP MAL E	2,852,336.09	2,763,526.13	1,988,245.68	1,937,830.92	1,404,623.01	1,548,180.76	1,505,806.74	0.00	0.00	0.00	0.00	0.00		14,000,549.33		
371G	ADULT <40% EXP FEM AL	1,605,524.56	1,472,687.76	1,073,635.38	1,106,222.16	812,781.75	829,440.95	874,170.13	0.00	0.00	0.00	0.00	0.00		7,774,462.69		
371H	ADULT <40% EXP M&F 4	2,523,268.04	2,262,250.08	1,652,940.26	1,764,209.76	1,371,358.12	1,475,309.30	1,589,786.49	0.00	0.00	0.00	0.00	0.00		12,639,122.05		
371J	ADULT <40% EXP M&F 6	2,019.24	1,369.87	8,989.45	9,843.47	14,388.28	6,204.26	229.81	0.00	0.00	0.00	0.00	0.00		43,044.38		
3724	ADULT <40% EXP MAL E	480.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480.74		
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 MAL E	3,936.06	7,430.66	5,545.33	9,313.29	11,355.77	10,877.75	14,327.14	0.00	0.00	0.00	0.00	0.00		62,786.00		

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3727	ADULT <40% EXP FEM AL	4,778.02	3,573.32	779.92	6,659.16	5,113.29	2,918.66	6,653.19	0.00	0.00	0.00	0.00	0.00		30,475.56		
3728	ADULT <40% EXP M&F 4	17,960.52	5,138.97	16,090.90	8,323.68	7,311.56	7,865.93	14,483.05	0.00	0.00	0.00	0.00	0.00		77,174.61		
3729	ADULT <40% EXP M&F 6	1,616.38	0.00	362.34	1,703.88	1,306.97	1,829.61	961.29	0.00	0.00	0.00	0.00	0.00		7,780.47		
372F	ADULT <40% EXP MAL E	0.00	711.09	4,151.16	502.35	1,161.06	1,005.13	921.65	0.00	0.00	0.00	0.00	0.00		8,452.44		
372G	ADULT <40% EXP FEM AL	598.25	1,319.88	2,540.22	0.00	720.86	0.00	409.71	0.00	0.00	0.00	0.00	0.00		5,588.92		
372H	ADULT <40% EXP M&F 4	470.36	1,351.60	251.86	3,328.61	540.65	828.41	2,193.50	0.00	0.00	0.00	0.00	0.00		8,964.99		
372J	ADULT <40% EXP M&F 6	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	165,497,664.64	143,465,516.48	0.00	0.00	0.00	0.00	0.00		975,669,749.44		

SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	176,469.55	272,778.55	241,599.87	270,837.95	231,084.26	214,949.85	175,607.48	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT A	447,342.88	597,836.74	736,611.04	684,333.12	601,967.17	620,647.36	717,122.21	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	835,597.21	892,729.69	0.00	0.00	0.00	0.00	0.00	

1,583,327.51	
4,405,860.52	
5,989,188.03	

SUBTOTAL:

3904	NEWLY ELIGIBLE MALE	0.00	55.96	346.93	367.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	2,243.33	4,164.05	5,522.85	5,309.15	5,518.15	9,318.50	10,565.88	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	11,101.01	5,502.90	2,869.12	7,915.29	2,425.56	4,158.75	1,129.12	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	30,815.43	20,891.02	14,759.65	37,342.86	44,998.23	60,330.54	57,389.35	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	3,752.37	6,340.48	6,828.68	14,529.93	9,597.38	15,397.05	12,373.66	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	4,408.22	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	558.35	584.83	0.00	417.38	411.65	1,086.80	280.67	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	20,702.19	14,075.84	19,780.97	33,511.35	12,219.55	8,555.27	11,466.53	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	3,743.08	5,233.41	11,173.35	15,825.83	6,081.31	7,661.22	913.63	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	833,795.61	798,115.51	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	1,008,820.92	996,795.30	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	7,824,417.74	7,340,679.20	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	6,457,501.35	6,891,154.05	7,326,735.48	9,254,679.43	9,714,688.16	10,684,151.74	10,499,771.28	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	7,992,989.32	8,091,976.44	8,244,535.29	10,079,365.67	10,259,563.30	11,593,254.48	10,470,856.13	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	13,274.71	12,857.15	12,513.51	18,274.33	14,084.40	15,516.59	9,490.38	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	22,443.06	17,900.44	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	32,952.23	33,640.41	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	242,813.42	268,572.71	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	575,662.05	557,633.73	466,745.78	408,568.59	242,094.96	275,085.07	301,121.78	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	598,828.85	481,913.67	459,344.28	364,265.20	257,808.17	411,137.03	361,868.37	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	3,178.08	11,525.06	33,951.68	6,142.56	16,607.25	2,170.60	15,700.85	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	1,900.90	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	0.00	3,064.18	3,059.32	744.64	384.04	384.04	1,030.50	0.00	0.00	0.00	0.00	0.00	

 
770.14	
42,641.91	
35,101.75	
266,527.08	
68,819.55	
318.47	
6,861.26	
3,339.68	
120,311.70	
50,631.83	
4,693,738.23	
5,661,524.64	
44,961,937.14	
60,828,681.49	
66,732,540.63	
96,011.07	
202,095.08	
260,194.24	
2,306,816.31	
2,826,911.96	
2,935,165.57	
89,276.08	
6,519.65	
8,666.72	

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

3928

3929

392F

NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

392G

392H

392J

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

6
SUBTOTAL:

9939	BIRTH SUPP PAYMENT N	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	447,193.00	474,637.31	0.00	0.00	0.00	0.00	0.00	
	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	447,193.00	474,637.31	0.00	0.00	0.00	0.00	0.00	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1,925.68	968.19	772.82	1,662.87	3,871.37	2,266.86	5,347.21	0.00	0.00	0.00	0.00	0.00	16,815.00	
598.20	308.72	649.48	1,129.09	384.46	438.37	336.83	0.00	0.00	0.00	0.00	0.00	3,845.15	
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	
0.00	0.00	0.00	0.00	0.00	0.00	63.38	0.00	0.00	0.00	0.00	0.00	63.38	
782.69	451.48	178.82	394.81	447.38	452.69	75.19	0.00	0.00	0.00	0.00	0.00	2,783.06	
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	
22,454,160.88	23,042,703.84	23,851,867.00	29,013,956.22	29,589,138.68	33,056,747.63	31,221,793.43	0.00	0.00	0.00	0.00	0.00	192,230,367.68	
													
												2,528,163.70	
												2,528,163.70	

SUBTOTAL:

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	115.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	100.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	475.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	227.07	113.90	227.80	1,524.18	1,263.32	1,497.66	1,288.17	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	2,472,060.61	2,222,646.29	2,028,673.87	5,518,655.29	5,786,559.34	6,504,075.28	6,148,562.04	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	2,437,464.16	2,188,063.14	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	1,627,175.04	1,485,905.55	1,372,014.41	3,133,836.80	3,215,261.55	3,650,054.64	3,297,801.80	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	16,933.27	18,946.08	66,346.90	88,725.94	53,097.98	60,583.43	66,675.86	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	43,363.06	43,378.72	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	15,755.99	20,553.56	83,770.13	68,104.17	69,588.51	70,370.00	62,662.32	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	162.83	119.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	5,278,024.25	4,784,466.49	4,561,528.24	10,991,313.12	11,330,662.67	12,767,408.23	11,808,432.05	0.00	0.00	0.00	0.00	0.00	

115.08	
100.87	
475.25	
6,142.10	
30,681,232.72	
11,985,144.11	
17,782,049.79	
371,309.46	
304,178.75	
390,804.68	
282.24	
61,521,835.05	

SUBTOTAL:

345,772.04

345,772.04

9944	BIRTH SUPP PAYMENT S	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	44,864.51	61,038.67	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	61,038.67	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	6,031.34	6,350.82	6,499.88	8,177.94	8,370.90	10,265.31	8,321.32	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	112,672.67	110,350.85	110,314.38	108,889.84	103,615.29	121,495.14	105,250.41	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	273.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	718.61	0.00	74.95	322.70	63.42	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	3,437.97	2,627.92	3,114.12	334.55	1,454.95	1,178.69	1,124.40	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	6,156.87	6,362.76	6,506.30	6,551.79	6,511.95	7,783.26	7,040.15	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	7,757.51	7,379.70	6,916.51	7,031.99	7,031.99	7,891.31	6,117.15	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	323.65	0.00	217.69	443.57	284.85	0.00	0.00	0.00	0.00	0.00	0.00	
461J	CC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	84.12	0.00	0.00	0.00	0.00	0.00	
9946	SB KICK PAYMENT FO R	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	127,937.55	0.00	0.00	0.00	0.00	0.00	

 
772,588.58

273.27

1,179.68

13,272.60

46,913.08

50,126.16

1,269.76

84.12

5,938.12

54,017.51

945,662.88

ACUTE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8600	SSI BLIND FREEDOM/W O	119.15	119.15	119.15	1,518.09	1,518.09	1,560.36	1,518.09	0.00	0.00	0.00	0.00	0.00		6,472.08		
8700	SSI DISABLED FREEDO M	1,387,627.33	1,409,227.99	1,427,434.60	1,601,635.36	1,588,056.71	1,637,025.33	1,591,790.75	0.00	0.00	0.00	0.00	0.00		10,642,798.07		
870Z	SSI DISABLED FREEDO M	14,851.04	13,861.37	11,262.22	8,619.47	2,040.24	6,583.34	4,961.16	0.00	0.00	0.00	0.00	0.00		62,178.84		
8710	SSI DISABLED FREEDO M	257,066.42	281,571.85	279,236.21	280,748.11	281,893.20	315,011.51	287,131.28	0.00	0.00	0.00	0.00	0.00		1,982,658.58		
871Z	SSI DISABLED FREEDO M	43,575.80	38,994.92	27,502.94	20,641.47	11,801.66	14,268.11	3,069.41	0.00	0.00	0.00	0.00	0.00		159,854.31		
8720	SSI DISABLED FREEDO M	165,188.17	161,572.52	163,088.68	196,297.59	193,686.35	206,157.70	192,992.30	0.00	0.00	0.00	0.00	0.00		1,278,983.31		
872Z	SSI DISABLED FREEDO M	1,871.66	508.27	103.48	1,383.63	2,517.01	116.45	59.39	0.00	0.00	0.00	0.00	0.00		6,559.89		
	1,870,299.57	1,905,856.07	1,908,747.28	2,110,843.72	2,081,513.26	2,180,722.80	2,081,522.38	0.00	0.00	0.00	0.00	0.00		14,139,505.08		

SUBTOTAL:

3,517,125,387.83

467,034,603.84	468,726,485.92	471,960,427.06	506,083,311.72	504,236,168.44	590,375,377.87	508,709,012.98	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016	
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	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
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	88.85	0.00	0.00	0.00	0.00	0.00		1,379.05		
1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	172.66	178.52	167.20	180.73	0.00	0.00	0.00	0.00	0.00		2,691.78		
1008	TANF 45-64 M & F WIT	870.42	1,013.58	1,168.84	270.09	273.04	266.32	287.84	0.00	0.00	0.00	0.00	0.00		4,150.13		
1009	TANF 65+ M & F WITH	306.00	373.68	430.56	102.88	96.13	94.11	87.56	0.00	0.00	0.00	0.00	0.00		1,490.92		
100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	7.53	2.94	4.64	1.60	0.00	0.00	0.00	0.00	0.00		61.00		
100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	3.15	5.45	1.70	3.97	0.00	0.00	0.00	0.00	0.00		87.80		
100H	TANF 44-64 M & F WIT	97.51	98.86	32.85	17.79	2.09	6.52	15.70	0.00	0.00	0.00	0.00	0.00		271.32		
100J	TANF 65+ M & F WITH	73.60	39.19	4.37	7.48	0.00	1.80	1.15	0.00	0.00	0.00	0.00	0.00		127.59		
1011	TANF <1 M & F NON-ME	14,502.91	14,510.24	13,463.57	13,936.63	14,198.27	14,300.74	13,670.15	0.00	0.00	0.00	0.00	0.00		98,582.51		
1012	TANF 01-05 M & F NON	41,759.21	34,503.32	30,981.55	27,621.68	24,016.57	21,026.70	18,892.95	0.00	0.00	0.00	0.00	0.00		198,801.98		
1013	TANF 06-13 M & F NON	68,866.70	57,435.45	51,559.68	45,958.63	39,586.45	34,097.21	29,354.28	0.00	0.00	0.00	0.00	0.00		326,858.40		
1014	TANF 14-20 MALE NON-	15,523.91	13,919.00	12,939.58	11,807.22	10,522.54	9,495.84	8,497.93	0.00	0.00	0.00	0.00	0.00		82,706.02		
1015	TANF 14-20 FEMALE N O	19,492.05	17,891.08	16,863.02	14,601.29	13,172.47	12,418.39	11,424.34	0.00	0.00	0.00	0.00	0.00		105,862.64		
1016	TANF 21-44 MALE NON-	32,422.89	35,110.56	38,554.07	24,200.36	24,611.24	24,754.24	24,834.01	0.00	0.00	0.00	0.00	0.00		204,487.37		
1017	TANF 21-44 FEMALE N O	100,171.76	104,138.61	110,548.82	79,561.23	79,226.74	80,892.09	80,005.97	0.00	0.00	0.00	0.00	0.00		634,545.22		
1018	TANF 45-64 M & F NON	26,326.13	28,376.39	30,996.33	18,878.67	18,943.85	19,080.68	19,188.73	0.00	0.00	0.00	0.00	0.00		161,790.78		
1019	TANF 65+ M & F NON-M	122.25	133.13	152.05	81.72	80.78	86.25	84.76	0.00	0.00	0.00	0.00	0.00		740.94		
101A	TANF < 1 M & F NON-M	1,323.68	1,107.58	523.24	1,443.78	1,155.18	1,652.91	1,382.43	0.00	0.00	0.00	0.00	0.00		8,588.80		
101B	TANF 01-05 M & F NON	323.00	173.98	234.10	366.13	146.78	232.53	252.01	0.00	0.00	0.00	0.00	0.00		1,728.53		
101C	TANF 06-13 M & F NON	235.43	179.19	176.48	403.54	132.78	157.92	91.82	0.00	0.00	0.00	0.00	0.00		1,377.16		
101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	167.74	56.94	64.69	56.71	0.00	0.00	0.00	0.00	0.00		744.81		
101E	TANF 14-20 FEMALE N O	278.91	237.91	174.02	171.86	90.58	108.68	115.54	0.00	0.00	0.00	0.00	0.00		1,177.50		
101F	TANF 21-44 MALE NON-	2,653.94	2,660.54	1,444.98	1,220.10	625.84	709.14	721.44	0.00	0.00	0.00	0.00	0.00		10,035.98		
101G	TANF 21-44 FEMALE N O	4,819.02	4,659.58	2,737.74	2,315.36	1,601.46	1,369.81	1,564.77	0.00	0.00	0.00	0.00	0.00		19,067.74		
101H	TANF 44-64 M & F NON	1,604.09	1,643.02	919.13	633.40	373.54	367.88	446.09	0.00	0.00	0.00	0.00	0.00		5,987.15		
101J	TANF 65+ N & F NON-M	31.66	19.50	26.80	1.88	6.42	11.98	5.21	0.00	0.00	0.00	0.00	0.00		103.45		
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	48.64	0.00	0.00	0.00	0.00	0.00		724.69		
1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	69.00	73.08	74.70	66.38	0.00	0.00	0.00	0.00	0.00		1,182.15		
1028	TANF 45-64 M & F WIT	257.30	401.73	481.56	80.44	93.69	103.67	92.98	0.00	0.00	0.00	0.00	0.00		1,511.37		
1029	TANF 65+ M & F WITH	125.59	199.79	245.43	39.43	45.00	49.00	48.00	0.00	0.00	0.00	0.00	0.00		752.24		
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	0.61	0.00	0.00	0.00	0.00	0.00		9.98		
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 January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102J	TANF 65+ M & F WITH	2.37	2.17	0.00	5.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.66		
2100	SSI AGED WITH MEDIC A	3,945.61	3,902.67	3,829.80	4,137.95	4,214.96	4,359.38	4,391.75	0.00	0.00	0.00	0.00	0.00		28,782.12		
210Z	SSI AGED WITH MEDIC A	450.53	377.60	249.36	270.80	307.49	255.39	261.89	0.00	0.00	0.00	0.00	0.00		2,173.06		
2110	SSI AGED NON-MEDIC AR	5,996.37	5,885.71	5,990.17	6,174.44	6,096.62	6,033.73	5,916.16	0.00	0.00	0.00	0.00	0.00		42,093.20		
211Z	SSI AGED NON-MEDIC AR	323.02	229.89	155.90	195.56	189.76	198.32	204.42	0.00	0.00	0.00	0.00	0.00		1,496.87		
2120	SSI AGED WITH QMB	16,192.79	16,392.49	16,583.32	22,041.82	22,291.57	22,547.75	22,646.53	0.00	0.00	0.00	0.00	0.00		138,696.27		
212Z	SSI AGED WITH QMB P P	60.27	61.77	97.36	67.89	76.81	46.22	61.93	0.00	0.00	0.00	0.00	0.00		472.25		
2200	SSI DISABLED WITH M E	3,600.36	3,525.64	3,506.17	3,597.87	3,563.55	3,636.76	3,612.73	0.00	0.00	0.00	0.00	0.00		25,043.08		
220Z	SSI DISABLED WITH M E	236.76	251.22	272.95	225.46	135.76	185.47	192.40	0.00	0.00	0.00	0.00	0.00		1,500.02		
2210	SSI DISABLED NON-ME D	57,143.85	56,902.31	56,909.61	56,665.32	56,824.83	57,078.70	56,900.23	0.00	0.00	0.00	0.00	0.00		398,424.85		
221Z	SSI DISABLED NON-ME D	983.56	949.62	911.29	771.37	711.59	852.26	792.85	0.00	0.00	0.00	0.00	0.00		5,972.54		
2220	SSI DISABLED WITH Q M	24,588.70	24,755.94	24,980.93	25,099.07	25,302.15	25,453.16	25,532.84	0.00	0.00	0.00	0.00	0.00		175,712.79		
222Z	SSI DISABLED WITH Q M	62.38	77.46	109.31	43.36	32.28	18.61	35.83	0.00	0.00	0.00	0.00	0.00		379.23		
2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	25.00	25.00	27.29	28.00	0.00	0.00	0.00	0.00	0.00		183.40		
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	428.12	430.04	436.15	439.00	442.38	450.43	460.83	0.00	0.00	0.00	0.00	0.00		3,086.95		
231Z	SSI BLIND NON-MEDIC A	8.02	26.80	11.45	13.31	4.79	28.85	12.72	0.00	0.00	0.00	0.00	0.00		105.94		
2320	SSI BLIND WITH QMB	207.48	205.10	207.96	204.24	202.09	202.70	201.56	0.00	0.00	0.00	0.00	0.00		1,431.13		
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	2.00	0.00	0.00	0.00	0.00	0.00		19.00		
4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	2.12	4.55	3.00	3.00	0.00	0.00	0.00	0.00	0.00		19.10		
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	3.00	0.00	0.00	0.00	0.00	0.00		10.83		
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	39,855.27	36,542.16	0.00	0.00	0.00	0.00	0.00		265,308.16		
4312	SOBRA CHILD 01-05 M	150,215.05	158,567.13	166,797.13	169,987.40	176,662.82	181,963.70	184,620.83	0.00	0.00	0.00	0.00	0.00		1,188,814.06		
4313	SOBRA CHILD 06-13 M	200,525.14	216,198.75	230,401.99	209,630.58	214,915.68	222,121.13	225,551.43	0.00	0.00	0.00	0.00	0.00		1,519,344.70		
4314	SOBRA CHILD 14-20 MA	49,529.14	51,683.40	55,100.09	50,842.03	51,365.72	52,543.25	53,287.11	0.00	0.00	0.00	0.00	0.00		364,350.74		
4315	SOBRA CHILD 14-20 FE	49,621.28	51,750.56	55,046.80	51,049.83	51,597.87	53,035.15	53,708.18	0.00	0.00	0.00	0.00	0.00		365,809.67		
431A	SOBRA CHILD < 1 M &	1,144.43	1,199.85	596.85	1,439.14	966.70	1,089.87	160.81	0.00	0.00	0.00	0.00	0.00		6,597.65		
431B	SOBRA CHILD 01-05 M	7,397.32	7,233.01	5,425.60	5,749.99	4,037.79	3,916.92	4,211.85	0.00	0.00	0.00	0.00	0.00		37,972.48		
431C	SOBRA CHILD 6-13 M& F	9,664.24	10,386.87	6,895.96	6,005.68	4,413.27	4,396.02	4,614.16	0.00	0.00	0.00	0.00	0.00		46,376.20		
431D	SOBRA CHILD 14-20 MA	2,729.60	2,547.00	1,740.21	1,587.56	1,149.00	1,156.75	1,160.65	0.00	0.00	0.00	0.00	0.00		12,070.77		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016	
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	1,097.16	1,159.06	0.00	0.00	0.00	0.00	0.00		11,761.65		
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	3.77	0.00	0.00	0.00	0.00	0.00		34.39		
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	44.60	44.25	49.08	47.32	34.99	31.66	30.85	0.00	0.00	0.00	0.00	0.00		282.75		
5008	SOBRA PREG 45-64 FE M	2.00	1.00	1.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00		12.00		
500G	SOBRA PREG 21-44 FE M	3.37	3.12	2.16	1.67	0.83	2.31	1.57	0.00	0.00	0.00	0.00	0.00		15.03		
5013	SOBRA PREG 09-13 FE M	6.00	7.38	7.00	6.00	6.20	10.00	8.12	0.00	0.00	0.00	0.00	0.00		50.70		
5015	SOBRA PREG 14-20 FE M	4,442.88	4,822.40	5,139.99	5,199.98	5,482.55	4,565.96	4,070.37	0.00	0.00	0.00	0.00	0.00		33,724.13		
5017	SOBRA PREG 21-44 FE M	19,288.96	21,436.17	23,639.77	25,479.28	26,864.80	23,372.29	20,244.07	0.00	0.00	0.00	0.00	0.00		160,325.34		
5018	SOBRA PREG 45-64 FE M	70.02	76.99	80.34	89.62	89.99	85.34	76.00	0.00	0.00	0.00	0.00	0.00		568.30		
501C	SOBRA PREG 09-13 FE M	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		
501E	SOBRA PREG 14-20 FE M	380.96	386.50	238.63	248.98	217.33	220.16	268.38	0.00	0.00	0.00	0.00	0.00		1,960.94		
501G	SOBRA PREG 21-44 FE M	1,656.15	1,536.50	1,187.87	1,135.67	915.46	931.65	1,074.80	0.00	0.00	0.00	0.00	0.00		8,438.10		
501H	SOBRA PREG 45-64 FE M	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		
5027	SOBRA PREG 21-44 FE M	9.11	11.00	8.99	9.12	11.00	10.67	9.12	0.00	0.00	0.00	0.00	0.00		69.01		
5028	SOBRA PREG 45-64 FE M	0.00	1.00	1.00	1.00	1.00	1.00	1.32	0.00	0.00	0.00	0.00	0.00		6.32		
502G	SOBRA PREG 21-44 FE M	0.87	0.00	0.00	0.00	0.00	0.00	0.87	0.00	0.00	0.00	0.00	0.00		1.74		
502H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.48	0.00	0.00	0.00	0.00	0.00		0.48		
5510	SOBRA FPS FEMALE W IT	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1.00		
	985,098.82	1,002,906.76	1,020,305.89	932,589.99	929,217.83	933,562.13	923,582.78	0.00	0.00	0.00	0.00	0.00		6,727,264.20		

SUBTOTAL:

9910	TANF & SOBRA CHILDR E	571.00	500.00	476.00	365.00	407.00	441.00	385.00	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	10.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	42.00	29.00	33.00	30.00	29.00	40.00	30.00	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	2,155.00	1,935.00	0.00	0.00	0.00	0.00	0.00	
	2,677.00	2,806.00	2,973.00	2,628.00	2,589.00	2,642.00	2,360.00	0.00	0.00	0.00	0.00	0.00	

3,145.00	
72.00	
233.00	
15,225.00	
18,675.00	

SUBTOTAL:

3100	TRANSPLANT OPTION 1	4.24	5.41	5.00	5.00	5.73	6.00	6.00	0.00	0.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION 1	5.74	4.58	0.00	0.00	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	9.98	9.99	5.00	5.00	5.99	6.00	6.00	0.00	0.00	0.00	0.00	0.00	

37.38	
10.58	
47.96	

SUBTOTAL:

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	925.69	903.23	849.28	816.35	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	1,573.87	1,565.40	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	2,834.97	2,802.58	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	634.27	568.85	533.33	1,133.83	1,112.02	1,083.36	1,081.24	0.00	0.00	0.00	0.00	0.00	

 
4,893.46

9,651.48

16,794.90

6,146.90

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110F	TANF EXPANDED 21-44	18.70	3.61	8.79	22.01	20.26	9.49	10.14	0.00	0.00	0.00	0.00	0.00		93.00		
110G	TANF EXPANDED 21-44	2.64	1.64	12.64	32.68	21.58	19.38	21.33	0.00	0.00	0.00	0.00	0.00		111.89		
110H	TANF EXPANDED 45-64	0.86	0.82	67.38	87.22	58.75	32.60	42.40	0.00	0.00	0.00	0.00	0.00		290.03		
110J	TANF EXPANDED 65+
M&	0.00	2.64	37.58	16.71	13.76	17.67	19.64	0.00	0.00	0.00	0.00	0.00		108.00		
1111	TANF EXPANDED <1 M
&F	12.00	8.00	1.36	3.00	3.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00		32.36		
1112	TANF EXPANDED 01-05	390.00	311.16	275.00	239.06	180.00	142.15	98.00	0.00	0.00	0.00	0.00	0.00		1,635.37		
1113	TANF EXPANDED 06-13	1,229.70	991.16	871.12	743.21	581.97	473.00	364.77	0.00	0.00	0.00	0.00	0.00		5,254.93		
1114	TANF EXPANDED 14-20	683.08	531.13	454.69	720.61	674.58	643.29	611.64	0.00	0.00	0.00	0.00	0.00		4,319.02		
1115	TANF EXPANDED 14-20	1,447.98	1,085.47	918.24	1,792.37	1,760.39	1,913.82	2,015.99	0.00	0.00	0.00	0.00	0.00		10,934.26		
1116	TANF EXPANDED 21-44	20,507.88	17,866.93	15,873.76	30,211.21	29,789.76	30,709.98	30,771.06	0.00	0.00	0.00	0.00	0.00		175,730.58		
1117	TANF EXPANDED 21-44	46,392.97	40,134.22	35,306.60	65,385.73	63,972.60	67,528.88	69,148.62	0.00	0.00	0.00	0.00	0.00		387,869.62		
1118	TANF EXPANDED 45-64	16,838.19	14,850.87	13,477.80	26,098.91	25,902.71	26,772.92	26,932.72	0.00	0.00	0.00	0.00	0.00		150,874.12		
1119	TANF EXPANDED 65+
M&	91.37	83.00	78.65	120.22	115.24	120.42	117.31	0.00	0.00	0.00	0.00	0.00		726.21		
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.35		
111B	TANF EXPANDED 01-05	0.00	0.83	0.00	0.00	0.00	0.25	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	0.22	0.00	0.00	0.00	0.00	0.00		10.02		
111D	TANF EXPANDED 14-20	0.54	5.28	14.31	10.92	28.27	20.03	14.80	0.00	0.00	0.00	0.00	0.00		94.15		
111E	TANF EXPANDED 14-20	7.24	9.73	31.24	50.14	45.83	35.66	39.98	0.00	0.00	0.00	0.00	0.00		219.82		
111F	TANF EXPANDED 21-44	101.48	104.36	529.77	956.02	855.10	845.14	904.49	0.00	0.00	0.00	0.00	0.00		4,296.36		
111G	TANF EXPANDED 21-44	197.09	224.68	1,011.19	1,606.35	1,326.72	1,205.40	1,450.30	0.00	0.00	0.00	0.00	0.00		7,021.73		
111H	TANF EXPANDED 45-64	28.12	127.83	423.04	661.57	557.64	690.42	593.63	0.00	0.00	0.00	0.00	0.00		3,082.25		
111J	TANF EXPANDED 65+
M&	22.31	0.00	3.65	34.70	3.11	10.46	38.52	0.00	0.00	0.00	0.00	0.00		112.75		
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	286.79	0.00	0.00	0.00	0.00	0.00		1,414.09		
1127	TANF EXPANDED 21-44	382.43	351.28	318.88	364.36	502.11	662.14	695.91	0.00	0.00	0.00	0.00	0.00		3,277.11		
1128	TANF EXPANDED 45-64	446.94	399.71	372.79	452.31	621.33	801.22	828.64	0.00	0.00	0.00	0.00	0.00		3,922.94		
1129	TANF EXPANDED 65+
M&	194.69	165.94	155.60	174.92	237.67	308.56	337.68	0.00	0.00	0.00	0.00	0.00		1,575.06		
112F	TANF EXPANDED 21-44	0.00	0.00	2.56	1.63	1.86	1.03	8.90	0.00	0.00	0.00	0.00	0.00		15.98		
112G	TANF EXPANDED 21-44	0.00	3.44	3.22	4.87	3.32	2.59	5.88	0.00	0.00	0.00	0.00	0.00		23.32		
112H	TANF EXPANDED 45-64	0.03	0.00	2.92	11.24	7.45	10.73	1.72	0.00	0.00	0.00	0.00	0.00		34.09		
112J	TANF EXPANDED 65+
M&	0.00	0.00	16.30	1.06	10.74	12.39	3.26	0.00	0.00	0.00	0.00	0.00		43.75		
2400	SSI AGED EXPANDED WI	518.42	487.04	456.81	384.84	352.94	389.52	358.97	0.00	0.00	0.00	0.00	0.00		2,948.54		
240Z	SSI AGED EXPANDED WI	304.76	401.03	244.49	252.11	184.84	258.54	156.32	0.00	0.00	0.00	0.00	0.00		1,802.09		
2410	SSI AGED EXPANDED NO	1,134.27	1,056.52	991.15	391.57	359.68	303.63	245.77	0.00	0.00	0.00	0.00	0.00		4,482.59		
241Z	SSI AGED EXPANDED NO	13.94	39.82	16.61	7.34	6.63	7.25	2.59	0.00	0.00	0.00	0.00	0.00		94.18		
2420	SSI AGED EXPANDED WI	26,853.34	26,842.37	26,813.66	21,188.36	20,913.29	20,739.95	20,647.27	0.00	0.00	0.00	0.00	0.00		163,998.24		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
242Z	SSI AGED EXPANDED WI	86.51	60.16	53.24	60.10	29.69	45.74	42.01	0.00	0.00	0.00	0.00	0.00		377.45		
2500	SSI BLIND EXPANDED W	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		4.00		
2510	SSI BLIND EXPANDED N	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		
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
2600	SSI DISABLED EXPAND E	387.35	391.10	363.58	405.75	407.66	442.08	415.01	0.00	0.00	0.00	0.00	0.00		2,812.53		
260Z	SSI DISABLED EXPAND E	198.57	225.21	193.65	131.93	83.98	116.36	132.48	0.00	0.00	0.00	0.00	0.00		1,082.18		
2610	SSI DISABLED EXPAND E	2,800.72	2,719.35	2,722.76	2,696.85	2,637.63	2,667.84	2,586.05	0.00	0.00	0.00	0.00	0.00		18,831.20		
261Z	SSI DISABLED EXPAND E	66.87	64.13	55.86	42.68	36.03	53.53	35.64	0.00	0.00	0.00	0.00	0.00		354.74		
2620	SSI DISABLED EXPAND E	15,882.49	16,101.98	16,689.39	17,152.91	17,493.44	17,902.98	18,067.75	0.00	0.00	0.00	0.00	0.00		119,290.94		
262Z	SSI DISABLED EXPAND E	70.33	62.70	88.07	53.98	24.93	36.36	21.97	0.00	0.00	0.00	0.00	0.00		358.34		
	141,707.24	129,594.34	122,483.07	179,619.05	176,720.38	182,594.47	184,345.74	0.00	0.00	0.00	0.00	0.00		1,117,064.29		

SUBTOTAL:

9911	SB PAYMENT FOR TAN F	105.00	122.00	113.00	177.00	141.00	253.00	239.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI E	2.00	3.00	4.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	108.00	126.00	117.00	179.00	143.00	255.00	241.00	0.00	0.00	0.00	0.00	0.00	

 
1,150.00

16.00

3.00

1,169.00

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 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	15.63	8.90	13.05	13.05	7.72	10.06	5.00	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	6.00	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	69.26	87.51	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	27.35	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	8.01	6.08	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	14.29	1.57	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	3,984.28	4,150.82	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	4,633.53	4,803.34	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	18,817.24	18,834.48	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	15,251.61	15,287.12	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	37,786.88	37,961.23	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	27.61	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	109.87	134.38	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	122.58	178.18	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	616.54	603.19	0.00	0.00	0.00	0.00	0.00	

 
73.41	
63.88	
548.57	
364.72	
16.83	
4.49	
71.50	
38.17	
25,089.26	
29,645.75	
126,376.55	
103,996.53	
255,457.64	
262.85	
1,017.86	
1,140.86	
5,045.14	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351G	ADULT 40-100% FEMAL E	687.03	645.80	559.94	543.04	370.45	528.33	509.10	0.00	0.00	0.00	0.00	0.00		3,843.69		
351H	ADULT 40-100% M&F 45	1,789.29	1,532.58	1,097.36	1,161.58	880.02	1,120.60	1,190.46	0.00	0.00	0.00	0.00	0.00		8,771.89		
351J	ADULT 40-100% M&F 65	40.88	22.67	29.32	20.45	46.89	6.12	18.38	0.00	0.00	0.00	0.00	0.00		184.71		
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	2.00	0.00	0.00	0.00	0.00	0.00		7.70		
3527	ADULT 40-100% FEMAL E	1.41	3.21	0.00	1.00	1.00	1.74	2.00	0.00	0.00	0.00	0.00	0.00		10.36		
3528	ADULT 40-100% M&F 45	20.96	15.68	24.16	19.28	23.00	24.79	19.36	0.00	0.00	0.00	0.00	0.00		147.23		
3529	ADULT 40-100% M&F 65	6.00	10.00	4.00	14.03	10.06	9.93	6.32	0.00	0.00	0.00	0.00	0.00		60.34		
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	1.47	0.00	0.00	0.00	0.00	0.00		6.40		
352J	ADULT 40-100% M&F 65	0.00	0.00	0.00	4.96	0.83	4.06	0.67	0.00	0.00	0.00	0.00	0.00		10.52		
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 MAL E	34.74	33.74	30.14	41.29	39.44	33.46	43.59	0.00	0.00	0.00	0.00	0.00		256.40		
3707	ADULT <40% EXP FEM AL	7.49	15.61	9.78	12.41	11.03	18.57	21.17	0.00	0.00	0.00	0.00	0.00		96.06		
3708	ADULT <40% EXP M&F 4	88.23	98.60	92.80	188.88	141.71	124.05	151.66	0.00	0.00	0.00	0.00	0.00		885.93		
3709	ADULT <40% EXP M&F 6	19.67	21.38	28.72	41.00	21.63	14.00	15.00	0.00	0.00	0.00	0.00	0.00		161.40		
370F	ADULT <40% EXP MAL E	5.51	8.57	6.12	3.49	3.21	1.63	4.63	0.00	0.00	0.00	0.00	0.00		33.16		
370G	ADULT <40% EXP FEM AL	1.54	1.81	0.06	2.37	3.89	1.15	5.04	0.00	0.00	0.00	0.00	0.00		15.86		
370H	ADULT <40% EXP M&F 4	14.58	15.74	30.56	13.97	3.56	15.97	8.47	0.00	0.00	0.00	0.00	0.00		102.85		
370J	ADULT <40% EXP M&F 6	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 MAL E	9,839.70	10,160.23	10,470.29	10,275.58	10,661.47	11,028.29	10,985.15	0.00	0.00	0.00	0.00	0.00		73,420.71		
3715	ADULT <40% EXP FEM AL	8,418.28	8,667.97	8,908.49	8,752.70	9,023.96	9,373.43	9,485.14	0.00	0.00	0.00	0.00	0.00		62,629.97		
3716	ADULT <40% EXP MAL E	58,247.03	58,634.00	61,113.02	62,941.19	63,352.21	65,477.71	64,345.30	0.00	0.00	0.00	0.00	0.00		434,110.46		
3717	ADULT <40% EXP FEM AL	34,827.18	34,929.63	36,183.66	37,298.36	37,725.55	38,555.88	38,148.00	0.00	0.00	0.00	0.00	0.00		257,668.26		
3718	ADULT <40% EXP M&F 4	72,820.34	73,231.71	75,412.07	76,737.78	77,207.05	78,744.45	77,238.57	0.00	0.00	0.00	0.00	0.00		531,391.97		
3719	ADULT <40% EXP M&F 6	80.88	80.74	94.53	128.19	96.22	106.84	65.67	0.00	0.00	0.00	0.00	0.00		653.07		
371D	ADULT <40% EXP MAL E	580.76	572.41	352.26	309.50	300.26	275.48	271.17	0.00	0.00	0.00	0.00	0.00		2,661.84		
371E	ADULT <40% EXP FEM AL	519.38	449.84	305.73	319.68	204.57	230.72	240.99	0.00	0.00	0.00	0.00	0.00		2,270.91		
371F	ADULT <40% EXP MAL E	4,244.00	4,145.00	2,990.61	2,888.14	2,110.81	2,317.84	2,239.00	0.00	0.00	0.00	0.00	0.00		20,935.40		
371G	ADULT <40% EXP FEM AL	2,410.81	2,215.92	1,619.33	1,656.46	1,211.17	1,233.71	1,297.56	0.00	0.00	0.00	0.00	0.00		11,644.96		
371H	ADULT <40% EXP M&F 4	3,754.97	3,389.75	2,459.44	2,612.62	2,030.56	2,177.41	2,352.17	0.00	0.00	0.00	0.00	0.00		18,776.92		
371J	ADULT <40% EXP M&F 6	2.98	2.00	16.46	13.76	23.12	9.87	0.32	0.00	0.00	0.00	0.00	0.00		68.51		
3724	ADULT <40% EXP MAL E	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
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 MAL E	9.00	8.05	8.35	11.73	10.99	9.77	16.18	0.00	0.00	0.00	0.00	0.00		74.07		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3727	ADULT <40% EXP FEM AL	6.12	3.96	3.43	7.00	7.36	2.03	8.66	0.00	0.00	0.00	0.00	0.00		38.56		
3728	ADULT <40% EXP M&F 4	23.78	6.39	19.82	15.21	14.20	12.68	22.17	0.00	0.00	0.00	0.00	0.00		114.25		
3729	ADULT <40% EXP M&F 6	4.00	0.00	1.00	4.00	3.00	3.90	2.00	0.00	0.00	0.00	0.00	0.00		17.90		
372F	ADULT <40% EXP MAL E	0.00	0.86	5.62	0.82	1.70	1.50	1.60	0.00	0.00	0.00	0.00	0.00		12.10		
372G	ADULT <40% EXP FEM AL	0.87	1.79	3.22	0.00	1.06	0.00	0.48	0.00	0.00	0.00	0.00	0.00		7.42		
372H	ADULT <40% EXP M&F 4	0.77	1.95	0.36	4.98	0.80	1.22	3.23	0.00	0.00	0.00	0.00	0.00		13.31		
372J	ADULT <40% EXP M&F 6	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		
	273,979.51	274,669.50	279,217.19	284,229.49	284,415.60	292,980.18	290,836.54	0.00	0.00	0.00	0.00	0.00		1,980,328.01		

SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	29.00	45.00	40.00	44.00	38.00	35.00	29.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT A	74.00	98.00	121.00	112.00	98.00	101.00	117.00	0.00	0.00	0.00	0.00	0.00	
	103.00	143.00	161.00	156.00	136.00	136.00	146.00	0.00	0.00	0.00	0.00	0.00	

260.00	
721.00	
981.00	

SUBTOTAL:

3904	NEWLY ELIGIBLE MALE	0.00	0.16	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	6.92	5.18	4.00	8.20	10.80	13.50	12.09	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	14.99	10.72	9.00	11.72	6.53	6.41	3.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	71.56	53.47	39.78	80.22	96.10	107.50	107.44	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	12.19	19.97	21.66	39.05	26.20	31.47	30.27	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	12.89	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1.83	2.06	0.00	1.25	1.46	4.00	1.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	64.25	40.88	59.19	97.73	35.73	28.14	36.38	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	10.96	14.95	34.33	49.11	17.80	22.41	2.57	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	2,036.37	2,076.47	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	2,488.10	2,599.72	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	19,046.12	19,049.48	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	20,086.40	21,456.04	22,844.42	23,906.19	25,104.94	26,525.34	27,185.45	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	24,879.24	25,158.44	25,656.88	25,845.50	26,301.97	27,031.43	26,861.59	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	43.11	41.59	40.65	49.90	38.52	39.64	25.99	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	141.51	112.48	116.75	61.70	47.08	66.46	54.38	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	97.10	99.92	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	733.56	806.99	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	1,726.49	1,680.05	1,394.47	1,209.37	730.12	830.37	899.40	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	1,771.32	1,458.13	1,385.33	1,103.78	772.01	1,213.88	1,092.09	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	8.86	33.37	111.19	18.08	52.44	6.35	45.98	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	2.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	0.00	3.00	3.00	2.00	1.00	1.00	2.77	0.00	0.00	0.00	0.00	0.00	

 
2.16	
60.69	
62.37	
556.07	
180.81	
0.83	
20.21	
11.60	
362.30	
152.13	
12,832.04	
15,584.36	
123,610.17	
167,108.78	
181,735.05	
279.40	
600.36	
776.52	
6,937.67	
8,470.27	
8,796.54	
276.27	
9.82	
12.77	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

3928

3929

392F

NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

392G

392H

392J

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

6
SUBTOTAL:

9939	BIRTH SUPP PAYMENT N	39.00	34.00	57.00	67.00	67.00	73.00	77.00	0.00	0.00	0.00	0.00	0.00	
	39.00	34.00	57.00	67.00	67.00	73.00	77.00	0.00	0.00	0.00	0.00	0.00	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6.22	3.11	2.43	4.57	6.66	5.38	14.77	0.00	0.00	0.00	0.00	0.00	43.14	
2.00	0.96	2.00	3.03	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	10.99	
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	
0.00	0.00	0.00	0.00	0.00	0.00	0.22	0.00	0.00	0.00	0.00	0.00	0.22	
2.40	1.28	0.56	1.41	1.10	1.60	0.25	0.00	0.00	0.00	0.00	0.00	8.60	
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	
69,593.33	71,546.64	74,129.68	75,276.24	76,599.20	80,337.25	81,024.11	0.00	0.00	0.00	0.00	0.00	528,506.45	
													
												414.00	
												414.00	

SUBTOTAL:

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	2.00	1.00	2.00	7.38	5.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	20,103.69	18,080.37	16,565.93	44,553.71	46,675.62	48,467.96	49,392.05	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	13,103.79	13,005.23	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	6,240.09	5,678.68	5,237.34	12,115.93	12,426.02	12,699.52	12,757.67	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	288.14	323.40	1,091.93	1,531.67	968.86	1,122.98	1,243.62	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	295.64	293.22	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	81.96	103.18	421.32	344.01	343.25	358.14	324.68	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	1.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	33,377.33	30,212.86	29,209.93	71,548.32	73,618.11	76,052.03	77,021.47	0.00	0.00	0.00	0.00	0.00	

1.00	
0.67	
1.00	
26.38	
243,839.33	
69,525.24	
67,155.25	
6,570.60	
1,942.31	
1,976.54	
1.73	
391,040.05	

SUBTOTAL:

57.00

57.00

9944	BIRTH SUPP PAYMENT S	8.00	13.00	3.00	3.00	12.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	
	8.00	13.00	3.00	3.00	12.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	23.96	25.35	26.00	27.58	28.33	27.64	28.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	251.91	246.16	245.84	240.06	227.69	233.21	231.08	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	3.64	0.00	0.41	1.66	0.35	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	10.28	5.89	8.11	0.93	5.34	3.76	3.30	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	15.86	16.54	17.00	18.03	17.83	19.47	20.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	18.00	17.00	16.00	16.00	16.00	15.00	14.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	1.45	0.00	0.96	2.16	1.51	0.00	0.00	0.00	0.00	0.00	0.00	
461J	CC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.32	0.00	0.00	0.00	0.00	0.00	
9946	SB KICK PAYMENT FO R	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	296.70	0.00	0.00	0.00	0.00	0.00	

 
1,675.95

0.77

6.06

37.61

124.73

112.00

6.08

0.32

1.00

186.86

2,151.38

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
8700	SSI DISABLED FREEDO M	1,505.00	1,555.45	1,576.90	1,602.26	1,594.23	1,632.59	1,633.56	0.00	0.00	0.00	0.00	0.00		11,099.99		
870Z	SSI DISABLED FREEDO M	161.37	146.05	125.37	96.31	27.40	81.11	61.34	0.00	0.00	0.00	0.00	0.00		698.95		
8710	SSI DISABLED FREEDO M	246.99	274.32	275.92	268.27	266.19	276.60	276.50	0.00	0.00	0.00	0.00	0.00		1,884.79		
871Z	SSI DISABLED FREEDO M	85.86	73.98	54.70	40.00	21.99	24.91	5.07	0.00	0.00	0.00	0.00	0.00		306.51		
8720	SSI DISABLED FREEDO M	213.90	216.30	223.90	223.30	228.07	240.46	236.51	0.00	0.00	0.00	0.00	0.00		1,582.44		
872Z	SSI DISABLED FREEDO M	20.61	6.41	1.03	15.63	27.86	2.32	0.83	0.00	0.00	0.00	0.00	0.00		74.69		
	2,234.73	2,273.51	2,258.82	2,246.77	2,166.74	2,258.99	2,214.81	0.00	0.00	0.00	0.00	0.00		15,654.37		

SUBTOTAL:

TOTAL:	1,509,256.72	1,514,651.63	1,531,233.53	1,548,851.83	1,545,990.86	1,571,205.99	1,562,162.15	0.00	0.00	0.00	0.00	0.00		10,783,352.71		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending January 31, 2016	
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	27,239.96	0.00	0.00	0.00	0.00	0.00		105,398.14		
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	2,288,974.62	0.00	0.00	0.00	0.00	0.00		15,925,704.96		
1020	TANF WITH QMB	3,414.03	3,414.03	3,414.03	3,433.17	3,433.17	6,955.78	6,883.58	0.00	0.00	0.00	0.00	0.00		30,947.79		
2100	SSI AGED WITH MEDIC A	31,188,469.28	36,229,127.20	31,473,122.65	31,111,647.19	36,054,042.87	31,219,612.97	30,619,272.74	0.00	0.00	0.00	0.00	0.00		227,895,294.90		
210Z	SSI AGED WITH MEDIC A	707,295.55	628,872.62	699,533.74	841,652.65	651,630.71	674,097.19	731,475.49	0.00	0.00	0.00	0.00	0.00		4,934,557.95		
2110	SSI AGED NON-MEDIC AR	2,884,201.93	3,146,295.69	2,948,885.35	3,040,662.77	3,335,679.23	3,063,216.81	2,952,096.08	0.00	0.00	0.00	0.00	0.00		21,371,037.86		
211Z	SSI AGED NON-MEDIC AR	20,970.93	11,535.77	26,120.35	18,541.95	9,394.51	32,330.18	43,450.16	0.00	0.00	0.00	0.00	0.00		162,343.85		
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	19,319,046.10	19,042,283.66	0.00	0.00	0.00	0.00	0.00		139,596,378.08		
212Z	SSI AGED WITH QMB P P	27,811.67	8,720.78	31,076.14	21,591.82	10,487.09	22,848.38	23,361.65	0.00	0.00	0.00	0.00	0.00		145,897.53		
2200	SSI DISABLED WITH M E	13,803,406.37	14,998,436.84	13,783,997.15	14,011,924.66	15,406,736.15	14,477,755.73	14,294,179.54	0.00	0.00	0.00	0.00	0.00		100,776,436.44		
220Z	SSI DISABLED WITH M E	40,564.67	63,879.36	93,590.05	124,380.26	73,436.67	93,117.27	101,516.47	0.00	0.00	0.00	0.00	0.00		590,484.75		
2210	SSI DISABLED NON-ME D	90,370,918.56	92,527,644.78	92,067,142.80	93,105,599.36	94,991,556.18	95,648,767.77	93,400,354.30	0.00	0.00	0.00	0.00	0.00		652,111,983.75		
221Z	SSI DISABLED NON-ME D	66,459.25	35,301.18	25,164.71	27,841.86	30,576.10	33,824.17	38,629.75	0.00	0.00	0.00	0.00	0.00		257,797.02		
2220	SSI DISABLED WITH Q M	21,237,804.05	22,510,241.65	21,355,507.04	21,308,948.47	22,578,485.06	21,695,984.63	21,391,282.55	0.00	0.00	0.00	0.00	0.00		152,078,253.45		
222Z	SSI DISABLED WITH Q M	2,948.16	9,227.84	6,397.97	6,604.08	8,888.32	7,078.53	4,972.05	0.00	0.00	0.00	0.00	0.00		46,116.95		
2300	SSI BLIND WITH MEDIC	64,338.16	65,260.19	64,541.02	62,567.40	68,202.65	66,548.80	68,372.70	0.00	0.00	0.00	0.00	0.00		459,830.92		
2310	SSI BLIND NON-MEDIC A	444,420.36	460,483.10	454,107.08	457,911.29	480,473.00	490,226.15	486,595.02	0.00	0.00	0.00	0.00	0.00		3,274,216.00		
2320	SSI BLIND WITH QMB	130,315.90	135,811.83	130,342.85	127,684.67	131,086.80	129,801.65	127,497.03	0.00	0.00	0.00	0.00	0.00		912,540.73		
	182,215,500.72	195,107,514.51	184,610,652.85	185,572,339.28	198,189,909.06	189,330,867.30	185,648,437.35	0.00	0.00	0.00	0.00	0.00		1,320,675,221.07		

SUBTOTAL:

8700	SSI DISABLED FREEDO M	70,007.12	77,437.98	70,007.12	70,803.89	73,814.89	71,344.62	74,872.30	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	19,620.38	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	113,605.70	118,717.57	126,429.56	130,091.75	134,898.58	121,559.40	120,950.51	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	2,876.81	-2,876.81	4,987.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	19,836.86	21,311.74	19,836.86	20,022.25	21,709.30	20,462.48	20,048.11	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	235,491.30	0.00	0.00	0.00	0.00	0.00	

 
508,287.92	
19,620.38	
866,253.07	
4,987.53	
143,227.60	
1,542,376.50	

TOTAL:

1,322,217,597.57

184,831,913.92	185,793,257.17	198,420,331.83	189,544,233.80	185,883,928.65	0.00	0.00	0.00	0.00	0.00	

182,421,827.21  195,322,104.99

LONG TERM CARE MEMBER MONTHS
For The Period Ending January 31, 2016	
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	8.00	0.00	0.00	0.00	0.00	0.00		31.00		
1010	TANF NON-MEDICARE	654.15	651.89	656.12	659.50	658.46	656.64	659.79	0.00	0.00	0.00	0.00	0.00		4,596.55		
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00		9.00		
2100	SSI AGED WITH MEDIC A	11,288.11	11,289.28	11,378.95	11,358.29	11,326.59	11,306.03	11,140.18	0.00	0.00	0.00	0.00	0.00		79,087.43		
210Z	SSI AGED WITH MEDIC A	717.21	639.08	710.00	851.48	668.68	692.76	751.99	0.00	0.00	0.00	0.00	0.00		5,031.20		
2110	SSI AGED NON-MEDIC AR	655.14	653.57	669.99	636.70	631.61	621.44	615.56	0.00	0.00	0.00	0.00	0.00		4,484.01		
211Z	SSI AGED NON-MEDIC AR	21.10	12.50	27.34	18.34	9.95	33.27	44.42	0.00	0.00	0.00	0.00	0.00		166.92		
2120	SSI AGED WITH QMB	7,334.44	7,374.82	7,392.70	7,402.32	7,425.32	7,457.15	7,403.18	0.00	0.00	0.00	0.00	0.00		51,789.93		
212Z	SSI AGED WITH QMB P P	27.75	9.33	32.14	22.04	11.00	24.46	26.59	0.00	0.00	0.00	0.00	0.00		153.31		
2200	SSI DISABLED WITH M E	4,540.03	4,507.46	4,531.49	4,608.07	4,649.47	4,687.31	4,696.20	0.00	0.00	0.00	0.00	0.00		32,220.03		
220Z	SSI DISABLED WITH M E	40.61	63.99	95.38	125.93	77.65	98.95	102.57	0.00	0.00	0.00	0.00	0.00		605.08		
2210	SSI DISABLED NON-ME D	25,726.52	25,794.02	25,992.12	25,925.40	25,930.65	25,987.21	25,945.81	0.00	0.00	0.00	0.00	0.00		181,301.73		
221Z	SSI DISABLED NON-ME D	68.02	35.27	25.38	30.27	31.72	32.83	41.26	0.00	0.00	0.00	0.00	0.00		264.75		
2220	SSI DISABLED WITH Q M	6,765.32	6,778.39	6,816.99	6,805.73	6,791.71	6,793.06	6,799.81	0.00	0.00	0.00	0.00	0.00		47,551.01		
222Z	SSI DISABLED WITH Q M	2.73	7.18	7.16	6.82	9.41	7.33	5.45	0.00	0.00	0.00	0.00	0.00		46.08		
2300	SSI BLIND WITH MEDIC	20.00	19.00	20.00	20.00	20.00	20.00	21.00	0.00	0.00	0.00	0.00	0.00		140.00		
2310	SSI BLIND NON-MEDIC A	128.16	130.38	131.06	129.55	134.00	134.12	136.77	0.00	0.00	0.00	0.00	0.00		924.04		
2320	SSI BLIND WITH QMB	42.00	42.00	42.00	40.83	40.30	40.96	41.00	0.00	0.00	0.00	0.00	0.00		289.09		
	58,035.29	58,012.16	58,532.82	58,645.27	58,422.52	58,601.52	58,441.58	0.00	0.00	0.00	0.00	0.00		408,691.16		

SUBTOTAL:

8700	SSI DISABLED FREEDO M	22.00	22.00	22.00	22.09	22.31	23.00	24.51	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	20.47	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	27.09	25.91	26.96	27.00	25.60	25.00	25.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	2.90	-2.90	5.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	7.00	7.00	7.00	7.00	7.00	7.09	7.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	58.99	52.01	60.99	56.09	54.91	55.09	76.98	0.00	0.00	0.00	0.00	0.00	

 
157.91

20.47

182.56

5.03

49.09

415.06

TOTAL:	58,094.28	58,064.17	58,593.81	58,701.36	58,477.43	58,656.61	58,518.56	0.00	0.00	0.00	0.00	0.00		409,106.22		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending January 31, 2016	
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	41.42	0.00	0.00	0.00	0.00	0.00		282.57		
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	3,146,884.50	0.00	0.00	0.00	0.00	0.00		32,210,808.48		
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-MEDIC AR	37.55	75.10	75.10	82.84	82.84	82.84	41.42	0.00	0.00	0.00	0.00	0.00		477.69		
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	37.55	37.55	37.55	82.84	165.68	174.16	248.52	0.00	0.00	0.00	0.00	0.00		783.85		
2210	SSI DISABLED NON-ME D	430,210.35	427,168.80	423,639.10	461,128.86	457,442.48	503,226.44	451,519.42	0.00	0.00	0.00	0.00	0.00		3,154,335.45		
2220	SSI DISABLED WITH Q M	225.30	225.30	225.30	248.52	207.10	241.02	207.10	0.00	0.00	0.00	0.00	0.00		1,579.64		
2310	SSI BLIND NON-MEDIC A	1,464.45	1,614.65	1,689.75	1,988.16	1,988.16	2,162.00	2,071.00	0.00	0.00	0.00	0.00	0.00		12,978.17		
4300	SOBRA CHILD WITH M ED	225.30	225.30	187.75	165.68	207.10	335.60	165.68	0.00	0.00	0.00	0.00	0.00		1,512.41		
4310	SOBRA CHILD NON-ME DI	17,147,019.75	18,291,093.15	19,577,631.25	20,609,680.76	21,238,146.42	23,190,384.24	22,317,882.98	0.00	0.00	0.00	0.00	0.00		142,371,838.55		
4320	SOBRA CHILD WITH Q MB	525.70	0.00	187.75	455.62	165.68	869.82	165.68	0.00	0.00	0.00	0.00	0.00		2,370.25		
5010	SOBRA PREGNANT WO MAN	20,427.20	22,567.55	25,233.60	28,828.32	30,195.18	26,234.24	23,609.40	0.00	0.00	0.00	0.00	0.00		177,095.49		
	23,601,939.85	23,828,366.35	24,635,691.35	25,662,133.78	25,736,772.62	28,526,404.32	25,942,837.12	0.00	0.00	0.00	0.00	0.00		177,934,145.39		

SUBTOTAL:

1110	TANF EXPANDED FOR FI	92,861.15	74,837.15	64,811.30	62,295.68	46,970.28	60,148.88	28,496.96	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	37.55	37.55	37.55	41.42	41.42	49.90	41.42	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	28,538.38	0.00	0.00	0.00	0.00	0.00	

 
430,421.40	
286.81	
430,708.21	

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 FO	0.00	37.55	75.10	82.84	82.84	165.68	82.84	0.00	0.00	0.00	0.00	0.00	
	37.55	75.10	150.20	165.68	165.68	207.10	82.84	0.00	0.00	0.00	0.00	0.00	

357.30	
526.85	
884.15	

SUBTOTAL:

82.84

82.84

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

SUBTOTAL:

4400	SOBRA 100-133% FOR F	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 F	1,137,201.75	1,021,510.20	921,589.65	2,674,365.14	2,781,021.64	2,992,223.40	2,917,086.34	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	2,917,086.34	0.00	0.00	0.00	0.00	0.00	

124.26	
14,444,998.12	
14,445,122.38	

SUBTOTAL:

192,810,942.97

24,832,077.85	24,924,826.35	25,622,280.05	28,399,084.54	28,565,013.06	31,579,075.02	28,888,586.10	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending January 31, 2016	
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	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
1010	TANF NON-MEDICARE	159,833.00	135,428.00	122,683.00	110,077.00	96,768.00	85,240.00	75,975.00	0.00	0.00	0.00	0.00	0.00		786,004.00		
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-MEDIC AR	1.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00		12.00		
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	1.00	1.00	1.00	2.00	4.00	4.00	6.00	0.00	0.00	0.00	0.00	0.00		19.00		
2210	SSI DISABLED NON-ME D	11,457.00	11,376.00	11,282.00	11,133.00	11,044.00	10,970.00	10,901.00	0.00	0.00	0.00	0.00	0.00		78,163.00		
2220	SSI DISABLED WITH Q M	6.00	6.00	6.00	6.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00		39.00		
2310	SSI BLIND NON-MEDIC A	39.00	43.00	45.00	48.00	48.00	48.00	50.00	0.00	0.00	0.00	0.00	0.00		321.00		
4300	SOBRA CHILD WITH M ED	6.00	6.00	5.00	4.00	5.00	8.00	4.00	0.00	0.00	0.00	0.00	0.00		38.00		
4310	SOBRA CHILD NON-ME DI	456,645.00	487,113.00	521,375.00	497,578.00	512,751.00	529,324.00	538,819.00	0.00	0.00	0.00	0.00	0.00		3,543,605.00		
4320	SOBRA CHILD WITH Q MB	14.00	0.00	5.00	11.00	4.00	21.00	4.00	0.00	0.00	0.00	0.00	0.00		59.00		
5010	SOBRA PREGNANT WO MAN	544.00	601.00	672.00	696.00	729.00	600.00	570.00	0.00	0.00	0.00	0.00	0.00		4,412.00		
	628,547.00	634,577.00	656,077.00	619,559.00	621,361.00	626,224.00	626,336.00	0.00	0.00	0.00	0.00	0.00		4,412,681.00		

SUBTOTAL:

1110	TANF EXPANDED FOR FI	2,473.00	1,993.00	1,726.00	1,504.00	1,134.00	904.00	688.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	1.00	1.00	1.00	1.00	1.00	1.00	1.00	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	689.00	0.00	0.00	0.00	0.00	0.00	

 
10,422.00	
7.00	
10,429.00	

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 FO	0.00	1.00	2.00	2.00	2.00	4.00	2.00	0.00	0.00	0.00	0.00	0.00	
	1.00	2.00	4.00	4.00	4.00	5.00	2.00	0.00	0.00	0.00	0.00	0.00	

9.00	
13.00	
22.00	

SUBTOTAL:

2.00

2.00

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

SUBTOTAL:

4400	SOBRA 100-133% FOR F	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 F	30,285.00	27,204.00	24,543.00	64,567.00	67,142.00	69,354.00	70,427.00	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	70,427.00	0.00	0.00	0.00	0.00	0.00	

3.00	
353,522.00	
353,525.00	

SUBTOTAL:

TOTAL:	661,307.00	663,777.00	682,351.00	685,637.00	689,643.00	696,489.00	697,455.00	0.00	0.00	0.00	0.00	0.00		4,776,659.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending January 31, 2016	
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	183.28	0.00	0.00	0.00	0.00	0.00		246,846.73		
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	449,525.80	0.00	0.00	0.00	0.00	0.00		21,783,019.76		
1020	TANF WITH QMB	24,837.03	36,897.81	45,074.61	701.52	761.56	220.68	82.16	0.00	0.00	0.00	0.00	0.00		108,575.37		
2100	SSI AGED WITH MEDIC A	139,789.21	137,949.43	136,722.91	13,714.40	13,869.24	19,412.00	1,093.36	0.00	0.00	0.00	0.00	0.00		462,550.55		
2110	SSI AGED NON-MEDIC AR	205,476.17	200,433.81	204,454.07	19,576.20	19,269.68	42,553.12	17,569.60	0.00	0.00	0.00	0.00	0.00		709,332.65		
2120	SSI AGED WITH QMB	595,679.88	602,630.16	609,410.09	73,883.96	74,771.92	96,621.20	5,469.96	0.00	0.00	0.00	0.00	0.00		2,058,467.17		
2200	SSI DISABLED WITH M E	134,133.59	132,327.88	130,488.10	11,537.16	11,508.72	20,634.20	2,673.36	0.00	0.00	0.00	0.00	0.00		443,303.01		
2210	SSI DISABLED NON-ME D	1,422,763.20	1,422,831.34	1,426,408.69	116,724.08	117,773.20	279,823.24	118,013.36	0.00	0.00	0.00	0.00	0.00		4,904,337.11		
2220	SSI DISABLED WITH Q M	832,159.75	837,747.23	844,561.23	70,060.36	70,610.20	107,153.96	9,160.84	0.00	0.00	0.00	0.00	0.00		2,771,453.57		
2300	SSI BLIND WITH MEDIC	1,226.52	1,158.38	1,056.17	94.80	88.48	155.48	18.96	0.00	0.00	0.00	0.00	0.00		3,798.79		
2310	SSI BLIND NON-MEDIC A	14,820.45	14,650.10	14,547.89	1,295.60	1,311.40	2,962.84	1,346.16	0.00	0.00	0.00	0.00	0.00		50,934.44		
2320	SSI BLIND WITH QMB	8,279.01	8,210.87	8,244.94	745.76	739.44	1,094.24	132.72	0.00	0.00	0.00	0.00	0.00		27,446.98		
4300	SOBRA CHILD WITH M ED	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		
4310	SOBRA CHILD NON-ME DI	834,544.65	810,661.58	852,976.52	73,251.96	73,425.76	148,481.52	70,607.04	0.00	0.00	0.00	0.00	0.00		2,863,949.03		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	1,260.59	1,226.52	1,328.73	113.76	94.80	188.68	6.32	0.00	0.00	0.00	0.00	0.00		4,219.40		
5010	SOBRA PREGNANT WO MAN	802,586.99	894,950.76	992,561.31	98,045.32	104,024.04	141,289.04	76,955.48	0.00	0.00	0.00	0.00	0.00		3,110,412.94		
5020	SOBRA PREGNANT WO MAN	306.63	408.84	340.70	34.76	37.92	22.56	3.16	0.00	0.00	0.00	0.00	0.00		1,154.57		
	11,162,967.36	11,575,827.62	12,286,834.45	923,642.72	934,219.24	1,913,761.36	752,841.56	0.00	0.00	0.00	0.00	0.00		39,550,094.31		

SUBTOTAL:

1100	TANF EXPANDED FPR FI	141,594.92	125,002.83	112,124.37	20,394.64	19,800.56	23,775.56	1,371.44	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	3,052,160.95	2,639,368.83	2,306,811.56	405,740.84	398,852.04	875,950.72	422,868.04	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	39,930.04	35,535.01	32,025.80	3,239.00	4,575.68	1,953.72	486.64	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	14,990.80	14,173.12	13,662.07	948.00	913.24	1,955.64	41.08	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	39,725.62	37,068.16	34,887.68	1,292.44	1,166.04	5,659.80	707.84	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	952,256.50	951,711.38	949,360.55	68,407.68	67,696.68	90,973.12	3,871.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED W	0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	68.14	68.14	68.14	3.16	3.16	10.92	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	34.07	34.07	34.07	3.16	3.16	7.76	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	9,505.53	9,335.18	9,198.90	850.04	894.28	2,012.24	82.16	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	91,103.18	87,900.60	88,070.95	6,955.16	6,847.72	11,323.48	6,436.92	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	488,427.52	493,674.30	511,867.68	42,394.56	43,298.32	35,731.36	2,464.80	0.00	0.00	0.00	0.00	0.00	
	4,829,797.27	4,393,871.62	4,058,111.77	550,231.84	544,054.04	1,049,354.32	438,329.92	0.00	0.00	0.00	0.00	0.00	

444,064.32	
10,101,752.98	
117,745.89	
46,683.95	
120,507.58	
3,084,276.91	
6.32	
221.66	
116.29	
31,878.33	
298,638.01	
1,617,858.54	
15,863,750.78	

SUBTOTAL:

11.64

11.64

3610	AHC CARE EXPANDED FO	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	

SUBTOTAL:

3500	ADULT 40-100% FOR FI	4,974.22	4,326.89	3,849.91	688.88	530.88	1,899.32	34.76	0.00	0.00	0.00	0.00	0.00	16,304.86

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending January 31, 2016	
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	259,075.76	0.00	0.00	0.00	0.00	0.00		9,070,307.96		
3520	ADULT 40-100% FOR FI	1,056.17	919.89	919.89	97.96	113.76	149.16	6.32	0.00	0.00	0.00	0.00	0.00		3,263.15		
3700	ADULT <40% EXP FOR F	4,463.17	4,667.59	4,769.80	774.20	609.88	1,647.40	63.20	0.00	0.00	0.00	0.00	0.00		16,995.24		
3710	AHC CARE EXPANDED FO	6,719,966.80	6,769,163.88	7,017,568.25	651,541.44	662,468.72	1,428,717.48	665,590.80	0.00	0.00	0.00	0.00	0.00		23,915,017.37		
3720	AHC CARE EXPANDED FO	1,328.73	476.98	953.96	94.80	94.80	118.12	15.80	0.00	0.00	0.00	0.00	0.00		3,083.19		
SUBTOTAL:	9,300,428.60	9,359,540.05	9,686,918.68	899,629.88	914,712.56	1,938,955.36	924,786.64	0.00	0.00	0.00	0.00	0.00		33,024,971.77		

3900	NEWLY ELIGIBLE FOR F	3,032.23	2,044.20	2,180.48	372.88	404.48	593.92	22.12	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	2,203,170.62	2,295,500.32	2,410,997.62	227,614.80	237,448.72	359,857.28	247,475.40	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	374.77	170.35	204.42	28.44	25.28	18.68	0.00	0.00	0.00	0.00	0.00	0.00	
	2,206,577.62	2,297,714.87	2,413,382.52	228,016.12	237,878.48	360,469.88	247,497.52	0.00	0.00	0.00	0.00	0.00	

8,650.31	
7,982,064.76	
821.94	
7,991,537.01	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	103,709.08	95,634.49	86,469.66	15,683.08	17,019.76	27,854.24	16,583.68	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	103,709.08	95,634.49	86,469.66	15,686.24	17,022.92	27,854.24	16,583.68	0.00	0.00	0.00	0.00	0.00	

362,953.99	
6.32	
362,960.31	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	9,471.46	9,301.11	9,267.04	837.40	799.48	2,012.92	790.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	1,192.45	1,158.38	1,124.31	104.28	104.28	278.16	107.44	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	897.44	0.00	0.00	0.00	0.00	0.00	

32,479.41	
4,069.30	
36,548.71	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	34.07	34.07	34.07	0.00	0.00	3.88	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	33,831.51	35,194.31	35,909.78	2,837.68	2,850.32	3,585.52	75.84	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	7,086.56	7,938.31	8,142.73	701.52	698.36	1,303.80	673.08	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	5,178.64	5,417.13	5,655.62	426.60	439.24	546.36	6.32	0.00	0.00	0.00	0.00	0.00	
	46,130.78	48,583.82	49,742.20	3,965.80	3,987.92	5,439.56	755.24	0.00	0.00	0.00	0.00	0.00	

106.09	
114,284.96	
26,544.36	
17,669.91	
158,605.32	

SUBTOTAL:

96,988,479.85

27,660,274.62	27,781,631.96	28,591,850.63	2,622,114.28	2,652,778.92	5,298,137.44	2,381,692.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending January 31, 2016	
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	58.00	0.00	0.00	0.00	0.00	0.00		8,370.00		
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	0.00	0.00	0.00	0.00	0.00		1,134,741.00		
1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	0.00	0.00	0.00	0.00	0.00		3,657.00		
2100	SSI AGED WITH MEDIC A	4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	0.00	0.00	0.00	0.00	0.00		21,579.00		
2110	SSI AGED NON-MEDIC AR	6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	5,560.00	0.00	0.00	0.00	0.00	0.00		41,387.00		
2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	0.00	0.00	0.00	0.00	0.00		103,577.00		
2200	SSI DISABLED WITH M E	3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	0.00	0.00	0.00	0.00	0.00		20,614.00		
2210	SSI DISABLED NON-ME D	41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	37,346.00	0.00	0.00	0.00	0.00	0.00		274,135.00		
2220	SSI DISABLED WITH Q M	24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	2,899.00	0.00	0.00	0.00	0.00	0.00		124,128.00		
2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00		170.00		
2310	SSI BLIND NON-MEDIC A	435.00	430.00	427.00	410.00	415.00	417.00	426.00	0.00	0.00	0.00	0.00	0.00		2,960.00		
2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	43.00	42.00	0.00	0.00	0.00	0.00	0.00		1,281.00		
4300	SOBRA CHILD WITH M ED	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		
4310	SOBRA CHILD NON-ME DI	24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	22,344.00	0.00	0.00	0.00	0.00	0.00		164,523.00		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	37.00	36.00	39.00	36.00	30.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00		182.00		
5010	SOBRA PREGNANT WO MAN	23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	24,353.00	0.00	0.00	0.00	0.00	0.00		195,297.00		
5020	SOBRA PREGNANT WO MAN	9.00	12.00	10.00	11.00	12.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		56.00		
	327,648.00	339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	238,241.00	0.00	0.00	0.00	0.00	0.00		2,096,670.00		

SUBTOTAL:

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	434.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	131,497.00	133,819.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	154.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	440.00	416.00	401.00	300.00	289.00	16.00	13.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	27,950.00	27,934.00	27,865.00	21,648.00	21,423.00	1,225.00	1,225.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED W	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	279.00	274.00	270.00	269.00	283.00	29.00	26.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	2,674.00	2,580.00	2,585.00	2,201.00	2,167.00	2,094.00	2,037.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	0.00	0.00	0.00	0.00	0.00	
	141,761.00	128,966.00	119,111.00	174,124.00	172,169.00	136,489.00	138,712.00	0.00	0.00	0.00	0.00	0.00	

24,708.00	
754,696.00	
5,930.00	
1,875.00	
4,551.00	
129,270.00	
2.00	
9.00	
5.00	
1,430.00	
16,338.00	
72,518.00	
1,011,332.00	

SUBTOTAL:

0.00

0.00

3610	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	0.00	0.00	0.00	0.00	0.00	791.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending January 31, 2016	
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	81,986.00	0.00	0.00	0.00	0.00	0.00		549,746.00		
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00		157.00		
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	13.00	20.00	0.00	0.00	0.00	0.00	0.00		879.00		
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	213,189.00	210,630.00	0.00	0.00	0.00	0.00	0.00		1,441,544.00		
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	30.00	30.00	3.00	5.00	0.00	0.00	0.00	0.00	0.00		149.00		
SUBTOTAL:	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	292,654.00	0.00	0.00	0.00	0.00	0.00		1,993,266.00		

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	128.00	5.00	7.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	64,666.00	67,376.00	70,766.00	72,030.00	75,142.00	77,456.00	78,315.00	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
	64,766.00	67,441.00	70,836.00	72,157.00	75,278.00	77,462.00	78,322.00	0.00	0.00	0.00	0.00	0.00	

471.00	
505,751.00	
40.00	
506,262.00	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	5,330.00	5,248.00	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	5,248.00	0.00	0.00	0.00	0.00	0.00	

29,316.00	
2.00	
29,318.00	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	278.00	273.00	272.00	265.00	253.00	249.00	250.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	35.00	34.00	33.00	33.00	33.00	34.00	34.00	0.00	0.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	0.00	0.00	0.00	0.00	0.00	

1,840.00	
236.00	
2,076.00	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	902.00	21.00	24.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	208.00	233.00	239.00	222.00	221.00	210.00	213.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	152.00	159.00	166.00	135.00	139.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	
	1,354.00	1,426.00	1,460.00	1,255.00	1,262.00	232.00	239.00	0.00	0.00	0.00	0.00	0.00	

3.00	
4,925.00	
1,546.00	
754.00	
7,228.00	

SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	753,700.00	0.00	0.00	0.00	0.00	0.00		5,646,152.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending January 31, 2016	
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	3,288.60	0.00	0.00	0.00	0.00	0.00		400,710.39		
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	8,065,858.50	0.00	0.00	0.00	0.00	0.00		58,930,112.30		
1020	TANF WITH QMB	33,410.07	49,633.89	60,633.09	12,587.40	13,664.70	2,022.30	1,474.20	0.00	0.00	0.00	0.00	0.00		173,425.65		
2100	SSI AGED WITH MEDIC A	188,040.49	185,565.67	183,915.79	246,078.00	248,856.30	43,045.38	19,618.20	0.00	0.00	0.00	0.00	0.00		1,115,119.83		
2110	SSI AGED NON-MEDIC AR	276,400.73	269,617.89	275,025.83	351,256.50	345,756.60	350,807.94	315,252.00	0.00	0.00	0.00	0.00	0.00		2,184,117.49		
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	98,147.70	0.00	0.00	0.00	0.00	0.00		5,414,413.85		
2200	SSI DISABLED WITH M E	180,432.71	178,003.72	175,528.90	207,011.70	206,501.40	70,141.68	47,968.20	0.00	0.00	0.00	0.00	0.00		1,065,588.31		
2210	SSI DISABLED NON-ME D	1,913,860.80	1,913,952.46	1,918,764.61	2,094,384.60	2,113,209.00	2,319,604.56	2,117,518.20	0.00	0.00	0.00	0.00	0.00		14,391,294.23		
2220	SSI DISABLED WITH Q M	1,119,397.75	1,126,913.87	1,136,079.87	1,257,095.70	1,266,961.50	292,241.88	164,373.30	0.00	0.00	0.00	0.00	0.00		6,363,063.87		
2300	SSI BLIND WITH MEDIC	1,649.88	1,558.22	1,420.73	1,701.00	1,587.60	464.94	340.20	0.00	0.00	0.00	0.00	0.00		8,722.57		
2310	SSI BLIND NON-MEDIC A	19,936.05	19,706.90	19,569.41	23,247.00	23,530.50	25,780.86	24,154.20	0.00	0.00	0.00	0.00	0.00		155,924.92		
2320	SSI BLIND WITH QMB	11,136.69	11,045.03	11,090.86	13,381.20	13,267.80	3,682.98	2,381.40	0.00	0.00	0.00	0.00	0.00		65,985.96		
4300	SOBRA CHILD WITH M ED	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		
4310	SOBRA CHILD NON-ME DI	1,122,605.85	1,090,479.02	1,147,399.88	1,314,362.70	1,317,481.20	1,372,952.70	1,266,904.80	0.00	0.00	0.00	0.00	0.00		8,632,186.15		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	1,695.71	1,649.88	1,787.37	2,041.20	1,701.00	350.28	113.40	0.00	0.00	0.00	0.00	0.00		9,338.84		
5010	SOBRA PREGNANT WO MAN	1,079,617.31	1,203,862.44	1,335,165.39	1,759,230.90	1,866,507.30	1,658,301.12	1,380,815.10	0.00	0.00	0.00	0.00	0.00		10,283,499.56		
5020	SOBRA PREGNANT WO MAN	412.47	549.96	458.30	623.70	680.40	81.90	56.70	0.00	0.00	0.00	0.00	0.00		2,863.43		
	15,016,107.84	15,571,475.78	16,527,902.05	16,572,956.40	16,762,731.30	15,237,584.46	13,508,264.70	0.00	0.00	0.00	0.00	0.00		109,197,022.53		

SUBTOTAL:

1100	TANF EXPANDED FPR FI	190,469.48	168,150.27	150,826.53	365,941.80	355,282.20	53,920.44	24,607.80	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	4,105,680.55	3,550,404.27	3,103,057.64	7,280,223.30	7,156,617.30	8,053,951.50	7,587,537.30	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	53,712.76	47,800.69	43,080.20	58,117.50	82,101.60	10,321.92	8,731.80	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	20,165.20	19,065.28	18,377.83	17,010.00	16,386.30	3,381.84	737.10	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	53,437.78	49,863.04	46,929.92	23,190.30	20,922.30	21,605.22	12,700.80	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	1,280,948.50	1,280,215.22	1,277,052.95	1,227,441.60	1,214,684.10	182,600.46	69,457.50	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED W	0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	91.66	91.66	91.66	56.70	56.70	66.78	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	45.83	45.83	45.83	56.70	56.70	10.08	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	12,786.57	12,557.42	12,374.10	15,252.30	16,046.10	4,139.10	1,474.20	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	122,549.42	118,241.40	118,470.55	124,796.70	122,868.90	124,843.32	115,497.90	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	657,018.88	664,076.70	688,549.92	760,687.20	776,903.40	86,912.28	44,226.00	0.00	0.00	0.00	0.00	0.00	
	6,496,906.63	5,910,511.78	5,458,857.13	9,872,830.80	9,761,982.30	8,541,752.94	7,864,970.40	0.00	0.00	0.00	0.00	0.00	

1,309,198.52	
40,837,471.86	
303,866.47	
95,123.55	
228,649.36	
6,532,400.33	
113.40	
455.16	
260.97	
74,629.79	
847,268.19	
3,678,374.38	
53,907,811.98	

SUBTOTAL:

15.12

15.12

3610	AHC CARE EXPANDED FO	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	

SUBTOTAL:

3500	ADULT 40-100% FOR FI	6,691.18	5,820.41	5,178.79	12,360.60	9,525.60	2,887.92	623.70	0.00	0.00	0.00	0.00	0.00	43,088.20

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending January 31, 2016	
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	4,648,606.20	0.00	0.00	0.00	0.00	0.00		29,004,079.00		
3520	ADULT 40-100% FOR FI	1,420.73	1,237.41	1,237.41	1,757.70	2,041.20	351.54	113.40	0.00	0.00	0.00	0.00	0.00		8,159.39		
3700	ADULT <40% EXP FOR F	6,003.73	6,278.71	6,416.20	13,891.50	10,943.10	2,823.66	1,134.00	0.00	0.00	0.00	0.00	0.00		47,490.90		
3710	AHC CARE EXPANDED FO	9,039,509.20	9,105,687.72	9,439,834.25	11,690,632.80	11,886,701.40	13,068,590.22	11,942,721.00	0.00	0.00	0.00	0.00	0.00		76,173,676.59		
3720	AHC CARE EXPANDED FO	1,787.37	641.62	1,283.24	1,701.00	1,701.00	311.22	283.50	0.00	0.00	0.00	0.00	0.00		7,708.95		
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	16,593,481.80	0.00	0.00	0.00	0.00	0.00		105,284,203.03		

3900	NEWLY ELIGIBLE FOR F	4,078.87	2,749.80	2,933.12	6,690.60	7,257.60	1,034.46	396.90	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	2,963,642.78	3,087,842.08	3,243,205.78	4,084,101.00	4,260,551.40	4,541,261.76	4,440,460.50	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	504.13	229.15	274.98	510.30	453.60	76.86	0.00	0.00	0.00	0.00	0.00	0.00	
	2,968,225.78	3,090,821.03	3,246,413.88	4,091,301.90	4,268,262.60	4,542,373.08	4,440,857.40	0.00	0.00	0.00	0.00	0.00	

25,141.35	
26,621,065.30	
2,049.02	
26,648,255.67	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	139,506.52	128,644.81	116,316.54	281,402.10	305,386.20	316,514.52	297,561.60	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	139,506.52	128,644.81	116,316.54	281,458.80	305,442.90	316,514.52	297,561.60	0.00	0.00	0.00	0.00	0.00	

1,585,332.29	
113.40	
1,585,445.69	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	12,740.74	12,511.59	12,465.76	15,025.50	14,345.10	15,710.94	14,175.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	1,604.05	1,558.22	1,512.39	1,871.10	1,871.10	2,149.56	1,927.80	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	16,102.80	0.00	0.00	0.00	0.00	0.00	

96,974.63	
12,494.22	
109,468.85	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	45.83	45.83	45.83	0.00	0.00	5.04	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	45,509.19	47,342.39	48,304.82	50,916.60	51,143.40	5,761.98	1,360.80	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	9,532.64	10,678.39	10,953.37	12,587.40	12,530.70	12,738.60	12,077.10	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	6,966.16	7,286.97	7,607.78	7,654.50	7,881.30	762.30	113.40	0.00	0.00	0.00	0.00	0.00	
	62,053.82	65,353.58	66,911.80	71,158.50	71,555.40	19,267.92	13,551.30	0.00	0.00	0.00	0.00	0.00	

142.53	
250,339.18	
81,098.20	
38,272.41	
369,852.32	

SUBTOTAL:

297,102,075.19

37,207,818.78	37,371,065.24	38,460,948.47	47,048,696.10	47,598,912.90	46,679,843.70	42,734,790.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending January 31, 2016	
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	58.00	0.00	0.00	0.00	0.00	0.00		8,370.00		
1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	0.00	0.00	0.00	0.00	0.00		1,134,741.00		
1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	0.00	0.00	0.00	0.00	0.00		3,657.00		
2100	SSI AGED WITH MEDIC A	4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	0.00	0.00	0.00	0.00	0.00		21,579.00		
2110	SSI AGED NON-MEDIC AR	6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	5,560.00	0.00	0.00	0.00	0.00	0.00		41,387.00		
2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	0.00	0.00	0.00	0.00	0.00		103,577.00		
2200	SSI DISABLED WITH M E	3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	0.00	0.00	0.00	0.00	0.00		20,614.00		
2210	SSI DISABLED NON-ME D	41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	37,346.00	0.00	0.00	0.00	0.00	0.00		274,135.00		
2220	SSI DISABLED WITH Q M	24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	2,899.00	0.00	0.00	0.00	0.00	0.00		124,128.00		
2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00		170.00		
2310	SSI BLIND NON-MEDIC A	435.00	430.00	427.00	410.00	415.00	417.00	426.00	0.00	0.00	0.00	0.00	0.00		2,960.00		
2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	43.00	42.00	0.00	0.00	0.00	0.00	0.00		1,281.00		
4300	SOBRA CHILD WITH M ED	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		
4310	SOBRA CHILD NON-ME DI	24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	22,344.00	0.00	0.00	0.00	0.00	0.00		164,523.00		
4320	SOBRA CHILD WITH Q MB	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		
5000	SOBRA PREGNANT WO MAN	37.00	36.00	39.00	36.00	30.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00		182.00		
5010	SOBRA PREGNANT WO MAN	23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	24,353.00	0.00	0.00	0.00	0.00	0.00		195,297.00		
5020	SOBRA PREGNANT WO MAN	9.00	12.00	10.00	11.00	12.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		56.00		
	327,648.00	339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	238,241.00	0.00	0.00	0.00	0.00	0.00		2,096,670.00		

SUBTOTAL:

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	434.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	131,497.00	133,819.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	154.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	440.00	416.00	401.00	300.00	289.00	16.00	13.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	27,950.00	27,934.00	27,865.00	21,648.00	21,423.00	1,225.00	1,225.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED W	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	279.00	274.00	270.00	269.00	283.00	29.00	26.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	2,674.00	2,580.00	2,585.00	2,201.00	2,167.00	2,094.00	2,037.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	0.00	0.00	0.00	0.00	0.00	
	141,761.00	128,966.00	119,111.00	174,124.00	172,169.00	136,489.00	138,712.00	0.00	0.00	0.00	0.00	0.00	

24,708.00	
754,696.00	
5,930.00	
1,875.00	
4,551.00	
129,270.00	
2.00	
9.00	
5.00	
1,430.00	
16,338.00	
72,518.00	
1,011,332.00	

SUBTOTAL:

0.00

0.00

3610	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	0.00	0.00	0.00	0.00	0.00	791.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending January 31, 2016	
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	81,986.00	0.00	0.00	0.00	0.00	0.00		549,746.00		
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00		157.00		
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	13.00	20.00	0.00	0.00	0.00	0.00	0.00		879.00		
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	213,189.00	210,630.00	0.00	0.00	0.00	0.00	0.00		1,441,544.00		
3720	AHC CARE EXPANDED FO	39.00	14.00	28.00	30.00	30.00	3.00	5.00	0.00	0.00	0.00	0.00	0.00		149.00		
SUBTOTAL:	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	292,654.00	0.00	0.00	0.00	0.00	0.00		1,993,266.00		

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	128.00	5.00	7.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	64,666.00	67,376.00	70,766.00	72,030.00	75,142.00	77,456.00	78,315.00	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
	64,766.00	67,441.00	70,836.00	72,157.00	75,278.00	77,462.00	78,322.00	0.00	0.00	0.00	0.00	0.00	

471.00	
505,751.00	
40.00	
506,262.00	

SUBTOTAL:

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	5,330.00	5,248.00	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	5,248.00	0.00	0.00	0.00	0.00	0.00	

29,316.00	
2.00	
29,318.00	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	278.00	273.00	272.00	265.00	253.00	249.00	250.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	35.00	34.00	33.00	33.00	33.00	34.00	34.00	0.00	0.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	0.00	0.00	0.00	0.00	0.00	

1,840.00	
236.00	
2,076.00	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	902.00	21.00	24.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	208.00	233.00	239.00	222.00	221.00	210.00	213.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	152.00	159.00	166.00	135.00	139.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	
	1,354.00	1,426.00	1,460.00	1,255.00	1,262.00	232.00	239.00	0.00	0.00	0.00	0.00	0.00	

3.00	
4,925.00	
1,546.00	
754.00	
7,228.00	

SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	753,700.00	0.00	0.00	0.00	0.00	0.00		5,646,152.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending January 31, 2016	
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	601,441.48	0.00	0.00	0.00	0.00	0.00		5,470,352.65		
2210	SSI DISABLED NON-ME D	339,019.30	338,090.48	337,161.66	358,241.15	375,396.36	431,901.92	388,515.05	0.00	0.00	0.00	0.00	0.00		2,568,325.92		
2310	SSI BLIND NON-MEDIC A	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		
4310	SOBRA CHILD NON-ME DI	13,288,627.74	13,621,145.30	13,792,048.18	14,711,097.14	15,234,835.61	16,974,862.22	15,937,190.09	0.00	0.00	0.00	0.00	0.00		103,559,806.28		
5010	SOBRA PREGNANT WO MAN	19,505.22	15,789.94	16,718.76	20,182.60	13,118.69	14,702.54	9,082.17	0.00	0.00	0.00	0.00	0.00		109,099.92		
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	16,936,228.79	0.00	0.00	0.00	0.00	0.00		111,713,504.21		

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

SUBTOTAL:	1,009.13	
		
	573,027.45	
SUBTOTAL:	573,027.45	
		
TOTAL:	112,287,540.79	

FO

1,009.13

4410	SOBRA 100-133% FOR F	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	89,800.52	89,812.57	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	89,812.57	0.00	0.00	0.00	0.00	0.00	

14,633,559.10	14,896,415.16	14,987,439.52	15,968,473.12	16,435,700.31	18,339,912.22	17,026,041.36	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending January 31, 2016	
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	596.00	0.00	0.00	0.00	0.00	0.00		5,470.00		
2210	SSI DISABLED NON-ME D	365.00	364.00	363.00	355.00	372.00	392.00	385.00	0.00	0.00	0.00	0.00	0.00		2,596.00		
2310	SSI BLIND NON-MEDIC A	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		
4310	SOBRA CHILD NON-ME DI	14,307.00	14,665.00	14,849.00	14,578.00	15,097.00	15,449.00	15,793.00	0.00	0.00	0.00	0.00	0.00		104,738.00		
5010	SOBRA PREGNANT WO MAN	21.00	17.00	18.00	20.00	13.00	13.00	9.00	0.00	0.00	0.00	0.00	0.00		111.00		
SUBTOTAL:	15,676.00	15,961.00	16,064.00	15,728.00	16,202.00	16,507.00	16,783.00	0.00	0.00	0.00	0.00	0.00		112,921.00		

1.00

1.00

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

3710	AHC CARE EXPANDED
FO
SUBTOTAL:

584.00

584.00

4410	SOBRA 100-133% FOR F	79.00	77.00	72.00	95.00	85.00	87.00	89.00	0.00	0.00	0.00	0.00	0.00	
	79.00	77.00	72.00	95.00	85.00	87.00	89.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

TOTAL:	15,755.00	16,038.00	16,136.00	15,824.00	16,287.00	16,594.00	16,872.00	0.00	0.00	0.00	0.00	0.00		113,506.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending January 31, 2016	
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	1,510.40	0.00	0.00	0.00	0.00	0.00		8,958.62		
1010	TANF NON-MEDICARE	133,111.44	130,590.39	131,598.81	194,610.24	194,610.24	193,135.92	197,862.40	0.00	0.00	0.00	0.00	0.00		1,175,519.44		
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	9,144.32	0.00	0.00	0.00	0.00	0.00		70,640.06		
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	8,667.20	0.00	0.00	0.00	0.00	0.00		110,528.06		
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	9,302.40	0.00	0.00	0.00	0.00	0.00		131,637.30		
1014	TANF 14-20 MALE NON-	8,513.34	6,845.58	6,098.97	5,921.88	5,921.88	4,530.48	4,174.08	0.00	0.00	0.00	0.00	0.00		42,006.21		
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	6,638.72	0.00	0.00	0.00	0.00	0.00		58,581.20		
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	833.88	833.88	833.88	927.60	1,391.40	1,391.40	1,431.36	0.00	0.00	0.00	0.00	0.00		7,643.40		
2110	SSI AGED NON-MEDIC AR	416.94	416.94	416.94	463.80	463.80	463.80	477.12	0.00	0.00	0.00	0.00	0.00		3,119.34		
2200	SSI DISABLED WITH M E	8,571.57	9,492.72	12,013.77	18,155.64	19,629.96	19,629.96	21,145.60	0.00	0.00	0.00	0.00	0.00		108,639.22		
2210	SSI DISABLED NON-ME D	3,071,131.98	3,075,185.07	3,070,908.99	4,422,630.00	4,413,676.56	4,434,590.40	4,544,230.40	0.00	0.00	0.00	0.00	0.00		27,032,353.40		
2220	SSI DISABLED WITH Q M	24,444.48	25,452.90	25,957.11	37,512.24	40,460.88	40,460.88	44,676.80	0.00	0.00	0.00	0.00	0.00		238,965.29		
2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	737.16	737.16	737.16	755.20	0.00	0.00	0.00	0.00	0.00		4,479.31		
2310	SSI BLIND NON-MEDIC A	27,624.87	28,129.08	27,624.87	39,640.80	39,831.24	39,094.08	40,821.76	0.00	0.00	0.00	0.00	0.00		242,766.70		
4311	SOBRA CHILD <1 M & F	21,273.72	19,935.63	18,180.60	24,292.56	22,164.00	24,375.48	25,003.52	0.00	0.00	0.00	0.00	0.00		155,225.51		
4312	SOBRA CHILD 01-05 M	137,425.89	146,162.22	148,906.26	180,325.32	185,783.40	191,871.12	190,816.32	0.00	0.00	0.00	0.00	0.00		1,181,290.53		
4313	SOBRA CHILD 06-13 M	130,832.34	140,421.96	154,045.26	197,710.08	200,468.28	209,255.88	222,698.56	0.00	0.00	0.00	0.00	0.00		1,255,432.36		
4314	SOBRA CHILD 14-20 MA	30,970.02	33,141.99	36,060.57	45,851.52	45,578.16	44,186.76	52,076.48	0.00	0.00	0.00	0.00	0.00		287,865.50		
4315	SOBRA CHILD 14-20 FE	35,226.69	37,815.60	35,886.03	47,433.36	48,278.04	50,679.96	53,469.76	0.00	0.00	0.00	0.00	0.00		308,789.44		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880.74		
5015	SOBRA PREG 14-20 FE M	3,005.85	2,588.91	2,171.97	2,592.36	3,056.16	1,664.76	1,232.32	0.00	0.00	0.00	0.00	0.00		16,312.33		
	3,709,033.47	3,715,811.19	3,724,586.34	5,279,166.00	5,275,563.12	5,302,266.72	5,436,134.72	0.00	0.00	0.00	0.00	0.00		32,442,561.56		

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	477.12	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	477.12	0.00	0.00	0.00	0.00	0.00	
	833.88	416.94	416.94	927.60	927.60	463.80	954.24	0.00	0.00	0.00	0.00	0.00	

416.94	
1,404.72	
2,178.42	
940.92	
4,941.00	

SUBTOTAL:

3514	ADULT 40-100% MALE
1	833.88	833.88	833.88	927.60	1,391.40	1,391.40	1,431.36	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	477.12	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	477.12	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 MAL E	6,254.10	7,087.98	6,671.04	6,029.40	6,029.40	6,029.40	6,679.68	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	6,202.56	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	416.94	416.94	416.94	1,391.40	927.60	927.60	477.12	0.00	0.00	0.00	0.00	0.00	

 
7,643.40	
4,370.16	
1,404.72	
463.80	
44,781.00	
34,526.82	
4,974.54	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEM
AL	416.94	416.94	416.94	463.80	927.60	1,391.40	1,431.36	0.00	0.00	0.00	0.00	0.00	5,464.98	
SUBTOTAL:	12,508.20	13,759.02	13,342.08	15,305.40	14,841.60	16,696.80	17,176.32	0.00	0.00	0.00	0.00	0.00	103,629.42	
														
													1,250.82	
SUBTOTAL:													1,250.82	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending January 31, 2016

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

4413	SOBRA 100-133% M&F
6	4,760.88	4,343.94	3,927.00	12,332.16	13,996.92	11,404.56	13,637.44	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	3,816.96	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	833.88	833.88	416.94	1,391.40	1,855.20	1,855.20	1,431.36	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	18,885.76	0.00	0.00	0.00	0.00	0.00	

64,402.90	
21,127.05	
8,617.86	
94,147.81	

SUBTOTAL:

32,646,530.61

3,730,142.28	3,737,336.94	3,744,027.39	5,313,570.12	5,311,168.20	5,337,134.64	5,473,151.04	0.00	0.00	0.00	0.00	0.00	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00		14.00		
1010	TANF NON-MEDICARE	264.00	259.00	261.00	264.00	264.00	262.00	262.00	0.00	0.00	0.00	0.00	0.00		1,836.00		
1011	TANF <1 M & F NON-ME	21.00	24.00	24.00	19.00	23.00	21.00	18.00	0.00	0.00	0.00	0.00	0.00		150.00		
1012	TANF 01-05 M & F NON	61.00	40.00	34.00	36.00	29.00	22.00	17.00	0.00	0.00	0.00	0.00	0.00		239.00		
1013	TANF 06-13 M & F NON	70.00	51.00	42.00	39.00	34.00	26.00	16.00	0.00	0.00	0.00	0.00	0.00		278.00		
1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	11.00	11.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00		87.00		
1015	TANF 14-20 FEMALE N O	21.00	18.00	20.00	19.00	15.00	16.00	11.00	0.00	0.00	0.00	0.00	0.00		120.00		
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	2.00	2.00	2.00	2.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00		17.00		
2110	SSI AGED NON-MEDIC AR	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
2200	SSI DISABLED WITH M E	17.00	19.00	24.00	25.00	27.00	27.00	28.00	0.00	0.00	0.00	0.00	0.00		167.00		
2210	SSI DISABLED NON-ME D	6,177.00	6,184.00	6,175.00	6,182.00	6,168.00	6,196.00	6,194.00	0.00	0.00	0.00	0.00	0.00		43,276.00		
2220	SSI DISABLED WITH Q M	49.00	51.00	52.00	52.00	56.00	56.00	61.00	0.00	0.00	0.00	0.00	0.00		377.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
2310	SSI BLIND NON-MEDIC A	56.00	57.00	56.00	56.00	57.00	56.00	57.00	0.00	0.00	0.00	0.00	0.00		395.00		
4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	40.00	36.00	39.00	39.00	0.00	0.00	0.00	0.00	0.00		282.00		
4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	311.00	321.00	330.00	323.00	0.00	0.00	0.00	0.00	0.00		2,230.00		
4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	342.00	345.00	361.00	377.00	0.00	0.00	0.00	0.00	0.00		2,363.00		
4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	80.00	80.00	77.00	87.00	0.00	0.00	0.00	0.00	0.00		545.00		
4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	84.00	87.00	91.00	94.00	0.00	0.00	0.00	0.00	0.00		598.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5015	SOBRA PREG 14-20 FE M	7.00	6.00	5.00	5.00	6.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00		34.00		
	7,546.00	7,561.00	7,581.00	7,572.00	7,566.00	7,600.00	7,600.00	0.00	0.00	0.00	0.00	0.00		53,026.00		

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

1.00	
3.00	
5.00	
2.00	
11.00	

SUBTOTAL:

3514	ADULT 40-100% MALE
1	2.00	2.00	2.00	2.00	3.00	3.00	3.00	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	1.00	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	1.00	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 MAL E	15.00	17.00	16.00	13.00	13.00	13.00	14.00	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	13.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	1.00	1.00	1.00	3.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	

 
17.00	
10.00	
3.00	
1.00	
101.00	
77.00	
11.00	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEM
AL	1.00	1.00	1.00	1.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	12.00	
SUBTOTAL:	30.00	33.00	32.00	33.00	32.00	36.00	36.00	0.00	0.00	0.00	0.00	0.00	232.00	
														
													3.00	
SUBTOTAL:													3.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending January 31, 2016

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

4413	SOBRA 100-133% M&F
6	11.00	10.00	9.00	26.00	29.00	24.00	28.00	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	8.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	2.00	2.00	1.00	3.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	
	17.00	16.00	12.00	38.00	41.00	37.00	39.00	0.00	0.00	0.00	0.00	0.00	

137.00	
44.00	
19.00	
200.00	

SUBTOTAL:

TOTAL:	7,596.00	7,612.00	7,627.00	7,645.00	7,641.00	7,674.00	7,677.00	0.00	0.00	0.00	0.00	0.00		53,472.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

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

1006	TANF 21-44 MALE WITH	13,748.51	11,706.46	23,270.89	8,748.57	7,149.61	14,460.00	3,194.53	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	17,515.57	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	11,308.56	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	6,374.27	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	1,098,938.02	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	442,817.74	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	461,596.57	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	114,807.96	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	304,973.91	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	1,519,545.50	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	4,843,007.69	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	1,809,130.45	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	12,607.29	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	-0.09	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	1,466.16	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	935.87	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	82.87	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	167,284.72	163,478.22	201,904.18	127,579.30	163,117.16	143,402.07	138,838.96	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	125,205.47	128,787.96	211,507.53	151,466.88	159,319.29	137,030.36	79,330.72	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	312,502.09	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	306,269.94	461,879.30	527,481.62	417,867.71	349,136.11	497,895.47	257,476.73	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	8,070,657.42	8,785,140.60	10,377,505.66	6,855,292.97	7,625,934.11	8,790,935.35	6,487,472.46	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	1,017,428.75	1,228,462.25	1,678,808.77	1,093,787.83	1,003,545.35	1,548,474.33	959,104.40	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	1,772.52	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	61,535.87	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	9,887.38	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	2,055,582.50	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	3,124,080.99	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	4,145,955.36	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	1,039,905.54	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	1,341,359.36	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	2,158.62	0.00	0.00	0.00	0.00	0.00	

 
82,278.57	
137,227.22	
249,110.41	
92,516.60	
7,808,626.75	
5,599,574.25	
8,441,588.18	
2,082,464.97	
3,955,438.80	
12,417,455.63	
44,696,079.66	
16,006,263.77	
57,078.31	
7,158.58	
15,125.57	
58,860.10	
26,955.81	
1,105,604.61	
992,648.21	
2,736,181.82	
2,818,006.88	
56,992,938.57	
8,529,611.68	
9,533.55	
620,598.92	
106,157.56	
700.00	
14,697,852.28	
22,304,907.80	
31,847,565.68	
8,470,711.00	
10,867,841.81	
4,466.28	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,357.53	1,572.17	700.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00		6,979.70		
5015	SOBRA PREG 14-20 FE M	396,630.45	405,096.39	479,727.39	392,622.76	525,109.97	463,461.69	314,495.69	0.00	0.00	0.00	0.00	0.00		2,977,144.34		
5017	SOBRA PREG 21-44 FE M	1,708,550.06	2,049,753.34	2,625,202.28	1,982,900.83	2,364,318.56	2,224,181.36	1,616,865.05	0.00	0.00	0.00	0.00	0.00		14,571,771.48		
5018	SOBRA PREG 45-64 FE M	4,193.00	14,500.38	2,450.00	1,822.16	1,347.29	4,635.72	2,106.99	0.00	0.00	0.00	0.00	0.00		31,055.54		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	12.47	0.00	0.00	0.00	122.80	0.00	0.00	0.00	0.00	0.00		135.27		
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	32,599,206.90	0.00	0.00	0.00	0.00	0.00		281,426,216.16		

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	

3100	TRANSPLANT OPTION
1
SUBTOTAL:

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	12,222.44	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	25,753.21	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	85,964.71	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	23,910.19	20,501.26	32,963.26	25,925.52	28,936.18	44,064.76	32,925.55	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	107.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	5,732.86	4,829.90	1,724.46	1,174.70	2,883.38	1,131.53	157.18	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	6,989.95	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	13,628.21	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	48,938.98	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	547,986.30	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	1,846,659.18	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	1,119,850.30	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	1,421.04	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	4,910.43	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	2,965.73	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	23,241.13	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	7,716.84	9,382.71	9,968.24	4,051.32	6,051.95	12,685.96	16,685.68	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	22,942.06	38,024.62	25,791.81	23,668.51	15,918.51	19,779.67	9,221.30	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	67,166.54	76,848.41	85,275.84	56,641.92	14,405.42	-6,248.62	27,759.57	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	381,632.77	433,733.65	560,695.33	355,819.68	312,801.61	402,841.73	287,149.02	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	12,133.96	14,195.83	29,503.82	33,613.80	21,605.09	25,316.76	20,282.52	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	300,375.73	232,843.02	283,300.90	217,797.74	205,261.69	195,292.13	256,913.01	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	285,198.27	311,126.24	453,402.95	307,810.33	270,330.08	426,260.66	264,912.45	0.00	0.00	0.00	0.00	0.00	
	3,645,170.04	3,654,958.78	4,322,859.94	3,374,479.87	4,570,982.50	5,635,703.78	4,656,537.89	0.00	0.00	0.00	0.00	0.00	

350.00	
84,235.54	
228,404.22	
550,430.88	
209,226.72	
107.79	
17,634.01	
107,541.18	
86,697.85	
225,205.53	
3,514,195.82	
10,621,292.69	
6,596,984.99	
12,684.23	
25,469.15	
26,397.40	
107,945.77	
66,542.70	
155,346.48	
321,849.08	
2,734,673.79	
156,651.78	
1,691,784.22	
2,319,040.98	
29,860,692.80	

SUBTOTAL:

3308	AHC CARE M&F 45-64 W	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-95.91	0.00	0.00	0.00	0.00	0.00	-8.71	0.00	0.00	0.00	0.00	0.00	

 
21.62

-104.62

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

SUBTOTAL:

-13,272.06

0.00

-316.00

-883.27

-304.13

-4,315.42

-390.50

0.00

0.00

0.00

0.00

0.00

-19,481.38

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	-381.79	0.00	0.00	0.00	0.00	0.00	-1,679.09	

3318	4
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	

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 1	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-23,081.14	-52.99	-475.87	-491.04	0.00	-6,343.50	-20.32	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,251.30	-100.95	0.00	-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	-20.32	0.00	0.00	0.00	0.00	0.00	

-1,057.32	
-189.98	
60.75	
-2,238.34	
12,313.57	
-30,464.86	
-1,789.78	
42,642.08	
19,276.12	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	100.62	646.90	826.55	497.49	10.06	856.86	1,069.02	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	10,702.23	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	367.82	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	41,908.79	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	42,310.21	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	810,029.73	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	383,720.88	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	1,631,110.70	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	1,092.24	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	103.71	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	4.35	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	254.18	187.24	2,147.85	720.29	183.04	2,139.90	710.15	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	3,196.60	2,984.95	5,735.57	5,555.83	3,319.35	11,243.02	3,917.52	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	20,398.58	29,175.88	21,993.36	25,199.18	23,133.12	24,274.24	12,893.26	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	662.62	898.69	1,365.10	1,918.68	573.77	221.31	248.38	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	222,884.44	394,365.52	460,111.11	290,538.55	301,852.22	316,910.70	209,200.65	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	293,885.85	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	5,628,508.71	6,879,358.31	8,226,675.54	5,692,613.38	6,424,354.58	7,064,928.46	5,710,963.95	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,131,984.98	3,612,847.61	4,415,525.36	3,018,805.67	3,263,582.99	3,938,144.69	2,814,367.59	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	7,505,601.56	8,385,725.63	10,052,601.97	7,135,426.84	7,938,678.59	9,242,278.61	7,114,978.63	0.00	0.00	0.00	0.00	0.00	

 
4,007.50	
402.04	
41,438.48	
10,680.19	
202,535.90	
536,981.79	
4,890,399.30	
3,267,860.59	
12,311,749.74	
27,999.39	
561.56	
346.29	
1,076.45	
68.79	
6,342.65	
35,952.84	
157,067.62	
5,888.55	
2,195,863.19	
2,161,715.86	
45,627,402.93	
24,195,258.89	
57,375,291.83	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	20,526.57	6,525.97	34,180.45	3,932.97	6,156.96	11,148.55	6,217.59	0.00	0.00	0.00	0.00	0.00		88,689.06		
3727	ADULT <40% EXP FEM AL	166.20	0.00	0.00	0.00	0.00	350.00	350.00	0.00	0.00	0.00	0.00	0.00		866.20		
3728	ADULT <40% EXP M&F 4	-612.98	2,336.87	599.83	1,113.03	476.91	1,324.77	274.77	0.00	0.00	0.00	0.00	0.00		5,513.20		
	19,765,638.49	22,705,157.72	27,297,474.93	19,115,291.56	21,060,068.76	24,117,901.35	19,090,428.02	0.00	0.00	0.00	0.00	0.00		153,151,960.83		

SUBTOTAL:

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	0.00	0.00	2,100.00	392.10	350.00	350.00	350.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	8,274.29	12,110.91	11,447.94	6,297.36	4,582.34	14,254.41	4,184.08	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	291.65	74.97	0.00	1,418.20	2,273.85	1,370.89	310.18	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	11,053.95	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	24,651.94	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	300,754.78	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	365,563.44	469,279.85	562,236.94	478,333.08	462,900.24	666,374.15	481,198.37	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	1,046,431.51	1,175,014.10	1,299,604.63	912,240.75	1,066,051.25	1,102,594.49	962,994.87	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	700.00	0.00	2,450.00	1,050.00	700.00	350.00	1,750.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	47.11	350.00	59.40	0.00	48.25	10.07	0.00	0.00	0.00	0.00	0.00	0.00	
	1,757,825.94	2,095,784.57	2,416,331.87	1,869,494.39	1,862,134.99	2,333,128.25	1,787,248.17	0.00	0.00	0.00	0.00	0.00	

2,534.34	
3,542.10	
61,151.33	
5,739.74	
94,247.90	
196,874.45	
2,699,525.82	
3,485,886.07	
7,564,931.60	
7,000.00	
514.83	
14,121,948.18	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	208,919.81	208,659.92	145,887.27	356,231.37	470,925.81	559,700.27	435,224.20	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	171,746.40	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	72,034.45	135,577.62	72,403.64	179,192.24	176,144.29	203,844.54	143,597.42	0.00	0.00	0.00	0.00	0.00	
	370,657.12	434,001.78	270,045.70	690,329.17	796,139.54	918,280.03	750,568.02	0.00	0.00	0.00	0.00	0.00	

700.00	
2,385,548.65	
860,978.51	
982,794.20	
4,230,021.36	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	5,936.00	6,300.97	5,519.97	999.09	457.38	700.00	350.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	1,513.47	2,898.87	2,896.09	4,542.74	42,584.08	9,620.42	19,560.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	8,655.21	1,050.00	485.19	7,330.09	-18.31	700.00	140.57	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	4,085.95	1,050.00	2,131.49	2,168.06	0.00	0.00	477.80	0.00	0.00	0.00	0.00	0.00	
	20,190.63	11,299.84	11,032.74	15,039.98	43,023.15	11,020.42	20,528.37	0.00	0.00	0.00	0.00	0.00	

20,263.41	
83,615.67	
18,342.75	
9,913.30	
132,135.13	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	3,861.91	11,145.71	10,454.38	6,107.64	5,084.31	10,824.80	3,234.54	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	2,100.00	2,528.61	332.93	1,759.52	13,816.87	1,050.00	350.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	59.40	237.60	367.94	0.00	10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	6,021.31	13,911.92	11,155.25	7,867.16	18,911.44	11,874.80	3,584.54	0.00	0.00	0.00	0.00	0.00	

50,713.29	
21,937.93	
675.20	
73,326.42	

SUBTOTAL:

482,995,894.41

64,487,605.57	71,142,743.92	86,213,717.58	59,713,116.53	66,827,976.28	75,703,043.44	58,907,691.09	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending January 31, 2016	
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	1,372.50	0.00	0.00	0.00	0.00	0.00		36,531.89		
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	279.94	0.00	0.00	0.00	0.00	0.00		1,012.51		
1014	TANF 14-20 MALE NON-	1,639.96	371.56	1,298.43	1,214.10	4,020.29	977.96	48.87	0.00	0.00	0.00	0.00	0.00		9,571.17		
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	9,837.71	0.00	0.00	0.00	0.00	0.00		57,264.29		
1016	TANF 21-44 MALE NON-	27,978.02	35,547.13	51,358.56	38,612.37	40,905.00	50,432.24	29,787.33	0.00	0.00	0.00	0.00	0.00		274,620.65		
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	151,562.92	0.00	0.00	0.00	0.00	0.00		859,457.35		
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	46,527.79	0.00	0.00	0.00	0.00	0.00		239,312.89		
2100	SSI AGED WITH MEDIC A	4,288.93	2,161.00	6,039.80	3,610.04	6,310.04	9,322.70	2,791.86	0.00	0.00	0.00	0.00	0.00		34,524.37		
2110	SSI AGED NON-MEDIC AR	16,932.19	33,017.03	46,637.60	18,239.09	16,129.07	54,594.05	4,788.76	0.00	0.00	0.00	0.00	0.00		190,337.79		
2120	SSI AGED WITH QMB	0.00	807.00	131.79	1,379.48	288.97	25.56	238.50	0.00	0.00	0.00	0.00	0.00		2,871.30		
2200	SSI DISABLED WITH M E	488.66	1,617.07	3,610.05	1,642.17	3,477.20	5,815.21	1,683.14	0.00	0.00	0.00	0.00	0.00		18,333.50		
2210	SSI DISABLED NON-ME D	39,007.48	95,497.11	23,513.88	6,329.44	33,843.11	15,669.91	13,471.38	0.00	0.00	0.00	0.00	0.00		227,332.31		
2220	SSI DISABLED WITH Q M	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		
2310	SSI BLIND NON-MEDIC A	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	71,543.07	0.00	0.00	0.00	0.00	0.00		488,052.07		
4312	SOBRA CHILD 01-05 M	64,184.72	52,686.05	65,786.94	66,664.94	55,185.47	50,219.69	40,749.56	0.00	0.00	0.00	0.00	0.00		395,477.37		
4313	SOBRA CHILD 06-13 M	34,405.76	34,320.87	47,228.07	40,773.76	40,430.70	52,470.13	167,539.54	0.00	0.00	0.00	0.00	0.00		417,168.83		
4314	SOBRA CHILD 14-20 MA	34,112.02	13,654.57	40,427.51	19,191.40	55,948.06	42,767.75	27,873.44	0.00	0.00	0.00	0.00	0.00		233,974.75		
4315	SOBRA CHILD 14-20 FE	25,544.79	41,450.78	33,073.65	31,045.68	27,206.23	30,313.34	36,811.72	0.00	0.00	0.00	0.00	0.00		225,446.19		
5007	SOBRA PREG 21-44 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		
5015	SOBRA PREG 14-20 FE M	17,081.33	30,674.40	30,351.24	28,628.36	24,395.73	18,499.32	16,365.78	0.00	0.00	0.00	0.00	0.00		165,996.16		
5017	SOBRA PREG 21-44 FE M	77,766.50	80,269.95	104,810.09	109,667.47	114,599.68	69,726.40	73,096.12	0.00	0.00	0.00	0.00	0.00		629,936.21		
5018	SOBRA PREG 45-64 FE M	0.00	28.27	0.00	0.00	-28.27	1,541.56	83.27	0.00	0.00	0.00	0.00	0.00		1,624.83		
8040	SLMB	6,944.53	49.41	807.03	-83.03	73.45	0.00	34.58	0.00	0.00	0.00	0.00	0.00		7,825.97		
8050	QI1	959.34	1,438.39	130.47	132.01	0.00	31.17	57.74	0.00	0.00	0.00	0.00	0.00		2,749.12		
	587,535.49	650,200.47	696,955.04	585,072.80	618,483.47	702,700.45	696,545.52	0.00	0.00	0.00	0.00	0.00		4,537,493.24		

SUBTOTAL:

1106	TANF EXPANDED 21-44	0.00	93.33	88.81	2,077.39	12.33	0.00	1,050.00	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	1,257.44	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	

 
3,321.86

1,001.27

13,244.19

515.10

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending January 31, 2016	
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	13,425.14	0.00	0.00	0.00	0.00	0.00		109,702.83		
1117	TANF EXPANDED 21-44	31,143.56	46,456.94	70,887.40	33,885.09	33,000.10	15,326.63	17,091.45	0.00	0.00	0.00	0.00	0.00		247,791.17		
1118	TANF EXPANDED 45-64	29,015.56	33,956.75	60,010.71	18,273.86	33,687.02	21,583.85	-510.85	0.00	0.00	0.00	0.00	0.00		196,016.90		
2400	SSI AGED EXPANDED WI	2,377.90	12,618.70	12,271.07	5,527.40	15,781.06	14,405.54	4,462.00	0.00	0.00	0.00	0.00	0.00		67,443.67		
2410	SSI AGED EXPANDED NO	979.32	10,480.42	0.00	3,960.00	1,445.40	-3,716.92	285.17	0.00	0.00	0.00	0.00	0.00		13,433.39		
2420	SSI AGED EXPANDED WI	550.98	1,286.23	328.44	378.82	327.11	134.82	1,901.11	0.00	0.00	0.00	0.00	0.00		4,907.51		
2600	SSI DISABLED EXPAND E	2,818.70	1,835.75	7,785.00	2,326.61	1,030.79	2,145.67	4,113.01	0.00	0.00	0.00	0.00	0.00		22,055.53		
2610	SSI DISABLED EXPAND E	3,572.35	3,805.02	18,910.75	13,966.80	2,598.34	1,128.87	116.78	0.00	0.00	0.00	0.00	0.00		44,098.91		
2620	SSI DISABLED EXPAND E	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		
	87,190.43	129,664.23	206,137.87	97,618.58	107,668.07	63,749.50	43,191.25	0.00	0.00	0.00	0.00	0.00		735,219.93		

SUBTOTAL:

3508	ADULT 40-100% M&F 45	39.84	0.00	636.68	0.00	6.87	832.12	35.00	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	1,001.74	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	8,774.71	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	31,559.03	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	18,907.11	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	228,412.04	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 MAL E	1,587.28	0.00	57.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	947.85	0.00	377.50	1,293.45	265.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	350.00	0.00	0.00	0.00	14.41	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	-3,202.73	15,501.02	18,183.71	10,358.26	16,379.49	3,249.11	8,077.80	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	3,889.25	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	167,516.26	204,690.38	358,830.19	199,648.63	205,387.98	182,804.58	164,588.69	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	161,052.04	116,919.92	123,724.40	87,699.35	97,976.52	61,746.47	85,889.56	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	492,428.69	286,192.87	473,719.11	334,168.08	251,532.72	264,130.42	218,569.58	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL E	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	
	1,010,189.83	816,937.56	1,273,874.71	893,696.29	744,323.30	688,336.40	769,718.92	0.00	0.00	0.00	0.00	0.00	

1,550.51	
39,135.22	
55,893.86	
276,699.09	
208,949.74	
901,383.81	
1,401.96	
661.55	
1,644.30	
2,883.82	
364.41	
68,546.66	
95,815.29	
1,483,466.71	
735,008.26	
2,320,741.47	
2,930.35	
6,197,077.01	

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	76.00	0.00	0.00	230.05	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	125.54	0.00	50.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	90.99	700.00	234.31	0.00	276.64	0.00	213.94	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	524.43	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	2,542.00	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	43,857.31	0.00	0.00	0.00	0.00	0.00	

 
306.05	
175.69	
1,515.88	
13,533.61	
29,803.71	
406,936.59	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
33,130.96	36,088.32	65,921.67	74,500.38	52,468.71	45,771.22	28,027.28	0.00	0.00	0.00	0.00	0.00	335,908.54	
88,508.51	131,570.76	163,768.01	128,365.27	173,085.98	142,740.97	94,421.96	0.00	0.00	0.00	0.00	0.00	922,461.46	
160,593.88	215,500.31	316,273.51	262,679.06	334,687.99	251,089.81	169,816.97	0.00	0.00	0.00	0.00	0.00	1,710,641.53	

4413	SOBRA 100-133% M&F
6	4,059.93	12,186.74	21,110.23	15,342.31	11,795.63	23,287.90	14,713.89	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	7,149.43	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	867.96	4,065.21	16,099.57	3,552.16	3,166.06	6,247.80	4,525.10	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	26,388.42	0.00	0.00	0.00	0.00	0.00	

 
102,496.63	
36,761.43	
38,523.86	
177,781.92	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

3917

3918

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE M&F

4
SUBTOTAL:

2,070.14

2,070.14

4518	BC PATIENT FEMALE 4 5	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	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	141.21	1,493.16	2,014.03	306.31	0.00	27.56	92.28	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	137.00	661.16	678.06	162.48	0.00	48.87	0.00	0.00	0.00	0.00	0.00	
	141.21	1,630.16	2,675.19	984.37	162.48	27.56	141.15	0.00	0.00	0.00	0.00	0.00	

4,074.55	
1,687.57	
5,762.12	

SUBTOTAL:

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	1,705,802.23	0.00	0.00	0.00	0.00	0.00		13,366,045.89		

FAMILY PLANNING SERVICES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION
5510

SOBRA FPS FEMALE W
IT

JULY
-39.37

AUGUST	SEPTEMBER

0.00

0.00

OCTOBER	NOVEMBER
0.00	0.00

DECEMBER
0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

-39.37

SUBTOTAL:	-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.37	
															
TOTAL:	-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	

FEDERAL EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	837.48	0.00	0.00	0.00	0.00	0.00		837.48		
1011	TANF <1 M & F NON-ME	0.00	455.46	3,231.96	0.00	2,515.08	1,013.45	383.08	0.00	0.00	0.00	0.00	0.00		7,599.03		
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	21,583.68	0.00	0.00	0.00	0.00	0.00		99,239.32		
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	48,001.49	0.00	0.00	0.00	0.00	0.00		363,217.51		
1014	TANF 14-20 MALE NON-	65,319.99	60,239.51	137,076.35	98,293.54	77,609.81	159,897.23	61,604.89	0.00	0.00	0.00	0.00	0.00		660,041.32		
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	354,063.14	0.00	0.00	0.00	0.00	0.00		2,824,717.09		
1016	TANF 21-44 MALE NON-	60,888.08	100,933.93	31,723.66	82,988.49	117,876.44	146,067.61	96,582.23	0.00	0.00	0.00	0.00	0.00		637,060.44		
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	2,369,438.49	0.00	0.00	0.00	0.00	0.00		19,645,346.38		
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	244,088.53	0.00	0.00	0.00	0.00	0.00		1,133,382.38		
1019	TANF 65+ M & F NON-M	974.37	580.16	36,530.93	189.47	5,569.41	908.59	2,030.43	0.00	0.00	0.00	0.00	0.00		46,783.36		
2100	SSI AGED WITH MEDIC A	1,028.00	1,134.36	2,508.08	3,684.44	9,408.49	13,782.91	14,408.61	0.00	0.00	0.00	0.00	0.00		45,954.89		
2110	SSI AGED NON-MEDIC AR	767,030.64	976,118.47	1,135,999.12	1,013,075.24	667,723.02	878,890.18	786,495.73	0.00	0.00	0.00	0.00	0.00		6,225,332.40		
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	15,487.16	14,895.52	19,590.18	15,828.97	7,325.35	7,561.88	13,231.61	0.00	0.00	0.00	0.00	0.00		93,920.67		
2210	SSI DISABLED NON-ME D	388,846.01	233,518.99	496,312.04	330,185.22	270,923.16	597,379.32	438,012.70	0.00	0.00	0.00	0.00	0.00		2,755,177.44		
2220	SSI DISABLED WITH Q M	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		
2310	SSI BLIND NON-MEDIC A	-213.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-213.81		
	4,601,455.29	4,572,491.25	5,962,347.42	5,124,818.57	4,140,928.85	5,688,268.31	4,450,762.09	0.00	0.00	0.00	0.00	0.00		34,541,071.78		

SUBTOTAL:

1106	TANF EXPANDED 21-44	942.36	1,534.47	1,505.09	822.46	57.30	121.67	57.30	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	553.96	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	2,501.96	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	216,293.07	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	756,845.93	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	254,634.73	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	5,837.82	4,006.70	13,397.27	6,670.37	1,703.95	965.56	7,008.44	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	3,738.85	228.58	31.65	378.59	28.32	492.32	200.13	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	91,019.49	40,318.46	59,658.59	49,583.24	58,225.17	37,166.59	16,710.77	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	698.31	742.38	385.05	49.30	660.78	697.68	981.64	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	34,997.13	35,849.69	53,494.32	45,988.82	18,108.10	55,317.19	4,986.48	0.00	0.00	0.00	0.00	0.00	
	1,597,437.04	1,711,374.62	2,288,194.10	2,317,605.90	1,391,409.20	1,616,401.84	1,260,774.41	0.00	0.00	0.00	0.00	0.00	

5,040.65	
4,651.51	
9,952.76	
107.93	
312.04	
22,640.92	
100,674.86	
2,676,999.03	
6,244,350.46	
2,468,139.22	
39,590.11	
5,098.44	
352,682.31	
4,215.14	
248,741.73	
12,183,197.11	

SUBTOTAL:

3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	11.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11.67

FEDERAL EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		2,942.57		
3517	ADULT 40-100% FEMAL E	0.00	3,220.32	764.56	0.00	470.90	2,523.03	764.56	0.00	0.00	0.00	0.00	0.00		7,743.37		
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 MAL E	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 MAL E	3,173.56	985.83	1,307.20	1,210.89	1,112.96	27.45	9.55	0.00	0.00	0.00	0.00	0.00		7,827.44		
3717	ADULT <40% EXP FEM AL	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		
3718	ADULT <40% EXP M&F 4	6,017.10	34,892.69	1,317.28	2,900.81	2,053.73	1,823.06	532.91	0.00	0.00	0.00	0.00	0.00		49,537.58		
	17,571.92	44,680.95	10,620.17	6,411.33	4,225.20	4,492.78	1,307.02	0.00	0.00	0.00	0.00	0.00		89,309.37		

SUBTOTAL:

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	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	947.60	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	3,134.87	5,350.82	1,445.22	2,455.88	3,337.80	7,501.84	344.52	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	294.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	22,970.43	28,098.00	35,654.89	64,365.00	22,203.74	56,797.49	115,313.60	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	47,549.41	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	506,476.45	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	300,086.49	238,508.95	403,994.50	295,796.76	356,891.79	448,073.55	369,933.52	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	894,595.81	1,176,047.32	1,802,982.03	1,288,816.29	895,641.23	1,294,633.12	1,452,260.05	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	15,863.94	1,457.81	4,116.70	11,314.92	4,086.67	9,586.01	4,959.54	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	46.58	46.58	718.50	666.40	737.18	713.70	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	695.06	694.80	694.15	694.28	57.30	57.30	639.47	0.00	0.00	0.00	0.00	0.00	
	1,701,574.81	1,999,987.75	3,176,830.75	2,397,433.76	1,935,178.27	2,586,750.28	2,498,424.16	0.00	0.00	0.00	0.00	0.00	

420.94	
947.60	
23,570.95	
294.80	
345,403.15	
287,529.10	
4,361,904.94	
2,413,285.56	
8,804,975.85	
51,385.59	
2,928.94	
3,532.36	
16,296,179.78	

SUBTOTAL:

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	8,211,267.68	0.00	0.00	0.00	0.00	0.00		63,109,758.04		

FEDERAL ESP CHRONIC SERVICES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	0.00	0.00	0.00	0.00	381.05	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	0.00	0.00	0.00	0.00	381.05	
														
TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	0.00	0.00	0.00	0.00	381.05	

QMB - FEE FOR SERVICE
For The Period Ending January 31, 2016

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	277,299.18	0.00	0.00	0.00	0.00	0.00	2,467,911.22	
SUBTOTAL:	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	277,299.18	0.00	0.00	0.00	0.00	0.00	2,467,911.22	

TOTAL:	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	277,299.18	0.00	0.00	0.00	0.00	0.00		2,467,911.22		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	3,227.31	2,397.42	0.00	5,425.92	0.00	0.00	2,234.31	0.00	0.00	0.00	0.00	0.00		13,284.96		
2100	SSI AGED WITH MEDIC A	15,412.32	89,978.84	21,245.35	45,417.87	26,065.20	121,503.30	55,073.43	0.00	0.00	0.00	0.00	0.00		374,696.31		
2110	SSI AGED NON-MEDIC AR	61,148.18	60,953.07	9,698.95	112,583.05	49,546.66	80,506.33	78,467.63	0.00	0.00	0.00	0.00	0.00		452,903.87		
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	4,280.93	0.00	0.00	0.00	121.42	30,146.45	9,920.49	0.00	0.00	0.00	0.00	0.00		44,469.29		
2210	SSI DISABLED NON-ME D	0.00	806.03	7.57	2,769.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,583.26		
2220	SSI DISABLED WITH Q M	5,933.83	6,506.08	0.00	0.00	13,921.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,361.78		
5017	SOBRA PREG 21-44 FE M	3,043.51	2,377.80	0.00	0.00	470.90	2,879.02	2,789.29	0.00	0.00	0.00	0.00	0.00		11,560.52		
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		
	94,139.63	163,354.77	30,951.87	166,196.50	96,395.46	235,227.60	148,485.15	0.00	0.00	0.00	0.00	0.00		934,750.98		

SUBTOTAL:

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 E	10,918.19	376.34	0.00	992.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	10,918.19	376.34	4,142.44	1,092.26	690.06	17,222.60	0.00	0.00	0.00	0.00	0.00	0.00	

22,155.15	
12,286.74	
34,441.89	

SUBTOTAL:

3516	ADULT 40-100% MALE
2	276.08	465.25	113.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	2,286.61	1,389.07	109,186.74	177.18	2,034.57	5,425.44	8,572.12	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	15.96	311.68	42.53	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	48,908.37	28,993.62	20,991.36	10,383.16	30,269.24	51,544.48	9,044.78	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	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 MAL E	282,960.57	239,237.96	160,049.34	141,590.13	133,394.48	227,715.34	294,101.69	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	8,006.01	55,446.91	23,944.21	15,778.68	10,519.22	55,297.61	28,330.54	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	235,458.94	434,500.79	215,685.56	224,311.09	328,728.18	442,676.83	224,084.36	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	1,495.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL E	73.01	0.00	-57.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	9,628.14	5,770.49	8,615.35	434.96	1,598.89	576.24	6,779.01	0.00	0.00	0.00	0.00	0.00	
	589,093.37	765,912.44	562,324.39	394,775.81	507,105.56	785,705.84	570,912.50	0.00	0.00	0.00	0.00	0.00	

854.41	
129,071.73	
370.17	
200,135.01	
28,665.47	
1,479,049.51	
197,323.18	
2,105,445.75	
1,495.64	
15.96	
33,403.08	
4,175,829.91	

SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	352.61	16,903.27	22,673.32	2,578.16	12,349.75	32,515.04	325.14	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	5,998.76	18,912.57	11,373.57	6,819.98	22,894.60	20,159.18	13,582.22	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	13,907.36	0.00	0.00	0.00	0.00	0.00	

87,697.29	
99,740.88	
187,438.17	

SUBTOTAL:

5,332,460.95

700,502.56	965,459.39	631,465.59	571,462.71	639,435.43	1,090,830.26	733,305.01	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCHISE COUNTY INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	479.53	209.84	2,974.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	479.53	209.84	2,974.00	0.00	0.00	0.00	0.00	0.00	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N
O	0.00	0.00	0.00	0.00	586.31	0.00	57.05	0.00	0.00	0.00	0.00	0.00	643.36	
SUBTOTAL:	0.00	0.00	0.00	0.00	586.31	0.00	57.05	0.00	0.00	0.00	0.00	0.00	643.36	
														
													3,663.37	
SUBTOTAL:													3,663.37	

TOTAL:	0.00	0.00	0.00	0.00	1,065.84	209.84	3,031.05	0.00	0.00	0.00	0.00	0.00		4,306.73		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MAL E	0.00	3,842.02	0.00	0.00	7.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,849.39		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	274.42	1,118.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,393.13		
3718	ADULT <40% EXP M&F 4	151.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151.74		
	151.74	3,842.02	0.00	274.42	1,126.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,394.26		

SUBTOTAL:

TOTAL:

151.74

3,842.02	0.00	274.42	1,126.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,394.26

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	0.00	0.00	7,504.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,504.65		
1016	TANF 21-44 MALE NON-	2,440.29	3,129.66	300.47	366.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,237.12		
1017	TANF 21-44 FEMALE N O	0.00	2,041.21	946.05	3,936.64	9,915.53	3,263.60	470.90	0.00	0.00	0.00	0.00	0.00		20,573.93		
2200	SSI DISABLED WITH M E	0.00	10,751.39	0.00	0.00	0.00	288.16	1,511.73	0.00	0.00	0.00	0.00	0.00		12,551.28		
2210	SSI DISABLED NON-ME D	18,422.83	10,195.76	34,766.80	17,317.71	168.87	5,679.57	5,210.08	0.00	0.00	0.00	0.00	0.00		91,761.62		
2220	SSI DISABLED WITH Q M	15.35	3,019.90	3,735.46	357.86	-36.16	7,396.96	55.07	0.00	0.00	0.00	0.00	0.00		14,544.44		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	13,693.10	0.00	0.00	0.00	0.00	0.00		13,693.10		
5007	SOBRA PREG 21-44 FE M	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		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	3,666.59	0.00	0.00	470.90	0.00	0.00	0.00	0.00	0.00		4,137.49		
5017	SOBRA PREG 21-44 FE M	0.00	5,306.85	4,658.33	5,451.17	203.40	11,761.22	8,322.52	0.00	0.00	0.00	0.00	0.00		35,703.49		
	20,878.47	34,444.77	51,911.76	33,508.53	11,088.37	28,389.51	29,734.30	0.00	0.00	0.00	0.00	0.00		209,955.71		

SUBTOTAL:

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	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	13,349.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	848.47	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	411.22	8.27	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	2,757.38	5,096.64	0.00	70.22	894.75	272.89	0.00	0.00	0.00	0.00	0.00	0.00	
	20,603.73	5,096.64	0.00	70.22	1,771.44	7,426.77	13,349.00	0.00	0.00	0.00	0.00	0.00	

10,436.54	
14,172.42	
13,349.00	
848.47	
419.49	
9,091.88	
48,317.80	

SUBTOTAL:

3516	ADULT 40-100% MALE
2	0.00	0.00	4,010.58	2,822.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	16,799.05	0.00	0.00	0.00	4,879.17	3,877.33	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 MAL E	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 MAL E	69,878.66	66,286.32	10,893.65	95,669.19	16,280.98	101,325.61	73,030.88	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	5,251.56	3,256.51	2,374.79	13,269.40	9,235.19	18,206.53	18,896.21	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	49,207.81	47,104.83	15,084.95	62,449.62	5,959.28	18,944.99	137,148.13	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	232,952.55	0.00	0.00	0.00	0.00	0.00	

 
6,833.38	
25,555.55	
83.10	
16,565.81	
433,365.29	
70,490.19	
335,899.61	
888,792.93	

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

149.02	
15,153.54	
15,302.56	

SUBTOTAL:

534.77

534.77

8720	SSI DISABLED FREEDO M	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	

SUBTOTAL:

TOTAL:	180,973.77	172,988.12	86,077.47	208,251.38	44,563.72	194,013.46	276,035.85	0.00	0.00	0.00	0.00	0.00		1,162,903.77		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016	
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		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	-72.49	0.00	0.00	0.00	0.00	0.00		-72.49		
2210	SSI DISABLED NON-ME D	327.15	591.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918.52		
5017	SOBRA PREG 21-44 FE M	11.66	2,253.21	4,046.52	8,752.09	858.70	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	-72.49	0.00	0.00	0.00	0.00	0.00		20,790.74		

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	
639.38	

SUBTOTAL:

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 MAL E	13,355.83	4,487.44	0.00	6,733.15	1,783.51	363.75	221.81	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	55.30	0.00	0.00	0.00	0.00	5,236.39	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	2,778.01	10,131.21	950.60	14,425.99	9,754.38	-52.78	0.00	0.00	0.00	0.00	0.00	0.00	
	16,189.14	14,618.65	968.10	21,238.63	11,636.13	5,547.36	221.81	0.00	0.00	0.00	0.00	0.00	

17.50	
177.73	
26,945.49	
5,291.69	
37,987.41	
70,419.82	

SUBTOTAL:

91,849.94

17,076.20	17,463.23	5,067.42	30,081.85	12,502.81	9,509.11	149.32	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	4,241.75	0.00	467.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,708.75		
2200	SSI DISABLED WITH M E	0.00	630.38	160.15	327.76	4,219.41	5,242.80	0.00	0.00	0.00	0.00	0.00	0.00		10,580.50		
2210	SSI DISABLED NON-ME D	0.00	160.89	0.00	0.00	327.76	67.24	6,691.96	0.00	0.00	0.00	0.00	0.00		7,247.85		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	142.83	0.00	0.00	0.00	0.00	0.00		142.83		
	0.00	791.27	4,401.90	327.76	5,014.17	5,310.04	6,834.79	0.00	0.00	0.00	0.00	0.00		22,679.93		

SUBTOTAL:

1117	TANF EXPANDED 21-44	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	
SUBTOTAL:	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	

 
7,877.62

7,877.62

3716	ADULT <40% EXP MAL E	7.98	1,430.76	0.00	0.00	250.57	3,790.43	9,903.28	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	144.34	0.00	0.00	0.00	0.00	0.00	739.54	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	8,014.50	-3,085.25	11,735.79	3,531.90	14,525.08	409.95	-2,091.78	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	8,551.04	0.00	0.00	0.00	0.00	0.00	

15,383.02	
883.88	
33,040.19	
49,307.09	

SUBTOTAL:

TOTAL:	8,166.82	-863.22	16,137.69	3,859.66	19,789.82	17,388.04	15,385.83	0.00	0.00	0.00	0.00	0.00		79,864.64		

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

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

2210

SSI DISABLED NON-ME
D

SUBTOTAL:

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 E	0.00	0.00	0.00	0.00	160.89	0.00	990.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	306.05	0.00	166.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	306.05	0.00	166.26	9,251.66	484.78	160.89	990.00	0.00	0.00	0.00	0.00	0.00	

9,736.44	
1,150.89	
472.31	
11,359.64	

SUBTOTAL:

19,967.98

306.05	0.00	166.26	9,251.66	484.78	8,769.23	990.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION
2210

SSI DISABLED NON-ME
D

JULY
0.00

AUGUST	SEPTEMBER
177.03	0.00

OCTOBER
4,575.16

NOVEMBER
0.00

DECEMBER
9,164.20

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

13,916.39

SUBTOTAL:	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 E	0.00	0.00	0.00	0.00	556.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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

12,562.96

3716	ADULT <40% EXP MAL E	0.00	673.35	580.79	372.54	6,342.26	0.00	122.84	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	3,152.09	110.80	0.00	0.00	3,362.36	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	258.61	0.00	0.00	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	122.84	0.00	0.00	0.00	0.00	0.00	

8,091.78	
6,625.25	
3,410.70	
18,127.73	

SUBTOTAL:

TOTAL:	0.00	4,261.08	691.59	4,947.70	10,050.55	24,533.32	122.84	0.00	0.00	0.00	0.00	0.00		44,607.08		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	350.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		700.00		
2100	SSI AGED WITH MEDIC A	1,867,476.11	2,106,357.37	3,001,652.11	2,153,315.25	2,357,150.67	2,661,401.68	2,147,531.09	0.00	0.00	0.00	0.00	0.00		16,294,884.28		
2110	SSI AGED NON-MEDIC AR	177,147.26	101,345.13	299,519.40	157,341.85	107,732.68	129,146.89	125,043.11	0.00	0.00	0.00	0.00	0.00		1,097,276.32		
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	3,090,157.66	0.00	0.00	0.00	0.00	0.00		22,640,821.32		
2200	SSI DISABLED WITH M E	543,524.04	474,214.50	724,208.95	536,644.76	552,216.34	695,544.60	497,483.69	0.00	0.00	0.00	0.00	0.00		4,023,836.88		
2210	SSI DISABLED NON-ME D	2,493,153.38	2,750,175.45	3,099,509.74	2,474,403.45	2,586,712.46	3,134,206.32	2,516,029.87	0.00	0.00	0.00	0.00	0.00		19,054,190.67		
2220	SSI DISABLED WITH Q M	639,532.10	693,460.39	974,750.74	671,858.25	672,467.60	904,432.53	746,390.37	0.00	0.00	0.00	0.00	0.00		5,302,891.98		
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	13,325.39	0.00	0.00	0.00	0.00	0.00		104,193.24		
2320	SSI BLIND WITH QMB	5,463.78	7,778.92	7,725.25	5,362.02	6,671.36	7,306.13	7,918.79	0.00	0.00	0.00	0.00	0.00		48,226.25		
	8,616,568.26	9,025,376.85	12,234,988.12	8,951,025.07	9,409,200.95	11,186,207.54	9,143,879.97	0.00	0.00	0.00	0.00	0.00		68,567,246.76		

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,044.41	2,637.12	99.53	2,709.12	2,578.56	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	4,112.64	2,741.76	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	5,320.32	0.00	0.00	0.00	0.00	0.00	

14,946.08	
19,814.76	
34,760.84	

SUBTOTAL:

68,602,007.60

8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	11,193,029.30	9,149,200.29	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

2100

2110

2120

SSI AGED WITH MEDIC
A
SSI AGED NON-MEDIC
AR
SSI AGED WITH QMB

2200

2210

2220

SSI DISABLED WITH M
E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q

M
SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4,497.83	12,645.58	24,804.14	14,473.36	13,002.49	20,599.26	2,159.50	0.00	0.00	0.00	0.00	0.00	92,182.16	
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	
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	
572.87	1,912.10	6,455.92	314.42	3,785.37	2,357.90	823.65	0.00	0.00	0.00	0.00	0.00	16,222.23	
10,415.23	19,351.87	894.64	5,932.66	1,560.41	-737.82	514.39	0.00	0.00	0.00	0.00	0.00	37,931.38	
0.00	0.00	0.00	0.00	0.00	0.00	9,017.63	0.00	0.00	0.00	0.00	0.00	9,017.63	
15,485.93	33,992.59	32,196.13	21,120.24	18,429.85	22,655.18	12,515.17	0.00	0.00	0.00	0.00	0.00	156,395.09	

TOTAL:	15,485.93	33,992.59	32,196.13	21,120.24	18,429.85	22,655.18	12,515.17	0.00	0.00	0.00	0.00	0.00		156,395.09		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending January 31, 2016	
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	14,148.50	0.00	0.00	0.00	0.00	0.00		171,103.55		
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	40,358.50	0.00	0.00	0.00	0.00	0.00		354,562.94		
1014	TANF 14-20 MALE NON-	8,473.78	2,483.13	8,146.57	6,639.55	4,375.95	7,509.81	3,255.57	0.00	0.00	0.00	0.00	0.00		40,884.36		
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	2,455.54	0.00	0.00	0.00	0.00	0.00		18,574.16		
2120	SSI AGED WITH QMB	0.00	0.00	69.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.53		
2200	SSI DISABLED WITH M E	33.88	103.18	181.14	0.00	0.00	1,721.70	0.00	0.00	0.00	0.00	0.00	0.00		2,039.90		
2210	SSI DISABLED NON-ME D	252,041.30	84,309.59	219,296.65	140,342.61	148,906.14	260,843.16	184,716.19	0.00	0.00	0.00	0.00	0.00		1,290,455.64		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	23.96	10.53	188.39	43.80	0.00	0.00	0.00	0.00	0.00		266.68		
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	1,140.36	0.00	0.00	0.00	0.00	0.00		9,780.85		
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	43,752.32	0.00	0.00	0.00	0.00	0.00		375,018.44		
4313	SOBRA CHILD 06-13 M	138,639.38	30,827.76	103,590.12	109,202.16	99,584.08	228,223.73	113,507.83	0.00	0.00	0.00	0.00	0.00		823,575.06		
4314	SOBRA CHILD 14-20 MA	12,134.57	3,360.74	12,303.21	9,010.79	9,606.28	18,550.26	9,231.76	0.00	0.00	0.00	0.00	0.00		74,197.61		
4315	SOBRA CHILD 14-20 FE	3,881.60	1,365.86	4,314.96	4,418.98	4,272.97	8,147.04	4,981.34	0.00	0.00	0.00	0.00	0.00		31,382.75		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	98.89	14.20	0.00	0.00	0.00	0.00	0.00		113.09		
	642,887.52	188,308.71	519,661.06	373,572.92	358,597.98	692,036.55	417,605.91	0.00	0.00	0.00	0.00	0.00		3,192,670.65		

SUBTOTAL:

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	84.66	8.13	232.43	39.21	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	1,254.12	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 E	210.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,732.49	3,154.87	3,999.21	1,229.12	650.75	2,923.36	1,293.33	0.00	0.00	0.00	0.00	0.00	

1,324.33	
13,727.37	
428.75	
292.07	
210.61	
15,983.13	

SUBTOTAL:

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 MAL E	1,726.70	9.31	990.53	137.29	119.45	572.34	166.36	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	48.08	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	856.23	1,732.17	0.00	0.00	0.00	0.00	0.00	
	3,053.49	48.92	1,139.73	151.29	246.21	1,523.58	1,946.61	0.00	0.00	0.00	0.00	0.00	

18.98	
123.64	
12.33	
34.11	
3,721.98	
1,610.39	
2,588.40	
8,109.83	

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	25,022.12	4,486.95	12,154.90	21,398.13	23,398.03	58,170.12	29,217.48	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	1,942.59	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	515.37	640.27	290.86	918.34	676.00	2,517.58	1,322.47	0.00	0.00	0.00	0.00	0.00	

 
173,847.73	
19,899.64	
6,880.89	

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending January 31, 2016	
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	32,482.54	0.00	0.00	0.00	0.00	0.00		200,628.26		

SUBTOTAL:

3,417,391.87

682,284.75	197,289.50	538,716.56	399,001.17	385,561.90	761,209.60	453,328.39	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

2200

2210

2220

2310

TANF NON-MEDICARE

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI BLIND NON-MEDIC

A
SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
831.19	0.00	115.74	154.36	496.51	387.64	62.44	0.00	0.00	0.00	0.00	0.00	2,047.88	
40,868.65	24,234.06	48,725.89	26,485.58	29,892.42	44,214.96	24,625.86	0.00	0.00	0.00	0.00	0.00	239,047.42	
2,871.13	789.16	3,394.59	1,281.47	667.85	3,130.34	2,521.84	0.00	0.00	0.00	0.00	0.00	14,656.38	
1,249,307.80	489,106.70	1,265,880.28	765,381.38	758,689.31	1,369,048.70	907,027.43	0.00	0.00	0.00	0.00	0.00	6,804,441.60	
2,114.42	-248.86	3,650.67	2,135.30	1,672.29	3,246.71	895.51	0.00	0.00	0.00	0.00	0.00	13,466.04	
7,193.15	6,514.48	11,947.59	4,341.28	8,117.72	10,057.63	6,770.86	0.00	0.00	0.00	0.00	0.00	54,942.71	
1,303,186.34	520,395.54	1,333,714.76	799,779.37	799,536.10	1,430,085.98	941,903.94	0.00	0.00	0.00	0.00	0.00	7,128,602.03	

TOTAL:	1,303,186.34	520,395.54	1,333,714.76	799,779.37	799,536.10	1,430,085.98	941,903.94	0.00	0.00	0.00	0.00	0.00		7,128,602.03		

ACUTE REINSURANCE
For The Period Ending January 31, 2016	
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	-0.01	0.00	0.00	0.00	0.00	0.00		8,520.37		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	17,401.25	945.08	0.00	0.00	0.00	0.00	0.00		18,346.33		
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	14,374.58	0.00	0.00	0.00	0.00	0.00		3,151,180.53		
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	10,070.95	0.00	0.00	0.00	0.00	0.00		425,032.85		
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	230,771.29	0.00	0.00	0.00	0.00	0.00		1,434,839.11		
1014	TANF 14-20 MALE NON-	12,269.60	19,354.41	57,649.19	33,553.81	369.86	44,304.16	-4,533.90	0.00	0.00	0.00	0.00	0.00		162,967.13		
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	18,112.88	0.00	0.00	0.00	0.00	0.00		229,663.66		
1016	TANF 21-44 MALE NON-	161,649.37	-21,881.23	40,292.26	305,406.83	277,743.49	140,429.72	317,406.13	0.00	0.00	0.00	0.00	0.00		1,221,046.57		
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	51,147.95	0.00	0.00	0.00	0.00	0.00		1,798,613.75		
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	41,059.66	0.00	0.00	0.00	0.00	0.00		707,857.40		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	6,170.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,170.15		
2100	SSI AGED WITH MEDIC A	624.78	33,070.16	362.69	24,212.27	12,180.72	34,105.65	7,812.85	0.00	0.00	0.00	0.00	0.00		112,369.12		
2110	SSI AGED NON-MEDIC AR	67,861.38	195,769.67	82,798.86	187,110.03	156,837.43	149,288.35	107,679.10	0.00	0.00	0.00	0.00	0.00		947,344.82		
2200	SSI DISABLED WITH M E	43,874.36	10,496.70	3,907.51	14,759.66	36,550.05	14,130.33	94,181.61	0.00	0.00	0.00	0.00	0.00		217,900.22		
2210	SSI DISABLED NON-ME D	4,045,297.65	3,940,603.94	4,946,163.58	5,434,310.93	4,089,111.34	5,950,914.30	1,392,585.91	0.00	0.00	0.00	0.00	0.00		29,798,987.65		
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	191,540.82	0.00	0.00	0.00	0.00	0.00		6,127,979.45		
4312	SOBRA CHILD 01-05 M	114,463.42	359,348.65	667,111.14	108,235.95	362,899.14	277,105.60	155,548.81	0.00	0.00	0.00	0.00	0.00		2,044,712.71		
4313	SOBRA CHILD 06-13 M	239,870.36	136,192.59	249,120.95	-32,500.15	196,513.15	581,907.40	218,483.01	0.00	0.00	0.00	0.00	0.00		1,589,587.31		
4314	SOBRA CHILD 14-20 MA	115,773.80	89,801.77	118,016.08	142,705.87	117,629.45	-526,014.65	85,800.66	0.00	0.00	0.00	0.00	0.00		143,712.98		
4315	SOBRA CHILD 14-20 FE	14,027.07	63,132.41	6,858.73	138,256.42	16,264.65	34,636.41	19,332.17	0.00	0.00	0.00	0.00	0.00		292,507.86		
5015	SOBRA PREG 14-20 FE M	0.00	9,507.28	408.56	4,728.20	1,067.70	335.40	3,573.89	0.00	0.00	0.00	0.00	0.00		19,621.03		
5017	SOBRA PREG 21-44 FE M	8,128.10	28,115.83	25,201.81	42,704.14	18,481.98	1,987.47	1,316.45	0.00	0.00	0.00	0.00	0.00		125,935.78		
	7,010,616.95	6,492,507.76	9,262,664.61	9,522,581.44	6,897,279.90	8,528,119.46	2,957,209.89	0.00	0.00	0.00	0.00	0.00		50,670,980.01		

SUBTOTAL:

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	329.59	0.01	264.91	45.17	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	298.15	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	214,553.76	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	-1,520.84	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	112,547.49	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	2,446.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	-18.11	42.85	43.82	25.93	10.31	0.00	-178.82	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	14,090.33	42,829.44	49,706.82	46,616.48	7,100.00	-5,141.12	4,585.12	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	35,356.98	19,953.70	40,311.53	39,071.56	75,248.39	1,399.37	430.74	0.00	0.00	0.00	0.00	0.00	

 
1,822.58

-8.67

7,228.93

685,743.47

470,379.74

1,014,481.90

2,446.74

-74.02

159,787.07

211,772.27

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
20,284.70	72,266.71	62,393.79	63,319.22	126,966.46	50,917.39	9,648.84	0.00	0.00	0.00	0.00	0.00	405,797.11	
316,711.60	410,028.71	481,700.77	717,276.86	425,099.18	268,150.39	340,409.61	0.00	0.00	0.00	0.00	0.00	2,959,377.12	

ACUTE REINSURANCE
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

2610

SSI DISABLED EXPAND
E

SUBTOTAL:

3316	AHC CARE MALE 21-44	22.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	742.92	2,889.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	765.22	2,889.03	0.00	0.00	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.30	
1,477.43	
3,631.95	
5,131.68	

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 2	0.00	0.00	0.00	0.00	1,239.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	28,195.73	-1,579.93	-5,079.21	0.00	-1,327.80	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	

-5,724.35	
13,341.66	
1,239.38	
21,385.18	
30,241.87	

SUBTOTAL:

3508	ADULT 40-100% M&F 45	-1,247.11	6.67	2.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	90,377.57	23.98	303.56	10,582.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	9,715.08	0.00	14,961.01	39,148.26	53,075.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	42,038.64	132,978.87	147,952.07	213,702.36	158,020.09	175,535.38	62,002.68	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	2,688.91	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	108,964.22	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	2,767.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	37,973.29	1,282.59	21,727.75	-1,549.73	0.00	21,253.88	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	150,958.00	173,540.11	140,658.64	168,686.95	205,746.27	47,735.55	92,529.83	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	12,512.37	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	502,179.54	650,833.61	591,737.89	1,117,820.73	788,610.97	750,365.46	70,705.12	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	256,435.90	98,701.30	250,260.17	399,461.42	410,941.85	345,450.11	65,666.55	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	1,083,021.23	1,159,557.65	1,128,258.45	2,023,672.20	1,885,371.09	1,267,187.18	615,990.59	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	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	
	2,668,847.78	2,823,947.50	2,802,363.03	4,495,407.23	4,032,864.88	3,139,981.93	1,031,060.27	0.00	0.00	0.00	0.00	0.00	

-1,238.16	
101,288.09	
116,899.49	
932,230.09	
651,577.20	
2,319,577.83	
2,767.51	
80,687.78	
979,855.35	
346,562.46	
4,472,253.32	
1,826,917.30	
9,163,058.39	
2,035.97	
20,994,472.62	

SUBTOTAL:

3908	NEWLY ELIGIBLE M&F 4	75,258.45	0.00	21,217.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,356.93	0.00	0.00	19,045.28	10,843.38	0.00	188.61	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	70,924.33	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	-833.32	13,544.41	28,948.15	38,254.97	33,953.18	7,099.39	16,258.67	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	163,410.54	348,055.35	252,590.82	236,488.95	162,860.24	163,485.29	63,258.33	0.00	0.00	0.00	0.00	0.00	
	276,371.96	479,009.69	344,793.74	397,029.20	359,861.18	225,309.10	150,629.94	0.00	0.00	0.00	0.00	0.00	

96,476.19	
34,434.20	
1,064.69	
573,654.76	
137,225.45	
1,390,149.52	
2,233,004.81	

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	19,844.57	10,180.96	21,606.21	141,092.28	121,073.24	36,860.81	162.87	0.00	0.00	0.00	0.00	0.00	

 
350,820.94

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

6,209.80	
855.98	
7,065.78	

8710	SSI DISABLED FREEDO M	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	

10,791,209.52	10,677,372.35	13,331,154.82	15,967,330.33	12,307,016.59	13,383,188.55	4,507,545.74	0.00	0.00	0.00	0.00	0.00	

ACUTE REINSURANCE
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION
4414

SOBRA 100-133% MALE

JULY
451,101.89

AUGUST	SEPTEMBER
451,107.67	426,127.94

OCTOBER
679,863.69

NOVEMBER	DECEMBER
468,911.44	1,180,962.21

JANUARY
27,990.69

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

3,686,065.53

4415

SOBRA 100-133% FEM

AL
SUBTOTAL:

188.17

471,134.63

9,280.96

470,569.59

106.64

447,840.79

4,451.52

825,407.49

-2,057.67	32.82

587,927.01	1,217,855.84

82.47

28,236.03

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

12,084.91

4,048,971.38

SUBTOTAL:		
	15,572.63	
SUBTOTAL:	15,572.63	
		
TOTAL:	80,964,817.90	

LONG TERM CARE REINSURANCE
For The Period Ending January 31, 2016	
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	327,108.06	281,473.61	410,214.64	182,410.50	337,086.99	210,136.17	398,027.74	0.00	0.00	0.00	0.00	0.00		2,146,457.71		
2110	SSI AGED NON-MEDIC AR	218,322.47	133,627.59	139,813.52	145,656.58	216,314.34	137,105.95	73,558.19	0.00	0.00	0.00	0.00	0.00		1,064,398.64		
2200	SSI DISABLED WITH M E	644,979.13	626,909.22	541,936.81	444,452.89	492,010.90	679,427.76	730,139.16	0.00	0.00	0.00	0.00	0.00		4,159,855.87		
2210	SSI DISABLED NON-ME D	2,840,717.50	2,796,391.98	3,888,127.51	3,540,048.52	4,792,282.42	2,737,929.54	1,970,903.40	0.00	0.00	0.00	0.00	0.00		22,566,400.87		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	61.17	91.91	28.00	0.00	0.00	0.00	0.00	0.00		181.08		
2310	SSI BLIND NON-MEDIC A	2,067.18	829.15	61,461.10	4,145.13	12,606.98	4,663.25	1,650.00	0.00	0.00	0.00	0.00	0.00		87,422.79		
	4,033,194.34	3,839,275.12	5,041,553.58	4,350,737.67	5,854,376.34	3,769,395.14	3,174,306.49	0.00	0.00	0.00	0.00	0.00		30,062,838.68		

SUBTOTAL:

14,898.11

14,898.11

8710	SSI DISABLED FREEDO M	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	21.05	0.00	0.00	0.00	0.00	0.00	
	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	21.05	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

TOTAL:	4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	5,856,334.10	3,769,395.14	3,174,327.54	0.00	0.00	0.00	0.00	0.00		30,077,736.79		

ACUTE SMIB
For The Period Ending January 31, 2016	
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	76,109.30	0.00	0.00	0.00	0.00	0.00		1,247,314.30		
1010	TANF NON-MEDICARE	419.60	314.70	419.60	419.60	839.20	524.50	487.20	0.00	0.00	0.00	0.00	0.00		3,424.40		
1020	TANF WITH QMB	59,218.50	89,224.80	136,060.20	153,998.10	21,979.00	27,224.00	33,977.90	0.00	0.00	0.00	0.00	0.00		521,682.50		
2100	SSI AGED WITH MEDIC A	55,177.40	57,030.30	58,179.30	62,320.40	92,112.00	76,322.10	86,876.80	0.00	0.00	0.00	0.00	0.00		488,018.30		
2110	SSI AGED NON-MEDIC AR	390,962.30	405,066.70	409,640.00	406,988.40	406,802.20	436,932.40	457,491.40	0.00	0.00	0.00	0.00	0.00		2,913,883.40		
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	2,872,361.20	0.00	0.00	0.00	0.00	0.00		15,172,667.30		
2200	SSI DISABLED WITH M E	156,570.80	143,157.80	137,314.10	138,468.00	135,216.10	127,558.40	153,205.80	0.00	0.00	0.00	0.00	0.00		991,491.00		
2210	SSI DISABLED NON-ME D	332,008.50	338,302.50	334,945.70	338,302.50	337,253.50	333,791.80	391,462.30	0.00	0.00	0.00	0.00	0.00		2,406,066.80		
2220	SSI DISABLED WITH Q M	2,831,922.00	2,873,883.50	2,914,800.20	2,923,716.10	2,934,708.00	2,924,607.70	3,421,032.10	0.00	0.00	0.00	0.00	0.00		20,824,669.60		
2300	SSI BLIND WITH MEDIC	419.60	419.60	314.70	314.70	314.70	314.70	713.90	0.00	0.00	0.00	0.00	0.00		2,811.90		
2310	SSI BLIND NON-MEDIC A	3,251.90	3,356.80	3,042.10	2,937.20	2,937.20	2,832.30	3,288.60	0.00	0.00	0.00	0.00	0.00		21,646.10		
2320	SSI BLIND WITH QMB	25,071.10	24,336.80	25,910.30	25,805.40	26,015.20	25,176.00	29,651.60	0.00	0.00	0.00	0.00	0.00		181,966.40		
4300	SOBRA CHILD WITH M ED	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		
4320	SOBRA CHILD WITH Q MB	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.50		
5000	SOBRA PREGNANT WO MAN	1,363.70	1,363.70	1,153.90	944.10	629.40	419.60	487.20	0.00	0.00	0.00	0.00	0.00		6,361.60		
5020	SOBRA PREGNANT WO MAN	944.10	839.20	1,153.90	944.10	1,363.70	1,049.00	1,096.20	0.00	0.00	0.00	0.00	0.00		7,390.20		
8000	SMIB ONLY NOT ELIGIB	0.00	0.00	-209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-209.80		
8020	QMB ONLY	543,517.80	550,391.10	561,940.30	555,491.40	568,562.80	566,367.00	668,106.30	0.00	0.00	0.00	0.00	0.00		4,014,376.70		
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	4,162,803.00	0.00	0.00	0.00	0.00	0.00		25,319,223.30		
8888	SMIB ONLY NOT ELIGIB	-52,359.80	-26,959.30	-20,035.90	-24,127.00	-7,238.10	-13,002.70	-16,844.70	0.00	0.00	0.00	0.00	0.00		-160,567.50		
9999	SMIB ONLY NOT ELIGIB	59,066.30	19,847.50	122,106.60	172,423.40	145,913.80	190,130.30	236,588.30	0.00	0.00	0.00	0.00	0.00		946,076.20		
	9,808,185.80	10,062,146.60	10,322,154.00	10,606,357.70	10,735,182.80	10,796,525.30	12,578,894.40	0.00	0.00	0.00	0.00	0.00		74,909,446.60		

SUBTOTAL:

1100	TANF EXPANDED FPR FI	470,376.20	412,891.00	362,329.20	338,157.10	689,298.50	630,171.70	693,195.30	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	209.80	104.90	104.90	104.90	104.90	104.90	1,309.50	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	128,342.70	125,775.10	114,341.00	103,116.70	130,285.80	198,051.20	270,459.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	3,042.10	1,468.60	1,253.90	419.60	209.80	314.70	243.60	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	524.50	524.50	524.50	419.60	314.70	314.70	365.40	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,928,537.00	2,921,828.60	2,878,145.10	2,887,841.00	2,295,255.90	2,268,575.50	2,597,155.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	104.90	104.90	104.90	104.90	104.90	104.90	121.80	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	-419.60	209.80	314.70	-104.90	314.70	209.80	-629.40	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,653,183.80	1,727,813.10	1,756,040.70	1,816,932.70	1,829,709.50	1,863,111.30	2,211,003.30	0.00	0.00	0.00	0.00	0.00	
	5,183,901.40	5,190,720.50	5,113,158.90	5,146,991.60	4,945,598.70	4,960,958.70	5,773,223.50	0.00	0.00	0.00	0.00	0.00	

3,596,419.00	
2,043.80	
1,070,371.50	
6,952.30	
2,987.90	
18,777,338.10	
751.20	
-104.90	
12,857,794.40	
36,314,553.30	

SUBTOTAL:

3520	ADULT 40-100% FOR FI	3,147.00	-1,743.30	3,147.00	3,356.80	4,930.30	4,510.70	5,802.70	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	3,776.40	1,468.60	1,153.90	1,783.30	3,566.60	2,622.50	2,385.30	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	8,188.00	0.00	0.00	0.00	0.00	0.00	

23,151.20	
16,756.60	
39,907.80	

SUBTOTAL:

ACUTE SMIB
For The Period Ending January 31, 2016

8720	SSI DISABLED FREEDO M	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	23,602.50	28,663.80	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	28,663.80	0.00	0.00	0.00	0.00	0.00	

15,021,878.80	15,275,565.50	15,462,796.70	15,783,140.90	15,713,300.50	15,789,163.80	18,390,817.10	0.00	0.00	0.00	0.00	0.00	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR
F	1,468.60	734.30	839.20	629.40	839.20	944.10	1,847.40	0.00	0.00	0.00	0.00	0.00	7,302.20	
SUBTOTAL:	1,468.60	734.30	839.20	629.40	839.20	944.10	1,847.40	0.00	0.00	0.00	0.00	0.00	7,302.20	
														
													165,453.40	
SUBTOTAL:													165,453.40	
														
TOTAL:													111,436,663.30	

ACUTE HIB
For The Period Ending January 31, 2016	
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	411.00	0.00	0.00	0.00	0.00	0.00		411.00		
2100	SSI AGED WITH MEDIC A	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		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	1,221.00	0.00	1,225.00	0.00	0.00	0.00	0.00	0.00		2,446.00		
2120	SSI AGED WITH QMB	173,720.20	179,916.50	193,518.70	197,193.80	189,836.80	195,941.80	196,838.50	0.00	0.00	0.00	0.00	0.00		1,326,966.30		
2220	SSI DISABLED WITH Q M	88,616.20	96,125.80	110,636.10	112,246.10	100,161.10	107,121.10	104,174.70	0.00	0.00	0.00	0.00	0.00		719,081.10		
2320	SSI BLIND WITH QMB	407.00	407.00	407.00	407.00	407.00	407.00	411.00	0.00	0.00	0.00	0.00	0.00		2,853.00		
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	4,884.60	0.00	0.00	0.00	0.00	0.00		30,092.00		
9999	SMIB ONLY NOT ELIGIB	-8,404.70	-4,538.50	-4,375.40	-7,780.00	-3,887.00	-6,817.40	-4,248.70	0.00	0.00	0.00	0.00	0.00		-40,051.70		
	261,768.80	274,049.90	304,238.40	305,976.50	291,872.30	302,006.90	303,696.10	0.00	0.00	0.00	0.00	0.00		2,043,608.90		

SUBTOTAL:

44,034.80

44,034.80

2420	SSI AGED EXPANDED WI	8,649.20	8,527.10	5,656.40	8,584.10	4,192.40	4,192.40	4,233.20	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	4,233.20	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

TOTAL:	270,418.00	282,577.00	309,894.80	314,560.60	296,064.70	306,199.30	307,929.30	0.00	0.00	0.00	0.00	0.00		2,087,643.70		

Q1
For The Period Ending January 31, 2016

2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	1,905,402.60	2,072,651.30	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:	2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	1,905,402.60	2,072,651.30	0.00	0.00	0.00	0.00	0.00		14,243,609.30	
															
TOTAL:														14,243,609.30	

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	3,268.80	0.00	0.00	0.00	0.00	0.00	12,246,732.60	
9999	SMIB ONLY NOT ELIGIB	-35,141.50	-2,907.10	-18,986.90	-13,112.50	-1,988.20	-369.60	2,069,382.50	0.00	0.00	0.00	0.00	0.00	1,996,876.70	

LTC SMIB
For The Period Ending January 31, 2016	
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	730.80	0.00	0.00	0.00	0.00	0.00		4,507.20		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	121.80	0.00	0.00	0.00	0.00	0.00		121.80		
1020	TANF WITH QMB	104.90	104.90	104.90	104.90	104.90	104.90	348.50	0.00	0.00	0.00	0.00	0.00		977.90		
2100	SSI AGED WITH MEDIC A	874,183.40	870,946.20	868,154.40	873,399.40	856,670.30	875,757.20	1,011,705.50	0.00	0.00	0.00	0.00	0.00		6,230,816.40		
2110	SSI AGED NON-MEDIC AR	155,566.70	157,769.60	157,769.60	157,664.70	161,336.20	159,657.80	185,866.80	0.00	0.00	0.00	0.00	0.00		1,135,631.40		
2120	SSI AGED WITH QMB	764,559.10	761,981.70	777,780.80	770,483.50	771,637.40	774,259.90	904,494.80	0.00	0.00	0.00	0.00	0.00		5,525,197.20		
2200	SSI DISABLED WITH M E	319,840.10	329,595.80	321,623.40	322,567.50	334,134.80	337,673.10	382,974.80	0.00	0.00	0.00	0.00	0.00		2,348,409.50		
2210	SSI DISABLED NON-ME D	15,630.10	25,513.40	17,308.50	18,147.70	26,318.60	19,721.20	20,306.80	0.00	0.00	0.00	0.00	0.00		142,946.30		
2220	SSI DISABLED WITH Q M	710,227.60	707,605.10	709,170.10	710,332.50	709,958.00	709,858.00	820,671.20	0.00	0.00	0.00	0.00	0.00		5,077,822.50		
2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	839.20	839.20	839.20	974.40	0.00	0.00	0.00	0.00	0.00		5,904.70		
2310	SSI BLIND NON-MEDIC A	209.80	104.90	209.80	104.90	104.90	104.90	121.80	0.00	0.00	0.00	0.00	0.00		961.00		
2320	SSI BLIND WITH QMB	4,300.90	4,510.70	4,405.80	4,405.80	4,615.60	4,300.90	4,993.80	0.00	0.00	0.00	0.00	0.00		31,533.50		
	2,846,091.20	2,859,286.20	2,857,681.20	2,858,469.70	2,866,139.50	2,883,850.60	3,333,311.00	0.00	0.00	0.00	0.00	0.00		20,504,829.40		

SUBTOTAL:

8720	SSI DISABLED FREEDO M	734.30	629.40	629.40	629.40	629.40	629.40	730.80	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	734.30	629.40	629.40	629.40	629.40	629.40	730.80	0.00	0.00	0.00	0.00	0.00	

 
4,612.10

4,612.10

TOTAL:	2,846,825.50	2,859,915.60	2,858,310.60	2,859,099.10	2,866,768.90	2,884,480.00	3,334,041.80	0.00	0.00	0.00	0.00	0.00		20,509,441.50		

LTC HIB
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	1,628.00	1,221.00	-407.00	0.00	0.00	0.00	0.00	0.00		2,442.00		
2110	SSI AGED NON-MEDIC AR	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	259,680.20	0.00	0.00	0.00	0.00	0.00		1,799,499.70		
2200	SSI DISABLED WITH M E	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		
2220	SSI DISABLED WITH Q M	12,923.00	14,144.00	12,516.00	7,909.20	13,106.00	11,885.00	11,183.00	0.00	0.00	0.00	0.00	0.00		83,666.20		
SUBTOTAL:	269,424.80	275,671.80	269,873.10	259,132.80	272,905.10	271,807.10	270,456.20	0.00	0.00	0.00	0.00	0.00		1,889,270.90		

TOTAL:

269,424.80

1,889,270.90

269,873.10	259,132.80	272,905.10	271,807.10	270,456.20	0.00	0.00	0.00	0.00	0.00	

275,671.80

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1006	TANF 21-44 MALE WITH	1,467.46	3,014.86	4,778.75	2,265.53	988.83	-1,150.92	884.20	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	3,379.94	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	4,426.36	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	2,570.35	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	621,469.66	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	338,642.60	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	411,907.45	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	100,365.49	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	237,949.60	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	865,821.45	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	3,380,658.45	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	1,120,390.09	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	2,450.00	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	249.09	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	223.14	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	653.61	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	81.16	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	51,457.56	41,686.19	96,120.74	33,984.56	29,250.14	35,691.27	31,687.44	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	60,414.26	72,757.77	86,289.46	47,067.16	74,476.35	68,323.34	38,010.52	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	123,845.47	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	118,193.79	139,630.47	151,342.90	119,909.21	78,796.47	118,798.48	85,544.29	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	3,959,038.86	4,322,461.60	5,500,714.34	3,203,783.82	4,183,126.66	4,481,420.16	3,626,990.97	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	327,062.97	435,664.94	615,950.69	349,244.88	330,111.22	433,897.25	294,451.23	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	421.47	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	34,406.29	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	5,651.93	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	1,371,721.36	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	2,462,344.83	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	3,377,653.35	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	792,309.44	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	1,013,657.53	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	2,101.86	0.00	0.00	0.00	0.00	0.00	

 
12,248.71	
37,803.26	
89,544.60	
38,385.54	
4,267,216.05	
4,184,792.35	
7,169,268.44	
1,713,092.63	
3,120,916.87	
8,033,868.35	
31,473,566.82	
10,258,534.00	
20,892.65	
2,396.24	
5,631.92	
26,774.99	
12,533.21	
319,877.90	
447,338.86	
1,176,241.59	
812,215.61	
29,277,536.41	
2,786,383.18	
4,558.12	
315,503.91	
39,706.17	
700.00	
9,864,745.28	
17,261,736.04	
26,045,748.10	
6,472,535.13	
8,391,431.07	
3,501.86	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	350.00	350.00	700.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00		1,750.00		
5015	SOBRA PREG 14-20 FE M	237,999.22	275,437.95	329,140.16	268,427.33	331,831.13	313,180.11	196,297.40	0.00	0.00	0.00	0.00	0.00		1,952,313.30		
5017	SOBRA PREG 21-44 FE M	1,131,352.11	1,456,601.24	1,697,144.79	1,250,264.34	1,615,075.39	1,490,352.46	954,856.86	0.00	0.00	0.00	0.00	0.00		9,595,647.19		
5018	SOBRA PREG 45-64 FE M	4,193.00	1,958.21	2,450.00	1,400.00	974.78	3,500.00	1,050.00	0.00	0.00	0.00	0.00	0.00		15,525.99		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	12.47	0.00	0.00	0.00	122.80	0.00	0.00	0.00	0.00	0.00		135.27		
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	21,505,597.68	0.00	0.00	0.00	0.00	0.00		185,252,597.61		

0.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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:

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	4,634.99	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	7,753.45	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	27,630.63	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	11,589.10	11,907.56	11,276.99	10,530.63	13,763.00	21,247.05	16,376.58	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	5,250.00	4,248.00	1,409.52	1,050.00	2,799.61	1,050.00	22.19	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	3,668.00	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	12,154.50	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	35,664.06	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	408,012.26	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	1,349,304.50	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	771,060.88	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	1,400.00	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	527.74	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	2,163.37	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	3,321.63	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	3,939.78	7,378.95	8,307.81	2,632.75	3,304.47	3,820.10	5,190.17	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	15,824.15	18,656.13	11,154.82	10,621.62	8,971.28	7,959.68	7,881.09	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	44,953.28	27,103.71	42,572.30	50,664.46	11,766.38	12,339.75	7,713.39	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	165,461.94	213,135.45	288,519.65	144,543.45	123,666.38	152,813.58	113,177.58	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	6,769.93	6,974.26	11,598.68	8,264.20	12,953.02	9,238.59	5,484.78	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	109,481.97	123,966.21	147,456.41	74,149.48	84,743.70	94,217.58	135,488.74	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	85,508.30	104,493.60	148,434.94	93,586.84	88,605.26	103,855.75	84,879.10	0.00	0.00	0.00	0.00	0.00	
	2,315,297.75	2,332,941.48	2,684,900.21	1,978,313.15	3,078,986.62	3,732,013.20	3,003,509.63	0.00	0.00	0.00	0.00	0.00	

350.00	
27,390.47	
66,800.00	
175,766.21	
96,690.91	
0.00	
15,829.32	
93,933.34	
59,397.64	
187,483.32	
2,567,271.90	
8,150,146.50	
4,580,694.70	
11,140.26	
3,866.00	
14,866.93	
20,109.10	
34,574.03	
81,068.77	
197,113.27	
1,201,318.03	
61,283.46	
769,504.09	
709,363.79	
19,125,962.04	

SUBTOTAL:

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

SUBTOTAL:

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

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	4
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	

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 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	-52.99	0.00	0.00	0.00	-5,828.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	-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	

0.00	
0.00	
0.00	
0.00	
0.00	
-5,880.99	
-2,268.00	
-6,446.00	
-14,594.99	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	85.05	386.37	826.55	497.49	10.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	350.00	-297.96	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	645.75	4,143.44	2,194.34	1,695.56	2,704.25	3,850.00	1,476.96	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	367.82	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	22,234.89	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	26,465.02	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	434,139.29	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	289,200.96	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	912,052.05	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	700.00	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	103.71	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	4.35	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	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	1,396.64	1,663.61	3,351.85	967.89	729.84	749.77	838.29	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	4,997.35	11,572.19	10,426.98	9,426.39	9,118.22	13,660.61	4,596.30	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	550.16	545.25	1,197.56	1,260.00	0.01	35.41	472.80	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	165,528.85	261,775.93	267,888.88	187,172.51	179,844.48	220,568.78	145,722.03	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	201,690.71	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	3,029,287.38	3,988,308.94	4,654,737.86	3,315,942.24	3,506,890.83	4,090,685.06	3,200,348.28	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,927,561.48	2,317,641.88	3,111,066.30	1,949,322.89	2,217,906.35	2,765,153.12	1,907,664.16	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	4,322,313.67	5,015,624.62	5,861,943.16	3,932,359.26	4,603,664.10	5,357,117.58	4,280,190.59	0.00	0.00	0.00	0.00	0.00	

 
1,805.52	
402.04	
16,710.30	
10,191.91	
135,784.30	
304,874.00	
2,749,064.25	
2,393,873.60	
7,281,481.30	
26,309.46	
561.56	
120.80	
453.71	
68.79	
4,516.75	
9,697.89	
63,798.04	
4,061.19	
1,428,501.46	
1,543,130.16	
25,786,200.59	
16,196,316.18	
33,373,212.98	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	1,400.00	4,739.20	2,450.00	1,017.76	4,900.00	8,050.00	5,250.00	0.00	0.00	0.00	0.00	0.00		27,806.96		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	350.00	350.00	0.00	0.00	0.00	0.00	0.00		700.00		
3728	ADULT <40% EXP M&F 4	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		
	11,438,207.99	13,697,919.67	16,488,135.56	11,210,955.33	12,505,028.97	14,588,104.34	11,433,868.21	0.00	0.00	0.00	0.00	0.00		91,362,220.07		

SUBTOTAL:

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	0.00	0.00	2,100.00	392.10	350.00	350.00	350.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	5,768.03	7,449.33	2,569.39	3,983.75	3,579.66	5,871.39	2,565.44	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	291.65	74.97	0.00	1,418.20	2,100.00	1,197.00	181.42	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	6,563.74	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	19,350.21	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	185,359.50	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	271,360.04	317,416.51	433,678.80	355,651.52	362,225.89	501,784.79	359,160.19	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	680,980.32	652,498.60	813,465.56	599,685.22	649,560.52	666,399.61	555,539.02	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	700.00	0.00	2,450.00	1,050.00	700.00	350.00	1,750.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	350.00	59.40	0.00	48.25	10.07	0.00	0.00	0.00	0.00	0.00	0.00	
	1,180,866.48	1,241,698.82	1,599,657.76	1,269,425.19	1,217,414.63	1,526,832.20	1,130,819.52	0.00	0.00	0.00	0.00	0.00	

2,458.58	
3,542.10	
31,786.99	
5,263.24	
57,825.78	
160,952.20	
1,678,011.40	
2,601,277.74	
4,618,128.85	
7,000.00	
467.72	
9,166,714.60	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	189,176.92	189,687.05	133,832.64	285,206.25	405,616.43	433,026.87	360,616.35	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	128,914.84	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	64,105.03	76,235.87	69,956.78	127,357.54	132,904.38	171,781.34	109,962.14	0.00	0.00	0.00	0.00	0.00	
	332,458.39	341,110.14	252,098.22	541,737.82	647,931.14	730,274.98	599,493.33	0.00	0.00	0.00	0.00	0.00	

700.00	
1,997,162.51	
694,938.43	
752,303.08	
3,445,104.02	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	5,936.00	4,286.25	3,859.52	1,400.00	0.00	700.00	350.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	1,109.40	2,490.00	2,861.40	2,835.67	37,424.01	9,240.32	19,560.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	350.00	1,050.00	0.00	0.00	350.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	4,085.95	1,050.00	708.87	2,109.55	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	
	11,481.35	8,876.25	7,429.79	6,345.22	37,774.01	10,640.32	20,260.00	0.00	0.00	0.00	0.00	0.00	

16,531.77	
75,520.80	
2,450.00	
8,304.37	
102,806.94	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	209.72	5,846.12	5,390.39	2,833.23	2,964.70	4,834.60	1,710.43	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	2,100.00	350.00	238.44	1,759.52	0.00	1,050.00	350.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	59.40	237.60	163.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,369.12	6,433.72	5,792.51	4,592.75	2,964.70	5,884.60	2,060.43	0.00	0.00	0.00	0.00	0.00	

23,789.19	
5,847.96	
460.68	
30,097.83	

SUBTOTAL:

TOTAL:	41,159,756.52	45,693,704.25	55,704,123.37	36,305,180.28	43,523,800.84	48,384,226.06	37,695,608.80	0.00	0.00	0.00	0.00	0.00		308,466,400.12		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1006	TANF 21-44 MALE WITH	12,234.63	8,503.24	18,275.63	6,381.31	5,844.83	15,562.91	2,310.33	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	14,021.73	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	6,256.38	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	3,803.92	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	435,578.73	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	94,219.08	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	48,130.96	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	14,155.92	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	60,578.87	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	566,137.67	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	1,358,567.59	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	628,995.15	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	10,157.29	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	-249.18	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	1,243.02	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	282.26	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	1.71	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	106,798.55	110,945.57	91,003.61	88,139.93	128,224.34	103,657.60	105,406.63	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	64,152.89	46,997.31	91,231.24	102,587.31	66,008.56	55,797.17	32,896.85	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	182,095.65	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	166,567.65	317,497.47	346,091.63	291,180.02	264,676.11	369,190.33	168,962.69	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	3,771,166.39	3,833,723.81	4,457,896.20	3,339,155.66	3,222,228.88	4,143,086.96	2,738,093.95	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	655,176.74	747,126.30	1,013,047.49	712,906.83	646,672.11	1,057,847.13	633,172.34	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	1,351.05	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	25,245.64	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	4,259.75	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	580,690.12	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	607,893.50	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	727,006.19	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	162,178.99	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	299,503.45	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	56.76	0.00	0.00	0.00	0.00	0.00	

 
69,112.88	
96,545.05	
150,111.51	
53,764.45	
3,116,346.43	
1,311,160.51	
1,218,243.51	
354,165.71	
780,031.23	
3,990,696.51	
12,155,340.66	
5,409,843.16	
35,935.93	
4,762.34	
9,493.65	
28,171.39	
14,422.60	
734,176.23	
459,671.33	
1,507,449.91	
1,924,165.90	
25,505,351.85	
5,465,948.94	
4,444.72	
294,702.91	
65,569.16	
0.00	
4,088,778.68	
4,618,776.40	
5,362,945.01	
1,732,202.06	
2,227,647.25	
964.42	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,007.53	1,222.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,229.70		
5015	SOBRA PREG 14-20 FE M	134,500.45	112,857.97	124,462.39	103,103.31	163,088.79	110,109.08	83,848.99	0.00	0.00	0.00	0.00	0.00		831,970.98		
5017	SOBRA PREG 21-44 FE M	505,008.76	490,355.70	786,301.26	601,673.87	660,195.38	611,434.78	546,493.37	0.00	0.00	0.00	0.00	0.00		4,201,463.12		
5018	SOBRA PREG 45-64 FE M	0.00	12,542.17	0.00	422.16	372.51	1,135.72	1,056.99	0.00	0.00	0.00	0.00	0.00		15,529.55		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	11,929,298.55	12,793,707.33	15,798,308.51	12,019,402.53	11,380,005.47	13,780,008.91	10,144,404.34	0.00	0.00	0.00	0.00	0.00		87,845,135.64		

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	

3100	TRANSPLANT OPTION
1
SUBTOTAL:

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	7,405.50	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	17,683.38	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	56,627.22	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	11,071.23	8,539.97	21,023.04	15,362.85	14,717.76	21,487.65	16,224.97	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	394.14	374.54	145.54	124.70	83.77	81.53	134.99	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	3,321.95	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	1,225.34	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	13,274.92	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	130,284.56	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	432,032.21	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	321,557.21	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	21.04	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	4,325.39	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	802.36	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	19,919.50	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	3,777.06	2,003.76	1,660.43	1,418.57	2,747.48	8,784.16	11,495.51	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	6,604.72	20,310.29	10,390.12	10,974.13	5,525.57	11,583.22	517.81	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	21,709.26	49,550.80	38,796.40	5,977.46	2,279.00	-18,632.68	20,046.18	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	212,432.79	214,996.21	262,436.77	205,237.08	184,165.63	237,477.41	165,793.51	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	4,806.76	6,477.98	17,263.02	20,022.37	7,260.02	14,046.10	12,628.26	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	109,739.51	100,550.95	88,862.91	27,616.73	84,045.66	86,870.54	118,947.72	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	194,924.82	195,369.54	290,524.12	205,743.06	175,024.36	301,966.96	168,378.94	0.00	0.00	0.00	0.00	0.00	
	1,175,224.23	1,233,590.49	1,416,332.84	1,198,668.24	1,343,866.61	1,761,113.34	1,522,648.47	0.00	0.00	0.00	0.00	0.00	

0.00	
58,854.79	
153,261.97	
358,764.51	
108,427.47	
0.00	
1,339.21	
13,592.84	
18,417.35	
37,513.17	
801,137.85	
2,160,092.17	
1,893,465.72	
175.04	
20,400.25	
11,243.80	
83,629.10	
31,886.97	
65,905.86	
119,726.42	
1,482,539.40	
82,504.51	
616,634.02	
1,531,931.80	
9,651,444.22	

SUBTOTAL:

3308	AHC CARE M&F 45-64 W	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-40.77	0.00	0.00	0.00	0.00	0.00	-8.71	0.00	0.00	0.00	0.00	0.00	

 
21.62

-49.48

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016

SUBTOTAL:

-13,216.92

0.00

0.00

-883.27

0.00

0.00

-390.50

0.00

0.00

0.00

0.00

0.00

-14,490.69

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	-381.79	0.00	0.00	0.00	0.00	0.00	-909.67	

3318	4
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	

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 1	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-24,077.78	0.00	-475.87	-491.04	0.00	-515.50	-20.32	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,335.41	-100.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	-7,509.71	0.00	1,439.72	0.00	0.00	-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	-20.32	0.00	0.00	0.00	0.00	0.00	

-1,057.32	
-99.09	
60.75	
-2,238.34	
12,313.57	
-25,580.51	
562.33	
-6,923.47	
-22,962.08	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	15.57	260.53	0.00	0.00	0.00	856.86	811.63	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	8,845.20	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	19,155.21	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	15,620.35	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	201,874.30	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	79,903.81	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	560,112.59	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	392.24	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 MAL E	-113.08	0.00	357.03	0.00	121.64	739.90	710.15	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	1,799.96	1,321.34	2,383.72	4,587.94	2,342.89	6,379.13	1,717.83	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	13,612.17	16,184.28	11,638.87	15,449.12	13,966.65	10,416.70	8,527.59	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	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 MAL E	49,424.42	117,557.97	171,586.96	99,739.77	114,797.94	83,920.83	61,098.55	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	85,925.14	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	2,375,248.97	2,548,511.24	3,291,598.46	2,203,928.16	2,372,006.70	2,723,598.34	2,256,037.92	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,081,236.95	1,138,344.74	1,153,915.66	971,417.23	957,390.07	1,048,765.58	776,059.38	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	2,866,722.75	3,197,371.03	3,873,212.13	2,943,218.44	3,088,403.47	3,573,456.33	2,611,868.95	0.00	0.00	0.00	0.00	0.00	

 
1,944.59	
0.00	
21,256.17	
335.70	
44,755.47	
223,336.82	
1,567,007.49	
753,444.33	
4,199,072.38	
1,689.93	
0.00	
225.49	
622.74	
0.00	
1,815.64	
20,532.81	
89,795.38	
2,051.78	
698,126.44	
558,879.27	
17,770,929.79	
7,127,129.61	
22,154,253.10	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	19,126.57	1,786.77	31,730.45	2,915.21	1,256.96	3,098.55	967.59	0.00	0.00	0.00	0.00	0.00		60,882.10		
3727	ADULT <40% EXP FEM AL	166.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.20		
3728	ADULT <40% EXP M&F 4	-612.98	600.54	599.83	413.03	126.91	274.77	274.77	0.00	0.00	0.00	0.00	0.00		1,676.87		
	7,472,143.33	8,169,422.64	9,769,959.27	7,199,220.14	7,472,730.42	8,526,551.10	6,689,903.20	0.00	0.00	0.00	0.00	0.00		55,299,930.10		

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	1,878.61	4,565.59	8,493.20	2,313.61	1,002.68	8,383.02	1,618.64	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	173.85	173.89	128.76	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	4,307.66	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	5,164.87	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	61,251.07	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	89,440.86	139,303.63	118,586.92	109,708.96	85,587.46	139,516.81	113,747.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	273,456.06	265,129.06	405,070.04	269,867.19	392,397.71	380,024.84	331,046.02	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	474,843.91	575,141.29	707,887.34	529,943.61	596,053.98	708,721.97	517,264.02	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
28,255.35	
476.50	
35,322.73	
31,307.74	
901,564.13	
795,891.64	
2,316,990.92	
0.00	
47.11	
4,109,856.12	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	18,822.56	18,033.29	11,971.57	66,627.29	61,087.04	112,144.19	68,203.82	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	21,604.33	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	7,170.95	59,145.25	2,446.86	47,194.94	40,459.21	26,628.68	32,029.01	0.00	0.00	0.00	0.00	0.00	
	36,511.95	91,686.76	17,556.74	139,303.24	136,390.98	166,906.42	121,837.16	0.00	0.00	0.00	0.00	0.00	

0.00	
356,889.76	
138,228.59	
215,074.90	
710,193.25	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	2,014.72	1,660.45	-400.91	457.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	393.90	393.23	34.69	1,707.07	5,144.43	380.10	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	4,917.91	0.00	344.62	7,470.66	-368.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	1,422.62	58.51	0.00	0.00	127.80	0.00	0.00	0.00	0.00	0.00	
	5,311.81	2,407.95	3,462.38	8,835.33	5,233.50	380.10	127.80	0.00	0.00	0.00	0.00	0.00	

3,731.64	
8,053.42	
12,364.88	
1,608.93	
25,758.87	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	3,652.19	5,276.89	5,063.99	2,938.66	1,991.80	5,632.26	1,477.18	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	94.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	204.26	0.00	10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,652.19	5,276.89	5,362.74	2,938.66	2,002.06	5,632.26	1,477.18	0.00	0.00	0.00	0.00	0.00	

26,032.97	
94.49	
214.52	
26,341.98	

SUBTOTAL:

157,631,207.41

21,049,296.39	22,871,233.35	27,733,419.01	21,096,836.49	20,936,283.02	24,946,887.80	18,997,251.35	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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:

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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:

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

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

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	4
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	

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	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:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

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

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

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

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	625.82	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	7,576.08	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	1,359.89	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	239.81	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	196.26	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	2,494.59	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	16,774.46	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	8,095.59	0.00	0.00	0.00	0.00	0.00	
1019	TANF 65+ M & F NON-M	249.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	14.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	241.77	1,611.38	1,217.37	578.23	1,624.74	2,126.97	1,264.25	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	371.10	7,188.56	32,792.94	1,605.68	18,626.89	9,771.81	8,423.35	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	1,819.28	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	274.99	1,222.09	2,462.28	265.65	1,191.01	1,835.64	215.54	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	25,287.18	285,986.08	63,667.08	20,539.73	10,339.15	19,142.49	6,249.43	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	3,344.91	11,090.04	4,388.06	4,281.31	7,564.03	5,685.08	5,093.78	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	4,221.82	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	12,097.72	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	13,965.41	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	80,849.97	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	2,749.26	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	

 
136.92	
0.00	
2,701.37	
284.13	
46,640.82	
21,381.72	
7,027.72	
5,755.05	
13,316.23	
83,668.59	
148,406.28	
47,610.59	
249.73	
0.00	
0.00	
14.61	
0.00	
8,664.71	
78,780.33	
6,733.88	
7,467.20	
431,211.14	
41,447.21	
0.00	
2,306.72	
0.00	
0.00	
46,798.67	
145,793.85	
179,457.23	
149,348.92	
62,399.11	
0.00	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	4,547.68	626.35	7,875.28	1,288.69	1,480.21	1,333.79	994.22	0.00	0.00	0.00	0.00	0.00		18,146.22		
5017	SOBRA PREG 21-44 FE M	21,818.94	29,403.82	43,513.99	31,655.97	15,933.90	13,446.16	23,742.27	0.00	0.00	0.00	0.00	0.00		179,515.05		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	212,022.47	488,372.66	298,566.78	176,603.03	155,045.74	205,604.52	199,048.80	0.00	0.00	0.00	0.00	0.00		1,735,264.00		

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	

3100	TRANSPLANT OPTION
1
SUBTOTAL:

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	245.33	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	21.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	107.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	88.72	207.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	983.30	246.21	480.41	221.56	5,436.61	488.81	93.00	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	2,406.31	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	19,007.30	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	3,778.42	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	338.53	-1,011.94	2,895.49	1,827.68	233.88	90.75	822.40	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	199.65	0.00	129.18	-72.61	-17.74	189.14	200.01	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	386.96	48.09	143.85	158.57	1,284.03	1,951.82	642.36	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	56,129.73	0.00	20,969.96	0.00	35,888.67	13,483.84	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	479.32	0.00	3,171.06	1,161.00	1,618.58	356.00	2,262.36	0.00	0.00	0.00	0.00	0.00	
	71,791.87	5,686.71	75,118.85	16,413.39	46,695.06	38,491.09	29,457.49	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
26.99	
453.43	
21.69	
107.79	
296.08	
0.00	
7,949.90	
155.05	
49,772.45	
63,868.33	
15,042.13	
0.00	
0.00	
0.00	
0.00	
0.00	
5,196.79	
0.00	
627.63	
4,615.68	
126,472.20	
9,048.32	
283,654.46	

SUBTOTAL:

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-55.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

-55.14

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016

SUBTOTAL:

-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

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	4
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	

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 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	996.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	56,134.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	57,131.53	0.00	0.00	0.00	0.00	-90.89	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
-90.89	
0.00	
0.00	
0.00	
996.64	
0.00	
56,134.89	
57,040.64	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	95.08	0.00	205.82	0.00	0.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	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	137.60	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	7,106.94	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	4,839.72	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	22,774.88	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	4,114.12	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	47.77	159.41	-72.49	153.28	0.00	57.02	-357.03	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	638.33	2,949.89	655.77	55.09	1,044.42	821.03	540.50	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	484.68	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	87,516.94	137,213.09	59,107.89	86,557.14	76,793.86	88,807.17	25,860.89	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	28,711.56	30,380.42	62,265.11	20,947.83	13,043.16	62,567.45	17,619.35	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	73,759.29	34,317.41	75,461.37	91,305.45	36,478.45	38,593.34	50,612.11	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
301.01	
61.23	
5,177.59	
4,182.25	
128,306.80	
47,613.60	
157,183.83	
0.00	
0.00	
0.00	
0.00	
0.00	
10.26	
4,114.12	
-12.04	
0.00	
6,705.03	
10,662.56	
561,856.98	
235,534.88	
400,527.42	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	257,558.65	252,306.42	248,671.91	234,260.23	195,405.22	244,403.45	129,619.64	0.00	0.00	0.00	0.00	0.00		1,562,225.52		

SUBTOTAL:

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	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	136.86	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	48,801.48	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	2,187.81	6,610.07	2,102.47	1,988.35	1,659.44	14,701.39	3,621.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	40,072.00	12,789.89	57,847.40	7,387.87	-635.14	5,689.64	31,000.16	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	44,437.01	23,067.06	66,686.47	17,761.16	1,707.45	29,639.64	83,559.50	0.00	0.00	0.00	0.00	0.00	

75.76	
0.00	
0.00	
0.00	
219.66	
136.86	
79,403.66	
32,870.53	
154,151.82	
0.00	
0.00	
266,858.29	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	332.82	31.19	1,392.55	1,273.75	5,386.27	3,719.75	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	20,204.79	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	169.44	0.00	0.00	636.29	424.71	-39.17	0.00	0.00	0.00	0.00	0.00	0.00	
	177.42	401.62	31.19	2,090.39	1,825.04	5,416.89	23,924.54	0.00	0.00	0.00	0.00	0.00	

0.00	
12,136.33	
20,539.49	
1,191.27	
33,867.09	

SUBTOTAL:

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

0.00	
0.00	
3,527.87	
0.00	
3,527.87	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	61.65	36.81	95.62	36.81	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	2,178.61	0.00	0.00	13,816.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	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	2,178.61	0.00	61.65	13,853.68	95.62	36.81	0.00	0.00	0.00	0.00	0.00	

230.89	
15,995.48	
0.00	
16,226.37	

SUBTOTAL:

3,957,980.34

646,451.11	771,726.45	689,215.77	447,049.28	414,228.06	523,522.32	465,787.35	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	0.00	0.00	0.00	0.00	0.00		191,141.79		
	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	0.00	0.00	0.00	0.00	0.00		191,141.79		

SUBTOTAL:

TOTAL:	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	0.00	0.00	0.00	0.00	0.00		191,141.79		

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	0.00	0.00	54.51	0.00	0.00	0.00	14.54	0.00	0.00	0.00	0.00	0.00		69.05		
	0.00	0.00	54.51	0.00	0.00	0.00	14.54	0.00	0.00	0.00	0.00	0.00		69.05		

SUBTOTAL:

69.05

0.00	0.00	54.51	0.00	0.00	0.00	14.54	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	0.00	0.00	0.00	0.00	0.00		2,275,922.07		
	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	0.00	0.00	0.00	0.00	0.00		2,275,922.07		

SUBTOTAL:

TOTAL:	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	0.00	0.00	0.00	0.00	0.00		2,275,922.07		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1006	TANF 21-44 MALE WITH	46.42	188.36	166.12	101.73	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	113.90	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	34,313.55	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	8,596.17	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	1,318.35	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	286.55	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	6,249.18	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	85,091.79	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	87,007.19	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	51,649.62	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	8,786.84	9,235.08	13,562.46	4,876.58	4,017.94	1,926.23	480.64	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDIC AR	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	4,741.69	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	21,233.51	3,529.27	27,584.81	6,512.83	4,472.52	8,071.02	2,754.21	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME D	231,778.99	342,969.11	271,027.04	176,793.76	210,239.42	204,543.74	177,331.11	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	31,844.13	34,580.97	45,422.53	27,354.81	19,197.99	51,044.87	26,387.05	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	1,883.94	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	-24.30	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	98,949.20	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	29,395.94	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	27,330.41	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	4,567.14	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	25,449.12	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	

 
780.06	
2,878.91	
6,752.93	
82.48	
378,423.45	
82,239.67	
47,048.51	
9,451.58	
41,174.47	
309,222.18	
918,765.90	
290,276.02	
0.00	
0.00	
0.00	
3,899.11	
0.00	
42,885.77	
6,857.69	
45,756.44	
74,158.17	
1,614,683.17	
235,832.35	
530.71	
8,085.38	
882.23	
0.00	
697,529.65	
266,252.51	
259,415.34	
116,624.89	
186,364.38	
0.00	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	19,583.10	16,174.12	18,249.56	19,803.43	28,709.84	38,838.71	33,355.08	0.00	0.00	0.00	0.00	0.00		174,713.84		
5017	SOBRA PREG 21-44 FE M	50,370.25	73,392.58	98,242.24	99,306.65	73,113.89	108,947.96	91,772.55	0.00	0.00	0.00	0.00	0.00		595,146.12		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	808,932.77	881,111.78	1,023,289.80	1,037,253.28	908,268.05	958,858.15	799,000.08	0.00	0.00	0.00	0.00	0.00		6,416,713.91		

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3100	TRANSPLANT OPTION
1
SUBTOTAL:

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	181.95	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	316.38	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	1,461.53	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	1,249.86	53.73	663.23	32.04	433.73	1,330.06	324.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	169.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	506.37	0.00	0.00	271.22	0.00	155.37	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	7,283.17	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	46,315.17	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	23,453.79	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	57.30	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&	0.00	0.00	0.00	0.00	0.00	81.70	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	174.66	70.14	1,351.38	245.08	1,187.78	146.02	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	504.00	193.90	3,907.14	0.00	360.04	44.31	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	3,538.39	5,601.99	9,609.73	6,111.76	4,987.34	12,361.60	7,977.92	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	170.31	695.50	498.27	5,168.66	108.02	80.25	1,527.12	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	13,636.52	8,325.86	26,011.62	1,009.53	583.66	720.17	2,476.55	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	4,285.83	11,263.10	11,272.83	7,319.43	5,081.88	20,081.95	9,392.05	0.00	0.00	0.00	0.00	0.00	
	71,468.19	82,740.10	146,508.04	66,063.09	101,434.21	104,086.15	100,922.30	0.00	0.00	0.00	0.00	0.00	

0.00	
-2,009.72	
8,315.26	
15,446.73	
4,086.65	
0.00	
169.40	
15.00	
932.96	
53.99	
96,013.62	
247,185.69	
107,782.44	
1,368.93	
1,202.90	
286.67	
4,207.57	
81.70	
3,175.06	
5,009.39	
50,188.73	
8,248.13	
52,763.91	
68,697.07	
673,222.08	

SUBTOTAL:

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016

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

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	4
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	

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 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	-84.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-123.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	-207.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
-84.11	
-123.34	
-207.45	

SUBTOTAL:

3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	257.39	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	380.07	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	381.09	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	224.84	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	166,909.20	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	9,776.39	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	136,171.18	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	246.62	0.00	1,361.40	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	1,741.29	1,260.00	0.00	170.39	48.25	139.91	126.40	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	-224.42	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	7,292.84	12,081.73	19,979.50	3,571.18	6,165.38	11,600.06	1,839.57	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	5,785.32	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	136,455.42	205,325.04	266,134.03	102,321.13	255,550.69	161,837.89	126,535.96	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	94,474.99	126,480.57	88,278.29	77,117.72	75,243.41	61,658.54	113,024.70	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	181,612.85	129,721.57	241,985.31	168,543.69	210,132.57	273,111.36	172,306.98	0.00	0.00	0.00	0.00	0.00	

 
257.39	
0.00	
3,171.00	
91.35	
16,818.54	
4,588.72	
441,079.76	
72,929.06	
589,811.23	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,608.02	
3,486.24	
-224.42	
62,530.26	
49,043.87	
1,254,160.16	
636,278.22	
1,377,414.33	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	1,260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,260.00		
	536,535.52	576,817.99	830,669.89	486,991.15	673,791.65	674,641.46	734,856.07	0.00	0.00	0.00	0.00	0.00		4,514,303.73		

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	627.65	95.99	385.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	697.18	0.00	0.00	182.55	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	5,342.73	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	2,574.73	5,949.64	7,868.75	10,984.25	13,427.45	10,371.16	4,670.18	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	51,923.13	16,392.55	23,221.63	35,300.47	24,728.16	50,480.40	45,409.67	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	57,678.54	27,673.40	42,100.30	52,364.43	46,958.93	67,934.44	55,605.13	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
1,108.99	
0.00	
879.73	
4,477.65	
40,546.63	
55,846.16	
247,456.01	
0.00	
0.00	
350,315.17	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	920.33	606.76	51.87	3,005.28	2,948.59	9,142.94	2,684.28	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	1,022.44	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	589.03	196.50	0.00	4,003.47	2,355.99	5,473.69	1,606.27	0.00	0.00	0.00	0.00	0.00	
	1,509.36	803.26	359.55	7,197.72	9,992.38	15,681.74	5,312.99	0.00	0.00	0.00	0.00	0.00	

0.00	
19,360.05	
7,272.00	
14,224.95	
40,857.00	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	10.17	15.64	0.00	0.00	15.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	10.17	15.64	0.00	0.00	15.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
41.45	
0.00	
0.00	
41.45	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	0.00	22.70	0.00	274.10	91.00	262.32	10.12	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	22.70	0.00	274.10	91.00	262.32	10.12	0.00	0.00	0.00	0.00	0.00	

660.24	
0.00	
0.00	
660.24	

SUBTOTAL:

11,995,906.13

1,476,134.55	1,569,184.87	2,042,720.13	1,650,143.77	1,740,551.86	1,821,464.26	1,695,706.69	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	350.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		700.00		
2100	SSI AGED WITH MEDIC A	106,605.75	138,772.37	243,060.06	109,396.22	86,575.09	110,463.52	87,654.44	0.00	0.00	0.00	0.00	0.00		882,527.45		
2110	SSI AGED NON-MEDIC AR	26,434.90	13,763.26	31,784.99	27,506.02	11,008.01	20,476.11	15,801.28	0.00	0.00	0.00	0.00	0.00		146,774.57		
2120	SSI AGED WITH QMB	121,926.99	174,038.05	225,195.50	122,450.70	94,459.04	143,149.01	108,417.25	0.00	0.00	0.00	0.00	0.00		989,636.54		
2200	SSI DISABLED WITH M E	45,476.20	32,686.17	56,715.55	29,618.96	25,027.91	41,363.82	24,516.31	0.00	0.00	0.00	0.00	0.00		255,404.92		
2210	SSI DISABLED NON-ME D	688,624.66	871,046.82	795,795.36	508,232.84	646,246.26	763,839.63	495,448.90	0.00	0.00	0.00	0.00	0.00		4,769,234.47		
2220	SSI DISABLED WITH Q M	48,687.58	68,819.71	112,495.22	51,083.18	51,662.77	56,329.19	40,683.06	0.00	0.00	0.00	0.00	0.00		429,760.71		
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	7,009.55	0.00	0.00	0.00	0.00	0.00		45,513.40		
2320	SSI BLIND WITH QMB	431.94	428.25	416.46	71.62	789.22	833.02	421.52	0.00	0.00	0.00	0.00	0.00		3,392.03		
	1,046,662.95	1,306,924.29	1,472,172.54	854,718.94	918,176.11	1,144,562.77	779,952.31	0.00	0.00	0.00	0.00	0.00		7,523,169.91		

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

106.88	
0.00	
106.88	

SUBTOTAL:

TOTAL:	1,046,662.95	1,306,924.29	1,472,179.89	854,718.94	918,275.64	1,144,562.77	779,952.31	0.00	0.00	0.00	0.00	0.00		7,523,276.79		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	1,685,117.40	1,915,799.87	2,681,450.39	1,999,482.31	2,206,654.38	2,521,199.26	1,971,919.68	0.00	0.00	0.00	0.00	0.00		14,981,623.29		
2110	SSI AGED NON-MEDIC AR	134,210.18	86,635.19	183,540.43	121,497.09	95,581.49	106,014.38	109,241.83	0.00	0.00	0.00	0.00	0.00		836,720.59		
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	2,966,589.34	0.00	0.00	0.00	0.00	0.00		21,556,133.78		
2200	SSI DISABLED WITH M E	484,829.08	429,355.23	623,488.25	496,865.31	514,028.21	644,163.05	445,334.53	0.00	0.00	0.00	0.00	0.00		3,638,063.66		
2210	SSI DISABLED NON-ME D	1,738,486.52	1,802,598.11	2,237,418.61	1,856,867.73	1,821,700.40	2,248,380.45	1,960,119.55	0.00	0.00	0.00	0.00	0.00		13,665,571.37		
2220	SSI DISABLED WITH Q M	585,872.48	620,560.01	851,203.88	615,551.90	612,586.36	832,248.41	699,418.83	0.00	0.00	0.00	0.00	0.00		4,817,441.87		
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	6,315.84	0.00	0.00	0.00	0.00	0.00		52,023.01		
2320	SSI BLIND WITH QMB	4,994.88	7,132.53	7,260.58	5,253.26	5,833.93	6,424.90	7,449.06	0.00	0.00	0.00	0.00	0.00		44,349.14		
	7,373,566.73	7,561,011.13	10,463,925.17	7,908,368.11	8,273,171.38	9,845,495.53	8,166,388.66	0.00	0.00	0.00	0.00	0.00		59,591,926.71		

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,037.06	2,637.12	0.00	2,709.12	2,578.56	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	4,112.64	2,741.76	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	5,320.32	0.00	0.00	0.00	0.00	0.00	

14,839.20	
19,814.76	
34,653.96	

SUBTOTAL:

59,626,580.67

7,375,279.25	7,565,879.35	10,473,110.87	7,913,057.23	8,275,227.70	9,852,317.29	8,171,708.98	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	57,961.58	35,627.77	43,341.81	22,249.92	35,336.54	18,733.95	43,788.71	0.00	0.00	0.00	0.00	0.00		257,040.28		
2110	SSI AGED NON-MEDIC AR	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	312.29	0.00	0.00	0.00	0.00	0.00		2,953.09		
2200	SSI DISABLED WITH M E	11,220.75	6,502.00	26,013.79	7,482.95	9,714.19	1,405.20	16,547.58	0.00	0.00	0.00	0.00	0.00		78,886.46		
2210	SSI DISABLED NON-ME D	26,834.51	19,004.26	28,589.63	10,783.29	71,004.32	45,428.28	10,585.96	0.00	0.00	0.00	0.00	0.00		212,230.25		
2220	SSI DISABLED WITH Q M	2,359.28	722.71	6,308.23	1,497.53	1,372.98	2,162.54	215.93	0.00	0.00	0.00	0.00	0.00		14,639.20		
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		
	121,910.37	64,311.03	187,810.07	50,919.11	118,392.99	70,411.89	71,450.47	0.00	0.00	0.00	0.00	0.00		685,205.93		

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

SUBTOTAL:

TOTAL:	121,910.37	64,311.03	187,810.07	50,919.11	118,392.99	70,411.89	71,450.47	0.00	0.00	0.00	0.00	0.00		685,205.93		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	17,791.38	16,157.36	33,799.85	22,186.80	28,584.66	11,004.95	44,168.26	0.00	0.00	0.00	0.00	0.00		173,693.26		
2110	SSI AGED NON-MEDIC AR	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	14,838.78	0.00	0.00	0.00	0.00	0.00		92,097.91		
2200	SSI DISABLED WITH M E	1,998.01	5,671.10	17,991.36	2,677.54	3,446.03	8,612.53	11,085.27	0.00	0.00	0.00	0.00	0.00		51,481.84		
2210	SSI DISABLED NON-ME D	39,207.69	57,526.26	37,706.14	98,519.59	47,761.48	76,557.96	49,875.46	0.00	0.00	0.00	0.00	0.00		407,154.58		
2220	SSI DISABLED WITH Q M	2,612.76	3,357.96	4,743.41	3,725.64	6,845.49	13,692.39	6,072.55	0.00	0.00	0.00	0.00	0.00		41,050.20		
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	48.21	0.00	0.00	0.00	0.00	0.00		485.08		
	74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	126,088.53	0.00	0.00	0.00	0.00	0.00		766,944.21		

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

SUBTOTAL:

766,944.21

74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	126,088.53	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION AMOUNTS
For The Period Ending January 31, 2016

SUBTOTAL:

183,782.09

170,408.91

173,185.84

164,735.13

157,227.01

237,286.25

145,035.95

0.00

0.00

0.00

0.00

0.00

1,231,661.18

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	479.18	0.00	0.00	0.00	0.00	0.00	7,388.02	

6012	C
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	46,353.98	0.00	0.00	0.00	0.00	0.00	397,333.05	
6014	KIDS 14-19 MALE NON-	49,755.46	44,451.13	44,464.06	45,078.81	41,422.38	59,062.76	40,125.21	0.00	0.00	0.00	0.00	0.00	324,359.81	
6015	KIDS 14-19 FEMALE NO	74,775.69	69,658.38	67,362.69	66,568.43	64,034.95	94,288.29	58,077.58	0.00	0.00	0.00	0.00	0.00	494,766.01	
9960	KIDSCARE KICK PAYM	0.00	0.00	6,160.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,160.56	
	EN														

TOTAL:	183,782.09	170,408.91	173,185.84	164,735.13	157,227.01	237,286.25	145,035.95	0.00	0.00	0.00	0.00	0.00		1,231,661.18		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending January 31, 2016

993.61	932.52	910.22	883.58	836.18	816.75	763.37	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:	993.61	932.52	910.22	883.58	836.18	816.75	763.37	0.00	0.00	0.00	0.00	0.00		6,136.23	
															
TOTAL:														6,136.23	

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	1.00	0.00	0.00	0.00	0.00	0.00	12.66	

6012	C
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	348.57	0.00	0.00	0.00	0.00	0.00	2,808.78	
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	242.85	218.16	218.83	207.34	0.00	0.00	0.00	0.00	0.00	1,619.64	
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	240.85	230.13	226.93	206.46	0.00	0.00	0.00	0.00	0.00	1,684.15	
9960	KIDSCARE KICK PAYM	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
	EN														

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	75.10	75.10	37.55	82.84	82.84	125.24	41.42	0.00	0.00	0.00	0.00	0.00		520.09		
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	14,165.64	0.00	0.00	0.00	0.00	0.00		112,881.39		
6014	KIDS 14-19 MALE NON-	9,776.08	8,979.83	9,075.34	10,574.10	9,401.08	11,247.46	8,858.20	0.00	0.00	0.00	0.00	0.00		67,912.09		
6015	KIDS 14-19 FEMALE NO	10,772.21	10,088.61	9,721.39	10,393.14	10,092.34	11,969.04	9,002.16	0.00	0.00	0.00	0.00	0.00		72,038.89		
SUBTOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	42,451.52	32,067.42	0.00	0.00	0.00	0.00	0.00		253,845.20		

TOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	42,451.52	32,067.42	0.00	0.00	0.00	0.00	0.00		253,845.20		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending January 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	2.00	2.00	1.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00		12.00		
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	342.00	0.00	0.00	0.00	0.00	0.00		2,746.00		
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	235.00	210.00	211.00	198.00	0.00	0.00	0.00	0.00	0.00		1,561.00		
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	231.00	223.00	220.00	200.00	0.00	0.00	0.00	0.00	0.00		1,645.00		
SUBTOTAL:	968.00	918.00	894.00	849.00	812.00	792.00	741.00	0.00	0.00	0.00	0.00	0.00		5,974.00		

TOTAL:

968.00

5,974.00

918.00	894.00	849.00	812.00	792.00	741.00	0.00	0.00	0.00	0.00	0.00

KidsCare - FEE FOR SERVICE
For The Period Ending January 31, 2016	
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	15.43	0.00	0.00	0.00	0.00	0.00		832.23		
	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	0.00	0.00	0.00	0.00	0.00		2,950.80		

SUBTOTAL:

TOTAL:	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	0.00	0.00	0.00	0.00	0.00		2,950.80		

KidsCare - REINSURANCE
For The Period Ending January 31, 2016	
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	85.90	0.00	0.00	0.00	0.00	0.00		210,835.11		
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	85.90	0.00	0.00	0.00	0.00	0.00		288,077.53		

SUBTOTAL:

TOTAL:

161.54

30,495.15	70,988.85	57,122.39	103,826.49	25,397.21	85.90	0.00	0.00	0.00	0.00	0.00	288,077.53

6

00

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending January 31, 2016

RATE CODE

DESCRIPTION

JULY

AUGUST     SEPTEMBER

OCTOBER

NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

200,992.10

200,992.10

24.00

4,525.23

9.00

1,124.14

32.19

1,904.20

12,443.03

0.00

151,697.97

0.70

28,060.09

1.00

95.00

797.25

194.30

49.00

14.00

21.00

1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	4.00	5.00	7.00	0.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	643.15	641.57	646.12	649.50	648.46	646.64	649.79	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	151.70	154.89	157.99	163.43	165.59	166.66	163.88	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.19	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	272.31	272.62	271.31	271.53	273.47	273.79	269.17	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH ME	1,753.65	1,745.73	1,754.42	1,769.90	1,793.19	1,805.13	1,821.01	0.00	0.00	0.00	0.00	0.00	
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	
2210	SSI DISABLED NON-MED	21,475.15	21,538.50	21,702.85	21,678.83	21,721.06	21,810.43	21,771.15	0.00	0.00	0.00	0.00	0.00	
221Z	SSI DISABLED NON-MED	0.03	0.00	0.00	0.03	0.00	0.64	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH QM	3,977.48	3,986.67	4,014.73	4,014.04	4,014.92	4,010.25	4,042.00	0.00	0.00	0.00	0.00	0.00	
222Z	SSI DISABLED WITH QM	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	13.00	13.00	13.00	14.00	14.00	14.00	14.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	111.00	112.38	114.06	111.81	116.00	115.00	117.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	28.00	29.00	28.00	28.00	27.30	27.00	27.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL: TOTAL:	28,445.47	28,515.36	28,722.48	28,721.26	28,794.99	28,892.54	28,900.00	0.00	0.00	0.00	0.00	0.00	
	28,445.47	28,515.36	28,722.48	28,721.2	28,794.99	28,892.54	28,900.00	0.00	0.00	0.	0.00	0.00	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending January 31, 2016

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	370,741.89	366,197.37	369,544.65	371,342.65	369,390.76	369,639.86	371,326.59	0.00	0.00	0.00	0.00	0.00	2,588,183.77	
EPD	84,945,196.47	97,607,756.74	86,404,566.22	86,818,575.78	99,193,232.58	87,521,696.46	86,043,306.40	0.00	0.00	0.00	0.00	0.00	628,534,330.65	
TOTAL AHCCCS LTC	85,315,938.36	97,973,954.11	86,774,110.87	87,189,918.43	99,562,623.34	87,891,336.32	86,414,632.99	0.00	0.00	0.00	0.00	0.00	631,122,514.42	
DES/DD	97,105,888.85	97,348,150.88	98,057,803.05	98,603,338.74	98,857,708.49	101,652,897.48	99,469,295.66	0.00	0.00	0.00	0.00	0.00	691,095,083.15	
TOTAL DES LTC	97,105,888.85	97,348,150.88	98,057,803.05	98,603,338.74	98,857,708.49	101,652,897.48	99,469,295.66	0.00	0.00	0.00	0.00	0.00	691,095,083.15	
TOTAL LTC - CAP	182,421,827.21	195,322,104.99	184,831,913.92	185,793,257.17	198,420,331.83	189,544,233.80	185,883,928.65	0.00	0.00	0.00	0.00	0.00	1,322,217,597.57	

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	9,149,200.29
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	68,602,007.60
0.00	
	0.00	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	9,149,200.29	0.00	0.00	0.00	0.00	0.00	68,602,007.60	

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	2,918,684.38
255,643.16	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	26,627,981.48
3,449,755.31	
	375,457.62	326,085.82	792,734.80	709,764.46	616,786.74	373,282.71	255,643.16	0.00	0.00	0.00	0.00	0.00	3,449,755.31	
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	3,174,327.54	0.00	0.00	0.00	0.00	0.00	30,077,736.79	

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	3,604,498.00	0.00	0.00	0.00	0.00	0.00	22,398,712.40	

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

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending January 31, 2016

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

TOTAL

Thursday, February 18, 2016

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	19,864,340.45	14,238,273.42	0.00	0.00	0.00	0.00	0.00	102,480,283.36	
010145	CRS ACUTE SEMI INTEGRATED - CAP	122,251.86	115,316.41	116,070.08	130,768.30	127,797.18	190,317.07	138,461.10	0.00	0.00	0.00	0.00	0.00	940,982.00	
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	4,916,352.00	0.00	0.00	0.00	0.00	0.00	29,011,854.09	
999135	CRS ONLY PLAN - CAP	476,979.36	481,148.76	485,318.16	546,356.40	545,428.80	542,646.00	556,799.04	0.00	0.00	0.00	0.00	0.00	3,634,676.52	
	17,327,365.74	17,345,286.10	17,436,869.01	19,387,801.16	19,328,796.24	25,391,792.16	19,849,885.56	0.00	0.00	0.00	0.00	0.00	136,067,795.97	

Subtotal

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	189,912.38	0.00	0.00	0.00	0.00	0.00	11,652,742.31	
	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	2,963,907.95	189,912.38	0.00	0.00	0.00	0.00	0.00	11,652,742.31	

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	27,578.53	0.00	0.00	0.00	0.00	0.00	213,906.59	
	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	49,375.16	27,578.53	0.00	0.00	0.00	0.00	0.00	213,906.59	

Subtotal

19,545,976.24	18,869,023.14	19,332,548.29	21,423,030.67	20,291,414.79	28,405,075.27	20,067,376.47	0.00	0.00	0.00	0.00	0.00	147,934,444.87	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending January 31, 2016

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

TOTAL

Thursday, February 18, 2016

010115	CRS FULLY INTEGRATED PLAN - MM	17,063.13	17,085.46	17,193.00	17,270.81	17,202.37	17,268.27	17,137.32	0.00	0.00	0.00	0.00	0.00	120,220.36	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	168.21	164.43	179.03	172.82	0.00	0.00	0.00	0.00	0.00	1,187.90	
999125	CRS SEMI INTEGRATED PLAN - MM	6,452.00	6,458.00	6,463.00	6,467.00	6,465.00	6,504.00	6,510.00	0.00	0.00	0.00	0.00	0.00	45,319.00	
999135	CRS ONLY PLAN - MM	1,144.00	1,154.00	1,164.00	1,178.00	1,176.00	1,170.00	1,167.00	0.00	0.00	0.00	0.00	0.00	8,153.00	
	24,833.16	24,861.60	24,985.24	25,084.02	25,007.80	25,121.30	24,987.14	0.00	0.00	0.00	0.00	0.00	174,880.26	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC MM	36.87	32.00	33.00	34.99	35.00	32.93	33.19	0.00	0.00	0.00	0.00	0.00	237.98	
	36.87	32.00	33.00	34.99	35.00	32.93	33.19	0.00	0.00	0.00	0.00	0.00	237.98	

Subtotal

24,870.03	24,893.60	25,018.24	25,119.01	25,042.80	25,154.23	25,020.33	0.00	0.00	0.00	0.00	0.00	175,118.24	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS
For the Period Ending January 31, 2016

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

TOTAL

Thursday, February 18, 2016

010700	HEALTH CHOICE INTEGRATED - CAP	0.00	0.00	-1,518.09	8,509,580.12	8,451,274.03	8,462,710.24	8,392,913.99	0.00	0.00	0.00	0.00	0.00	33,814,960.29	
010725	CENPATICO INTEGRATED - CAP	0.00	0.00	18,507.72	21,037,755.17	20,895,096.45	20,870,006.63	20,650,744.57	0.00	0.00	0.00	0.00	0.00	83,472,110.54	
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	45,020,020.63	44,903,579.02	0.00	0.00	0.00	0.00	0.00	320,872,601.09	
	47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	74,352,737.50	73,947,237.58	0.00	0.00	0.00	0.00	0.00	438,159,671.92	

Subtotal

47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	74,352,737.50	73,947,237.58	0.00	0.00	0.00	0.00	0.00	438,159,671.92	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS
For the Period Ending January 31, 2016

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

TOTAL

Thursday, February 18, 2016

010700	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	-1.00	5,604.33	5,566.18	5,573.46	5,527.22	0.00	0.00	0.00	0.00	0.00	22,270.19	
010725	CENPATICO INTEGRATED - MM	0.00	0.00	12.00	13,638.68	13,546.91	13,530.10	13,387.94	0.00	0.00	0.00	0.00	0.00	54,115.63	
078999	MERCY MARICOPA INTEGRATED - MM	19,430.16	19,501.43	19,702.99	19,787.96	19,758.81	20,073.60	20,020.25	0.00	0.00	0.00	0.00	0.00	138,275.20	
	19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,177.16	38,935.41	0.00	0.00	0.00	0.00	0.00	214,661.02	

Subtotal

19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,177.16	38,935.41	0.00	0.00	0.00	0.00	0.00	214,661.02	

GRAND TOTAL