April 25, 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 March 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 March 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. April 25, 2016
Page 2

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

Enrollment Update – March 2016 enrollment is 1,849,048 members, a 3,518 member increase over the prior month. Enrollment for April 2016 decreased to 1,841,997 members, a decrease of 7,051 members.

Major April changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 8,927; Supplemental Security Income – decrease of 1,904; Prop 204 Restoration – increase of 833; Adult Expansion - increase of 2,431; Medicare Cost Sharing – decrease of 180; and Federal Emergency Services – increase of 661.

Tobacco Funds Revenue Update –Tobacco tax collections through March 2016 are $8.5 million more than the AHCCCS monthly projected flows. In April, AHCCCS received approximately $98.9 million in Tobacco Litigation Settlement funding which is about $1.1 million lower than the FY16 appropriation of $100,000,000. 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 March 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 March 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	$	75,225,400		$	52,369,600		$	51,834,392		$	535,208		$	75,225,400		$	-	
AHCCCS Prop 204 Administration	11,565,300		5,708,400		6,986,501		(1,278,101)		11,565,300		-	
DES Eligibility	54,874,500		38,459,700		43,570,346		(5,110,646)		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		26,504,100		16,523,563		9,980,537		38,358,700		-	
TOTAL ADMINISTRATION	180,023,900		123,041,800		118,914,803		4,126,997		180,023,900		-	

APPROPRIATIONS: ADMINISTRATION

Traditional Medicaid Services	3,438,803,700	2,541,641,800	2,772,351,927	(230,710,127)	3,438,803,700	-
Proposition 204 Services	2,507,700,600	1,843,851,100	1,825,993,778	17,857,322	2,507,700,600	-
ACA Adult Expansion	396,683,800	291,169,900	290,421,402	748,498	396,683,800	-
Children's Rehabilitative Services	233,839,100	172,915,200	180,108,992	(7,193,792)	233,839,100	-
KidsCare Services	6,295,200	4,735,800	1,581,230	3,154,570	6,295,200	-
ALTCS Services	1,386,588,900	1,023,117,600	968,401,228	54,716,372	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	356,228,786	245,048,400	245,048,395	5	356,228,786	-

 	 	 	 	
TOTAL PROGRAMMATIC	8,353,877,186	6,122,479,800	6,289,152,903	(166,673,103)	8,353,877,186	-

TOTAL EXPENDITURES

$	8,533,901,086

$    6,245,521,600

$   6,408,067,705

$	(162,546,105)

$  8,533,901,086	$	-

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending March 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	
$	35,302,200	
$	31,548,958		
3,753,242		
$	51,537,900		
$	-	
Proposition 204 - Administrative Expenditures	20,280,700	13,904,300	6,801,495		7,102,805		20,280,700		-	
Programmatic Expenditures Traditional Medicaid Services	
800,323,100	
587,389,500	
654,935,740		
(67,546,240)		
800,323,100		
-	
Proposition 204 Services	90,000,000	135,892,600	57,872,863		78,019,737		90,000,000		-	
Children's Rehabilitative Services	72,487,200	53,789,500	54,334,223		(544,723)		72,487,200		-	
KidsCare Services	338,000	338,000	(29,094)		367,094		338,000		-	
ALTCS Services	162,880,800	119,992,900	122,160,600		(2,167,700)		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	946,609,000	929,255,225		17,353,775		1,205,162,300		-		

Administrative Expenditures	
78,114,000		
55,381,500	
63,684,054		
(8,302,554)		
78,114,000		
-	
Proposition 204 - Administrative Expenditures	26,160,400		15,901,700	14,967,119		934,581		26,160,400		-	
Programmatic Expenditures Traditional Medicaid Services	
2,271,456,100		
1,678,892,500	
1,799,558,189		
(120,665,689)		
2,271,456,100		
-	
Proposition 204 Services	2,048,414,400		1,505,912,400	1,543,286,587		(37,374,187)		2,048,414,400		-	
ACA Adult Expansion	396,683,800		291,169,900	290,421,402		748,498		396,683,800		-	
Children's Rehabilitative Services	161,351,900		119,125,700	125,774,769		(6,649,069)		161,351,900		-	
KidsCare Services	5,587,200		4,126,700	1,610,324		2,516,376		5,587,200		-	
ALTCS Services and Nursing Facility Assessment	931,056,600		687,206,500	643,964,150		43,242,350		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	242,746,591	162,016,100	162,016,104	(4)	242,746,591	-
 	 	 	 	
TOTAL FEDERAL EXPENDITURES	6,181,993,491	4,519,733,000	4,648,898,207	(129,165,207)	6,181,993,491	-

	
2,406,500		
1,741,450		
665,050		
3,482,900		
-	
Traditional Medicaid Services Acute Care		49,879,700		37,409,400		37,409,400		-		49,879,700		-	
ALTCS Services		249,234,600		183,608,500		167,073,487		16,535,013		249,234,600		-	
	223,424,400		206,224,337		17,200,063		302,597,200		-	
TOBACCO FUNDS										
Traditional Medicaid Services Acute Care - Medically Needy		31,180,000		23,415,000		23,385,000		30,000		31,180,000		-	
Proposition 204 Services - Emergency Health Services		17,331,400		13,044,800		12,998,550		46,250		17,331,400		-	
Proposition 204 Services - Proposition 204 Protection		36,396,000		27,332,200		27,297,000		35,200		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	-

	63,680,550		111,450		184,907,400		-	
	OTHER											

Prescription Drug Rebate Program	448,000	145,600		
171,727		
(26,127)		
448,000		
-	
									
Acute Care - Prescription Drug Rebate Program State Match		77,855,000	58,578,900		69,578,750		(10,999,850)		77,855,000		-	
Acute Care - Prescription Drug Rebate Program Federal Authority		207,883,900	155,913,300		187,095,510		(31,182,210)		207,883,900		-	
Long Term Care - Prescription Drug Rebate Program State Match		5,475,800	4,037,800		4,106,850		(69,050)		5,475,800		-	
Long Term Care - Prescription Drug Rebate Program Federal Authority		14,574,200	10,746,900		13,116,780		(2,369,880)		14,574,200		-	
Proposition 204 Services - Hospital Assessment		215,558,800	161,669,100		184,538,777		(22,869,677)		215,558,800		-	
Traditional Medicaid Services - TPL		194,700	-		350,454		(350,454)		194,700		-	
ALTCS Services - TPL		-	-		521,095		(521,095)		-		-	

TOTAL TOBACCO EXPENDITURES	184,907,400	63,792,000

Administrative Expenditures

Programmatic Expenditures

ALTCS Services - Nursing Facility Assessment	23,366,900	17,525,000	17,458,266	66,734	23,366,900	-
KidsCare Services Premiums	370,000	271,100	-	271,100	370,000	-
Freedom to Work Premiums	31,200	43,200	38,884	4,316	31,200	-
Voluntary Political Subdivision Programs - See Note 5		113,482,195		83,032,300		83,032,292		8		113,482,195		-	
TOTAL OTHER EXPENDITURES		659,240,695		491,963,200		560,009,385		(68,046,185)		659,240,695		-	
TOTAL

Administrative Expenditures	180,023,900	123,041,800	118,914,803	4,126,997	180,023,900	-
Acute Care	6,967,288,286	5,099,362,200	5,320,751,674	(221,389,474)	6,967,288,286	-
Long Term Care	1,386,588,900	1,023,117,600	968,401,228	54,716,372	1,386,588,900	-

TOTAL EXPENDITURES

$	8,533,901,086

$	6,245,521,600

$	6,408,067,705

$	(162,546,105)

$	8,533,901,086	$	-

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 March 31, 2016

GENERAL FUND:

FEDERAL:

COUNTY:

TOBACCO FUNDS:

OTHER:

TOTAL REVENUE

$

8,533,901,086

$

6,245,521,600

$

6,667,360,904

Traditional Medicaid Services & Administrative	$	931,662,800		$	676,481,200		$	742,449,362	
Proposition 204 Services & Administrative	110,280,700		149,796,900		64,674,358	
KidsCare Services	338,000		338,000		(29,094)	
ALTCS Services	 	162,880,800 			 	119,992,900 			 	122,160,600 		
TOTAL	1,205,162,300		946,609,000		929,255,226	

Acute & Administrative	5,245,349,691		3,828,399,800		4,147,081,236	
KidsCare Services	5,587,200		4,126,700		2,350,431	
ALTCS Services	 	931,056,600 			 	687,206,500 			 	684,758,752 		
TOTAL	6,181,993,491		4,519,733,000		4,834,190,419	

Acute & Administrative	53,362,600		39,815,900		38,639,871	
ALTCS Services	 	249,234,600 			 	183,608,500 			 	186,925,959 		
TOTAL	302,597,200		223,424,400		225,565,830	

Traditional Medicaid Services	31,180,000		23,415,000		23,385,000	
Proposition 204 Services	 	153,727,400 			 	40,377,000 			 	40,295,550 		
TOTAL	184,907,400		63,792,000		63,680,550	

Administrative	448,000		145,600		171,727	
Acute Care - Prescription Drug Rebate Program	285,738,900		214,492,200		256,674,260	
Long Term Care - Prescription Drug Rebate Program	20,050,000		14,784,700		17,223,630	
Hospital Assessment	215,558,800		161,669,100		187,608,757	
ALTCS - Nursing Facility Assessment	23,366,900		17,525,000		173,499	
Acute TPL - Note 1	194,700		-		350,454	
LTC TPL - Note 1	-		-		521,095	
KidsCare TPL - Note 1	-		-		20,940	
Member Premiums - CHIP	370,000		271,100		245,087	
Member Premiums - Freedom to Work	31,200		43,200		38,884	
Voluntary Political Subdivision - State Match	 	113,482,195 			 	83,032,300 			 	151,640,544 		
TOTAL	659,240,695		491,963,200		614,668,879	

 	

Appropriation Status Report
Footnotes

FY 16 Total

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

Note 1:	Third Party Liability Collections: Gross Collections:	March 2016		March 2015		July 1, 2015
March 31, 2016		July 1, 2014
March 31, 2015	
	Acute	$	833,571		$	480,631		$	3,839,389		$	3,978,184	
	LTC	140,203		388,604		2,215,637		2,623,014	
	KidsCare	-		3,184		104,447		17,021	
	Total TPL Collections	$	973,774		$	872,419		$	6,159,473		$	6,618,219	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	63,231		$	71,948		$	350,454		$	544,743	
LTC	32,324		93,167		521,095		612,134	
KidsCare	-		474		20,940		3,069	
Total Expenditure Offsets	$	95,555		$	165,589		$	892,489		$	1,159,946	

Note 2:	Authorized Positions	1,029.2	
	Actual Positions as of March 31, 2016	973.0	

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2015	

$	2,853,728	
	Revenues	4,337,494	
	Transfers-In	 	418,840 		
	Total Revenues	 	4,756,334 		
	Expenditures	4,693,402	
	Transfers-out	 	1,840,132 		
	Total Expenditures	 	6,533,534 		
	Ending Balance March 31, 2016	  $	1,076,528 		

Of the $1,076,528 ending balance, $896,672 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through April 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of March 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 March 31, 2016

Note 5:	Summary of Voluntary Political Subdivision Contribution Expenditures.			

As of March 31, 2016 Expenditures		
		State Match		Federal		Total	
	
DSH Voluntary	
$	10,711,315		
$	21,975,030		
$	32,686,345	
	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	$	83,032,292		$	162,016,104		$	245,048,395	

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 March 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 March 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	272,095,883	272,355,528	0	0	0	2,515,212,236	
CAPITATION - LTC	182,421,827	195,322,105	184,831,914	185,793,257	198,420,332	189,544,234	185,883,929	199,185,388	186,873,769	0	0	0	1,708,276,754	
MENTAL HEALTH - CHILD	24,739,142	24,849,877	25,557,281	28,336,540	28,517,836	31,518,669	28,859,923	28,380,653	28,823,640	0	0	0	249,583,560	
MENTAL HEALTH - ADULT	11,323,471	11,730,505	12,433,438	944,236	956,134	1,949,346	771,078	766,629	757,951	0	0	0	41,632,789	
MENTAL HEALTH - GENERAL	15,232,013	15,779,544	16,725,109	16,942,470	17,155,946	15,591,227	13,835,480	13,755,647	13,599,949	0	0	0	138,617,385	
MENTAL HEALTH - CMDP	14,633,559	14,896,415	14,987,440	15,967,464	16,435,700	18,339,912	17,026,041	16,807,060	16,873,663	0	0	0	145,967,255	
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	5,450,009	5,442,457	0	0	0	43,429,176	
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	37,727,621	43,368,229	0	0	0	366,957,634	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	607,419	638,824	734,158	723,075	606,255	821,459	0	0	0	6,150,821	
EMERGENCY SERVICES - FEDERAL	4,601,455	4,572,491	5,962,347	5,124,819	4,140,929	5,688,268	4,450,762	4,173,846	8,111,942	0	0	0	46,826,860	
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	606,337	811,813	0	0	0	4,811,448	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	374,616	274,232	543,181	277,299	336,648	529,055	0	0	0	3,333,615	
INPATIENT INMATES FFS	94,140	163,355	30,952	166,197	96,395	235,228	148,485	181,967	153,706	0	0	0	1,270,424	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	33,509	11,088	28,421	29,734	32,892	42,452	0	0	0	285,835	
MOHAVE COUNTY INMATES FFS	0	177	0	4,575	0	9,164	0	0	170	0	0	0	14,087	
COCHISE COUNTY INMATES FFS	0	0	0	0	586	0	57	4,196	0	0	0	0	4,839	
PINAL COUNTY INMATES FFS	0	791	4,402	328	5,014	5,310	6,835	218	7,317	0	0	0	30,215	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	0	8,608	0	21	0	0	0	0	8,630	
PIMA COUNTY INMATES FFS	339	2,845	4,099	8,752	867	3,962	-72	1,288	1,337	0	0	0	23,416	
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	9,448,572	10,992,893	0	0	0	89,043,472	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	21,120	18,430	22,655	12,515	59,722	35,967	0	0	0	252,084	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,303,186	520,396	1,333,715	799,779	799,536	1,430,086	941,904	1,244,422	1,542,255	0	0	0	9,915,279	
REINSURANCE - ACUTE	7,490,557	6,963,077	9,713,101	10,354,036	7,487,802	9,748,571	2,985,446	11,137,891	9,623,325	0	0	0	75,503,806	
REINSURANCE - LTC	4,045,763	3,839,634	5,041,535	4,350,748	5,856,334	3,769,395	3,174,328	2,438,655	2,645,182	0	0	0	35,161,574	
SMIB - ACUTE	9,829,585	10,084,385	10,344,498	10,630,380	10,758,366	10,820,128	12,607,558	12,692,750	12,667,321	0	0	0	100,434,971	
HIB - ACUTE	261,769	274,050	304,238	305,977	291,872	302,007	303,696	331,309	367,799	0	0	0	2,742,717	
Q1	2,399,485	1,983,017	1,927,946	1,981,086	1,974,022	1,905,403	2,072,651	2,017,375	1,458,507	0	0	0	17,719,491	
SMIB - LTC	2,846,826	2,859,916	2,858,311	2,859,099	2,866,769	2,884,480	3,334,042	3,299,110	3,341,122	0	0	0	27,149,674	
HIB - LTC	269,425	275,672	269,873	259,133	272,905	271,807	270,456	282,746	283,468	0	0	0	2,455,485	
	607,107,950	627,019,248	641,497,165	611,279,516	626,123,714	677,684,870	597,505,643	623,065,109	621,532,273	0	0	0	5,632,815,489	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending March 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	205,514,246	206,407,386	0	0	0	1,763,527,663	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	62,503	47,177	60,406	28,621	21,828	18,432	0	0	0	471,853	
MENTAL HEALTH - ADULT	14,130,226	13,753,412	13,745,030	1,449,862	1,458,767	2,988,321	1,363,117	1,361,161	1,369,399	0	0	0	51,619,293	
MENTAL HEALTH - GENERAL	19,007,580	18,500,700	18,489,426	26,014,924	26,174,705	26,546,243	24,458,452	24,423,355	24,571,172	0	0	0	208,186,557	
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	18,608	20,516	0	0	0	147,694	
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	26,589,875	29,445,227	0	0	0	239,047,550	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	991,315	851,991	752,086	812,910	983,171	801,675	0	0	0	8,717,143	
EMERGENCY SERVICES - FEDERAL	1,615,009	1,756,056	2,298,814	2,324,017	1,395,634	1,620,895	1,262,081	1,473,419	2,518,890	0	0	0	16,264,816	
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	3,492	2,300	0	0	0	29,885	
INPATIENT INMATES FFS	600,012	766,289	566,467	395,868	507,796	802,928	570,913	698,310	1,142,205	0	0	0	6,050,787	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	174,594	33,475	165,593	246,302	120,342	199,833	0	0	0	1,257,285	
YAVAPAI COUNTY INMATES FFS	306	0	166	9,252	485	161	990	243	0	0	0	0	11,603	
PINAL COUNTY INMATES FFS	8,167	-1,654	11,736	3,532	14,776	12,078	8,551	16,196	5,012	0	0	0	78,393	
MOHAVE COUNTY INMATES FFS	0	4,084	692	373	10,051	15,369	123	191	0	0	0	0	30,882	
COCONINO COUNTY INMATES FFS	152	3,842	0	274	1,126	0	0	2,970	0	0	0	0	8,364	
COCHISE COUNTY INMATES FFS	0	0	0	0	480	210	2,974	0	0	0	0	0	3,663	
PIMA COUNTY INMATES FFS	16,737	14,619	968	21,330	11,636	5,547	222	9,490	3,405	0	0	0	83,954	
REINSURANCE - ACUTE	3,024,281	3,235,285	3,273,260	5,216,265	4,459,353	3,409,309	1,371,470	3,818,302	2,437,508	0	0	0	30,245,033	
SMIB - ACUTE	5,190,825	5,190,446	5,117,460	5,152,132	4,954,096	4,968,092	5,781,412	5,787,241	5,803,082	0	0	0	47,944,784	
HIB - ACUTE	8,649	8,527	5,656	8,584	4,192	4,192	4,233	4,233	6,473	0	0	0	54,741	
	240,353,793	239,927,923	245,334,015	265,589,419	265,094,455	306,553,506	265,331,036	270,846,673	274,752,515	0	0	0	2,373,783,335	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending March 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	33,123,165	32,894,898	0	0	0	260,776,594	
MENTAL HEALTH - CHILD	0	0	0	41	0	0	41	124	124	0	0	0	331	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	228,016	237,878	360,470	247,498	259,095	259,847	0	0	0	8,510,479	
MENTAL HEALTH - GENERAL	2,968,226	3,090,821	3,246,414	4,091,302	4,268,263	4,542,373	4,440,857	4,648,946	4,662,441	0	0	0	35,959,643	
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	1,841,089	2,310,528	0	0	0	18,273,566	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	262,679	334,688	251,090	169,817	161,614	277,124	0	0	0	2,149,380	
EMERGENCY SERVICES - FEDERAL	1,701,575	1,999,988	3,176,831	2,397,434	1,935,178	2,586,750	2,498,424	2,253,745	3,885,436	0	0	0	22,435,360	
FEDERAL ESP CHRONIC SERVICES	0	0	0	0	0	0	0	0	341	0	0	0	341	
FFS MEDICAID IN PUBLIC SCHOOLS	0	0	0	0	0	0	0	64	205	0	0	0	269	
INPATIENT INMATES FFS	6,351	35,816	34,047	9,398	35,244	52,674	13,907	2,877	44,673	0	0	0	234,989	
MARICOPA CTY INMATES FFS	15,154	0	0	149	0	0	0	1,344	0	0	0	0	16,646	
REINSURANCE - ACUTE	276,372	479,010	344,794	397,029	359,861	225,309	150,630	615,514	442,999	0	0	0	3,291,518	
SMIB - ACUTE	1,469	734	839	629	839	944	1,847	1,949	1,583	0	0	0	10,834	
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	42,909,526	44,780,200	0	0	0	351,661,201	
	879,246,680	900,414,248	922,981,760	915,542,763	930,249,842	1,028,095,055	903,843,380	936,821,309	941,064,989	0	0	0	8,358,260,025	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	183,782	170,409	173,186	164,735	157,227	237,286	145,036	134,596	138,961	0	0	0	1,505,218	
KidsCare - FEE FOR SERVICE	-819	774	436	1,805	404	335	15	140	230	0	0	0	3,320	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	36,831	35,192	42,452	32,067	30,376	29,528	0	0	0	313,748	
KidsCare - REINSURANCE	162	30,495	70,989	57,122	103,826	25,397	86	25,622	104,594	0	0	0	418,293	

220,533	237,043	279,141	260,493	296,650	305,470	177,205	190,734	273,311	0	0	0	2,240,580	

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	937,012,042	941,338,300	0	0	0	8,360,500,318	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487.67	0.00	0.00	0.00		487.67		
1003	TANF 06-13 M & F WIT	113.17	113.17	113.17	114.37	114.37	156.60	114.91	114.91	114.91	0.00	0.00	0.00		1,069.58		
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	23,811.49	30,012.38	0.00	0.00	0.00		486,909.77		
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	89,493.44	79,924.83	0.00	0.00	0.00		1,517,388.75		
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	161,844.72	155,323.73	0.00	0.00	0.00		2,580,478.08		
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	41,202.65	43,510.83	0.00	0.00	0.00		724,959.65		
100F	TANF 21-44 MALE WITH	3,124.94	3,371.26	1,066.32	1,235.50	433.09	661.05	235.42	100.66	328.78	0.00	0.00	0.00		10,557.02		
100G	TANF 21-44 FEMALE WI	6,088.86	5,158.50	4,029.73	604.18	1,064.56	319.24	830.22	62.06	2,184.26	0.00	0.00	0.00		20,341.61		
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	5,607.20	832.65	0.00	0.00	0.00		118,046.93		
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	1,090.86	0.00	0.00	0.00		54,642.37		
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	6,704,299.71	6,553,485.55	0.00	0.00	0.00		63,548,345.16		
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	2,101,396.67	1,919,713.70	0.00	0.00	0.00		31,095,024.41		
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	3,262,379.37	2,991,241.44	0.00	0.00	0.00		50,903,690.27		
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	1,423,173.32	1,346,796.28	0.00	0.00	0.00		18,605,645.35		
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	2,819,018.06	2,693,953.54	0.00	0.00	0.00		35,551,159.40		
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	4,295,113.41	4,248,867.60	0.00	0.00	0.00		44,142,609.36		
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	21,443,536.77	20,946,382.78	0.00	0.00	0.00		218,096,081.56		
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	8,604,601.21	8,644,283.41	0.00	0.00	0.00		90,015,349.43		
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	34,137.90	33,205.56	0.00	0.00	0.00		386,136.72		
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	786,166.24	1,022,789.79	0.00	0.00	0.00		11,111,629.20		
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	17,334.97	9,571.54	0.00	0.00	0.00		126,082.55		
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	5,102.34	10,341.26	0.00	0.00	0.00		102,271.99		
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	7,920.64	11,000.58	0.00	0.00	0.00		139,130.65		
101E	TANF 14-20 FEMALE N	56,482.84	48,295.58	35,281.43	34,103.87	17,747.19	21,343.15	22,638.34	19,568.78	27,129.01	0.00	0.00	0.00		282,590.19		
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	102,597.85	125,092.10	0.00	0.00	0.00		1,852,401.40		
101G	TANF 21-44 FEMALE N	967,547.84	939,350.71	551,924.22	458,482.24	314,016.32	266,567.51	305,275.97	300,490.82	335,065.89	0.00	0.00	0.00		4,438,721.52		
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	183,845.78	133,589.05	0.00	0.00	0.00		2,739,700.75		
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	1,420.23	0.00	0.00	0.00	0.00		44,282.37		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	503.59	0.00	0.00	0.00	0.00	487.78	0.00	0.00	0.00		991.37		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	228.55	0.00	0.00	0.00	0.00		228.55		
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	15,640.80	16,893.24	0.00	0.00	0.00		251,602.66		
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	42,935.81	34,441.50	0.00	0.00	0.00		712,701.15		
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	54,128.75	48,866.04	0.00	0.00	0.00		926,617.31		
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	20,112.95	19,711.04	0.00	0.00	0.00		359,685.08		
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		

O

O

ACUTE CAPITATION - AMOUNTS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102G	TANF 21-44 FEMALE WI	894.71	245.67	322.44	0.00	0.00	395.42	119.25	173.25	0.00	0.00	0.00	0.00		2,150.74		
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		
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	813,327.93	798,093.80	0.00	0.00	0.00		6,742,840.38		
210Z	SSI AGED WITH MEDIC	42,792.60	35,137.07	23,993.14	22,253.33	24,247.34	19,520.95	19,495.37	19,890.65	18,143.62	0.00	0.00	0.00		225,474.07		
2110	SSI AGED NON-MEDICA R	4,841,984.49	4,755,477.85	4,841,046.00	5,319,754.55	5,244,733.49	6,162,557.25	5,104,276.41	5,130,074.42	5,108,582.02	0.00	0.00	0.00		46,508,486.48		
211Z	SSI AGED NON-MEDICA	168,114.98	120,300.70	81,292.69	107,483.51	100,740.24	114,287.30	119,704.75	175,066.51	111,843.10	0.00	0.00	0.00		1,098,833.78		
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	4,398,672.58	4,569,732.50	0.00	0.00	0.00		35,422,505.31		
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	3,360.61	3,840.72	0.00	0.00	0.00		48,964.03		
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	1,747,698.04	1,749,844.45	0.00	0.00	0.00		14,734,926.70		
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	14,991.40	12,804.89	0.00	0.00	0.00		154,862.87		
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	59,301,825.99	59,336,977.25	0.00	0.00	0.00		530,485,654.25		
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	417,817.56	416,781.56	0.00	0.00	0.00		3,969,137.58		
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	14,362,561.61	14,750,430.51	0.00	0.00	0.00		118,083,583.68		
222Z	SSI DISABLED WITH Q	5,921.17	7,380.90	10,401.43	3,840.12	2,524.99	1,306.61	2,738.93	4,557.97	2,678.40	0.00	0.00	0.00		41,350.52		
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	7,139.89	6,935.36	0.00	0.00	0.00		53,825.86		
230Z	SSI BLIND WITH MEDIC	448.85	0.00	0.00	0.00	0.00	1,400.03	0.00	56.44	85.57	0.00	0.00	0.00		1,990.89		
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	418,997.08	421,466.68	0.00	0.00	0.00		3,608,760.62		
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	5,902.93	3,187.32	0.00	0.00	0.00		61,871.61		
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	49,546.44	49,775.92	0.00	0.00	0.00		440,867.26		
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		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	238.60	0.00	0.00	0.00		238.60		
4302	SOBRA CHILD 01-05 M	541.57	1,125.47	-453.71	224.19	224.19	260.25	224.91	224.91	224.91	0.00	0.00	0.00		2,596.69		
4303	SOBRA CHILD 06-13 M	227.07	227.07	276.11	244.30	1,116.27	1,036.83	1,061.37	946.46	1,020.69	0.00	0.00	0.00		6,156.17		
4304	SOBRA CHILD 14-20 MA	162.24	162.24	162.24	0.00	-162.83	198.38	0.00	0.00	282.94	0.00	0.00	0.00		805.21		
4305	SOBRA CHILD 14-20 FE	789.59	840.59	831.97	868.03	704.35	1,568.24	1,896.27	2,134.53	1,509.17	0.00	0.00	0.00		11,142.74		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,935.90	0.00	0.00	0.00		2,935.90		
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	19.37	0.00	0.00	0.00		239.84		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419.05	0.00	0.00	0.00		419.05		
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	18,103,709.20	18,570,135.61	0.00	0.00	0.00		169,938,265.05		
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	23,829,863.40	23,910,286.69	0.00	0.00	0.00		201,161,597.74		
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	29,242,293.95	29,596,802.27	0.00	0.00	0.00		255,910,853.35		
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	9,323,412.03	9,371,481.54	0.00	0.00	0.00		82,682,871.67		
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	14,285,459.16	14,286,732.09	0.00	0.00	0.00		126,093,977.10		

A

R

M

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

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	722,163.04	627,444.79	0.00	0.00	0.00	8,176,521.74	
494,252.81	475,898.40	360,178.32	407,643.39	262,251.61	248,010.60	271,540.03	285,522.70	281,974.96	0.00	0.00	0.00	3,087,272.82	
634,059.19	670,453.45	453,423.37	439,439.88	292,079.09	274,008.02	282,295.62	287,299.33	301,871.12	0.00	0.00	0.00	3,634,929.07	
467,748.21	431,434.92	303,172.79	265,677.52	189,364.34	182,262.95	177,918.24	199,621.43	151,192.39	0.00	0.00	0.00	2,368,392.79	
506,841.24	521,342.83	357,514.83	325,476.02	233,036.41	227,826.88	230,531.24	256,907.98	214,615.87	0.00	0.00	0.00	2,874,093.30	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	447.85	418.95	0.00	0.00	0.00	866.80	
329.97	0.00	220.65	332.81	115.27	299.36	0.00	0.00	229.81	0.00	0.00	0.00	1,527.87	
755.82	0.00	107.48	558.29	399.46	1,577.25	411.36	1,037.18	103.17	0.00	0.00	0.00	4,950.01	
623.74	0.00	162.24	137.86	272.28	450.17	0.00	0.00	154.87	0.00	0.00	0.00	1,801.16	
490.95	259.91	523.40	0.00	0.00	1,031.53	0.00	0.00	466.96	0.00	0.00	0.00	2,772.75	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.20	0.00	0.00	0.00	0.00	70.20	
28,646.09	29,529.54	34,810.47	37,003.71	22,770.15	24,460.37	22,927.68	27,517.14	29,767.39	0.00	0.00	0.00	257,432.54	
856.00	405.55	405.55	898.29	898.29	1,365.91	898.29	898.29	898.29	0.00	0.00	0.00	7,524.46	
667.73	637.69	427.13	403.02	162.14	432.77	318.82	590.42	125.53	0.00	0.00	0.00	3,765.25	
791.84	960.27	778.66	664.29	689.41	1,113.84	900.22	1,705.68	1,850.21	0.00	0.00	0.00	9,454.42	
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	1,104,515.96	1,146,978.48	0.00	0.00	0.00	11,111,768.06	
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	5,535,954.65	5,761,262.03	0.00	0.00	0.00	53,512,081.30	
29,226.73	32,189.69	33,578.00	41,189.47	41,350.99	43,398.65	34,884.14	30,714.35	33,529.21	0.00	0.00	0.00	320,061.23	
0.00	98.71	0.00	0.00	43.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142.38	
77,023.42	77,726.43	48,097.14	49,640.39	42,451.40	43,034.61	52,196.23	47,256.44	46,004.34	0.00	0.00	0.00	483,430.40	
331,612.75	308,457.61	239,213.41	224,480.35	178,215.34	181,213.77	209,298.69	195,747.73	201,549.59	0.00	0.00	0.00	2,069,789.24	
3,630.96	10,740.73	531.17	334.55	0.00	588.34	0.00	1,231.29	4,856.48	0.00	0.00	0.00	21,913.52	
2,329.77	2,829.66	4,481.72	4,273.54	4,730.15	7,022.63	4,272.15	5,525.45	11,776.44	0.00	0.00	0.00	47,241.51	
0.00	2,426.39	2,426.39	2,242.66	2,242.66	2,242.66	2,361.11	2,242.66	0.00	0.00	0.00	0.00	16,184.53	
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	
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	
-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	

RATE CODE	DESCRIPTION 431A	SOBRA CHILD < 1 M &
431B	SOBRA CHILD 01-05 M

431C	SOBRA CHILD 6-13 M&
F
431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

4321	SOBRA CHILD <1 M & F

4322	SOBRA CHILD 01-05 M

4323	SOBRA CHILD 06-13 M

4324	SOBRA CHILD 14-20 MA

4325	SOBRA CHILD 14-20 FE

432A	SOBRA CHILD < 1 M &

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

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   242,934,062.77  243,407,082.96	0.00	0.00	0.00	2,266,475,225.38

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	2,057,153.87	2,101,519.46	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	41,626.41	55,846.52	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	253,912.66	175,567.47	201,893.70	182,160.74	179,014.54	246,059.59	185,727.70	156,155.58	182,645.21	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     12,615,623.07	12,323,843.70	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	14,870,558.93	14,663,854.89	0.00	0.00	0.00	

23,358,340.30	
536,199.63	
1,763,137.19	
117,549,915.77	
143,207,592.89	

SUBTOTAL:

782.28

174.72

3100	TRANSPLANT OPTION 1	70.26	89.42	82.50	82.50	94.60	99.00	99.00	99.00	66.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION	94.74	75.58	0.00	0.00	4.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1

ACUTE CAPITATION - AMOUNTS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	165.00	165.00	82.50	82.50	99.00	99.00	99.00	99.00	66.00	0.00	0.00	0.00		957.00		

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	308,791.80	307,036.35	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	907,719.68	908,596.01	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	1,641,033.66	1,668,794.15	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	482,211.24	489,065.07	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	3,682.62	630.49	1,486.57	3,392.63	3,061.27	1,445.35	1,532.16	2,681.33	1,799.43	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	520.84	324.33	2,552.22	7,103.54	4,282.02	3,757.64	4,112.14	3,033.02	3,825.80	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	161.40	385.93	27,647.67	33,347.53	20,685.44	12,573.42	14,788.08	19,770.84	16,572.32	0.00	0.00	0.00	
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	4,550.01	4,586.50	0.00	0.00	0.00	
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	471.96	0.00	0.00	0.00	0.00	
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	9,990.22	7,748.03	0.00	0.00	0.00	
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	34,834.76	29,636.75	0.00	0.00	0.00	
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	99,928.56	97,182.96	0.00	0.00	0.00	
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	483,329.78	485,759.30	0.00	0.00	0.00	
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	5,065,789.75	5,109,844.17	0.00	0.00	0.00	
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	17,987,316.07	18,277,785.98	0.00	0.00	0.00	
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	11,619,640.14	11,663,707.38	0.00	0.00	0.00	
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	49,972.15	48,378.86	0.00	0.00	0.00	
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	
111B	TANF EXPANDED 01-05	0.00	51.33	0.00	0.00	0.00	14.09	0.00	182.22	635.80	0.00	0.00	0.00	
111C	TANF EXPANDED 06-13	60.93	0.00	0.00	166.42	306.00	60.93	12.33	0.00	11.25	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	91.04	817.44	2,346.34	1,783.04	4,380.55	2,916.80	2,166.48	3,767.22	2,019.51	0.00	0.00	0.00	
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	9,471.42	7,485.20	0.00	0.00	0.00	
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	127,509.01	119,985.50	0.00	0.00	0.00	
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	253,578.80	256,991.42	0.00	0.00	0.00	
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	217,655.72	176,268.15	0.00	0.00	0.00	
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	3,016.57	2,364.07	0.00	0.00	0.00	
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	
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	145,291.67	152,337.34	0.00	0.00	0.00	
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	448,380.89	455,301.06	0.00	0.00	0.00	
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	517,029.17	532,025.45	0.00	0.00	0.00	
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	158,094.56	170,273.52	0.00	0.00	0.00	
112F	TANF EXPANDED 21-44	0.00	0.00	406.00	246.72	273.24	148.50	1,391.61	1,660.72	562.18	0.00	0.00	0.00	
112G	TANF EXPANDED 21-44	0.00	681.07	726.03	964.10	648.57	537.96	1,154.70	860.84	127.81	0.00	0.00	0.00	
112H	TANF EXPANDED 45-64	10.59	0.00	1,235.44	3,753.28	2,524.51	3,607.70	638.24	4,455.98	3,780.82	0.00	0.00	0.00	

 
2,350,263.06	
7,357,865.56	
13,121,103.52	
3,750,704.74	
19,711.85	
29,511.55	
145,932.63	
48,995.21	
21,971.91	
241,061.13	
803,224.27	
982,229.60	
3,906,917.89	
40,011,043.48	
140,311,475.32	
90,313,712.65	
406,794.62	
-402.42	
883.44	
617.86	
20,288.42	
60,152.86	
904,756.06	
1,891,336.13	
1,527,276.01	
48,601.33	
259.91	
976,298.85	
2,908,542.16	
3,410,610.98	
1,060,761.72	
4,688.97	
5,701.08	
20,006.56	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	6,378.93	344.31	4,119.33	5,140.99	1,028.83	761.06	1,228.30	0.00	0.00	0.00	19,001.75	
90,318.38	78,003.38	74,504.07	71,589.26	68,291.67	87,163.90	64,453.13	72,449.66	62,753.37	0.00	0.00	0.00	669,526.82	
28,495.79	37,821.60	22,409.28	21,024.30	14,619.96	20,639.55	11,037.06	13,574.15	10,937.45	0.00	0.00	0.00	180,559.14	
929,746.50	864,149.68	813,310.62	351,969.12	320,177.38	502,076.63	219,435.89	208,221.70	172,110.53	0.00	0.00	0.00	4,381,198.05	
7,401.77	16,962.83	8,306.20	4,276.52	3,695.68	4,224.09	1,447.14	3,241.36	3,618.13	0.00	0.00	0.00	53,173.72	
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	4,491,431.68	4,451,541.83	0.00	0.00	0.00	44,107,590.73	
7,997.68	5,766.54	4,987.33	5,330.17	2,179.50	3,525.88	2,827.84	5,983.58	2,042.61	0.00	0.00	0.00	40,641.13	
0.00	0.00	0.00	140.23	140.23	140.23	140.23	140.23	140.23	0.00	0.00	0.00	841.38	
1,458.65	1,458.65	1,458.65	755.69	755.69	869.56	0.00	0.00	0.00	0.00	0.00	0.00	6,756.89	
124.99	124.99	124.99	130.02	130.02	214.81	130.02	130.02	130.02	0.00	0.00	0.00	1,239.88	
159,975.75	157,902.91	154,039.57	218,895.60	207,386.21	239,347.71	231,849.47	258,398.76	247,224.99	0.00	0.00	0.00	1,875,020.97	
17,956.66	21,077.50	16,146.29	10,542.62	5,850.05	8,936.66	10,113.57	9,065.35	9,852.23	0.00	0.00	0.00	109,540.93	
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	2,565,586.20	2,418,699.91	0.00	0.00	0.00	24,232,211.98	
33,355.68	32,438.70	29,106.19	22,550.86	20,810.52	30,567.23	19,261.47	25,900.90	18,839.67	0.00	0.00	0.00	232,831.22	
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	11,029,521.05	10,623,129.96	0.00	0.00	0.00	88,513,284.12	
6,428.48	5,511.39	8,031.41	4,310.82	1,836.82	3,073.81	1,560.51	3,301.91	2,202.01	0.00	0.00	0.00	36,257.16	
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	59,299,727.37	59,024,939.38	0.00	0.00	0.00	481,122,574.78	

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

RATE CODE	DESCRIPTION

112J

2400

240Z

2410

241Z

2420

242Z

2500

2510

2520

2600

260Z

2610

261Z

2620

262Z

TANF EXPANDED 65+
M&
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI BLIND EXPANDED
W
SSI BLIND EXPANDED
N
SSI BLIND EXPANDED
W
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

E
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	1,337,791.04	1,321,393.12	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	6,316.29	12,655.86	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI	5,743.01	5,963.77	0.00	6,235.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	656,262.88	768,544.97	716,894.72	1,091,599.62	880,352.01	1,563,937.84	1,469,881.99	1,344,107.33	1,334,048.98	0.00	0.00	0.00	

9,689,382.35	
118,305.88	
17,942.11	
9,825,630.34	

E
SUBTOTAL:

1,586.09

125.06

1,711.15

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

2

3504	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	475.74	0.00	0.00	0.00	
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	4,845.63	7,696.82	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	3,828.23	7,678.11	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	60,152.88	68,779.32	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	12,552.09	20,573.80	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	459.43	612.90	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	1,724.48	1,480.14	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	28,335.02	25,608.84	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	20,532.02	6,353.47	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	1,927,483.56	1,996,084.38	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	1,633,845.08	1,727,407.10	1,811,455.28	1,845,511.21	1,949,540.67	2,348,680.27	2,176,541.43	2,242,833.24	2,286,783.23	0.00	0.00	0.00	

475.74	
65,220.53	
84,613.57	
453,300.89	
190,550.91	
11,762.02	
6,586.99	
102,152.83	
50,874.11	
15,292,659.63	
18,022,597.51	

E

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	8,889,458.57	8,869,719.32	0.00	0.00	0.00	76,296,990.95	
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	7,299,113.79	7,319,928.48	0.00	0.00	0.00	63,355,349.91	
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	17,754,934.89	17,830,685.98	0.00	0.00	0.00	152,274,821.63	
16,506.64	15,041.42	15,084.02	22,447.95	13,832.15	20,370.03	12,054.26	6,999.64	9,642.10	0.00	0.00	0.00	131,978.21	
148,997.70	115,709.11	88,931.32	77,872.89	78,610.60	74,037.41	91,239.55	91,182.08	119,748.64	0.00	0.00	0.00	886,329.30	
144,852.52	143,422.42	95,008.93	105,596.06	74,569.94	82,977.04	119,502.32	97,959.49	112,122.23	0.00	0.00	0.00	976,010.95	
646,088.27	613,079.90	479,928.59	471,628.16	336,866.99	413,200.04	403,697.51	459,136.16	388,448.01	0.00	0.00	0.00	4,212,073.63	
458,558.32	429,699.96	368,800.73	356,601.53	246,284.78	355,331.06	338,219.87	366,505.47	273,571.49	0.00	0.00	0.00	3,193,573.21	
1,204,084.30	1,016,417.29	728,945.34	784,761.29	597,289.00	758,626.02	802,383.13	743,712.38	661,749.49	0.00	0.00	0.00	7,297,968.24	
27,457.81	15,740.35	20,203.21	13,703.32	28,147.70	3,538.93	12,732.65	2,749.32	6,512.57	0.00	0.00	0.00	130,785.86	
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	
1,168.26	0.00	0.00	0.00	905.24	584.84	914.43	-349.98	658.41	0.00	0.00	0.00	3,881.20	
668.80	1,504.94	0.00	366.57	441.10	2,105.01	2,683.76	889.55	930.65	0.00	0.00	0.00	9,590.38	
10,626.75	7,689.50	12,719.11	12,289.73	10,883.20	14,398.75	12,861.10	8,971.05	17,543.37	0.00	0.00	0.00	107,982.56	
2,416.71	4,002.70	1,585.00	5,981.76	4,387.94	5,346.12	2,711.73	2,585.84	5,433.31	0.00	0.00	0.00	34,451.11	
0.00	0.00	0.00	0.00	0.00	162.24	0.00	0.00	492.11	0.00	0.00	0.00	654.35	
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	
16.98	1,224.13	886.83	72.11	0.00	1,096.69	1,002.81	5,277.83	1,939.31	0.00	0.00	0.00	11,516.69	
0.00	0.00	0.00	3,228.03	616.59	2,867.30	457.81	526.47	130.80	0.00	0.00	0.00	7,827.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	464.14	0.00	0.00	0.00	0.00	464.14	
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	
34,143.30	26,154.77	20,573.49	39,142.26	28,932.51	26,253.84	35,940.46	32,898.39	42,775.50	0.00	0.00	0.00	286,814.52	
12,691.88	18,567.70	11,647.93	10,314.66	6,489.86	16,865.89	19,177.00	12,350.37	16,822.95	0.00	0.00	0.00	124,928.24	
47,370.84	58,639.06	54,729.62	114,253.12	92,664.47	99,216.03	92,080.32	81,739.02	116,609.98	0.00	0.00	0.00	757,302.46	
8,255.13	8,986.58	12,316.96	18,221.48	9,722.62	8,101.26	6,854.86	10,486.52	11,060.69	0.00	0.00	0.00	94,006.10	
3,590.13	5,678.35	4,459.00	2,315.61	2,138.02	952.88	3,315.80	2,167.25	1,853.02	0.00	0.00	0.00	26,470.06	
824.34	1,262.96	35.10	1,823.55	2,665.44	784.80	3,403.18	0.00	4,403.66	0.00	0.00	0.00	15,203.03	
8,737.58	10,393.47	21,133.34	9,344.88	2,526.64	10,753.79	5,476.93	4,588.76	16,370.41	0.00	0.00	0.00	89,325.80	
0.00	0.00	2,297.94	0.00	0.00	1,394.62	0.00	2,402.41	0.00	0.00	0.00	0.00	6,094.97	
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	5,070,284.60	5,374,137.33	0.00	0.00	0.00	45,109,012.28	
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	4,364,329.76	4,664,493.57	0.00	0.00	0.00	38,493,430.98	
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	32,182,837.36	31,975,225.03	0.00	0.00	0.00	280,325,287.87	
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	19,439,969.87	19,399,809.80	0.00	0.00	0.00	169,911,067.37	
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	38,273,412.69	38,424,149.45	0.00	0.00	0.00	338,534,748.18	
36,205.17	36,567.62	42,431.28	59,561.30	45,300.27	53,028.22	31,341.67	24,710.44	31,153.08	0.00	0.00	0.00	360,299.05	
392,849.93	382,830.27	238,138.75	208,431.92	203,147.49	183,401.52	184,039.62	192,955.00	273,765.06	0.00	0.00	0.00	2,259,559.56	

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

RATE CODE	DESCRIPTION 3516	ADULT 40-100% MALE 2
3517	ADULT 40-100% FEMAL
E
3518	ADULT 40-100% M&F 45

3519	ADULT 40-100% M&F 65

351D	ADULT 40-100% MALE 1

351E	ADULT 40-100% FEMAL
E
351F	ADULT 40-100% MALE 2

351G	ADULT 40-100% FEMAL
E
351H	ADULT 40-100% M&F 45

351J	ADULT 40-100% M&F 65

3525	ADULT 40-100% FEMAL
E
3526	ADULT 40-100% MALE 2

3527	ADULT 40-100% FEMAL
E
3528	ADULT 40-100% M&F 45

3529	ADULT 40-100% M&F 65

352F	ADULT 40-100% MALE 2

352G	ADULT 40-100% FEMAL
E
352H	ADULT 40-100% M&F 45

352J	ADULT 40-100% M&F 65

3704	ADULT <40% EXP MALE

3705	ADULT <40% EXP FEM
AL
3706	ADULT <40% EXP MALE

3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
370F	ADULT <40% EXP MALE

370G	ADULT <40% EXP FEM
AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MALE

3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MALE

3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
371D	ADULT <40% EXP MALE

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
356,021.60	295,087.13	201,535.90	214,164.42	137,476.12	155,663.63	164,778.45	186,130.37	216,512.82	0.00	0.00	0.00	1,927,370.44	
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	1,582,007.26	1,989,023.19	0.00	0.00	0.00	17,571,579.78	
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	961,732.41	895,110.75	0.00	0.00	0.00	9,631,305.85	
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	1,676,114.28	1,611,565.69	0.00	0.00	0.00	15,926,802.02	
2,019.24	1,369.87	8,989.45	9,843.47	14,388.28	6,204.26	229.81	0.00	675.81	0.00	0.00	0.00	43,720.19	
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	
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	
3,936.06	7,430.66	5,545.33	9,313.29	11,355.77	10,877.75	14,327.14	14,560.20	10,279.49	0.00	0.00	0.00	87,625.69	
4,778.02	3,573.32	779.92	6,659.16	5,113.29	2,918.66	6,653.19	7,859.42	6,092.60	0.00	0.00	0.00	44,427.58	
17,960.52	5,138.97	16,090.90	8,323.68	7,311.56	7,865.93	14,483.05	7,669.40	17,322.53	0.00	0.00	0.00	102,166.54	
1,616.38	0.00	362.34	1,703.88	1,306.97	1,829.61	961.29	2,271.10	2,668.01	0.00	0.00	0.00	12,719.58	
0.00	711.09	4,151.16	502.35	1,161.06	1,005.13	921.65	1,994.42	3,717.48	0.00	0.00	0.00	14,164.34	
598.25	1,319.88	2,540.22	0.00	720.86	0.00	409.71	135.79	0.00	0.00	0.00	0.00	5,724.71	
470.36	1,351.60	251.86	3,328.61	540.65	828.41	2,193.50	1,613.25	7,035.05	0.00	0.00	0.00	17,613.29	
0.00	0.00	0.00	0.00	0.00	67.48	0.00	686.88	0.00	0.00	0.00	0.00	754.36	

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

RATE CODE	DESCRIPTION

371E

371F

371G

371H

371J

3724

3725

3726

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

ADULT <40% EXP FEM AL
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
ADULT <40% EXP MALE

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

3727

3728

3729

372F

ADULT <40% EXP FEM
AL
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
ADULT <40% EXP MALE

372G

372H

372J

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

6
SUBTOTAL:

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   144,170,770.49   145,154,015.97

0.00

0.00

0.00

1,264,994,535.90

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	181,058.62	213,114.08	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	447,342.88	597,836.74	736,611.04	684,333.12	601,967.17	620,647.36	717,122.21	518,582.16	681,267.82	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	699,640.78	894,381.90	0.00	0.00	0.00	

1,977,500.21	
5,605,710.50	
7,583,210.71	

A
SUBTOTAL:

3904	NEWLY ELIGIBLE MALE	0.00	55.96	346.93	367.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	2,243.33	4,164.05	5,522.85	5,309.15	5,518.15	9,318.50	10,565.88	9,835.08	14,986.01	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	5,369.11	10,896.82	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	61,740.71	111,899.92	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	14,728.51	13,483.55	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	1,101.81	660.08	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA	558.35	584.83	0.00	417.38	411.65	1,086.80	280.67	785.37	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	39,025.57	10,632.91	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	22,686.57	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	828,889.74	851,066.36	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	1,020,969.68	1,057,786.62	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	7,644,072.48	7,628,695.42	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	11,190,273.76	11,243,985.41	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	10,730,897.79	10,726,172.25	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F	13,274.71	12,857.15	12,513.51	18,274.33	14,084.40	15,516.59	9,490.38	7,626.00	8,103.77	0.00	0.00	0.00	

770.14	
67,463.00	
51,367.68	
440,167.71	
97,031.61	
318.47	
8,623.15	
4,125.05	
169,970.18	
73,318.40	
6,373,694.33	
7,740,280.94	
60,234,705.04	
83,262,940.66	
88,189,610.67	
111,740.84	

L

ACUTE CAPITATION - AMOUNTS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	20,251.19	35,604.48	0.00	0.00	0.00		257,950.75		
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	37,226.81	27,856.93	0.00	0.00	0.00		325,277.98		
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	222,778.17	202,897.08	0.00	0.00	0.00		2,732,491.56		
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	311,931.33	236,013.74	0.00	0.00	0.00		3,374,857.03		
391H	NEWLY ELIGIBLE M&F	598,828.85	481,913.67	459,344.28	364,265.20	257,808.17	411,137.03	361,868.37	327,977.49	268,605.32	0.00	0.00	0.00		3,531,748.38		
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	278.34	2,302.51	0.00	0.00	0.00		91,856.93		
3926	NEWLY ELIGIBLE MALE	282.13	198.55	587.36	3,072.08	383.64	94.99	1,900.90	464.00	0.00	0.00	0.00	0.00		6,983.65		
3927	NEWLY ELIGIBLE FEMA L	0.00	3,064.18	3,059.32	744.64	384.04	384.04	1,030.50	384.04	384.04	0.00	0.00	0.00		9,434.80		
3928	NEWLY ELIGIBLE M&F 4	1,925.68	968.19	772.82	1,662.87	3,871.37	2,266.86	5,347.21	3,163.33	6,964.99	0.00	0.00	0.00		26,943.32		
3929	NEWLY ELIGIBLE M&F 6	598.20	308.72	649.48	1,129.09	384.46	438.37	336.83	1,110.87	1,833.69	0.00	0.00	0.00		6,789.71		
392F	NEWLY ELIGIBLE MALE	0.00	81.24	11.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.63		
392G	NEWLY ELIGIBLE FEMA L	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		
392H	NEWLY ELIGIBLE M&F 4	782.69	451.48	178.82	394.81	447.38	452.69	75.19	4,192.00	118.27	0.00	0.00	0.00		7,093.33		
392J	NEWLY ELIGIBLE M&F 6	0.00	11.02	0.00	1,013.76	341.50	0.00	0.00	3,407.40	0.00	0.00	0.00	0.00		4,773.68		
	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	32,511,167.15	32,460,950.17	0.00	0.00	0.00		257,202,485.00		

4

SUBTOTAL:

3,574,108.84

3,574,108.84

9939	BIRTH SUPP PAYMENT	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	447,193.00	474,637.31	611,997.77	433,947.37	0.00	0.00	0.00	
SUBTOTAL:	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	447,193.00	474,637.31	611,997.77	433,947.37	0.00	0.00	0.00	

N

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	823.42	943.08	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	6,281,853.69	6,360,847.53	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	2,221,233.03	2,200,581.66	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,627,175.04	1,485,905.55	1,372,014.41	3,133,836.80	3,215,261.55	3,650,054.64	3,297,801.80	3,368,365.36	3,322,121.30	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.88	26.41	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	64,738.37	57,107.10	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	50,898.34	47,069.01	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	15,755.99	20,553.56	83,770.13	68,104.17	69,588.51	70,370.00	62,662.32	70,878.23	44,032.92	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	12,058,792.32	12,032,729.01	0.00	0.00	0.00	

115.08	
100.87	
475.25	
7,908.60	
43,323,933.94	
16,406,958.80	
24,472,536.45	
28.29	
493,154.93	
402,146.10	
505,715.83	
282.24	
85,613,356.38	

1

SUBTOTAL:

455,596.98

455,596.98

9944	BIRTH SUPP PAYMENT	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	44,864.51	61,038.67	43,525.27	66,299.67	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	43,525.27	66,299.67	0.00	0.00	0.00	

S
SUBTOTAL:

70,155.94

976,299.20

4517	BC PATIENT FEMALE 2	6,031.34	6,350.82	6,499.88	8,177.94	8,370.90	10,265.31	8,321.32	8,321.32	7,817.11	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	112,672.67	110,350.85	110,314.38	108,889.84	103,615.29	121,495.14	105,250.41	104,058.38	99,652.24	0.00	0.00	0.00	

1

ACUTE CAPITATION - AMOUNTS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		273.27		
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		1,179.68		
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	2,413.66	0.00	0.00	0.00	0.00		15,686.26		
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	7,040.15	7,040.15	0.00	0.00	0.00		60,993.38		
4618	CC PATIENT FEMALE 4	7,757.51	7,379.70	6,916.51	7,031.99	7,031.99	7,891.31	6,117.15	6,117.15	6,229.57	0.00	0.00	0.00		62,472.88		
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		1,269.76		
461H	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	513.13	0.00	0.00	0.00		513.13		
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		84.12		
9946	SB KICK PAYMENT FOR	0.00	0.00	0.00	0.00	5,938.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,938.12		
	136,329.63	134,114.31	133,351.19	131,278.75	133,689.47	148,961.98	127,937.55	127,950.66	121,252.20	0.00	0.00	0.00		1,194,865.74		

5

5

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	119.15	119.15	119.15	1,518.09	1,518.09	1,560.36	1,518.09	1,518.09	1,518.09	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,387,627.33	1,409,227.99	1,427,434.60	1,601,635.36	1,588,056.71	1,637,025.33	1,591,790.75	1,567,952.60	1,599,792.12	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	14,851.04	13,861.37	11,262.22	8,619.47	2,040.24	6,583.34	4,961.16	4,382.09	4,341.45	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	257,066.42	281,571.85	279,236.21	280,748.11	281,893.20	315,011.51	287,131.28	286,851.00	280,388.82	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	43,575.80	38,994.92	27,502.94	20,641.47	11,801.66	14,268.11	3,069.41	20,858.59	1,881.08	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	165,188.17	161,572.52	163,088.68	196,297.59	193,686.35	206,157.70	192,992.30	179,145.98	176,003.66	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	1,871.66	508.27	103.48	1,383.63	2,517.01	116.45	59.39	185.54	317.70	0.00	0.00	0.00	
	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	2,060,893.89	2,064,242.92	0.00	0.00	0.00	

9,508.26	
13,810,542.79	
70,902.38	
2,549,898.40	
182,593.98	
1,634,132.95	
7,063.13	
18,264,641.89	

M

M

SUBTOTAL:

4,539,516,492.98

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	510,733,293.73	511,657,811.42	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00		1.00		
1003	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00		9.00		
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	86.17	94.90	0.00	0.00	0.00		1,560.12		
1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	172.66	178.52	167.20	180.73	174.06	161.31	0.00	0.00	0.00		3,027.15		
1008	TANF 45-64 M & F WIT	870.42	1,013.58	1,168.84	270.09	273.04	266.32	287.84	284.32	268.18	0.00	0.00	0.00		4,702.63		
1009	TANF 65+ M & F WITH	306.00	373.68	430.56	102.88	96.13	94.11	87.56	94.00	98.74	0.00	0.00	0.00		1,683.66		
100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	7.53	2.94	4.64	1.60	0.68	2.28	0.00	0.00	0.00		63.96		
100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	3.15	5.45	1.70	3.97	0.27	11.52	0.00	0.00	0.00		99.59		
100H	TANF 44-64 M & F WIT	97.51	98.86	32.85	17.79	2.09	6.52	15.70	13.25	3.20	0.00	0.00	0.00		287.77		
100J	TANF 65+ M & F WITH	73.60	39.19	4.37	7.48	0.00	1.80	1.15	0.00	3.46	0.00	0.00	0.00		131.05		
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	13,656.55	13,345.44	0.00	0.00	0.00		125,584.50		
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	16,696.94	15,209.33	0.00	0.00	0.00		230,708.25		
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	25,504.12	23,266.32	0.00	0.00	0.00		375,628.84		
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	7,632.07	7,156.78	0.00	0.00	0.00		97,494.87		
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	10,412.75	9,939.42	0.00	0.00	0.00		126,214.81		
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	24,572.59	24,326.12	0.00	0.00	0.00		253,386.08		
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	78,007.69	76,290.22	0.00	0.00	0.00		788,843.13		
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	19,070.86	19,142.51	0.00	0.00	0.00		200,004.15		
1019	TANF 65+ M & F NON-M	122.25	133.13	152.05	81.72	80.78	86.25	84.76	80.07	78.00	0.00	0.00	0.00		899.01		
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	767.94	1,007.34	0.00	0.00	0.00		10,364.08		
101B	TANF 01-05 M & F NON	323.00	173.98	234.10	366.13	146.78	232.53	252.01	191.29	165.58	0.00	0.00	0.00		2,085.40		
101C	TANF 06-13 M & F NON	235.43	179.19	176.48	403.54	132.78	157.92	91.82	90.90	184.00	0.00	0.00	0.00		1,652.06		
101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	167.74	56.94	64.69	56.71	53.53	72.46	0.00	0.00	0.00		870.80		
101E	TANF 14-20 FEMALE N	278.91	237.91	174.02	171.86	90.58	108.68	115.54	100.32	138.81	0.00	0.00	0.00		1,416.63		
101F	TANF 21-44 MALE NON-	2,653.94	2,660.54	1,444.98	1,220.10	625.84	709.14	721.44	699.27	848.75	0.00	0.00	0.00		11,584.00		
101G	TANF 21-44 FEMALE N	4,819.02	4,659.58	2,737.74	2,315.36	1,601.46	1,369.81	1,564.77	1,543.92	1,723.94	0.00	0.00	0.00		22,335.60		
101H	TANF 44-64 M & F NON	1,604.09	1,643.02	919.13	633.40	373.54	367.88	446.09	541.55	401.37	0.00	0.00	0.00		6,930.07		
101J	TANF 65+ N & F NON-M	31.66	19.50	26.80	1.88	6.42	11.98	5.21	4.38	0.00	0.00	0.00	0.00		107.83		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00		2.00		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	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	46.48	43.25	0.00	0.00	0.00		814.42		
1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	69.00	73.08	74.70	66.38	66.43	54.28	0.00	0.00	0.00		1,302.86		
1028	TANF 45-64 M & F WIT	257.30	401.73	481.56	80.44	93.69	103.67	92.98	96.98	89.00	0.00	0.00	0.00		1,697.35		
1029	TANF 65+ M & F WITH	125.59	199.79	245.43	39.43	45.00	49.00	48.00	47.09	47.00	0.00	0.00	0.00		846.33		
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		

O

O

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102G	TANF 21-44 FEMALE WI	4.49	1.22	1.63	0.00	0.00	2.03	0.61	0.93	0.00	0.00	0.00	0.00		10.91		
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		
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	4,443.21	4,424.63	0.00	0.00	0.00		37,649.96		
210Z	SSI AGED WITH MEDIC	450.53	377.60	249.36	270.80	307.49	255.39	261.89	279.68	249.44	0.00	0.00	0.00		2,702.18		
2110	SSI AGED NON-MEDICA R	5,996.37	5,885.71	5,990.17	6,174.44	6,096.62	6,033.73	5,916.16	5,946.07	5,919.51	0.00	0.00	0.00		53,958.78		
211Z	SSI AGED NON-MEDICA	323.02	229.89	155.90	195.56	189.76	198.32	204.42	302.80	201.80	0.00	0.00	0.00		2,001.47		
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	22,893.84	23,701.93	0.00	0.00	0.00		185,292.04		
212Z	SSI AGED WITH QMB P P	60.27	61.77	97.36	67.89	76.81	46.22	61.93	49.50	50.08	0.00	0.00	0.00		571.83		
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	3,624.31	3,615.47	0.00	0.00	0.00		32,282.86		
220Z	SSI DISABLED WITH M E	236.76	251.22	272.95	225.46	135.76	185.47	192.40	201.39	176.45	0.00	0.00	0.00		1,877.86		
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	56,841.86	56,796.45	0.00	0.00	0.00		512,063.16		
221Z	SSI DISABLED NON-ME D	983.56	949.62	911.29	771.37	711.59	852.26	792.85	749.12	729.04	0.00	0.00	0.00		7,450.70		
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	25,732.27	26,359.81	0.00	0.00	0.00		227,804.87		
222Z	SSI DISABLED WITH Q	62.38	77.46	109.31	43.36	32.28	18.61	35.83	62.57	35.61	0.00	0.00	0.00		477.41		
2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	25.00	25.00	27.29	28.00	29.44	28.48	0.00	0.00	0.00		241.32		
230Z	SSI BLIND WITH MEDIC	4.45	0.00	0.00	0.00	0.00	14.70	0.00	1.00	1.51	0.00	0.00	0.00		21.66		
2310	SSI BLIND NON-MEDIC A	428.12	430.04	436.15	439.00	442.38	450.43	460.83	465.17	466.67	0.00	0.00	0.00		4,018.79		
231Z	SSI BLIND NON-MEDIC A	8.02	26.80	11.45	13.31	4.79	28.85	12.72	11.68	5.15	0.00	0.00	0.00		122.77		
2320	SSI BLIND WITH QMB	207.48	205.10	207.96	204.24	202.09	202.70	201.56	200.99	201.97	0.00	0.00	0.00		1,834.09		
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		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.51	0.00	0.00	0.00		0.51		
4302	SOBRA CHILD 01-05 M	5.00	3.99	2.01	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00		23.00		
4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	2.12	4.55	3.00	3.00	2.00	2.64	0.00	0.00	0.00		23.74		
4304	SOBRA CHILD 14-20 MA	1.00	1.00	1.00	0.00	-1.00	1.00	0.00	0.00	1.77	0.00	0.00	0.00		4.77		
4305	SOBRA CHILD 14-20 FE	1.00	1.19	1.13	1.25	0.62	2.64	3.00	4.00	1.36	0.00	0.00	0.00		16.19		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.93	0.00	0.00	0.00		2.93		
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	0.35	0.00	0.00	0.00		4.24		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.86	0.00	0.00	0.00		2.86		
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	37,521.97	38,470.88	0.00	0.00	0.00		341,301.01		
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	187,042.23	187,523.41	0.00	0.00	0.00		1,563,379.70		
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	227,738.94	230,469.30	0.00	0.00	0.00		1,977,552.94		
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	54,232.15	54,459.41	0.00	0.00	0.00		473,042.30		
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	54,641.30	54,653.79	0.00	0.00	0.00		475,104.76		

A

R

M

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

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1,144.43	1,199.85	596.85	1,439.14	966.70	1,089.87	160.81	750.96	650.09	0.00	0.00	0.00	7,998.70	
7,397.32	7,233.01	5,425.60	5,749.99	4,037.79	3,916.92	4,211.85	4,585.99	4,476.73	0.00	0.00	0.00	47,035.20	
9,664.24	10,386.87	6,895.96	6,005.68	4,413.27	4,396.02	4,614.16	4,716.20	4,741.13	0.00	0.00	0.00	55,833.53	
2,729.60	2,547.00	1,740.21	1,587.56	1,149.00	1,156.75	1,160.65	1,263.87	955.56	0.00	0.00	0.00	14,290.20	
2,479.42	2,548.58	1,750.39	1,574.77	1,152.27	1,097.16	1,159.06	1,285.02	1,062.29	0.00	0.00	0.00	14,108.96	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.93	0.87	0.00	0.00	0.00	1.80	
3.00	0.00	2.00	3.00	1.00	2.67	0.00	0.00	2.00	0.00	0.00	0.00	13.67	
7.00	0.00	1.00	5.06	3.56	14.00	3.77	3.00	1.00	0.00	0.00	0.00	38.39	
4.00	0.00	1.00	1.00	1.56	3.00	0.00	0.00	0.90	0.00	0.00	0.00	11.46	
2.00	1.00	2.00	0.00	0.00	2.00	0.00	0.00	2.00	0.00	0.00	0.00	9.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.06	0.00	0.00	0.00	0.00	0.06	
44.60	44.25	49.08	47.32	34.99	31.66	30.85	40.94	42.35	0.00	0.00	0.00	366.04	
2.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	16.00	
3.37	3.12	2.16	1.67	0.83	2.31	1.57	3.02	0.64	0.00	0.00	0.00	18.69	
6.00	7.38	7.00	6.00	6.20	10.00	8.12	9.00	9.00	0.00	0.00	0.00	68.70	
4,442.88	4,822.40	5,139.99	5,199.98	5,482.55	4,565.96	4,070.37	4,268.62	4,431.19	0.00	0.00	0.00	42,423.94	
19,288.96	21,436.17	23,639.77	25,479.28	26,864.80	23,372.29	20,244.07	21,217.76	22,069.97	0.00	0.00	0.00	203,613.07	
70.02	76.99	80.34	89.62	89.99	85.34	76.00	68.18	74.99	0.00	0.00	0.00	711.47	
0.00	1.61	0.00	0.00	0.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.41	
380.96	386.50	238.63	248.98	217.33	220.16	268.38	241.64	238.08	0.00	0.00	0.00	2,440.66	
1,656.15	1,536.50	1,187.87	1,135.67	915.46	931.65	1,074.80	1,009.58	1,035.87	0.00	0.00	0.00	10,483.55	
7.91	23.95	1.29	0.93	0.00	1.63	0.00	3.63	11.90	0.00	0.00	0.00	51.24	
9.11	11.00	8.99	9.12	11.00	10.67	9.12	14.00	23.00	0.00	0.00	0.00	106.01	
0.00	1.00	1.00	1.00	1.00	1.00	1.32	1.00	0.00	0.00	0.00	0.00	7.32	
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	
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	
-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	923,044.29	922,563.28	0.00	0.00	0.00	8,572,871.77	
													
												3,823.00	
												88.00	
												288.00	
												19,315.00	
												23,514.00	
												47.38	
												10.58	

RATE CODE	DESCRIPTION 431A	SOBRA CHILD < 1 M &
431B	SOBRA CHILD 01-05 M

431C	SOBRA CHILD 6-13 M&
F
431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

4321	SOBRA CHILD <1 M & F

4322	SOBRA CHILD 01-05 M

4323	SOBRA CHILD 06-13 M

4324	SOBRA CHILD 14-20 MA

4325	SOBRA CHILD 14-20 FE

432A	SOBRA CHILD < 1 M &

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

9910	TANF & SOBRA CHILDR E	571.00	500.00	476.00	365.00	407.00	441.00	385.00	336.00	342.00	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	7.00	9.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	42.00	29.00	33.00	30.00	29.00	40.00	30.00	25.00	30.00	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	2,070.00	2,020.00	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	2,438.00	2,401.00	0.00	0.00	0.00	

SUBTOTAL:

3100	TRANSPLANT OPTION 1	4.24	5.41	5.00	5.00	5.73	6.00	6.00	6.00	4.00	0.00	0.00	0.00	
310Z	TRANSPLANT OPTION	5.74	4.58	0.00	0.00	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	9.98	9.99	5.00	5.00	5.99	6.00	6.00	6.00	4.00	0.00	0.00	0.00		57.96		

SUBTOTAL:

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	925.69	903.23	849.28	816.35	826.08	834.14	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	1,575.51	1,580.33	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	2,798.46	2,862.28	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	1,095.22	1,106.90	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	18.70	3.61	8.79	22.01	20.26	9.49	10.14	18.25	11.97	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	2.64	1.64	12.64	32.68	21.58	19.38	21.33	15.44	20.04	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	0.86	0.82	67.38	87.22	58.75	32.60	42.40	57.76	46.32	0.00	0.00	0.00	
110J	TANF EXPANDED 65+
M&	0.00	2.64	37.58	16.71	13.76	17.67	19.64	13.69	13.78	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	12.00	8.00	1.36	3.00	3.00	3.00	2.00	1.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	390.00	311.16	275.00	239.06	180.00	142.15	98.00	75.93	62.43	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	1,229.70	991.16	871.12	743.21	581.97	473.00	364.77	279.99	239.75	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	683.08	531.13	454.69	720.61	674.58	643.29	611.64	594.73	562.93	0.00	0.00	0.00	
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	1,906.73	1,901.06	0.00	0.00	0.00	
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	30,480.12	30,772.99	0.00	0.00	0.00	
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	68,569.96	69,593.09	0.00	0.00	0.00	
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	26,739.25	26,872.04	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	91.37	83.00	78.65	120.22	115.24	120.42	117.31	117.99	114.95	0.00	0.00	0.00	
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	
111B	TANF EXPANDED 01-05	0.00	0.83	0.00	0.00	0.00	0.25	0.00	4.06	11.54	0.00	0.00	0.00	
111C	TANF EXPANDED 06-13	1.00	0.00	0.00	2.80	5.00	1.00	0.22	0.00	0.25	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	0.54	5.28	14.31	10.92	28.27	20.03	14.80	24.68	13.26	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	7.24	9.73	31.24	50.14	45.83	35.66	39.98	48.74	38.58	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	101.48	104.36	529.77	956.02	855.10	845.14	904.49	871.90	814.21	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	197.09	224.68	1,011.19	1,606.35	1,326.72	1,205.40	1,450.30	1,305.36	1,321.77	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	28.12	127.83	423.04	661.57	557.64	690.42	593.63	662.72	516.88	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	22.31	0.00	3.65	34.70	3.11	10.46	38.52	11.84	7.65	0.00	0.00	0.00	
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	
1126	TANF EXPANDED 21-44	172.31	149.33	132.42	154.79	225.85	292.60	286.79	298.57	305.48	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	382.43	351.28	318.88	364.36	502.11	662.14	695.91	715.93	726.52	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	446.94	399.71	372.79	452.31	621.33	801.22	828.64	864.66	892.53	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	194.69	165.94	155.60	174.92	237.67	308.56	337.68	352.83	387.60	0.00	0.00	0.00	
112F	TANF EXPANDED 21-44	0.00	0.00	2.56	1.63	1.86	1.03	8.90	10.61	3.82	0.00	0.00	0.00	
112G	TANF EXPANDED 21-44	0.00	3.44	3.22	4.87	3.32	2.59	5.88	4.49	0.66	0.00	0.00	0.00	
112H	TANF EXPANDED 45-64	0.03	0.00	2.92	11.24	7.45	10.73	1.72	11.77	11.26	0.00	0.00	0.00	

 
6,553.68	
12,807.32	
22,455.64	
8,349.02	
123.22	
147.37	
394.11	
135.47	
33.36	
1,773.73	
5,774.67	
5,476.68	
14,742.05	
236,983.69	
526,032.67	
204,485.41	
959.15	
-0.35	
16.68	
10.27	
132.09	
307.14	
5,982.47	
9,648.86	
4,261.85	
132.24	
1.00	
2,018.14	
4,719.56	
5,680.13	
2,315.49	
30.41	
28.47	
57.12	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	16.30	1.06	10.74	12.39	3.26	2.13	4.67	0.00	0.00	0.00	50.55	
518.42	487.04	456.81	384.84	352.94	389.52	358.97	366.07	339.83	0.00	0.00	0.00	3,654.44	
304.76	401.03	244.49	252.11	184.84	258.54	156.32	178.68	158.85	0.00	0.00	0.00	2,139.62	
1,134.27	1,056.52	991.15	391.57	359.68	303.63	245.77	233.03	193.72	0.00	0.00	0.00	4,909.34	
13.94	39.82	16.61	7.34	6.63	7.25	2.59	5.75	6.29	0.00	0.00	0.00	106.22	
26,853.34	26,842.37	26,813.66	21,188.36	20,913.29	20,739.95	20,647.27	20,592.33	20,269.68	0.00	0.00	0.00	204,860.25	
86.51	60.16	53.24	60.10	29.69	45.74	42.01	76.94	29.80	0.00	0.00	0.00	484.19	
0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	6.00	
2.00	2.00	2.00	1.00	1.00	0.99	0.00	0.00	0.00	0.00	0.00	0.00	8.99	
1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	9.00	
387.35	391.10	363.58	405.75	407.66	442.08	415.01	494.78	489.00	0.00	0.00	0.00	3,796.31	
198.57	225.21	193.65	131.93	83.98	116.36	132.48	134.20	147.53	0.00	0.00	0.00	1,363.91	
2,800.72	2,719.35	2,722.76	2,696.85	2,637.63	2,667.84	2,586.05	2,409.33	2,246.15	0.00	0.00	0.00	23,486.68	
66.87	64.13	55.86	42.68	36.03	53.53	35.64	46.78	33.27	0.00	0.00	0.00	434.79	
15,882.49	16,101.98	16,689.39	17,152.91	17,493.44	17,902.98	18,067.75	18,082.96	17,473.89	0.00	0.00	0.00	154,847.79	
70.33	62.70	88.07	53.98	24.93	36.36	21.97	45.62	35.04	0.00	0.00	0.00	439.00	
141,707.24	129,594.34	122,483.07	179,619.05	176,720.38	182,594.47	184,345.74	183,024.87	183,076.73	0.00	0.00	0.00	1,483,165.89	

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

RATE CODE	DESCRIPTION

112J

2400

240Z

2410

241Z

2420

242Z

2500

2510

2520

2600

260Z

2610

261Z

2620

262Z

TANF EXPANDED 65+
M&
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI BLIND EXPANDED
W
SSI BLIND EXPANDED
N
SSI BLIND EXPANDED
W
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

E
SUBTOTAL:

9911	SB PAYMENT FOR TAN F	105.00	122.00	113.00	177.00	141.00	253.00	239.00	218.00	217.00	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	1.00	2.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	108.00	126.00	117.00	179.00	143.00	255.00	241.00	219.00	219.00	0.00	0.00	0.00	

1,585.00	
19.00	
3.00	
1,607.00	

E
SUBTOTAL:

0.00

0.00

0.00

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

2

89.22

75.85

789.55

434.57

18.70

9.16

151.34

75.65

33,759.63

1.00

39,664.84

3504	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	
3506	ADULT 40-100% MALE 2	15.63	8.90	13.05	13.05	7.72	10.06	5.00	6.91	8.90	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	4.43	7.54	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	107.21	133.77	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	25.71	44.14	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	0.78	1.09	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	2.55	2.12	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	43.39	36.45	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	27.30	10.18	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	4,261.55	4,408.82	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	3,734.50	3,945.56	4,139.94	4,065.25	4,323.63	4,633.53	4,803.34	4,969.94	5,049.15	0.00	0.00	0.00	

E

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
17,324.13	17,315.90	17,767.16	18,063.18	18,254.46	18,817.24	18,834.48	19,085.44	19,007.23	0.00	0.00	0.00	164,469.22	
14,579.12	14,409.13	14,673.49	14,867.88	14,928.18	15,251.61	15,287.12	15,557.04	15,572.16	0.00	0.00	0.00	135,125.73	
35,161.66	35,276.58	36,112.19	36,443.44	36,715.66	37,786.88	37,961.23	38,751.79	38,908.66	0.00	0.00	0.00	333,118.09	
39.09	36.01	35.99	49.54	31.82	42.79	27.61	16.17	21.12	0.00	0.00	0.00	300.14	
223.89	174.95	140.00	114.00	120.77	109.87	134.38	137.82	180.52	0.00	0.00	0.00	1,336.20	
215.10	215.28	142.27	157.72	109.73	122.58	178.18	146.03	170.39	0.00	0.00	0.00	1,457.28	
970.65	931.86	710.83	703.38	508.69	616.54	603.19	690.09	580.58	0.00	0.00	0.00	6,315.81	
687.03	645.80	559.94	543.04	370.45	528.33	509.10	549.46	412.09	0.00	0.00	0.00	4,805.24	
1,789.29	1,532.58	1,097.36	1,161.58	880.02	1,120.60	1,190.46	1,109.60	981.45	0.00	0.00	0.00	10,862.94	
40.88	22.67	29.32	20.45	46.89	6.12	18.38	4.00	9.50	0.00	0.00	0.00	198.21	
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	
3.00	0.00	0.00	0.00	2.00	0.70	2.00	-0.84	1.51	0.00	0.00	0.00	8.37	
1.41	3.21	0.00	1.00	1.00	1.74	2.00	2.00	2.00	0.00	0.00	0.00	14.36	
20.96	15.68	24.16	19.28	23.00	24.79	19.36	20.38	31.92	0.00	0.00	0.00	199.53	
6.00	10.00	4.00	14.03	10.06	9.93	6.32	6.00	12.80	0.00	0.00	0.00	79.14	
0.00	0.00	0.00	0.00	0.00	0.29	0.00	0.00	0.68	0.00	0.00	0.00	0.97	
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	
0.03	1.83	1.26	0.12	0.00	1.69	1.47	7.67	2.29	0.00	0.00	0.00	16.36	
0.00	0.00	0.00	4.96	0.83	4.06	0.67	1.00	0.19	0.00	0.00	0.00	11.71	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	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	0.00	0.00	0.00	0.00	0.00	
34.74	33.74	30.14	41.29	39.44	33.46	43.59	41.41	51.51	0.00	0.00	0.00	349.32	
7.49	15.61	9.78	12.41	11.03	18.57	21.17	17.69	20.46	0.00	0.00	0.00	134.21	
88.23	98.60	92.80	188.88	141.71	124.05	151.66	136.11	176.40	0.00	0.00	0.00	1,198.44	
19.67	21.38	28.72	41.00	21.63	14.00	15.00	23.61	25.00	0.00	0.00	0.00	210.01	
5.51	8.57	6.12	3.49	3.21	1.63	4.63	3.19	2.71	0.00	0.00	0.00	39.06	
1.54	1.81	0.06	2.37	3.89	1.15	5.04	0.00	6.49	0.00	0.00	0.00	22.35	
14.58	15.74	30.56	13.97	3.56	15.97	8.47	6.57	24.14	0.00	0.00	0.00	133.56	
0.00	0.00	2.73	0.00	0.00	2.00	0.00	3.37	0.00	0.00	0.00	0.00	8.10	
9,839.70	10,160.23	10,470.29	10,275.58	10,661.47	11,028.29	10,985.15	10,908.23	11,573.42	0.00	0.00	0.00	95,902.36	
8,418.28	8,667.97	8,908.49	8,752.70	9,023.96	9,373.43	9,485.14	9,442.54	10,101.48	0.00	0.00	0.00	82,173.99	
58,247.03	58,634.00	61,113.02	62,941.19	63,352.21	65,477.71	64,345.30	64,160.17	63,772.18	0.00	0.00	0.00	562,042.81	
34,827.18	34,929.63	36,183.66	37,298.36	37,725.55	38,555.88	38,148.00	38,016.92	37,902.65	0.00	0.00	0.00	333,587.83	
72,820.34	73,231.71	75,412.07	76,737.78	77,207.05	78,744.45	77,238.57	77,221.85	77,398.51	0.00	0.00	0.00	686,012.33	
80.88	80.74	94.53	128.19	96.22	106.84	65.67	53.17	64.80	0.00	0.00	0.00	771.04	
580.76	572.41	352.26	309.50	300.26	275.48	271.17	290.30	403.43	0.00	0.00	0.00	3,355.57	

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

RATE CODE	DESCRIPTION 3516	ADULT 40-100% MALE 2
3517	ADULT 40-100% FEMAL
E
3518	ADULT 40-100% M&F 45

3519	ADULT 40-100% M&F 65

351D	ADULT 40-100% MALE 1

351E	ADULT 40-100% FEMAL
E
351F	ADULT 40-100% MALE 2

351G	ADULT 40-100% FEMAL
E
351H	ADULT 40-100% M&F 45

351J	ADULT 40-100% M&F 65

3525	ADULT 40-100% FEMAL
E
3526	ADULT 40-100% MALE 2

3527	ADULT 40-100% FEMAL
E
3528	ADULT 40-100% M&F 45

3529	ADULT 40-100% M&F 65

352F	ADULT 40-100% MALE 2

352G	ADULT 40-100% FEMAL
E
352H	ADULT 40-100% M&F 45

352J	ADULT 40-100% M&F 65

3704	ADULT <40% EXP MALE

3705	ADULT <40% EXP FEM
AL
3706	ADULT <40% EXP MALE

3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
370F	ADULT <40% EXP MALE

370G	ADULT <40% EXP FEM
AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MALE

3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MALE

3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
371D	ADULT <40% EXP MALE

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
519.38	449.84	305.73	319.68	204.57	230.72	240.99	282.80	320.66	0.00	0.00	0.00	2,874.37	
4,244.00	4,145.00	2,990.61	2,888.14	2,110.81	2,317.84	2,239.00	2,376.69	2,973.23	0.00	0.00	0.00	26,285.32	
2,410.81	2,215.92	1,619.33	1,656.46	1,211.17	1,233.71	1,297.56	1,433.00	1,335.77	0.00	0.00	0.00	14,413.73	
3,754.97	3,389.75	2,459.44	2,612.62	2,030.56	2,177.41	2,352.17	2,479.90	2,389.86	0.00	0.00	0.00	23,646.68	
2.98	2.00	16.46	13.76	23.12	9.87	0.32	0.00	1.00	0.00	0.00	0.00	69.51	
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
9.00	8.05	8.35	11.73	10.99	9.77	16.18	12.61	11.04	0.00	0.00	0.00	97.72	
6.12	3.96	3.43	7.00	7.36	2.03	8.66	7.35	7.00	0.00	0.00	0.00	52.91	
23.78	6.39	19.82	15.21	14.20	12.68	22.17	11.96	23.22	0.00	0.00	0.00	149.43	
4.00	0.00	1.00	4.00	3.00	3.90	2.00	5.00	6.00	0.00	0.00	0.00	28.90	
0.00	0.86	5.62	0.82	1.70	1.50	1.60	2.91	5.50	0.00	0.00	0.00	20.51	
0.87	1.79	3.22	0.00	1.06	0.00	0.48	0.20	0.00	0.00	0.00	0.00	7.62	
0.77	1.95	0.36	4.98	0.80	1.22	3.23	2.78	10.31	0.00	0.00	0.00	26.40	
0.00	0.00	0.00	0.00	0.00	0.09	0.00	1.00	0.00	0.00	0.00	0.00	1.09	
273,979.51	274,669.50	279,217.19	284,229.49	284,415.60	292,980.18	290,836.54	292,475.75	294,205.02	0.00	0.00	0.00	2,567,008.78	

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

RATE CODE	DESCRIPTION

371E

371F

371G

371H

371J

3724

3725

3726

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

ADULT <40% EXP FEM AL
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
ADULT <40% EXP MALE

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

3727

3728

3729

372F

ADULT <40% EXP FEM
AL
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
ADULT <40% EXP MALE

372G

372H

372J

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

6
SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	29.00	45.00	40.00	44.00	38.00	35.00	29.00	30.00	35.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	74.00	98.00	121.00	112.00	98.00	101.00	117.00	85.00	111.00	0.00	0.00	0.00	
	103.00	143.00	161.00	156.00	136.00	136.00	146.00	115.00	146.00	0.00	0.00	0.00	

325.00	
917.00	
1,242.00	

A
SUBTOTAL:

3904	NEWLY ELIGIBLE MALE	0.00	0.16	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	6.92	5.18	4.00	8.20	10.80	13.50	12.09	12.16	21.25	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	4.15	6.00	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	129.96	240.11	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	36.46	33.00	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	3.82	1.74	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA	1.83	2.06	0.00	1.25	1.46	4.00	1.00	1.93	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	115.81	31.30	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	68.47	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	2,160.18	2,207.19	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	2,661.10	2,751.45	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	19,863.08	19,785.35	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	29,049.38	29,183.79	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	27,501.52	27,480.45	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F	43.11	41.59	40.65	49.90	38.52	39.64	25.99	21.17	22.25	0.00	0.00	0.00	

2.16	
94.10	
72.52	
926.14	
250.27	
0.83	
25.77	
13.53	
509.41	
220.60	
17,199.41	
20,996.91	
163,258.60	
225,341.95	
236,717.02	
322.82	

L

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
391D	NEWLY ELIGIBLE MALE	141.51	112.48	116.75	61.70	47.08	66.46	54.38	63.02	107.07	0.00	0.00	0.00		770.45		
391E	NEWLY ELIGIBLE FEMA L	153.51	153.08	97.96	106.98	67.97	97.10	99.92	109.48	82.68	0.00	0.00	0.00		968.68		
391F	NEWLY ELIGIBLE MALE	1,523.12	1,206.66	1,086.31	945.80	635.23	733.56	806.99	671.82	606.73	0.00	0.00	0.00		8,216.22		
391G	NEWLY ELIGIBLE FEMA L	1,726.49	1,680.05	1,394.47	1,209.37	730.12	830.37	899.40	941.25	712.53	0.00	0.00	0.00		10,124.05		
391H	NEWLY ELIGIBLE M&F	1,771.32	1,458.13	1,385.33	1,103.78	772.01	1,213.88	1,092.09	988.85	801.07	0.00	0.00	0.00		10,586.46		
391J	NEWLY ELIGIBLE M&F 6	8.86	33.37	111.19	18.08	52.44	6.35	45.98	1.00	6.74	0.00	0.00	0.00		284.01		
3926	NEWLY ELIGIBLE MALE	1.00	0.70	1.96	3.16	1.00	0.00	2.00	0.20	0.00	0.00	0.00	0.00		10.02		
3927	NEWLY ELIGIBLE FEMA L	0.00	3.00	3.00	2.00	1.00	1.00	2.77	1.00	1.00	0.00	0.00	0.00		14.77		
3928	NEWLY ELIGIBLE M&F 4	6.22	3.11	2.43	4.57	6.66	5.38	14.77	8.84	19.54	0.00	0.00	0.00		71.52		
3929	NEWLY ELIGIBLE M&F 6	2.00	0.96	2.00	3.03	1.00	1.00	1.00	3.00	5.00	0.00	0.00	0.00		18.99		
392F	NEWLY ELIGIBLE MALE	0.00	0.29	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.32		
392G	NEWLY ELIGIBLE FEMA L	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		
392H	NEWLY ELIGIBLE M&F 4	2.40	1.28	0.56	1.41	1.10	1.60	0.25	11.37	0.45	0.00	0.00	0.00		20.42		
392J	NEWLY ELIGIBLE M&F 6	0.00	0.03	0.00	2.96	1.00	0.00	0.00	9.00	0.00	0.00	0.00	0.00		12.99		
	69,593.33	71,546.64	74,129.68	75,276.24	76,599.20	80,337.25	81,024.11	84,438.02	84,106.69	0.00	0.00	0.00		697,051.16		

4

SUBTOTAL:

585.00

585.00

9939	BIRTH SUPP PAYMENT	39.00	34.00	57.00	67.00	67.00	73.00	77.00	100.00	71.00	0.00	0.00	0.00	
SUBTOTAL:	39.00	34.00	57.00	67.00	67.00	73.00	77.00	100.00	71.00	0.00	0.00	0.00	

N

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	7.33	8.44	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	50,386.04	50,933.22	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	13,193.17	13,075.74	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	6,240.09	5,678.68	5,237.34	12,115.93	12,426.02	12,699.52	12,757.67	13,024.01	12,856.32	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.48	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	1,188.81	1,067.57	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	342.97	320.45	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	81.96	103.18	421.32	344.01	343.25	358.14	324.68	362.29	224.13	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	78,504.65	78,486.35	0.00	0.00	0.00	

1.00	
0.67	
1.00	
42.15	
345,158.59	
95,794.15	
93,035.58	
0.51	
8,826.98	
2,605.73	
2,562.96	
1.73	
548,031.05	

1

SUBTOTAL:

75.00

75.00

9944	BIRTH SUPP PAYMENT	8.00	13.00	3.00	3.00	12.00	8.00	10.00	7.00	11.00	0.00	0.00	0.00	
	8.00	13.00	3.00	3.00	12.00	8.00	10.00	7.00	11.00	0.00	0.00	0.00	

S
SUBTOTAL:

240.86

2,127.92

4517	BC PATIENT FEMALE 2	23.96	25.35	26.00	27.58	28.33	27.64	28.00	28.00	26.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	251.91	246.16	245.84	240.06	227.69	233.21	231.08	228.93	223.04	0.00	0.00	0.00	

1

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.77		
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		6.06		
451H	BC PATIENT FEMALE 4 5	10.28	5.89	8.11	0.93	5.34	3.76	3.30	8.60	0.00	0.00	0.00	0.00		46.21		
4617	CC PATIENT FEMALE 2 1	15.86	16.54	17.00	18.03	17.83	19.47	20.00	20.00	20.00	0.00	0.00	0.00		164.73		
4618	CC PATIENT FEMALE 4	18.00	17.00	16.00	16.00	16.00	15.00	14.00	14.00	14.03	0.00	0.00	0.00		140.03		
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		6.08		
461H	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.96	0.00	0.00	0.00		1.96		
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		0.32		
9946	SB KICK PAYMENT FOR	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
	320.78	316.03	312.95	303.97	300.01	300.94	296.70	299.53	285.03	0.00	0.00	0.00		2,735.94		

5

5

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,505.00	1,555.45	1,576.90	1,602.26	1,594.23	1,632.59	1,633.56	1,628.89	1,659.37	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	161.37	146.05	125.37	96.31	27.40	81.11	61.34	53.48	55.38	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	246.99	274.32	275.92	268.27	266.19	276.60	276.50	274.66	267.18	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	85.86	73.98	54.70	40.00	21.99	24.91	5.07	36.95	3.24	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	213.90	216.30	223.90	223.30	228.07	240.46	236.51	225.61	225.34	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	20.61	6.41	1.03	15.63	27.86	2.32	0.83	3.24	3.63	0.00	0.00	0.00	
	2,234.73	2,273.51	2,258.82	2,246.77	2,166.74	2,258.99	2,214.81	2,223.83	2,215.14	0.00	0.00	0.00	

9.00	
14,388.25	
807.81	
2,426.63	
346.70	
2,033.39	
81.56	
20,093.34	

M

M

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	1,566,895.94	1,567,790.24	0.00	0.00	0.00		13,918,038.89		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9,923.14	10,424.50	9,923.14	10,013.77	17,381.47	20,492.16	27,239.96	27,799.67	27,239.96	0.00	0.00	0.00	160,437.77	
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	2,312,334.75	2,294,801.55	0.00	0.00	0.00	20,532,841.26	
3,414.03	3,414.03	3,414.03	3,433.17	3,433.17	6,955.78	6,883.58	6,883.58	6,883.58	0.00	0.00	0.00	44,714.95	
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	35,672,776.45	30,670,123.38	0.00	0.00	0.00	294,238,194.73	
707,295.55	628,872.62	699,533.74	841,652.65	651,630.71	674,097.19	731,475.49	687,149.55	856,029.56	0.00	0.00	0.00	6,477,737.06	
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	3,254,121.17	2,950,657.78	0.00	0.00	0.00	27,575,816.81	
20,970.93	11,535.77	26,120.35	18,541.95	9,394.51	32,330.18	43,450.16	39,444.88	37,861.52	0.00	0.00	0.00	239,650.25	
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	22,091,359.25	19,090,065.59	0.00	0.00	0.00	180,777,802.92	
27,811.67	8,720.78	31,076.14	21,591.82	10,487.09	22,848.38	23,361.65	12,897.63	35,332.72	0.00	0.00	0.00	194,127.88	
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	15,712,431.84	14,374,439.34	0.00	0.00	0.00	130,863,307.62	
40,564.67	63,879.36	93,590.05	124,380.26	73,436.67	93,117.27	101,516.47	89,437.07	101,963.98	0.00	0.00	0.00	781,885.80	
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	95,656,370.93	94,045,250.29	0.00	0.00	0.00	841,813,604.97	
66,459.25	35,301.18	25,164.71	27,841.86	30,576.10	33,824.17	38,629.75	27,817.69	79,843.41	0.00	0.00	0.00	365,458.12	
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	22,688,860.14	21,413,285.59	0.00	0.00	0.00	196,180,399.18	
2,948.16	9,227.84	6,397.97	6,604.08	8,888.32	7,078.53	4,972.05	3,232.14	3,869.53	0.00	0.00	0.00	53,218.62	
64,338.16	65,260.19	64,541.02	62,567.40	68,202.65	66,548.80	68,372.70	68,592.83	65,059.47	0.00	0.00	0.00	593,483.22	
444,420.36	460,483.10	454,107.08	457,911.29	480,473.00	490,226.15	486,595.02	474,957.86	478,945.88	0.00	0.00	0.00	4,228,119.74	
130,315.90	135,811.83	130,342.85	127,684.67	131,086.80	129,801.65	127,497.03	135,174.46	130,938.82	0.00	0.00	0.00	1,178,654.01	

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending March 31, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

210Z

2110

211Z

2120

SSI AGED WITH MEDIC
A
SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

212Z

2200

220Z

2210

221Z

2220

222Z

2300

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

2310

2320

SSI BLIND NON-MEDIC
A
SSI BLIND WITH QMB

SUBTOTAL:

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   198,961,641.89   186,662,591.95

0.00

0.00

0.00

1,706,299,454.91

1,708,276,754.31

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	79,836.70	73,619.88	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	-15,252.27	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	134,133.33	117,508.72	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	3,141.37	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	19,836.86	21,311.74	19,836.86	20,022.25	21,709.30	20,462.48	20,048.11	21,887.06	20,048.11	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	223,746.19	211,176.71	0.00	0.00	0.00	

661,744.50	
4,368.11	
1,117,895.12	
8,128.90	
185,162.77	
1,977,299.40	

184,831,913.92	185,793,257.17	198,420,331.83	189,544,233.80	185,883,928.65	199,185,388.08	186,873,768.66	0.00	0.00	0.00	

M

TOTAL:

182,421,827.21  195,322,104.99

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3.00	3.00	3.00	3.00	5.00	6.00	8.00	8.00	8.00	0.00	0.00	0.00	47.00	
1010	TANF NON-MEDICARE	654.15	651.89	656.12	659.50	658.46	656.64	659.79	665.10	661.45	0.00	0.00	0.00	5,923.10	
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	13.00	
2100	SSI AGED WITH MEDIC	11,288.11	11,289.28	11,378.95	11,358.29	11,326.59	11,306.03	11,140.18	11,162.78	11,195.20	0.00	0.00	0.00	101,445.41	
210Z	A
SSI AGED WITH MEDIC	717.21	639.08	710.00	851.48	668.68	692.76	751.99	715.66	881.40	0.00	0.00	0.00	
6,628.26	
2110	A
SSI AGED NON-MEDICA	655.14	653.57	669.99	636.70	631.61	621.44	615.56	613.03	615.23	0.00	0.00	0.00	
5,712.27	
211Z	R
SSI AGED NON-MEDICA	21.10	12.50	27.34	18.34	9.95	33.27	44.42	39.22	42.74	0.00	0.00	0.00	
248.88	

2120	R
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	
7,397.98	
7,414.86	
0.00	
0.00	
0.00	
66,602.77	
212Z	SSI AGED WITH QMB P	27.75	9.33	32.14	22.04	11.00	24.46	26.59	14.28	36.56	0.00	0.00	0.00	204.15	

2200	P
SSI DISABLED WITH M	
4,540.03	
4,507.46	
4,531.49	
4,608.07	
4,649.47	
4,687.31	
4,696.20	
4,730.81	
4,729.29	
0.00	
0.00	
0.00	
41,680.13	
220Z	E
SSI DISABLED WITH M	40.61	63.99	95.38	125.93	77.65	98.95	102.57	98.56	105.74	0.00	0.00	0.00	
809.38	

2210	E
SSI DISABLED NON-ME	
25,726.52	
25,794.02	
25,992.12	
25,925.40	
25,930.65	
25,987.21	
25,945.81	
26,051.86	
26,144.32	
0.00	
0.00	
0.00	
233,497.91	
221Z	D
SSI DISABLED NON-ME	68.02	35.27	25.38	30.27	31.72	32.83	41.26	29.92	70.81	0.00	0.00	0.00	
365.48	
2220	D
SSI DISABLED WITH Q	6,765.32	6,778.39	6,816.99	6,805.73	6,791.71	6,793.06	6,799.81	6,813.92	6,805.25	0.00	0.00	0.00	
61,170.18	
222Z	M
SSI DISABLED WITH Q	2.73	7.18	7.16	6.82	9.41	7.33	5.45	4.24	4.12	0.00	0.00	0.00	
54.44	
2300	M
SSI BLIND WITH MEDIC	20.00	19.00	20.00	20.00	20.00	20.00	21.00	20.17	20.00	0.00	0.00	0.00	
180.17	
2310	SSI BLIND NON-MEDIC	128.16	130.38	131.06	129.55	134.00	134.12	136.77	135.03	135.00	0.00	0.00	0.00	1,194.07	

2320	A
SSI BLIND WITH QMB	
42.00	
42.00	
42.00	
40.83	
40.30	
40.96	
41.00	
41.55	
42.00	
0.00	
0.00	
0.00	
372.64	

LONG TERM CARE MEMBER MONTHS
For The Period Ending March 31, 2016

SUBTOTAL:

58,035.29

58,012.16

58,532.82

58,645.27

58,422.52

58,601.52

58,441.58

58,544.11

58,913.97

0.00

0.00

0.00

526,149.24

203.43

4.64

231.83

7.75

63.09

510.74

8700	SSI DISABLED FREEDO M	22.00	22.00	22.00	22.09	22.31	23.00	24.51	22.52	23.00	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	-15.83	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	25.27	24.00	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	2.72	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	7.00	7.00	7.00	7.00	7.00	7.09	7.00	7.00	7.00	0.00	0.00	0.00	
SUBTOTAL:	58.99	52.01	60.99	56.09	54.91	55.09	76.98	41.68	54.00	0.00	0.00	0.00	

M

TOTAL:	58,094.28	58,064.17	58,593.81	58,701.36	58,477.43	58,656.61	58,518.56	58,585.79	58,967.97	0.00	0.00	0.00		526,659.98		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending March 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	41.42	41.42	0.00	0.00	0.00		365.41		
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	2,796,222.78	2,567,708.64	0.00	0.00	0.00		37,574,739.90		
1020	TANF WITH QMB	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	41.42	0.00	0.00	0.00		82.84		
2110	SSI AGED NON-MEDICA R	37.55	75.10	75.10	82.84	82.84	82.84	41.42	82.84	41.42	0.00	0.00	0.00		601.95		
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	248.52	207.10	0.00	0.00	0.00		1,239.47		
2210	SSI DISABLED NON-ME	430,210.35	427,168.80	423,639.10	461,128.86	457,442.48	503,226.44	451,519.42	447,336.00	442,034.24	0.00	0.00	0.00		4,043,705.69		
2220	SSI DISABLED WITH Q M	225.30	225.30	225.30	248.52	207.10	241.02	207.10	289.94	248.52	0.00	0.00	0.00		2,118.10		
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	2,153.84	2,153.84	0.00	0.00	0.00		17,285.85		
4300	SOBRA CHILD WITH ME D	225.30	225.30	187.75	165.68	207.10	335.60	165.68	124.26	289.94	0.00	0.00	0.00		1,926.61		
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     22,136,173.44	22,791,313.58	0.00	0.00	0.00		187,299,325.57		
4320	SOBRA CHILD WITH Q MB	525.70	0.00	187.75	455.62	165.68	869.82	165.68	82.84	248.52	0.00	0.00	0.00		2,701.61		
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	24,479.22	25,307.62	0.00	0.00	0.00		226,882.33		
	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	25,407,235.10	25,829,636.26	0.00	0.00	0.00		229,171,016.75		

D

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	21,704.08	18,307.64	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	37.55	37.55	37.55	41.42	41.42	49.90	41.42	41.42	41.42	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	21,745.50	18,349.06	0.00	0.00	0.00	

470,433.12	
369.65	
470,802.77	

E

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

357.30	
692.53	
1,049.83	

FO
SUBTOTAL:

331.36

331.36

3910	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	41.42	0.00	0.00	41.42	124.26	124.26	0.00	0.00	0.00	
	0.00	0.00	0.00	41.42	0.00	0.00	41.42	124.26	124.26	0.00	0.00	0.00	

F
SUBTOTAL:

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	41.42	41.42	41.42	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR 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	2,973,417.54	2,994,003.28	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	2,973,417.54	2,994,003.28	0.00	0.00	0.00	

124.26	
20,412,418.94	
20,412,543.20	

F

SUBTOTAL:

250,055,743.91

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	28,402,605.24	28,842,195.70	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending March 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	1.00	1.00	0.00	0.00	0.00		9.00		
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	67,509.00	61,992.00	0.00	0.00	0.00		915,505.00		
1020	TANF WITH QMB	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00		2.00		
2110	SSI AGED NON-MEDICA R	1.00	2.00	2.00	2.00	2.00	2.00	1.00	2.00	1.00	0.00	0.00	0.00		15.00		
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	6.00	5.00	0.00	0.00	0.00		30.00		
2210	SSI DISABLED NON-ME	11,457.00	11,376.00	11,282.00	11,133.00	11,044.00	10,970.00	10,901.00	10,800.00	10,672.00	0.00	0.00	0.00		99,635.00		
2220	SSI DISABLED WITH Q M	6.00	6.00	6.00	6.00	5.00	5.00	5.00	7.00	6.00	0.00	0.00	0.00		52.00		
2310	SSI BLIND NON-MEDIC A	39.00	43.00	45.00	48.00	48.00	48.00	50.00	52.00	52.00	0.00	0.00	0.00		425.00		
4300	SOBRA CHILD WITH ME D	6.00	6.00	5.00	4.00	5.00	8.00	4.00	3.00	7.00	0.00	0.00	0.00		48.00		
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	534,432.00	550,249.00	0.00	0.00	0.00		4,628,286.00		
4320	SOBRA CHILD WITH Q MB	14.00	0.00	5.00	11.00	4.00	21.00	4.00	2.00	6.00	0.00	0.00	0.00		67.00		
5010	SOBRA PREGNANT WO MAN	544.00	601.00	672.00	696.00	729.00	600.00	570.00	591.00	611.00	0.00	0.00	0.00		5,614.00		
	628,547.00	634,577.00	656,077.00	619,559.00	621,361.00	626,224.00	626,336.00	613,405.00	623,603.00	0.00	0.00	0.00		5,649,689.00		

D

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	524.00	442.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	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	525.00	443.00	0.00	0.00	0.00	

11,388.00	
9.00	
11,397.00	

E

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

9.00	
17.00	
26.00	

FO
SUBTOTAL:

8.00

8.00

3910	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	1.00	0.00	0.00	1.00	3.00	3.00	0.00	0.00	0.00	
	0.00	0.00	0.00	1.00	0.00	0.00	1.00	3.00	3.00	0.00	0.00	0.00	

F
SUBTOTAL:

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR F	30,285.00	27,204.00	24,543.00	64,567.00	67,142.00	69,354.00	70,427.00	71,787.00	72,284.00	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	71,787.00	72,284.00	0.00	0.00	0.00	

3.00	
497,593.00	
497,596.00	

F

SUBTOTAL:

TOTAL:	661,307.00	663,777.00	682,351.00	685,637.00	689,643.00	696,489.00	697,455.00	685,722.00	696,335.00	0.00	0.00	0.00		6,158,716.00		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
67,083.83	80,473.34	92,942.96	1,873.88	1,880.20	2,409.24	183.28	176.96	170.64	0.00	0.00	0.00	247,194.33	
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	440,014.20	432,196.36	0.00	0.00	0.00	22,655,230.32	
24,837.03	36,897.81	45,074.61	701.52	761.56	220.68	82.16	75.84	75.84	0.00	0.00	0.00	108,727.05	
139,789.21	137,949.43	136,722.91	13,714.40	13,869.24	19,412.00	1,093.36	1,074.40	1,068.08	0.00	0.00	0.00	464,693.03	
205,476.17	200,433.81	204,454.07	19,576.20	19,269.68	42,553.12	17,569.60	17,594.88	17,626.48	0.00	0.00	0.00	744,554.01	
595,679.88	602,630.16	609,410.09	73,883.96	74,771.92	96,621.20	5,469.96	5,536.32	5,656.40	0.00	0.00	0.00	2,069,659.89	
134,133.59	132,327.88	130,488.10	11,537.16	11,508.72	20,634.20	2,673.36	2,622.80	2,581.72	0.00	0.00	0.00	448,507.53	
1,422,763.20	1,422,831.34	1,426,408.69	116,724.08	117,773.20	279,823.24	118,013.36	118,414.68	118,455.76	0.00	0.00	0.00	5,141,207.55	
832,159.75	837,747.23	844,561.23	70,060.36	70,610.20	107,153.96	9,160.84	9,157.68	9,233.52	0.00	0.00	0.00	2,789,844.77	
1,226.52	1,158.38	1,056.17	94.80	88.48	155.48	18.96	15.80	15.80	0.00	0.00	0.00	3,830.39	
14,820.45	14,650.10	14,547.89	1,295.60	1,311.40	2,962.84	1,346.16	1,371.44	1,368.28	0.00	0.00	0.00	53,674.16	
8,279.01	8,210.87	8,244.94	745.76	739.44	1,094.24	132.72	135.88	132.72	0.00	0.00	0.00	27,715.58	
34.07	34.07	68.14	6.32	3.16	0.00	0.00	0.00	3.16	0.00	0.00	0.00	148.92	
834,544.65	810,661.58	852,976.52	73,251.96	73,425.76	148,481.52	70,607.04	71,359.12	67,642.96	0.00	0.00	0.00	3,002,951.11	
68.14	34.07	34.07	3.16	3.16	3.88	0.00	0.00	0.00	0.00	0.00	0.00	146.48	
1,260.59	1,226.52	1,328.73	113.76	94.80	188.68	6.32	3.16	3.16	0.00	0.00	0.00	4,225.72	
802,586.99	894,950.76	992,561.31	98,045.32	104,024.04	141,289.04	76,955.48	80,671.64	84,138.16	0.00	0.00	0.00	3,275,222.74	
306.63	408.84	340.70	34.76	37.92	22.56	3.16	6.32	6.32	0.00	0.00	0.00	1,167.21	
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	748,231.12	740,375.36	0.00	0.00	0.00	41,038,700.79	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending March 31, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

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

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

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	1,320.88	1,308.24	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	418,990.72	424,072.00	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	508.76	540.36	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	50.56	60.04	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	39,725.62	37,068.16	34,887.68	1,292.44	1,166.04	5,659.80	707.84	647.80	562.48	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	3,899.44	3,798.32	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	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	94.80	88.48	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	6,004.00	5,545.80	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	488,427.52	493,674.30	511,867.68	42,394.56	43,298.32	35,731.36	2,464.80	2,496.40	2,385.80	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	434,013.36	438,361.52	0.00	0.00	0.00	

446,693.44	
10,944,815.70	
118,795.01	
46,794.55	
121,717.86	
3,091,974.67	
6.32	
221.66	
116.29	
32,061.61	
310,187.81	
1,622,740.74	
16,736,125.66	

NO

W

E
SUBTOTAL:

11.64

11.64

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

FO
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	34.76	37.92	0.00	0.00	0.00	16,377.54

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending March 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	263,891.60	265,661.20	0.00	0.00	0.00		9,599,860.76		
3520	ADULT 40-100% FOR FI	1,056.17	919.89	919.89	97.96	113.76	149.16	6.32	12.64	12.64	0.00	0.00	0.00		3,288.43		
3700	ADULT <40% EXP FOR F	4,463.17	4,667.59	4,769.80	774.20	609.88	1,647.40	63.20	47.40	47.40	0.00	0.00	0.00		17,090.04		
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	663,138.64	665,259.00	0.00	0.00	0.00		25,243,415.01		
3720	AHC CARE EXPANDED	1,328.73	476.98	953.96	94.80	94.80	118.12	15.80	22.12	18.96	0.00	0.00	0.00		3,124.27		
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	927,147.16	931,037.12	0.00	0.00	0.00		34,883,156.05		

FO

3900	NEWLY ELIGIBLE FOR F	3,032.23	2,044.20	2,180.48	372.88	404.48	593.92	22.12	28.44	44.24	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	259,066.28	259,799.40	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR	374.77	170.35	204.42	28.44	25.28	18.68	0.00	0.00	3.16	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	259,094.72	259,846.80	0.00	0.00	0.00	

8,722.99	
8,500,930.44	
825.10	
8,510,478.53	

F
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	16,776.44	15,954.84	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	103,709.08	95,634.49	86,469.66	15,686.24	17,022.92	27,854.24	16,583.68	16,776.44	15,954.84	0.00	0.00	0.00	

395,685.27	
6.32	
395,691.59	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	9,471.46	9,301.11	9,267.04	837.40	799.48	2,012.92	790.00	774.20	774.20	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	107.44	104.28	0.00	0.00	0.00	
	10,663.91	10,459.49	10,391.35	941.68	903.76	2,291.08	897.44	881.64	878.48	0.00	0.00	0.00	

34,027.81	
4,281.02	
38,308.83	

N

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	72.68	75.84	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	660.44	657.28	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	5,178.64	5,417.13	5,655.62	426.60	439.24	546.36	6.32	6.32	9.48	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	739.44	742.60	0.00	0.00	0.00	

106.09	
114,433.48	
27,862.08	
17,685.71	
160,087.36	

M
SUBTOTAL:

101,762,560.45

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	2,386,883.88	2,387,196.72	0.00	0.00	0.00	

TOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	58.00	56.00	54.00	0.00	0.00	0.00	8,480.00	
178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	139,245.00	136,771.00	0.00	0.00	0.00	1,410,757.00	
729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	24.00	24.00	0.00	0.00	0.00	3,705.00	
4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	340.00	338.00	0.00	0.00	0.00	22,257.00	
6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	5,560.00	5,568.00	5,578.00	0.00	0.00	0.00	52,533.00	
17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	1,752.00	1,790.00	0.00	0.00	0.00	107,119.00	
3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	830.00	817.00	0.00	0.00	0.00	22,261.00	
41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	37,346.00	37,473.00	37,486.00	0.00	0.00	0.00	349,094.00	
24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	2,899.00	2,898.00	2,922.00	0.00	0.00	0.00	129,948.00	
36.00	34.00	31.00	30.00	28.00	5.00	6.00	5.00	5.00	0.00	0.00	0.00	180.00	
435.00	430.00	427.00	410.00	415.00	417.00	426.00	434.00	433.00	0.00	0.00	0.00	3,827.00	
243.00	241.00	242.00	236.00	234.00	43.00	42.00	43.00	42.00	0.00	0.00	0.00	1,366.00	
1.00	1.00	2.00	2.00	1.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	8.00	
24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	22,344.00	22,582.00	21,406.00	0.00	0.00	0.00	208,511.00	
2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
37.00	36.00	39.00	36.00	30.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	184.00	
23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	24,353.00	25,529.00	26,626.00	0.00	0.00	0.00	247,452.00	
9.00	12.00	10.00	11.00	12.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	60.00	
327,648.00	339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	238,241.00	236,782.00	234,296.00	0.00	0.00	0.00	2,567,748.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending March 31, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

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

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

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	418.00	414.00	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	132,592.00	134,200.00	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	161.00	171.00	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	16.00	19.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	205.00	178.00	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	1,234.00	1,202.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	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	30.00	28.00	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	1,900.00	1,755.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	790.00	755.00	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	137,346.00	138,722.00	0.00	0.00	0.00	

25,540.00	
1,021,488.00	
6,262.00	
1,910.00	
4,934.00	
131,706.00	
2.00	
9.00	
5.00	
1,488.00	
19,993.00	
74,063.00	
1,287,400.00	

NO

W

E
SUBTOTAL:

0.00

0.00

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

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	11.00	12.00	0.00	0.00	0.00	814.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending March 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	83,510.00	84,070.00	0.00	0.00	0.00		717,326.00		
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	4.00	4.00	0.00	0.00	0.00		165.00		
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	13.00	20.00	15.00	15.00	0.00	0.00	0.00		909.00		
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	209,854.00	210,525.00	0.00	0.00	0.00		1,861,923.00		
3720	AHC CARE EXPANDED	39.00	14.00	28.00	30.00	30.00	3.00	5.00	7.00	6.00	0.00	0.00	0.00		162.00		
SUBTOTAL:	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	292,654.00	293,401.00	294,632.00	0.00	0.00	0.00		2,581,299.00		

FO

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	128.00	5.00	7.00	9.00	14.00	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	81,983.00	82,215.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR	11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	1.00	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	81,992.00	82,230.00	0.00	0.00	0.00	

494.00	
669,949.00	
41.00	
670,484.00	

F
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	5,309.00	5,049.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	5,248.00	5,309.00	5,049.00	0.00	0.00	0.00	

39,674.00	
2.00	
39,676.00	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	250.00	245.00	245.00	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	34.00	33.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	279.00	278.00	0.00	0.00	0.00	

2,330.00	
303.00	
2,633.00	

N

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	23.00	24.00	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	209.00	208.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	152.00	159.00	166.00	135.00	139.00	1.00	2.00	2.00	3.00	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	234.00	235.00	0.00	0.00	0.00	

3.00	
4,972.00	
1,963.00	
759.00	
7,697.00	

M
SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	753,700.00	755,343.00	755,442.00	0.00	0.00	0.00		7,156,937.00		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
90,239.27	108,250.46	125,024.24	33,623.10	33,736.50	6,548.22	3,288.60	3,175.20	3,061.80	0.00	0.00	0.00	406,947.39	
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	7,895,191.50	7,754,915.70	0.00	0.00	0.00	74,580,219.50	
33,410.07	49,633.89	60,633.09	12,587.40	13,664.70	2,022.30	1,474.20	1,360.80	1,360.80	0.00	0.00	0.00	176,147.25	
188,040.49	185,565.67	183,915.79	246,078.00	248,856.30	43,045.38	19,618.20	19,278.00	19,164.60	0.00	0.00	0.00	1,153,562.43	
276,400.73	269,617.89	275,025.83	351,256.50	345,756.60	350,807.94	315,252.00	315,705.60	316,272.60	0.00	0.00	0.00	2,816,095.69	
801,291.72	810,641.04	819,761.21	1,325,702.70	1,341,635.40	217,234.08	98,147.70	99,338.40	101,493.00	0.00	0.00	0.00	5,615,245.25	
180,432.71	178,003.72	175,528.90	207,011.70	206,501.40	70,141.68	47,968.20	47,061.00	46,323.90	0.00	0.00	0.00	1,158,973.21	
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	2,124,719.10	2,125,456.20	0.00	0.00	0.00	18,641,469.53	
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	164,316.60	165,677.40	0.00	0.00	0.00	6,693,057.87	
1,649.88	1,558.22	1,420.73	1,701.00	1,587.60	464.94	340.20	283.50	283.50	0.00	0.00	0.00	9,289.57	
19,936.05	19,706.90	19,569.41	23,247.00	23,530.50	25,780.86	24,154.20	24,607.80	24,551.10	0.00	0.00	0.00	205,083.82	
11,136.69	11,045.03	11,090.86	13,381.20	13,267.80	3,682.98	2,381.40	2,438.10	2,381.40	0.00	0.00	0.00	70,805.46	
45.83	45.83	91.66	113.40	56.70	0.00	0.00	0.00	56.70	0.00	0.00	0.00	410.12	
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	1,280,399.40	1,213,720.20	0.00	0.00	0.00	11,126,305.75	
91.66	45.83	45.83	56.70	56.70	5.04	0.00	0.00	0.00	0.00	0.00	0.00	301.76	
1,695.71	1,649.88	1,787.37	2,041.20	1,701.00	350.28	113.40	56.70	56.70	0.00	0.00	0.00	9,452.24	
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	1,447,494.30	1,509,694.20	0.00	0.00	0.00	13,240,688.06	
412.47	549.96	458.30	623.70	680.40	81.90	56.70	113.40	113.40	0.00	0.00	0.00	3,090.23	
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	13,425,539.40	13,284,583.20	0.00	0.00	0.00	135,907,145.13	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending March 31, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

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

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

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	23,700.60	23,473.80	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	7,517,966.40	7,609,140.00	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	9,128.70	9,695.70	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	907.20	1,077.30	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	53,437.78	49,863.04	46,929.92	23,190.30	20,922.30	21,605.22	12,700.80	11,623.50	10,092.60	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	69,967.80	68,153.40	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	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	1,701.00	1,587.60	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	107,730.00	99,508.50	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	657,018.88	664,076.70	688,549.92	760,687.20	776,903.40	86,912.28	44,226.00	44,793.00	42,808.50	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	7,787,518.20	7,865,537.40	0.00	0.00	0.00	

1,356,372.92	
55,964,578.26	
322,690.87	
97,108.05	
250,365.46	
6,670,521.53	
113.40	
455.16	
260.97	
77,918.39	
1,054,506.69	
3,765,975.88	
69,560,867.58	

NO

W

E
SUBTOTAL:

15.12

15.12

3610	AHC CARE EXPANDED	0.00	0.00	0.00	0.00	0.00	15.12	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	15.12	0.00	0.00	0.00	0.00	0.00	0.00	

FO
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	623.70	680.40	0.00	0.00	0.00	44,392.30

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending March 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	4,735,017.00	4,766,769.00	0.00	0.00	0.00		38,505,865.00		
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	226.80	226.80	0.00	0.00	0.00		8,612.99		
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	850.50	850.50	0.00	0.00	0.00		49,191.90		
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     11,898,721.80	11,936,767.50	0.00	0.00	0.00		100,009,165.89		
3720	AHC CARE EXPANDED	1,787.37	641.62	1,283.24	1,701.00	1,701.00	311.22	283.50	396.90	340.20	0.00	0.00	0.00		8,446.05		
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	16,635,836.70	16,705,634.40	0.00	0.00	0.00		138,625,674.13		

FO

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	510.30	793.80	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	4,648,436.10	4,661,590.50	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR	504.13	229.15	274.98	510.30	453.60	76.86	0.00	0.00	56.70	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	4,648,946.40	4,662,441.00	0.00	0.00	0.00	

26,445.45	
35,931,091.90	
2,105.72	
35,959,643.07	

F
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	301,020.30	286,278.30	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	139,506.52	128,644.81	116,316.54	281,458.80	305,442.90	316,514.52	297,561.60	301,020.30	286,278.30	0.00	0.00	0.00	

2,172,630.89	
113.40	
2,172,744.29	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	12,740.74	12,511.59	12,465.76	15,025.50	14,345.10	15,710.94	14,175.00	13,891.50	13,891.50	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	1,927.80	1,871.10	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	15,819.30	15,762.60	0.00	0.00	0.00	

124,757.63	
16,293.12	
141,050.75	

N

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	1,304.10	1,360.80	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	11,850.30	11,793.60	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	6,966.16	7,286.97	7,607.78	7,654.50	7,881.30	762.30	113.40	113.40	170.10	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	13,267.80	13,324.50	0.00	0.00	0.00	

142.53	
253,004.08	
104,742.10	
38,555.91	
396,444.62	

M
SUBTOTAL:

382,763,584.69

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	42,827,948.10	42,833,561.40	0.00	0.00	0.00	

TOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	58.00	56.00	54.00	0.00	0.00	0.00	8,480.00	
178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	139,245.00	136,771.00	0.00	0.00	0.00	1,410,757.00	
729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	24.00	24.00	0.00	0.00	0.00	3,705.00	
4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	340.00	338.00	0.00	0.00	0.00	22,257.00	
6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	5,560.00	5,568.00	5,578.00	0.00	0.00	0.00	52,533.00	
17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	1,752.00	1,790.00	0.00	0.00	0.00	107,119.00	
3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	830.00	817.00	0.00	0.00	0.00	22,261.00	
41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	37,346.00	37,473.00	37,486.00	0.00	0.00	0.00	349,094.00	
24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	2,899.00	2,898.00	2,922.00	0.00	0.00	0.00	129,948.00	
36.00	34.00	31.00	30.00	28.00	5.00	6.00	5.00	5.00	0.00	0.00	0.00	180.00	
435.00	430.00	427.00	410.00	415.00	417.00	426.00	434.00	433.00	0.00	0.00	0.00	3,827.00	
243.00	241.00	242.00	236.00	234.00	43.00	42.00	43.00	42.00	0.00	0.00	0.00	1,366.00	
1.00	1.00	2.00	2.00	1.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	8.00	
24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	22,344.00	22,582.00	21,406.00	0.00	0.00	0.00	208,511.00	
2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
37.00	36.00	39.00	36.00	30.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	184.00	
23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	24,353.00	25,529.00	26,626.00	0.00	0.00	0.00	247,452.00	
9.00	12.00	10.00	11.00	12.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	60.00	
327,648.00	339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	238,241.00	236,782.00	234,296.00	0.00	0.00	0.00	2,567,748.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending March 31, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

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

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

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	418.00	414.00	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	132,592.00	134,200.00	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	161.00	171.00	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	16.00	19.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	205.00	178.00	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	1,234.00	1,202.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	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	30.00	28.00	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	1,900.00	1,755.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	790.00	755.00	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	137,346.00	138,722.00	0.00	0.00	0.00	

25,540.00	
1,021,488.00	
6,262.00	
1,910.00	
4,934.00	
131,706.00	
2.00	
9.00	
5.00	
1,488.00	
19,993.00	
74,063.00	
1,287,400.00	

NO

W

E
SUBTOTAL:

0.00

0.00

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

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	11.00	12.00	0.00	0.00	0.00	814.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending March 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	83,510.00	84,070.00	0.00	0.00	0.00		717,326.00		
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	4.00	4.00	0.00	0.00	0.00		165.00		
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	13.00	20.00	15.00	15.00	0.00	0.00	0.00		909.00		
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	209,854.00	210,525.00	0.00	0.00	0.00		1,861,923.00		
3720	AHC CARE EXPANDED	39.00	14.00	28.00	30.00	30.00	3.00	5.00	7.00	6.00	0.00	0.00	0.00		162.00		
SUBTOTAL:	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	292,654.00	293,401.00	294,632.00	0.00	0.00	0.00		2,581,299.00		

FO

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	128.00	5.00	7.00	9.00	14.00	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	81,983.00	82,215.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR	11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	1.00	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	81,992.00	82,230.00	0.00	0.00	0.00	

494.00	
669,949.00	
41.00	
670,484.00	

F
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	5,309.00	5,049.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	5,248.00	5,309.00	5,049.00	0.00	0.00	0.00	

39,674.00	
2.00	
39,676.00	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	250.00	245.00	245.00	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	34.00	33.00	0.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	279.00	278.00	0.00	0.00	0.00	

2,330.00	
303.00	
2,633.00	

N

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	23.00	24.00	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	209.00	208.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	152.00	159.00	166.00	135.00	139.00	1.00	2.00	2.00	3.00	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	234.00	235.00	0.00	0.00	0.00	

3.00	
4,972.00	
1,963.00	
759.00	
7,697.00	

M
SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	753,700.00	755,343.00	755,442.00	0.00	0.00	0.00		7,156,937.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending March 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	556,030.63	500,528.48	0.00	0.00	0.00		6,526,911.76		
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	392,551.57	391,542.44	0.00	0.00	0.00		3,352,419.93		
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     15,756,555.82	15,870,587.51	0.00	0.00	0.00		135,186,949.61		
5010	SOBRA PREGNANT WO	19,505.22	15,789.94	16,718.76	20,182.60	13,118.69	14,702.54	9,082.17	13,118.69	16,146.08	0.00	0.00	0.00		138,364.69		
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	16,718,256.71	16,778,804.51	0.00	0.00	0.00		145,210,565.43		

MAN

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	
		
	756,689.11	
F
SUBTOTAL:	
756,689.11	
		
TOTAL:	145,968,263.67	

FO

1,009.13

4410	SOBRA 100-133% FOR	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	89,800.52	89,812.57	88,803.44	94,858.22	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	88,803.44	94,858.22	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	16,807,060.15	16,873,662.73	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending March 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	551.00	496.00	0.00	0.00	0.00		6,517.00		
2210	SSI DISABLED NON-ME D	365.00	364.00	363.00	355.00	372.00	392.00	385.00	389.00	388.00	0.00	0.00	0.00		3,373.00		
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	15,614.00	15,727.00	0.00	0.00	0.00		136,079.00		
5010	SOBRA PREGNANT WO	21.00	17.00	18.00	20.00	13.00	13.00	9.00	13.00	16.00	0.00	0.00	0.00		140.00		
SUBTOTAL:	15,676.00	15,961.00	16,064.00	15,728.00	16,202.00	16,507.00	16,783.00	16,567.00	16,627.00	0.00	0.00	0.00		146,115.00		

MAN

1.00

1.00

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

3710	AHC CARE EXPANDED
FO
SUBTOTAL:

766.00

766.00

4410	SOBRA 100-133% FOR	79.00	77.00	72.00	95.00	85.00	87.00	89.00	88.00	94.00	0.00	0.00	0.00	
	79.00	77.00	72.00	95.00	85.00	87.00	89.00	88.00	94.00	0.00	0.00	0.00	

F
SUBTOTAL:

TOTAL:	15,755.00	16,038.00	16,136.00	15,824.00	16,287.00	16,594.00	16,872.00	16,655.00	16,721.00	0.00	0.00	0.00		146,882.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending March 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	1,510.40	1,510.40	0.00	0.00	0.00		11,979.42		
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	196,352.00	195,596.80	0.00	0.00	0.00		1,567,468.24		
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	8,190.08	10,177.60	0.00	0.00	0.00		89,007.74		
1012	TANF 01-05 M & F NON	25,956.96	17,113.95	14,612.31	18,336.96	14,543.64	11,297.04	8,667.20	7,235.84	5,327.36	0.00	0.00	0.00		123,091.26		
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	8,149.12	7,672.00	0.00	0.00	0.00		147,458.42		
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	4,452.16	3,696.96	0.00	0.00	0.00		50,155.33		
1015	TANF 14-20 FEMALE N	9,017.55	7,766.73	8,687.88	9,905.64	7,777.08	8,787.60	6,638.72	4,452.16	3,418.88	0.00	0.00	0.00		66,452.24		
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	1,431.36	1,431.36	0.00	0.00	0.00		10,506.12		
2110	SSI AGED NON-MEDICA R	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		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	477.12	477.12	0.00	0.00	0.00		954.24		
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	23,411.20	23,888.32	0.00	0.00	0.00		155,938.74		
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	4,533,774.72	4,534,529.92	0.00	0.00	0.00		36,100,658.04		
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	43,921.60	43,921.60	0.00	0.00	0.00		326,808.49		
2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	737.16	737.16	737.16	755.20	755.20	755.20	0.00	0.00	0.00		5,989.71		
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	40,543.68	41,298.88	0.00	0.00	0.00		324,609.26		
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	26,314.88	21,028.48	0.00	0.00	0.00		202,568.87		
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	191,849.60	196,778.88	0.00	0.00	0.00		1,569,919.01		
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	227,826.88	221,308.16	0.00	0.00	0.00		1,704,567.40		
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	55,296.32	54,143.04	0.00	0.00	0.00		397,304.86		
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	55,378.24	55,179.20	0.00	0.00	0.00		419,346.88		
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	1,232.32	954.24	0.00	0.00	0.00		18,498.89		
	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	5,432,554.88	5,423,094.40	0.00	0.00	0.00		43,298,210.84		

O

SUBTOTAL:

1113	TANF EXPANDED 06-13	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	463.80	0.00	463.80	477.12	477.12	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	477.12	0.00	0.00	0.00	0.00	

416.94	
1,881.84	
2,178.42	
940.92	
5,418.12	

SUBTOTAL:

3514	ADULT 40-100% MALE 1	833.88	833.88	833.88	927.60	1,391.40	1,391.40	1,431.36	2,385.60	2,385.60	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	954.24	954.24	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	477.12	477.12	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	477.12	477.12	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	6,254.10	7,087.98	6,671.04	6,029.40	6,029.40	6,029.40	6,679.68	6,679.68	8,111.04	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM	3,752.46	4,169.40	4,169.40	5,101.80	5,101.80	6,029.40	6,202.56	6,202.56	7,156.80	0.00	0.00	0.00	

12,414.60	
6,278.64	
2,358.96	
1,418.04	
59,571.72	
47,886.18	

AL

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

RATE CODE	DESCRIPTION
3716

ADULT <40% EXP MALE

JULY
416.94

AUGUST	SEPTEMBER
416.94	416.94

OCTOBER
1,391.40

NOVEMBER
927.60

DECEMBER
927.60

JANUARY
477.12

FEBRUARY
477.12

MARCH
477.12

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

5,928.78

3717

ADULT <40% EXP FEM

AL
SUBTOTAL:

416.94

12,508.20

416.94

13,759.02

416.94

13,342.08

463.80

15,305.40

927.60

14,841.60

1,391.40

16,696.80

1,431.36

17,176.32

477.12

18,130.56

477.12

20,516.16

0.00

0.00

0.00

0.00

0.00

0.00

6,419.22

142,276.14

1,250.82

1,250.82

3915	NEWLY ELIGIBLE FEMA	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

L

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	12,206.08	13,160.32	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	3,816.96	4,294.08	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	833.88	833.88	416.94	1,391.40	1,855.20	1,855.20	1,431.36	1,431.36	1,908.48	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	17,454.40	19,362.88	0.00	0.00	0.00	

89,769.30	
29,238.09	
11,957.70	
130,965.09	

L
SUBTOTAL:

43,578,121.01

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	5,468,616.96	5,462,973.44	0.00	0.00	0.00	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending March 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	2.00	2.00	0.00	0.00	0.00		18.00		
1010	TANF NON-MEDICARE	264.00	259.00	261.00	264.00	264.00	262.00	262.00	260.00	259.00	0.00	0.00	0.00		2,355.00		
1011	TANF <1 M & F NON-ME	21.00	24.00	24.00	19.00	23.00	21.00	18.00	16.00	19.00	0.00	0.00	0.00		185.00		
1012	TANF 01-05 M & F NON	61.00	40.00	34.00	36.00	29.00	22.00	17.00	14.00	10.00	0.00	0.00	0.00		263.00		
1013	TANF 06-13 M & F NON	70.00	51.00	42.00	39.00	34.00	26.00	16.00	13.00	12.00	0.00	0.00	0.00		303.00		
1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	11.00	11.00	8.00	7.00	7.00	6.00	0.00	0.00	0.00		100.00		
1015	TANF 14-20 FEMALE N	21.00	18.00	20.00	19.00	15.00	16.00	11.00	7.00	6.00	0.00	0.00	0.00		133.00		
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	3.00	3.00	0.00	0.00	0.00		23.00		
2110	SSI AGED NON-MEDICA R	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		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00		2.00		
2200	SSI DISABLED WITH M E	17.00	19.00	24.00	25.00	27.00	27.00	28.00	31.00	32.00	0.00	0.00	0.00		230.00		
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	6,175.00	6,176.00	0.00	0.00	0.00		55,627.00		
2220	SSI DISABLED WITH Q M	49.00	51.00	52.00	52.00	56.00	56.00	61.00	60.00	60.00	0.00	0.00	0.00		497.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00		9.00		
2310	SSI BLIND NON-MEDIC A	56.00	57.00	56.00	56.00	57.00	56.00	57.00	57.00	58.00	0.00	0.00	0.00		510.00		
4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	40.00	36.00	39.00	39.00	40.00	33.00	0.00	0.00	0.00		355.00		
4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	311.00	321.00	330.00	323.00	324.00	332.00	0.00	0.00	0.00		2,886.00		
4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	342.00	345.00	361.00	377.00	386.00	377.00	0.00	0.00	0.00		3,126.00		
4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	80.00	80.00	77.00	87.00	92.00	89.00	0.00	0.00	0.00		726.00		
4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	84.00	87.00	91.00	94.00	98.00	97.00	0.00	0.00	0.00		793.00		
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	2.00	2.00	0.00	0.00	0.00		38.00		
	7,546.00	7,561.00	7,581.00	7,572.00	7,566.00	7,600.00	7,600.00	7,589.00	7,575.00	0.00	0.00	0.00		68,190.00		

O

SUBTOTAL:

1113	TANF EXPANDED 06-13	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	1.00	0.00	1.00	1.00	1.00	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	1.00	0.00	0.00	0.00	0.00	

1.00	
4.00	
5.00	
2.00	
12.00	

SUBTOTAL:

3514	ADULT 40-100% MALE 1	2.00	2.00	2.00	2.00	3.00	3.00	3.00	5.00	5.00	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	2.00	2.00	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	1.00	1.00	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	1.00	1.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	15.00	17.00	16.00	13.00	13.00	13.00	14.00	14.00	17.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM	9.00	10.00	10.00	11.00	11.00	13.00	13.00	13.00	15.00	0.00	0.00	0.00	

27.00	
14.00	
5.00	
3.00	
132.00	
105.00	

AL

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

RATE CODE	DESCRIPTION
3716

ADULT <40% EXP MALE

JULY
1.00

AUGUST	SEPTEMBER
1.00	1.00

OCTOBER
3.00

NOVEMBER
2.00

DECEMBER
2.00

JANUARY
1.00

FEBRUARY
1.00

MARCH
1.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

13.00

3717

ADULT <40% EXP FEM

AL
SUBTOTAL:

1.00

30.00

1.00

33.00

1.00

32.00

1.00

33.00

2.00

32.00

3.00

36.00

3.00

36.00

1.00

38.00

1.00

43.00

0.00

0.00

0.00

0.00

0.00

0.00

14.00

313.00

3.00

3.00

3915	NEWLY ELIGIBLE FEMA	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

L

4413	SOBRA 100-133% M&F
6	11.00	10.00	9.00	26.00	29.00	24.00	28.00	25.00	27.00	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	8.00	9.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	2.00	2.00	1.00	3.00	4.00	4.00	3.00	3.00	4.00	0.00	0.00	0.00	
	17.00	16.00	12.00	38.00	41.00	37.00	39.00	36.00	40.00	0.00	0.00	0.00	

189.00	
61.00	
26.00	
276.00	

L
SUBTOTAL:

TOTAL:	7,596.00	7,612.00	7,627.00	7,645.00	7,641.00	7,674.00	7,677.00	7,664.00	7,658.00	0.00	0.00	0.00		68,794.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 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	1,092.57	4,020.51	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	17,394.35	18,811.72	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	10,333.60	13,834.50	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	9,839.90	6,684.57	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	1,167,621.49	1,393,494.73	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	422,555.75	429,550.76	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	407,893.17	362,611.93	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	104,596.61	135,873.26	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	267,364.55	343,076.17	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	1,517,622.85	1,716,325.37	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	5,346,047.51	6,014,474.27	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	1,947,442.44	2,184,548.78	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	2,489.62	2,008.17	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	757.91	-795.52	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	9,792.04	3,745.74	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	3,817.11	5,130.56	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	321.47	835.65	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	100,955.06	115,057.59	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	125,205.47	128,787.96	211,507.53	151,466.88	159,319.29	137,030.36	79,330.72	104,082.71	122,697.74	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	431,984.17	491,704.98	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	311,838.41	351,602.56	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	8,070,657.42	8,785,140.60	10,377,505.66	6,855,292.97	7,625,934.11	8,790,935.35	6,487,472.46	7,149,338.35	8,605,092.22	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	1,168,128.25	1,458,952.67	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	1,810.10	1,465.51	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	65,945.33	66,188.40	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	13,553.32	14,945.44	0.00	0.00	0.00	
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	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	
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.40	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	2,206,041.64	2,830,393.06	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	4,062,923.99	4,593,546.76	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	4,435,539.88	5,177,069.20	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	1,174,919.15	1,451,591.65	0.00	0.00	0.00	

87,391.65	
173,433.29	
273,278.51	
109,041.07	
10,369,742.97	
6,451,680.76	
9,212,093.28	
2,322,934.84	
4,565,879.52	
15,651,403.85	
56,056,601.44	
20,138,254.99	
61,576.10	
7,120.97	
28,663.35	
67,807.77	
28,112.93	
1,321,617.26	
1,219,428.66	
3,659,870.97	
3,481,447.85	
72,747,369.14	
11,156,692.60	
12,809.16	
752,732.65	
134,656.32	
368.00	
700.00	
411.40	
19,734,286.98	
30,961,378.55	
41,460,174.76	
11,097,221.80	

D

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	1,854,063.98	1,731,347.86	0.00	0.00	0.00		14,453,253.65		
5007	SOBRA PREG 21-44 FE M	0.00	700.00	700.00	0.00	21.79	885.87	2,158.62	1,054.83	601.96	0.00	0.00	0.00		6,123.07		
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	442,194.06	373,712.68	0.00	0.00	0.00		3,793,051.08		
5017	SOBRA PREG 21-44 FE	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	2,090,744.67	2,370,240.47	0.00	0.00	0.00		19,032,756.62		
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	6,217.94	5,797.37	0.00	0.00	0.00		43,070.85		
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	122.80	0.00	13.42	0.00	0.00	0.00		148.69		
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.44	972.25	0.00	0.00	0.00		1,195.69		
	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	36,858,542.22	42,398,004.36	0.00	0.00	0.00		360,682,762.74		

M

M

SUBTOTAL:

310.15

310.15

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	85.42	0.00	215.79	8.94	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	85.42	0.00	215.79	8.94	0.00	0.00	0.00	

1
SUBTOTAL:

1103	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	
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	6,469.57	16,041.72	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	37,544.22	46,247.87	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	94,142.74	113,370.04	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	23,910.19	20,501.26	32,963.26	25,925.52	28,936.18	44,064.76	32,925.55	36,555.48	51,233.02	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	10,572.08	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	700.00	2,193.04	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	4,081.97	3,187.71	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	25,278.96	17,711.99	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	21,152.12	32,015.69	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	691,986.06	831,793.09	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	2,022,623.52	2,272,005.03	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	1,479,753.31	1,712,417.59	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	4,243.61	1,769.51	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	17,196.24	33,652.25	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	10,412.75	8,900.15	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	40,218.45	30,699.43	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	18,941.10	18,596.14	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	7,563.99	10,437.33	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	6,894.62	14,304.97	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	342,898.10	387,850.64	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	22,118.60	22,690.42	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	300,375.73	232,843.02	283,300.90	217,797.74	205,261.69	195,292.13	256,913.01	238,778.45	154,090.29	0.00	0.00	0.00	

700.00	
350.00	
106,746.83	
312,196.31	
757,943.66	
297,015.22	
10,679.87	
20,527.05	
114,810.86	
129,688.80	
278,373.34	
5,037,974.97	
14,915,921.24	
9,789,155.89	
18,697.35	
76,317.64	
45,710.30	
178,863.65	
104,079.94	
173,347.80	
343,048.67	
3,465,422.53	
201,460.80	
2,084,652.96	

M&

E

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

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
285,198.27	311,126.24	453,402.95	307,810.33	270,330.08	426,260.66	264,912.45	354,964.61	400,100.25	0.00	0.00	0.00	3,074,105.84	
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	5,495,090.55	6,182,008.17	0.00	0.00	0.00	41,537,791.52	

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	
3317	AHC CARE FEMALE 21- 4	-527.88	0.00	-316.00	0.00	0.00	-453.42	-381.79	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	-12,669.89	0.00	0.00	-883.27	-304.13	-3,862.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
21.62	
-104.62	
-1,679.09	
-17,719.29	
-19,481.38	

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	-2,555.66	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	
SUBTOTAL:	22,658.87	-52.99	14,341.74	-591.99	0.00	-17,059.19	-20.32	-2,555.66	0.00	0.00	0.00	0.00	

 
-1,057.32	
-189.98	
60.75	
-2,238.34	
12,313.57	
-30,464.86	
-4,345.44	
42,642.08	
16,720.46	

3506	ADULT 40-100% MALE 2	100.62	646.90	826.55	497.49	10.06	856.86	1,069.02	1,858.79	1,822.67	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	5,851.40	8,541.99	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	123.99	1,443.91	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	37,993.00	32,505.45	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	67,697.22	69,756.52	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	690,624.50	911,327.86	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	448,531.84	490,065.88	644,008.43	391,103.49	455,793.22	454,636.85	383,720.88	497,374.37	568,875.75	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	1,710,645.51	1,990,367.28	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	1,050.00	1,071.06	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	99.44	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45.52	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	139.94	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	278.87	1,063.00	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	61.40	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	254.18	187.24	2,147.85	720.29	183.04	2,139.90	710.15	794.19	1,633.86	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	535.05	1,398.23	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	20,398.58	29,175.88	21,993.36	25,199.18	23,133.12	24,274.24	12,893.26	18,257.36	19,368.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	662.62	898.69	1,365.10	1,918.68	573.77	221.31	248.38	485.23	0.00	0.00	0.00	0.00	

7,688.96	
402.04	
55,831.87	
12,248.09	
273,034.35	
674,435.53	
6,492,351.66	
4,334,110.71	
16,012,762.53	
30,120.45	
661.00	
45.52	
486.23	
2,418.32	
130.19	
8,770.70	
37,886.12	
194,692.98	
6,373.78	

E

4

6

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	222,884.44	394,365.52	460,111.11	290,538.55	301,852.22	316,910.70	209,200.65	351,331.06	245,132.00	0.00	0.00	0.00		2,792,326.25		
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	337,307.92	367,114.90	0.00	0.00	0.00		2,866,138.68		
3716	ADULT <40% EXP MALE	5,628,508.71	6,879,358.31	8,226,675.54	5,692,613.38	6,424,354.58	7,064,928.46	5,710,963.95	6,116,850.11	6,433,015.94	0.00	0.00	0.00		58,177,268.98		
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	3,323,535.99	3,679,812.69	0.00	0.00	0.00		31,198,607.57		
3718	ADULT <40% EXP M&F	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	7,926,659.09	8,921,833.44	0.00	0.00	0.00		74,223,784.36		
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	6,975.10	4,539.12	0.00	0.00	0.00		100,203.28		
3727	ADULT <40% EXP FEM	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	1,050.00	2,310.25	0.00	0.00	0.00		8,873.45		
	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	21,097,340.15	23,263,218.82	0.00	0.00	0.00		197,512,519.80		

4

AL

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	21.47	708.58	404.29	0.00	101.64	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	838.07	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	1,191.85	8,667.13	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	1,221.62	583.12	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	9,201.50	8,963.80	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	40,600.22	33,218.76	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	341,854.67	413,690.33	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	504,371.44	758,419.76	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	942,329.91	1,085,969.23	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	164.48	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71.47	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	47.11	350.00	59.40	0.00	48.25	10.07	0.00	145.14	13.39	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	1,841,089.46	2,310,528.07	0.00	0.00	0.00	

2,635.98	
4,380.17	
71,010.31	
7,544.48	
112,413.20	
270,693.43	
3,455,070.82	
4,748,677.27	
9,593,230.74	
7,164.48	
71.47	
673.36	
18,273,565.71	

4
SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	208,919.81	208,659.92	145,887.27	356,231.37	470,925.81	559,700.27	435,224.20	502,373.49	599,023.51	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	155,565.47	129,054.20	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	72,034.45	135,577.62	72,403.64	179,192.24	176,144.29	203,844.54	143,597.42	184,770.46	212,895.75	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	842,709.42	940,973.46	0.00	0.00	0.00	

700.00	
3,486,945.65	
1,145,598.18	
1,380,460.41	
6,013,704.24	

SUBTOTAL:

20,613.41

104,527.50

22.40

18,342.75

9,981.77

153,487.83

4517	BC PATIENT FEMALE 2 1	5,936.00	6,300.97	5,519.97	999.09	457.38	700.00	350.00	350.00	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	9,371.41	11,540.42	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.40	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	4,085.95	1,050.00	2,131.49	2,168.06	0.00	0.00	477.80	0.00	68.47	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	9,721.41	11,631.29	0.00	0.00	0.00	

5
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	11,561.27	8,806.49	0.00	0.00	0.00	71,081.05

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

RATE CODE	DESCRIPTION
8710

JULY
2,100.00

AUGUST	SEPTEMBER
2,528.61	332.93

OCTOBER	NOVEMBER
1,759.52	13,816.87

DECEMBER
1,050.00

JANUARY
350.00

FEBRUARY
4,815.46

MARCH
6,771.98

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

33,525.37

8720

SSI DISABLED FREEDO
M
SSI DISABLED FREEDO

M
SUBTOTAL:

59.40

6,021.31

237.60

13,911.92

367.94

11,155.25

0.00

7,867.16

10.26

18,911.44

0.00

11,874.80

0.00

3,584.54

54.94

16,431.67

2,032.04

17,610.51

0.00

0.00

0.00

0.00

0.00

0.00

2,762.18

107,368.60

624,278,463.04

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	66,158,585.01	75,123,983.62	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending March 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	1,741.47	0.00	0.00	0.00	2,072.05	
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	4,559.67	1,252.84	0.00	0.00	0.00	42,344.40	
1012	TANF 01-05 M & F NON	1,999.68	0.00	6,173.64	0.00	177.03	57.31	0.00	2,537.49	2,118.94	0.00	0.00	0.00	13,064.09	
1013	TANF 06-13 M & F NON	0.00	0.00	-29.23	37.11	314.79	409.90	279.94	-77.87	2,547.85	0.00	0.00	0.00	3,482.49	
1014	TANF 14-20 MALE NON-	1,639.96	371.56	1,298.43	1,214.10	4,020.29	977.96	48.87	2,339.30	3,778.06	0.00	0.00	0.00	15,688.53	
1015	TANF 14-20 FEMALE N	10,367.88	4,369.23	19,961.56	6,311.54	3,726.06	2,690.31	9,837.71	9,941.07	24,032.76	0.00	0.00	0.00	91,238.12	

1016	O
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	
47,120.66	
53,047.20	
0.00	
0.00	
0.00	
374,788.51	
1017	TANF 21-44 FEMALE N	85,071.84	122,995.47	128,349.71	151,849.80	85,693.87	133,933.74	151,562.92	158,767.56	160,552.67	0.00	0.00	0.00	1,178,777.58	

1018	O
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	
80,416.65	
92,502.55	
0.00	
0.00	
0.00	
412,232.09	
2100	SSI AGED WITH MEDIC	4,288.93	2,161.00	6,039.80	3,610.04	6,310.04	9,322.70	2,791.86	9,847.88	21,030.41	0.00	0.00	0.00	65,402.66	
2110	A
SSI AGED NON-MEDICA	16,932.19	33,017.03	46,637.60	18,239.09	16,129.07	54,594.05	4,788.76	8,599.35	20,725.80	0.00	0.00	0.00	
219,662.94	
2120	R
SSI AGED WITH QMB	0.00	807.00	131.79	1,379.48	288.97	25.56	238.50	125.82	133.38	0.00	0.00	0.00	
3,130.50	
2200	SSI DISABLED WITH M	488.66	1,617.07	3,610.05	1,642.17	3,477.20	5,815.21	1,683.14	2,500.96	5,972.70	0.00	0.00	0.00	26,807.16	
2210	E
SSI DISABLED NON-ME	39,007.48	95,497.11	23,513.88	6,329.44	33,843.11	15,669.91	13,471.38	6,126.55	48,631.41	0.00	0.00	0.00	
282,090.27	

2220	D
SSI DISABLED WITH Q	
0.00	
1,277.10	
1,336.18	
934.55	
209.71	
96.81	
0.00	
0.00	
687.60	
0.00	
0.00	
0.00	
4,541.95	
2310	M
SSI BLIND NON-MEDIC	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	A
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	
35,891.36	
55,084.76	
0.00	
0.00	
0.00	
579,028.19	
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	38,609.61	83,319.77	0.00	0.00	0.00	517,406.75	
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	45,523.31	46,763.87	0.00	0.00	0.00	509,456.01	
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	24,593.48	17,117.66	0.00	0.00	0.00	275,685.89	
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	14,069.64	19,010.66	0.00	0.00	0.00	258,526.49	
5007	SOBRA PREG 21-44 FE	1,316.92	-622.54	620.43	373.01	0.00	0.00	0.00	0.00	295.24	0.00	0.00	0.00	1,983.06	
5015	M
SOBRA PREG 14-20 FE	17,081.33	30,674.40	30,351.24	28,628.36	24,395.73	18,499.32	16,365.78	17,807.82	22,922.79	0.00	0.00	0.00	
206,726.77	
5017	M
SOBRA PREG 21-44 FE	77,766.50	80,269.95	104,810.09	109,667.47	114,599.68	69,726.40	73,096.12	81,771.79	101,626.20	0.00	0.00	0.00	
813,334.20	

5018	M
SOBRA PREG 45-64 FE	
0.00	
28.27	
0.00	
0.00	
-28.27	
1,541.56	
83.27	
28.84	
625.41	
0.00	
0.00	
0.00	
2,279.08	
8040	M SLMB	6,944.53	49.41	807.03	-83.03	73.45	0.00	34.58	1,075.71	0.00	0.00	0.00	0.00	
8,901.68	
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	

SUBTOTAL:

587,535.49

650,200.47	696,955.04	585,072.80	618,483.47	702,700.45	696,545.52	592,176.65	785,522.00	0.00	0.00	0.00	5,915,191.89

1106	TANF EXPANDED 21-44	0.00	93.33	88.81	2,077.39	12.33	0.00	1,050.00	6.45	21.58	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	919.37	7.78	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	

 
3,349.89

1,001.27

14,171.34

515.10

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending March 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	864.92	1,201.10	0.00	0.00	0.00		111,768.85		
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	23,316.76	10,728.11	0.00	0.00	0.00		281,836.04		
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	7,451.35	1,663.35	0.00	0.00	0.00		205,131.60		
1119	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,132.11	1,817.74	0.00	0.00	0.00		11,949.85		
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	6,540.46	5,919.34	0.00	0.00	0.00		79,903.47		
2410	SSI AGED EXPANDED	979.32	10,480.42	0.00	3,960.00	1,445.40	-3,716.92	285.17	0.00	249.90	0.00	0.00	0.00		13,683.29		
2420	SSI AGED EXPANDED WI	550.98	1,286.23	328.44	378.82	327.11	134.82	1,901.11	604.06	305.72	0.00	0.00	0.00		5,817.29		
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	111.94	5,713.92	0.00	0.00	0.00		27,881.39		
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	2,986.58	919.23	0.00	0.00	0.00		48,004.72		
2620	SSI DISABLED EXPAND E	260.03	91.97	253.43	619.21	133.42	173.46	0.00	15.22	973.78	0.00	0.00	0.00		2,520.52		
	87,190.43	129,664.23	206,137.87	97,618.58	107,668.07	63,749.50	43,191.25	52,949.22	29,521.55	0.00	0.00	0.00		817,690.70		

M&

NO

SUBTOTAL:

3508	ADULT 40-100% M&F 45	39.84	0.00	636.68	0.00	6.87	832.12	35.00	0.00	1.69	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	1,101.67	817.81	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	1,886.22	8,315.13	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	29,842.62	41,392.16	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	32,675.55	17,076.85	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	86,660.18	70,960.55	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	83.25	1,075.63	243.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	35.04	0.00	128.60	309.42	104.58	83.91	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	1,587.28	0.00	57.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	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	42.68	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	-3,202.73	15,501.02	18,183.71	10,358.26	16,379.49	3,249.11	8,077.80	8,476.52	16,599.09	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	10,607.81	9,525.98	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	167,516.26	204,690.38	358,830.19	199,648.63	205,387.98	182,804.58	164,588.69	183,990.26	291,256.94	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	65,397.36	89,375.74	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	509,517.40	226,831.70	0.00	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	2,252.43	677.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.72	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	930,221.99	772,153.64	0.00	0.00	0.00	

1,552.20	
41,054.70	
66,095.21	
347,933.87	
258,702.14	
1,059,004.54	
1,401.96	
661.55	
1,644.30	
2,883.82	
407.09	
93,622.27	
115,949.08	
1,958,713.91	
889,781.36	
3,057,090.57	
2,930.35	
23.72	
7,899,452.64	

4
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	21.82	70.22	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	2,767.69	4,758.35	0.00	0.00	0.00	

 
306.05	
175.69	
1,607.92	
21,059.65	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	4,542.23	3,408.12	0.00	0.00	0.00		37,754.06		
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	35,051.94	83,243.55	0.00	0.00	0.00		525,232.08		
3917	NEWLY ELIGIBLE FEMA L	33,130.96	36,088.32	65,921.67	74,500.38	52,468.71	45,771.22	28,027.28	52,197.86	64,634.93	0.00	0.00	0.00		452,741.33		
3918	NEWLY ELIGIBLE M&F 4	88,508.51	131,570.76	163,768.01	128,365.27	173,085.98	142,740.97	94,421.96	67,032.79	121,009.27	0.00	0.00	0.00		1,110,503.52		
	160,593.88	215,500.31	316,273.51	262,679.06	334,687.99	251,089.81	169,816.97	161,614.33	277,124.44	0.00	0.00	0.00		2,149,380.30		

SUBTOTAL:

4412	SOBRA 100-133% M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	824.77	0.00	0.00	0.00	
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	6,564.92	23,413.21	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	760.22	3,442.07	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	867.96	4,065.21	16,099.57	3,552.16	3,166.06	6,247.80	4,525.10	2,673.99	7,383.42	0.00	0.00	0.00	
	10,263.36	18,645.33	51,585.46	21,237.13	18,232.67	31,429.55	26,388.42	9,999.13	35,063.47	0.00	0.00	0.00	

824.77	
132,474.76	
40,963.72	
48,581.27	
222,844.52	

1

L
SUBTOTAL:

2,070.14

2,070.14

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

5
SUBTOTAL:

5,703.96

5,010.33

10,714.29

8700	SSI DISABLED FREEDO M	141.21	1,493.16	2,014.03	306.31	0.00	27.56	92.28	756.38	873.03	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	0.00	137.00	661.16	678.06	162.48	0.00	48.87	3,322.76	0.00	0.00	0.00	0.00	
SUBTOTAL:	141.21	1,630.16	2,675.19	984.37	162.48	27.56	141.15	4,079.14	873.03	0.00	0.00	0.00	

M

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	1,751,040.46	1,900,258.13	0.00	0.00	0.00		17,017,344.48		

FAMILY PLANNING SERVICES
For The Period Ending March 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 March 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	93.19	912.23	0.00	0.00	0.00		8,604.45		
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	6,607.26	43,346.34	0.00	0.00	0.00		149,192.92		
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	71,497.01	96,250.56	0.00	0.00	0.00		530,965.08		
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	67,461.91	108,773.37	0.00	0.00	0.00		836,276.60		
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	314,537.89	527,009.92	0.00	0.00	0.00		3,666,264.90		
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	143,587.50	260,670.29	0.00	0.00	0.00		1,041,318.23		
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	2,239,111.05	4,698,671.32	0.00	0.00	0.00		26,583,128.75		
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	212,412.20	353,970.52	0.00	0.00	0.00		1,699,765.10		
1019	TANF 65+ M & F NON-M	974.37	580.16	36,530.93	189.47	5,569.41	908.59	2,030.43	1,232.20	18,953.67	0.00	0.00	0.00		66,969.23		
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	3,801.23	13,388.49	0.00	0.00	0.00		63,144.61		
2110	SSI AGED NON-MEDICA R	767,030.64	976,118.47	1,135,999.12	1,013,075.24	667,723.02	878,890.18	786,495.73	845,723.02	1,373,759.25	0.00	0.00	0.00		8,444,814.67		
2120	SSI AGED WITH QMB	0.00	1,247.40	0.00	491.05	0.00	30.26	0.00	0.00	0.00	0.00	0.00	0.00		1,768.71		
2200	SSI DISABLED WITH M E	15,487.16	14,895.52	19,590.18	15,828.97	7,325.35	7,561.88	13,231.61	12,318.35	16,646.04	0.00	0.00	0.00		122,885.06		
2210	SSI DISABLED NON-ME	388,846.01	233,518.99	496,312.04	330,185.22	270,923.16	597,379.32	438,012.70	255,428.45	599,589.63	0.00	0.00	0.00		3,610,195.52		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	764.97	142.20	0.00	35.09	0.00	0.00	0.00	0.00		942.26		
2310	SSI BLIND NON-MEDIC	-213.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-213.81		
	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	4,173,846.35	8,111,941.63	0.00	0.00	0.00		46,826,859.76		

D

A
SUBTOTAL:

1106	TANF EXPANDED 21-44	942.36	1,534.47	1,505.09	822.46	57.30	121.67	57.30	718.25	1,569.76	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	57.30	803.06	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	-1,801.37	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	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	137.60	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	830.92	700.11	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	5,344.01	15,369.13	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	358,011.75	454,998.05	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	776,624.15	1,467,576.31	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	280,931.39	455,141.28	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	3,657.03	11,697.59	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	779.03	753.90	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	1,289.11	250.98	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	32,073.51	61,013.58	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND	698.31	742.38	385.05	49.30	660.78	697.68	981.64	57.30	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	34,997.13	35,849.69	53,494.32	45,988.82	18,108.10	55,317.19	4,986.48	11,640.20	46,573.91	0.00	0.00	0.00	

7,328.66	
5,511.87	
8,151.39	
107.93	
312.04	
137.60	
24,171.95	
121,388.00	
3,490,008.83	
8,488,550.92	
3,204,211.89	
54,944.73	
1,532.93	
6,638.53	
445,769.40	
4,272.44	
306,955.84	

E

E

FEDERAL EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	1,472,013.95	2,514,783.89	0.00	0.00	0.00		16,169,994.95		

SUBTOTAL:

11.67

2,942.57

7,743.37

3,237.29

228.24

307.21

1,672.15

8,001.40

16,372.45

54,294.92

9.55

94,820.82

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	11.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	631.64	303.33	2,007.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	0.00	3,220.32	764.56	0.00	470.90	2,523.03	764.56	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	363.70	744.09	123.30	1,408.45	277.68	0.00	0.00	0.00	320.07	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	0.00	83.87	0.00	0.00	0.00	0.00	0.00	144.37	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	96.03	153.89	0.00	0.00	57.29	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	689.22	934.06	0.00	0.00	0.00	0.00	48.87	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	3,173.56	985.83	1,307.20	1,210.89	1,112.96	27.45	9.55	173.96	0.00	0.00	0.00	0.00	
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	
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	981.00	3,776.34	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.55	0.00	0.00	0.00	
	17,571.92	44,680.95	10,620.17	6,411.33	4,225.20	4,492.78	1,307.02	1,405.49	4,105.96	0.00	0.00	0.00	

E

4

6
SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	61.58	57.52	40.91	260.93	0.00	2,371.26	1,195.27	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	947.60	6.15	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	3,180.23	1,535.26	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F	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	-58,571.35	55,032.00	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	17,582.16	53,987.93	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	764,181.12	773,226.84	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	429,222.30	578,613.23	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	1,085,396.95	2,396,481.86	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	9,141.17	25,353.15	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	695.06	694.80	694.15	694.28	57.30	57.30	639.47	1,234.74	10.22	0.00	0.00	0.00	
SUBTOTAL:	1,701,574.81	1,999,987.75	3,176,830.75	2,397,433.76	1,935,178.27	2,586,750.28	2,498,424.16	2,253,744.73	3,885,435.76	0.00	0.00	0.00	

3,987.47	
953.75	
28,286.44	
294.80	
341,863.80	
359,099.19	
5,899,312.90	
3,421,121.09	
12,286,854.66	
85,879.91	
2,928.94	
4,777.32	
22,435,360.27	

L

6

4

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	7,901,010.52	14,516,267.24	0.00	0.00	0.00		85,527,035.80		

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	
														
													341.03	
4
SUBTOTAL:													

341.03	

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

722.08

3918	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	341.03	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	341.03	0.00	0.00	0.00	

0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	341.03	0.00	0.00	0.00	

TOTAL:

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

SUBTOTAL:

293,436.77

211,412.30

493,734.53

374,615.82

274,231.57

543,181.05

277,299.18

336,647.83

529,055.48

0.00

0.00

0.00

3,333,614.53

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	336,625.36	529,055.48	0.00	0.00	0.00	3,333,592.06	
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.47	0.00	0.00	0.00	0.00	22.47	

TOTAL:	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	277,299.18	336,647.83	529,055.48	0.00	0.00	0.00		3,333,614.53		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending March 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	0.00	0.00	0.00	0.00	0.00	0.00	3,673.21	0.00	0.00	0.00		3,673.21		
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	843.73	0.00	0.00	0.00	0.00		14,128.69		
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	12,660.82	32,213.81	0.00	0.00	0.00		419,570.94		
2110	SSI AGED NON-MEDICA R	61,148.18	60,953.07	9,698.95	112,583.05	49,546.66	80,506.33	78,467.63	118,752.34	102,231.07	0.00	0.00	0.00		673,887.28		
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	34,643.38	1,618.26	0.00	0.00	0.00		80,730.93		
2210	SSI DISABLED NON-ME	0.00	806.03	7.57	2,769.66	0.00	0.00	0.00	12,274.33	6,413.28	0.00	0.00	0.00		22,270.87		
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	2,792.64	7,556.14	0.00	0.00	0.00		21,909.30		
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	181,967.24	153,705.77	0.00	0.00	0.00		1,270,423.99		

D

SUBTOTAL:

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,974.54	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	4,142.44	100.05	690.06	17,222.60	0.00	6,246.70	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	10,918.19	376.34	0.00	992.21	0.00	0.00	0.00	1,024.28	11,311.28	0.00	0.00	0.00	
SUBTOTAL:	10,918.19	376.34	4,142.44	1,092.26	690.06	17,222.60	0.00	7,270.98	14,285.82	0.00	0.00	0.00	

2,974.54	
28,401.85	
24,622.30	
55,998.69	

E

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	
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.22	2,963.50	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	3,442.07	394.46	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	2,286.61	1,389.07	109,186.74	177.18	2,034.57	5,425.44	8,572.12	-269.79	29,935.60	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	5,063.86	6,161.28	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	37,307.68	85,051.66	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	108.35	23,795.80	2,084.65	249.30	2,427.37	0.00	1,009.98	7,350.16	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	282,960.57	239,237.96	160,049.34	141,590.13	133,394.48	227,715.34	294,101.69	217,747.77	364,952.82	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	58,898.95	47,546.42	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	235,458.94	434,500.79	215,685.56	224,311.09	328,728.18	442,676.83	224,084.36	367,426.67	560,773.75	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	22,779.63	0.00	0.00	0.00	
3726	ADULT <40% EXP MALE	73.01	0.00	-57.05	0.00	0.00	0.00	0.00	0.00	9.82	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	9,628.14	5,770.49	8,615.35	434.96	1,598.89	576.24	6,779.01	188.73	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	691,039.14	1,127,919.10	0.00	0.00	0.00	

854.41	
3,186.72	
3,836.53	
158,737.54	
11,595.31	
322,494.35	
37,025.61	
2,061,750.10	
303,768.55	
3,033,646.17	
24,275.27	
25.78	
33,591.81	
5,994,788.15	

E

4

4
SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	352.61	16,903.27	22,673.32	2,578.16	12,349.75	32,515.04	325.14	2,779.90	18,592.43	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	1,095.65	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	5,998.76	18,912.57	11,373.57	6,819.98	22,894.60	20,159.18	13,582.22	97.02	24,985.34	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	2,876.92	44,673.42	0.00	0.00	0.00	

109,069.62	
1,095.65	
124,823.24	
234,988.51	

4
SUBTOTAL:

TOTAL:

700,502.56

965,459.39	631,465.59	571,462.71	639,435.43	1,090,830.26	733,305.01	883,154.28	1,340,584.11	0.00	0.00	0.00	7,556,199.34

COCHISE COUNTY INMATES FEE FOR SERVICE
For The Period Ending March 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	4,195.50	0.00	0.00	0.00	0.00	4,838.86	
SUBTOTAL:	0.00	0.00	0.00	0.00	586.31	0.00	57.05	4,195.50	0.00	0.00	0.00	0.00	4,838.86	
														
													3,663.37	
SUBTOTAL:													3,663.37	

TOTAL:	0.00	0.00	0.00	0.00	1,065.84	209.84	3,031.05	4,195.50	0.00	0.00	0.00	0.00		8,502.23		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	3,842.02	0.00	0.00	7.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,849.39		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	274.42	1,118.71	0.00	0.00	2,970.00	0.00	0.00	0.00	0.00		4,363.13		
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	2,970.00	0.00	0.00	0.00	0.00		8,364.26		

SUBTOTAL:

TOTAL:

151.74

3,842.02	0.00	274.42	1,126.08	0.00	0.00	2,970.00	0.00	0.00	0.00	0.00	8,364.26

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending March 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	841.68	0.00	0.00	0.00	0.00		7,078.80		
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	17,262.73	1,113.58	0.00	0.00	0.00		38,950.24		
2200	SSI DISABLED WITH M E	0.00	10,751.39	0.00	0.00	0.00	288.16	1,511.73	114.34	8,766.74	0.00	0.00	0.00		21,432.36		
2210	SSI DISABLED NON-ME	18,422.83	10,195.76	34,766.80	17,317.71	168.87	5,679.57	5,210.08	9,183.48	31,612.24	0.00	0.00	0.00		132,557.34		
2220	SSI DISABLED WITH Q M	15.35	3,019.90	3,735.46	357.86	-36.16	7,396.96	55.07	903.60	96.04	0.00	0.00	0.00		15,544.08		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	13,693.10	3,171.34	0.00	0.00	0.00	0.00		16,864.44		
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	31.06	0.00	0.00	0.00	0.00		4,168.55		
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	1,383.89	863.35	0.00	0.00	0.00		37,950.73		
	20,878.47	34,444.77	51,911.76	33,508.53	11,088.37	28,389.51	29,734.30	32,892.12	42,451.95	0.00	0.00	0.00		285,299.78		

D

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+	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	3,360.13	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	411.22	8.27	0.00	0.00	3,707.36	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	189.29	162.48	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	189.29	7,229.97	0.00	0.00	0.00	

10,436.54	
14,172.42	
13,349.00	
4,208.60	
4,126.85	
9,443.65	
55,737.06	

M&

E

SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	4,010.58	2,822.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	16,799.05	0.00	0.00	0.00	4,879.17	3,877.33	550.13	3,197.65	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	83.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	1,298.03	229.50	228.46	14,809.82	0.00	4,012.40	2,870.90	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	69,878.66	66,286.32	10,893.65	95,669.19	16,280.98	101,325.61	73,030.88	34,823.19	76,104.65	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	5,251.56	3,256.51	2,374.79	13,269.40	9,235.19	18,206.53	18,896.21	20,537.17	9,037.36	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	60,229.42	101,392.31	0.00	0.00	0.00	
	124,338.03	133,446.71	33,662.00	174,523.61	31,703.91	158,166.12	232,952.55	120,152.31	192,602.87	0.00	0.00	0.00	

6,833.38	
0.00	
29,303.33	
83.10	
23,449.11	
544,293.13	
100,064.72	
497,521.34	
1,201,548.11	

AL

SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	149.02	0.00	0.00	0.00	1,343.71	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	15,153.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	15,153.54	0.00	0.00	149.02	0.00	0.00	0.00	1,343.71	0.00	0.00	0.00	0.00	

1,492.73	
15,153.54	
16,646.27	

4
SUBTOTAL:

534.77

534.77

8720	SSI DISABLED FREEDO	0.00	0.00	503.71	0.00	0.00	31.06	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	503.71	0.00	0.00	31.06	0.00	0.00	0.00	0.00	0.00	0.00	

M
SUBTOTAL:

TOTAL:	180,973.77	172,988.12	86,077.47	208,251.38	44,563.72	194,013.46	276,035.85	154,577.43	242,284.79	0.00	0.00	0.00		1,559,765.99		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending March 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	955.38	0.00	0.00	0.00	0.00		3,147.62		
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	11.66	2,253.21	4,046.52	8,752.09	858.70	1,769.51	0.00	332.40	1,337.32	0.00	0.00	0.00		19,361.41		
SUBTOTAL:	338.81	2,844.58	4,099.32	8,752.09	866.68	3,961.75	-72.49	1,287.78	1,337.32	0.00	0.00	0.00		23,415.84		

M

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 MALE	13,355.83	4,487.44	0.00	6,733.15	1,783.51	363.75	221.81	9,489.63	3,405.44	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	9,489.63	3,405.44	0.00	0.00	0.00	

17.50	
177.73	
39,840.56	
5,291.69	
37,987.41	
83,314.89	

SUBTOTAL:

107,370.11

17,076.20	17,463.23	5,067.42	30,081.85	12,502.81	9,509.11	149.32	10,777.41	4,742.76	0.00	0.00	0.00	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending March 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	593.21	0.00	0.00	0.00		5,301.96		
2200	SSI DISABLED WITH M E	0.00	630.38	160.15	327.76	4,219.41	5,242.80	0.00	0.00	937.14	0.00	0.00	0.00		11,517.64		
2210	SSI DISABLED NON-ME D	0.00	160.89	0.00	0.00	327.76	67.24	6,691.96	0.00	5,541.27	0.00	0.00	0.00		12,789.12		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	142.83	217.59	245.38	0.00	0.00	0.00		605.80		
	0.00	791.27	4,401.90	327.76	5,014.17	5,310.04	6,834.79	217.59	7,317.00	0.00	0.00	0.00		30,214.52		

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 MALE	7.98	1,430.76	0.00	0.00	250.57	3,790.43	9,903.28	31.06	3,369.68	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	1,181.28	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	8,014.50	-3,085.25	11,735.79	3,531.90	14,525.08	409.95	-2,091.78	14,984.06	1,642.57	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	16,196.40	5,012.25	0.00	0.00	0.00	

18,783.76	
2,065.16	
49,666.82	
70,515.74	

4
SUBTOTAL:

TOTAL:	8,166.82	-863.22	16,137.69	3,859.66	19,789.82	17,388.04	15,385.83	16,413.99	12,329.25	0.00	0.00	0.00		108,607.88		

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	21.43	0.00	0.00	0.00	0.00	8,629.77	
0.00	0.00	0.00	0.00	0.00	8,608.34	0.00	21.43	0.00	0.00	0.00	0.00	8,629.77	

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending March 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	0.00	0.00	0.00	0.00	160.89	0.00	990.00	243.08	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	306.05	0.00	166.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	306.05	0.00	166.26	9,251.66	484.78	160.89	990.00	243.08	0.00	0.00	0.00	0.00	

9,736.44	
1,393.97	
472.31	
11,602.72	

E

SUBTOTAL:

20,232.49

306.05	0.00	166.26	9,251.66	484.78	8,769.23	990.00	264.51	0.00	0.00	0.00	0.00	

TOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME	0.00	177.03	0.00	4,575.16	0.00	9,164.20	0.00	0.00	170.19	0.00	0.00	0.00	14,086.58	
D														
SUBTOTAL:	0.00	177.03	0.00	4,575.16	0.00	9,164.20	0.00	0.00	170.19	0.00	0.00	0.00	14,086.58	
														
													12,006.76	
													556.20	
E													

12,562.96	

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

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	12,006.76	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	556.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	556.20	12,006.76	0.00	0.00	0.00	0.00	0.00	0.00	

3716	ADULT <40% EXP MALE	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	0.00	3,152.09	110.80	0.00	0.00	3,362.36	0.00	191.20	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	0.00	258.61	0.00	0.00	3,152.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	4,084.05	691.59	372.54	9,494.35	3,362.36	122.84	191.20	0.00	0.00	0.00	0.00	

8,091.78	
6,816.45	
3,410.70	
18,318.93	

AL

4
SUBTOTAL:

TOTAL:	0.00	4,261.08	691.59	4,947.70	10,050.55	24,533.32	122.84	191.20	170.19	0.00	0.00	0.00		44,968.47		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending March 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	2,267,449.08	2,638,951.32	0.00	0.00	0.00		21,201,284.68		
2110	SSI AGED NON-MEDICA R	177,147.26	101,345.13	299,519.40	157,341.85	107,732.68	129,146.89	125,043.11	148,417.98	164,724.39	0.00	0.00	0.00		1,410,418.69		
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	3,056,867.31	3,641,257.51	0.00	0.00	0.00		29,338,946.14		
2200	SSI DISABLED WITH M	543,524.04	474,214.50	724,208.95	536,644.76	552,216.34	695,544.60	497,483.69	592,629.85	582,465.93	0.00	0.00	0.00		5,198,932.66		
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	2,621,292.75	3,021,310.06	0.00	0.00	0.00		24,696,793.48		
2220	SSI DISABLED WITH Q	639,532.10	693,460.39	974,750.74	671,858.25	672,467.60	904,432.53	746,390.37	736,523.86	912,274.60	0.00	0.00	0.00		6,951,690.44		
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	11,019.07	18,112.88	0.00	0.00	0.00		133,325.19		
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	6,147.01	7,790.21	0.00	0.00	0.00		62,163.47		
	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	9,440,346.91	10,986,886.90	0.00	0.00	0.00		88,994,480.57		

E

M

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	5,483.52	2,578.56	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	4,112.64	2,741.76	2,741.76	3,427.20	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	8,225.28	6,005.76	0.00	0.00	0.00	

23,008.16	
25,983.72	
48,991.88	

M
SUBTOTAL:

89,043,472.45

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	9,448,572.19	10,992,892.66	0.00	0.00	0.00	

TOTAL:

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

RATE CODE	DESCRIPTION

2100

2110

2120

SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
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	9,692.60	14,160.62	0.00	0.00	0.00	116,035.38	
0.00	0.00	0.00	399.80	0.00	435.84	0.00	49,449.40	0.00	0.00	0.00	0.00	50,285.04	
0.00	83.04	41.43	0.00	81.58	0.00	0.00	0.00	28.93	0.00	0.00	0.00	234.98	
572.87	1,912.10	6,455.92	314.42	3,785.37	2,357.90	823.65	73.28	7,226.92	0.00	0.00	0.00	23,522.43	
10,415.23	19,351.87	894.64	5,932.66	1,560.41	-737.82	514.39	506.82	14,550.81	0.00	0.00	0.00	52,989.01	
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	59,722.10	35,967.28	0.00	0.00	0.00	252,084.47	

TOTAL:	15,485.93	33,992.59	32,196.13	21,120.24	18,429.85	22,655.18	12,515.17	59,722.10	35,967.28	0.00	0.00	0.00		252,084.47		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending March 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	33,536.35	23,635.37	0.00	0.00	0.00		228,275.27		
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	58,653.90	53,691.86	0.00	0.00	0.00		466,908.70		
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	7,721.08	7,323.84	0.00	0.00	0.00		55,929.28		
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	2,917.37	2,543.63	0.00	0.00	0.00		24,035.16		
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	502.96	1,038.60	0.00	0.00	0.00		3,581.46		
2210	SSI DISABLED NON-ME	252,041.30	84,309.59	219,296.65	140,342.61	148,906.14	260,843.16	184,716.19	241,806.32	315,652.30	0.00	0.00	0.00		1,847,914.26		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	23.96	10.53	188.39	43.80	742.15	269.15	0.00	0.00	0.00		1,277.98		
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	1,634.60	3,401.81	0.00	0.00	0.00		14,817.26		
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	21.68	0.00	0.00	0.00	0.00		96.42		
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	56,485.23	79,048.00	0.00	0.00	0.00		510,551.67		
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	142,796.15	230,989.71	0.00	0.00	0.00		1,197,360.92		
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	15,097.53	19,378.03	0.00	0.00	0.00		108,673.17		
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	5,921.74	7,967.56	0.00	0.00	0.00		45,272.05		
5015	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	98.89	14.20	18.08	0.00	0.00	0.00	0.00		131.17		
	642,887.52	188,308.71	519,661.06	373,572.92	358,597.98	692,036.55	417,605.91	567,855.14	744,939.86	0.00	0.00	0.00		4,505,465.65		

D

M
SUBTOTAL:

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	84.66	8.13	232.43	39.21	0.00	20.05	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	2,528.53	1,542.08	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	84.42	84.42	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	135.37	38.36	7.30	96.39	7.30	7.35	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	210.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,732.49	3,154.87	3,999.21	1,229.12	650.75	2,923.36	1,293.33	2,612.95	1,646.55	0.00	0.00	0.00	

1,344.38	
17,797.98	
597.59	
292.07	
210.61	
20,242.63	

E
SUBTOTAL:

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	18.98	0.00	32.96	86.74	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	95.69	27.95	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	12.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	6.83	27.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	1,726.70	9.31	990.53	137.29	119.45	572.34	166.36	447.55	343.62	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	223.06	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	856.23	1,732.17	399.03	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	879.54	653.42	0.00	0.00	0.00	

138.68	
123.64	
12.33	
34.11	
4,513.15	
1,833.45	
2,987.43	
9,642.79	

SUBTOTAL:

269.11

269.11

3915	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.08	205.03	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.08	205.03	0.00	0.00	0.00	

L
SUBTOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	33,174.28	60,643.62	0.00	0.00	0.00		267,665.63		
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	3,113.51	3,895.13	0.00	0.00	0.00		26,908.28		
4415	SOBRA 100-133% FEMA L	515.37	640.27	290.86	918.34	676.00	2,517.58	1,322.47	2,193.68	2,333.95	0.00	0.00	0.00		11,408.52		
	33,611.25	5,777.00	13,916.56	24,047.84	26,066.96	64,726.11	32,482.54	38,481.47	66,872.70	0.00	0.00	0.00		305,982.43		

SUBTOTAL:

TOTAL:

682,284.75

197,289.50	538,716.56	399,001.17	385,561.90	761,209.60	453,328.39	609,893.18	814,317.56	0.00	0.00	0.00	4,841,602.61

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending March 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	256.74	0.00	0.00	0.00	2,304.62	
40,868.65	24,234.06	48,725.89	26,485.58	29,892.42	44,214.96	24,625.86	32,195.61	36,971.36	0.00	0.00	0.00	308,214.39	
2,871.13	789.16	3,394.59	1,281.47	667.85	3,130.34	2,521.84	1,376.74	2,684.87	0.00	0.00	0.00	18,717.99	
1,249,307.80	489,106.70	1,265,880.28	765,381.38	758,689.31	1,369,048.70	907,027.43	1,203,840.89	1,492,777.95	0.00	0.00	0.00	9,501,060.44	
2,114.42	-248.86	3,650.67	2,135.30	1,672.29	3,246.71	895.51	1,029.44	1,784.76	0.00	0.00	0.00	16,280.24	
7,193.15	6,514.48	11,947.59	4,341.28	8,117.72	10,057.63	6,770.86	5,979.21	7,779.80	0.00	0.00	0.00	68,701.72	
1,303,186.34	520,395.54	1,333,714.76	799,779.37	799,536.10	1,430,085.98	941,903.94	1,244,421.89	1,542,255.48	0.00	0.00	0.00	9,915,279.40	

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	1,244,421.89	1,542,255.48	0.00	0.00	0.00		9,915,279.40		

ACUTE REINSURANCE
For The Period Ending March 31, 2016

SUBTOTAL:

7,010,616.95	6,492,507.76	9,262,664.61	9,522,581.44	6,897,279.90	8,528,119.46	2,957,209.89     10,159,805.98	8,817,910.15

0.00

0.00

0.00

69,648,696.14

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	12.17	0.00	0.00	0.00	0.00	8,532.54	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	17,401.25	945.08	0.00	-17,401.25	0.00	0.00	0.00	945.08	
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	669,996.89	494,469.06	0.00	0.00	0.00	4,315,646.48	
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	19,531.26	21,185.49	0.00	0.00	0.00	465,749.60	
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	133,472.74	140,755.28	0.00	0.00	0.00	1,709,067.13	
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	10,180.37	4,597.98	0.00	0.00	0.00	177,745.48	
1015	TANF 14-20 FEMALE N	18,361.96	12,714.48	18,838.21	15,383.78	25,213.02	121,039.33	18,112.88	108,048.88	22,568.61	0.00	0.00	0.00	360,281.15	

1016	O
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	
345,135.26	
222,554.84	
0.00	
0.00	
0.00	
1,788,736.67	
1017	TANF 21-44 FEMALE N	127,936.47	159,048.89	395,075.50	504,125.42	255,419.19	305,860.33	51,147.95	146,277.97	574,915.30	0.00	0.00	0.00	2,519,807.02	

1018	O
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	
314,062.77	
95,181.78	
0.00	
0.00	
0.00	
1,117,101.95	
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	624.78	33,070.16	362.69	24,212.27	12,180.72	34,105.65	7,812.85	3,859.28	9,100.43	0.00	0.00	0.00	125,328.83	
2110	A
SSI AGED NON-MEDICA	67,861.38	195,769.67	82,798.86	187,110.03	156,837.43	149,288.35	107,679.10	242,464.68	40,814.89	0.00	0.00	0.00	
1,230,624.39	
2200	R
SSI DISABLED WITH M	43,874.36	10,496.70	3,907.51	14,759.66	36,550.05	14,130.33	94,181.61	27,579.43	13,012.80	0.00	0.00	0.00	
258,492.45	
2210	E
SSI DISABLED NON-ME	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	5,743,532.97	4,690,013.45	0.00	0.00	0.00	
40,232,534.07	
2300	D
SSI BLIND WITH MEDIC	0.00	0.00	0.00	79,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
79,766.51	
2310	SSI BLIND NON-MEDIC	40,412.86	2,873.76	1,068.77	-75,896.96	5,691.49	32,166.80	0.00	8,459.11	17,427.51	0.00	0.00	0.00	32,203.34	

4311	A
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	
1,411,456.98	
824,915.21	
0.00	
0.00	
0.00	
8,364,351.64	
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	225,339.91	430,819.42	0.00	0.00	0.00	2,700,872.04	
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	443,895.52	500,179.92	0.00	0.00	0.00	2,533,662.75	
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	182,336.96	512,847.12	0.00	0.00	0.00	838,897.06	
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	48,151.93	64,896.39	0.00	0.00	0.00	405,556.18	
5015	SOBRA PREG 14-20 FE	0.00	9,507.28	408.56	4,728.20	1,067.70	335.40	3,573.89	49,455.69	58,284.77	0.00	0.00	0.00	127,361.49	
5017	M
SOBRA PREG 21-44 FE	8,128.10	28,115.83	25,201.81	42,704.14	18,481.98	1,987.47	1,316.45	26,555.21	96,771.15	0.00	0.00	0.00	
249,262.14	
	M														

2,753.97

-1,794.73

-8.67

7,228.93

873,738.14

707,180.91

1,264,917.86

2,446.74

-60.20

194,500.07

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	329.59	0.01	264.91	45.17	298.84	632.55	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	-1,794.73	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	93,537.01	94,457.66	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	249,679.33	-12,878.16	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	219,550.04	30,885.92	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	-18.11	42.85	43.82	25.93	10.31	0.00	-178.82	13.82	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED	14,090.33	42,829.44	49,706.82	46,616.48	7,100.00	-5,141.12	4,585.12	11,351.53	23,361.47	0.00	0.00	0.00	

WI

NO

ACUTE REINSURANCE
For The Period Ending March 31, 2016

RATE CODE	DESCRIPTION

2600

2610

SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

E
SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
35,356.98	19,953.70	40,311.53	39,071.56	75,248.39	1,399.37	430.74	9,100.38	433.36	0.00	0.00	0.00	221,306.01	
20,284.70	72,266.71	62,393.79	63,319.22	126,966.46	50,917.39	9,648.84	106,884.08	8,416.67	0.00	0.00	0.00	521,097.86	
316,711.60	410,028.71	481,700.77	717,276.86	425,099.18	268,150.39	340,409.61	688,620.30	145,309.47	0.00	0.00	0.00	3,793,306.89	

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

 
22.30	
1,477.43	
3,631.95	
5,131.68	

3410	MED ELIGIBILITY NON-	0.00	0.00	-5,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	9,760.41	0.00	0.00	3,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	1,239.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	28,195.73	-1,579.93	-5,079.21	0.00	-1,327.80	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	198.84	7,538.05	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	308,900.04	153,525.49	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	3,904.61	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	309,524.54	96,929.36	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 MALE	150,958.00	173,540.11	140,658.64	168,686.95	205,746.27	47,735.55	92,529.83	53,362.67	169,561.02	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	28,359.53	5,093.03	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	502,179.54	650,833.61	591,737.89	1,117,820.73	788,610.97	750,365.46	70,705.12	784,944.99	639,132.55	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	256,435.90	98,701.30	250,260.17	399,461.42	410,941.85	345,450.11	65,666.55	159,813.61	170,264.75	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	1,484,577.46	1,046,249.45	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F	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	3,129,681.68	2,292,198.31	0.00	0.00	0.00	

-1,238.16	
101,288.09	
124,636.38	
1,394,655.62	
655,481.81	
2,726,031.73	
2,767.51	
80,687.78	
1,202,779.04	
380,015.02	
5,896,330.86	
2,156,995.66	
11,693,885.30	
2,035.97	
26,416,352.61	

AL

6
SUBTOTAL:

3908	NEWLY ELIGIBLE M&F 4	75,258.45	0.00	21,217.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,356.93	0.00	0.00	19,045.28	10,843.38	0.00	188.61	62,202.00	62,202.00	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	114,151.58	187,753.76	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	107,566.77	11,868.33	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	163,410.54	348,055.35	252,590.82	236,488.95	162,860.24	163,485.29	63,258.33	331,593.42	181,175.18	0.00	0.00	0.00	
SUBTOTAL:	276,371.96	479,009.69	344,793.74	397,029.20	359,861.18	225,309.10	150,629.94	615,513.77	442,999.27	0.00	0.00	0.00	

96,476.19	
158,838.20	
1,064.69	
875,560.10	
256,660.55	
1,902,918.12	
3,291,517.85	

4

ACUTE REINSURANCE
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	130,937.24	112,102.67	0.00	0.00	0.00		593,860.85		
4414	SOBRA 100-133% MALE	451,101.89	451,107.67	426,127.94	679,863.69	468,911.44	1,180,962.21	27,990.69	692,202.74	676,826.12	0.00	0.00	0.00		5,055,094.39		
4415	SOBRA 100-133% FEMA L	188.17	9,280.96	106.64	4,451.52	-2,057.67	32.82	82.47	141,812.83	13,891.52	0.00	0.00	0.00		167,789.26		
	471,134.63	470,569.59	447,840.79	825,407.49	587,927.01	1,217,855.84	28,236.03	964,952.81	802,820.31	0.00	0.00	0.00		5,816,744.50		

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	6,209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	0.00	0.00	0.00	855.98	0.00	0.00	0.00	7,109.74	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,209.80	0.00	0.00	855.98	0.00	0.00	0.00	7,109.74	0.00	0.00	0.00	0.00	

6,209.80	
7,965.72	
14,175.52	

5

24,189.43

24,189.43

8710	SSI DISABLED FREEDO	2,595.44	0.00	2,595.44	5,190.88	2,595.43	2,595.44	0.00	6,022.60	2,594.20	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	6,022.60	2,594.20	0.00	0.00	0.00	

M
SUBTOTAL:

109,040,356.49

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	15,571,706.88	12,503,831.71	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE REINSURANCE
For The Period Ending March 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	254,136.53	156,719.55	0.00	0.00	0.00		2,557,313.79		
2110	SSI AGED NON-MEDICA R	218,322.47	133,627.59	139,813.52	145,656.58	216,314.34	137,105.95	73,558.19	33,888.42	11,340.11	0.00	0.00	0.00		1,109,627.17		
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	409,632.55	481,841.68	0.00	0.00	0.00		5,051,330.10		
2210	SSI DISABLED NON-ME	2,840,717.50	2,796,391.98	3,888,127.51	3,540,048.52	4,792,282.42	2,737,929.54	1,970,903.40	1,738,732.48	1,996,443.79	0.00	0.00	0.00		26,301,577.14		
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	2,067.18	829.15	61,461.10	4,145.13	12,606.98	4,663.25	1,650.00	2,265.20	-1,161.52	0.00	0.00	0.00		88,526.47		
	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	2,438,655.18	2,645,183.61	0.00	0.00	0.00		35,146,677.47		

D

A
SUBTOTAL:

14,896.33

14,896.33

8710	SSI DISABLED FREEDO	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	21.05	0.00	-1.78	0.00	0.00	0.00	
	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	21.05	0.00	-1.78	0.00	0.00	0.00	

M
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	2,438,655.18	2,645,181.83	0.00	0.00	0.00		35,161,573.80		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
194,274.80	239,591.60	285,013.30	307,878.00	71,122.20	73,325.10	76,109.30	85,112.60	76,345.30	0.00	0.00	0.00	1,408,772.20	
419.60	314.70	419.60	419.60	839.20	524.50	487.20	365.40	470.30	0.00	0.00	0.00	4,260.10	
59,218.50	89,224.80	136,060.20	153,998.10	21,979.00	27,224.00	33,977.90	30,886.50	28,345.60	0.00	0.00	0.00	580,914.60	
55,177.40	57,030.30	58,179.30	62,320.40	92,112.00	76,322.10	86,876.80	100,163.30	85,856.70	0.00	0.00	0.00	674,038.30	
390,962.30	405,066.70	409,640.00	406,988.40	406,802.20	436,932.40	457,491.40	500,581.20	476,446.10	0.00	0.00	0.00	3,890,910.70	
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	2,877,496.60	2,907,473.80	0.00	0.00	0.00	20,957,637.70	
156,570.80	143,157.80	137,314.10	138,468.00	135,216.10	127,558.40	153,205.80	145,012.80	143,107.10	0.00	0.00	0.00	1,279,610.90	
332,008.50	338,302.50	334,945.70	338,302.50	337,253.50	333,791.80	391,462.30	394,361.60	396,368.10	0.00	0.00	0.00	3,196,796.50	
2,831,922.00	2,873,883.50	2,914,800.20	2,923,716.10	2,934,708.00	2,924,607.70	3,421,032.10	3,432,314.70	3,454,683.80	0.00	0.00	0.00	27,711,668.10	
419.60	419.60	314.70	314.70	314.70	314.70	713.90	487.20	365.40	0.00	0.00	0.00	3,664.50	
3,251.90	3,356.80	3,042.10	2,937.20	2,937.20	2,832.30	3,288.60	3,410.40	3,410.40	0.00	0.00	0.00	28,466.90	
25,071.10	24,336.80	25,910.30	25,805.40	26,015.20	25,176.00	29,651.60	29,861.40	36,764.80	0.00	0.00	0.00	248,592.60	
104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	629.40	
104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524.50	
1,363.70	1,363.70	1,153.90	944.10	629.40	419.60	487.20	487.20	365.40	0.00	0.00	0.00	7,214.20	
944.10	839.20	1,153.90	944.10	1,363.70	1,049.00	1,096.20	1,096.20	1,705.20	0.00	0.00	0.00	10,191.60	
0.00	0.00	-209.80	0.00	0.00	0.00	0.00	-226.70	-243.60	0.00	0.00	0.00	-680.10	
543,517.80	550,391.10	561,940.30	555,491.40	568,562.80	566,367.00	668,106.30	685,633.30	699,569.90	0.00	0.00	0.00	5,399,579.90	
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	4,165,784.10	4,230,303.80	0.00	0.00	0.00	33,715,311.20	
-52,359.80	-26,959.30	-20,035.90	-24,127.00	-7,238.10	-13,002.70	-16,844.70	4,254.20	-19,214.10	0.00	0.00	0.00	-175,527.40	
59,066.30	19,847.50	122,106.60	172,423.40	145,913.80	190,130.30	236,588.30	208,313.90	118,766.40	0.00	0.00	0.00	1,273,156.50	
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	12,665,395.90	12,640,890.40	0.00	0.00	0.00	100,215,732.90	

ACUTE SMIB
For The Period Ending March 31, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

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

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4320

5000

5020

8000

SOBRA CHILD WITH ME
D
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SMIB ONLY NOT ELIGIB

8020

8040

QMB ONLY

SLMB

8888

SMIB ONLY NOT ELIGIB

9999

SMIB ONLY NOT ELIGIB

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	684,101.00	682,181.90	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	209.80	104.90	104.90	104.90	104.90	104.90	1,309.50	801.90	365.40	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	266,539.20	284,643.70	0.00	0.00	0.00	
2400	SSI AGED EXPANDED	3,042.10	1,468.60	1,253.90	419.60	209.80	314.70	243.60	243.60	243.60	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	243.60	121.80	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	2,604,289.20	2,589,349.80	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	121.80	121.80	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	243.60	-121.80	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	1,653,183.80	1,727,813.10	1,756,040.70	1,816,932.70	1,829,709.50	1,863,111.30	2,211,003.30	2,223,027.00	2,239,720.70	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	5,779,610.90	5,796,626.90	0.00	0.00	0.00	

4,962,701.90	
3,211.10	
1,621,554.40	
7,439.50	
3,353.30	
23,970,977.10	
994.80	
16.90	
17,320,542.10	
47,890,791.10	

FI

WI

E
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	2,784.50	3,532.20	0.00	0.00	0.00	
3720	AHC CARE EXPANDED	3,776.40	1,468.60	1,153.90	1,783.30	3,566.60	2,622.50	2,385.30	4,845.20	2,923.20	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	7,629.70	6,455.40	0.00	0.00	0.00	

29,467.90	
24,525.00	
53,992.90	

FO
SUBTOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR	1,468.60	734.30	839.20	629.40	839.20	944.10	1,847.40	1,948.80	1,583.40	0.00	0.00	0.00	10,834.40	
F														
SUBTOTAL:	1,468.60	734.30	839.20	629.40	839.20	944.10	1,847.40	1,948.80	1,583.40	0.00	0.00	0.00	10,834.40	
														
													219,238.30	
M
SUBTOTAL:													

219,238.30	

ACUTE SMIB
For The Period Ending March 31, 2016

148,390,589.60

8720	SSI DISABLED FREEDO	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	23,602.50	28,663.80	27,354.30	26,430.60	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	27,354.30	26,430.60	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	18,481,939.60	18,471,986.70	0.00	0.00	0.00	

TOTAL:

ACUTE HIB
For The Period Ending March 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	-411.00	0.00	0.00	0.00	0.00		0.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	676.00	226.00	0.00	0.00	0.00		902.00		
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-MEDICA R	0.00	0.00	0.00	0.00	1,221.00	0.00	1,225.00	1,644.00	0.00	0.00	0.00	0.00		4,090.00		
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	216,471.40	241,815.40	0.00	0.00	0.00		1,785,253.10		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.00	0.00	0.00	0.00	0.00		411.00		
2220	SSI DISABLED WITH Q	88,616.20	96,125.80	110,636.10	112,246.10	100,161.10	107,121.10	104,174.70	113,062.70	123,186.70	0.00	0.00	0.00		955,330.50		
2320	SSI BLIND WITH QMB	407.00	407.00	407.00	407.00	407.00	407.00	411.00	411.00	411.00	0.00	0.00	0.00		3,675.00		
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	3,988.60	3,988.60	0.00	0.00	0.00		38,069.20		
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	-4,944.80	-1,829.00	0.00	0.00	0.00		-46,825.50		
	261,768.80	274,049.90	304,238.40	305,976.50	291,872.30	302,006.90	303,696.10	331,308.90	367,798.70	0.00	0.00	0.00		2,742,716.50		

M

SUBTOTAL:

54,741.20

54,741.20

2420	SSI AGED EXPANDED	8,649.20	8,527.10	5,656.40	8,584.10	4,192.40	4,192.40	4,233.20	4,233.20	6,473.20	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	4,233.20	6,473.20	0.00	0.00	0.00	

WI
SUBTOTAL:

TOTAL:	270,418.00	282,577.00	309,894.80	314,560.60	296,064.70	306,199.30	307,929.30	335,542.10	374,271.90	0.00	0.00	0.00		2,797,457.70		

Q1
For The Period Ending March 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	2,017,375.10	1,458,506.60	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	2,017,375.10	1,458,506.60	0.00	0.00	0.00		17,719,491.00	
															
TOTAL:														17,719,491.00	

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	1,709,715.40	1,923,831.00	0.00	0.00	0.00	15,880,279.00	
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	307,659.70	-465,324.40	0.00	0.00	0.00	1,839,212.00	

LTC SMIB
For The Period Ending March 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	730.80	974.40	0.00	0.00	0.00		6,212.40		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	121.80	121.80	121.80	0.00	0.00	0.00		365.40		
1020	TANF WITH QMB	104.90	104.90	104.90	104.90	104.90	104.90	348.50	243.60	243.60	0.00	0.00	0.00		1,465.10		
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	973,512.00	1,005,477.20	0.00	0.00	0.00		8,209,805.60		
2110	SSI AGED NON-MEDICA	155,566.70	157,769.60	157,769.60	157,664.70	161,336.20	159,657.80	185,866.80	186,841.20	185,988.60	0.00	0.00	0.00		1,508,461.20		
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	881,879.80	896,668.70	0.00	0.00	0.00		7,303,745.70		
2200	SSI DISABLED WITH M	319,840.10	329,595.80	321,623.40	322,567.50	334,134.80	337,673.10	382,974.80	388,117.20	400,929.50	0.00	0.00	0.00		3,137,456.20		
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	19,853.40	20,949.60	0.00	0.00	0.00		183,749.30		
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	840,867.40	822,582.70	0.00	0.00	0.00		6,741,272.60		
2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	839.20	839.20	839.20	974.40	974.40	974.40	0.00	0.00	0.00		7,853.50		
2310	SSI BLIND NON-MEDIC A	209.80	104.90	209.80	104.90	104.90	104.90	121.80	243.60	243.60	0.00	0.00	0.00		1,448.20		
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	4,993.80	5,237.40	0.00	0.00	0.00		41,764.70		
	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	3,298,379.00	3,340,391.50	0.00	0.00	0.00		27,143,599.90		

R

E

SUBTOTAL:

6,073.70

6,073.70

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

M

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	3,299,109.80	3,341,122.30	0.00	0.00	0.00		27,149,673.60		

2,455,485.30

LTC HIB
For The Period Ending March 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-MEDICA R	407.00	0.00	1,221.00	0.00	0.00	1,221.00	0.00	0.00	1,233.00	0.00	0.00	0.00		4,082.00		
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	269,105.20	269,001.20	0.00	0.00	0.00		2,337,606.10		
2200	SSI DISABLED WITH M E	0.00	407.00	0.00	407.00	-407.00	407.00	0.00	0.00	411.00	0.00	0.00	0.00		1,225.00		
2220	SSI DISABLED WITH Q	12,923.00	14,144.00	12,516.00	7,909.20	13,106.00	11,885.00	11,183.00	13,641.00	12,823.00	0.00	0.00	0.00		110,130.20		
SUBTOTAL:	269,424.80	275,671.80	269,873.10	259,132.80	272,905.10	271,807.10	270,456.20	282,746.20	283,468.20	0.00	0.00	0.00		2,455,485.30		

269,873.10	259,132.80	272,905.10	271,807.10	270,456.20	282,746.20	283,468.20	0.00	0.00	0.00	

M

TOTAL:

269,424.80

275,671.80

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 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	-282.60	1,271.34	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	3,407.68	2,962.20	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	4,175.97	4,017.54	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	2,626.64	3,113.93	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	677,687.46	800,105.24	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	329,100.87	325,586.65	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	297,914.87	310,558.34	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	85,993.18	98,170.68	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	209,661.78	231,542.66	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	998,023.57	991,554.86	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	3,986,912.11	4,001,228.32	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	1,259,222.62	1,427,925.92	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	1,050.00	350.00	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	-47.61	3.66	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	506.97	379.36	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	1,667.80	1,702.59	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	279.43	715.23	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	36,033.43	37,819.89	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	60,414.26	72,757.77	86,289.46	47,067.16	74,476.35	68,323.34	38,010.52	55,366.93	45,435.93	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	169,819.40	163,457.44	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	95,889.13	101,974.68	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	3,959,038.86	4,322,461.60	5,500,714.34	3,203,783.82	4,183,126.66	4,481,420.16	3,626,990.97	3,798,442.91	4,020,156.73	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	340,423.14	376,095.07	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	481.41	510.11	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	43,511.85	38,045.18	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	4,931.97	4,929.02	0.00	0.00	0.00	
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	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	
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.40	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	1,509,236.50	1,767,787.27	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	3,162,458.55	3,561,498.18	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	3,508,568.09	3,988,078.66	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	916,657.99	1,029,270.52	0.00	0.00	0.00	

13,237.45	
44,173.14	
97,738.11	
44,126.11	
5,745,008.75	
4,839,479.87	
7,777,741.65	
1,897,256.49	
3,562,121.31	
10,023,446.78	
39,461,707.25	
12,945,682.54	
22,292.65	
2,352.29	
6,518.25	
30,145.38	
13,527.87	
393,731.22	
548,141.72	
1,509,518.43	
1,010,079.42	
37,096,136.05	
3,502,901.39	
5,549.64	
397,060.94	
49,567.16	
368.00	
700.00	
411.40	
13,141,769.05	
23,985,692.77	
33,542,394.85	
8,418,463.64	

D

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	1,508,575.86	1,317,700.51	0.00	0.00	0.00		11,217,707.44		
5007	SOBRA PREG 21-44 FE M	0.00	700.00	700.00	0.00	0.00	0.00	2,101.86	0.00	470.90	0.00	0.00	0.00		3,972.76		
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	285,715.60	259,281.99	0.00	0.00	0.00		2,497,310.89		
5017	SOBRA PREG 21-44 FE	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	1,289,612.04	1,460,713.12	0.00	0.00	0.00		12,345,972.35		
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	805.12	3,500.00	0.00	0.00	0.00		19,831.11		
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	122.80	0.00	13.42	0.00	0.00	0.00		148.69		
5028	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		
	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	24,584,430.66	26,378,706.54	0.00	0.00	0.00		236,215,734.81		

M

M

SUBTOTAL:

0.00

0.00

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1
SUBTOTAL:

1103	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	
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	4,630.52	3,816.01	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	10,923.61	8,891.76	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	37,396.38	28,331.98	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	11,589.10	11,907.56	11,276.99	10,530.63	13,763.00	21,247.05	16,376.58	18,888.24	17,179.50	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	1,050.00	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	700.00	1,759.55	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	3,500.00	3,159.55	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	16,592.96	11,135.99	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	18,253.86	25,452.27	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	529,552.17	549,826.85	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	1,506,203.50	1,564,192.96	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	1,014,086.77	1,077,636.83	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	4,200.00	1,769.51	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	1,175.01	952.93	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	3,474.05	1,048.80	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	5,566.95	6,707.97	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	7,563.13	8,905.24	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	5,958.01	9,897.73	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	7,107.45	13,699.28	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	142,847.01	147,575.79	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	4,785.88	8,289.82	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	109,481.97	123,966.21	147,456.41	74,149.48	84,743.70	94,217.58	135,488.74	90,250.95	79,294.56	0.00	0.00	0.00	

700.00	
350.00	
35,837.00	
86,615.37	
241,494.57	
132,758.65	
1,050.00	
18,288.87	
100,592.89	
87,126.59	
231,189.45	
3,646,650.92	
11,220,542.96	
6,672,418.30	
17,109.77	
5,993.94	
19,389.78	
32,384.02	
51,042.40	
96,924.51	
217,920.00	
1,491,740.83	
74,359.16	
939,049.60	

M&

E

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

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
85,508.30	104,493.60	148,434.94	93,586.84	88,605.26	103,855.75	84,879.10	89,887.12	101,628.35	0.00	0.00	0.00	900,879.26	
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	3,524,593.57	3,671,853.23	0.00	0.00	0.00	26,322,408.84	

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	-316.00	0.00	0.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	-3,862.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
0.00	
0.00	
-646.00	
-3,862.00	
-4,508.00	

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	
SUBTOTAL:	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	

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	2,354.72	1,076.80	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	123.99	852.86	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	20,546.84	20,985.98	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	53,090.03	58,478.22	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	440,947.39	485,542.68	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	316,477.56	364,737.12	475,335.36	280,789.77	334,025.70	333,307.13	289,200.96	374,139.32	363,291.41	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	1,117,043.50	1,149,647.05	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	1,050.00	707.39	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	99.44	0.00	0.00	0.00	
3527	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	
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	96.03	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	61.40	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	357.00	187.24	1,790.82	720.29	61.40	1,400.00	0.00	350.00	411.40	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	420.54	66.54	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	4,997.35	11,572.19	10,426.98	9,426.39	9,118.22	13,660.61	4,596.30	6,578.36	12,738.05	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	550.16	545.25	1,197.56	1,260.00	0.01	35.41	472.80	358.69	0.00	0.00	0.00	0.00	

1,805.52	
402.04	
20,141.82	
11,168.76	
177,317.12	
416,442.25	
3,675,554.32	
3,131,304.33	
9,548,171.85	
28,066.85	
661.00	
0.00	
120.80	
549.74	
130.19	
5,278.15	
10,184.97	
83,114.45	
4,419.88	

E

4

6

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	165,528.85	261,775.93	267,888.88	187,172.51	179,844.48	220,568.78	145,722.03	252,843.36	151,528.75	0.00	0.00	0.00		1,832,873.57		
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	261,729.23	269,866.06	0.00	0.00	0.00		2,074,725.45		
3716	ADULT <40% EXP MALE	3,029,287.38	3,988,308.94	4,654,737.86	3,315,942.24	3,506,890.83	4,090,685.06	3,200,348.28	3,888,105.17	3,325,474.61	0.00	0.00	0.00		32,999,780.37		
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	2,380,301.97	2,495,966.19	0.00	0.00	0.00		21,072,584.34		
3718	ADULT <40% EXP M&F	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	4,772,648.91	4,824,753.00	0.00	0.00	0.00		42,970,614.89		
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	3,867.93	2,657.34	0.00	0.00	0.00		34,332.23		
3727	ADULT <40% EXP FEM	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	1,050.00	2,300.63	0.00	0.00	0.00		5,926.96		
	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	13,577,707.38	13,166,444.40	0.00	0.00	0.00		118,106,371.85		

4

AL

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	0.00	708.58	350.00	0.00	101.64	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	838.07	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	2,133.68	1,686.47	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	1,221.62	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	6,835.16	6,890.42	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	35,561.93	26,299.89	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	266,222.84	256,462.40	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	419,451.86	563,183.55	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	624,889.10	670,028.81	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	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71.47	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	0.00	350.00	59.40	0.00	48.25	10.07	0.00	145.14	13.39	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	1,356,634.44	1,525,403.00	0.00	0.00	0.00	

2,560.22	
4,380.17	
35,607.14	
6,484.86	
71,551.36	
222,814.02	
2,200,696.64	
3,583,913.15	
5,913,046.76	
7,000.00	
71.47	
626.25	
12,048,752.04	

4
SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	189,176.92	189,687.05	133,832.64	285,206.25	405,616.43	433,026.87	360,616.35	402,640.87	464,263.95	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	115,161.64	102,620.84	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	64,105.03	76,235.87	69,956.78	127,357.54	132,904.38	171,781.34	109,962.14	153,144.66	164,706.72	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	670,947.17	731,591.51	0.00	0.00	0.00	

700.00	
2,864,067.33	
912,720.91	
1,070,154.46	
4,847,642.70	

SUBTOTAL:

16,881.77

87,271.22

0.00

2,450.00

8,304.37

114,907.36

4517	BC PATIENT FEMALE 2 1	5,936.00	4,286.25	3,859.52	1,400.00	0.00	700.00	350.00	350.00	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	8,924.42	2,826.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 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	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	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	9,274.42	2,826.00	0.00	0.00	0.00	

5
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	5,663.74	2,739.16	0.00	0.00	0.00	32,192.09

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	2,100.00	350.00	238.44	1,759.52	0.00	1,050.00	350.00	4,550.00	350.00	0.00	0.00	0.00		10,747.96		
8720	SSI DISABLED FREEDO M	59.40	237.60	163.68	0.00	0.00	0.00	0.00	22.82	350.00	0.00	0.00	0.00		833.50		
	2,369.12	6,433.72	5,792.51	4,592.75	2,964.70	5,884.60	2,060.43	10,236.56	3,439.16	0.00	0.00	0.00		43,773.55		

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	43,733,824.20	45,480,263.84	0.00	0.00	0.00		397,680,488.16		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 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	1,375.17	2,749.17	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	13,916.38	14,392.79	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	5,877.51	9,720.88	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	7,213.26	3,570.64	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	397,272.03	559,336.66	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	81,363.09	92,407.01	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	108,565.70	50,829.25	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	17,860.97	36,917.25	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	47,997.35	104,291.25	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	485,817.07	612,245.98	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	1,231,647.93	1,827,739.54	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	612,831.90	690,805.40	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	1,395.61	1,383.49	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	805.52	-799.18	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	9,285.07	3,366.38	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	2,149.31	3,354.02	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	42.04	120.42	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	59,952.13	73,657.08	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	64,152.89	46,997.31	91,231.24	102,587.31	66,008.56	55,797.17	32,896.85	42,304.98	31,047.88	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	253,850.54	315,665.20	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	206,510.09	241,729.43	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	3,771,166.39	3,833,723.81	4,457,896.20	3,339,155.66	3,222,228.88	4,143,086.96	2,738,093.95	3,133,366.79	4,271,203.62	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	773,645.46	1,028,742.93	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	1,328.69	955.40	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	22,433.48	27,581.26	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	8,621.35	10,016.42	0.00	0.00	0.00	
4303	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	
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	
4305	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	
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	540,601.99	957,696.34	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	709,005.68	921,801.38	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	865,742.88	1,114,262.45	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	220,962.95	372,939.26	0.00	0.00	0.00	

73,237.22	
124,854.22	
165,709.90	
64,548.35	
4,072,955.12	
1,484,930.61	
1,377,638.46	
408,943.93	
932,319.83	
5,088,759.56	
15,214,728.13	
6,713,480.46	
38,715.03	
4,768.68	
22,145.10	
33,674.72	
14,585.06	
867,785.44	
533,024.19	
2,076,965.65	
2,372,405.42	
32,909,922.26	
7,268,337.33	
6,728.81	
344,717.65	
84,206.93	
0.00	
0.00	
0.00	
5,587,077.01	
6,249,583.46	
7,342,950.34	
2,326,104.27	

D

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	308,693.49	367,377.24	0.00	0.00	0.00		2,903,717.98		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	21.79	885.87	56.76	1,054.83	131.06	0.00	0.00	0.00		2,150.31		
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	123,081.74	91,873.39	0.00	0.00	0.00		1,046,926.11		
5017	SOBRA PREG 21-44 FE	505,008.76	490,355.70	786,301.26	601,673.87	660,195.38	611,434.78	546,493.37	649,264.97	749,191.42	0.00	0.00	0.00		5,599,919.51		
5018	SOBRA PREG 45-64 FE M	0.00	12,542.17	0.00	422.16	372.51	1,135.72	1,056.99	5,412.82	2,297.37	0.00	0.00	0.00		23,239.74		
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.44	915.08	0.00	0.00	0.00		1,138.52		
	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	10,951,474.21	14,591,515.16	0.00	0.00	0.00		113,388,125.01		

M

M

SUBTOTAL:

224.73

224.73

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.79	8.94	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.79	8.94	0.00	0.00	0.00	

1
SUBTOTAL:

1103	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	
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	2,655.78	11,663.46	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	25,167.36	36,449.41	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	55,476.59	82,093.34	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	11,071.23	8,539.97	21,023.04	15,362.85	14,717.76	21,487.65	16,224.97	17,528.83	33,895.48	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	9,522.08	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	433.49	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	581.97	28.16	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	3,269.18	6,576.00	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	1,412.21	6,563.42	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	150,344.61	229,785.84	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	450,299.99	648,404.88	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	416,612.07	584,776.55	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	43.61	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	13,867.90	31,821.12	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	6,847.41	7,589.89	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	33,314.92	21,762.67	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	11,377.97	9,690.90	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	1,605.98	1,291.27	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	-567.93	605.69	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	184,271.57	213,024.75	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	16,886.98	13,663.76	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	109,739.51	100,550.95	88,862.91	27,616.73	84,045.66	86,870.54	118,947.72	147,487.93	73,464.32	0.00	0.00	0.00	

0.00	
0.00	
73,174.03	
214,878.74	
496,334.44	
159,851.78	
9,522.08	
1,772.70	
14,202.97	
28,262.53	
45,488.80	
1,181,268.30	
3,258,797.04	
2,894,854.34	
218.65	
66,089.27	
25,681.10	
138,706.69	
52,955.84	
68,803.11	
119,764.18	
1,879,835.72	
113,055.25	
837,586.27	

M&

E

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

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
194,924.82	195,369.54	290,524.12	205,743.06	175,024.36	301,966.96	168,378.94	251,695.49	284,728.09	0.00	0.00	0.00	2,068,355.38	
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	1,799,702.50	2,298,312.49	0.00	0.00	0.00	13,749,459.21	

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	
3317	AHC CARE FEMALE 21- 4	-527.88	0.00	0.00	0.00	0.00	0.00	-381.79	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	-12,669.89	0.00	0.00	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
21.62	
-49.48	
-909.67	
-13,553.16	
-14,490.69	

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	-387.32	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	
SUBTOTAL:	-34,472.66	0.00	14,549.19	-591.99	0.00	-2,426.30	-20.32	-387.32	0.00	0.00	0.00	0.00	

 
-1,057.32	
-99.09	
60.75	
-2,238.34	
12,313.57	
-25,580.51	
175.01	
-6,923.47	
-23,349.40	

3506	ADULT 40-100% MALE 2	15.57	260.53	0.00	0.00	0.00	856.86	811.63	1,322.26	1,601.21	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	3,469.33	7,402.79	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	17,446.16	6,778.06	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	14,451.52	10,831.78	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	191,491.58	270,341.10	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	109,841.40	105,802.51	150,353.68	93,953.55	100,102.01	113,487.37	79,903.81	93,980.77	154,512.89	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	484,915.30	761,475.56	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	363.67	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	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45.52	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	139.94	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	182.84	1,063.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	-113.08	0.00	357.03	0.00	121.64	739.90	710.15	444.19	774.75	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	4.71	1,331.69	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	13,612.17	16,184.28	11,638.87	15,449.12	13,966.65	10,416.70	8,527.59	10,972.44	6,408.99	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	112.46	353.44	167.54	658.68	573.76	185.90	0.00	126.54	0.00	0.00	0.00	0.00	

4,868.06	
0.00	
32,128.29	
335.70	
68,979.69	
248,620.12	
2,028,840.17	
1,001,937.99	
5,445,463.24	
2,053.60	
0.00	
45.52	
365.43	
1,868.58	
0.00	
3,034.58	
21,869.21	
107,176.81	
2,178.32	

E

4

6

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	49,424.42	117,557.97	171,586.96	99,739.77	114,797.94	83,920.83	61,098.55	71,453.75	86,498.07	0.00	0.00	0.00		856,078.26		
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	60,408.16	87,220.92	0.00	0.00	0.00		706,508.35		
3716	ADULT <40% EXP MALE	2,375,248.97	2,548,511.24	3,291,598.46	2,203,928.16	2,372,006.70	2,723,598.34	2,256,037.92	1,965,625.96	2,691,391.84	0.00	0.00	0.00		22,427,947.59		
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	819,007.28	1,088,554.16	0.00	0.00	0.00		9,034,691.05		
3718	ADULT <40% EXP M&F	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	2,771,996.73	3,716,351.61	0.00	0.00	0.00		28,642,601.44		
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	1,613.61	1,004.31	0.00	0.00	0.00		63,500.02		
3727	ADULT <40% EXP FEM	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	9.62	0.00	0.00	0.00		1,686.49		
	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	6,508,913.13	8,894,101.48	0.00	0.00	0.00		70,702,944.71		

4

AL

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	274.17	6,927.35	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	2,278.36	2,073.38	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	4,467.35	6,353.53	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	68,798.11	151,247.59	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	66,017.31	162,703.51	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	250,636.80	356,127.26	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	164.48	0.00	0.00	0.00	
3926	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	
3928	NEWLY ELIGIBLE M&F	47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	474,843.91	575,141.29	707,887.34	529,943.61	596,053.98	708,721.97	517,264.02	392,472.10	685,597.10	0.00	0.00	0.00	

0.00	
0.00	
35,456.87	
476.50	
39,674.47	
42,128.62	
1,121,609.83	
1,024,612.46	
2,923,754.98	
164.48	
0.00	
47.11	
5,187,925.32	

4
SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	18,822.56	18,033.29	11,971.57	66,627.29	61,087.04	112,144.19	68,203.82	91,771.61	121,961.96	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	39,404.07	25,244.64	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	7,170.95	59,145.25	2,446.86	47,194.94	40,459.21	26,628.68	32,029.01	30,053.40	45,106.33	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	161,229.08	192,312.93	0.00	0.00	0.00	

0.00	
570,623.33	
202,877.30	
290,234.63	
1,063,735.26	

SUBTOTAL:

3,731.64

17,112.91

0.00

12,364.88

1,677.40

34,886.83

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	380.10	8,679.39	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 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	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	0.00	0.00	1,422.62	58.51	0.00	0.00	127.80	0.00	68.47	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	380.10	8,747.86	0.00	0.00	0.00	

5
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	4,607.48	5,100.65	0.00	0.00	0.00	35,741.10

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	0.00	0.00	94.49	0.00	0.00	0.00	0.00	265.46	0.00	0.00	0.00	0.00		359.95		
8720	SSI DISABLED FREEDO M	0.00	0.00	204.26	0.00	10.26	0.00	0.00	32.12	1,682.04	0.00	0.00	0.00		1,928.68		
	3,652.19	5,276.89	5,362.74	2,938.66	2,002.06	5,632.26	1,477.18	4,905.06	6,782.69	0.00	0.00	0.00		38,029.73		

SUBTOTAL:

204,127,490.71

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	19,818,904.65	26,677,378.65	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 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-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4303	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	
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	
4305	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	
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	

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

D

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5028	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		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

M

M

SUBTOTAL:

0.00

0.00

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1
SUBTOTAL:

1103	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	
1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

M&

E

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

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

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	

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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	
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	

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	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	
3527	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

E

4

6

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	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		0.00		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
3718	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	0.00	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		

4

AL

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	
3926	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	
3928	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

4
SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	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

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	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5
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	0.00

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		

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 March 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	183.70	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	8,801.60	4,971.29	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	513.74	701.82	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	411.59	596.64	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	517.95	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	783.30	336.81	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	2,369.89	1,849.24	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	10,699.83	21,174.22	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	5,814.36	5,037.85	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	44.01	274.68	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	3,360.93	104.85	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	371.10	7,188.56	32,792.94	1,605.68	18,626.89	9,771.81	8,423.35	6,410.80	45,935.51	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	2,074.13	3,346.54	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	1,722.46	1,448.93	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	25,287.18	285,986.08	63,667.08	20,539.73	10,339.15	19,142.49	6,249.43	29,799.24	44,897.80	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	4,318.16	1,521.87	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	
4303	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	
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	
4305	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	
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	9,210.15	5,389.08	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	16,014.39	25,026.74	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	20,889.98	21,785.68	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	22,040.45	13,301.06	0.00	0.00	0.00	

136.92	
0.00	
2,885.07	
284.13	
60,413.71	
22,597.28	
8,035.95	
6,273.00	
14,436.34	
87,887.72	
180,280.33	
58,462.80	
568.42	
0.00	
0.00	
14.61	
0.00	
12,130.49	
131,126.64	
12,154.55	
10,638.59	
505,908.18	
47,287.24	
0.00	
2,306.72	
0.00	
0.00	
0.00	
0.00	
61,397.90	
186,834.98	
222,132.89	
184,690.43	

D

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	1,611.34	10,524.83	0.00	0.00	0.00		74,535.28		
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		
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	8,174.96	6,546.86	0.00	0.00	0.00		32,868.04		
5017	SOBRA PREG 21-44 FE	21,818.94	29,403.82	43,513.99	31,655.97	15,933.90	13,446.16	23,742.27	33,941.80	36,361.11	0.00	0.00	0.00		249,817.96		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5028	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		
	212,022.47	488,372.66	298,566.78	176,603.03	155,045.74	205,604.52	199,048.80	189,190.81	251,651.36	0.00	0.00	0.00		2,176,106.17		

M

M

SUBTOTAL:

85.42

85.42

3100	TRANSPLANT OPTION	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	

1
SUBTOTAL:

1103	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	
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	-841.65	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	132.07	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	21.69	0.00	0.00	0.00	153.06	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	169.08	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	3,257.32	-6,106.30	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	8,693.49	13,018.09	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	9,569.22	10,220.29	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	-707.17	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	198.47	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	56,129.73	0.00	20,969.96	0.00	35,888.67	13,483.84	0.00	0.00	299.10	0.00	0.00	0.00	

0.00	
0.00	
-841.65	
26.99	
585.50	
174.75	
107.79	
296.08	
0.00	
7,949.90	
324.13	
46,923.47	
85,579.91	
34,831.64	
0.00	
0.00	
0.00	
0.00	
0.00	
4,489.62	
0.00	
627.63	
4,814.15	
126,771.30	

M&

E

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

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
479.32	0.00	3,171.06	1,161.00	1,618.58	356.00	2,262.36	2,870.22	1,574.70	0.00	0.00	0.00	13,493.24	
71,791.87	5,686.71	75,118.85	16,413.39	46,695.06	38,491.09	29,457.49	23,916.15	18,583.84	0.00	0.00	0.00	326,154.45	

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-55.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	-123.42	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	-304.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
0.00	
-55.14	
-123.42	
-304.13	
-482.69	

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	-2,168.34	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	56,134.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	57,131.53	0.00	0.00	0.00	0.00	-90.89	0.00	-2,168.34	0.00	0.00	0.00	0.00	

 
0.00	
-90.89	
0.00	
0.00	
0.00	
996.64	
-2,168.34	
56,134.89	
54,872.30	

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	591.05	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	4,240.15	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	197.37	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	5,001.69	8,897.10	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	9,918.88	16,192.67	4,216.11	6,873.78	4,424.35	1,148.09	4,839.72	12,931.67	1,560.75	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	14,463.63	10,232.53	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	
3527	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	447.71	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	47.77	159.41	-72.49	153.28	0.00	57.02	-357.03	706.56	220.96	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
301.01	
652.28	
9,417.74	
4,379.62	
142,205.59	
62,106.02	
181,879.99	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
457.97	
4,114.12	
915.48	
0.00	

E

4

6

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	638.33	2,949.89	655.77	55.09	1,044.42	821.03	540.50	5,932.12	2,591.74	0.00	0.00	0.00		15,228.89		
3715	ADULT <40% EXP FEM AL	6,886.22	1,333.58	986.35	0.00	0.00	971.73	484.68	663.21	0.00	0.00	0.00	0.00		11,325.77		
3716	ADULT <40% EXP MALE	87,516.94	137,213.09	59,107.89	86,557.14	76,793.86	88,807.17	25,860.89	62,765.55	61,978.04	0.00	0.00	0.00		686,600.57		
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	38,352.76	19,283.84	0.00	0.00	0.00		293,171.48		
3718	ADULT <40% EXP M&F	73,759.29	34,317.41	75,461.37	91,305.45	36,478.45	38,593.34	50,612.11	84,271.10	64,520.47	0.00	0.00	0.00		549,318.99		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,493.56	877.47	0.00	0.00	0.00		2,371.03		
3727	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	226,581.85	175,639.18	0.00	0.00	0.00		1,964,446.55		

4

AL

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	53.31	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	583.12	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	570.94	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	2,127.19	1,269.37	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	2,026.18	3,238.05	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	22,348.22	15,304.83	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	
3926	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	
3928	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	44,437.01	23,067.06	66,686.47	17,761.16	1,707.45	29,639.64	83,559.50	27,072.53	20,448.68	0.00	0.00	0.00	

75.76	
0.00	
53.31	
583.12	
219.66	
707.80	
82,800.22	
38,134.76	
191,804.87	
0.00	
0.00	
0.00	
314,379.50	

4
SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	332.82	31.19	1,392.55	1,273.75	5,386.27	3,719.75	3,749.35	2,648.22	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	211.82	782.81	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	169.44	0.00	0.00	636.29	424.71	-39.17	0.00	0.00	216.87	0.00	0.00	0.00	
	177.42	401.62	31.19	2,090.39	1,825.04	5,416.89	23,924.54	3,961.17	3,647.90	0.00	0.00	0.00	

0.00	
18,533.90	
21,534.12	
1,408.14	
41,476.16	

SUBTOTAL:

0.00

35.03

22.40

3,527.87

0.00

3,585.30

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	35.03	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.40	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	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	57.43	0.00	0.00	0.00	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO
M

0.00	0.00	0.00	61.65	36.81	95.62	36.81	1,290.05	966.68	0.00	0.00	0.00	2,487.62

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	0.00	2,178.61	0.00	0.00	13,816.87	0.00	0.00	0.00	6,421.98	0.00	0.00	0.00		22,417.46		
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	2,178.61	0.00	61.65	13,853.68	95.62	36.81	1,290.05	7,388.66	0.00	0.00	0.00		24,905.08		

SUBTOTAL:

4,905,241.61

646,451.11	771,726.45	689,215.77	447,049.28	414,228.06	523,522.32	465,787.35	469,844.22	477,417.05	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 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	19,435.74	28,348.02	0.00	0.00	0.00		238,925.55		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	19,435.74	28,348.02	0.00	0.00	0.00		238,925.55		

SUBTOTAL:

TOTAL:	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	19,435.74	28,348.02	0.00	0.00	0.00		238,925.55		

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending March 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	1,306.08	0.00	0.00	0.00	0.00		1,375.13		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	54.51	0.00	0.00	0.00	14.54	1,306.08	0.00	0.00	0.00	0.00		1,375.13		

SUBTOTAL:

TOTAL:

0.00

0.00	54.51	0.00	0.00	0.00	14.54	1,306.08	0.00	0.00	0.00	0.00	1,375.13

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 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	315,568.31	500,143.03	0.00	0.00	0.00		3,091,633.41		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.47	0.00	0.00	0.00	0.00		22.47		
	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	315,590.78	500,143.03	0.00	0.00	0.00		3,091,655.88		

SUBTOTAL:

TOTAL:	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	315,590.78	500,143.03	0.00	0.00	0.00		3,091,655.88		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 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	70.29	1,456.73	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	96.42	96.08	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	83,860.40	29,081.54	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	11,578.05	10,855.28	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	1,001.01	627.70	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	742.46	267.38	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	8,922.12	6,905.45	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	31,412.32	110,675.29	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	116,787.64	164,332.19	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	69,573.56	60,779.61	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	73.95	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	1,608.57	3,475.77	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	267.22	1,844.32	1,193.89	206.73	207.49	3,138.04	0.00	0.00	278.42	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	6,240.10	9,235.80	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	7,716.73	6,449.52	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME	231,778.99	342,969.11	271,027.04	176,793.76	210,239.42	204,543.74	177,331.11	196,420.41	252,320.07	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	49,741.49	52,592.80	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	561.96	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	
4303	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	
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	
4305	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	
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	146,993.00	99,520.37	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	175,445.37	85,220.46	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	40,338.93	52,942.41	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	15,257.76	36,080.81	0.00	0.00	0.00	

780.06	
4,405.93	
6,945.43	
82.48	
491,365.39	
104,673.00	
48,677.22	
10,461.42	
57,002.04	
451,309.79	
1,199,885.73	
420,629.19	
0.00	
0.00	
0.00	
3,973.06	
0.00	
47,970.11	
7,136.11	
61,232.34	
88,324.42	
2,063,423.65	
338,166.64	
530.71	
8,647.34	
882.23	
0.00	
0.00	
0.00	
944,043.02	
526,918.34	
352,696.68	
167,963.46	

D

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	35,183.29	35,745.28	0.00	0.00	0.00		257,292.95		
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		
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	25,221.76	16,010.44	0.00	0.00	0.00		215,946.04		
5017	SOBRA PREG 21-44 FE	50,370.25	73,392.58	98,242.24	99,306.65	73,113.89	108,947.96	91,772.55	117,925.86	123,974.82	0.00	0.00	0.00		837,046.80		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.17	0.00	0.00	0.00		57.17		
	808,932.77	881,111.78	1,023,289.80	1,037,253.28	908,268.05	958,858.15	799,000.08	1,142,137.54	1,159,617.30	0.00	0.00	0.00		8,718,468.75		

M

M

SUBTOTAL:

0.00

0.00

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1
SUBTOTAL:

1103	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	
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	24.92	562.25	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	1,453.25	906.70	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	1,269.77	2,812.65	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	1,249.86	53.73	663.23	32.04	433.73	1,330.06	324.00	138.41	4.98	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	5,416.82	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	1,316.97	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	8,831.96	58,286.70	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	57,426.54	46,389.10	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	39,485.25	39,783.92	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	2,153.33	878.20	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	91.29	261.46	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	1,336.58	2,228.79	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	-44.50	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	355.10	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	15,779.52	27,250.10	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	247.27	736.84	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	13,636.52	8,325.86	26,011.62	1,009.53	583.66	720.17	2,476.55	1,039.57	1,032.31	0.00	0.00	0.00	

0.00	
0.00	
-1,422.55	
10,675.21	
19,529.15	
4,230.04	
0.00	
169.40	
15.00	
6,349.78	
1,370.96	
163,132.28	
351,001.33	
187,051.61	
1,368.93	
4,234.43	
639.42	
7,772.94	
81.70	
3,130.56	
5,364.49	
93,218.35	
9,232.24	
54,835.79	

M&

E

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

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4,285.83	11,263.10	11,272.83	7,319.43	5,081.88	20,081.95	9,392.05	10,511.78	12,169.11	0.00	0.00	0.00	91,377.96	
71,468.19	82,740.10	146,508.04	66,063.09	101,434.21	104,086.15	100,922.30	146,878.33	193,258.61	0.00	0.00	0.00	1,013,359.02	

3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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	
SUBTOTAL:	0.00	0.00	-207.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	257.39	536.53	221.46	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	27.35	62.40	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	501.26	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	155.67	249.15	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	53,183.84	146,546.98	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	12,294.00	3,333.58	14,103.28	9,486.39	17,241.16	6,694.26	9,776.39	16,322.61	49,510.70	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	94,223.08	69,012.14	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	
3527	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	246.62	0.00	1,361.40	109.80	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	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	0.00	0.00	0.00	0.00	0.00	0.00	-224.42	0.00	0.00	0.00	0.00	0.00	

1,015.38	
0.00	
3,260.75	
91.35	
17,319.80	
4,993.54	
640,810.58	
138,762.37	
753,046.45	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,717.82	
3,486.24	
-224.42	

E

4

6

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	7,292.84	12,081.73	19,979.50	3,571.18	6,165.38	11,600.06	1,839.57	21,101.83	4,513.44	0.00	0.00	0.00		88,145.53		
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	14,507.32	10,027.92	0.00	0.00	0.00		73,579.11		
3716	ADULT <40% EXP MALE	136,455.42	205,325.04	266,134.03	102,321.13	255,550.69	161,837.89	126,535.96	200,353.43	354,171.45	0.00	0.00	0.00		1,808,685.04		
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	85,873.98	76,008.50	0.00	0.00	0.00		798,160.70		
3718	ADULT <40% EXP M&F	181,612.85	129,721.57	241,985.31	168,543.69	210,132.57	273,111.36	172,306.98	297,742.35	316,208.36	0.00	0.00	0.00		1,991,365.04		
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	0.00	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	784,137.79	1,027,033.76	0.00	0.00	0.00		6,325,475.28		

4

AL

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	-1,216.00	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	87.98	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	565.34	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	4,706.53	4,710.97	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	16,876.09	29,294.65	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	44,455.79	44,508.33	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	
3926	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	
3928	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	57,678.54	27,673.40	42,100.30	52,364.43	46,958.93	67,934.44	55,605.13	64,910.39	79,079.29	0.00	0.00	0.00	

0.00	
0.00	
-107.01	
0.00	
967.71	
5,042.99	
49,964.13	
102,016.90	
336,420.13	
0.00	
0.00	
0.00	
494,304.85	

4
SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	920.33	606.76	51.87	3,005.28	2,948.59	9,142.94	2,684.28	4,211.66	10,149.38	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	787.94	405.91	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	589.03	196.50	0.00	4,003.47	2,355.99	5,473.69	1,606.27	1,572.40	2,865.83	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	6,572.00	13,421.12	0.00	0.00	0.00	

0.00	
33,721.09	
8,465.85	
18,663.18	
60,850.12	

SUBTOTAL:

0.00

108.34

0.00

0.00

0.00

108.34

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	66.89	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	10.17	15.64	0.00	0.00	15.64	0.00	0.00	66.89	0.00	0.00	0.00	0.00	

5
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	660.24

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending March 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	22.70	0.00	274.10	91.00	262.32	10.12	0.00	0.00	0.00	0.00	0.00		660.24		

SUBTOTAL:

16,613,019.15

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	2,144,702.94	2,472,410.08	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending March 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	143,745.18	106,223.61	0.00	0.00	0.00		1,132,496.24		
2110	SSI AGED NON-MEDICA R	26,434.90	13,763.26	31,784.99	27,506.02	11,008.01	20,476.11	15,801.28	35,485.17	47,163.43	0.00	0.00	0.00		229,423.17		
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	127,249.33	132,429.19	0.00	0.00	0.00		1,249,315.06		
2200	SSI DISABLED WITH M	45,476.20	32,686.17	56,715.55	29,618.96	25,027.91	41,363.82	24,516.31	25,071.19	28,005.89	0.00	0.00	0.00		308,482.00		
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	797,805.28	649,141.58	0.00	0.00	0.00		6,216,181.33		
2220	SSI DISABLED WITH Q	48,687.58	68,819.71	112,495.22	51,083.18	51,662.77	56,329.19	40,683.06	55,679.68	57,484.17	0.00	0.00	0.00		542,924.56		
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	5,745.60	5,363.93	0.00	0.00	0.00		56,622.93		
2320	SSI BLIND WITH QMB	431.94	428.25	416.46	71.62	789.22	833.02	421.52	274.18	191.34	0.00	0.00	0.00		3,857.55		
	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	1,191,055.61	1,026,003.14	0.00	0.00	0.00		9,740,228.66		

E

M

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	0.00	0.00	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	

M
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	1,191,055.61	1,026,003.14	0.00	0.00	0.00		9,740,335.54		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending March 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	2,053,589.56	2,482,402.80	0.00	0.00	0.00		19,517,615.65		
2110	SSI AGED NON-MEDICA R	134,210.18	86,635.19	183,540.43	121,497.09	95,581.49	106,014.38	109,241.83	92,529.35	115,438.69	0.00	0.00	0.00		1,044,688.63		
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	2,913,764.31	3,487,725.23	0.00	0.00	0.00		27,957,623.32		
2200	SSI DISABLED WITH M	484,829.08	429,355.23	623,488.25	496,865.31	514,028.21	644,163.05	445,334.53	555,686.95	542,999.94	0.00	0.00	0.00		4,736,750.55		
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	1,762,751.80	2,202,913.44	0.00	0.00	0.00		17,631,236.61		
2220	SSI DISABLED WITH Q	585,872.48	620,560.01	851,203.88	615,551.90	612,586.36	832,248.41	699,418.83	675,434.25	843,309.26	0.00	0.00	0.00		6,336,185.38		
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	5,273.47	12,748.95	0.00	0.00	0.00		70,045.43		
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	5,835.69	7,493.66	0.00	0.00	0.00		57,678.49		
	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	8,064,865.38	9,695,031.97	0.00	0.00	0.00		77,351,824.06		

E

M

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	5,483.52	2,578.56	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	4,112.64	2,741.76	2,741.76	3,427.20	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	8,225.28	6,005.76	0.00	0.00	0.00	

22,901.28	
25,983.72	
48,885.00	

M
SUBTOTAL:

77,400,709.06

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	8,073,090.66	9,701,037.73	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending March 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	42,146.50	28,592.89	0.00	0.00	0.00		327,779.67		
2110	SSI AGED NON-MEDICA R	16,433.83	946.68	83,538.56	8,338.74	936.50	2,605.51	0.00	20,403.46	0.00	0.00	0.00	0.00		133,203.28		
2120	SSI AGED WITH QMB	443.59	1,507.61	18.05	566.68	28.46	76.41	312.29	12.87	2,062.75	0.00	0.00	0.00		5,028.71		
2200	SSI DISABLED WITH M	11,220.75	6,502.00	26,013.79	7,482.95	9,714.19	1,405.20	16,547.58	1,364.39	4,430.82	0.00	0.00	0.00		84,681.67		
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	170.30	50,760.97	0.00	0.00	0.00		263,161.52		
2220	SSI DISABLED WITH Q	2,359.28	722.71	6,308.23	1,497.53	1,372.98	2,162.54	215.93	1,994.88	1,570.30	0.00	0.00	0.00		18,204.38		
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	66,092.40	87,417.73	0.00	0.00	0.00		838,716.06		

E

M

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

0.00	
0.00	
0.00	

M
SUBTOTAL:

TOTAL:	121,910.37	64,311.03	187,810.07	50,919.11	118,392.99	70,411.89	71,450.47	66,092.40	87,417.73	0.00	0.00	0.00		838,716.06		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending March 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	27,967.84	21,732.02	0.00	0.00	0.00		223,393.12		
2110	SSI AGED NON-MEDICA R	68.35	0.00	655.42	0.00	206.68	50.89	0.00	0.00	2,122.27	0.00	0.00	0.00		3,103.61		
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	15,840.80	19,040.34	0.00	0.00	0.00		126,979.05		
2200	SSI DISABLED WITH M	1,998.01	5,671.10	17,991.36	2,677.54	3,446.03	8,612.53	11,085.27	10,507.32	7,029.28	0.00	0.00	0.00		69,018.44		
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	60,565.37	118,494.07	0.00	0.00	0.00		586,214.02		
2220	SSI DISABLED WITH Q	2,612.76	3,357.96	4,743.41	3,725.64	6,845.49	13,692.39	6,072.55	3,415.05	9,910.87	0.00	0.00	0.00		54,376.12		
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	37.14	105.21	0.00	0.00	0.00		627.43		
	74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	126,088.53	118,333.52	178,434.06	0.00	0.00	0.00		1,063,711.79		

E

M

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

0.00	
0.00	
0.00	

M
SUBTOTAL:

1,063,711.79

74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	126,088.53	118,333.52	178,434.06	0.00	0.00	0.00	

TOTAL:

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

N
SUBTOTAL:

183,782.09

170,408.91

173,185.84

164,735.13

157,227.01

237,286.25

145,035.95

134,596.32

138,960.53

0.00

0.00

0.00

1,505,218.03

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	479.18	911.99	0.00	0.00	0.00	8,779.19	

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	44,050.29	41,851.79	0.00	0.00	0.00	483,235.13	
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	36,864.12	37,371.18	0.00	0.00	0.00	398,595.11	
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	53,202.73	52,590.24	0.00	0.00	0.00	600,558.98	
9960	KIDSCARE KICK PAYME	0.00	0.00	6,160.56	0.00	0.00	0.00	0.00	0.00	6,235.33	0.00	0.00	0.00	12,395.89	

TOTAL:	183,782.09	170,408.91	173,185.84	164,735.13	157,227.01	237,286.25	145,035.95	134,596.32	138,960.53	0.00	0.00	0.00		1,505,218.03		

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

993.61	932.52	910.22	883.58	836.18	816.75	763.37	720.42	704.92	0.00	0.00	0.00	

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	1.00	1.90	0.00	0.00	0.00	15.56	

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	328.13	314.83	0.00	0.00	0.00	3,451.74	
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	242.85	218.16	218.83	207.34	199.29	198.00	0.00	0.00	0.00	2,016.93	
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	240.85	230.13	226.93	206.46	192.00	189.19	0.00	0.00	0.00	2,065.34	
9960	KIDSCARE KICK PAYME N	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	2.00	
SUBTOTAL:	993.61	932.52	910.22	883.58	836.18	816.75	763.37	720.42	704.92	0.00	0.00	0.00		7,561.57	
															
TOTAL:														7,561.57	

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending March 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	41.42	41.42	0.00	0.00	0.00		602.93		
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	13,254.40	12,674.52	0.00	0.00	0.00		138,810.31		
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	8,661.96	8,476.58	0.00	0.00	0.00		85,050.63		
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	8,417.86	8,335.02	0.00	0.00	0.00		88,791.77		
SUBTOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	42,451.52	32,067.42	30,375.64	29,527.54	0.00	0.00	0.00		313,748.38		

TOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	42,451.52	32,067.42	30,375.64	29,527.54	0.00	0.00	0.00		313,748.38		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending March 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	1.00	1.00	0.00	0.00	0.00		14.00		
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	320.00	306.00	0.00	0.00	0.00		3,372.00		
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	235.00	210.00	211.00	198.00	194.00	191.00	0.00	0.00	0.00		1,946.00		
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	231.00	223.00	220.00	200.00	187.00	185.00	0.00	0.00	0.00		2,017.00		
SUBTOTAL:	968.00	918.00	894.00	849.00	812.00	792.00	741.00	702.00	683.00	0.00	0.00	0.00		7,359.00		

TOTAL:

968.00

7,359.00

918.00	894.00	849.00	812.00	792.00	741.00	702.00	683.00	0.00	0.00	0.00

KidsCare - FEE FOR SERVICE
For The Period Ending March 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	93.55	0.00	0.00	0.00		3,040.27		
6014	KIDS 14-19 MALE NON-	-652.26	85.01	0.00	96.20	0.00	0.00	0.00	0.00	15.43	0.00	0.00	0.00		-455.62		
6015	KIDS 14-19 FEMALE NO	-174.33	326.70	118.31	203.32	331.61	11.19	15.43	139.88	120.75	0.00	0.00	0.00		1,092.86		
	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	139.88	229.73	0.00	0.00	0.00		3,320.41		

SUBTOTAL:

TOTAL:	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	139.88	229.73	0.00	0.00	0.00		3,320.41		

KidsCare - REINSURANCE
For The Period Ending March 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	25,621.74	104,593.60	0.00	0.00	0.00		341,050.45		
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	25,621.74	104,593.60	0.00	0.00	0.00		418,292.87		

SUBTOTAL:

TOTAL:

161.54

30,495.15	70,988.85	57,122.39	103,826.49	25,397.21	85.90	25,621.74	104,593.60	0.00	0.00	0.00	418,292.87

6

00

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

RATE CODE

DESCRIPTION

JULY

AUGUST     SEPTEMBER

OCTOBER

NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

259,213.49

259,213.49

38.00

5,831.78

13.00

1,446.74

40.19

2,441.37

16,109.75

0.00

195,599.38

5.05

36,177.68

1.00

123.00

1,028.25

250.30

64.00

17.00

27.00

1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	4.00	5.00	7.00	7.00	7.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	643.15	641.57	646.12	649.50	648.46	646.64	649.79	655.10	651.45	0.00	0.00	0.00	
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	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	160.60	162.00	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	4.00	4.00	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	269.00	268.17	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	1,828.18	1,838.54	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	21,887.82	22,013.59	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	4.35	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	4,051.30	4,066.29	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	14.00	14.00	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	115.00	116.00	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	28.00	28.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	8.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	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	29,034.00	29,187.39	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	29,034.00	29,187.39	0.	0.00	0.00	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending March 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	375,239.67	372,982.88	0.00	0.00	0.00	3,336,406.32	
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	98,880,037.83	86,041,307.17	0.00	0.00	0.00	813,455,675.65	
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	99,255,277.50	86,414,290.05	0.00	0.00	0.00	816,792,081.97	
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	99,930,110.58	100,459,478.61	0.00	0.00	0.00	891,484,672.34	
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	99,930,110.58	100,459,478.61	0.00	0.00	0.00	891,484,672.34	
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	199,185,388.08	186,873,768.66	0.00	0.00	0.00	1,708,276,754.31	

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	9,448,572.19
0.00	10,992,892.66
0.00	0.00
0.00	0.00
0.00	0.00
0.00	89,043,472.45
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	
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	9,448,572.19	10,992,892.66	0.00	0.00	0.00	89,043,472.45	

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	1,941,692.74
496,962.44	2,187,299.24
457,882.59	0.00
0.00	0.00
0.00	0.00
0.00	30,756,973.46
4,404,600.34	
	375,457.62	326,085.82	792,734.80	709,764.46	616,786.74	373,282.71	255,643.16	496,962.44	457,882.59	0.00	0.00	0.00	4,404,600.34	
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	2,438,655.18	2,645,181.83	0.00	0.00	0.00	35,161,573.80	

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	3,581,856.00	3,624,590.50	0.00	0.00	0.00	29,605,158.90	

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 March 31, 2016

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

TOTAL

Tuesday, April 12, 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	14,161,860.04	14,223,154.37	0.00	0.00	0.00	130,865,297.77	
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	145,302.07	144,121.20	0.00	0.00	0.00	1,230,405.27	
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	4,920,883.20	4,913,331.20	0.00	0.00	0.00	38,846,068.49	
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	547,733.76	549,642.24	0.00	0.00	0.00	4,732,052.52	
	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	19,775,779.07	19,830,249.01	0.00	0.00	0.00	175,673,824.05	

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	3,233,117.99	1,312,151.22	0.00	0.00	0.00	16,198,011.52	
	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	3,233,117.99	1,312,151.22	0.00	0.00	0.00	16,198,011.52	

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	23,263.52	23,263.52	0.00	0.00	0.00	260,433.63	
	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	49,375.16	27,578.53	23,263.52	23,263.52	0.00	0.00	0.00	260,433.63	

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	23,032,160.58	21,165,663.75	0.00	0.00	0.00	192,132,269.20	

GRAND TOTAL

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

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

TOTAL

Tuesday, April 12, 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	17,043.20	17,117.52	0.00	0.00	0.00	154,381.08	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	168.21	164.43	179.03	172.82	181.83	180.00	0.00	0.00	0.00	1,549.73	
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	6,516.00	6,506.00	0.00	0.00	0.00	58,341.00	
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	1,148.00	1,152.00	0.00	0.00	0.00	10,453.00	
	24,833.16	24,861.60	24,985.24	25,084.02	25,007.80	25,121.30	24,987.14	24,889.03	24,955.52	0.00	0.00	0.00	224,724.81	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC MM	36.87	32.00	33.00	34.99	35.00	32.93	33.19	28.00	28.00	0.00	0.00	0.00	293.98	
	36.87	32.00	33.00	34.99	35.00	32.93	33.19	28.00	28.00	0.00	0.00	0.00	293.98	

Subtotal

24,870.03	24,893.60	25,018.24	25,119.01	25,042.80	25,154.23	25,020.33	24,917.03	24,983.52	0.00	0.00	0.00	225,018.79	

GRAND TOTAL

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

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

TOTAL

Tuesday, April 12, 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	8,306,683.94	8,299,374.31	0.00	0.00	0.00	50,421,018.54	
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	20,514,578.77	20,420,411.06	0.00	0.00	0.00	124,407,100.37	
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	44,581,909.48	44,898,393.66	0.00	0.00	0.00	410,352,904.23	
	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	73,403,172.19	73,618,179.03	0.00	0.00	0.00	585,181,023.14	

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	73,403,172.19	73,618,179.03	0.00	0.00	0.00	585,181,023.14	

GRAND TOTAL

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

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

TOTAL

Tuesday, April 12, 2016

010700	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	-1.00	5,604.33	5,566.18	5,573.46	5,527.22	5,470.36	5,465.61	0.00	0.00	0.00	33,206.16	
010725	CENPATICO INTEGRATED - MM	0.00	0.00	12.00	13,638.68	13,546.91	13,530.10	13,387.94	13,298.98	13,238.06	0.00	0.00	0.00	80,652.67	
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	19,884.25	20,022.32	0.00	0.00	0.00	178,181.77	
	19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,177.16	38,935.41	38,653.59	38,725.99	0.00	0.00	0.00	292,040.60	

Subtotal

19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,177.16	38,935.41	38,653.59	38,725.99	0.00	0.00	0.00	292,040.60	

GRAND TOTAL