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

May 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

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

Status Summary – Laws 2016, Chapter 117, included the following FY 2016 appropriation adjustments:

Section 112(A) - Prescription Drug Rebate (State) increase of $22,100,000
Section 112(B) – Emergency Health Services account increase of $830,800
Section 112(C) – Medically Needy Account increase of $3,318,500
Section 112(D) – Expenditure Authority increase of $539,311,600

With   these   appropriation   adjustments,   AHCCCS   projections   indicate   that   the   existing appropriations are expected to be sufficient to cover agency expenditures.

There are several issues this fiscal year that have the potential to affect the final expenditures. 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.  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. May 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 – April 2016 enrollment is 1,841,997 members, a 7,051 member decrease over the prior month.  Enrollment for May 2016 decreased to 1,833,152 members, a decrease of
8,845 members.

Major May changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 6,204; Supplemental Security Income – increase of 476; Prop 204 Restoration – decrease of 1,739; Adult Expansion - decrease of 47; Medicare Cost Sharing – decrease of 166; and Federal Emergency Services – decrease of 1,305.

Tobacco  Funds  Revenue  Update  –Tobacco  tax  collections  through  April  2016  are  $10.8 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 April 30, 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 April 30, 2016
SUMMARY OF APPROPRIATED EXPENDITURES

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

APPROPRIATIONS:

ADMINISTRATION

AHCCCS Operating Lump Sum	$	75,225,400		$	59,268,800		$	59,761,636		$	(492,836)		$	75,225,400		$	-	
AHCCCS Prop 204 Administration	14,970,800		8,177,700		8,993,781		(816,081)		14,970,800		-	
DES Eligibility	71,874,500		44,156,100		54,730,684		(10,574,584)		71,874,500		-	
DES Prop 204 Eligibility	41,358,700		30,644,200		31,988,473		(1,344,273)		41,358,700		-	
TOTAL ADMINISTRATION	203,429,400		142,246,800		155,474,574		(13,227,774)		203,429,400		-	

Traditional Medicaid Services	3,782,135,000		3,120,183,800		3,036,991,558		83,192,242		3,782,135,000		-	
Proposition 204 Services	2,666,524,700		2,194,386,100		1,988,592,623		205,793,477		2,666,524,700		-	
ACA Adult Expansion	406,683,800		334,567,900		328,787,427		5,780,473		406,683,800		-	
Children's Rehabilitative Services	251,839,100		207,550,100		208,788,165		(1,238,065)		251,839,100		-	
KidsCare Services	6,295,200		5,253,400		1,779,947		3,473,453		6,295,200		-	
ALTCS Services	1,398,588,900		1,151,067,400		1,072,286,295		78,781,105		1,398,588,900		-	
Disproportionate Share Payments	5,087,100		-		-		-		5,087,100		-	
Rural Hospitals	22,650,000		5,245,900		5,245,950		(50)		22,650,000		-	
Voluntary Political Subdivision Programs	356,228,800		263,434,500		263,434,460		40		356,228,800		-	
TOTAL PROGRAMMATIC	8,896,032,600		7,281,689,100		6,905,906,424		375,782,676		8,896,032,600		-	

TOTAL EXPENDITURES

$	9,099,462,000

$    7,423,935,900

$   7,061,380,998

$	362,554,902

$  9,099,462,000	$	-

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT For the Period Ending April 30, 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		$ 	40,735,900		$ 	45,360,009		(4,624,109)		$ 	51,537,900		$ 	-	
Proposition 204 - Administrative  Expenditures	20,280,700		16,127,900		15,040,758		1,087,142		20,280,700		-	
Programmatic  Expenditures
Traditional Medicaid Services	
800,323,100		
656,549,700		
709,478,251		
(52,928,551)		
800,323,100		
-	
Proposition 204 Services	90,000,000		74,528,300		(36,611,201)		111,139,501		90,000,000		-	
Children's Rehabilitative  Services	72,487,200		59,769,500		60,334,689		(565,189)		72,487,200		-	
KidsCare Services	338,000		338,000		(29,638)		367,638		338,000		-	
ALTCS Services	162,880,800		134,652,900		135,734,000		(1,081,100)		162,880,800		-	
DSH and Rural Hospitals	7,314,600		1,630,400		1,630,441		(41)		7,314,600		-	
TOTAL GF EXPENDITURES	1,205,162,300 	984,332,600 	930,937,309 	53,395,291 	1,205,162,300 	-

Administrative  Expenditures	95,114,000		62,401,200		68,956,403		(6,555,203)		95,114,000		-	
Proposition 204 - Administrative  Expenditures	32,565,900		19,911,600		23,329,321		(3,417,721)		32,565,900		-	
Programmatic  Expenditures
Traditional Medicaid Services	
2,463,050,600		
2,031,470,800		
1,970,544,594		
60,926,206		
2,463,050,600		
-	
Proposition 204 Services	2,166,808,800		1,782,679,900		1,689,566,869		93,113,031		2,166,808,800		-	
ACA Adult Expansion	406,683,800		334,567,900		328,787,427		5,780,473		406,683,800		-	
Children's Rehabilitative  Services	179,351,900		147,780,600		148,453,476		(672,876)		179,351,900		-	
KidsCare Services	5,587,200		4,616,100		1,809,584		2,806,516		5,587,200		-	
ALTCS Services and Nursing Facility Assessment	931,056,600		766,331,800		712,633,331		53,698,469		931,056,600		-	
DSH and Rural Hospitals	20,422,500		3,615,500		3,615,509		(9)		20,422,500		-	
Voluntary Political Subdivision Programs - See Note 5	242,746,600		174,902,200		174,902,168		32		242,746,600		-	
TOTAL FEDERAL EXPENDITURES	6,543,387,900		5,328,277,600		5,122,598,683		205,678,917		6,543,387,900		-	

Administrative  Expenditures  Proposition 204 - BNCF 	3,482,900 	2,782,400 	2,612,175 	170,225 	3,482,900 	- Programmatic  Expenditures
Traditional Medicaid Services Acute Care 	     49,879,700 		  41,566,000 		41,566,000 		- 		  49,879,700 	   - ALTCS Services 	249,234,600 	206,041,000 	186,678,985 	19,362,015 	249,234,600 	- TOTAL COUNTY EXPENDITURES	   302,597,200 		250,389,400 	   230,857,160 	   19,532,240 		302,597,200 	   -

Programmatic  Expenditures

TOBACCO FUNDS

Traditional Medicaid Services Acute Care - Medically Needy 	     34,498,500 		   28,686,600 		31,010,805 	   (2,324,205) 		  34,498,500 	   - Proposition 204 Services - Emergency Health Services 	  18,162,200 		19,367,600 	15,795,280 	 3,572,320 	  18,162,200 	- Proposition 204 Services - Proposition 204 Protection 	  41,492,900 		30,264,700 	36,396,000 	(6,131,300) 	  41,492,900 	- Proposition 204 Services - ATLSF 	100,000,000 	100,000,000 	98,906,897 	 1,093,103 	100,000,000 	- TOTAL TOBACCO EXPENDITURES	   194,153,600 		 178,318,900 	 182,108,982 	   (3,790,082) 		194,153,600 	   -

Administrative  Expenditures

OTHER

Prescription Drug Rebate Program                                                                                                               448,000                                         287,800                                         175,907                                         111,893                                          448,000                                                  - Programmatic  Expenditures
Acute Care - Prescription Drug Rebate Program State Match 	     99,955,000 		   83,295,700 		76,087,500 	     7,208,200 		  99,955,000 	   - Acute Care - Prescription Drug Rebate Program Federal Authority 	334,202,200 	278,502,000 	207,883,900 	70,618,100 	334,202,200 	- Long Term Care - Prescription Drug Rebate Program State Match 	    5,475,800 		 4,530,400 	    4,563,167 		(32,767) 		 5,475,800 	- Long Term Care - Prescription Drug Rebate Program Federal Authority 	  26,574,200 		21,986,300 	  14,574,200 	  7,412,100 	  26,574,200 	- Proposition 204 Services - Hospital Assessment 	250,060,800 	187,545,600 	184,538,777 	  3,006,823 	250,060,800 	- Traditional Medicaid Services - TPL 		194,700 			64,900 		  377,384 	    (312,484) 		    194,700 	- ALTCS Services - TPL 			- 			      - 		  644,346 	    (644,346) 			- 	- ALTCS Services - Nursing Facility Assessment 	  23,366,900 		17,525,000 	  17,458,266 		 66,734 	  23,366,900 	- KidsCare Services Premiums 		370,000 		     299,300 			- 	     299,300 		    370,000 	- Freedom to Work Premiums 		  31,200 			48,100 		    43,124 		    4,976 		      31,200 	- Voluntary Political Subdivision Programs - See Note 5 	113,482,200 		88,532,300 	  88,532,292 			8 	113,482,200 	- TOTAL OTHER  EXPENDITURES	   854,161,000 		 682,617,400 	   594,878,863 	   87,738,537 		854,161,000 	   -

TOTAL

Administrative  Expenditures                                                                                                                      203,429,400                                  142,246,800                                  155,474,574                                   (13,227,774)                                  203,429,400                                                  - Acute Care                                                                                                                                               7,497,443,700                               6,130,621,700                                5,833,620,129                                   297,001,571                                7,497,443,700                                                  - Long Term Care                                                                                                                                      1,398,588,900                               1,151,067,400                                1,072,286,295                                     78,781,105                                1,398,588,900                                                  -

TOTAL EXPENDITURES

$ 	9,099,462,000

$ 	7,423,935,900

$ 	7,061,380,998 	$

362,554,902

$ 	9,099,462,000 	$ 	-

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

BUDGET 	BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	931,662,800		$	758,685,500		$	816,803,390	
Proposition 204 Services & Administrative	110,280,700		90,656,200		(21,570,442)	
KidsCare Services	338,000		338,000		(29,638)	
ALTCS Services	162,880,800		134,652,900		135,734,000	
TOTAL	1,205,162,300		984,332,600		930,937,310	

FEDERAL:
Acute & Administrative	5,606,744,100		4,557,329,700		4,542,711,602	
KidsCare Services	5,587,200		4,616,100		2,618,613	
ALTCS Services	931,056,600		766,331,800		753,476,512	
TOTAL	6,543,387,900		5,328,277,600		5,298,806,727	

COUNTY:
Acute & Administrative	53,362,600		44,348,400		43,420,968	
ALTCS Services	249,234,600		206,041,000		207,695,510	
TOTAL	302,597,200		250,389,400		251,116,478	

TOBACCO FUNDS:
Traditional Medicaid Services	34,498,500		28,686,600		31,010,805	
Proposition 204 Services	159,655,100		149,632,300		151,098,177	
TOTAL	194,153,600		178,318,900		182,108,982	

OTHER:
Administrative	448,000		287,800		175,907	
Acute Care - Prescription Drug Rebate Program	434,157,200		361,797,700		283,971,400	
Long Term Care - Prescription Drug Rebate Program	32,050,000		26,516,700		19,137,367	
Hospital Assessment	250,060,800		187,545,600		187,810,309	
ALTCS - Nursing Facility Assessment	23,366,900		17,525,000		173,999	
Acute TPL - Note 1	194,700		64,900		377,384	
LTC TPL - Note 1	-		-		644,346	
KidsCare TPL - Note 1	-		-		26,362	
Member Premiums - CHIP	370,000		299,300		268,024	
Member Premiums - Freedom to Work	31,200		48,100		43,124	
Voluntary Political Subdivision - State Match	113,482,200		88,532,300		151,640,544	
TOTAL	854,161,000		682,617,400		644,268,767	

TOTAL REVENUE

$	9,099,462,000

$	7,423,935,900

$	7,307,238,264

Appropriation Status Report

Footnotes

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

Note 1:	Third Party Liability Collections: Gross Collections:	April 2016		April 2015		July 1, 2015
April 30, 2016		July 1, 2014
April 30, 2015	
	Acute	$ 	858,861		$ 	382,026		$ 	4,698,251		$ 	4,360,210	
	LTC	417,909		166,384		2,633,546		2,789,398	
	KidsCare	27,655		18,282		132,102		35,304	
	Total TPL Collections	$ 	1,304,425		$ 	566,692		$ 	7,463,899		$ 	7,184,912	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$ 	26,930		$ 	53,004		$ 	377,384		$ 	597,747	
LTC	123,251		39,082		644,346		651,216	
KidsCare	5,422		2,588		26,362		5,657	
Total Expenditure Offsets	$ 	155,603		$ 	94,674		$ 	1,048,092		$ 	1,254,620	

FY 16 Total

Note 2:	Authorized Positions	1,029.2	
	Actual Positions as of April 30, 2016	1,003.0	

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:	1716621.85	
	Beginning Balance July 1, 2015	$ 	2,853,728	
	Revenues	5,736,175	
	Transfers-In	 	472,167 		
	Total Revenues	 	6,208,342 		
	Expenditures	5,272,134	
	Transfers-out	 	1,840,132 		
	Total Expenditures	 	7,112,266 		

Ending Balance April 30, 2016

$ 	1,949,804

Of the $1,949,804 ending balance, $1,716,622 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through June 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities
As of April 30, 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 April 30, 2016

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of April 30, 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 	25,424,057 	41,768,173 	67,192,230

Total Voluntary Political Subdivision Program Expenditures

$ 	88,532,292 	$

174,902,168 	$

263,434,460

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 April 30, 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 April 30, 2016

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	270,015,053	0	0	2,785,227,289	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	6,699,728	0	0	6,699,728	
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	186,800,013	0	0	1,895,076,767	
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	28,770,870	0	0	278,354,430	
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	734,014	0	0	42,366,803	
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	13,170,446	0	0	151,787,831	
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	17,031,087	0	0	162,998,342	
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	5,445,914	0	0	48,875,090	
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	38,406,669	0	0	405,364,302	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	607,419	638,824	734,158	723,075	606,255	821,459	620,137	0	0	6,770,958	
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	7,930,509	0	0	54,757,368	
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	473,549	0	0	5,284,997	
INPATIENT INMATES FFS	94,140	163,355	30,952	166,197	96,395	235,228	148,485	181,967	153,706	251,781	0	0	1,522,205	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	374,616	274,232	543,181	277,299	336,648	529,055	429,691	0	0	3,763,306	
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	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	33,509	11,088	28,421	29,734	32,892	42,452	45,440	0	0	331,274	
PINAL COUNTY INMATES FFS	0	791	4,402	328	5,014	5,310	6,835	218	7,317	6,631	0	0	36,846	
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	9,756,948	0	0	98,800,420	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	21,120	18,430	22,655	12,515	59,722	35,967	7,476	0	0	259,560	
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	972,580	0	0	10,887,859	
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	6,832,486	0	0	82,336,292	
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	2,385,483	0	0	37,547,056	
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	12,879,077	0	0	113,314,048	
HIB - ACUTE	261,769	274,050	304,238	305,977	291,872	302,007	303,696	331,309	367,799	268,692	0	0	3,011,409	
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	2,091,077	0	0	19,810,568	
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	3,332,189	0	0	30,481,863	
HIB - LTC	269,425	275,672	269,873	259,133	272,905	271,807	270,456	282,746	283,468	204,899	0	0	2,660,385	
	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	615,562,439	0	0	6,248,377,928	

TITLE XIX TRADITIONAL

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

TOTAL

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending April 30, 2016

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	206,401,578	0	0	1,969,929,240	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	1,747,009	0	0	1,747,009	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	62,503	47,177	60,406	28,621	21,828	18,432	16,154	0	0	488,006	
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	1,369,591	0	0	52,988,885	
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	24,574,631	0	0	232,761,187	
MENTAL HEALTH - CMDP	0	0	0	1,009	0	0	0	0	0	1,009	0	0	2,018	
CHILDREN'S REHAB SERVICES	13,342	14,176	13,759	16,233	15,769	17,161	18,131	18,608	20,516	21,948	0	0	169,642	
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	26,048,154	0	0	265,095,705	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	991,315	851,991	752,086	812,910	983,171	801,675	802,902	0	0	9,520,045	
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	2,126,391	0	0	18,391,207	
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	533	0	0	30,418	
INPATIENT INMATES FFS	600,012	766,289	566,467	395,868	507,796	802,928	570,913	698,310	1,142,205	1,149,825	0	0	7,200,611	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	174,594	33,475	165,593	246,302	120,342	199,833	167,423	0	0	1,424,708	
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	11,022	0	0	89,416	
PIMA COUNTY INMATES FFS	16,737	14,619	968	21,330	11,636	5,547	222	9,490	3,405	10,275	0	0	94,229	
MOHAVE COUNTY INMATES FFS	0	4,084	692	373	10,051	15,369	123	191	0	672	0	0	31,554	
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	609	0	0	4,273	
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	3,260,174	0	0	33,505,207	
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	5,747,110	0	0	53,691,894	
HIB - ACUTE	8,649	8,527	5,656	8,584	4,192	4,192	4,233	4,233	6,473	3,288	0	0	58,029	
	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	273,460,298	0	0	2,647,243,633	

TITLE XIX PROP 204

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

TOTAL

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending April 30, 2016

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

TITLE XIX ACA ADULT EXPANSION

TOTAL

SUBTOTAL

TOTAL TITLE XIX

CAPITATION - ACUTE	22,690,376	23,251,291	24,201,251	29,417,656	29,997,586	33,503,941	31,696,431	33,123,165	32,894,898	33,739,805	0	0	294,516,399	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	3,959,253	0	0	3,959,253	
MENTAL HEALTH - CHILD	0	0	0	41	0	0	41	124	124	124	0	0	456	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	228,016	237,878	360,470	247,498	259,095	259,847	268,107	0	0	8,778,586	
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	4,810,655	0	0	40,770,298	
CHILDREN'S REHAB SERVICES	417	417	417	0	0	0	0	0	0	477	0	0	1,728	
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	2,157,616	0	0	20,431,181	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	262,679	334,688	251,090	169,817	161,614	277,124	236,881	0	0	2,386,261	
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	3,407,174	0	0	25,842,534	
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	94	0	0	363	
INPATIENT INMATES FFS	6,351	35,816	34,047	9,398	35,244	52,674	13,907	2,877	44,673	50,234	0	0	285,222	
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	406,924	0	0	3,698,442	
SMIB - ACUTE	1,469	734	839	629	839	944	1,847	1,949	1,583	4,287	0	0	15,121	
	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	49,041,630	0	0	400,702,831	
	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	938,064,366	0	0	9,296,324,392	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	183,782	170,409	173,186	164,735	157,227	237,286	145,036	134,596	138,961	125,403	0	0	1,630,621	
KidsCare - FEE FOR SERVICE	-819	774	436	1,805	404	335	15	140	230	117	0	0	3,437	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	36,831	35,192	42,452	32,067	30,376	29,528	27,613	0	0	341,362	
KidsCare - REINSURANCE	162	30,495	70,989	57,122	103,826	25,397	86	25,622	104,594	52,989	0	0	471,282	

220,533	237,043	279,141	260,493	296,650	305,470	177,205	190,734	273,311	206,122	0	0	2,446,702	

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	938,270,489	0	0	9,298,770,807	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 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	114.91	0.00	0.00	1,184.49

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	35,086.14	0.00	0.00	521,995.91

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	79,478.28	0.00	0.00	1,596,867.03

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	151,749.02	0.00	0.00	2,732,227.10

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	40,821.96	0.00	0.00	765,781.61

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	165.42	0.00	0.00	10,722.44

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	757.66	0.00	0.00	21,099.27

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	4,838.30	0.00	0.00	122,885.23

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	333.72	0.00	0.00	54,976.09

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	6,305,585.56	0.00	0.00	69,853,930.72

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	1,863,050.49	0.00	0.00	32,958,074.90

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	2,841,696.96	0.00	0.00	53,745,387.23

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	1,276,043.17	0.00	0.00	19,881,688.52

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	2,580,039.52	0.00	0.00	38,131,198.92

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	4,065,817.03	0.00	0.00	48,208,426.39

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     20,006,126.10	0.00	0.00	238,102,207.66

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	8,254,486.63	0.00	0.00	98,269,836.06

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	31,820.13	0.00	0.00	417,956.85

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	985,281.94	0.00	0.00	12,096,911.14

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	16,423.43	0.00	0.00	142,505.98

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	21,348.95	0.00	0.00	123,620.94

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	22,844.79	0.00	0.00	161,975.44

101E	TANF 14-20 FEMALE N O

56,482.84	48,295.58	35,281.43	34,103.87	17,747.19	21,343.15	22,638.34	19,568.78	27,129.01	46,828.45	0.00	0.00	329,418.64

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	170,600.25	0.00	0.00	2,023,001.65

101G	TANF 21-44 FEMALE N O

967,547.84	939,350.71	551,924.22	458,482.24	314,016.32	266,567.51	305,275.97	300,490.82	335,065.89	457,291.62	0.00	0.00	4,896,013.14

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	202,935.00	0.00	0.00	2,942,635.75

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	2,901.30	0.00	0.00	47,183.67

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	487.78	0.00	0.00	1,479.15

1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	228.55	0.00	1,518.09	0.00	0.00	1,746.64

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	13,628.72	0.00	0.00	265,231.38

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	37,223.00	0.00	0.00	749,924.15

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	40,984.85	0.00	0.00	967,602.16

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	17,550.04	0.00	0.00	377,235.12

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

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 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	417.15	0.00	0.00	10,183.05

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	178.81	0.00	0.00	4,416.16

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

646,891.69	640,426.15	626,324.88	741,218.85	763,396.08	912,983.06	800,177.94	813,327.93	798,093.80	794,830.83	0.00	0.00	7,537,671.21

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	24,027.67	0.00	0.00	249,501.74

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	4,887,567.55	0.00	0.00	51,396,054.03

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	141,277.45	0.00	0.00	1,240,111.23

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	4,519,560.67	0.00	0.00	39,942,065.98

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

5,569.66	5,916.01	9,571.88	5,721.66	6,731.50	3,193.40	5,058.59	3,360.61	3,840.72	6,421.17	0.00	0.00	55,385.20

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	1,732,920.84	0.00	0.00	16,467,847.54

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	14,590.53	0.00	0.00	169,453.40

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     59,064,702.16	0.00	0.00	589,550,356.41

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	549,572.74	0.00	0.00	4,518,710.32

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     14,939,771.34	0.00	0.00	133,023,355.02

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	2,723.90	0.00	0.00	44,074.42

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	7,040.92	0.00	0.00	60,866.78

230Z	SSI BLIND WITH MEDIC	448.85	0.00	0.00	0.00	0.00	1,400.03	0.00	56.44	85.57	80.25	0.00	0.00	2,071.14

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

353,568.15	356,359.13	362,835.95	397,898.39	397,764.11	482,839.14	417,031.99	418,997.08	421,466.68	415,449.43	0.00	0.00	4,024,210.05

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	4,466.88	0.00	0.00	66,338.49

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	50,191.93	0.00	0.00	491,059.19

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	462.29	0.00	0.00	700.89

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	224.91	0.00	0.00	2,821.60

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	946.46	0.00	0.00	7,102.63

4304	SOBRA CHILD 14-20 MA	162.24	162.24	162.24	0.00	-162.83	198.38	0.00	0.00	282.94	315.45	0.00	0.00	1,120.66

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	2,167.70	0.00	0.00	13,310.44

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	162.14	0.00	0.00	282.97

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     18,772,012.29	0.00	0.00	188,710,277.34

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     23,928,306.37	0.00	0.00	225,089,904.11

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     29,695,108.27	0.00	0.00	285,605,961.62

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	9,286,419.04	0.00	0.00	91,969,290.71

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     14,139,882.48	0.00	0.00	140,233,859.58

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2016

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

431A	SOBRA CHILD < 1 M &	1,266,381.59	1,304,281.60	634,368.33	1,482,032.17	977,262.62	1,098,964.98	63,622.62	722,163.04	627,444.79	819,667.04	0.00	0.00	8,996,188.78

431B	SOBRA CHILD 01-05 M	494,252.81	475,898.40	360,178.32	407,643.39	262,251.61	248,010.60	271,540.03	285,522.70	281,974.96	350,717.77	0.00	0.00	3,437,990.59

431C	SOBRA CHILD 6-13 M& F

634,059.19	670,453.45	453,423.37	439,439.88	292,079.09	274,008.02	282,295.62	287,299.33	301,871.12	340,145.08	0.00	0.00	3,975,074.15

431D	SOBRA CHILD 14-20 MA	467,748.21	431,434.92	303,172.79	265,677.52	189,364.34	182,262.95	177,918.24	199,621.43	151,192.39	187,821.01	0.00	0.00	2,556,213.80

431E	SOBRA CHILD 14-20 FE	506,841.24	521,342.83	357,514.83	325,476.02	233,036.41	227,826.88	230,531.24	256,907.98	214,615.87	263,090.79	0.00	0.00	3,137,184.09

4321	SOBRA CHILD <1 M & F	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

4322	SOBRA CHILD 01-05 M	329.97	0.00	220.65	332.81	115.27	299.36	0.00	0.00	229.81	668.93	0.00	0.00	2,196.80

4323	SOBRA CHILD 06-13 M	755.82	0.00	107.48	558.29	399.46	1,577.25	411.36	1,037.18	103.17	320.83	0.00	0.00	5,270.84

4324	SOBRA CHILD 14-20 MA	623.74	0.00	162.24	137.86	272.28	450.17	0.00	0.00	154.87	265.32	0.00	0.00	2,066.48

4325	SOBRA CHILD 14-20 FE	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

432A	SOBRA CHILD < 1 M &	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

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:

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	29,124.13	0.00	0.00	286,556.67

856.00	405.55	405.55	898.29	898.29	1,365.91	898.29	898.29	898.29	898.29	0.00	0.00	8,422.75

667.73	637.69	427.13	403.02	162.14	432.77	318.82	590.42	125.53	1,180.09	0.00	0.00	4,945.34

791.84	960.27	778.66	664.29	689.41	1,113.84	900.22	1,705.68	1,850.21	2,077.04	0.00	0.00	11,531.46

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	1,168,888.00	0.00	0.00	12,280,656.06

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	5,806,090.39	0.00	0.00	59,318,171.69

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	32,102.30	0.00	0.00	352,163.53

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

77,023.42	77,726.43	48,097.14	49,640.39	42,451.40	43,034.61	52,196.23	47,256.44	46,004.34	71,734.96	0.00	0.00	555,165.36

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	304,247.68	0.00	0.00	2,374,036.92

3,630.96	10,740.73	531.17	334.55	0.00	588.34	0.00	1,231.29	4,856.48	2,326.94	0.00	0.00	24,240.46

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	14,910.63	0.00	0.00	62,152.14

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	2,242.66	0.00	0.00	18,427.19

218.29	0.00	0.00	0.00	0.00	0.00	169.46	0.00	0.00	251.61	0.00	0.00	639.36

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

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   241,956,430.32	0.00	0.00	2,508,431,655.70

25,346,057.50	
584,575.37	
1,922,253.77	
129,239,997.43	
157,092,884.07	

E

SUBTOTAL:

9910	TANF & SOBRA CHILDR	3,483,562.65	3,047,996.25	2,907,424.24	2,225,583.72	2,475,483.80	2,699,633.43	2,359,982.88	2,057,153.87	2,101,519.46	1,987,717.20	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	48,375.74	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	159,116.58	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	11,690,081.66	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	13,885,291.18	0.00	0.00	

3100	TRANSPLANT OPTION	70.26	89.42	82.50	82.50	94.60	99.00	99.00	99.00	66.00	52.80	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	79.20	0.00	0.00	

835.08
1
253.92
1

SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 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	132.00	0.00	0.00		1,089.00		

2,637,484.30	
8,252,968.10	
14,766,211.83	
4,245,582.12	
23,355.46	
35,583.80	
174,252.75	
57,205.84	
21,971.91	
247,691.02	
829,789.55	
1,074,984.95	
4,402,593.58	
45,056,069.16	
158,654,112.13	
101,684,935.45	
450,409.60	
-402.42	
1,160.57	
628.78	
23,805.74	
71,538.74	
1,071,902.82	
2,265,971.52	
1,756,154.79	
51,919.99	
259.91	
1,110,132.92	
3,359,756.31	
3,916,197.61	
1,242,604.38	
5,014.95	
7,036.81	
24,045.77	

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	287,221.24	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	895,102.54	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	1,645,108.31	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	494,877.38	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	3,643.61	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	6,072.25	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	28,320.12	0.00	0.00

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

0.00	1,210.32	15,631.07	6,020.54	4,765.67	5,992.18	6,238.92	4,550.01	4,586.50	8,210.63	0.00	0.00

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	6,629.89	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	26,565.28	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	92,755.35	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	495,675.69	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	5,045,025.68	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     18,342,636.81	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     11,371,222.80	0.00	0.00

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

38,116.96	34,638.80	32,844.67	50,449.55	48,551.01	54,580.40	49,262.22	49,972.15	48,378.86	43,614.98	0.00	0.00

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	277.13	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	10.92	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	3,517.32	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	11,385.88	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	167,146.76	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	374,635.39	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	228,878.78	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	3,318.66	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	133,834.07	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	451,214.15	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	505,586.63	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	181,842.66	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	325.98	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	1,335.73	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	4,039.21	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2016

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

112J	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
241Z	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
242Z	SSI AGED EXPANDED
WI
2500	SSI BLIND EXPANDED
W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
260Z	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
261Z	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E

0.00	0.00	6,378.93	344.31	4,119.33	5,140.99	1,028.83	761.06	1,228.30	4,573.10	0.00	0.00	23,574.85

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	77,420.94	0.00	0.00	746,947.76

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	16,253.00	0.00	0.00	196,812.14

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	135,150.07	0.00	0.00	4,516,348.12

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	4,416.17	0.00	0.00	57,589.89

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	4,274,700.25	0.00	0.00	48,382,290.98

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	11,302.42	0.00	0.00	51,943.55

0.00	0.00	0.00	140.23	140.23	140.23	140.23	140.23	140.23	140.23	0.00	0.00	981.61

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	130.02	0.00	0.00	1,369.90

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	286,115.62	0.00	0.00	2,161,136.59

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	11,365.25	0.00	0.00	120,906.18

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	2,152,141.36	0.00	0.00	26,384,353.34

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	40,538.81	0.00	0.00	273,370.03

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     10,053,074.62	0.00	0.00	98,566,358.74

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	2,084.62	0.00	0.00	38,341.78

SUBTOTAL:

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     57,929,438.31	0.00	0.00	539,052,013.09

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

638,069.14	744,028.48	692,146.52	1,079,073.38	867,744.81	1,551,281.98	1,457,853.88	1,337,791.04	1,321,393.12	1,155,802.41	0.00	0.00

10,845,184.76	
131,035.78	
17,942.11	
10,994,162.65	

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	12,729.90	0.00	0.00

5,743.01	5,963.77	0.00	6,235.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

656,262.88

768,544.97	716,894.72	1,091,599.62	880,352.01	1,563,937.84	1,469,881.99	1,344,107.33	1,334,048.98	1,168,532.31	0.00	0.00

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

1,586.09

125.06
2
1,711.15

475.74	
71,794.11	
89,363.83	
483,537.89	
206,515.48	
11,762.02	
7,433.73	
115,023.48	
53,667.46	
17,394,417.82	
20,414,159.75	

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	6,573.58	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	4,750.26	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	30,237.00	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	15,964.57	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	846.74	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	12,870.65	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	2,793.35	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	2,101,758.19	0.00	0.00

3515	ADULT 40-100% FEMAL E

1,633,845.08	1,727,407.10	1,811,455.28	1,845,511.21	1,949,540.67	2,348,680.27	2,176,541.43	2,242,833.24	2,286,783.23	2,391,562.24	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2016

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

3516	ADULT 40-100% MALE 2	7,573,355.50	7,578,276.66	7,770,879.64	8,378,901.15	8,463,151.65     10,011,398.23	8,761,850.23	8,889,458.57	8,869,719.32	8,895,001.39	0.00	0.00	85,191,992.34

3517	ADULT 40-100% FEMAL E

6,410,679.09	6,346,041.90	6,476,413.17	6,980,125.28	6,982,308.75	8,356,713.50	7,184,025.95	7,299,113.79	7,319,928.48	7,395,078.43	0.00	0.00	70,750,428.34

3518	ADULT 40-100% M&F 45    15,191,483.66    15,250,141.05     15,625,452.65     16,626,431.57     16,759,472.47     19,876,479.58     17,359,739.78     17,754,934.89     17,830,685.98     18,003,463.80	0.00	0.00	170,278,285.43

3519	ADULT 40-100% M&F 65	16,506.64	15,041.42	15,084.02	22,447.95	13,832.15	20,370.03	12,054.26	6,999.64	9,642.10	16,259.19	0.00	0.00	148,237.40

351D	ADULT 40-100% MALE 1	148,997.70	115,709.11	88,931.32	77,872.89	78,610.60	74,037.41	91,239.55	91,182.08	119,748.64	182,252.27	0.00	0.00	1,068,581.57

351E	ADULT 40-100% FEMAL E

144,852.52	143,422.42	95,008.93	105,596.06	74,569.94	82,977.04	119,502.32	97,959.49	112,122.23	185,880.07	0.00	0.00	1,161,891.02

351F	ADULT 40-100% MALE 2	646,088.27	613,079.90	479,928.59	471,628.16	336,866.99	413,200.04	403,697.51	459,136.16	388,448.01	498,252.50	0.00	0.00	4,710,326.13

351G	ADULT 40-100% FEMAL E

458,558.32	429,699.96	368,800.73	356,601.53	246,284.78	355,331.06	338,219.87	366,505.47	273,571.49	305,310.69	0.00	0.00	3,498,883.90

351H	ADULT 40-100% M&F 45	1,204,084.30	1,016,417.29	728,945.34	784,761.29	597,289.00	758,626.02	802,383.13	743,712.38	661,749.49	824,931.99	0.00	0.00	8,122,900.23

351J	ADULT 40-100% M&F 65	27,457.81	15,740.35	20,203.21	13,703.32	28,147.70	3,538.93	12,732.65	2,749.32	6,512.57	3,379.05	0.00	0.00	134,164.91

3525	ADULT 40-100% FEMAL E

351.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	351.97

3526	ADULT 40-100% MALE 2	1,168.26	0.00	0.00	0.00	905.24	584.84	914.43	-349.98	658.41	165.72	0.00	0.00	4,046.92

3527	ADULT 40-100% FEMAL E

668.80	1,504.94	0.00	366.57	441.10	2,105.01	2,683.76	889.55	930.65	507.39	0.00	0.00	10,097.77

3528	ADULT 40-100% M&F 45	10,626.75	7,689.50	12,719.11	12,289.73	10,883.20	14,398.75	12,861.10	8,971.05	17,543.37	4,963.05	0.00	0.00	112,945.61

3529	ADULT 40-100% M&F 65	2,416.71	4,002.70	1,585.00	5,981.76	4,387.94	5,346.12	2,711.73	2,585.84	5,433.31	1,776.93	0.00	0.00	36,228.04

352F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	162.24	0.00	0.00	492.11	450.54	0.00	0.00	1,104.89

352G	ADULT 40-100% FEMAL E

0.00	531.77	0.00	21.80	0.00	0.00	0.00	0.00	0.00	585.70	0.00	0.00	1,139.27

352H	ADULT 40-100% M&F 45	16.98	1,224.13	886.83	72.11	0.00	1,096.69	1,002.81	5,277.83	1,939.31	690.58	0.00	0.00	12,207.27

352J	ADULT 40-100% M&F 65	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

3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	464.14	0.00	224.22	0.00	0.00	688.36

3705	ADULT <40% EXP FEM AL

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

3706	ADULT <40% EXP MALE	34,143.30	26,154.77	20,573.49	39,142.26	28,932.51	26,253.84	35,940.46	32,898.39	42,775.50	22,385.18	0.00	0.00	309,199.70

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

12,691.88	18,567.70	11,647.93	10,314.66	6,489.86	16,865.89	19,177.00	12,350.37	16,822.95	10,807.02	0.00	0.00	135,735.26

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	68,650.88	0.00	0.00	825,953.34

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	7,581.30	0.00	0.00	101,587.40

370D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	337.91	0.00	0.00	337.91

370F	ADULT <40% EXP MALE	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	7,964.76	0.00	0.00	34,434.82

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

824.34	1,262.96	35.10	1,823.55	2,665.44	784.80	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	15,092.55	0.00	0.00	104,418.35

0.00	0.00	2,297.94	0.00	0.00	1,394.62	0.00	2,402.41	0.00	1,644.81	0.00	0.00	7,739.78

3714	ADULT <40% EXP MALE	4,383,132.32	4,528,025.34	4,668,083.27	4,798,971.65	4,966,868.66	6,197,353.47	5,122,155.64	5,070,284.60	5,374,137.33	5,517,468.11	0.00	0.00	50,626,480.39

3715	ADULT <40% EXP FEM AL

3,752,637.27	3,863,233.89	3,962,050.58	4,047,408.69	4,164,982.97	5,285,430.48	4,388,863.77	4,364,329.76	4,664,493.57	4,795,085.87	0.00	0.00	43,288,516.85

3716	ADULT <40% EXP MALE    27,106,086.04    27,395,881.26     28,559,100.18     31,597,706.11     31,781,110.59     37,440,882.09     32,286,459.21     32,182,837.36     31,975,225.03     31,561,612.10	0.00	0.00	311,886,899.97

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

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     19,359,124.85	0.00	0.00	189,270,192.22

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     38,248,911.10	0.00	0.00	376,783,659.28

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	48,118.52	0.00	0.00	408,417.57

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2016

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

371D	ADULT <40% EXP MALE	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	375,407.49	0.00	0.00	2,634,967.05

371E	ADULT <40% EXP FEM AL

356,021.60	295,087.13	201,535.90	214,164.42	137,476.12	155,663.63	164,778.45	186,130.37	216,512.82	317,200.03	0.00	0.00	2,244,570.47

371F	ADULT <40% EXP MALE	2,852,336.09	2,763,526.13	1,988,245.68	1,937,830.92	1,404,623.01	1,548,180.76	1,505,806.74	1,582,007.26	1,989,023.19	2,048,605.16	0.00	0.00	19,620,184.94

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

1,605,524.56	1,472,687.76	1,073,635.38	1,106,222.16	812,781.75	829,440.95	874,170.13	961,732.41	895,110.75	1,155,086.40	0.00	0.00	10,786,392.25

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	1,989,428.13	0.00	0.00	17,916,230.15

2,019.24	1,369.87	8,989.45	9,843.47	14,388.28	6,204.26	229.81	0.00	675.81	2,522.13	0.00	0.00	46,242.32

3724	ADULT <40% EXP MALE	480.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	464.14	0.00	0.00	944.88

3725	ADULT <40% EXP FEM AL

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

3726	ADULT <40% EXP MALE	3,936.06	7,430.66	5,545.33	9,313.29	11,355.77	10,877.75	14,327.14	14,560.20	10,279.49	7,146.62	0.00	0.00	94,772.31

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

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	1,542.31	0.00	0.00	45,969.89

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	8,271.34	0.00	0.00	110,437.88

1,616.38	0.00	362.34	1,703.88	1,306.97	1,829.61	961.29	2,271.10	2,668.01	464.14	0.00	0.00	13,183.72

372F	ADULT <40% EXP MALE	0.00	711.09	4,151.16	502.35	1,161.06	1,005.13	921.65	1,994.42	3,717.48	2,424.63	0.00	0.00	16,588.97

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

598.25	1,319.88	2,540.22	0.00	720.86	0.00	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	3,426.66	0.00	0.00	21,039.95

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

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   146,463,304.23	0.00	0.00	1,411,457,840.13

A A
SUBTOTAL:

2,181,452.19

6,242,061.18

8,423,513.37

9935	BIRTH SUPP PAYMENT	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	203,951.98	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	636,350.68	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	840,302.66	0.00	0.00	

770.14	
71,835.13	
58,609.76	
481,059.08	
107,389.42	
318.47	
11,491.43	
4,125.05	
175,424.76	
79,417.42	
7,260,527.67	
8,812,148.57	
67,914,268.51	
94,960,864.61	
99,032,561.56	

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	4,372.13	0.00	0.00

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

11,101.01	5,502.90	2,869.12	7,915.29	2,425.56	4,158.75	1,129.12	5,369.11	10,896.82	7,242.08	0.00	0.00

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	40,891.37	0.00	0.00

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	10,357.81	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	2,868.28	0.00	0.00

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

558.35	584.83	0.00	417.38	411.65	1,086.80	280.67	785.37	0.00	0.00	0.00	0.00

20,702.19	14,075.84	19,780.97	33,511.35	12,219.55	8,555.27	11,466.53	39,025.57	10,632.91	5,454.58	0.00	0.00

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	6,099.02	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	886,833.34	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	1,071,867.63	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	7,679,563.47	0.00	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F

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     11,697,923.95	0.00	0.00

7,992,989.32	8,091,976.44	8,244,535.29     10,079,365.67     10,259,563.30     11,593,254.48     10,470,856.13     10,730,897.79     10,726,172.25     10,842,950.89	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2016

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

3919	NEWLY ELIGIBLE M&F
6

13,274.71	12,857.15	12,513.51	18,274.33	14,084.40	15,516.59	9,490.38	7,626.00	8,103.77	9,318.45	0.00	0.00	121,059.29

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	32,915.06	0.00	0.00	290,865.81

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	41,987.98	0.00	0.00	367,265.96

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	244,763.69	0.00	0.00	2,977,255.25

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

575,662.05	557,633.73	466,745.78	408,568.59	242,094.96	275,085.07	301,121.78	311,931.33	236,013.74	300,581.66	0.00	0.00	3,675,438.69

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	299,975.41	0.00	0.00	3,831,723.79

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	2,459.41	0.00	0.00	94,316.34

3926	NEWLY ELIGIBLE MALE	282.13	198.55	587.36	3,072.08	383.64	94.99	1,900.90	464.00	0.00	958.13	0.00	0.00	7,941.78

3927	NEWLY ELIGIBLE FEMA L
3928	NEWLY ELIGIBLE M&F
4
3929	NEWLY ELIGIBLE M&F
6

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

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	2,853.95	0.00	0.00	29,797.27

598.20	308.72	649.48	1,129.09	384.46	438.37	336.83	1,110.87	1,833.69	676.01	0.00	0.00	7,465.72

392F	NEWLY ELIGIBLE MALE	0.00	81.24	11.39	0.00	0.00	0.00	0.00	0.00	0.00	364.87	0.00	0.00	457.50

392G	NEWLY ELIGIBLE FEMA L
392H	NEWLY ELIGIBLE M&F
4
392J	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	63.38	0.00	0.00	0.00	0.00	0.00	63.38

782.69	451.48	178.82	394.81	447.38	452.69	75.19	4,192.00	118.27	198.94	0.00	0.00	7,292.27

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

SUBTOTAL:

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     33,193,478.11	0.00	0.00	290,395,963.11

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	546,326.69	0.00	0.00	
236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	447,193.00	474,637.31	611,997.77	433,947.37	546,326.69	0.00	0.00	

9939	BIRTH SUPP PAYMENT N
SUBTOTAL:

4,120,435.53

115.08	
100.87	
475.25	
8,718.04	
49,630,625.58	
18,576,449.07	
27,719,138.82	
28.29	
568,536.96	
452,644.65	
565,285.59	
282.24	
97,522,400.44	

4,120,435.53

4403	SOBRA 100-133% M&F
6

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

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

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

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

227.07	113.90	227.80	1,524.18	1,263.32	1,497.66	1,288.17	823.42	943.08	809.44	0.00	0.00

2,472,060.61	2,222,646.29	2,028,673.87	5,518,655.29	5,786,559.34	6,504,075.28	6,148,562.04	6,281,853.69	6,360,847.53	6,306,691.64	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	2,169,490.27	0.00	0.00

4415	SOBRA 100-133% FEMA L
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

1,627,175.04	1,485,905.55	1,372,014.41	3,133,836.80	3,215,261.55	3,650,054.64	3,297,801.80	3,368,365.36	3,322,121.30	3,246,602.37	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.88	26.41	0.00	0.00	0.00

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	75,382.03	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	50,498.55	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	59,569.76	0.00	0.00

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

SUBTOTAL:

5,278,024.25

4,784,466.49	4,561,528.24    10,991,313.12    11,330,662.67     12,767,408.23    11,808,432.05     12,058,792.32    12,032,729.01     11,909,044.06	0.00	0.00

S
SUBTOTAL:

535,552.11

535,552.11

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	79,955.13	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	79,955.13	0.00	0.00	

4517	BC PATIENT FEMALE 2
1

6,031.34	6,350.82	6,499.88	8,177.94	8,370.90	10,265.31	8,321.32	8,321.32	7,817.11	5,149.15	0.00	0.00	75,305.09

ACUTE CAPITATION - AMOUNTS

For The Period Ending April 30, 2016

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

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

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	92,974.64	0.00	0.00	1,069,273.84

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

0.00	718.61	0.00	74.95	322.70	63.42	0.00	0.00	0.00	570.61	0.00	0.00	1,750.29

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	2,527.08	0.00	0.00	18,213.34

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	6,940.73	0.00	0.00	67,934.11

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	5,778.61	0.00	0.00	68,251.49

0.00	323.65	0.00	217.69	443.57	284.85	0.00	0.00	0.00	655.05	0.00	0.00	1,924.81

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

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

SUBTOTAL:

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	114,595.87	0.00	0.00	1,309,461.61

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

119.15	119.15	119.15	1,518.09	1,518.09	1,560.36	1,518.09	1,518.09	1,518.09	1,518.09	0.00	0.00

11,026.35	
15,415,407.36	
73,477.72	
2,823,245.07	
194,298.39	
1,809,728.37	
7,063.13	
20,334,246.39	

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	1,604,864.57	0.00	0.00

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	2,575.34	0.00	0.00

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	273,346.67	0.00	0.00

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	11,704.41	0.00	0.00

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	175,595.42	0.00	0.00

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

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	510,156,435.37	0.00	0.00	

SUBTOTAL:

1,870,299.57

1,905,856.07	1,908,747.28	2,110,843.72	2,081,513.26	2,180,722.80	2,081,522.38	2,060,893.89	2,064,242.92	2,069,604.50	0.00	0.00

TOTAL:

5,049,672,928.35

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 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	1.00	0.00	0.00	10.00

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	91.53	0.00	0.00	1,651.65

1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	172.66	178.52	167.20	180.73	174.06	161.31	162.62	0.00	0.00	3,189.77

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	265.48	0.00	0.00	4,968.11

1009	TANF 65+ M & F WITH	306.00	373.68	430.56	102.88	96.13	94.11	87.56	94.00	98.74	96.20	0.00	0.00	1,779.86

100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	7.53	2.94	4.64	1.60	0.68	2.28	1.13	0.00	0.00	65.09

100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	3.15	5.45	1.70	3.97	0.27	11.52	3.98	0.00	0.00	103.57

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	13.68	0.00	0.00	301.45

100J	TANF 65+ M & F WITH	73.60	39.19	4.37	7.48	0.00	1.80	1.15	0.00	3.46	0.80	0.00	0.00	131.85

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	12,835.13	0.00	0.00	138,419.63

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	14,700.46	0.00	0.00	245,408.71

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	21,934.52	0.00	0.00	397,563.36

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	6,746.33	0.00	0.00	104,241.20

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	9,519.63	0.00	0.00	135,734.44

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	23,298.38	0.00	0.00	276,684.46

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	72,598.93	0.00	0.00	861,442.06

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	18,244.50	0.00	0.00	218,248.65

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	75.16	0.00	0.00	974.17

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	964.72	0.00	0.00	11,328.80

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	285.11	0.00	0.00	2,370.51

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	389.82	0.00	0.00	2,041.88

101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	167.74	56.94	64.69	56.71	53.53	72.46	152.48	0.00	0.00	1,023.28

101E	TANF 14-20 FEMALE N O

278.91	237.91	174.02	171.86	90.58	108.68	115.54	100.32	138.81	239.35	0.00	0.00	1,655.98

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	1,162.68	0.00	0.00	12,746.68

101G	TANF 21-44 FEMALE N O

4,819.02	4,659.58	2,737.74	2,315.36	1,601.46	1,369.81	1,564.77	1,543.92	1,723.94	2,355.55	0.00	0.00	24,691.15

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	602.26	0.00	0.00	7,532.33

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	7.82	0.00	0.00	115.65

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	1.00	0.00	0.00	3.00

1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	1.00	0.00	0.00	2.00

1026	TANF 21-44 MALE WITH	136.90	188.45	227.64	39.06	37.00	47.00	48.64	46.48	43.25	42.00	0.00	0.00	856.42

1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	69.00	73.08	74.70	66.38	66.43	54.28	55.00	0.00	0.00	1,357.86

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	73.28	0.00	0.00	1,770.63

1029	TANF 65+ M & F WITH	125.59	199.79	245.43	39.43	45.00	49.00	48.00	47.09	47.00	42.50	0.00	0.00	888.83

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

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 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	1.00	0.00	0.00	23.39

102J	TANF 65+ M & F WITH	2.37	2.17	0.00	5.12	0.00	0.00	0.00	0.00	0.00	0.50	0.00	0.00	10.16

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

3,945.61	3,902.67	3,829.80	4,137.95	4,214.96	4,359.38	4,391.75	4,443.21	4,424.63	4,446.33	0.00	0.00	42,096.29

450.53	377.60	249.36	270.80	307.49	255.39	261.89	279.68	249.44	332.43	0.00	0.00	3,034.61

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	5,655.14	0.00	0.00	59,613.92

323.02	229.89	155.90	195.56	189.76	198.32	204.42	302.80	201.80	241.71	0.00	0.00	2,243.18

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	23,677.76	0.00	0.00	208,969.80

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

60.27	61.77	97.36	67.89	76.81	46.22	61.93	49.50	50.08	88.93	0.00	0.00	660.76

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	3,662.79	0.00	0.00	35,945.65

236.76	251.22	272.95	225.46	135.76	185.47	192.40	201.39	176.45	205.44	0.00	0.00	2,083.30

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	56,605.18	0.00	0.00	568,668.34

983.56	949.62	911.29	771.37	711.59	852.26	792.85	749.12	729.04	960.29	0.00	0.00	8,410.99

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	26,703.46	0.00	0.00	254,508.33

62.38	77.46	109.31	43.36	32.28	18.61	35.83	62.57	35.61	39.58	0.00	0.00	516.99

2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	25.00	25.00	27.29	28.00	29.44	28.48	28.86	0.00	0.00	270.18

230Z	SSI BLIND WITH MEDIC	4.45	0.00	0.00	0.00	0.00	14.70	0.00	1.00	1.51	1.13	0.00	0.00	22.79

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

428.12	430.04	436.15	439.00	442.38	450.43	460.83	465.17	466.67	458.14	0.00	0.00	4,476.93

8.02	26.80	11.45	13.31	4.79	28.85	12.72	11.68	5.15	7.79	0.00	0.00	130.56

2320	SSI BLIND WITH QMB	207.48	205.10	207.96	204.24	202.09	202.70	201.56	200.99	201.97	205.99	0.00	0.00	2,040.08

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	1.00	0.00	0.00	1.51

4302	SOBRA CHILD 01-05 M	5.00	3.99	2.01	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	25.00

4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	2.12	4.55	3.00	3.00	2.00	2.64	2.00	0.00	0.00	25.74

4304	SOBRA CHILD 14-20 MA	1.00	1.00	1.00	0.00	-1.00	1.00	0.00	0.00	1.77	2.00	0.00	0.00	6.77

4305	SOBRA CHILD 14-20 FE	1.00	1.19	1.13	1.25	0.62	2.64	3.00	4.00	1.36	4.16	0.00	0.00	20.35

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	0.83	0.00	0.00	1.44

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	38,884.18	0.00	0.00	380,185.19

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	187,773.81	0.00	0.00	1,751,153.51

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	230,998.22	0.00	0.00	2,208,551.16

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	54,035.98	0.00	0.00	527,078.28

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	54,158.61	0.00	0.00	529,263.37

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2016

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

431A	SOBRA CHILD < 1 M &	1,144.43	1,199.85	596.85	1,439.14	966.70	1,089.87	160.81	750.96	650.09	851.78	0.00	0.00	8,850.48

431B	SOBRA CHILD 01-05 M	7,397.32	7,233.01	5,425.60	5,749.99	4,037.79	3,916.92	4,211.85	4,585.99	4,476.73	5,827.16	0.00	0.00	52,862.36

431C	SOBRA CHILD 6-13 M& F

9,664.24	10,386.87	6,895.96	6,005.68	4,413.27	4,396.02	4,614.16	4,716.20	4,741.13	5,853.12	0.00	0.00	61,686.65

431D	SOBRA CHILD 14-20 MA	2,729.60	2,547.00	1,740.21	1,587.56	1,149.00	1,156.75	1,160.65	1,263.87	955.56	1,237.70	0.00	0.00	15,527.90

431E	SOBRA CHILD 14-20 FE	2,479.42	2,548.58	1,750.39	1,574.77	1,152.27	1,097.16	1,159.06	1,285.02	1,062.29	1,324.41	0.00	0.00	15,433.37

4321	SOBRA CHILD <1 M & F	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

4322	SOBRA CHILD 01-05 M	3.00	0.00	2.00	3.00	1.00	2.67	0.00	0.00	2.00	6.00	0.00	0.00	19.67

4323	SOBRA CHILD 06-13 M	7.00	0.00	1.00	5.06	3.56	14.00	3.77	3.00	1.00	3.00	0.00	0.00	41.39

4324	SOBRA CHILD 14-20 MA	4.00	0.00	1.00	1.00	1.56	3.00	0.00	0.00	0.90	2.00	0.00	0.00	13.46

4325	SOBRA CHILD 14-20 FE	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

432A	SOBRA CHILD < 1 M &	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

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

44.60	44.25	49.08	47.32	34.99	31.66	30.85	40.94	42.35	47.69	0.00	0.00	413.73

2.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	18.00

3.37	3.12	2.16	1.67	0.83	2.31	1.57	3.02	0.64	5.29	0.00	0.00	23.98

6.00	7.38	7.00	6.00	6.20	10.00	8.12	9.00	9.00	11.00	0.00	0.00	79.70

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	4,526.09	0.00	0.00	46,950.03

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	22,294.51	0.00	0.00	225,907.58

70.02	76.99	80.34	89.62	89.99	85.34	76.00	68.18	74.99	74.40	0.00	0.00	785.87

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	369.78	0.00	0.00	2,810.44

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	1,565.52	0.00	0.00	12,049.07

7.91	23.95	1.29	0.93	0.00	1.63	0.00	3.63	11.90	6.68	0.00	0.00	57.92

9.11	11.00	8.99	9.12	11.00	10.67	9.12	14.00	23.00	27.70	0.00	0.00	133.71

0.00	1.00	1.00	1.00	1.00	1.00	1.32	1.00	0.00	1.00	0.00	0.00	8.32

0.87	0.00	0.00	0.00	0.00	0.00	0.87	0.00	0.00	1.30	0.00	0.00	3.04

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

SUBTOTAL:

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	920,187.40	0.00	0.00	9,493,059.17

4,148.00	
96.00	
314.00	
21,232.00	
25,790.00	

E

SUBTOTAL:

9910	TANF & SOBRA CHILDR	571.00	500.00	476.00	365.00	407.00	441.00	385.00	336.00	342.00	325.00	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	8.00	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	26.00	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	1,917.00	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	2,276.00	0.00	0.00	

3100	TRANSPLANT OPTION	4.24	5.41	5.00	5.00	5.73	6.00	6.00	6.00	4.00	3.20	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	4.80	0.00	0.00	

50.58
1
15.38
1

SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 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	8.00	0.00	0.00		65.96		

7,356.21	
14,364.63	
25,284.62	
9,465.60	
148.19	
178.62	
474.62	
162.00	
33.36	
1,825.94	
5,986.47	
6,032.23	
16,671.24	
267,527.52	
595,952.80	
230,701.85	
1,062.12	
-0.35	
21.44	
10.47	
156.04	
366.06	
7,119.12	
11,578.76	
4,949.10	
142.25	
1.00	
2,326.59	
5,427.80	
6,548.83	
2,722.75	
32.63	
35.37	
68.40	

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	925.69	903.23	849.28	816.35	826.08	834.14	802.53	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	1,557.31	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	2,828.98	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	1,116.58	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	24.97	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	31.25	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	80.51	0.00	0.00

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

0.00	2.64	37.58	16.71	13.76	17.67	19.64	13.69	13.78	26.53	0.00	0.00

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	52.21	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	211.80	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	555.55	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	1,929.19	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	30,543.83	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	69,920.13	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	26,216.44	0.00	0.00

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

91.37	83.00	78.65	120.22	115.24	120.42	117.31	117.99	114.95	102.97	0.00	0.00

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	4.76	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	0.20	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	23.95	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	58.92	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	1,136.65	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	1,929.90	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	687.25	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	10.01	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	308.45	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	708.24	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	868.70	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	407.26	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	2.22	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	6.90	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	11.28	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2016

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

112J	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
241Z	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
242Z	SSI AGED EXPANDED
WI
2500	SSI BLIND EXPANDED
W
2510	SSI BLIND EXPANDED
N
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E
260Z	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
261Z	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E

0.00	0.00	16.30	1.06	10.74	12.39	3.26	2.13	4.67	15.48	0.00	0.00	66.03

518.42	487.04	456.81	384.84	352.94	389.52	358.97	366.07	339.83	345.04	0.00	0.00	3,999.48

304.76	401.03	244.49	252.11	184.84	258.54	156.32	178.68	158.85	229.94	0.00	0.00	2,369.56

1,134.27	1,056.52	991.15	391.57	359.68	303.63	245.77	233.03	193.72	150.62	0.00	0.00	5,059.96

13.94	39.82	16.61	7.34	6.63	7.25	2.59	5.75	6.29	7.34	0.00	0.00	113.56

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	19,541.12	0.00	0.00	224,401.37

86.51	60.16	53.24	60.10	29.69	45.74	42.01	76.94	29.80	150.87	0.00	0.00	635.06

0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	7.00

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	1.00	0.00	0.00	10.00

387.35	391.10	363.58	405.75	407.66	442.08	415.01	494.78	489.00	517.12	0.00	0.00	4,313.43

198.57	225.21	193.65	131.93	83.98	116.36	132.48	134.20	147.53	167.33	0.00	0.00	1,531.24

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	2,016.95	0.00	0.00	25,503.63

66.87	64.13	55.86	42.68	36.03	53.53	35.64	46.78	33.27	70.93	0.00	0.00	505.72

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	16,708.46	0.00	0.00	171,556.25

70.33	62.70	88.07	53.98	24.93	36.36	21.97	45.62	35.04	30.43	0.00	0.00	469.43

SUBTOTAL:

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	182,119.10	0.00	0.00	1,665,284.99

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

105.00	122.00	113.00	177.00	141.00	253.00	239.00	218.00	217.00	190.00	0.00	0.00

1,775.00	
21.00	
3.00	
1,799.00	

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

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

SUBTOTAL:

108.00

126.00	117.00	179.00	143.00	255.00	241.00	219.00	219.00	192.00	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	

0.00

0.00
2
0.00

1.00	
97.18	
79.85	
851.87	
472.43	
18.70	
10.16	
167.55	
79.78	
38,403.55	
44,951.39	

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	7.96	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	4.00	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	62.32	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	37.86	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	1.00	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	16.21	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	4.13	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	4,643.92	0.00	0.00

3515	ADULT 40-100% FEMAL E

3,734.50	3,945.56	4,139.94	4,065.25	4,323.63	4,633.53	4,803.34	4,969.94	5,049.15	5,286.55	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2016

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

3516	ADULT 40-100% MALE 2	17,324.13	17,315.90	17,767.16	18,063.18	18,254.46	18,817.24	18,834.48	19,085.44	19,007.23	19,035.02	0.00	0.00	183,504.24

3517	ADULT 40-100% FEMAL E

14,579.12	14,409.13	14,673.49	14,867.88	14,928.18	15,251.61	15,287.12	15,557.04	15,572.16	15,678.27	0.00	0.00	150,804.00

3518	ADULT 40-100% M&F 45	35,161.66	35,276.58	36,112.19	36,443.44	36,715.66	37,786.88	37,961.23	38,751.79	38,908.66	39,246.47	0.00	0.00	372,364.56

3519	ADULT 40-100% M&F 65	39.09	36.01	35.99	49.54	31.82	42.79	27.61	16.17	21.12	36.20	0.00	0.00	336.34

351D	ADULT 40-100% MALE 1	223.89	174.95	140.00	114.00	120.77	109.87	134.38	137.82	180.52	273.62	0.00	0.00	1,609.82

351E	ADULT 40-100% FEMAL E

215.10	215.28	142.27	157.72	109.73	122.58	178.18	146.03	170.39	277.89	0.00	0.00	1,735.17

351F	ADULT 40-100% MALE 2	970.65	931.86	710.83	703.38	508.69	616.54	603.19	690.09	580.58	746.49	0.00	0.00	7,062.30

351G	ADULT 40-100% FEMAL E

687.03	645.80	559.94	543.04	370.45	528.33	509.10	549.46	412.09	455.23	0.00	0.00	5,260.47

351H	ADULT 40-100% M&F 45	1,789.29	1,532.58	1,097.36	1,161.58	880.02	1,120.60	1,190.46	1,109.60	981.45	1,232.71	0.00	0.00	12,095.65

351J	ADULT 40-100% M&F 65	40.88	22.67	29.32	20.45	46.89	6.12	18.38	4.00	9.50	5.00	0.00	0.00	203.21

3525	ADULT 40-100% FEMAL E

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

3526	ADULT 40-100% MALE 2	3.00	0.00	0.00	0.00	2.00	0.70	2.00	-0.84	1.51	0.33	0.00	0.00	8.70

3527	ADULT 40-100% FEMAL E

1.41	3.21	0.00	1.00	1.00	1.74	2.00	2.00	2.00	1.13	0.00	0.00	15.49

3528	ADULT 40-100% M&F 45	20.96	15.68	24.16	19.28	23.00	24.79	19.36	20.38	31.92	11.06	0.00	0.00	210.59

3529	ADULT 40-100% M&F 65	6.00	10.00	4.00	14.03	10.06	9.93	6.32	6.00	12.80	4.00	0.00	0.00	83.14

352F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.29	0.00	0.00	0.68	0.66	0.00	0.00	1.63

352G	ADULT 40-100% FEMAL E

0.00	0.77	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.86	0.00	0.00	1.66

352H	ADULT 40-100% M&F 45	0.03	1.83	1.26	0.12	0.00	1.69	1.47	7.67	2.29	0.93	0.00	0.00	17.29

352J	ADULT 40-100% M&F 65	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

3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.50	0.00	0.00	1.50

3705	ADULT <40% EXP FEM AL

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

3706	ADULT <40% EXP MALE	34.74	33.74	30.14	41.29	39.44	33.46	43.59	41.41	51.51	27.39	0.00	0.00	376.71

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

7.49	15.61	9.78	12.41	11.03	18.57	21.17	17.69	20.46	11.00	0.00	0.00	145.21

88.23	98.60	92.80	188.88	141.71	124.05	151.66	136.11	176.40	105.58	0.00	0.00	1,304.02

19.67	21.38	28.72	41.00	21.63	14.00	15.00	23.61	25.00	17.03	0.00	0.00	227.04

370D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.50	0.00	0.00	0.50

370F	ADULT <40% EXP MALE	5.51	8.57	6.12	3.49	3.21	1.63	4.63	3.19	2.71	10.94	0.00	0.00	50.00

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

1.54	1.81	0.06	2.37	3.89	1.15	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	23.22	0.00	0.00	156.78

0.00	0.00	2.73	0.00	0.00	2.00	0.00	3.37	0.00	2.96	0.00	0.00	11.06

3714	ADULT <40% EXP MALE	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	11,875.78	0.00	0.00	107,778.14

3715	ADULT <40% EXP FEM AL

8,418.28	8,667.97	8,908.49	8,752.70	9,023.96	9,373.43	9,485.14	9,442.54	10,101.48	10,356.84	0.00	0.00	92,530.83

3716	ADULT <40% EXP MALE	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	62,788.77	0.00	0.00	624,831.58

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

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	37,621.35	0.00	0.00	371,209.18

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	76,783.65	0.00	0.00	762,795.98

80.88	80.74	94.53	128.19	96.22	106.84	65.67	53.17	64.80	96.00	0.00	0.00	867.04

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2016

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

371D	ADULT <40% EXP MALE	580.76	572.41	352.26	309.50	300.26	275.48	271.17	290.30	403.43	555.83	0.00	0.00	3,911.40

371E	ADULT <40% EXP FEM AL

519.38	449.84	305.73	319.68	204.57	230.72	240.99	282.80	320.66	471.45	0.00	0.00	3,345.82

371F	ADULT <40% EXP MALE	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	3,078.43	0.00	0.00	29,363.75

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

2,410.81	2,215.92	1,619.33	1,656.46	1,211.17	1,233.71	1,297.56	1,433.00	1,335.77	1,717.13	0.00	0.00	16,130.86

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	2,935.28	0.00	0.00	26,581.96

2.98	2.00	16.46	13.76	23.12	9.87	0.32	0.00	1.00	3.00	0.00	0.00	72.51

3724	ADULT <40% EXP MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	2.00

3725	ADULT <40% EXP FEM AL

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

3726	ADULT <40% EXP MALE	9.00	8.05	8.35	11.73	10.99	9.77	16.18	12.61	11.04	7.95	0.00	0.00	105.67

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

6.12	3.96	3.43	7.00	7.36	2.03	8.66	7.35	7.00	1.00	0.00	0.00	53.91

23.78	6.39	19.82	15.21	14.20	12.68	22.17	11.96	23.22	12.26	0.00	0.00	161.69

4.00	0.00	1.00	4.00	3.00	3.90	2.00	5.00	6.00	1.00	0.00	0.00	29.90

372F	ADULT <40% EXP MALE	0.00	0.86	5.62	0.82	1.70	1.50	1.60	2.91	5.50	4.02	0.00	0.00	24.53

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

0.87	1.79	3.22	0.00	1.06	0.00	0.48	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	4.54	0.00	0.00	30.94

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

SUBTOTAL:

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	295,584.22	0.00	0.00	2,862,593.00

A A
SUBTOTAL:

358.00

1,021.00

1,379.00

9935	BIRTH SUPP PAYMENT	29.00	45.00	40.00	44.00	38.00	35.00	29.00	30.00	35.00	33.00	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	104.00	0.00	0.00	
	103.00	143.00	161.00	156.00	136.00	136.00	146.00	115.00	146.00	137.00	0.00	0.00	

2.16	
105.62	
75.85	
1,004.74	
274.71	
0.83	
34.22	
13.53	
524.61	
238.49	
19,497.23	
23,858.18	
183,198.59	
255,685.35	
264,565.32	

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	11.52	0.00	0.00

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

14.99	10.72	9.00	11.72	6.53	6.41	3.00	4.15	6.00	3.33	0.00	0.00

71.56	53.47	39.78	80.22	96.10	107.50	107.44	129.96	240.11	78.60	0.00	0.00

12.19	19.97	21.66	39.05	26.20	31.47	30.27	36.46	33.00	24.44	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	8.45	0.00	0.00

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

1.83	2.06	0.00	1.25	1.46	4.00	1.00	1.93	0.00	0.00	0.00	0.00

64.25	40.88	59.19	97.73	35.73	28.14	36.38	115.81	31.30	15.20	0.00	0.00

10.96	14.95	34.33	49.11	17.80	22.41	2.57	68.47	0.00	17.89	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	2,297.82	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	2,861.27	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	19,939.99	0.00	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F

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	30,343.40	0.00	0.00

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	27,848.30	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2016

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

3919	NEWLY ELIGIBLE M&F
6

43.11	41.59	40.65	49.90	38.52	39.64	25.99	21.17	22.25	25.53	0.00	0.00	348.35

391D	NEWLY ELIGIBLE MALE	141.51	112.48	116.75	61.70	47.08	66.46	54.38	63.02	107.07	97.98	0.00	0.00	868.43

391E	NEWLY ELIGIBLE FEMA L

153.51	153.08	97.96	106.98	67.97	97.10	99.92	109.48	82.68	125.91	0.00	0.00	1,094.59

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	733.41	0.00	0.00	8,949.63

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

1,726.49	1,680.05	1,394.47	1,209.37	730.12	830.37	899.40	941.25	712.53	905.63	0.00	0.00	11,029.68

1,771.32	1,458.13	1,385.33	1,103.78	772.01	1,213.88	1,092.09	988.85	801.07	903.70	0.00	0.00	11,490.16

8.86	33.37	111.19	18.08	52.44	6.35	45.98	1.00	6.74	6.46	0.00	0.00	290.47

3926	NEWLY ELIGIBLE MALE	1.00	0.70	1.96	3.16	1.00	0.00	2.00	0.20	0.00	2.69	0.00	0.00	12.71

3927	NEWLY ELIGIBLE FEMA L
3928	NEWLY ELIGIBLE M&F
4
3929	NEWLY ELIGIBLE M&F
6

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

6.22	3.11	2.43	4.57	6.66	5.38	14.77	8.84	19.54	7.46	0.00	0.00	78.98

2.00	0.96	2.00	3.03	1.00	1.00	1.00	3.00	5.00	2.00	0.00	0.00	20.99

392F	NEWLY ELIGIBLE MALE	0.00	0.29	0.03	0.00	0.00	0.00	0.00	0.00	0.00	1.29	0.00	0.00	1.61

392G	NEWLY ELIGIBLE FEMA L
392H	NEWLY ELIGIBLE M&F
4
392J	NEWLY ELIGIBLE M&F
6

0.00	0.00	0.00	0.00	0.00	0.00	0.22	0.00	0.00	0.00	0.00	0.00	0.22

2.40	1.28	0.56	1.41	1.10	1.60	0.25	11.37	0.45	0.70	0.00	0.00	21.12

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

SUBTOTAL:

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	86,262.97	0.00	0.00	783,314.13

39.00	34.00	57.00	67.00	67.00	73.00	77.00	100.00	71.00	89.00	0.00	0.00	
39.00	34.00	57.00	67.00	67.00	73.00	77.00	100.00	71.00	89.00	0.00	0.00	

9939	BIRTH SUPP PAYMENT N
SUBTOTAL:

674.00

1.00	
0.67	
1.00	
49.25	
395,638.43	
108,646.05	
105,595.84	
0.51	
10,197.27	
2,954.90	
2,868.80	
1.73	
625,955.45	

674.00

4403	SOBRA 100-133% M&F
6

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

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

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

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

2.00	1.00	2.00	7.38	5.00	4.00	5.00	7.33	8.44	7.10	0.00	0.00

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	50,479.84	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	12,851.90	0.00	0.00

4415	SOBRA 100-133% FEMA L
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

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	12,560.26	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.48	0.00	0.00	0.00

288.14	323.40	1,091.93	1,531.67	968.86	1,122.98	1,243.62	1,188.81	1,067.57	1,370.29	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	349.17	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	305.84	0.00	0.00

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

SUBTOTAL:

33,377.33

30,212.86	29,209.93	71,548.32	73,618.11	76,052.03	77,021.47	78,504.65	78,486.35	77,924.40	0.00	0.00

S
SUBTOTAL:

88.00

88.00

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

4517	BC PATIENT FEMALE 2
1

23.96	25.35	26.00	27.58	28.33	27.64	28.00	28.00	26.00	14.61	0.00	0.00	255.47

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending April 30, 2016

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

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

251.91	246.16	245.84	240.06	227.69	233.21	231.08	228.93	223.04	211.59	0.00	0.00	2,339.51

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

0.00	3.64	0.00	0.41	1.66	0.35	0.00	0.00	0.00	2.95	0.00	0.00	9.01

10.28	5.89	8.11	0.93	5.34	3.76	3.30	8.60	0.00	6.83	0.00	0.00	53.04

15.86	16.54	17.00	18.03	17.83	19.47	20.00	20.00	20.00	19.63	0.00	0.00	184.36

18.00	17.00	16.00	16.00	16.00	15.00	14.00	14.00	14.03	13.00	0.00	0.00	153.03

0.00	1.45	0.00	0.96	2.16	1.51	0.00	0.00	0.00	3.36	0.00	0.00	9.44

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

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

SUBTOTAL:

320.78

316.03	312.95	303.97	300.01	300.94	296.70	299.53	285.03	271.97	0.00	0.00	3,007.91

8600	SSI BLIND FREEDOM/W O
8700	SSI DISABLED FREEDO
M
870Z	SSI DISABLED FREEDO
M
8710	SSI DISABLED FREEDO
M
871Z	SSI DISABLED FREEDO
M
8720	SSI DISABLED FREEDO
M
872Z	SSI DISABLED FREEDO
M

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

10.00	
16,051.23	
844.59	
2,688.43	
367.06	
2,259.39	
81.56	
22,302.26	

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	1,662.98	0.00	0.00

161.37	146.05	125.37	96.31	27.40	81.11	61.34	53.48	55.38	36.78	0.00	0.00

246.99	274.32	275.92	268.27	266.19	276.60	276.50	274.66	267.18	261.80	0.00	0.00

85.86	73.98	54.70	40.00	21.99	24.91	5.07	36.95	3.24	20.36	0.00	0.00

213.90	216.30	223.90	223.30	228.07	240.46	236.51	225.61	225.34	226.00	0.00	0.00

20.61	6.41	1.03	15.63	27.86	2.32	0.83	3.24	3.63	0.00	0.00	0.00

SUBTOTAL:

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	2,208.92	0.00	0.00

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	1,567,273.98	0.00	0.00		15,485,312.87		

ACUTE CAPITATION RURAL HOSPITAL - AMOUNTS

For The Period Ending April 30, 2016

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

9810	RURAL HOSP PMT TACI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,935,150.50	0.00	0.00	1,935,150.50

9812	RURAL HOSP PMT TAC S
9814	RURAL HOSP PMT MAL
E
9816	RURAL HOSP PMT FMA
L
9818	RURAL HOSP PMT ADL
T
9821	RURAL HOSP PMT SSI
W

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,730.56	0.00	0.00	9,730.56

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,212.14	0.00	0.00	4,212.14

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,398,268.06	0.00	0.00	3,398,268.06

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	192.72	0.00	0.00	192.72

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,342,522.49	0.00	0.00	1,342,522.49

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,690,076.47	0.00	0.00	6,690,076.47

674.16	
633.52	
2,372.16	
1,669,531.20	
372.80	
73,424.72	
1,747,008.56	

9811	RURAL HOSP PMT TACI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	674.16	0.00	0.00

9813	RURAL HOSP PMT TAC S
9815	RURAL HOSP PMT MAL
E
9817	RURAL HOSP PMT FMA
L
9819	RURAL HOSP PMT ADL
T
9823	RURAL HOSP PMT FOR
S

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	633.52	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,372.16	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,669,531.20	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	372.80	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,424.72	0.00	0.00

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,747,008.56	0.00	0.00

A A

9845	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	600.00	0.00	0.00	
9846	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	737.38	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,337.38	0.00	0.00	

SUBTOTAL:

1,247,623.57

2,711,628.93

3,959,252.50

9835	RURAL HOSPITAL PMT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,247,623.57	0.00	0.00	
9837	RURAL HOSPITAL PMT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,711,628.93	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,959,252.50	0.00	0.00	

B C
SUBTOTAL:

600.00

737.38

1,337.38

MT 

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,405,988.73	0.00	0.00	

SUBTOTAL:

8,313.82

8,313.82

9887	RH PAYMENT FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,313.82	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,313.82	0.00	0.00	

TOTAL:

12,405,988.73

ACUTE CAPITATION RURAL HOSPITAL - MEMBER MONTHS

For The Period Ending April 30, 2016

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

9810	RURAL HOSP PMT TACI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9812	RURAL HOSP PMT TAC S
9814	RURAL HOSP PMT MAL
E
9816	RURAL HOSP PMT FMA
L
9818	RURAL HOSP PMT ADL
T
9821	RURAL HOSP PMT SSI
W

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

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

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

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

0.00	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	

9811	RURAL HOSP PMT TACI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9813	RURAL HOSP PMT TAC S
9815	RURAL HOSP PMT MAL
E
9817	RURAL HOSP PMT FMA
L
9819	RURAL HOSP PMT ADL
T
9823	RURAL HOSP PMT FOR
S

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

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

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

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

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

A A

9845	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9846	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	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

9835	RURAL HOSPITAL PMT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9837	RURAL HOSPITAL PMT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

B C

9887	RH PAYMENT FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

0.00

0.00

0.00

MT 
SUBTOTAL:

0.00

0.00

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		

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	9,923.14	10,424.50	9,923.14	10,013.77	17,381.47	20,492.16	27,239.96	27,799.67	27,239.96	23,798.17	0.00	0.00	184,235.94

1010	TANF NON-MEDICARE	2,246,124.76	2,243,143.25	2,252,388.63	2,282,295.84	2,283,614.83	2,329,163.03	2,288,974.62	2,312,334.75	2,294,801.55	2,329,465.20	0.00	0.00	22,862,306.46

1020	TANF WITH QMB	3,414.03	3,414.03	3,414.03	3,433.17	3,433.17	6,955.78	6,883.58	6,883.58	6,883.58	6,883.58	0.00	0.00	51,598.53

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

31,188,469.28    36,229,127.20     31,473,122.65     31,111,647.19     36,054,042.87     31,219,612.97     30,619,272.74     35,672,776.45     30,670,123.38     30,500,842.76	0.00	0.00	324,739,037.49

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	705,817.18	0.00	0.00	7,183,554.24

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	2,931,926.66	0.00	0.00	30,507,743.47

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	28,422.15	0.00	0.00	268,072.40

2120	SSI AGED WITH QMB	18,966,113.95    22,019,693.90     19,185,398.15     19,009,038.07     22,054,804.25     19,319,046.10     19,042,283.66     22,091,359.25     19,090,065.59     19,109,506.84	0.00	0.00	199,887,309.76

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

27,811.67	8,720.78	31,076.14	21,591.82	10,487.09	22,848.38	23,361.65	12,897.63	35,332.72	26,460.54	0.00	0.00	220,588.42

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     14,462,069.03	0.00	0.00	145,325,376.65

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	54,844.32	0.00	0.00	836,730.12

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     94,042,278.43	0.00	0.00	935,855,883.40

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	63,929.13	0.00	0.00	429,387.25

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     21,601,569.19	0.00	0.00	217,781,968.37

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	2,306.32	0.00	0.00	55,524.94

2300	SSI BLIND WITH MEDIC	64,338.16	65,260.19	64,541.02	62,567.40	68,202.65	66,548.80	68,372.70	68,592.83	65,059.47	61,912.04	0.00	0.00	655,395.26

2310	SSI BLIND NON-MEDIC A

444,420.36	460,483.10	454,107.08	457,911.29	480,473.00	490,226.15	486,595.02	474,957.86	478,945.88	484,827.16	0.00	0.00	4,712,946.90

2320	SSI BLIND WITH QMB	130,315.90	135,811.83	130,342.85	127,684.67	131,086.80	129,801.65	127,497.03	135,174.46	130,938.82	137,252.87	0.00	0.00	1,315,906.88

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   186,574,111.57	0.00	0.00	1,892,873,566.48

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

70,007.12	77,437.98	70,007.12	70,803.89	73,814.89	71,344.62	74,872.30	79,836.70	73,619.88	86,057.13	0.00	0.00

747,801.63	
4,368.11	
1,240,838.33	
8,128.90	
202,063.45	
2,203,200.42	

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

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	122,943.21	0.00	0.00

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

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	16,900.68	0.00	0.00

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	186,800,012.59	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	225,901.02	0.00	0.00

TOTAL:

182,421,827.21  195,322,104.99

1,895,076,766.90

LONG TERM CARE MEMBER MONTHS

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	3.00	3.00	3.00	3.00	5.00	6.00	8.00	8.00	8.00	7.00	0.00	0.00	54.00

1010	TANF NON-MEDICARE	654.15	651.89	656.12	659.50	658.46	656.64	659.79	665.10	661.45	671.37	0.00	0.00	6,594.47

1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	15.00

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

11,288.11	11,289.28	11,378.95	11,358.29	11,326.59	11,306.03	11,140.18	11,162.78	11,195.20	11,158.06	0.00	0.00	112,603.47

717.21	639.08	710.00	851.48	668.68	692.76	751.99	715.66	881.40	730.68	0.00	0.00	7,358.94

655.14	653.57	669.99	636.70	631.61	621.44	615.56	613.03	615.23	613.90	0.00	0.00	6,326.17

21.10	12.50	27.34	18.34	9.95	33.27	44.42	39.22	42.74	30.44	0.00	0.00	279.32

2120	SSI AGED WITH QMB	7,334.44	7,374.82	7,392.70	7,402.32	7,425.32	7,457.15	7,403.18	7,397.98	7,414.86	7,433.25	0.00	0.00	74,036.02

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

27.75	9.33	32.14	22.04	11.00	24.46	26.59	14.28	36.56	27.22	0.00	0.00	231.37

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	4,760.40	0.00	0.00	46,440.53

40.61	63.99	95.38	125.93	77.65	98.95	102.57	98.56	105.74	56.24	0.00	0.00	865.62

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	26,181.47	0.00	0.00	259,679.38

68.02	35.27	25.38	30.27	31.72	32.83	41.26	29.92	70.81	57.14	0.00	0.00	422.62

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	6,884.76	0.00	0.00	68,054.94

2.73	7.18	7.16	6.82	9.41	7.33	5.45	4.24	4.12	2.00	0.00	0.00	56.44

2300	SSI BLIND WITH MEDIC	20.00	19.00	20.00	20.00	20.00	20.00	21.00	20.17	20.00	19.00	0.00	0.00	199.17

2310	SSI BLIND NON-MEDIC A

128.16	130.38	131.06	129.55	134.00	134.12	136.77	135.03	135.00	137.66	0.00	0.00	1,331.73

2320	SSI BLIND WITH QMB	42.00	42.00	42.00	40.83	40.30	40.96	41.00	41.55	42.00	44.00	0.00	0.00	416.64

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	58,816.59	0.00	0.00	584,965.83

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

22.00	22.00	22.00	22.09	22.31	23.00	24.51	22.52	23.00	27.00	0.00	0.00

230.43	
4.64	
256.83	
7.75	
69.09	
568.74	

0.00	0.00	0.00	0.00	0.00	0.00	20.47	-15.83	0.00	0.00	0.00	0.00

27.09	25.91	26.96	27.00	25.60	25.00	25.00	25.27	24.00	25.00	0.00	0.00

2.90	-2.90	5.03	0.00	0.00	0.00	0.00	2.72	0.00	0.00	0.00	0.00

7.00	7.00	7.00	7.00	7.00	7.09	7.00	7.00	7.00	6.00	0.00	0.00

SUBTOTAL:

58.99

52.01	60.99	56.09	54.91	55.09	76.98	41.68	54.00	58.00	0.00	0.00

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	58,874.59	0.00	0.00		585,534.57		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending April 30, 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	41.42	0.00	0.00	406.83

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	2,442,164.62	0.00	0.00	40,016,904.52

1020	TANF WITH QMB	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	41.42	41.42	0.00	0.00	124.26

2110	SSI AGED NON-MEDICA R

37.55	75.10	75.10	82.84	82.84	82.84	41.42	82.84	41.42	82.84	0.00	0.00	684.79

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

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

37.55	37.55	37.55	82.84	165.68	174.16	248.52	248.52	207.10	248.52	0.00	0.00	1,487.99

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	437,809.40	0.00	0.00	4,481,515.09

225.30	225.30	225.30	248.52	207.10	241.02	207.10	289.94	248.52	248.52	0.00	0.00	2,366.62

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	2,153.84	0.00	0.00	19,439.69

225.30	225.30	187.75	165.68	207.10	335.60	165.68	124.26	289.94	331.36	0.00	0.00	2,257.97

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     22,887,366.56	0.00	0.00	210,186,692.13

525.70	0.00	187.75	455.62	165.68	869.82	165.68	82.84	248.52	455.62	0.00	0.00	3,157.23

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	25,183.36	0.00	0.00	252,065.69

SUBTOTAL:

23,601,939.85

23,828,366.35    24,635,691.35    25,662,133.78    25,736,772.62     28,526,404.32    25,942,837.12     25,407,235.10    25,829,636.26     25,796,127.48	0.00	0.00	254,967,144.23

1110	TANF EXPANDED FOR	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	15,988.12	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	41.42	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	16,029.54	0.00	0.00	

486,421.24
FI
411.07
E
486,832.31

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	124.26	0.00	0.00	
	37.55	75.10	150.20	165.68	165.68	207.10	82.84	82.84	82.84	124.26	0.00	0.00	

357.30

FO
SUBTOTAL:

816.79

1,174.09

F
SUBTOTAL:

455.62

455.62

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

F F

24,832,077.85	24,924,826.35	25,622,280.05	28,399,084.54	28,565,013.06	31,579,075.02	28,888,586.10	28,402,605.24	28,842,195.70	28,787,148.52	0.00	0.00	

SUBTOTAL:

124.26

23,387,161.92

23,387,286.18

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	41.42	41.42	41.42	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	1,137,201.75	1,021,510.20	921,589.65	2,674,365.14	2,781,021.64	2,992,223.40	2,917,086.34	2,973,417.54	2,994,003.28	2,974,742.98	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	2,974,742.98	0.00	0.00	

TOTAL:

278,842,892.43

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending April 30, 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	1.00	0.00	0.00	10.00

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	58,961.00	0.00	0.00	974,466.00

1020	TANF WITH QMB	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	3.00

2110	SSI AGED NON-MEDICA R

1.00	2.00	2.00	2.00	2.00	2.00	1.00	2.00	1.00	2.00	0.00	0.00	17.00

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

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

1.00	1.00	1.00	2.00	4.00	4.00	6.00	6.00	5.00	6.00	0.00	0.00	36.00

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	10,570.00	0.00	0.00	110,205.00

6.00	6.00	6.00	6.00	5.00	5.00	5.00	7.00	6.00	6.00	0.00	0.00	58.00

39.00	43.00	45.00	48.00	48.00	48.00	50.00	52.00	52.00	52.00	0.00	0.00	477.00

6.00	6.00	5.00	4.00	5.00	8.00	4.00	3.00	7.00	8.00	0.00	0.00	56.00

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	552,568.00	0.00	0.00	5,180,854.00

14.00	0.00	5.00	11.00	4.00	21.00	4.00	2.00	6.00	11.00	0.00	0.00	78.00

544.00	601.00	672.00	696.00	729.00	600.00	570.00	591.00	611.00	608.00	0.00	0.00	6,222.00

SUBTOTAL:

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	622,794.00	0.00	0.00	6,272,483.00

1110	TANF EXPANDED FOR	2,473.00	1,993.00	1,726.00	1,504.00	1,134.00	904.00	688.00	524.00	442.00	386.00	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	1.00	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	387.00	0.00	0.00	

11,774.00
FI
10.00
E
11,784.00

3510	ADULT 40-100% FOR FI	1.00	1.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED	0.00	1.00	2.00	2.00	2.00	4.00	2.00	2.00	2.00	3.00	0.00	0.00	
	1.00	2.00	4.00	4.00	4.00	5.00	2.00	2.00	2.00	3.00	0.00	0.00	

9.00

FO
SUBTOTAL:

20.00

29.00

F

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	30,285.00	27,204.00	24,543.00	64,567.00	67,142.00	69,354.00	70,427.00	71,787.00	72,284.00	71,819.00	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	71,819.00	0.00	0.00	

SUBTOTAL:

11.00

11.00

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

F F
SUBTOTAL:

3.00

569,412.00

569,415.00

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	695,006.00	0.00	0.00		6,853,722.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	67,083.83	80,473.34	92,942.96	1,873.88	1,880.20	2,409.24	183.28	176.96	170.64	158.00	0.00	0.00	247,352.33

1010	TANF NON-MEDICARE	6,077,917.65	6,393,201.43	6,925,613.32	441,979.72	444,046.36	1,050,735.48	449,525.80	440,014.20	432,196.36	412,474.80	0.00	0.00	23,067,705.12

1020	TANF WITH QMB	24,837.03	36,897.81	45,074.61	701.52	761.56	220.68	82.16	75.84	75.84	63.20	0.00	0.00	108,790.25

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

139,789.21	137,949.43	136,722.91	13,714.40	13,869.24	19,412.00	1,093.36	1,074.40	1,068.08	1,058.60	0.00	0.00	465,751.63

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	16,883.88	0.00	0.00	761,437.89

2120	SSI AGED WITH QMB	595,679.88	602,630.16	609,410.09	73,883.96	74,771.92	96,621.20	5,469.96	5,536.32	5,656.40	5,621.64	0.00	0.00	2,075,281.53

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

134,133.59	132,327.88	130,488.10	11,537.16	11,508.72	20,634.20	2,673.36	2,622.80	2,581.72	2,607.00	0.00	0.00	451,114.53

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	118,291.44	0.00	0.00	5,259,498.99

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	9,239.84	0.00	0.00	2,799,084.61

2300	SSI BLIND WITH MEDIC	1,226.52	1,158.38	1,056.17	94.80	88.48	155.48	18.96	15.80	15.80	15.80	0.00	0.00	3,846.19

2310	SSI BLIND NON-MEDIC A

14,820.45	14,650.10	14,547.89	1,295.60	1,311.40	2,962.84	1,346.16	1,371.44	1,368.28	1,343.00	0.00	0.00	55,017.16

2320	SSI BLIND WITH QMB	8,279.01	8,210.87	8,244.94	745.76	739.44	1,094.24	132.72	135.88	132.72	129.56	0.00	0.00	27,845.14

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

34.07	34.07	68.14	6.32	3.16	0.00	0.00	0.00	3.16	3.16	0.00	0.00	152.08

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	63,907.84	0.00	0.00	3,066,858.95

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	3.16	0.00	0.00	4,228.88

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	85,572.80	0.00	0.00	3,360,795.54

306.63	408.84	340.70	34.76	37.92	22.56	3.16	6.32	6.32	6.32	0.00	0.00	1,173.53

SUBTOTAL:

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	717,380.04	0.00	0.00	41,756,080.83

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

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	1,324.04	0.00	0.00

448,017.48	
11,367,936.54	
119,316.41	
46,864.07	
122,251.90	
3,095,507.55	
6.32	
221.66	
116.29	
32,159.57	
315,288.05	
1,624,955.90	
17,172,641.74	

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	423,120.84	0.00	0.00

39,930.04	35,535.01	32,025.80	3,239.00	4,575.68	1,953.72	486.64	508.76	540.36	521.40	0.00	0.00

14,990.80	14,173.12	13,662.07	948.00	913.24	1,955.64	41.08	50.56	60.04	69.52	0.00	0.00

39,725.62	37,068.16	34,887.68	1,292.44	1,166.04	5,659.80	707.84	647.80	562.48	534.04	0.00	0.00

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	3,532.88	0.00	0.00

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

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

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

9,505.53	9,335.18	9,198.90	850.04	894.28	2,012.24	82.16	94.80	88.48	97.96	0.00	0.00

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	5,100.24	0.00	0.00

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	2,215.16	0.00	0.00

SUBTOTAL:

4,829,797.27

4,393,871.62	4,058,111.77	550,231.84	544,054.04	1,049,354.32	438,329.92	434,013.36	438,361.52	436,516.08	0.00	0.00

FO
SUBTOTAL:

11.64

11.64

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

3500	ADULT 40-100% FOR FI	4,974.22	4,326.89	3,849.91	688.88	530.88	1,899.32	34.76	34.76	37.92	34.76	0.00	0.00	16,412.30

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending April 30, 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	269,557.48	0.00	0.00	9,869,418.24

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	6.32	0.00	0.00	3,294.75

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

4,463.17	4,667.59	4,769.80	774.20	609.88	1,647.40	63.20	47.40	47.40	22.12	0.00	0.00	17,112.16

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	663,435.68	0.00	0.00	25,906,850.69

1,328.73	476.98	953.96	94.80	94.80	118.12	15.80	22.12	18.96	18.96	0.00	0.00	3,143.23

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	933,075.32	0.00	0.00	35,816,231.37

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

3,032.23	2,044.20	2,180.48	372.88	404.48	593.92	22.12	28.44	44.24	15.80	0.00	0.00

8,738.79	
8,769,018.52	
828.26	
8,778,585.57	

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	268,088.08	0.00	0.00

374.77	170.35	204.42	28.44	25.28	18.68	0.00	0.00	3.16	3.16	0.00	0.00

SUBTOTAL:

2,206,577.62

2,297,714.87	2,413,382.52	228,016.12	237,878.48	360,469.88	247,497.52	259,094.72	259,846.80	268,107.04	0.00	0.00

F F
SUBTOTAL:

410,783.75

6.32

410,790.07

4410	SOBRA 100-133% FOR	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	15,098.48	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	15,098.48	0.00	0.00	

N N
SUBTOTAL:

34,754.61

4,382.14

39,136.75

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	726.80	0.00	0.00	
4610	CC PATIENT FOR FINA	1,192.45	1,158.38	1,124.31	104.28	104.28	278.16	107.44	107.44	104.28	101.12	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	827.92	0.00	0.00	

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

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

106.09	
114,503.00	
28,490.92	
17,695.19	
160,795.20	

33,831.51	35,194.31	35,909.78	2,837.68	2,850.32	3,585.52	75.84	72.68	75.84	69.52	0.00	0.00

7,086.56	7,938.31	8,142.73	701.52	698.36	1,303.80	673.08	660.44	657.28	628.84	0.00	0.00

5,178.64	5,417.13	5,655.62	426.60	439.24	546.36	6.32	6.32	9.48	9.48	0.00	0.00

27,660,274.62	27,781,631.96	28,591,850.63	2,622,114.28	2,652,778.92	5,298,137.44	2,381,692.00	2,386,883.88	2,387,196.72	2,371,712.72	0.00	0.00	

SUBTOTAL:

46,130.78

48,583.82	49,742.20	3,965.80	3,987.92	5,439.56	755.24	739.44	742.60	707.84	0.00	0.00

TOTAL:

104,134,273.17

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	58.00	56.00	54.00	50.00	0.00	0.00	8,530.00

1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	139,245.00	136,771.00	130,530.00	0.00	0.00	1,541,287.00

1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	24.00	24.00	20.00	0.00	0.00	3,725.00

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

4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	340.00	338.00	335.00	0.00	0.00	22,592.00

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	5,343.00	0.00	0.00	57,876.00

2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	1,752.00	1,790.00	1,779.00	0.00	0.00	108,898.00

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

3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	830.00	817.00	825.00	0.00	0.00	23,086.00

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	37,434.00	0.00	0.00	386,528.00

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	2,924.00	0.00	0.00	132,872.00

2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	5.00	6.00	5.00	5.00	5.00	0.00	0.00	185.00

2310	SSI BLIND NON-MEDIC A

435.00	430.00	427.00	410.00	415.00	417.00	426.00	434.00	433.00	425.00	0.00	0.00	4,252.00

2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	43.00	42.00	43.00	42.00	41.00	0.00	0.00	1,407.00

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

1.00	1.00	2.00	2.00	1.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	9.00

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	20,224.00	0.00	0.00	228,735.00

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	1.00	0.00	0.00	185.00

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	27,080.00	0.00	0.00	274,532.00

9.00	12.00	10.00	11.00	12.00	1.00	1.00	2.00	2.00	2.00	0.00	0.00	62.00

SUBTOTAL:

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	227,019.00	0.00	0.00	2,794,767.00

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

4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	434.00	418.00	414.00	419.00	0.00	0.00

25,959.00	
1,155,387.00	
6,427.00	
1,932.00	
5,103.00	
132,824.00	
2.00	
9.00	
5.00	
1,519.00	
21,607.00	
74,764.00	
1,425,538.00	

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	133,899.00	0.00	0.00

1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	154.00	161.00	171.00	165.00	0.00	0.00

440.00	416.00	401.00	300.00	289.00	16.00	13.00	16.00	19.00	22.00	0.00	0.00

1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	205.00	178.00	169.00	0.00	0.00

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	1,118.00	0.00	0.00

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

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

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

279.00	274.00	270.00	269.00	283.00	29.00	26.00	30.00	28.00	31.00	0.00	0.00

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	1,614.00	0.00	0.00

14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	790.00	755.00	701.00	0.00	0.00

SUBTOTAL:

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	138,138.00	0.00	0.00

FO
SUBTOTAL:

0.00

0.00

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

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	11.00	12.00	11.00	0.00	0.00	825.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending April 30, 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	85,303.00	0.00	0.00	802,629.00

3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	4.00	4.00	2.00	0.00	0.00	167.00

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

131.00	137.00	140.00	245.00	193.00	13.00	20.00	15.00	15.00	7.00	0.00	0.00	916.00

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	209,948.00	0.00	0.00	2,071,871.00

39.00	14.00	28.00	30.00	30.00	3.00	5.00	7.00	6.00	6.00	0.00	0.00	168.00

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	295,277.00	0.00	0.00	2,876,576.00

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

89.00	60.00	64.00	118.00	128.00	5.00	7.00	9.00	14.00	5.00	0.00	0.00

499.00	
754,787.00	
42.00	
755,328.00	

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	84,838.00	0.00	0.00

11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	1.00	1.00	0.00	0.00

SUBTOTAL:

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	84,844.00	0.00	0.00

F F
SUBTOTAL:

44,452.00

2.00

44,454.00

4410	SOBRA 100-133% FOR	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	4,778.00	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	4,778.00	0.00	0.00	

N N
SUBTOTAL:

2,560.00

335.00

2,895.00

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	250.00	245.00	245.00	230.00	0.00	0.00	
4610	CC PATIENT FOR FINA	35.00	34.00	33.00	33.00	33.00	34.00	34.00	34.00	33.00	32.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	279.00	278.00	262.00	0.00	0.00	

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

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

3.00	
4,994.00	
2,162.00	
762.00	
7,921.00	

993.00	1,033.00	1,054.00	898.00	902.00	21.00	24.00	23.00	24.00	22.00	0.00	0.00

208.00	233.00	239.00	222.00	221.00	210.00	213.00	209.00	208.00	199.00	0.00	0.00

152.00	159.00	166.00	135.00	139.00	1.00	2.00	2.00	3.00	3.00	0.00	0.00

SUBTOTAL:

1,354.00

1,426.00	1,460.00	1,255.00	1,262.00	232.00	239.00	234.00	235.00	224.00	0.00	0.00

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	750,542.00	0.00	0.00		7,907,479.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	90,239.27	108,250.46	125,024.24	33,623.10	33,736.50	6,548.22	3,288.60	3,175.20	3,061.80	2,835.00	0.00	0.00	409,782.39

1010	TANF NON-MEDICARE	8,175,842.85	8,599,953.67	9,316,139.08	7,930,458.90	7,967,540.70	8,874,318.60	8,065,858.50	7,895,191.50	7,754,915.70	7,401,051.00	0.00	0.00	81,981,270.50

1020	TANF WITH QMB	33,410.07	49,633.89	60,633.09	12,587.40	13,664.70	2,022.30	1,474.20	1,360.80	1,360.80	1,134.00	0.00	0.00	177,281.25

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

188,040.49	185,565.67	183,915.79	246,078.00	248,856.30	43,045.38	19,618.20	19,278.00	19,164.60	18,994.50	0.00	0.00	1,172,556.93

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	302,948.10	0.00	0.00	3,119,043.79

2120	SSI AGED WITH QMB	801,291.72	810,641.04	819,761.21	1,325,702.70	1,341,635.40	217,234.08	98,147.70	99,338.40	101,493.00	100,869.30	0.00	0.00	5,716,114.55

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

180,432.71	178,003.72	175,528.90	207,011.70	206,501.40	70,141.68	47,968.20	47,061.00	46,323.90	46,777.50	0.00	0.00	1,205,750.71

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	2,122,507.80	0.00	0.00	20,763,977.33

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	165,790.80	0.00	0.00	6,858,848.67

2300	SSI BLIND WITH MEDIC	1,649.88	1,558.22	1,420.73	1,701.00	1,587.60	464.94	340.20	283.50	283.50	283.50	0.00	0.00	9,573.07

2310	SSI BLIND NON-MEDIC A

19,936.05	19,706.90	19,569.41	23,247.00	23,530.50	25,780.86	24,154.20	24,607.80	24,551.10	24,097.50	0.00	0.00	229,181.32

2320	SSI BLIND WITH QMB	11,136.69	11,045.03	11,090.86	13,381.20	13,267.80	3,682.98	2,381.40	2,438.10	2,381.40	2,324.70	0.00	0.00	73,130.16

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

45.83	45.83	91.66	113.40	56.70	0.00	0.00	0.00	56.70	56.70	0.00	0.00	466.82

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	1,146,700.80	0.00	0.00	12,273,006.55

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	56.70	0.00	0.00	9,508.94

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	1,535,436.00	0.00	0.00	14,776,124.06

412.47	549.96	458.30	623.70	680.40	81.90	56.70	113.40	113.40	113.40	0.00	0.00	3,203.63

SUBTOTAL:

15,016,107.84

15,571,475.78    16,527,902.05    16,572,956.40    16,762,731.30     15,237,584.46    13,508,264.70     13,425,539.40    13,284,583.20     12,871,977.30	0.00	0.00	148,779,122.43

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

190,469.48	168,150.27	150,826.53	365,941.80	355,282.20	53,920.44	24,607.80	23,700.60	23,473.80	23,757.30	0.00	0.00

1,380,130.22	
63,556,651.56	
332,046.37	
98,355.45	
259,947.76	
6,733,912.13	
113.40	
455.16	
260.97	
79,676.09	
1,146,020.49	
3,805,722.58	
77,393,292.18	

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	7,592,073.30	0.00	0.00

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	9,355.50	0.00	0.00

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	1,247.40	0.00	0.00

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	9,582.30	0.00	0.00

1,280,948.50	1,280,215.22	1,277,052.95	1,227,441.60	1,214,684.10	182,600.46	69,457.50	69,967.80	68,153.40	63,390.60	0.00	0.00

0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00

91.66	91.66	91.66	56.70	56.70	66.78	0.00	0.00	0.00	0.00	0.00	0.00

45.83	45.83	45.83	56.70	56.70	10.08	0.00	0.00	0.00	0.00	0.00	0.00

12,786.57	12,557.42	12,374.10	15,252.30	16,046.10	4,139.10	1,474.20	1,701.00	1,587.60	1,757.70	0.00	0.00

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	91,513.80	0.00	0.00

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	39,746.70	0.00	0.00

SUBTOTAL:

6,496,906.63

5,910,511.78	5,458,857.13	9,872,830.80	9,761,982.30	8,541,752.94	7,864,970.40	7,787,518.20	7,865,537.40	7,832,424.60	0.00	0.00

FO
SUBTOTAL:

15.12

15.12

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

3500	ADULT 40-100% FOR FI	6,691.18	5,820.41	5,178.79	12,360.60	9,525.60	2,887.92	623.70	623.70	680.40	623.70	0.00	0.00	45,016.00

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending April 30, 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	4,836,680.10	0.00	0.00	43,342,545.10

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	113.40	0.00	0.00	8,726.39

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

6,003.73	6,278.71	6,416.20	13,891.50	10,943.10	2,823.66	1,134.00	850.50	850.50	396.90	0.00	0.00	49,588.80

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     11,904,051.60	0.00	0.00	111,913,217.49

1,787.37	641.62	1,283.24	1,701.00	1,701.00	311.22	283.50	396.90	340.20	340.20	0.00	0.00	8,786.25

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     16,742,205.90	0.00	0.00	155,367,880.03

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

4,078.87	2,749.80	2,933.12	6,690.60	7,257.60	1,034.46	396.90	510.30	793.80	283.50	0.00	0.00

26,728.95	
40,741,406.50	
2,162.42	
40,770,297.87	

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	4,810,314.60	0.00	0.00

504.13	229.15	274.98	510.30	453.60	76.86	0.00	0.00	56.70	56.70	0.00	0.00

SUBTOTAL:

2,968,225.78

3,090,821.03	3,246,413.88	4,091,301.90	4,268,262.60	4,542,373.08	4,440,857.40	4,648,946.40	4,662,441.00	4,810,654.80	0.00	0.00

F F
SUBTOTAL:

2,443,543.49

113.40

2,443,656.89

4410	SOBRA 100-133% FOR	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	270,912.60	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	270,912.60	0.00	0.00	

N N
SUBTOTAL:

137,798.63

18,107.52

155,906.15

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	13,041.00	0.00	0.00	
4610	CC PATIENT FOR FINA	1,604.05	1,558.22	1,512.39	1,871.10	1,871.10	2,149.56	1,927.80	1,927.80	1,871.10	1,814.40	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	14,855.40	0.00	0.00	

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

45.83	45.83	45.83	0.00	0.00	5.04	0.00	0.00	0.00	0.00	0.00	0.00

142.53	
254,251.48	
116,025.40	
38,726.01	
409,145.42	

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	1,247.40	0.00	0.00

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	11,283.30	0.00	0.00

6,966.16	7,286.97	7,607.78	7,654.50	7,881.30	762.30	113.40	113.40	170.10	170.10	0.00	0.00

37,207,818.78	37,371,065.24	38,460,948.47	47,048,696.10	47,598,912.90	46,679,843.70	42,734,790.00	42,827,948.10	42,833,561.40	42,555,731.40	0.00	0.00	

SUBTOTAL:

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	12,700.80	0.00	0.00

TOTAL:

425,319,316.09

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	58.00	56.00	54.00	50.00	0.00	0.00	8,530.00

1010	TANF NON-MEDICARE	178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	139,245.00	136,771.00	130,530.00	0.00	0.00	1,541,287.00

1020	TANF WITH QMB	729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	24.00	24.00	20.00	0.00	0.00	3,725.00

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

4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	340.00	338.00	335.00	0.00	0.00	22,592.00

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	5,343.00	0.00	0.00	57,876.00

2120	SSI AGED WITH QMB	17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	1,752.00	1,790.00	1,779.00	0.00	0.00	108,898.00

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

3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	830.00	817.00	825.00	0.00	0.00	23,086.00

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	37,434.00	0.00	0.00	386,528.00

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	2,924.00	0.00	0.00	132,872.00

2300	SSI BLIND WITH MEDIC	36.00	34.00	31.00	30.00	28.00	5.00	6.00	5.00	5.00	5.00	0.00	0.00	185.00

2310	SSI BLIND NON-MEDIC A

435.00	430.00	427.00	410.00	415.00	417.00	426.00	434.00	433.00	425.00	0.00	0.00	4,252.00

2320	SSI BLIND WITH QMB	243.00	241.00	242.00	236.00	234.00	43.00	42.00	43.00	42.00	41.00	0.00	0.00	1,407.00

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

1.00	1.00	2.00	2.00	1.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	9.00

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	20,224.00	0.00	0.00	228,735.00

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	1.00	0.00	0.00	185.00

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	27,080.00	0.00	0.00	274,532.00

9.00	12.00	10.00	11.00	12.00	1.00	1.00	2.00	2.00	2.00	0.00	0.00	62.00

SUBTOTAL:

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	227,019.00	0.00	0.00	2,794,767.00

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

4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	434.00	418.00	414.00	419.00	0.00	0.00

25,959.00	
1,155,387.00	
6,427.00	
1,932.00	
5,103.00	
132,824.00	
2.00	
9.00	
5.00	
1,519.00	
21,607.00	
74,764.00	
1,425,538.00	

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	133,899.00	0.00	0.00

1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	154.00	161.00	171.00	165.00	0.00	0.00

440.00	416.00	401.00	300.00	289.00	16.00	13.00	16.00	19.00	22.00	0.00	0.00

1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	205.00	178.00	169.00	0.00	0.00

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	1,118.00	0.00	0.00

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

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

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

279.00	274.00	270.00	269.00	283.00	29.00	26.00	30.00	28.00	31.00	0.00	0.00

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	1,614.00	0.00	0.00

14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	790.00	755.00	701.00	0.00	0.00

SUBTOTAL:

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	138,138.00	0.00	0.00

FO
SUBTOTAL:

0.00

0.00

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

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	11.00	12.00	11.00	0.00	0.00	825.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending April 30, 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	85,303.00	0.00	0.00	802,629.00

3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	4.00	4.00	2.00	0.00	0.00	167.00

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

131.00	137.00	140.00	245.00	193.00	13.00	20.00	15.00	15.00	7.00	0.00	0.00	916.00

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	209,948.00	0.00	0.00	2,071,871.00

39.00	14.00	28.00	30.00	30.00	3.00	5.00	7.00	6.00	6.00	0.00	0.00	168.00

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	295,277.00	0.00	0.00	2,876,576.00

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

89.00	60.00	64.00	118.00	128.00	5.00	7.00	9.00	14.00	5.00	0.00	0.00

499.00	
754,787.00	
42.00	
755,328.00	

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	84,838.00	0.00	0.00

11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	1.00	1.00	0.00	0.00

SUBTOTAL:

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	84,844.00	0.00	0.00

F F
SUBTOTAL:

44,452.00

2.00

44,454.00

4410	SOBRA 100-133% FOR	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	4,778.00	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	4,778.00	0.00	0.00	

N N
SUBTOTAL:

2,560.00

335.00

2,895.00

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	250.00	245.00	245.00	230.00	0.00	0.00	
4610	CC PATIENT FOR FINA	35.00	34.00	33.00	33.00	33.00	34.00	34.00	34.00	33.00	32.00	0.00	0.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	279.00	278.00	262.00	0.00	0.00	

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

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

3.00	
4,994.00	
2,162.00	
762.00	
7,921.00	

993.00	1,033.00	1,054.00	898.00	902.00	21.00	24.00	23.00	24.00	22.00	0.00	0.00

208.00	233.00	239.00	222.00	221.00	210.00	213.00	209.00	208.00	199.00	0.00	0.00

152.00	159.00	166.00	135.00	139.00	1.00	2.00	2.00	3.00	3.00	0.00	0.00

SUBTOTAL:

1,354.00

1,426.00	1,460.00	1,255.00	1,262.00	232.00	239.00	234.00	235.00	224.00	0.00	0.00

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	750,542.00	0.00	0.00		7,907,479.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending April 30, 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	461,172.41	0.00	0.00	6,988,084.17

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

339,019.30	338,090.48	337,161.66	358,241.15	375,396.36	431,901.92	388,515.05	392,551.57	391,542.44	396,588.09	0.00	0.00	3,749,008.02

928.82	928.82	928.82	1,009.13	1,009.13	1,114.72	0.00	0.00	0.00	0.00	0.00	0.00	5,919.44

13,288,627.74    13,621,145.30     13,792,048.18     14,711,097.14     15,234,835.61     16,974,862.22     15,937,190.09     15,756,555.82     15,870,587.51     16,039,112.22	0.00	0.00	151,226,061.83

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	16,146.08	0.00	0.00	154,510.77

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     16,913,018.80	0.00	0.00	162,123,584.23

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

3710	AHC CARE EXPANDED FO
SUBTOTAL:

2,018.26

2,018.26

F

14,633,559.10	14,896,415.16	14,987,439.52	15,968,473.12	16,435,700.31	18,339,912.22	17,026,041.36	16,807,060.15	16,873,662.73	17,032,096.14	0.00	0.00	

SUBTOTAL:

874,757.32

874,757.32

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	118,068.21	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	118,068.21	0.00	0.00	

TOTAL:

163,000,359.81

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending April 30, 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	457.00	0.00	0.00	6,974.00

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

365.00	364.00	363.00	355.00	372.00	392.00	385.00	389.00	388.00	393.00	0.00	0.00	3,766.00

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

14,307.00	14,665.00	14,849.00	14,578.00	15,097.00	15,449.00	15,793.00	15,614.00	15,727.00	15,894.00	0.00	0.00	151,973.00

21.00	17.00	18.00	20.00	13.00	13.00	9.00	13.00	16.00	16.00	0.00	0.00	156.00

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	16,760.00	0.00	0.00	162,875.00

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	1.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	

3710	AHC CARE EXPANDED FO

4410	SOBRA 100-133% FOR	79.00	77.00	72.00	95.00	85.00	87.00	89.00	88.00	94.00	117.00	0.00	0.00	
	79.00	77.00	72.00	95.00	85.00	87.00	89.00	88.00	94.00	117.00	0.00	0.00	

SUBTOTAL:

2.00

2.00

F
SUBTOTAL:

883.00

883.00

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	16,878.00	0.00	0.00		163,760.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending April 30, 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	1,510.40	0.00	0.00	13,489.82

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	194,841.60	0.00	0.00	1,762,309.84

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	9,422.40	0.00	0.00	98,430.14

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	4,929.28	0.00	0.00	128,020.54

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	3,975.04	0.00	0.00	151,433.46

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	3,219.84	0.00	0.00	53,375.17

1015	TANF 14-20 FEMALE N O

9,017.55	7,766.73	8,687.88	9,905.64	7,777.08	8,787.60	6,638.72	4,452.16	3,418.88	3,418.88	0.00	0.00	69,871.12

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	927.60	0.00	0.00	0.00	0.00	0.00	0.00	927.60

1017	TANF 21-44 FEMALE N O
2110	SSI AGED NON-MEDICA
R

833.88	833.88	833.88	927.60	1,391.40	1,391.40	1,431.36	1,431.36	1,431.36	1,431.36	0.00	0.00	11,937.48

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

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	22,377.92	0.00	0.00	178,316.66

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	4,535,165.12	0.00	0.00	40,635,823.16

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	47,896.64	0.00	0.00	374,705.13

2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	737.16	737.16	737.16	755.20	755.20	755.20	755.20	0.00	0.00	6,744.91

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	42,054.08	0.00	0.00	366,663.34

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	26,991.04	0.00	0.00	229,559.91

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	195,467.52	0.00	0.00	1,765,386.53

4313	SOBRA CHILD 06-13 M	130,832.34	140,421.96	154,045.26	197,710.08	200,468.28	209,255.88	222,698.56	227,826.88	221,308.16	222,461.44	0.00	0.00	1,927,028.84

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	54,699.20	0.00	0.00	452,004.06

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	54,224.96	0.00	0.00	473,571.84

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

0.00	0.00	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	880.74

3,005.85	2,588.91	2,171.97	2,592.36	3,056.16	1,664.76	1,232.32	1,232.32	954.24	1,709.44	0.00	0.00	20,208.33

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	477.12	0.00	0.00	477.12

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	

SUBTOTAL:

3,709,033.47

3,715,811.19	3,724,586.34	5,279,166.00	5,275,563.12	5,302,266.72	5,436,134.72	5,432,554.88	5,423,094.40	5,427,028.48	0.00	0.00	48,725,239.32

416.94	
1,881.84	
2,178.42	
940.92	
5,418.12	

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	2,385.60	0.00	0.00	
3515	ADULT 40-100% FEMAL	833.88	833.88	833.88	463.80	463.80	463.80	477.12	954.24	954.24	1,431.36	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	477.12	0.00	0.00	
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	463.80	0.00	0.00	0.00	477.12	477.12	477.12	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	8,588.16	0.00	0.00	

SUBTOTAL:

14,800.20	
7,710.00	
2,836.08	
1,895.16	
68,159.88	

E

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SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	7,633.92	0.00	0.00		55,520.10		
3716	ADULT <40% EXP MALE	416.94	416.94	416.94	1,391.40	927.60	927.60	477.12	477.12	477.12	477.12	0.00	0.00		6,405.90		
3717	ADULT <40% EXP FEM	416.94	416.94	416.94	463.80	927.60	1,391.40	1,431.36	477.12	477.12	477.12	0.00	0.00		6,896.34		
	12,508.20	13,759.02	13,342.08	15,305.40	14,841.60	16,696.80	17,176.32	18,130.56	20,516.16	21,947.52	0.00	0.00		164,223.66		

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	477.12	0.00	0.00	
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	477.12	0.00	0.00	

477.12

1,250.82
L

4413	SOBRA 100-133% M&F	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	12,683.20	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	3,816.96	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	2,385.60	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	18,885.76	0.00	0.00	

1,727.94

102,452.50	
33,055.05	
14,343.30	
149,850.85	

6

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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	5,468,338.88	0.00	0.00	

SUBTOTAL:

TOTAL:

49,046,459.89

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending April 30, 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	2.00	0.00	0.00	20.00

1010	TANF NON-MEDICARE	264.00	259.00	261.00	264.00	264.00	262.00	262.00	260.00	259.00	258.00	0.00	0.00	2,613.00

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	18.00	0.00	0.00	203.00

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	8.00	0.00	0.00	271.00

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	6.00	0.00	0.00	309.00

1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	11.00	11.00	8.00	7.00	7.00	6.00	5.00	0.00	0.00	105.00

1015	TANF 14-20 FEMALE N O

21.00	18.00	20.00	19.00	15.00	16.00	11.00	7.00	6.00	6.00	0.00	0.00	139.00

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

1017	TANF 21-44 FEMALE N O
2110	SSI AGED NON-MEDICA
R

2.00	2.00	2.00	2.00	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	26.00

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

17.00	19.00	24.00	25.00	27.00	27.00	28.00	31.00	32.00	30.00	0.00	0.00	260.00

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	6,175.00	0.00	0.00	61,802.00

49.00	51.00	52.00	52.00	56.00	56.00	61.00	60.00	60.00	66.00	0.00	0.00	563.00

2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	10.00

2310	SSI BLIND NON-MEDIC A

56.00	57.00	56.00	56.00	57.00	56.00	57.00	57.00	58.00	59.00	0.00	0.00	569.00

4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	40.00	36.00	39.00	39.00	40.00	33.00	42.00	0.00	0.00	397.00

4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	311.00	321.00	330.00	323.00	324.00	332.00	331.00	0.00	0.00	3,217.00

4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	342.00	345.00	361.00	377.00	386.00	377.00	380.00	0.00	0.00	3,506.00

4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	80.00	80.00	77.00	87.00	92.00	89.00	89.00	0.00	0.00	815.00

4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	84.00	87.00	91.00	94.00	98.00	97.00	95.00	0.00	0.00	888.00

5013	SOBRA PREG 09-13 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

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

7.00	6.00	5.00	5.00	6.00	3.00	2.00	2.00	2.00	3.00	0.00	0.00	41.00

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

1113	TANF EXPANDED 06-13	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

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	7,578.00	0.00	0.00	75,768.00

1.00	
4.00	
5.00	
2.00	
12.00	

3514	ADULT 40-100% MALE 1	2.00	2.00	2.00	2.00	3.00	3.00	3.00	5.00	5.00	5.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	2.00	2.00	2.00	1.00	1.00	1.00	1.00	2.00	2.00	3.00	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	1.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	1.00	0.00	0.00	0.00	1.00	1.00	1.00	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	18.00	0.00	0.00	

SUBTOTAL:

32.00	
17.00	
6.00	
4.00	
150.00	

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SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM	9.00	10.00	10.00	11.00	11.00	13.00	13.00	13.00	15.00	16.00	0.00	0.00		121.00		
3716	ADULT <40% EXP MALE	1.00	1.00	1.00	3.00	2.00	2.00	1.00	1.00	1.00	1.00	0.00	0.00		14.00		
3717	ADULT <40% EXP FEM	1.00	1.00	1.00	1.00	2.00	3.00	3.00	1.00	1.00	1.00	0.00	0.00		15.00		
	30.00	33.00	32.00	33.00	32.00	36.00	36.00	38.00	43.00	46.00	0.00	0.00		359.00		

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
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	1.00	0.00	0.00	

1.00

3.00
L

4413	SOBRA 100-133% M&F	11.00	10.00	9.00	26.00	29.00	24.00	28.00	25.00	27.00	26.00	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	8.00	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	5.00	0.00	0.00	
	17.00	16.00	12.00	38.00	41.00	37.00	39.00	36.00	40.00	39.00	0.00	0.00	

4.00

215.00	
69.00	
31.00	
315.00	

6

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	7,664.00	0.00	0.00		76,458.00		

AT
SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		
	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		

89,032.14	
179,403.43	
285,057.69	
117,760.69	
11,359,455.37	
6,824,445.87	
9,565,934.87	
2,398,174.72	
4,790,160.11	
17,180,481.66	
60,788,168.56	
22,035,219.50	
62,576.73	
6,590.53	
30,101.28	
73,232.07	
28,156.49	
1,423,907.70	
1,367,342.35	
4,134,764.17	
3,798,087.22	
80,636,239.76	
12,307,543.21	
14,361.21	
822,234.25	
151,357.97	
368.00	
700.00	
490.80	
22,466,770.29	
34,871,481.90	
47,096,376.77	
12,285,026.47	

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	1,640.49	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	5,970.14	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	11,779.18	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	8,719.62	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	989,712.40	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	372,765.11	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	353,841.59	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	75,239.88	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	224,280.59	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	1,529,077.81	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	4,731,567.12	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	1,896,964.51	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	1,000.63	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	-530.44	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	1,437.93	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	5,424.30	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	43.56	0.00	0.00

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

167,284.72	163,478.22	201,904.18	127,579.30	163,117.16	143,402.07	138,838.96	100,955.06	115,057.59	102,290.44	0.00	0.00

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	147,913.69	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	474,893.20	0.00	0.00

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

306,269.94	461,879.30	527,481.62	417,867.71	349,136.11	497,895.47	257,476.73	311,838.41	351,602.56	316,639.37	0.00	0.00

8,070,657.42	8,785,140.60     10,377,505.66	6,855,292.97	7,625,934.11	8,790,935.35	6,487,472.46	7,149,338.35	8,605,092.22	7,888,870.62	0.00	0.00

1,017,428.75	1,228,462.25	1,678,808.77	1,093,787.83	1,003,545.35	1,548,474.33	959,104.40	1,168,128.25	1,458,952.67	1,150,850.61	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	1,552.05	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	69,501.60	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	16,701.65	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	79.40	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	2,732,483.31	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	3,910,103.35	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	5,636,202.01	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	1,187,804.67	0.00	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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	1,428,299.75	0.00	0.00	15,881,553.40

5007	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
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M

0.00	700.00	700.00	0.00	21.79	885.87	2,158.62	1,054.83	601.96	591.47	0.00	0.00	6,714.54

0.00	0.00	4,357.53	1,572.17	700.00	0.00	350.00	0.00	0.00	1,609.29	0.00	0.00	8,588.99

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	331,518.59	0.00	0.00	4,124,569.67

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	1,976,763.71	0.00	0.00	21,009,520.33

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	11,731.59	0.00	0.00	54,802.44

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.44	972.25	393.04	0.00	0.00	1,588.73

SUBTOTAL:

38,912,715.23

42,227,968.93    51,870,791.41    34,642,089.66    38,477,020.03     42,696,424.00    32,599,206.90     36,858,542.22    42,398,004.36     37,595,727.83	0.00	0.00	398,278,490.57

1
SUBTOTAL:

2,223.95

2,223.95

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	85.42	0.00	215.79	8.94	1,913.80	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	85.42	0.00	215.79	8.94	1,913.80	0.00	0.00	

940.24	
350.00	
123,538.90	
334,737.58	
862,212.13	
349,413.33	
10,679.87	
21,281.05	
117,304.62	
141,526.59	
304,950.44	
5,660,546.42	
16,941,673.19	
11,163,504.01	
19,344.88	
90,377.50	
53,685.37	
204,507.37	
123,544.21	
186,298.68	
352,335.86	
3,825,083.25	
222,069.24	
2,249,385.27	

1103	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	240.24	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	16,792.07	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	22,541.27	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	104,268.47	0.00	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

23,910.19	20,501.26	32,963.26	25,925.52	28,936.18	44,064.76	32,925.55	36,555.48	51,233.02	52,398.11	0.00	0.00

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	754.00	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	2,493.76	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	11,837.79	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	26,577.10	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	622,571.45	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	2,025,751.95	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	1,374,348.12	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	647.53	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	14,059.86	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	7,975.07	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	25,643.72	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

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	19,464.27	0.00	0.00

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	12,950.88	0.00	0.00

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	9,287.19	0.00	0.00

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	359,660.72	0.00	0.00

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	20,608.44	0.00	0.00

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	164,732.31	0.00	0.00

E

3308	AHC CARE M&F 45-64	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-95.91	0.00	0.00	0.00	0.00	0.00	-8.71	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	-527.88	0.00	-316.00	0.00	0.00	-453.42	-381.79	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2620	SSI DISABLED EXPAND	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	325,975.87	0.00	0.00		3,400,081.71		
	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	5,221,580.19	0.00	0.00		46,759,371.71		

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

W

4

-1,057.32	
-387.84	
60.75	
-2,238.34	
7,709.44	
-30,464.86	
-4,345.44	
42,642.08	
11,918.47	

1

2

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	-197.86	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	60.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	-2,238.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	-4,604.13	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	-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	-4,801.99	0.00	0.00	

8,974.91	
402.04	
56,367.63	
12,479.72	
306,290.44	
724,386.08	
7,296,847.56	
4,836,538.11	
17,795,426.24	
43,157.16	
661.00	
387.29	
1,388.50	
3,059.22	
130.19	
14,309.37	
38,477.87	
215,849.85	
7,524.12	

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	1,285.95	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	535.76	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	231.63	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	33,256.09	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	49,950.55	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	804,495.90	0.00	0.00

3517	ADULT 40-100% FEMAL E

448,531.84	490,065.88	644,008.43	391,103.49	455,793.22	454,636.85	383,720.88	497,374.37	568,875.75	502,427.40	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	1,782,663.71	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	13,036.71	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	341.77	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	902.27	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	640.90	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	5,538.67	0.00	0.00

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

3,196.60	2,984.95	5,735.57	5,555.83	3,319.35	11,243.02	3,917.52	535.05	1,398.23	591.75	0.00	0.00

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	21,156.87	0.00	0.00

662.62	898.69	1,365.10	1,918.68	573.77	221.31	248.38	485.23	0.00	1,150.34	0.00	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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	199,937.04	0.00	0.00	2,992,263.29

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	263,356.55	0.00	0.00	3,129,495.23

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	5,817,311.19	0.00	0.00	63,994,580.17

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

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	3,373,769.13	0.00	0.00	34,572,376.70

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	7,950,474.10	0.00	0.00	82,174,258.46

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	2,679.16	0.00	0.00	102,882.44

3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	0.00	0.00	368.00

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

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

-612.98	2,336.87	599.83	1,113.03	476.91	1,324.77	274.77	1,050.00	2,310.25	5,080.45	0.00	0.00	13,953.90

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194.20	0.00	0.00	194.20

SUBTOTAL:

19,765,638.49

22,705,157.72    27,297,474.93    19,115,291.56    21,060,068.76     24,117,901.35    19,090,428.02     21,097,340.15    23,263,218.82     20,831,376.09	0.00	0.00	218,343,895.89

4,842.82	
5,398.30	
74,664.66	
8,257.55	
134,402.91	
314,604.44	
3,895,587.86	
5,430,553.65	
10,554,959.97	
7,164.48	
71.47	
673.36	
20,431,181.47	

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	21.47	708.58	404.29	0.00	101.64	0.00	2,206.84	0.00	0.00

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

0.00	0.00	2,100.00	392.10	350.00	350.00	350.00	0.00	838.07	1,018.13	0.00	0.00

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	3,654.35	0.00	0.00

291.65	74.97	0.00	1,418.20	2,273.85	1,370.89	310.18	1,221.62	583.12	713.07	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	21,989.71	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	43,911.01	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	440,517.04	0.00	0.00

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

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	681,876.38	0.00	0.00

1,046,431.51	1,175,014.10	1,299,604.63	912,240.75	1,066,051.25	1,102,594.49	962,994.87	942,329.91	1,085,969.23	961,729.23	0.00	0.00

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
4

47.11	350.00	59.40	0.00	48.25	10.07	0.00	145.14	13.39	0.00	0.00	0.00

SUBTOTAL:

1,757,825.94

2,095,784.57	2,416,331.87	1,869,494.39	1,862,134.99	2,333,128.25	1,787,248.17	1,841,089.46	2,310,528.07	2,157,615.76	0.00	0.00

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

0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

700.00	
4,020,841.07	
1,240,727.90	
1,537,266.10	
6,799,535.07	

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	533,895.42	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	95,129.72	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	156,805.69	0.00	0.00

SUBTOTAL:

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	785,830.83	0.00	0.00

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

5,936.00	6,300.97	5,519.97	999.09	457.38	700.00	350.00	350.00	0.00	736.00	0.00	0.00

21,349.41	
118,199.51	
22.40	
18,342.75	
11,463.32	

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	13,672.01	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.40	0.00	0.00	0.00

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

4,085.95	1,050.00	2,131.49	2,168.06	0.00	0.00	477.80	0.00	68.47	1,481.55	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	15,889.56	0.00	0.00		169,377.39		

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

3,861.91	11,145.71	10,454.38	6,107.64	5,084.31	10,824.80	3,234.54	11,561.27	8,806.49	4,653.18	0.00	0.00

75,734.23	
35,232.59	
3,708.50	
114,675.32	

2,100.00	2,528.61	332.93	1,759.52	13,816.87	1,050.00	350.00	4,815.46	6,771.98	1,707.22	0.00	0.00

59.40	237.60	367.94	0.00	10.26	0.00	0.00	54.94	2,032.04	946.32	0.00	0.00

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	66,612,438.79	0.00	0.00	

SUBTOTAL:

6,021.31

13,911.92	11,155.25	7,867.16	18,911.44	11,874.80	3,584.54	16,431.67	17,610.51	7,306.72	0.00	0.00

TOTAL:

64,487,605.57

71,142,743.92

690,890,901.83

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 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	21.79	0.00	0.00	100.94

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	12.47	0.00	0.00	0.00	88.95	0.00	0.00	101.42

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	154.46	0.00	0.00	2,226.51

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	13.45	0.00	0.00	1,325.20

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	8,191.98	0.00	0.00	50,536.38

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	577.56	0.00	0.00	13,641.65

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	1,608.39	0.00	0.00	17,296.92

1015	TANF 14-20 FEMALE N O

10,367.88	4,369.23	19,961.56	6,311.54	3,726.06	2,690.31	9,837.71	9,941.07	24,032.76	14,397.02	0.00	0.00	105,635.14

1016	TANF 21-44 MALE NON-	27,978.02	35,547.13	51,358.56	38,612.37	40,905.00	50,432.24	29,787.33	47,120.66	53,047.20	27,432.84	0.00	0.00	402,221.35

1017	TANF 21-44 FEMALE N O

85,071.84	122,995.47	128,349.71	151,849.80	85,693.87	133,933.74	151,562.92	158,767.56	160,552.67	118,137.11	0.00	0.00	1,296,914.69

1018	TANF 45-64 M & F NON	19,601.63	63,726.19	20,776.67	18,549.31	28,491.67	41,639.63	46,527.79	80,416.65	92,502.55	55,748.19	0.00	0.00	467,980.28

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

4,288.93	2,161.00	6,039.80	3,610.04	6,310.04	9,322.70	2,791.86	9,847.88	21,030.41	4,079.89	0.00	0.00	69,482.55

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	47,835.16	0.00	0.00	267,498.10

2120	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 E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

488.66	1,617.07	3,610.05	1,642.17	3,477.20	5,815.21	1,683.14	2,500.96	5,972.70	7,641.48	0.00	0.00	34,448.64

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	66,101.09	0.00	0.00	348,191.36

0.00	1,277.10	1,336.18	934.55	209.71	96.81	0.00	0.00	687.60	27.14	0.00	0.00	4,569.09

0.00	0.00	0.00	812.46	700.00	875.48	0.00	0.00	0.00	350.00	0.00	0.00	2,737.94

4311	SOBRA CHILD <1 M & F	117,403.64	23,297.12	59,254.42	35,673.44	67,380.83	113,499.55	71,543.07	35,891.36	55,084.76	49,931.89	0.00	0.00	628,960.08

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	56,586.00	0.00	0.00	573,992.75

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	34,029.99	0.00	0.00	543,486.00

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	11,275.83	0.00	0.00	286,961.72

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	9,842.28	0.00	0.00	268,368.77

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

1,316.92	-622.54	620.43	373.01	0.00	0.00	0.00	0.00	295.24	114.05	0.00	0.00	2,097.11

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	19,205.03	0.00	0.00	225,931.80

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	69,001.37	0.00	0.00	882,335.57

0.00	28.27	0.00	0.00	-28.27	1,541.56	83.27	28.84	625.41	962.19	0.00	0.00	3,241.27

8040	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	603,355.13	0.00	0.00	6,518,547.02

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	0.96	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	122.80	0.00	0.00	

3,349.89	
1,001.27	
14,172.30	
122.80	

M&

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 2016

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

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	515.10

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	221.60	0.00	0.00	10,377.68

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	4,057.08	0.00	0.00	115,825.93

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	14,944.24	0.00	0.00	296,780.28

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	2,228.50	0.00	0.00	207,360.10

1119	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,132.11	1,817.74	1,091.48	0.00	0.00	13,041.33

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	20,036.25	0.00	0.00	99,939.72

979.32	10,480.42	0.00	3,960.00	1,445.40	-3,716.92	285.17	0.00	249.90	57.40	0.00	0.00	13,740.69

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

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	3,225.04	0.00	0.00	31,106.43

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	4,953.28	0.00	0.00	52,958.00

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

SUBTOTAL:

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	50,938.63	0.00	0.00	868,629.33

1,631.37	
42,538.65	
75,781.95	
364,565.21	
271,609.66	
1,157,084.46	
1,401.96	
661.55	
1,644.30	
2,883.82	
853.76	
156,887.48	
120,707.70	
2,166,881.98	
946,016.75	
3,337,311.48	
2,930.35	
23.72	
8,651,416.15	

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	79.17	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	1,483.95	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	9,686.74	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	16,631.34	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	12,907.52	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	98,079.92	0.00	0.00

3519	ADULT 40-100% M&F 65	0.00	83.25	1,075.63	243.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3527	ADULT 40-100% FEMAL E

35.04	0.00	128.60	309.42	104.58	83.91	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	1,587.28	0.00	57.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

947.85	0.00	377.50	1,293.45	265.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	350.00	0.00	0.00	0.00	14.41	42.68	0.00	446.67	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	63,265.21	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	4,758.62	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	208,168.07	0.00	0.00

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

161,052.04	116,919.92	123,724.40	87,699.35	97,976.52	61,746.47	85,889.56	65,397.36	89,375.74	56,235.39	0.00	0.00

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	280,220.91	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
4

0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.72	0.00	0.00	0.00	0.00

SUBTOTAL:

1,010,189.83

816,937.56	1,273,874.71	893,696.29	744,323.30	688,336.40	769,718.92	930,221.99	772,153.64	751,963.51	0.00	0.00

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	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	90.99	700.00	234.31	0.00	276.64	0.00	213.94	21.82	70.22	219.01	0.00	0.00	

306.05

175.69
L
1,826.93
4

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 2016

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

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	2,322.59	0.00	0.00	23,382.24

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	1,406.59	0.00	0.00	39,160.65

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	80,651.33	0.00	0.00	605,883.41

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

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	53,004.88	0.00	0.00	505,746.21

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	99,276.54	0.00	0.00	1,209,780.06

SUBTOTAL:

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	236,880.94	0.00	0.00	2,386,261.24

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	824.77	0.00	0.00	0.00

824.77	
146,507.67	
42,841.35	
49,453.09	
239,626.88	

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	14,032.91	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	1,877.63	0.00	0.00

4415	SOBRA 100-133% FEMA L

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	871.82	0.00	0.00

SUBTOTAL:

10,263.36

18,645.33	51,585.46	21,237.13	18,232.67	31,429.55	26,388.42	9,999.13	35,063.47	16,782.36	0.00	0.00

5

8700	SSI DISABLED FREEDO	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	
	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	

SUBTOTAL:

2,070.14

2,070.14

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

M M
SUBTOTAL:

5,703.96

5,010.33

10,714.29

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	1,659,920.57	0.00	0.00		18,677,265.05		

IT

-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

FAMILY PLANNING SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.37		
	-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.37		

TOTAL:

-39.37

FEDERAL EMERGENCY SERVICES

For The Period Ending April 30, 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	526.59	0.00	0.00	9,131.04

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	42,498.51	0.00	0.00	191,691.43

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	144,987.19	0.00	0.00	675,952.27

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	151,749.53	0.00	0.00	988,026.13

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	582,424.90	0.00	0.00	4,248,689.80

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	214,291.33	0.00	0.00	1,255,609.56

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	4,774,396.65	0.00	0.00	31,357,525.40

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	291,004.99	0.00	0.00	1,990,770.09

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	5,000.72	0.00	0.00	71,969.95

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

1,028.00	1,134.36	2,508.08	3,684.44	9,408.49	13,782.91	14,408.61	3,801.23	13,388.49	6,838.62	0.00	0.00	69,983.23

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	1,424,210.88	0.00	0.00	9,869,025.55

2120	SSI AGED WITH QMB	0.00	1,247.40	0.00	491.05	0.00	30.26	0.00	0.00	0.00	0.00	0.00	0.00	1,768.71

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

15,487.16	14,895.52	19,590.18	15,828.97	7,325.35	7,561.88	13,231.61	12,318.35	16,646.04	11,364.42	0.00	0.00	134,249.48

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	281,214.19	0.00	0.00	3,891,409.71

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

-213.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-213.81

SUBTOTAL:

4,601,455.29

4,572,491.25	5,962,347.42	5,124,818.57	4,140,928.85	5,688,268.31	4,450,762.09	4,173,846.35	8,111,941.63	7,930,508.52	0.00	0.00	54,757,368.28

10,895.46	
6,926.53	
8,151.39	
107.93	
312.04	
1,266.58	
24,171.95	
140,236.78	
3,925,681.49	
9,694,664.50	
3,607,173.00	
47,842.91	
1,532.93	
11,299.51	
488,406.69	
981.45	
4,272.44	

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	3,566.80	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	1,414.66	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	1,128.98	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	18,848.78	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	435,672.66	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	1,206,113.58	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	402,961.11	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	-7,101.82	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
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E

3,738.85	228.58	31.65	378.59	28.32	492.32	200.13	1,289.11	250.98	4,660.98	0.00	0.00

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	42,637.29	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	981.45	0.00	0.00

698.31	742.38	385.05	49.30	660.78	697.68	981.64	57.30	0.00	0.00	0.00	0.00

E
SUBTOTAL:

FEDERAL EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	15,506.39	0.00	0.00		322,462.23		
	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	2,126,390.86	0.00	0.00		18,296,385.81		

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 E

0.00	3,220.32	764.56	0.00	470.90	2,523.03	764.56	0.00	0.00	0.00	0.00	0.00

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
4

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

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.55	0.00	0.00	0.00

SUBTOTAL:

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

7,168.57	
953.75	
31,228.19	
704.90	
415,811.00	
416,357.09	
6,607,284.94	
3,997,479.75	
14,239,067.98	
118,035.97	
2,928.94	
5,513.21	
25,842,534.29	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	61.58	57.52	40.91	260.93	0.00	2,371.26	1,195.27	3,181.10	0.00	0.00

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

0.00	0.00	0.00	0.00	0.00	0.00	947.60	6.15	0.00	0.00	0.00	0.00

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	2,941.75	0.00	0.00

0.00	0.00	0.00	294.80	0.00	0.00	0.00	0.00	0.00	410.10	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	73,947.20	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	57,257.90	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	707,972.04	0.00	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
3927	NEWLY ELIGIBLE FEMA
L
3928	NEWLY ELIGIBLE M&F
4

300,086.49	238,508.95	403,994.50	295,796.76	356,891.79	448,073.55	369,933.52	429,222.30	578,613.23	576,358.66	0.00	0.00

894,595.81	1,176,047.32	1,802,982.03	1,288,816.29	895,641.23	1,294,633.12	1,452,260.05	1,085,396.95	2,396,481.86	1,952,213.32	0.00	0.00

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	32,156.06	0.00	0.00

46.58	46.58	718.50	666.40	737.18	713.70	0.00	0.00	0.00	0.00	0.00	0.00

695.06	694.80	694.15	694.28	57.30	57.30	639.47	1,234.74	10.22	735.89	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	3,407,174.02	0.00	0.00

TOTAL:	7,918,039.06	8,328,534.57	11,437,992.44	9,846,269.56	7,471,741.52	9,895,913.21	8,211,267.68	7,901,010.52	14,516,267.24	13,464,073.40	0.00	0.00		98,991,109.20		

SUBTOTAL:

4

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

SUBTOTAL:

341.03

FEDERAL ESP CHRONIC SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	0.00	0.00	0.00	0.00		381.05		
	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

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	

TOTAL:

722.08

QMB - FEE FOR SERVICE

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	277,299.18	336,625.36	529,055.48	429,541.31	0.00	0.00		3,763,133.37		
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		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	149.96	0.00	0.00		149.96		
	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	429,691.27	0.00	0.00		3,763,305.80		

SUBTOTAL:

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	429,691.27	0.00	0.00		3,763,305.80		

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending April 30, 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	7.39	0.00	0.00	3,680.60

1017	TANF 21-44 FEMALE N O
2100	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R

3,227.31	2,397.42	0.00	5,425.92	0.00	0.00	2,234.31	843.73	0.00	0.00	0.00	0.00	14,128.69

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	109,490.07	0.00	0.00	529,061.01

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	102,818.63	0.00	0.00	776,705.91

2120	SSI AGED WITH QMB	1,093.55	171.15	0.00	0.00	6,269.41	192.50	0.00	0.00	0.00	0.00	0.00	0.00	7,726.61

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

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

0.00	806.03	7.57	2,769.66	0.00	0.00	0.00	12,274.33	6,413.28	31,590.09	0.00	0.00	53,860.96

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

4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,416.65	0.00	0.00	2,416.65

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	5,458.60	0.00	0.00	27,367.90

8020	QMB ONLY	0.00	164.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	164.38

SUBTOTAL:

94,139.63

163,354.77	30,951.87	166,196.50	96,395.46	235,227.60	148,485.15	181,967.24	153,705.77	251,781.43	0.00	0.00	1,522,205.42

2,974.54	
28,819.48	
2,416.65	
31,072.11	
65,282.78	

E

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	417.63	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	2,416.65	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	6,449.81	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	9,284.09	0.00	0.00	

854.41	
3,186.72	
3,836.53	
457,482.39	
11,595.31	
385,440.73	
37,025.61	
2,283,630.56	
359,121.72	
3,534,444.18	
24,275.27	
186.20	
34,248.99	
7,135,328.62	

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 E

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	298,744.85	0.00	0.00

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

0.00	0.00	0.00	15.96	311.68	42.53	0.00	5,063.86	6,161.28	0.00	0.00	0.00

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	62,946.38	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	221,880.46	0.00	0.00

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

8,006.01	55,446.91	23,944.21	15,778.68	10,519.22	55,297.61	28,330.54	58,898.95	47,546.42	55,353.17	0.00	0.00

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	500,798.01	0.00	0.00

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	160.42	0.00	0.00

3728	ADULT <40% EXP M&F
4

9,628.14	5,770.49	8,615.35	434.96	1,598.89	576.24	6,779.01	188.73	0.00	657.18	0.00	0.00

SUBTOTAL:

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	1,140,540.47	0.00	0.00

3916	NEWLY ELIGIBLE MALE	352.61	16,903.27	22,673.32	2,578.16	12,349.75	32,515.04	325.14	2,779.90	18,592.43	17,662.58	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,095.65	105.95	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	32,465.04	0.00	0.00	

126,732.20

1,201.60
L
157,288.28
4

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	1,451,839.56	0.00	0.00	

SUBTOTAL:

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	50,233.57	0.00	0.00		285,222.08		

TOTAL:

9,008,038.90

O
SUBTOTAL:

COCHISE COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	586.31	0.00	57.05	4,195.50	0.00	0.00	0.00	0.00		4,838.86		
	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		

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	

3,663.37

SUBTOTAL:

3,663.37

3717	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	609.40	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	609.40	0.00	0.00	

609.40
AL
609.40

TOTAL:	0.00	0.00	0.00	0.00	1,065.84	209.84	3,031.05	4,195.50	0.00	609.40	0.00	0.00		9,111.63		

AL

4
SUBTOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 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	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	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		

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 April 30, 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	6,746.62	0.00	0.00	13,825.42

1017	TANF 21-44 FEMALE N O
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

0.00	2,041.21	946.05	3,936.64	9,915.53	3,263.60	470.90	17,262.73	1,113.58	277.68	0.00	0.00	39,227.92

0.00	10,751.39	0.00	0.00	0.00	288.16	1,511.73	114.34	8,766.74	13,320.72	0.00	0.00	34,753.08

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	14,784.65	0.00	0.00	147,341.99

15.35	3,019.90	3,735.46	357.86	-36.16	7,396.96	55.07	903.60	96.04	140.47	0.00	0.00	15,684.55

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	3,158.03	0.00	0.00	20,022.47

5007	SOBRA PREG 21-44 FE M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

0.00	0.00	0.00	2,411.86	836.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,248.59

0.00	0.00	0.00	3,666.59	0.00	0.00	470.90	31.06	0.00	0.00	0.00	0.00	4,168.55

0.00	5,306.85	4,658.33	5,451.17	203.40	11,761.22	8,322.52	1,383.89	863.35	4,167.43	0.00	0.00	42,118.16

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,844.19	0.00	0.00	2,844.19

SUBTOTAL:

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	45,439.79	0.00	0.00	330,739.57

10,436.54	
14,172.42	
13,349.00	
5,568.89	
4,126.85	
12,805.93	
60,459.63	

1116	TANF EXPANDED 21-44	3,673.93	0.00	0.00	0.00	465.47	6,297.14	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	14,172.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	0.00	13,349.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	848.47	0.00	0.00	3,360.13	1,360.29	0.00	0.00

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

2,757.38	5,096.64	0.00	70.22	894.75	272.89	0.00	189.29	162.48	3,362.28	0.00	0.00

SUBTOTAL:

20,603.73

5,096.64	0.00	70.22	1,771.44	7,426.77	13,349.00	189.29	7,229.97	4,722.57	0.00	0.00

7,396.91	
0.00	
29,303.33	
83.10	
29,318.55	
615,321.04	
117,725.63	
565,100.16	
1,364,248.72	

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	563.53	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	5,869.44	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	71,027.91	0.00	0.00

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

5,251.56	3,256.51	2,374.79	13,269.40	9,235.19	18,206.53	18,896.21	20,537.17	9,037.36	17,660.91	0.00	0.00

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	67,578.82	0.00	0.00

SUBTOTAL:

124,338.03

133,446.71	33,662.00	174,523.61	31,703.91	158,166.12	232,952.55	120,152.31	192,602.87	162,700.61	0.00	0.00

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

4

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	

SUBTOTAL:

15,153.54

16,646.27

M
SUBTOTAL:

534.77

534.77

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	212,862.97	0.00	0.00		1,772,628.96		

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 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
2210	SSI DISABLED NON-ME
D
5017	SOBRA PREG 21-44 FE
M

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

327.15	591.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	918.52

11.66	2,253.21	4,046.52	8,752.09	858.70	1,769.51	0.00	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

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

526.42

112.96

SUBTOTAL:

639.38

10,292.59	
177.73	
39,840.56	
5,291.69	
37,987.41	
93,589.98	

3516	ADULT 40-100% MALE 2	0.00	0.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00	10,275.09	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
3718	ADULT <40% EXP M&F
4

55.30	0.00	0.00	0.00	0.00	5,236.39	0.00	0.00	0.00	0.00	0.00	0.00

2,778.01	10,131.21	950.60	14,425.99	9,754.38	-52.78	0.00	0.00	0.00	0.00	0.00	0.00

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	10,275.09	0.00	0.00	

SUBTOTAL:

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	10,275.09	0.00	0.00

TOTAL:

117,645.20

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 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	1,485.00	0.00	0.00	6,786.96

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

0.00	630.38	160.15	327.76	4,219.41	5,242.80	0.00	0.00	937.14	5,146.37	0.00	0.00	16,664.01

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

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

SUBTOTAL:

0.00

791.27	4,401.90	327.76	5,014.17	5,310.04	6,834.79	217.59	7,317.00	6,631.37	0.00	0.00	36,845.89

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

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	621.78	0.00	0.00	
3717	ADULT <40% EXP FEM	144.34	0.00	0.00	0.00	0.00	0.00	739.54	1,181.28	0.00	9,989.70	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	410.95	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	11,022.43	0.00	0.00	

7,877.62

19,405.54	
12,054.86	
50,077.77	
81,538.17	

AL

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	17,653.80	0.00	0.00		126,261.68		

D
SUBTOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	8,608.34	0.00	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		

9,736.44	
1,393.97	
472.31	
11,602.72	

E

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	

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	

TOTAL:

20,232.49

D
SUBTOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE

For The Period Ending April 30, 2016	
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		
	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		

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

12,006.76

556.20
E

3716	ADULT <40% EXP MALE	0.00	673.35	580.79	372.54	6,342.26	0.00	122.84	0.00	0.00	671.85	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	671.85	0.00	0.00	

12,562.96

8,763.63	
6,816.45	
3,410.70	
18,990.78	

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	671.85	0.00	0.00		45,640.32		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD

For The Period Ending April 30, 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
2110	SSI AGED NON-MEDICA
R

1,867,476.11	2,106,357.37	3,001,652.11	2,153,315.25	2,357,150.67	2,661,401.68	2,147,531.09	2,267,449.08	2,638,951.32	2,228,942.38	0.00	0.00	23,430,227.06

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	155,941.28	0.00	0.00	1,566,359.97

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	3,062,311.34	0.00	0.00	32,401,257.48

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

543,524.04	474,214.50	724,208.95	536,644.76	552,216.34	695,544.60	497,483.69	592,629.85	582,465.93	628,315.81	0.00	0.00	5,827,248.47

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	2,913,308.90	0.00	0.00	27,610,102.38

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	739,230.30	0.00	0.00	7,690,920.74

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	16,541.88	0.00	0.00	149,867.07

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	6,839.94	0.00	0.00	69,003.41

SUBTOTAL:

8,616,568.26

9,025,376.85    12,234,988.12	8,951,025.07	9,409,200.95     11,186,207.54	9,143,879.97	9,440,346.91    10,986,886.90	9,751,431.83	0.00	0.00	98,745,912.40

M M

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	9,756,947.99	0.00	0.00	

SUBTOTAL:

25,782.56

28,725.48

54,508.04

8710	SSI DISABLED FREEDO	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	2,774.40	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	2,741.76	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	5,516.16	0.00	0.00	

TOTAL:

98,800,420.44

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending April 30, 2016

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

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

4,497.83	12,645.58	24,804.14	14,473.36	13,002.49	20,599.26	2,159.50	9,692.60	14,160.62	4,837.87	0.00	0.00	120,873.25

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

2120	SSI AGED WITH QMB	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

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

572.87	1,912.10	6,455.92	314.42	3,785.37	2,357.90	823.65	73.28	7,226.92	361.91	0.00	0.00	23,884.34

10,415.23	19,351.87	894.64	5,932.66	1,560.41	-737.82	514.39	506.82	14,550.81	2,276.19	0.00	0.00	55,265.20

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

SUBTOTAL:

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	7,475.97	0.00	0.00	259,560.44

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	7,475.97	0.00	0.00		259,560.44		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending April 30, 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	10,619.84	0.00	0.00	238,895.11

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	14,151.61	0.00	0.00	481,060.31

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	3,549.11	0.00	0.00	59,478.39

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	1,918.93	0.00	0.00	25,954.09

2120	SSI AGED WITH QMB	0.00	0.00	69.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69.53

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

33.88	103.18	181.14	0.00	0.00	1,721.70	0.00	502.96	1,038.60	1,127.36	0.00	0.00	4,708.82

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	181,505.20	0.00	0.00	2,029,419.46

0.00	0.00	0.00	23.96	10.53	188.39	43.80	742.15	269.15	615.96	0.00	0.00	1,893.94

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	2,327.07	0.00	0.00	17,144.33

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	47,211.45	0.00	0.00	557,763.12

4313	SOBRA CHILD 06-13 M	138,639.38	30,827.76	103,590.12	109,202.16	99,584.08	228,223.73	113,507.83	142,796.15	230,989.71	144,456.73	0.00	0.00	1,341,817.65

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	12,789.55	0.00	0.00	121,462.72

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	5,459.95	0.00	0.00	50,732.00

5015	SOBRA PREG 14-20 FE M

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

SUBTOTAL:

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	425,732.76	0.00	0.00	4,931,198.41

1,083.30	
18,248.18	
353.35	
292.07	
210.61	
20,187.51	

E
SUBTOTAL:

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	84.66	8.13	232.43	39.21	0.00	20.05	-261.08	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	450.20	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	-244.24	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	-55.12	0.00	0.00	

252.59	
123.64	
12.33	
34.11	
4,733.52	
2,087.14	
2,987.43	
10,230.76	

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	18.98	0.00	32.96	86.74	113.91	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	220.37	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	253.69	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

3915	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.08	205.03	94.08	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.08	205.03	94.08	0.00	0.00	

SUBTOTAL:

3,053.49

48.92	1,139.73	151.29	246.21	1,523.58	1,946.61	879.54	653.42	587.97	0.00	0.00

L
SUBTOTAL:

363.19

363.19

6

L
SUBTOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F	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	42,973.92	0.00	0.00		310,639.55		
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	3,806.82	0.00	0.00		30,715.10		
4415	SOBRA 100-133% FEMA	515.37	640.27	290.86	918.34	676.00	2,517.58	1,322.47	2,193.68	2,333.95	1,035.47	0.00	0.00		12,443.99		
	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	47,816.21	0.00	0.00		353,798.64		

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	474,175.90	0.00	0.00	5,315,778.51

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	831.19	0.00	115.74	154.36	496.51	387.64	62.44	0.00	256.74	104.08	0.00	0.00	2,408.70

1010	TANF NON-MEDICARE	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	26,856.39	0.00	0.00	335,070.78

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

2,871.13	789.16	3,394.59	1,281.47	667.85	3,130.34	2,521.84	1,376.74	2,684.87	1,912.14	0.00	0.00	20,630.13

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	937,980.61	0.00	0.00	10,439,041.05

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	478.41	0.00	0.00	16,758.65

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	5,248.12	0.00	0.00	73,949.84

SUBTOTAL:

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	972,579.75	0.00	0.00	10,887,859.15

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	972,579.75	0.00	0.00		10,887,859.15		

ACUTE REINSURANCE

For The Period Ending April 30, 2016

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

1006	TANF 21-44 MALE WITH	98.96	0.00	0.01	17,434.82	-9,013.41	0.00	-0.01	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	344,729.33	0.00	0.00	4,660,375.81

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	75,484.14	0.00	0.00	541,233.74

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	51,233.01	0.00	0.00	1,760,300.14

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	9.12	0.00	0.00	177,754.60

1015	TANF 14-20 FEMALE N O

18,361.96	12,714.48	18,838.21	15,383.78	25,213.02	121,039.33	18,112.88	108,048.88	22,568.61	64,147.02	0.00	0.00	424,428.17

1016	TANF 21-44 MALE NON-	161,649.37	-21,881.23	40,292.26	305,406.83	277,743.49	140,429.72	317,406.13	345,135.26	222,554.84	193,275.22	0.00	0.00	1,982,011.89

1017	TANF 21-44 FEMALE N O

127,936.47	159,048.89	395,075.50	504,125.42	255,419.19	305,860.33	51,147.95	146,277.97	574,915.30	268,172.00	0.00	0.00	2,787,979.02

1018	TANF 45-64 M & F NON	84,129.25	65,348.37	87,293.71	207,392.12	65,634.10	157,000.19	41,059.66	314,062.77	95,181.78	80,567.20	0.00	0.00	1,197,669.15

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	6,170.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,170.15

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D

624.78	33,070.16	362.69	24,212.27	12,180.72	34,105.65	7,812.85	3,859.28	9,100.43	7,938.48	0.00	0.00	133,267.31

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	41,159.33	0.00	0.00	1,271,783.72

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	24,227.96	0.00	0.00	282,720.41

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	3,096,541.27	0.00	0.00	43,329,075.34

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	79,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,766.51

2310	SSI BLIND NON-MEDIC A

40,412.86	2,873.76	1,068.77	-75,896.96	5,691.49	32,166.80	0.00	8,459.11	17,427.51	0.00	0.00	0.00	32,203.34

4311	SOBRA CHILD <1 M & F	929,626.36	754,864.21	1,574,042.96	1,471,872.89	543,338.74	662,693.47	191,540.82	1,411,456.98	824,915.21	472,073.68	0.00	0.00	8,836,425.32

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	328,626.45	0.00	0.00	3,029,498.49

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	249,872.76	0.00	0.00	2,783,535.51

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	352,794.37	0.00	0.00	1,191,691.43

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	67,878.97	0.00	0.00	473,435.15

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M

0.00	9,507.28	408.56	4,728.20	1,067.70	335.40	3,573.89	49,455.69	58,284.77	0.00	0.00	0.00	127,361.49

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	2,378.48	0.00	0.00	251,640.62

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	5,721,108.79	0.00	0.00	75,369,804.93

3,283.18	
-1,794.73	
-8.67	
7,228.93	
895,204.22	
865,482.18	
1,352,428.10	
16,052.59	
-60.20	
197,495.59	

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	329.59	0.01	264.91	45.17	298.84	632.55	529.21	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	21,466.08	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	158,301.27	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	87,510.24	0.00	0.00

1119	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO

0.00	0.00	0.00	0.00	2,446.74	0.00	0.00	0.00	0.00	13,605.85	0.00	0.00

-18.11	42.85	43.82	25.93	10.31	0.00	-178.82	13.82	0.00	0.00	0.00	0.00

14,090.33	42,829.44	49,706.82	46,616.48	7,100.00	-5,141.12	4,585.12	11,351.53	23,361.47	2,995.52	0.00	0.00

E

E

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

SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2600	SSI DISABLED EXPAND	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	12,060.16	0.00	0.00		233,366.17		
2610	SSI DISABLED EXPAND	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	73,701.04	0.00	0.00		594,798.90		
	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	370,169.37	0.00	0.00		4,163,476.26		

22.30	
1,477.43	
3,631.95	
5,131.68	

4

-5,724.35	
13,341.66	
1,239.38	
21,343.09	
30,199.78	

2

SUBTOTAL:

3410	MED ELIGIBILITY NON-	0.00	0.00	-5,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	9,760.41	0.00	0.00	3,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	1,239.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	28,195.73	-1,579.93	-5,079.21	0.00	-1,327.80	1,176.39	0.00	0.00	0.00	-42.09	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	-42.09	0.00	0.00	

-1,238.16	
101,644.02	
126,346.77	
1,582,884.69	
655,481.81	
3,131,343.30	
2,767.51	
89,010.84	
1,277,050.66	
404,189.43	
6,639,438.41	
2,269,477.75	
13,025,966.72	
2,035.97	
29,306,399.72	

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	355.93	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	1,710.39	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	188,229.07	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	405,311.57	0.00	0.00

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

0.00	0.00	2,767.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

37,973.29	1,282.59	21,727.75	-1,549.73	0.00	21,253.88	0.00	0.00	0.00	8,323.06	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	74,271.62	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	24,174.41	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	743,107.55	0.00	0.00

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

256,435.90	98,701.30	250,260.17	399,461.42	410,941.85	345,450.11	65,666.55	159,813.61	170,264.75	112,482.09	0.00	0.00

1,083,021.23	1,159,557.65	1,128,258.45	2,023,672.20	1,885,371.09	1,267,187.18	615,990.59	1,484,577.46	1,046,249.45	1,332,081.42	0.00	0.00

0.00	0.00	0.00	1,152.60	0.00	883.37	0.00	0.00	0.00	0.00	0.00	0.00

96,476.19	
223,813.07	
1,064.69	
1,003,944.23	
304,081.11	
2,069,062.88	
3,698,442.17	

SUBTOTAL:

2,668,847.78

2,823,947.50	2,802,363.03	4,495,407.23	4,032,864.88	3,139,981.93	1,031,060.27	3,129,681.68	2,292,198.31	2,890,047.11	0.00	0.00

3908	NEWLY ELIGIBLE M&F
4

75,258.45	0.00	21,217.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	4,356.93	0.00	0.00	19,045.28	10,843.38	0.00	188.61	62,202.00	62,202.00	64,974.87	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	128,384.13	0.00	0.00

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

-833.32	13,544.41	28,948.15	38,254.97	33,953.18	7,099.39	16,258.67	107,566.77	11,868.33	47,420.56	0.00	0.00

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	166,144.76	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	406,924.32	0.00	0.00

6

L
SUBTOTAL:

ACUTE REINSURANCE

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F	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	92,069.09	0.00	0.00		685,929.94		
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	1,004,927.24	0.00	0.00		6,060,021.63		
4415	SOBRA 100-133% FEMA	188.17	9,280.96	106.64	4,451.52	-2,057.67	32.82	82.47	141,812.83	13,891.52	4,245.79	0.00	0.00		172,035.05		
	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	1,101,242.12	0.00	0.00		6,917,986.62		

4517	BC PATIENT FEMALE 2	6,209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	0.00	0.00	0.00	855.98	0.00	0.00	0.00	7,109.74	0.00	7,540.92	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	7,540.92	0.00	0.00	

6,209.80
1
15,506.64
5

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	2,594.20	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	2,594.20	0.00	0.00	

21,716.44

M

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	10,499,584.74	0.00	0.00	

SUBTOTAL:

26,783.63

26,783.63

TOTAL:

119,539,941.23

LONG TERM CARE REINSURANCE

For The Period Ending April 30, 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	266.86	0.00	0.00	38,388.58

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D

327,108.06	281,473.61	410,214.64	182,410.50	337,086.99	210,136.17	398,027.74	254,136.53	156,719.55	158,925.57	0.00	0.00	2,716,239.36

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	82,207.60	0.00	0.00	1,191,834.77

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	333,411.83	0.00	0.00	5,384,741.93

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	1,808,113.90	0.00	0.00	28,109,691.04

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	61.17	91.91	28.00	0.00	0.00	0.00	0.00	0.00	181.08

2310	SSI BLIND NON-MEDIC A

2,067.18	829.15	61,461.10	4,145.13	12,606.98	4,663.25	1,650.00	2,265.20	-1,161.52	2,556.93	0.00	0.00	91,083.40

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	

SUBTOTAL:

4,033,194.34

3,839,275.12	5,041,553.58	4,350,737.67	5,854,376.34	3,769,395.14	3,174,306.49	2,438,655.18	2,645,183.61	2,385,482.69	0.00	0.00	37,532,160.16

M
SUBTOTAL:

14,896.33

14,896.33

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	2,385,482.69	0.00	0.00		37,547,056.49		

ACUTE SMIB

For The Period Ending April 30, 2016

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

1000	TANF WITH MEDICARE	194,274.80	239,591.60	285,013.30	307,878.00	71,122.20	73,325.10	76,109.30	85,112.60	76,345.30	74,217.00	0.00	0.00	1,482,989.20

1010	TANF NON-MEDICARE	419.60	314.70	419.60	419.60	839.20	524.50	487.20	365.40	470.30	487.20	0.00	0.00	4,747.30

1020	TANF WITH QMB	59,218.50	89,224.80	136,060.20	153,998.10	21,979.00	27,224.00	33,977.90	30,886.50	28,345.60	26,900.90	0.00	0.00	607,815.50

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

55,177.40	57,030.30	58,179.30	62,320.40	92,112.00	76,322.10	86,876.80	100,163.30	85,856.70	86,567.10	0.00	0.00	760,605.40

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	515,922.40	0.00	0.00	4,406,833.10

2120	SSI AGED WITH QMB	1,817,089.90	1,837,723.90	1,860,966.00	1,885,790.10	2,434,377.40	2,464,358.80	2,872,361.20	2,877,496.60	2,907,473.80	2,989,697.50	0.00	0.00	23,947,335.20

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

156,570.80	143,157.80	137,314.10	138,468.00	135,216.10	127,558.40	153,205.80	145,012.80	143,107.10	139,933.50	0.00	0.00	1,419,544.40

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	395,586.60	0.00	0.00	3,592,383.10

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	3,520,290.60	0.00	0.00	31,231,958.70

2300	SSI BLIND WITH MEDIC	419.60	419.60	314.70	314.70	314.70	314.70	713.90	487.20	365.40	243.60	0.00	0.00	3,908.10

2310	SSI BLIND NON-MEDIC A

3,251.90	3,356.80	3,042.10	2,937.20	2,937.20	2,832.30	3,288.60	3,410.40	3,410.40	3,410.40	0.00	0.00	31,877.30

2320	SSI BLIND WITH QMB	25,071.10	24,336.80	25,910.30	25,805.40	26,015.20	25,176.00	29,651.60	29,861.40	36,764.80	31,796.80	0.00	0.00	280,389.40

4300	SOBRA CHILD WITH ME D
4320	SOBRA CHILD WITH Q
MB
5000	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	629.40

104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524.50

1,363.70	1,363.70	1,153.90	944.10	629.40	419.60	487.20	487.20	365.40	365.40	0.00	0.00	7,579.60

944.10	839.20	1,153.90	944.10	1,363.70	1,049.00	1,096.20	1,096.20	1,705.20	2,923.20	0.00	0.00	13,114.80

8000	SMIB ONLY NOT ELIGIB	0.00	0.00	-209.80	0.00	0.00	0.00	0.00	-226.70	-243.60	-487.20	0.00	0.00	-1,167.30

8020	QMB ONLY	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	724,020.40	0.00	0.00	6,123,600.30

8040	SLMB	3,389,057.50	3,504,045.60	3,489,229.70	3,653,533.40	3,562,064.70	3,558,489.40	4,162,803.00	4,165,784.10	4,230,303.80	4,226,326.90	0.00	0.00	37,941,638.10

8888	SMIB ONLY NOT ELIGIB	-52,359.80	-26,959.30	-20,035.90	-24,127.00	-7,238.10	-13,002.70	-16,844.70	4,254.20	-19,214.10	-11,412.40	0.00	0.00	-186,939.80

9999	SMIB ONLY NOT ELIGIB	59,066.30	19,847.50	122,106.60	172,423.40	145,913.80	190,130.30	236,588.30	208,313.90	118,766.40	126,221.40	0.00	0.00	1,399,377.90

SUBTOTAL:

9,808,185.80

10,062,146.60    10,322,154.00    10,606,357.70    10,735,182.80     10,796,525.30    12,578,894.40     12,665,395.90    12,640,890.40     12,853,011.30	0.00	0.00	113,068,744.20

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

470,376.20	412,891.00	362,329.20	338,157.10	689,298.50	630,171.70	693,195.30	684,101.00	682,181.90	701,168.00	0.00	0.00

5,663,869.90	
6,476.40	
1,912,798.60	
7,439.50	
3,475.10	
26,537,757.50	
1,116.60	
-348.50	
19,494,719.50	
53,627,304.60	

209.80	104.90	104.90	104.90	104.90	104.90	1,309.50	801.90	365.40	3,265.30	0.00	0.00

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	291,244.20	0.00	0.00

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

524.50	524.50	524.50	419.60	314.70	314.70	365.40	243.60	121.80	121.80	0.00	0.00

2,928,537.00	2,921,828.60	2,878,145.10	2,887,841.00	2,295,255.90	2,268,575.50	2,597,155.00	2,604,289.20	2,589,349.80	2,566,780.40	0.00	0.00

104.90	104.90	104.90	104.90	104.90	104.90	121.80	121.80	121.80	121.80	0.00	0.00

-419.60	209.80	314.70	-104.90	314.70	209.80	-629.40	243.60	-121.80	-365.40	0.00	0.00

1,653,183.80	1,727,813.10	1,756,040.70	1,816,932.70	1,829,709.50	1,863,111.30	2,211,003.30	2,223,027.00	2,239,720.70	2,174,177.40	0.00	0.00

SUBTOTAL:

5,183,901.40

5,190,720.50	5,113,158.90	5,146,991.60	4,945,598.70	4,960,958.70	5,773,223.50	5,779,610.90	5,796,626.90	5,736,513.50	0.00	0.00

3520	ADULT 40-100% FOR FI	3,147.00	-1,743.30	3,147.00	3,356.80	4,930.30	4,510.70	5,802.70	2,784.50	3,532.20	6,455.40	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	4,141.20	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	10,596.60	0.00	0.00	

35,923.30

FO
SUBTOTAL:

28,666.20

64,589.50

F
SUBTOTAL:

M

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	18,630,473.40	0.00	0.00	

SUBTOTAL:

245,303.50

ACUTE SMIB

For The Period Ending April 30, 2016	
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	4,286.80	0.00	0.00		15,121.20		
	1,468.60	734.30	839.20	629.40	839.20	944.10	1,847.40	1,948.80	1,583.40	4,286.80	0.00	0.00		15,121.20		

245,303.50

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	26,065.20	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	26,065.20	0.00	0.00	

TOTAL:

167,021,063.00

ACUTE HIB

For The Period Ending April 30, 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	226.00	0.00	0.00	1,128.00

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

2,442.00	-814.00	0.00	-557.50	0.00	1,628.00	0.00	0.00	0.00	-1,292.90	0.00	0.00	1,405.60

0.00	0.00	0.00	0.00	1,221.00	0.00	1,225.00	1,644.00	0.00	-2,004.30	0.00	0.00	2,085.70

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	187,593.50	0.00	0.00	1,972,846.60

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.00	0.00	0.00	0.00	0.00	411.00

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	114,270.20	0.00	0.00	1,069,600.70

2320	SSI BLIND WITH QMB	407.00	407.00	407.00	407.00	407.00	407.00	411.00	411.00	411.00	-1,373.70	0.00	0.00	2,301.30

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	-2,081.20	0.00	0.00	35,988.00

9999	SMIB ONLY NOT ELIGIB	-8,404.70	-4,538.50	-4,375.40	-7,780.00	-3,887.00	-6,817.40	-4,248.70	-4,944.80	-1,829.00	-26,645.50	0.00	0.00	-73,471.00

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	3,288.00	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	3,288.00	0.00	0.00	

SUBTOTAL:

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	268,692.10	0.00	0.00	3,011,408.60

WI
SUBTOTAL:

58,029.20

58,029.20

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	271,980.10	0.00	0.00		3,069,437.80		

2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	1,905,402.60	2,072,651.30	2,017,375.10	1,458,506.60	2,091,076.50	0.00	0.00	

SUBTOTAL:

Q1

For The Period Ending April 30, 2016	
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	2,075,477.00	0.00	0.00		17,955,756.00		
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	15,599.50	0.00	0.00		1,854,811.50		
	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	2,091,076.50	0.00	0.00		19,810,567.50		

TOTAL:

19,810,567.50

LTC SMIB

For The Period Ending April 30, 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	609.00	0.00	0.00	6,821.40

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	121.80	121.80	121.80	121.80	0.00	0.00	487.20

1020	TANF WITH QMB	104.90	104.90	104.90	104.90	104.90	104.90	348.50	243.60	243.60	243.60	0.00	0.00	1,708.70

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

874,183.40	870,946.20	868,154.40	873,399.40	856,670.30	875,757.20	1,011,705.50	973,512.00	1,005,477.20	1,003,337.80	0.00	0.00	9,213,143.40

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	183,796.20	0.00	0.00	1,692,257.40

2120	SSI AGED WITH QMB	764,559.10	761,981.70	777,780.80	770,483.50	771,637.40	774,259.90	904,494.80	881,879.80	896,668.70	896,584.20	0.00	0.00	8,200,329.90

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

319,840.10	329,595.80	321,623.40	322,567.50	334,134.80	337,673.10	382,974.80	388,117.20	400,929.50	392,930.90	0.00	0.00	3,530,387.10

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	22,045.80	0.00	0.00	205,795.10

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	825,577.00	0.00	0.00	7,566,849.60

2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	839.20	839.20	839.20	974.40	974.40	974.40	852.60	0.00	0.00	8,706.10

2310	SSI BLIND NON-MEDIC A

209.80	104.90	209.80	104.90	104.90	104.90	121.80	243.60	243.60	243.60	0.00	0.00	1,691.80

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	5,237.40	0.00	0.00	47,002.10

SUBTOTAL:

2,846,091.20

2,859,286.20	2,857,681.20	2,858,469.70	2,866,139.50	2,883,850.60	3,333,311.00	3,298,379.00	3,340,391.50	3,331,579.90	0.00	0.00	30,475,179.80

8720	SSI DISABLED FREEDO	734.30	629.40	629.40	629.40	629.40	629.40	730.80	730.80	730.80	609.00	0.00	0.00	
SUBTOTAL:	734.30	629.40	629.40	629.40	629.40	629.40	730.80	730.80	730.80	609.00	0.00	0.00	

6,682.70
M
6,682.70

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	3,332,188.90	0.00	0.00		30,481,862.50		

LTC HIB

For The Period Ending April 30, 2016

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

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

0.00	0.00	0.00	0.00	1,628.00	1,221.00	-407.00	0.00	0.00	-973.40	0.00	0.00	1,468.60

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	208,454.20	0.00	0.00	2,546,060.30

2200	SSI DISABLED WITH M E
2220	SSI DISABLED WITH Q
M

0.00	407.00	0.00	407.00	-407.00	407.00	0.00	0.00	411.00	0.00	0.00	0.00	1,225.00

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	-1,685.10	0.00	0.00	108,445.10

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-896.30	0.00	0.00	-896.30

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	204,899.40	0.00	0.00	

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	204,899.40	0.00	0.00	2,660,384.70

TOTAL:

2,660,384.70

AT
SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

14,855.74	
46,394.49	
102,697.83	
48,709.09	
6,335,726.90	
5,150,274.31	
8,071,900.96	
1,961,091.36	
3,741,844.91	
11,046,647.89	
42,957,479.52	
14,325,769.14	
23,360.65	
2,352.29	
7,244.35	
32,605.40	
13,571.43	
447,837.90	
607,659.70	
1,753,505.24	
1,170,812.63	
41,318,624.33	
3,962,522.85	
7,056.04	
437,053.00	
57,147.14	
368.00	
700.00	
490.80	
14,965,543.87	
27,110,856.19	
38,349,459.33	
9,338,741.95	

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	1,618.29	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	2,221.35	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	4,959.72	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	4,582.98	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	590,718.15	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	310,794.44	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	294,159.31	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	63,834.87	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	179,723.60	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	1,023,201.11	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	3,495,772.27	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	1,380,086.60	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	1,068.00	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	726.10	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	2,460.02	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	43.56	0.00	0.00

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

51,457.56	41,686.19	96,120.74	33,984.56	29,250.14	35,691.27	31,687.44	36,033.43	37,819.89	54,106.68	0.00	0.00

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	59,517.98	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	243,986.81	0.00	0.00

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

118,193.79	139,630.47	151,342.90	119,909.21	78,796.47	118,798.48	85,544.29	95,889.13	101,974.68	160,733.21	0.00	0.00

3,959,038.86	4,322,461.60	5,500,714.34	3,203,783.82	4,183,126.66	4,481,420.16	3,626,990.97	3,798,442.91	4,020,156.73	4,222,488.28	0.00	0.00

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	459,621.46	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	1,506.40	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	39,992.06	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	7,579.98	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	79.40	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	1,823,774.82	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	3,125,163.42	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	4,807,064.48	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	920,278.31	0.00	0.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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	1,100,468.94	0.00	0.00	12,318,176.38

5007	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
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M

0.00	700.00	700.00	0.00	0.00	0.00	2,101.86	0.00	470.90	350.00	0.00	0.00	4,322.76

0.00	0.00	350.00	350.00	700.00	0.00	350.00	0.00	0.00	1,104.00	0.00	0.00	2,854.00

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	227,381.24	0.00	0.00	2,724,692.13

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	1,335,333.98	0.00	0.00	13,681,306.33

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	2,298.00	0.00	0.00	22,129.11

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

0.00	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:

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     25,948,799.82	0.00	0.00	262,164,534.63

1
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	

940.24	
350.00	
41,434.39	
96,719.93	
277,061.30	
154,218.31	
1,050.00	
19,042.87	
103,086.65	
92,600.59	
251,286.41	
4,112,552.27	
12,714,810.89	
7,612,780.68	
17,693.77	
7,422.02	
21,771.75	
39,949.82	
59,552.89	
105,959.94	
225,628.69	
1,676,880.77	
85,123.76	
1,030,246.38	

1103	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	240.24	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	5,597.39	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	10,104.56	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	35,566.73	0.00	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

11,589.10	11,907.56	11,276.99	10,530.63	13,763.00	21,247.05	16,376.58	18,888.24	17,179.50	21,459.66	0.00	0.00

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	754.00	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	2,493.76	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	5,474.00	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	20,096.96	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	465,901.35	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	1,494,267.93	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	940,362.38	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	584.00	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	1,428.08	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	2,381.97	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	7,565.80	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

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	8,510.49	0.00	0.00

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	9,035.43	0.00	0.00

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	7,708.69	0.00	0.00

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	185,139.94	0.00	0.00

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	10,764.60	0.00	0.00

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	91,196.78	0.00	0.00

E

3308	AHC CARE M&F 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	-316.00	0.00	0.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2620	SSI DISABLED EXPAND	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	131,017.61	0.00	0.00		1,031,896.87		
	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	3,457,652.35	0.00	0.00		29,780,061.19		

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

W

4

0.00	
0.00	
0.00	
0.00	
-4,544.00	
-5,880.99	
-2,268.00	
-6,446.00	
-19,138.99	

1

2

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4,544.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	-52.99	0.00	0.00	0.00	-5,828.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	-2,268.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	-6,446.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-52.99	0.00	0.00	0.00	-14,542.00	0.00	0.00	0.00	-4,544.00	0.00	0.00	

1,879.27	
402.04	
20,640.39	
11,389.22	
201,403.44	
459,670.28	
4,173,610.43	
3,488,650.26	
10,726,093.83	
30,642.85	
661.00	
0.00	
918.20	
875.45	
130.19	
5,344.40	
10,184.97	
98,737.51	
5,570.22	

3506	ADULT 40-100% MALE 2	85.05	386.37	826.55	497.49	10.06	0.00	0.00	0.00	0.00	73.75	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	498.57	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	220.46	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	24,086.32	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	43,228.03	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	498,056.11	0.00	0.00

3517	ADULT 40-100% FEMAL E

316,477.56	364,737.12	475,335.36	280,789.77	334,025.70	333,307.13	289,200.96	374,139.32	363,291.41	357,345.93	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	1,177,921.98	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	2,576.00	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	797.40	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	325.71	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	66.25	0.00	0.00

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

1,396.64	1,663.61	3,351.85	967.89	729.84	749.77	838.29	420.54	66.54	0.00	0.00	0.00

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	15,623.06	0.00	0.00

550.16	545.25	1,197.56	1,260.00	0.01	35.41	472.80	358.69	0.00	1,150.34	0.00	0.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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	147,632.94	0.00	0.00	1,980,506.51

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	169,682.57	0.00	0.00	2,244,408.02

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	3,618,983.36	0.00	0.00	36,618,763.73

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

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	2,284,915.12	0.00	0.00	23,357,499.46

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	4,756,402.44	0.00	0.00	47,727,017.33

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	2,648.00	0.00	0.00	36,980.23

3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	0.00	0.00	368.00

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

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

0.00	476.33	0.00	700.00	350.00	1,050.00	0.00	1,050.00	2,300.63	3,503.00	0.00	0.00	9,429.96

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194.20	0.00	0.00	194.20

SUBTOTAL:

11,438,207.99

13,697,919.67    16,488,135.56    11,210,955.33    12,505,028.97     14,588,104.34    11,433,868.21     13,577,707.38    13,166,444.40     13,106,299.54	0.00	0.00	131,212,671.39

4,430.47	
5,398.30	
37,310.32	
6,618.62	
87,110.25	
259,928.22	
2,488,641.87	
4,058,955.27	
6,599,841.24	
7,000.00	
71.47	
626.25	
13,555,932.28	

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	0.00	708.58	350.00	0.00	101.64	0.00	1,870.25	0.00	0.00

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

0.00	0.00	2,100.00	392.10	350.00	350.00	350.00	0.00	838.07	1,018.13	0.00	0.00

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	1,703.18	0.00	0.00

291.65	74.97	0.00	1,418.20	2,100.00	1,197.00	181.42	1,221.62	0.00	133.76	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	15,558.89	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	37,114.20	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	287,945.23	0.00	0.00

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

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	475,042.12	0.00	0.00

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	686,794.48	0.00	0.00

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
4

0.00	350.00	59.40	0.00	48.25	10.07	0.00	145.14	13.39	0.00	0.00	0.00

SUBTOTAL:

1,180,866.48

1,241,698.82	1,599,657.76	1,269,425.19	1,217,414.63	1,526,832.20	1,130,819.52	1,356,634.44	1,525,403.00	1,507,180.24	0.00	0.00

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

0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

700.00	
3,301,398.74	
996,065.21	
1,200,754.43	
5,498,918.38	

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	437,331.41	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	83,344.30	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	130,599.97	0.00	0.00

SUBTOTAL:

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	651,275.68	0.00	0.00

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

5,936.00	4,286.25	3,859.52	1,400.00	0.00	700.00	350.00	350.00	0.00	736.00	0.00	0.00

17,617.77	
93,238.13	
0.00	
2,450.00	
9,785.92	

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	5,966.91	0.00	0.00

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

350.00	1,050.00	0.00	0.00	350.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00

4,085.95	1,050.00	708.87	2,109.55	0.00	0.00	350.00	0.00	0.00	1,481.55	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	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	8,184.46	0.00	0.00		123,091.82		

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

209.72	5,846.12	5,390.39	2,833.23	2,964.70	4,834.60	1,710.43	5,663.74	2,739.16	2,667.31	0.00	0.00

34,859.40	
10,747.96	
851.50	
46,458.86	

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

59.40	237.60	163.68	0.00	0.00	0.00	0.00	22.82	350.00	18.00	0.00	0.00

SUBTOTAL:

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	2,685.31	0.00	0.00

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	44,677,533.40	0.00	0.00		442,358,021.56		

AT
SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

73,259.42	
128,598.75	
172,389.76	
68,684.99	
4,421,630.82	
1,536,331.03	
1,431,223.42	
418,953.24	
971,635.27	
5,564,331.86	
16,346,034.69	
7,204,379.26	
38,647.66	
4,238.24	
22,856.93	
36,639.00	
14,585.06	
913,220.52	
589,867.72	
2,299,949.43	
2,521,176.31	
36,027,451.61	
7,928,907.63	
6,774.46	
373,369.85	
92,745.23	
0.00	
0.00	
0.00	
6,411,099.22	
6,951,788.91	
8,140,658.76	
2,583,676.69	

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	22.20	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	3,744.53	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	6,679.86	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	4,136.64	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	348,675.70	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	51,400.42	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	53,584.96	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	10,009.31	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	39,315.44	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	475,572.30	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	1,131,306.56	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	490,898.80	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	-67.37	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	-530.44	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	711.83	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	2,964.28	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
2110	SSI AGED NON-MEDICA
R

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	45,435.08	0.00	0.00

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	56,843.53	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	222,983.78	0.00	0.00

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

166,567.65	317,497.47	346,091.63	291,180.02	264,676.11	369,190.33	168,962.69	206,510.09	241,729.43	148,770.89	0.00	0.00

3,771,166.39	3,833,723.81	4,457,896.20	3,339,155.66	3,222,228.88	4,143,086.96	2,738,093.95	3,133,366.79	4,271,203.62	3,117,529.35	0.00	0.00

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	660,570.30	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	45.65	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	28,652.20	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	8,538.30	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	824,022.21	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	702,205.45	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	797,708.42	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	257,572.42	0.00	0.00

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 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	293,283.69	0.00	0.00	3,197,001.67

5007	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
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M

0.00	0.00	0.00	0.00	21.79	885.87	56.76	1,054.83	131.06	241.47	0.00	0.00	2,391.78

0.00	0.00	4,007.53	1,222.17	0.00	0.00	0.00	0.00	0.00	505.29	0.00	0.00	5,734.99

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	76,053.08	0.00	0.00	1,122,979.19

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	534,289.21	0.00	0.00	6,134,208.72

0.00	12,542.17	0.00	422.16	372.51	1,135.72	1,056.99	5,412.82	2,297.37	1,418.33	0.00	0.00	24,658.07

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.44	915.08	335.87	0.00	0.00	1,474.39

SUBTOTAL:

11,929,298.55

12,793,707.33    15,798,308.51    12,019,402.53    11,380,005.47     13,780,008.91    10,144,404.34     10,951,474.21    14,591,515.16     10,395,429.54	0.00	0.00	123,783,554.55

1
SUBTOTAL:

1,974.32

1,974.32

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.79	8.94	1,749.59	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.79	8.94	1,749.59	0.00	0.00	

0.00	
0.00	
84,059.32	
226,024.86	
561,828.39	
189,833.36	
9,522.08	
1,772.70	
14,202.97	
34,335.22	
49,327.45	
1,315,908.39	
3,718,146.13	
3,276,652.46	
282.18	
78,721.05	
30,614.37	
156,753.78	
63,904.67	
72,690.36	
121,342.68	
2,030,840.22	
121,197.47	
910,694.79	

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	10,885.29	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	11,146.12	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	65,493.95	0.00	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

11,071.23	8,539.97	21,023.04	15,362.85	14,717.76	21,487.65	16,224.97	17,528.83	33,895.48	29,981.58	0.00	0.00

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	6,072.69	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	3,838.65	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	134,640.09	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	459,349.09	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	381,798.12	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	63.53	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	12,631.78	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	4,933.27	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	18,047.09	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

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	10,948.83	0.00	0.00

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	3,887.25	0.00	0.00

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	1,578.50	0.00	0.00

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	151,004.50	0.00	0.00

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	8,142.22	0.00	0.00

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	73,108.52	0.00	0.00

E

3308	AHC CARE M&F 45-64	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-40.77	0.00	0.00	0.00	0.00	0.00	-8.71	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	-527.88	0.00	0.00	0.00	0.00	0.00	-381.79	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2620	SSI DISABLED EXPAND	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	185,758.53	0.00	0.00		2,254,113.91		
	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	1,573,309.60	0.00	0.00		15,322,768.81		

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

W

4

-1,057.32	
-296.95	
60.75	
-2,238.34	
12,313.57	
-25,580.51	
175.01	
-6,923.47	
-23,547.26	

1

2

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	-197.86	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	60.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	-2,238.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-24,077.78	0.00	-475.87	-491.04	0.00	-515.50	-20.32	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	-672.13	0.00	1,335.41	-100.95	0.00	0.00	0.00	-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	-197.86	0.00	0.00	

5,816.57	
0.00	
32,165.48	
346.87	
77,558.14	
254,720.39	
2,247,685.79	
1,135,067.36	
5,993,239.18	
12,410.13	
0.00	
387.29	
470.30	
2,183.77	
0.00	
6,963.16	
22,460.96	
111,888.08	
2,178.32	

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	948.51	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	37.19	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	11.17	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	8,578.45	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	6,100.27	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	218,845.62	0.00	0.00

3517	ADULT 40-100% FEMAL E

109,841.40	105,802.51	150,353.68	93,953.55	100,102.01	113,487.37	79,903.81	93,980.77	154,512.89	133,129.37	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	547,775.94	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	10,356.53	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	341.77	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	104.87	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	315.19	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	3,928.58	0.00	0.00

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

1,799.96	1,321.34	2,383.72	4,587.94	2,342.89	6,379.13	1,717.83	4.71	1,331.69	591.75	0.00	0.00

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	4,711.27	0.00	0.00

112.46	353.44	167.54	658.68	573.76	185.90	0.00	126.54	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 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	45,818.52	0.00	0.00	901,896.78

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	89,555.57	0.00	0.00	796,063.92

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	1,978,711.13	0.00	0.00	24,406,658.72

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

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	982,077.81	0.00	0.00	10,016,768.86

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	3,009,546.48	0.00	0.00	31,652,147.92

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	31.16	0.00	0.00	63,531.18

3726	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

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

166.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166.20

-612.98	600.54	599.83	413.03	126.91	274.77	274.77	0.00	9.62	1,577.45	0.00	0.00	3,263.94

0.00	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:

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	7,043,094.60	0.00	0.00	77,746,039.31

336.59	
0.00	
37,153.67	
1,055.81	
44,914.33	
48,708.73	
1,263,048.57	
1,187,690.40	
3,142,744.41	
164.48	
0.00	
47.11	
5,725,864.10	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	336.59	0.00	0.00

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

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

1,878.61	4,565.59	8,493.20	2,313.61	1,002.68	8,383.02	1,618.64	274.17	6,927.35	1,696.80	0.00	0.00

0.00	0.00	0.00	0.00	173.85	173.89	128.76	0.00	0.00	579.31	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	5,239.86	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	6,580.11	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	141,438.74	0.00	0.00

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

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	163,077.94	0.00	0.00

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	218,989.43	0.00	0.00

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
4

47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

474,843.91

575,141.29	707,887.34	529,943.61	596,053.98	708,721.97	517,264.02	392,472.10	685,597.10	537,938.78	0.00	0.00

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

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

0.00	
662,580.54	
214,545.59	
313,401.43	
1,190,527.56	

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	91,957.21	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	11,668.29	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	23,166.80	0.00	0.00

SUBTOTAL:

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	126,792.30	0.00	0.00

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

0.00	2,014.72	1,660.45	-400.91	457.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,731.64	
24,802.22	
0.00	
12,364.88	
1,677.40	

393.90	393.23	34.69	1,707.07	5,144.43	380.10	0.00	380.10	8,679.39	7,689.31	0.00	0.00

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

4,917.91	0.00	344.62	7,470.66	-368.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	1,422.62	58.51	0.00	0.00	127.80	0.00	68.47	0.00	0.00	0.00

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	5,311.81	2,407.95	3,462.38	8,835.33	5,233.50	380.10	127.80	380.10	8,747.86	7,689.31	0.00	0.00		42,576.14		

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

3,652.19	5,276.89	5,063.99	2,938.66	1,991.80	5,632.26	1,477.18	4,607.48	5,100.65	1,624.07	0.00	0.00

37,365.17	
359.95	
2,857.00	
40,582.12	

0.00	0.00	94.49	0.00	0.00	0.00	0.00	265.46	0.00	0.00	0.00	0.00

0.00	0.00	204.26	0.00	10.26	0.00	0.00	32.12	1,682.04	928.32	0.00	0.00

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	19,688,358.25	0.00	0.00	

SUBTOTAL:

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	2,552.39	0.00	0.00

TOTAL:

21,049,296.39

22,871,233.35

223,815,848.96

AT
SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N O

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

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N O

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

1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

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

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

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

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

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC A

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

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
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

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

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

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

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

0.00	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

1
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	

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

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+ M&
1111	TANF EXPANDED <1 M
&F

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

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

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&

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

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

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

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

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

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

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

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

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

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2620	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00	
0.00	
0.00	
0.00	
0.00	

W

4

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

1

2

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3507	ADULT 40-100% FEMAL E

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

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3515	ADULT 40-100% FEMAL E

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

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

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

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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
3718	ADULT <40% EXP M&F
4
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

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

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

3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

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

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

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

SUBTOTAL:

0.00

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

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

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3915	NEWLY ELIGIBLE FEMA L

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

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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
4

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

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	
0.00	
0.00	
0.00	
0.00	

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

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4415	SOBRA 100-133% FEMA L

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

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

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

0.00	
0.00	
0.00	
0.00	
0.00	

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

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

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

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:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	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		

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

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

0.00	
0.00	
0.00	
0.00	

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

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

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

AT
SUBTOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		
	0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-286.63		

136.92	
0.00	
3,024.67	
284.13	
73,327.16	
24,837.13	
9,042.89	
7,412.25	
17,581.87	
89,654.52	
193,283.31	
60,200.46	
568.42	
0.00	
0.00	
14.61	
0.00	
13,354.13	
160,966.62	
12,401.78	
11,175.89	
526,146.91	
48,896.24	
0.00	
2,306.72	
0.00	
0.00	
0.00	
0.00	
65,470.35	
214,429.82	
233,141.56	
187,100.28	

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	139.60	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	12,913.45	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	2,239.85	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	1,006.94	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	1,139.25	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	3,145.53	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	1,766.80	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	13,002.98	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	1,737.66	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
2110	SSI AGED NON-MEDICA
R

241.77	1,611.38	1,217.37	578.23	1,624.74	2,126.97	1,264.25	3,360.93	104.85	1,223.64	0.00	0.00

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	29,839.98	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	247.23	0.00	0.00

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

274.99	1,222.09	2,462.28	265.65	1,191.01	1,835.64	215.54	1,722.46	1,448.93	537.30	0.00	0.00

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	20,238.73	0.00	0.00

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	1,609.00	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	4,072.45	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	27,594.84	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	11,008.67	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	2,409.85	0.00	0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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	7,767.18	0.00	0.00	82,302.46

5007	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
5027	SOBRA PREG 21-44 FE
M
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

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	1,498.27	0.00	0.00	34,366.31

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	34,971.26	0.00	0.00	284,789.22

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,015.26	0.00	0.00	8,015.26

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

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

SUBTOTAL:

212,022.47

488,372.66	298,566.78	176,603.03	155,045.74	205,604.52	199,048.80	189,190.81	251,651.36	188,125.72	0.00	0.00	2,364,231.89

1
SUBTOTAL:

249.63

249.63

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	164.21	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	164.21	0.00	0.00	

0.00	
0.00	
-841.65	
26.99	
730.73	
174.75	
107.79	
296.08	
0.00	
8,241.00	
324.13	
49,263.36	
101,248.83	
67,057.53	
0.00	
0.00	
0.00	
0.00	
0.00	
4,517.82	
0.00	
629.80	
5,169.64	
126,771.30	

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	145.23	0.00	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

0.00	0.00	0.00	0.00	21.69	0.00	0.00	0.00	153.06	0.00	0.00	0.00

0.00	107.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1112	TANF EXPANDED 01-05	88.72	207.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1114	TANF EXPANDED 14-20	983.30	246.21	480.41	221.56	5,436.61	488.81	93.00	0.00	0.00	291.10	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	2,339.89	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	15,668.92	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	32,225.89	0.00	0.00

1119	TANF EXPANDED 65+ M&

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

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

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

338.53	-1,011.94	2,895.49	1,827.68	233.88	90.75	822.40	0.00	-707.17	28.20	0.00	0.00

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

199.65	0.00	129.18	-72.61	-17.74	189.14	200.01	0.00	0.00	2.17	0.00	0.00

386.96	48.09	143.85	158.57	1,284.03	1,951.82	642.36	198.47	0.00	355.49	0.00	0.00

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

E

3308	AHC CARE M&F 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-55.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	0.00	-123.42	0.00	0.00	0.00	0.00	0.00	0.00	
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	

SUBTOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2620	SSI DISABLED EXPAND	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	51,056.89	0.00	0.00		377,211.34		

0.00	
-55.14	
-123.42	
-304.13	
-482.69	

W

4

0.00	
-90.89	
0.00	
0.00	
-60.13	
996.64	
-2,168.34	
56,134.89	
54,812.17	

1

2

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	-90.89	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-60.13	0.00	0.00	
3616	AHC CARE/MI MALE 21-	996.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-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	-60.13	0.00	0.00	

0.00	
0.00	
301.01	
652.28	
9,417.74	
4,472.62	
198,277.62	
62,652.05	
206,898.44	
47.01	
0.00	
0.00	
0.00	
0.00	
0.00	
1,992.65	
4,114.12	
1,738.02	
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	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	93.00	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	56,072.03	0.00	0.00

3517	ADULT 40-100% FEMAL E

9,918.88	16,192.67	4,216.11	6,873.78	4,424.35	1,148.09	4,839.72	12,931.67	1,560.75	546.03	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	25,018.45	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	47.01	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	1,534.68	0.00	0.00

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

0.00	0.00	0.00	0.00	0.00	4,114.12	0.00	0.00	0.00	0.00	0.00	0.00

47.77	159.41	-72.49	153.28	0.00	57.02	-357.03	706.56	220.96	822.54	0.00	0.00

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

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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	4,557.10	0.00	0.00	19,785.99

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	136.86	0.00	0.00	11,462.63

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	77,669.91	0.00	0.00	764,270.48

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

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	34,537.98	0.00	0.00	327,709.46

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	76,150.82	0.00	0.00	625,469.81

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

3726	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

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

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

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

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

SUBTOTAL:

257,558.65

252,306.42	248,671.91	234,260.23	195,405.22	244,403.45	129,619.64	226,581.85	175,639.18	277,186.41	0.00	0.00	2,241,632.96

75.76	
0.00	
289.33	
583.12	
933.77	
707.80	
88,857.55	
39,313.20	
205,503.51	
0.00	
0.00	
0.00	
336,264.04	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	21.47	0.00	54.29	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.31	236.02	0.00	0.00

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	714.11	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	6,057.33	0.00	0.00

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

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	1,178.44	0.00	0.00

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	13,698.64	0.00	0.00

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

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
4

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

SUBTOTAL:

44,437.01

23,067.06	66,686.47	17,761.16	1,707.45	29,639.64	83,559.50	27,072.53	20,448.68	21,884.54	0.00	0.00

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

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

0.00	
19,886.64	
21,533.64	
1,408.14	
42,828.42	

0.00	332.82	31.19	1,392.55	1,273.75	5,386.27	3,719.75	3,749.35	2,648.22	1,352.74	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	-0.48	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

SUBTOTAL:

177.42

401.62	31.19	2,090.39	1,825.04	5,416.89	23,924.54	3,961.17	3,647.90	1,352.26	0.00	0.00

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

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

0.00	
50.82	
22.40	
3,527.87	
0.00	

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.03	15.79	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.40	0.00	0.00	0.00

3,387.30	0.00	140.57	-140.57	0.00	0.00	140.57	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	3,387.30	0.00	140.57	-140.57	0.00	0.00	140.57	0.00	57.43	15.79	0.00	0.00		3,601.09		

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

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

2,524.43	
24,124.68	
0.00	
26,649.11	

0.00	2,178.61	0.00	0.00	13,816.87	0.00	0.00	0.00	6,421.98	1,707.22	0.00	0.00

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

689,215.77	447,049.28	414,228.06	523,522.32	465,787.35	469,844.22	477,417.05	541,469.72	0.00	0.00	

SUBTOTAL:

0.00

2,178.61	0.00	61.65	13,853.68	95.62	36.81	1,290.05	7,388.66	1,744.03	0.00	0.00

TOTAL:

646,451.11

771,726.45

5,446,711.33

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	19,435.74	28,348.02	40,057.83	0.00	0.00		278,983.38		
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		
8050	QI1	0.00	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	40,057.83	0.00	0.00		278,983.38		

IT

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	40,057.83	0.00	0.00		278,983.38		

IT

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	

SUBTOTAL:

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	0.00	0.00	54.51	0.00	0.00	0.00	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		
8050	QI1	0.00	0.00	0.00	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		

TOTAL:

1,375.13

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	315,568.31	500,143.03	389,444.78	0.00	0.00		3,481,078.19		
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		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	149.96	0.00	0.00		149.96		
	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	389,594.74	0.00	0.00		3,481,250.62		

IT

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	389,594.74	0.00	0.00		3,481,250.62		

AT
SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13AD	MARICOPA ADULT INM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

780.06	
4,410.19	
6,945.43	
82.48	
528,770.49	
113,003.40	
53,767.60	
10,717.87	
59,098.06	
479,847.39	
1,291,371.04	
444,870.64	
0.00	
0.00	
0.00	
3,973.06	
0.00	
49,495.15	
8,848.31	
68,907.72	
94,922.39	
2,222,688.91	
367,216.49	
530.71	
9,504.68	
1,465.60	
0.00	
0.00	
0.00	
1,024,656.85	
577,817.98	
373,117.12	
175,507.55	

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	4.26	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	37,405.10	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	8,330.40	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	5,090.38	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	256.45	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	2,096.02	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	28,537.60	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	91,485.31	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	24,241.45	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
2110	SSI AGED NON-MEDICA
R

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	1,525.04	0.00	0.00

267.22	1,844.32	1,193.89	206.73	207.49	3,138.04	0.00	0.00	278.42	1,712.20	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	7,675.38	0.00	0.00

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

21,233.51	3,529.27	27,584.81	6,512.83	4,472.52	8,071.02	2,754.21	7,716.73	6,449.52	6,597.97	0.00	0.00

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	159,265.26	0.00	0.00

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	29,049.85	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	857.34	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	583.37	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	80,613.83	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	50,899.64	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	20,420.44	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	7,544.09	0.00	0.00

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 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	26,779.94	0.00	0.00	284,072.89

5007	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
5027	SOBRA PREG 21-44 FE
M
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

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	26,586.00	0.00	0.00	242,532.04

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	72,169.26	0.00	0.00	909,216.06

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.17	57.17	0.00	0.00	114.34

SUBTOTAL:

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	689,783.75	0.00	0.00	9,408,252.50

1
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	

0.00	
0.00	
-1,113.16	
11,965.80	
22,591.71	
5,186.91	
0.00	
169.40	
15.00	
6,349.78	
4,012.45	
182,822.40	
407,467.34	
207,013.34	
1,368.93	
4,234.43	
1,299.25	
7,803.77	
86.65	
3,130.56	
5,364.49	
116,732.46	
10,578.37	
55,262.80	

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	309.39	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	1,290.59	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	3,062.56	0.00	0.00

1109	TANF EXPANDED 65+ M&
1111	TANF EXPANDED <1 M
&F

1,249.86	53.73	663.23	32.04	433.73	1,330.06	324.00	138.41	4.98	956.87	0.00	0.00

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

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	2,641.49	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	19,690.12	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	56,466.01	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	19,961.73	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	659.83	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	30.83	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

0.00	0.00	0.00	0.00	0.00	81.70	0.00	0.00	0.00	4.95	0.00	0.00

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

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

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	23,514.11	0.00	0.00

170.31	695.50	498.27	5,168.66	108.02	80.25	1,527.12	247.27	736.84	1,346.13	0.00	0.00

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	427.01	0.00	0.00

E

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

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2620	SSI DISABLED EXPAND	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	9,199.73	0.00	0.00		100,577.69		
	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	139,561.35	0.00	0.00		1,152,920.37		

0.00	
0.00	
0.00	
0.00	
0.00	

W

4

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

1

2

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE	0.00	0.00	-84.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-123.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

1,279.07	
0.00	
3,260.75	
91.35	
17,911.12	
5,522.79	
672,332.72	
150,168.44	
784,993.79	
57.17	
0.00	
0.00	
0.00	
0.00	
0.00	
9.16	
1,717.82	
3,486.24	
-224.42	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	257.39	536.53	221.46	263.69	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	591.32	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	529.25	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	31,522.14	0.00	0.00

3517	ADULT 40-100% FEMAL E

12,294.00	3,333.58	14,103.28	9,486.39	17,241.16	6,694.26	9,776.39	16,322.61	49,510.70	11,406.07	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	31,947.34	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	57.17	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	9.16	0.00	0.00

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

0.00	0.00	0.00	0.00	246.62	0.00	1,361.40	109.80	0.00	0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	0.00	0.00	-224.42	0.00	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 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	1,928.48	0.00	0.00	90,074.01

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	3,981.55	0.00	0.00	77,560.66

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	141,946.79	0.00	0.00	1,950,631.83

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

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	72,238.22	0.00	0.00	870,398.92

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	108,374.36	0.00	0.00	2,099,739.40

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

3726	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

3727	ADULT <40% EXP FEM AL
3728	ADULT <40% EXP M&F
4
3729	ADULT <40% EXP M&F
6

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

0.00	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

0.00	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:

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	404,795.54	0.00	0.00	6,730,270.82

0.00	
0.00	
-88.66	
0.00	
1,444.56	
5,259.69	
55,039.87	
144,594.78	
378,666.81	
0.00	
0.00	
0.00	
584,917.05	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

627.65	95.99	385.35	0.00	0.00	0.00	0.00	-1,216.00	0.00	18.35	0.00	0.00

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

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	697.18	0.00	0.00	182.55	87.98	0.00	476.85	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	216.70	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	5,075.74	0.00	0.00

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

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	42,577.88	0.00	0.00

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	42,246.68	0.00	0.00

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
4

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

SUBTOTAL:

57,678.54

27,673.40	42,100.30	52,364.43	46,958.93	67,934.44	55,605.13	64,910.39	79,079.29	90,612.20	0.00	0.00

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

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

0.00	
36,975.15	
8,583.46	
21,702.10	
67,260.71	

920.33	606.76	51.87	3,005.28	2,948.59	9,142.94	2,684.28	4,211.66	10,149.38	3,254.06	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	117.61	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	3,038.92	0.00	0.00

SUBTOTAL:

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	6,410.59	0.00	0.00

4517	BC PATIENT FEMALE 2
1
4518	BC PATIENT FEMALE 4
5
4519	BC PATIENT FEMALE 6
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

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

0.00	
108.34	
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

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

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

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:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	10.17	15.64	0.00	0.00	15.64	0.00	0.00	66.89	0.00	0.00	0.00	0.00		108.34		

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

0.00	22.70	0.00	274.10	91.00	262.32	10.12	0.00	0.00	324.99	0.00	0.00

985.23	
0.00	
0.00	
985.23	

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

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

2,042,720.13	1,650,143.77	1,740,551.86	1,821,464.26	1,695,706.69	2,144,702.94	2,472,410.08	1,331,488.42	0.00	0.00	

SUBTOTAL:

0.00

22.70	0.00	274.10	91.00	262.32	10.12	0.00	0.00	324.99	0.00	0.00

TOTAL:

1,476,134.55

1,569,184.87

17,944,507.57

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER

For The Period Ending April 30, 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
2110	SSI AGED NON-MEDICA
R

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	176,974.54	0.00	0.00	1,309,470.78

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	24,189.70	0.00	0.00	253,612.87

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	181,919.62	0.00	0.00	1,431,234.68

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

45,476.20	32,686.17	56,715.55	29,618.96	25,027.91	41,363.82	24,516.31	25,071.19	28,005.89	40,283.81	0.00	0.00	348,765.81

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	704,622.90	0.00	0.00	6,920,804.23

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	65,696.57	0.00	0.00	608,621.13

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	7,280.00	0.00	0.00	63,902.93

2320	SSI BLIND WITH QMB	431.94	428.25	416.46	71.62	789.22	833.02	421.52	274.18	191.34	736.00	0.00	0.00	4,593.55

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

SUBTOTAL:

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	1,201,703.14	0.00	0.00	10,941,931.80

M M
SUBTOTAL:

106.88

0.00

106.88

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	1,201,703.14	0.00	0.00		10,942,038.68		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending April 30, 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
2110	SSI AGED NON-MEDICA
R

1,685,117.40	1,915,799.87	2,681,450.39	1,999,482.31	2,206,654.38	2,521,199.26	1,971,919.68	2,053,589.56	2,482,402.80	2,002,232.73	0.00	0.00	21,519,848.38

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	96,169.75	0.00	0.00	1,140,858.38

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	2,863,327.97	0.00	0.00	30,820,951.29

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

484,829.08	429,355.23	623,488.25	496,865.31	514,028.21	644,163.05	445,334.53	555,686.95	542,999.94	556,486.40	0.00	0.00	5,293,236.95

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	2,150,461.81	0.00	0.00	19,781,698.42

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	667,418.48	0.00	0.00	7,003,603.86

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	9,261.88	0.00	0.00	79,307.31

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	6,103.94	0.00	0.00	63,782.43

SUBTOTAL:

7,373,566.73

7,561,011.13    10,463,925.17	7,908,368.11	8,273,171.38	9,845,495.53	8,166,388.66	8,064,865.38	9,695,031.97	8,351,462.96	0.00	0.00	85,703,287.02

M M

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	8,356,979.12	0.00	0.00	

SUBTOTAL:

25,675.68

28,725.48

54,401.16

8710	SSI DISABLED FREEDO	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	2,774.40	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	2,741.76	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	5,516.16	0.00	0.00	

TOTAL:

85,757,688.18

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending April 30, 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
2110	SSI AGED NON-MEDICA
R

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	30,062.43	0.00	0.00	357,842.10

16,433.83	946.68	83,538.56	8,338.74	936.50	2,605.51	0.00	20,403.46	0.00	35,545.96	0.00	0.00	168,749.24

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	4,839.65	0.00	0.00	9,868.36

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

11,220.75	6,502.00	26,013.79	7,482.95	9,714.19	1,405.20	16,547.58	1,364.39	4,430.82	24,058.22	0.00	0.00	108,739.89

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	38,195.51	0.00	0.00	301,357.03

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	7.48	0.00	0.00	18,211.86

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

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

SUBTOTAL:

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	132,709.25	0.00	0.00	971,425.31

M M
SUBTOTAL:

0.00

0.00

0.00

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	132,709.25	0.00	0.00		971,425.31		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV

For The Period Ending April 30, 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
2110	SSI AGED NON-MEDICA
R

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	19,672.68	0.00	0.00	243,065.80

68.35	0.00	655.42	0.00	206.68	50.89	0.00	0.00	2,122.27	35.87	0.00	0.00	3,139.48

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	12,224.10	0.00	0.00	139,203.15

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

1,998.01	5,671.10	17,991.36	2,677.54	3,446.03	8,612.53	11,085.27	10,507.32	7,029.28	7,487.38	0.00	0.00	76,505.82

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	20,028.68	0.00	0.00	606,242.70

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	6,107.77	0.00	0.00	60,483.89

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

SUBTOTAL:

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	65,556.48	0.00	0.00	1,129,268.27

M M

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	65,556.48	0.00	0.00	

SUBTOTAL:

0.00

0.00

0.00

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

TOTAL:

1,129,268.27

KidsCare - CAPITATION AMOUNTS

For The Period Ending April 30, 2016	
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	958.36	0.00	0.00		9,737.55		
6012	KIDS 1-5 M & F NON-M	220.96	220.96	220.96	223.26	223.26	544.33	0.00	0.00	0.00	0.00	0.00	0.00		1,653.73		
6013	KIDS 6-13 M & F NON-	58,022.76	55,071.22	54,144.19	51,905.62	50,587.41	81,247.87	46,353.98	44,050.29	41,851.79	39,485.08	0.00	0.00		522,720.21		
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	35,442.31	0.00	0.00		434,037.42		
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	49,517.68	0.00	0.00		650,076.66		
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		
	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	125,403.43	0.00	0.00		1,630,621.46		

C

N
SUBTOTAL:

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	125,403.43	0.00	0.00		1,630,621.46		

C

N

993.61	932.52	910.22	883.58	836.18	816.75	763.37	720.42	704.92	663.35	0.00	0.00	

SUBTOTAL:

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2016	
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	2.00	0.00	0.00		17.56		
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
6013	KIDS 6-13 M & F NON-	456.25	434.86	420.34	395.88	383.89	368.99	348.57	328.13	314.83	293.41	0.00	0.00		3,745.15		
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	242.85	218.16	218.83	207.34	199.29	198.00	190.63	0.00	0.00		2,207.56		
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	240.85	230.13	226.93	206.46	192.00	189.19	177.31	0.00	0.00		2,242.65		
9960	KIDSCARE KICK PAYME	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		
	993.61	932.52	910.22	883.58	836.18	816.75	763.37	720.42	704.92	663.35	0.00	0.00		8,224.92		

TOTAL:

8,224.92

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	75.10	75.10	37.55	82.84	82.84	125.24	41.42	41.42	41.42	82.84	0.00	0.00		685.77		
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	11,639.02	0.00	0.00		150,449.33		
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	8,171.36	0.00	0.00		93,221.99		
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	7,720.16	0.00	0.00		96,511.93		
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	27,613.38	0.00	0.00		341,361.76		

C

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	27,613.38	0.00	0.00		341,361.76		

894.00	849.00	812.00	792.00	741.00	702.00	683.00	639.00	0.00	0.00	

C

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending April 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	2.00	2.00	1.00	2.00	2.00	2.00	1.00	1.00	1.00	2.00	0.00	0.00		16.00		
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	281.00	0.00	0.00		3,653.00		
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	235.00	210.00	211.00	198.00	194.00	191.00	184.00	0.00	0.00		2,130.00		
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	231.00	223.00	220.00	200.00	187.00	185.00	172.00	0.00	0.00		2,189.00		
SUBTOTAL:	968.00	918.00	894.00	849.00	812.00	792.00	741.00	702.00	683.00	639.00	0.00	0.00		7,998.00		

TOTAL:

968.00

918.00

7,998.00

KidsCare - FEE FOR SERVICE

For The Period Ending April 30, 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	30.89	0.00	0.00		3,071.16		
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	85.89	0.00	0.00		1,178.75		
	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	139.88	229.73	116.78	0.00	0.00		3,437.19		

SUBTOTAL:

TOTAL:	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	139.88	229.73	116.78	0.00	0.00		3,437.19		

SUBTOTAL:

KidsCare - REINSURANCE

For The Period Ending April 30, 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	52,988.75	0.00	0.00		394,039.20		
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	52,988.75	0.00	0.00		471,281.62		

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	52,988.75	0.00	0.00	471,281.62

110007

DES-DD - CAP MEMBER MONTHS

For The Period Ending April 30, 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	4.00	5.00	7.00	7.00	7.00	6.00	0.00	0.00	44.00

1010	TANF NON-MEDICARE	643.15	641.57	646.12	649.50	648.46	646.64	649.79	655.10	651.45	661.37	0.00	0.00	6,493.15

1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	15.00

2100	SSI AGED WITH MEDICA	151.70	154.89	157.99	163.43	165.59	166.66	163.88	160.60	162.00	163.43	0.00	0.00	1,610.17

2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.19	4.00	4.00	4.00	4.00	4.00	5.00	0.00	0.00	45.19

2120	SSI AGED WITH QMB	272.31	272.62	271.31	271.53	273.47	273.79	269.17	269.00	268.17	273.30	0.00	0.00	2,714.67

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	1,874.85	0.00	0.00	17,984.60

220Z	SSI DISABLED WITH ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2210	SSI DISABLED NON-MED	21,475.15	21,538.50	21,702.85	21,678.83	21,721.06	21,810.43	21,771.15	21,887.82	22,013.59	22,057.19	0.00	0.00	217,656.57

221Z	SSI DISABLED NON-MED	0.03	0.00	0.00	0.03	0.00	0.64	0.00	0.00	4.35	4.22	0.00	0.00	9.27

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	4,076.82	0.00	0.00	40,254.50

222Z	SSI DISABLED WITH QM	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00

2300	SSI BLIND WITH MEDIC	13.00	13.00	13.00	14.00	14.00	14.00	14.00	14.00	14.00	14.00	0.00	0.00	137.00

2310	SSI BLIND NON-MEDICA	111.00	112.38	114.06	111.81	116.00	115.00	117.00	115.00	116.00	117.66	0.00	0.00	1,145.91

2320	SSI BLIND WITH QMB	28.00	29.00	28.00	28.00	27.30	27.00	27.00	28.00	28.00	28.00	0.00	0.00	278.30

8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	8.00	9.00	0.00	0.00	73.00

8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	0.00	0.00	18.00

8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	30.00

SUBTOTAL: TOTAL:

28,445.47

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	29,296.84	0.00

6

4

28,515.36	28,722.48	28,721.2	28,794.99	28,892.54	28,900.00	29,034.00	29,187.39	29,296.8	0.00

0.00	288,510.33

0.00	288,510.33

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending April 30, 2016

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL EPD
TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	370,741.89
84,945,196.47	366,197.37
97,607,756.74	369,544.65
86,404,566.22	371,342.65
86,818,575.78	369,390.76
99,193,232.58	369,639.86
87,521,696.46	371,326.59
86,043,306.40	375,239.67
98,880,037.83	372,982.88
86,041,307.17	377,626.94
85,586,531.41	0.00
0.00	0.00
0.00	3,714,033.26
899,042,207.06	
	85,315,938.36
97,105,888.85	97,973,954.11
97,348,150.88	86,774,110.87
98,057,803.05	87,189,918.43
98,603,338.74	99,562,623.34
98,857,708.49	87,891,336.32
101,652,897.48	86,414,632.99
99,469,295.66	99,255,277.50
99,930,110.58	86,414,290.05
100,459,478.61	85,964,158.35
100,835,854.24	0.00
0.00	0.00
0.00	902,756,240.32
992,320,526.58	
	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	100,835,854.24	0.00	0.00	992,320,526.58	
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	186,800,012.59	0.00	0.00	1,895,076,766.90	

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	9,756,947.99
0.00	0.00
0.00	0.00
0.00	98,800,420.44
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	9,756,947.99	0.00	0.00	98,800,420.44	

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	2,136,870.97
248,611.72	0.00
0.00	0.00
0.00	32,893,844.43
4,653,212.06	
	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	248,611.72	0.00	0.00	4,653,212.06	
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	2,385,482.69	0.00	0.00	37,547,056.49	

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	3,537,088.30	0.00	0.00	33,142,247.20	

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

128

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending April 30, 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	14,156,915.89	0.00	0.00	145,022,213.66	
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	154,143.83	0.00	0.00	1,384,549.10	
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	4,920,128.00	0.00	0.00	43,766,196.49	
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	548,210.88	0.00	0.00	5,280,263.40	
	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	19,779,398.60	0.00	0.00	195,453,222.65	

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

TOTAL

Thursday, May 19, 2016

999155	CRS REINSURANCE ONLY	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	2,963,907.95	189,912.38	3,233,117.99	1,312,151.22	1,912,964.11	0.00	0.00	18,110,975.63	
	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	1,912,964.11	0.00	0.00	18,110,975.63	

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	22,432.68	0.00	0.00	282,866.31	
	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	22,432.68	0.00	0.00	282,866.31	

Subtotal

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	21,714,795.39	0.00	0.00	213,847,064.59	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending April 30, 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	17,037.71	0.00	0.00	171,418.79	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	168.21	164.43	179.03	172.82	181.83	180.00	193.70	0.00	0.00	1,743.43	
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	6,515.00	0.00	0.00	64,856.00	
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	1,149.00	0.00	0.00	11,602.00	
	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	24,895.41	0.00	0.00	249,620.22	

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

TOTAL

Thursday, May 19, 2016

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	27.00	0.00	0.00	320.98	
	36.87	32.00	33.00	34.99	35.00	32.93	33.19	28.00	28.00	27.00	0.00	0.00	320.98	

Subtotal

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	24,922.41	0.00	0.00	249,941.20	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending April 30, 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	8,314,349.07	0.00	0.00	58,735,367.61	
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	20,100,652.09	0.00	0.00	144,507,752.46	
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	44,399,729.00	0.00	0.00	454,752,633.23	
	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	72,814,730.16	0.00	0.00	657,995,753.30	

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

TOTAL

Thursday, May 19, 2016

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	72,814,730.16	0.00	0.00	657,995,753.30	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending April 30, 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	5,475.75	0.00	0.00	38,681.91	
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	13,031.26	0.00	0.00	93,683.93	
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	19,801.82	0.00	0.00	197,983.59	
	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	38,308.83	0.00	0.00	330,349.43	

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

TOTAL

Thursday, May 19, 2016

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	38,308.83	0.00	0.00	330,349.43	

GRAND TOTAL