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

September 27, 2016

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

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

SUBJECT: FY 2017 Appropriation Status Report for the Period Ended August 31, 2016

Dear President Biggs and Speaker Gowan:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended August 31, 2016.

Status Summary – As part of the FY 2018 budget request to the Governor’s Office of Strategic Planning and Budgeting, a FY 2017 rebase was prepared.  AHCCCS is currently forecasting a FY 2017 Total Fund shortfall of $169.1 million.  This shortfall is comprised entirely of Federal Expenditure Authority.

There are several issues this fiscal year that have the potential to affect the projected shortfall. They include:
•	Continued volatility in caseload growth and prior period expenditures.
•	Potential Agency audit liabilities, which are detailed in the ASR.

AHCCCS intends to utilize surplus FY 2016 General Fund and Expenditure Authority for administrative adjustments of expenditures with dates of service prior to July 1, 2016.  These administrative adjustments will reduce the projected Expenditure Authority shortfall.

Given these issues and options, for purposes of this report, projected annual expenditures equal the FY 2017 appropriations.

Enrollment  Update   –  August  2016  enrollment  is  1,869,747  members,  a  15,621  member increase over the prior month.  Enrollment for September 2016 increased to 1,888,006 members, an 18,259 member increase.

Major   September   changes   by   eligibility   category   include:   1931   for   Families   and
Children/SOBRA – increase of 11,743; Supplemental Security Income – increase of 343; Prop

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. September 27, 2016
Page 2

204 Restoration - increase of 1,666; Adult Expansion - increase of 447; Medicare Cost Sharing –
increase of 542; and Federal Emergency Services - increase of 1,153.

Tobacco Funds Revenue Update – Tobacco tax collections through August 2016 are $371,000 more than the AHCCCS monthly projected flows. AHCCCS will monitor the tobacco funds revenue collections throughout the year to determine any impact on the FY 2017 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	2017

Through August 31, 2016

Prepared by: Division of Business and Finance

Appropriation	Status	Report
Table	of	Contents

APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 2017……………………………….2
Appropriated Expenditures by Funding Source………………………………….……..3
Appropriated Revenue Received Detail Schedule………………………………………5

FOOTNOTES……………………………………………………………………………………….7

CASELOAD AND EXPENDITURES BY RATE CODE………………………………11

Appropriation Status Report

Appropriated Sources and
Uses	of	Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 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	$ 	91,098,800		$ 	14,372,200		$ 	11,585,939		$ 	2,786,261		$ 	91,098,800		$ 	-	
AHCCCS Prop 204 Administration	12,639,000		2,006,400		2,289,707		(283,307)		12,639,000		-	
DES Eligibility	54,874,500		8,696,400		2,913,185		5,783,215		54,874,500		-	
DES Prop 204 Eligibility	38,358,700		6,015,600		1,682,371		4,333,230		38,358,700		-	
TOTAL ADMINISTRATION	196,971,000		31,090,600		18,471,201		12,619,399		196,971,000		-	

Traditional Medicaid Services	3,836,187,500		633,683,600		649,262,370		(15,578,770)		3,836,187,500		-	
Proposition 204 Services	2,877,688,100		435,132,000		462,624,322		(27,492,322)		2,877,688,100		-	
ACA Adult Expansion	462,284,600		73,749,300		75,452,548		(1,703,248)		462,284,600		-	
Children's Rehabilitative Services	275,375,700		41,467,800		42,203,673		(735,873)		275,375,700		-	
KidsCare Services	1,955,000		40,600		228,294		(187,694)		1,955,000		-	
ALTCS Services	1,422,354,600		236,022,500		228,398,884		7,623,616		1,422,354,600		-	
Disproportionate  Share Payments	5,087,100		-		-		-		5,087,100		-	
Rural Hospitals	22,650,000		-		-		-		22,650,000		-	
Voluntary Political Subdivision Programs	319,888,600		740,900		740,908		(8)		319,888,600		-	
Behavioral Health Traditional Medicaid Services	960,228,100		152,131,200		149,522,047		2,609,153		960,228,100		-	
Behavioral Health Proposition 204 Services	612,844,800		95,459,400		93,317,421		2,141,979		612,844,800		-	
Behavioral Health ACA Adult Expansion	77,702,300		11,823,600		11,037,865		785,735		77,702,300		-	
Behavioral Health CMDP	208,027,400		35,335,400		32,583,543		2,751,857		208,027,400		-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900		13,141,200		13,161,789		(20,589)		78,846,900		-	
Supported Housing	5,324,800		887,400		887,467		(67)		5,324,800		-	
Crisis Services	16,391,300		2,731,800		2,709,383		22,417		16,391,300		-	
TOTAL PROGRAMMATIC	11,182,836,800		1,732,346,700		1,762,130,513		(29,783,813)		11,182,836,800		-	

$ 	11,379,807,800		$    1,763,437,300		$   1,780,601,714		$ 	(17,164,414)		$    11,379,807,800		$ 	-	

TOTAL EXPENDITURES

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT For the Period Ending August 31, 2016
APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

STATE - GENERAL FUND

Administrative  Expenditures	
$ 	55,109,000	
$ 	8,701,500	
$ 	5,538,838	
3,162,662	
$ 	55,109,000	
$ 	-	
Proposition 204 - Administrative  Expenditures	21,232,700	3,334,600	1,075,225	2,259,375	21,232,700	-	

Programmatic  Expenditures
Traditional Medicaid Services	783,058,800		142,986,500		165,097,098		(22,110,598)		783,058,800		-	
Proposition 204 Services	100,000,000		(23,297,800)		1,239,828		(24,537,628)		100,000,000		-	
Children's Rehabilitative  Services	84,937,900		12,901,400		11,906,144		995,256		84,937,900		-	
KidsCare Services	-		-		(13,834)		13,834		-		-	
ALTCS Services	167,841,100		27,249,300		27,973,517		(724,217)		167,841,100		-	
DSH and Rural Hospitals	7,239,300		-		-		-		7,239,300		-	
Behavioral Health Traditional Medicaid Services	259,356,900		41,419,400		47,139,104		(5,719,704)		259,356,900		-	
Behavioral Health Proposition 204 Services	109,250,500		16,922,700		16,290,462		632,238		109,250,500		-	
Behavioral Health ACA Adult Expansion	831,900		-		-		-		831,900		-	
Behavioral Health CMDP	63,770,500		10,915,900		10,100,221		815,679		63,770,500		-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900		13,141,200		13,161,789		(20,589)		78,846,900		-	
Supported Housing	5,324,800		887,400		887,467		(67)		5,324,800		-	
Crisis Services	14,141,100		2,356,800		2,334,350		22,450		14,141,100		-	
TOTAL GF EXPENDITURES	1,750,941,400		269,342,500		302,730,210		(45,211,310)		1,750,941,400		-	

	FEDERAL		

Administrative  Expenditures		
90,666,200		
14,334,400		
8,953,319		
5,381,081		
90,666,200		
-	
Proposition 204 - Administrative  Expenditures		26,201,700		4,128,600		2,896,852		1,231,748		26,201,700		-	

Programmatic  Expenditures
Traditional Medicaid Services		
2,558,500,000		
410,616,800		
359,578,123		
51,038,677		
2,558,500,000		
-	
Proposition 204 Services		2,375,352,300		372,327,900		399,867,594		(27,539,694)		2,375,352,300		-	
ACA Adult Expansion		456,023,100		73,749,300		75,452,548		(1,703,248)		456,023,100		-	
Children's Rehabilitative  Services		190,437,800		28,566,400		30,297,529		(1,731,129)		190,437,800		-	
KidsCare Services		1,585,000		(4,700)		242,127		(246,827)		1,585,000		-	
ALTCS Services and Nursing Facility Assessment		953,302,500		157,944,500		146,268,270		11,676,230		953,302,500		-	
DSH and Rural Hospitals		20,497,800		-		-		-		20,497,800		-	
Behavioral Health Traditional Medicaid Services		665,305,400		105,032,000		102,382,943		2,649,057		665,305,400		-	
Behavioral Health Proposition 204 Services		503,594,300		78,536,700		77,026,959		1,509,741		503,594,300		-	
Behavioral Health ACA Adult Expansion		76,870,400		11,823,600		11,037,865		785,735		76,870,400		-	
Behavioral Health CMDP		144,256,900		24,419,500		22,483,322		1,936,178		144,256,900		-	
Voluntary Political Subdivision Programs - See Note 5		151,245,700		504,200		504,238		(38)		151,245,700		-	
TOTAL FEDERAL EXPENDITURES		8,213,839,100		1,281,979,200		1,236,991,687		44,987,513		8,213,839,100		-	

	COUNTY		

Administrative  Expenditures  Proposition 204 - BNCF Programmatic  Expenditures
Traditional Medicaid Services Acute Care		
3,563,300

49,687,700		
558,800

8,095,200		
- 	558,800

8,281,283 	(186,083)		
3,563,300

49,687,700		
-

-	
ALTCS Services		249,980,000		40,591,800		46,497,576 	(5,905,776)		249,980,000		-	
TOTAL COUNTY EXPENDITURES		303,231,000		49,245,800		54,778,859 	(5,533,059)		303,231,000		-	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT For the Period Ending August 31, 2016
APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

	TOBACCO FUNDS		

Programmatic  Expenditures			
Traditional Medicaid Services - Medically Needy	37,432,400		6,098,600		- 	6,098,600		37,432,400		-	
Behavioral Health Traditional Medicaid Services - Medically Needy	35,565,800		5,679,800		- 	5,679,800		35,565,800		-	
Proposition 204 Services - Emergency Health Services	18,747,200		2,949,400		- 	2,949,400		18,747,200		-	
Proposition 204 Services - Proposition 204 Protection	37,521,000		5,903,000		- 	5,903,000		37,521,000		-	
Proposition 204 Services - ATLSF	100,000,000		15,732,600		- 	15,732,600		100,000,000		-	

	OTHER		

Administrative  Expenditures
Prescription Drug Rebate Program		
198,100		
32,700		
6,968		
25,732		
198,100		
-	
Acute Care - Prescription Drug Rebate Program State Match		106,139,500		17,292,500		8,844,958		8,447,542		106,139,500		-	
Acute Care - Prescription Drug Rebate Program Federal Authority		301,143,200		48,562,300		107,409,541		(58,847,241)		301,143,200		-	
Long Term Care - Prescription Drug Rebate Program State Match		7,441,300		1,211,000		620,108		590,892		7,441,300		-	
Long Term Care - Prescription Drug Rebate Program Federal Authority		21,600,300		3,478,500		6,865,508		(3,387,008)		21,600,300		-	
Proposition 204 Services - Hospital Assessment		246,067,600		61,516,900		61,516,900		-		246,067,600		-	
ACA Adult Expansion - Hospital Assessment		6,261,500		-		-		-		6,261,500		-	
Traditional Medicaid Services - TPL		194,700		31,700		41,679		(9,979)		194,700		-	
ALTCS Services - TPL		-		-		173,905		(173,905)		-		-	
ALTCS Services - Nursing Facility Assessment		22,189,400		5,547,400		-		5,547,400		22,189,400		-	
KidsCare Services Premiums		370,000		45,300		-		45,300		370,000		-	
Freedom to Work Premiums		31,200		-		9,688		(9,688)		31,200		-	
Crisis Services - Substance Abuse Services Fund		2,250,200		375,000		375,033		(33)		2,250,200		-	
Voluntary Political Subdivision Programs - See Note 5		168,642,900		236,700		236,670		30		168,642,900		-	
TOTAL OTHER  EXPENDITURES		882,529,900		138,330,000		186,100,958		(47,770,958)		882,529,900		-	

TOTAL TOBACCO EXPENDITURES	229,266,400 	36,363,400 	- 	36,363,400 	229,266,400 	-

Programmatic  Expenditures

	TOTAL		

Administrative  Expenditures		
196,971,000		
31,090,600		
18,471,201		
12,619,399		
196,971,000		
-	
Acute Care		9,760,482,200		1,496,324,200		1,533,731,629		(37,407,429)		9,760,482,200		-	
Long Term Care		1,422,354,600		236,022,500		228,398,884		7,623,616		1,422,354,600		-	
TOTAL EXPENDITURES	$	11,379,807,800		$ 	1,763,437,300		$ 	1,780,601,714		$ 	(17,164,414)		$ 	11,379,807,800		$ 	-	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE  AND OTHER COLLECTIONS RECEIVED  DETAIL SCHEDULE For the Period Ending August 31, 2016

BUDGET 	BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	930,345,000		$	164,589,400		$	182,542,080	
Proposition 204 Services & Administrative	121,232,700		(19,963,200)		18,605,515	
KidsCare Services	-		-		(13,834)	
ALTCS Services	167,841,100		27,249,300		27,973,517	
Behavioral Health Traditional Medicaid Services	531,522,600		85,643,400		73,622,931	
TOTAL	1,750,941,400		257,518,900		302,730,209	

FEDERAL:
Acute & Administrative	5,868,924,600		904,227,600		879,144,838	
KidsCare Services	1,585,000		(4,700)		271,447	
ALTCS Services	953,302,500		157,944,500		146,268,272	
Behavioral Health Traditional Medicaid Services	1,390,027,000		219,811,800		212,969,362	
TOTAL	8,213,839,100		1,281,979,200		1,238,653,919	

COUNTY:
Acute & Administrative	53,251,000		8,654,000		7,337,518	
ALTCS Services	249,980,000		40,591,800		41,663,334	
TOTAL	303,231,000		49,245,800		49,000,852	

TOBACCO FUNDS:
Traditional Medicaid Services	72,998,200		11,778,400		-	
Proposition 204 Services	156,268,200		24,585,000		-	
TOTAL	229,266,400		36,363,400		-	

OTHER:
Administrative	198,100		32,700		6,968	
Acute Care - Prescription Drug Rebate Program	407,282,700		65,854,800		116,254,499	
Long Term Care - Prescription Drug Rebate Program	29,041,600		4,689,500		7,485,616	
Hospital Assessment	252,329,100		61,516,900		66,108,934	
ALTCS - Nursing Facility Assessment	22,189,400		5,547,400		4,946,145	
Acute TPL - Note 1	194,700		31,700		41,679	
LTC TPL - Note 1	-		-		173,905	
KidsCare TPL - Note 1	-		-		(2)	
Member Premiums - CHIP	370,000		45,300		34,898	
Member Premiums - Freedom to Work	31,200		-		9,688	
Behavioral Health Traditional Medicaid Services	2,250,200		375,000		-	
Voluntary Political Subdivision - State Match	168,642,900		236,700		468,976	
TOTAL	882,529,900		138,330,000		195,531,308	

TOTAL REVENUE

$	11,379,807,800

$	1,763,437,300

$	1,785,916,288

Appropriation Status Report

Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT For the Period Ending August 31, 2016

Note 1:	Third Party Liability Collections: Gross Collections:	August 2016		August 2015		July 1, 2015
August 31, 2016		July 1, 2014
August 31, 2015	
	Acute	$ 	535,095		$ 	335,362		$ 	741,962		$ 	818,607	
	LTC	290,705		477,470		780,033		588,731	
	KidsCare	-		104,605		-		105,342	
	Total TPL Collections	$ 	825,800		$ 	917,437		$ 	1,521,995		$ 	1,512,680	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$ 	26,905		$ 	53,101		$ 	41,679		$ 	104,555	
LTC	58,901		110,063		173,905		133,442	
KidsCare	-		20,901		(2)		21,015	
Total Expenditure Offsets	$ 	85,806		$ 	184,065		$ 	215,582		$ 	259,012	

FY 17 Total

Note 2:	Authorized Positions	1,141.2	
	Actual Positions as of August 31, 2016	1,026.0	

ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM
FY 2017 APPROPRIATION STATUS REPORT For the Period Ending August 31, 2016

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2016	

$ 	1,933,160	
	Revenues	1,344,084	
	Transfers-In	 	93,468 		
	Total Revenues	 	1,437,552 		
	Expenditures	570,769	
	Transfers-out	 	327,536 		
	Total Expenditures	 	898,305 		

Ending Balance August 31, 2016

$ 	2,472,407

Of the $2,472,407 ending balance, $1,513,464 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through August 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities
As of August 31, 2016

Description 	Amount

Type

School Based Claiming Medicaid Administrative Costs 	18,941,355 	HHS-OIG & AHCCCS Self Reported

School Based Claiming Direct Services Costs 	19,923,489 	HHS-OIG

38,864,844

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT For the Period Ending August 31, 2016

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures.

As of August 31, 2016
Expenditures

State Match 	Federal 	Total

DSH Voluntary

$ 	236,670 	$

504,238 	$

740,908

GME Voluntary 	- 	- 	- Safety Net Care Pool 	- 	- 	-

Total Voluntary Political Subdivision Program Expenditures

$ 	236,670 	$

504,238 	$

740,908

Appropriation Status Report

Caseload	and	Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY

For the Period Ending August 31, 2016

CAPITATION - ACUTE	278,655,778	277,811,900	0	0	0	0	0	0	0	0	0	0	556,467,678	
CAPITATION - LTC	190,311,536	204,030,120	0	0	0	0	0	0	0	0	0	0	394,341,656	
MENTAL HEALTH - CHILD	26,813,238	27,044,552	0	0	0	0	0	0	0	0	0	0	53,857,790	
MENTAL HEALTH - ADULT	698,830	704,425	0	0	0	0	0	0	0	0	0	0	1,403,255	
MENTAL HEALTH - GENERAL	12,634,372	12,735,509	0	0	0	0	0	0	0	0	0	0	25,369,881	
MENTAL HEALTH - CMDP	16,373,946	16,310,154	0	0	0	0	0	0	0	0	0	0	32,684,101	
CHILDREN'S REHAB SERVICES	5,498,579	5,487,093	0	0	0	0	0	0	0	0	0	0	10,985,672	
FEE FOR SERVICE - ACUTE	43,169,220	49,076,411	0	0	0	0	0	0	0	0	0	0	92,245,631	
FFS - PRIOR QUARTER COVERAGE	399,183	701,172	0	0	0	0	0	0	0	0	0	0	1,100,355	
EMERGENCY SERVICES - FEDERAL	4,723,538	6,876,303	0	0	0	0	0	0	0	0	0	0	11,599,842	
FFS MEDICAID IN PUBLIC SCHOOLS	334,212	144,833	0	0	0	0	0	0	0	0	0	0	479,045	
STATE ONLY TRBHA FFS	0	12,155	0	0	0	0	0	0	0	0	0	0	12,155	
FFS TRBHA FEE FOR SERVICE	1,636,296	6,817,558	0	0	0	0	0	0	0	0	0	0	8,453,854	
QMB - FEE FOR SERVICE	400,115	462,259	0	0	0	0	0	0	0	0	0	0	862,374	
INPATIENT INMATES FFS	125,819	53,097	0	0	0	0	0	0	0	0	0	0	178,916	
PINAL COUNTY INMATES FFS	4,630	3,154	0	0	0	0	0	0	0	0	0	0	7,785	
MARICOPA CTY INMATES FFS	22,177	38,629	0	0	0	0	0	0	0	0	0	0	60,806	
MOHAVE COUNTY INMATES FFS	31	8,322	0	0	0	0	0	0	0	0	0	0	8,353	
PIMA COUNTY INMATES FFS	1,278	26,237	0	0	0	0	0	0	0	0	0	0	27,515	
FEE FOR SERVICE - LTC	9,673,620	11,818,762	0	0	0	0	0	0	0	0	0	0	21,492,382	
LFFS - PRIOR QUARTER COVERAGE	25,539	27,090	0	0	0	0	0	0	0	0	0	0	52,629	
LFFS MEDICAID IN PUBLIC SCHOOLS	828,652	474,874	0	0	0	0	0	0	0	0	0	0	1,303,526	
REINSURANCE - ACUTE	10,931,804	9,903,096	0	0	0	0	0	0	0	0	0	0	20,834,900	
REINSURANCE - LTC	4,967,043	5,508,763	0	0	0	0	0	0	0	0	0	0	10,475,806	
SMIB - ACUTE	13,288,395	13,803,812	0	0	0	0	0	0	0	0	0	0	27,092,207	
HIB - ACUTE	361,563	411,610	0	0	0	0	0	0	0	0	0	0	773,173	
Q1	2,222,029	2,257,441	0	0	0	0	0	0	0	0	0	0	4,479,469	
SMIB - LTC	3,328,913	3,313,965	0	0	0	0	0	0	0	0	0	0	6,642,878	
HIB - LTC	283,717	285,570	0	0	0	0	0	0	0	0	0	0	569,287	
	627,714,053	656,148,867	0	0	0	0	0	0	0	0	0	0	1,283,862,920	

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 August 31, 2016

CAPITATION - ACUTE	212,953,625	204,441,592	0	0	0	0	0	0	0	0	0	0	417,395,217	
MENTAL HEALTH - CHILD	9,369	8,680	0	0	0	0	0	0	0	0	0	0	18,049	
MENTAL HEALTH - ADULT	1,251,199	1,266,938	0	0	0	0	0	0	0	0	0	0	2,518,137	
MENTAL HEALTH - GENERAL	22,620,819	22,905,356	0	0	0	0	0	0	0	0	0	0	45,526,175	
MENTAL HEALTH - CMDP	938	2,814	0	0	0	0	0	0	0	0	0	0	3,752	
CHILDREN'S REHAB SERVICES	24,810	23,856	0	0	0	0	0	0	0	0	0	0	48,666	
FEE FOR SERVICE - ACUTE	30,892,242	33,585,002	0	0	0	0	0	0	0	0	0	0	64,477,244	
FFS - PRIOR QUARTER COVERAGE	626,645	888,463	0	0	0	0	0	0	0	0	0	0	1,515,108	
FFS - PRESUMPTIVE ELIGIBILITY	0	576	0	0	0	0	0	0	0	0	0	0	576	
EMERGENCY SERVICES - FEDERAL	2,005,165	2,692,463	0	0	0	0	0	0	0	0	0	0	4,697,628	
FFS MEDICAID IN PUBLIC SCHOOLS	935	797	0	0	0	0	0	0	0	0	0	0	1,732	
INPATIENT INMATES FFS	802,511	1,152,396	0	0	0	0	0	0	0	0	0	0	1,954,907	
FFS TRBHA FEE FOR SERVICE	668,712	3,783,524	0	0	0	0	0	0	0	0	0	0	4,452,236	
STATE ONLY TRBHA FFS	11,429	35,462	0	0	0	0	0	0	0	0	0	0	46,892	
GRAHAM COUNTY INMATES FFS	5,378	0	0	0	0	0	0	0	0	0	0	0	5,378	
PINAL COUNTY INMATES FFS	12,241	42,848	0	0	0	0	0	0	0	0	0	0	55,089	
PIMA COUNTY INMATES FFS	17,640	22,452	0	0	0	0	0	0	0	0	0	0	40,092	
MARICOPA CTY INMATES FFS	136,056	149,042	0	0	0	0	0	0	0	0	0	0	285,097	
COCONINO COUNTY INMATES FFS	3,420	-3,257	0	0	0	0	0	0	0	0	0	0	163	
COCHISE COUNTY INMATES FFS	0	57	0	0	0	0	0	0	0	0	0	0	57	
MOHAVE COUNTY INMATES FFS	962	0	0	0	0	0	0	0	0	0	0	0	962	
REINSURANCE - ACUTE	3,834,787	4,856,893	0	0	0	0	0	0	0	0	0	0	8,691,679	
SMIB - ACUTE	5,139,071	5,095,292	0	0	0	0	0	0	0	0	0	0	10,234,362	
HIB - ACUTE	5,630	6,904	0	0	0	0	0	0	0	0	0	0	12,535	
	281,023,583	280,958,151	0	0	0	0	0	0	0	0	0	0	561,981,734	

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 August 31, 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	32,527,702	31,697,577	0	0	0	0	0	0	0	0	0	0	64,225,279	
MENTAL HEALTH - CHILD	115	38	0	0	0	0	0	0	0	0	0	0	153	
MENTAL HEALTH - ADULT	229,129	228,372	0	0	0	0	0	0	0	0	0	0	457,501	
MENTAL HEALTH - GENERAL	4,142,494	4,128,810	0	0	0	0	0	0	0	0	0	0	8,271,304	
CHILDREN'S REHAB SERVICES	1,431	1,431	0	0	0	0	0	0	0	0	0	0	2,863	
FEE FOR SERVICE - ACUTE	2,287,256	2,691,862	0	0	0	0	0	0	0	0	0	0	4,979,118	
FFS - PRIOR QUARTER COVERAGE	202,656	242,552	0	0	0	0	0	0	0	0	0	0	445,207	
EMERGENCY SERVICES - FEDERAL	3,157,734	4,543,147	0	0	0	0	0	0	0	0	0	0	7,700,881	
FFS MEDICAID IN PUBLIC SCHOOLS	0	143	0	0	0	0	0	0	0	0	0	0	143	
INPATIENT INMATES FFS	47,079	7,086	0	0	0	0	0	0	0	0	0	0	54,165	
FFS TRBHA FEE FOR SERVICE	21,432	99,702	0	0	0	0	0	0	0	0	0	0	121,133	
MARICOPA CTY INMATES FFS	0	8,584	0	0	0	0	0	0	0	0	0	0	8,584	
REINSURANCE - ACUTE	394,053	1,131,954	0	0	0	0	0	0	0	0	0	0	1,526,008	
SMIB - ACUTE	487	365	0	0	0	0	0	0	0	0	0	0	853	
	43,011,568	44,781,624	0	0	0	0	0	0	0	0	0	0	87,793,192	
	951,749,204	981,888,641	0	0	0	0	0	0	0	0	0	0	1,933,637,845	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	105,825	60,026	0	0	0	0	0	0	0	0	0	0	165,851	
KidsCare - FEE FOR SERVICE	0	230	0	0	0	0	0	0	0	0	0	0	230	
KidsCare - MENTAL HEALTH	20,728	19,967	0	0	0	0	0	0	0	0	0	0	40,695	
KidsCare - REINSURANCE	82,674	199	0	0	0	0	0	0	0	0	0	0	82,873	

209,226	80,423	0	0	0	0	0	0	0	0	0	0	289,649	

TOTAL TITLE XXI

951,958,430	981,969,064	0	0	0	0	0	0	0	0	0	0	1,933,927,494	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016

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

1003	TANF 06-13 M & F WIT	0.00	-2.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-2.43

1004	TANF 14-20 MALE WITH	330.49	330.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	660.98

1005	TANF 14-20 FEMALE WI	4,171.93	2,017.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,189.41

1006	TANF 21-44 MALE WITH	46,322.50	44,791.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91,114.35

1007	TANF 21-44 FEMALE WI	95,394.39	105,867.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	201,262.01

1008	TANF 45-64 M & F WIT	142,836.05	148,048.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	290,884.81

1009	TANF 65+ M & F WITH	49,195.35	58,493.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,689.05

100F	TANF 21-44 MALE WITH	2,174.21	932.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,106.47

100G	TANF 21-44 FEMALE WI	979.52	875.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,855.40

100H	TANF 44-64 M & F WIT	2,819.97	2,677.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,497.14

100J	TANF 65+ M & F WITH	1,265.56	285.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,551.00

1011	TANF <1 M & F NON-ME	5,979,797.90	5,818,316.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,798,114.32

1012	TANF 01-05 M & F NON	1,982,751.29	2,047,597.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,030,348.77

1013	TANF 06-13 M & F NON	3,400,616.72	3,421,770.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,822,387.59

1014	TANF 14-20 MALE NON-	1,438,649.82	1,450,579.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,889,229.23

1015	TANF 14-20 FEMALE N O

2,947,635.53	2,963,712.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,911,348.00

1016	TANF 21-44 MALE NON-	4,500,694.58	4,626,964.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,127,658.63

1017	TANF 21-44 FEMALE N O

21,599,593.38    22,024,671.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,624,264.44

1018	TANF 45-64 M & F NON	9,002,157.42	9,224,599.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,226,757.34

1019	TANF 65+ M & F NON-M	34,981.92	37,207.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,189.78

101A	TANF < 1 M & F NON-M	1,374,906.97	824,333.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,199,240.78

101B	TANF 01-05 M & F NON	37,377.77	34,988.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,365.86

101C	TANF 06-13 M & F NON	31,887.35	38,379.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70,266.35

101D	TANF 14-20 MALE NON-	40,214.75	26,404.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,619.46

101E	TANF 14-20 FEMALE N O

75,894.61	51,114.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127,009.47

101F	TANF 21-44 MALE NON-	332,694.14	181,172.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	513,866.74

101G	TANF 21-44 FEMALE N O

1,014,213.65	519,454.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,533,668.13

101H	TANF 44-64 M & F NON	352,715.91	224,440.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	577,156.55

101J	TANF 65+ N & F NON-M	2,006.75	449.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,456.44

1026	TANF 21-44 MALE WITH	9,851.45	9,746.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,597.50

1027	TANF 21-44 FEMALE WI	37,746.13	34,109.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71,855.63

1028	TANF 45-64 M & F WIT	39,714.64	36,360.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,074.86

1029	TANF 65+ M & F WITH	11,125.03	11,154.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,279.47

102F	TANF 21-44 MALE WITH	586.66	47.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	633.74

102G	TANF 21-44 FEMALE WI	0.00	420.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	420.35

102H	TANF 44-64 M & F WIT	0.00	1,084.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,084.40

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016

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

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

842,955.42	868,175.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,711,130.97

28,411.56	21,306.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,718.44

4,812,760.61	4,806,493.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,619,254.55

127,183.08	147,235.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	274,418.17

2120	SSI AGED WITH QMB	5,230,861.87	5,318,628.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,549,490.66

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

4,349.89	5,632.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,982.19

2,492,441.51	2,520,758.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,013,200.19

17,675.35	12,942.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,618.08

58,494,437.05    58,018,801.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116,513,238.16

433,439.79	419,148.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	852,588.69

15,152,983.36    15,434,374.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,587,357.70

3,347.64	4,509.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,856.79

2300	SSI BLIND WITH MEDIC	6,019.11	6,344.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,363.55

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

416,766.24	425,608.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	842,374.76

8,216.96	9,934.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,151.39

2320	SSI BLIND WITH QMB	48,973.62	48,961.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,935.29

4302	SOBRA CHILD 01-05 M	335.78	335.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	671.56

4303	SOBRA CHILD 06-13 M	1,544.93	1,519.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,064.79

4304	SOBRA CHILD 14-20 MA	453.68	315.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	769.13

4305	SOBRA CHILD 14-20 FE	2,687.14	3,209.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,896.77

430C	SOBRA CHILD 06-13 M	19.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.65

4311	SOBRA CHILD <1 M & F     19,199,383.74    19,304,900.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,504,284.43

4312	SOBRA CHILD 01-05 M	23,848,737.73    23,824,566.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,673,304.35

4313	SOBRA CHILD 06-13 M	29,886,460.52    30,038,640.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,925,101.29

4314	SOBRA CHILD 14-20 MA	9,328,457.36	9,454,281.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,782,739.10

4315	SOBRA CHILD 14-20 FE     14,077,063.28    14,260,086.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,337,150.08

431A	SOBRA CHILD < 1 M &	1,177,252.46	693,970.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,871,223.09

431B	SOBRA CHILD 01-05 M	566,517.45	313,543.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	880,061.44

431C	SOBRA CHILD 6-13 M& F

721,463.46	331,359.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,052,822.90

431D	SOBRA CHILD 14-20 MA	521,496.21	233,778.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	755,275.11

431E	SOBRA CHILD 14-20 FE	561,544.85	276,156.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	837,701.33

4321	SOBRA CHILD <1 M & F	0.00	507.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	507.63

4322	SOBRA CHILD 01-05 M	230.53	225.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	456.47

4323	SOBRA CHILD 06-13 M	0.00	-110.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-110.88

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M

29,492.39	23,326.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,818.62

4,151.82	3,635.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,787.20

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016

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

500G	SOBRA PREG 21-44 FE M
500H	SOBRA PREG 45-64 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

9910	TANF & SOBRA CHILDR	1,823,715.69	2,120,615.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	37,798.01	36,893.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	190,093.86	236,566.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	13,033,453.67	14,801,044.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	15,085,061.23	17,195,121.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

621.37	527.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,148.59

242.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	242.26

1,407.36	911.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,319.14

1,116,187.80	1,054,868.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,171,056.49

5,647,435.21	5,224,978.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,872,414.20

29,549.66	22,736.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,286.60

33.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.46

137,111.91	56,188.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	193,299.91

501,169.31	249,043.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	750,212.93

2,476.09	1,453.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,929.64

13,528.33	12,323.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,851.53

2,212.75	2,212.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,425.50

163.64	246.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	410.36

250,093,559.53  247,431,996.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	497,525,556.27

3,944,331.56	
74,691.86	
426,660.76	
27,834,498.11	
32,280,182.29	

E

SUBTOTAL:

1
SUBTOTAL:

99.00

99.00

3100	TRANSPLANT OPTION	49.50	49.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	49.50	49.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

576,451.77	
1,725,613.05	
3,251,515.35	
963,378.82	
10,373.81	
18,134.72	
56,659.69	
23,038.79	
1,022.53	
5,783.91	
28,947.93	
190,277.80	
1,067,695.50	
10,161,586.64	

1106	TANF EXPANDED 21-44	282,644.01	293,807.76	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	858,361.36	867,251.69	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	1,613,497.29	1,638,018.06	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&

484,476.89	478,901.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110F	TANF EXPANDED 21-44	8,177.12	2,196.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110G	TANF EXPANDED 21-44	9,142.58	8,992.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110H	TANF EXPANDED 45-64	33,794.96	22,864.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

9,199.74	13,839.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

557.66	464.87	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	4,050.10	1,733.81	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	16,864.25	12,083.68	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	95,489.34	94,788.46	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	534,805.44	532,890.06	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	5,053,008.48	5,108,578.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016

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

1117	TANF EXPANDED 21-44     18,426,686.32    18,570,201.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,996,887.82

1118	TANF EXPANDED 45-64     11,268,281.74    11,270,199.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,538,481.07

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

36,120.95	39,232.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,353.90

1,927.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,927.54

111B	TANF EXPANDED 01-05	8.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.90

111C	TANF EXPANDED 06-13	281.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	281.75

111D	TANF EXPANDED 14-20	10,758.18	4,036.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,794.48

111E	TANF EXPANDED 14-20	27,269.64	15,641.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,911.02

111F	TANF EXPANDED 21-44	307,744.28	160,720.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	468,464.86

111G	TANF EXPANDED 21-44	731,144.87	324,566.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,055,711.36

111H	TANF EXPANDED 45-64	466,357.73	201,524.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	667,882.65

111J	TANF EXPANDED 65+ M&

8,779.85	4,133.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,913.12

1125	TANF EXPANDED 14-20	0.00	2,212.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,212.75

1126	TANF EXPANDED 21-44	153,790.27	156,066.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	309,856.27

1127	TANF EXPANDED 21-44	446,215.59	474,049.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	920,265.05

1128	TANF EXPANDED 45-64	504,237.50	518,590.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,022,827.87

1129	TANF EXPANDED 65+ M&

168,961.75	179,353.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	348,315.33

112F	TANF EXPANDED 21-44	1,973.32	1,569.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,542.93

112G	TANF EXPANDED 21-44	1,409.59	2,117.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,527.52

112H	TANF EXPANDED 45-64	6,149.15	3,315.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,464.87

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
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

2,268.02	1,088.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,356.64

79,751.62	88,972.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	168,724.10

18,469.11	13,440.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,910.03

113,134.36	107,329.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220,463.86

5,881.63	3,345.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,227.03

3,821,442.08	3,751,853.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,573,295.40

8,856.22	3,806.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,662.52

140.23	140.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	280.46

270.25	113.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	383.87

254,582.86	222,372.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	476,955.51

10,892.09	7,541.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,433.55

1,833,932.47	1,565,603.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,399,536.24

33,726.08	25,186.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,912.75

8,960,995.29	8,821,264.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,782,259.37

3,880.96	3,944.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,825.88

SUBTOTAL:

F E
SUBTOTAL:

2,598,442.20

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	56,720,391.41	55,619,947.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,340,338.58		

25,165.43

2,623,607.63

9911	SB PAYMENT FOR TAN	1,240,641.58	1,357,800.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI	18,874.52	6,290.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,259,516.10	1,364,091.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-18.46	
-43.38	
-24.92	
-2,158.27	
-3,005.17	
-4,860.31	
-5,400.74	
-16,486.80	
-42.89	
-24.43	
-32,065.37	

3306	AHC CARE MALE 21-44	0.00	-18.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3308	AHC CARE M&F 45-64
W

0.00	-43.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3309	AHC CARE M&F 65+ W/	0.00	-24.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3314	AHC CARE MALE 14-20	0.00	-2,158.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3315	AHC CARE FEMALE 14-
2

0.00	-3,005.17	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	-4,860.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3317	AHC CARE FEMALE 21-
4

0.00	-5,400.74	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	-16,486.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3326	AHC CARE MALE 21-44	0.00	-42.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3328	AHC CARE M&F 45-64
W

0.00	-24.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

-32,065.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

-16.83	
-9.23	
-24.92	
-14,265.28	
-13,424.11	
-18,172.03	
-14,897.12	
-36,015.33	
-7.60	
-7.60	
-96,840.05	

3606	AHC CARE/MI MALE 21-	0.00	-16.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3607	AHC CARE/MI FEMALE
2

0.00	-9.23	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	-24.92	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	-14,265.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3615	AHC CARE/MI FEMALE
1

0.00	-13,424.11	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	-18,172.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

0.00	-14,897.12	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	-36,015.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3619	AHC CARE/MI M&F 65+	0.00	-7.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3628	AHC CARE/MI M&F 45-6	0.00	-7.60	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	-1,357.37	3,232.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL	655.96	919.44	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	26,030.20	33,829.91	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	5,034.18	4,586.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	780.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL	321.93	523.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	6,378.29	3,428.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	1,172.03	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

-96,840.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,875.16	
1,575.40	
59,860.11	
9,620.57	
780.79	
845.14	
9,806.62	
1,172.03	

E

E

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016

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

3514	ADULT 40-100% MALE 1	2,409,491.88	2,474,191.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,883,682.94

3515	ADULT 40-100% FEMAL E

2,652,207.33	2,709,011.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,361,218.55

3516	ADULT 40-100% MALE 2	9,091,685.89	9,213,419.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,305,105.62

3517	ADULT 40-100% FEMAL E

7,488,728.50	7,584,675.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,073,403.73

3518	ADULT 40-100% M&F 45    18,275,289.94    18,558,142.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,833,432.42

3519	ADULT 40-100% M&F 65	9,481.02	11,136.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,617.18

351D	ADULT 40-100% MALE 1	230,773.61	92,793.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	323,566.98

351E	ADULT 40-100% FEMAL E

202,837.35	98,746.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	301,583.99

351F	ADULT 40-100% MALE 2	854,550.14	446,008.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,300,558.53

351G	ADULT 40-100% FEMAL E

641,841.39	306,040.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	947,882.25

351H	ADULT 40-100% M&F 45	1,495,397.19	742,706.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,238,103.43

351J	ADULT 40-100% M&F 65	15,371.19	2,027.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,398.62

3526	ADULT 40-100% MALE 2	938.25	2,394.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,332.31

3527	ADULT 40-100% FEMAL E

489.55	428.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	917.82

3528	ADULT 40-100% M&F 45	6,566.58	4,703.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,270.51

3529	ADULT 40-100% M&F 65	59.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59.89

352F	ADULT 40-100% MALE 2	0.00	239.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	239.80

352H	ADULT 40-100% M&F 45	0.00	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	218.00

352J	ADULT 40-100% M&F 65	1,264.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,264.42

3704	ADULT <40% EXP MALE	0.00	524.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	524.38

3706	ADULT <40% EXP MALE	13,532.14	18,941.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,473.14

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

8,594.39	14,900.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,495.26

52,776.27	51,121.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,897.67

1,670.61	3,656.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,327.20

370F	ADULT <40% EXP MALE	23.96	2,730.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,754.35

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

5,014.07	87.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,101.27

41,292.32	3,366.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,658.52

3714	ADULT <40% EXP MALE	5,588,252.13	5,551,951.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,140,203.47

3715	ADULT <40% EXP FEM AL

4,892,572.32	4,914,224.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,806,796.79

3716	ADULT <40% EXP MALE    30,620,225.72    31,120,943.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,741,169.35

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

18,697,678.92    18,946,793.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,644,472.76

37,997,636.85    38,500,400.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,498,037.69

24,175.96	27,528.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,704.51

371D	ADULT <40% EXP MALE	527,076.34	241,808.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	768,885.15

371E	ADULT <40% EXP FEM AL

415,699.52	230,089.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	645,788.88

371F	ADULT <40% EXP MALE	4,933,492.46	1,889,607.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,823,099.50

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016

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

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

2,488,666.27	1,102,987.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,591,654.21

4,347,109.87	1,716,162.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,063,272.62

0.00	1,906.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,906.05

3726	ADULT <40% EXP MALE	3,446.36	2,080.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,526.44

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

1,623.77	1,311.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,935.28

7,151.55	6,415.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,566.88

475.74	475.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	951.48

372F	ADULT <40% EXP MALE	1,504.22	452.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,956.76

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

675.81	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	893.81

1,005.63	1,712.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,717.71

154,087,363.33  146,645,800.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	300,733,163.94

A A
SUBTOTAL:

550,171.86

1,276,840.26

1,827,012.12

9935	BIRTH SUPP PAYMENT	287,840.28	262,331.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	598,513.41	678,326.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	886,353.69	940,658.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,529.70	
6,163.80	
71,454.33	
4,554.34	
-236.15	
2,174.49	
4,547.93	
1,321.06	
2,004,135.12	
2,380,772.34	
14,270,620.13	
20,444,811.09	
21,131,445.94	
11,951.12	
84,562.68	
111,060.42	
808,849.12	
964,907.09	
798,520.19	
3,073.64	
717.46	

3906	NEWLY ELIGIBLE MALE	4,896.46	3,633.24	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

2,726.25	3,437.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

37,160.26	34,294.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,216.27	2,338.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390F	NEWLY ELIGIBLE MALE	0.00	-236.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1,662.50	511.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4,162.37	385.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

11.02	1,310.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	993,353.20	1,010,781.92	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

1,183,692.34	1,197,080.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	7,130,854.84	7,139,765.29	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

10,276,450.45    10,168,360.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

10,565,542.96    10,565,902.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5,613.74	6,337.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391D	NEWLY ELIGIBLE MALE	53,561.17	31,001.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391E	NEWLY ELIGIBLE FEMA L

73,185.98	37,874.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391F	NEWLY ELIGIBLE MALE	544,427.88	264,421.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

645,279.14	319,627.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

535,632.09	262,888.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	3,073.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3926	NEWLY ELIGIBLE MALE	384.04	333.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4

4
SUBTOTAL:

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3928	NEWLY ELIGIBLE M&F	1,094.45	1,114.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,208.55		
392F	NEWLY ELIGIBLE MALE	0.00	52.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.48		
392H	NEWLY ELIGIBLE M&F	0.00	384.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.57		
	32,061,907.41	31,054,674.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,116,581.44		

465,794.15	642,903.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
465,794.15	642,903.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9939	BIRTH SUPP PAYMENT N
SUBTOTAL:

1,108,697.52

1,108,697.52

146.73	
3,377.42	
11,689,676.70	
3,992,086.29	
6,003,606.60	
445.44	
239,340.58	
136,914.09	
204,431.97	
22,270,025.82	

4404	SOBRA 100-133% MALE	0.00	146.73	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

1,928.16	1,449.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5,874,723.53	5,814,953.17	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	1,999,246.85	1,992,839.44	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
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

3,005,921.37	2,997,685.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

445.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

164,704.59	74,635.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

441D	SOBRA 100-133% MALE	86,665.55	50,248.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

441E	SOBRA 100-133% FEMA L

139,238.73	65,193.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

11,272,874.22

10,997,151.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

S
SUBTOTAL:

91,844.06

91,844.06

9944	BIRTH SUPP PAYMENT	35,856.55	55,987.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	35,856.55	55,987.51	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
451G	BC PATIENT FEMALE 2
1
451H	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

5,396.74	5,104.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

10,501.43	
143,024.40	
163.19	
1,731.41	
10,812.22	
7,257.42	
173,490.07	

75,925.22	67,099.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

163.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

851.62	879.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5,421.52	5,390.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,628.71	3,628.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

91,387.00

82,103.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1,497.85	1,497.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,995.70	
3,193,767.39	
6,505.07	
569,980.20	
26,163.50	
326,738.59	
329.78	
4,126,480.23	

1,599,503.27	1,594,264.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5,284.74	1,220.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

290,544.03	279,436.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

20,843.53	5,319.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

159,107.87	167,630.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

208.68	121.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

2,076,989.97

2,049,490.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	524,137,104.09	513,951,069.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,038,088,173.55		

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016

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

1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1004	TANF 14-20 MALE WITH	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

1005	TANF 14-20 FEMALE WI	4.99	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.99

1006	TANF 21-44 MALE WITH	105.64	116.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	222.14

1007	TANF 21-44 FEMALE WI	181.79	195.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	377.69

1008	TANF 45-64 M & F WIT	268.21	287.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	556.00

1009	TANF 65+ M & F WITH	116.75	130.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	247.39

100F	TANF 21-44 MALE WITH	12.95	6.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.33

100G	TANF 21-44 FEMALE WI	5.05	4.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.37

100H	TANF 44-64 M & F WIT	9.51	7.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.86

100J	TANF 65+ M & F WITH	4.22	1.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.34

1011	TANF <1 M & F NON-ME	12,190.91	11,954.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,145.49

1012	TANF 01-05 M & F NON	15,922.62	16,925.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,847.69

1013	TANF 06-13 M & F NON	26,685.75	27,709.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,395.40

1014	TANF 14-20 MALE NON-	7,849.50	8,080.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,930.41

1015	TANF 14-20 FEMALE N O

10,947.41	11,170.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,118.30

1016	TANF 21-44 MALE NON-	25,794.90	26,636.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,431.13

1017	TANF 21-44 FEMALE N O

78,741.67	80,653.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	159,394.94

1018	TANF 45-64 M & F NON	20,054.80	20,572.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,626.91

1019	TANF 65+ M & F NON-M	82.44	87.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	170.39

101A	TANF < 1 M & F NON-M	1,368.89	819.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,188.29

101B	TANF 01-05 M & F NON	682.65	652.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,334.98

101C	TANF 06-13 M & F NON	588.07	716.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,304.97

101D	TANF 14-20 MALE NON-	275.74	179.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	455.28

101E	TANF 14-20 FEMALE N O

392.46	264.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	656.49

101F	TANF 21-44 MALE NON-	2,233.16	1,246.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,479.71

101G	TANF 21-44 FEMALE N O

5,212.42	2,680.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,892.55

101H	TANF 44-64 M & F NON	1,044.93	668.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,713.49

101J	TANF 65+ N & F NON-M	7.16	1.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.63

1026	TANF 21-44 MALE WITH	40.21	39.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79.56

1027	TANF 21-44 FEMALE WI	55.59	51.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	106.71

1028	TANF 45-64 M & F WIT	75.00	69.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144.96

1029	TANF 65+ M & F WITH	27.20	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.20

102F	TANF 21-44 MALE WITH	3.38	0.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.70

102G	TANF 21-44 FEMALE WI	0.00	2.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.15

102H	TANF 44-64 M & F WIT	0.00	3.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.03

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016

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

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

4,687.07	4,820.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,507.35

401.49	304.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	706.10

5,548.22	5,555.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,103.72

216.60	250.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	466.69

2120	SSI AGED WITH QMB	27,168.47	27,829.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,998.23

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

67.03	76.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143.45

5,051.73	5,011.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,063.10

259.75	180.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	440.70

56,419.86	56,072.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	112,492.82

759.89	735.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,495.19

27,588.74	27,999.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,588.59

50.54	64.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	114.78

2300	SSI BLIND WITH MEDIC	27.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.00

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

461.02	472.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	933.96

14.08	16.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30.10

2320	SSI BLIND WITH QMB	208.99	210.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419.03

4302	SOBRA CHILD 01-05 M	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

4303	SOBRA CHILD 06-13 M	6.70	6.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.82

4304	SOBRA CHILD 14-20 MA	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

4305	SOBRA CHILD 14-20 FE	6.38	8.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.87

430C	SOBRA CHILD 06-13 M	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.06

4311	SOBRA CHILD <1 M & F	39,790.63	40,146.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,937.39

4312	SOBRA CHILD 01-05 M	188,466.60	189,087.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	377,553.75

4313	SOBRA CHILD 06-13 M	233,049.16	235,593.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	468,642.82

4314	SOBRA CHILD 14-20 MA	54,382.11	55,359.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,741.12

4315	SOBRA CHILD 14-20 FE	54,106.61	55,018.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109,124.79

431A	SOBRA CHILD < 1 M &	1,208.09	704.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,912.80

431B	SOBRA CHILD 01-05 M	9,938.87	5,510.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,449.36

431C	SOBRA CHILD 6-13 M& F

12,342.03	5,854.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,196.61

431D	SOBRA CHILD 14-20 MA	3,383.27	1,549.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,933.10

431E	SOBRA CHILD 14-20 FE	2,833.78	1,413.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,247.58

4321	SOBRA CHILD <1 M & F	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

4322	SOBRA CHILD 01-05 M	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

4323	SOBRA CHILD 06-13 M	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

5007	SOBRA PREG 21-44 FE M
5008	SOBRA PREG 45-64 FE
M

54.43	49.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103.77

5.32	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.32

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016

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

500G	SOBRA PREG 21-44 FE M
500H	SOBRA PREG 45-64 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

3.19	2.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.89

0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.67

6.16	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.16

4,337.46	4,046.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,383.92

21,665.43	19,993.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,659.41

69.37	50.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119.84

0.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.61

704.07	289.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	993.32

2,575.10	1,286.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,861.86

6.61	4.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.66

22.12	25.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47.47

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

0.87	1.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.96

9910	TANF & SOBRA CHILDR	296.00	348.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	31.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,139.00	2,428.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,472.00	2,821.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

968,893.15

957,619.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,926,512.21

644.00	
12.00	
70.00	
4,567.00	
5,293.00	

E

SUBTOTAL:

1
SUBTOTAL:

6.00

6.00

3100	TRANSPLANT OPTION	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,604.82	
3,118.12	
5,646.24	
2,180.22	
69.85	
91.35	
169.88	
65.39	
2.22	
51.83	
251.04	
1,149.48	
4,162.54	
61,502.02	

1106	TANF EXPANDED 21-44	788.67	816.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	1,546.66	1,571.46	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	2,802.54	2,843.70	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&

1,093.73	1,086.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110F	TANF EXPANDED 21-44	55.35	14.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110G	TANF EXPANDED 21-44	45.79	45.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

110H	TANF EXPANDED 45-64	104.82	65.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

27.91	37.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1.22	1.00	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	29.83	22.00	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	131.04	120.00	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	576.14	573.34	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	2,070.37	2,092.17	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	30,546.64	30,955.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016

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

1117	TANF EXPANDED 21-44	70,413.69	71,216.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	141,629.99

1118	TANF EXPANDED 45-64	26,030.37	26,097.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,128.04

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

83.66	90.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	174.39

1.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.77

111B	TANF EXPANDED 01-05	0.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.16

111C	TANF EXPANDED 06-13	5.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.16

111D	TANF EXPANDED 14-20	70.26	26.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96.96

111E	TANF EXPANDED 14-20	140.45	79.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	219.75

111F	TANF EXPANDED 21-44	2,076.01	1,098.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,174.81

111G	TANF EXPANDED 21-44	3,752.64	1,672.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,424.97

111H	TANF EXPANDED 45-64	1,397.05	614.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,011.41

111J	TANF EXPANDED 65+ M&

27.62	12.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39.89

1125	TANF EXPANDED 14-20	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

1126	TANF EXPANDED 21-44	306.62	308.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	615.18

1127	TANF EXPANDED 21-44	702.41	738.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,440.57

1128	TANF EXPANDED 45-64	861.34	884.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,745.74

1129	TANF EXPANDED 65+ M&

379.94	403.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	783.79

112F	TANF EXPANDED 21-44	13.19	10.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.95

112G	TANF EXPANDED 21-44	7.14	11.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.35

112H	TANF EXPANDED 45-64	18.32	9.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.16

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
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

7.02	3.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.06

426.73	443.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	870.17

259.45	185.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	444.69

126.95	125.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	252.64

10.56	5.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.08

17,593.09	17,259.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,852.91

124.19	55.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	179.63

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

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

492.88	464.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	957.22

161.06	113.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	275.00

1,749.60	1,549.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,299.05

60.98	43.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104.90

14,973.36	14,550.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,523.87

57.37	57.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115.08

SUBTOTAL:

F E
SUBTOTAL:

425.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	182,154.75	178,380.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		360,535.34		

4.00

429.00

9911	SB PAYMENT FOR TAN	203.00	222.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	206.00	223.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3306	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

3308	AHC CARE M&F 45-64
W

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

3309	AHC CARE M&F 65+ 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

3314	AHC CARE MALE 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

3315	AHC CARE FEMALE 14-
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

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

3317	AHC CARE FEMALE 21-
4

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

3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3326	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

3328	AHC CARE M&F 45-64
W

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

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	

3606	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

3607	AHC CARE/MI FEMALE
2

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

3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3615	AHC CARE/MI FEMALE
1

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

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3617	AHC CARE/MI FEMALE
2

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

3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3619	AHC CARE/MI 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

3628	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

3506	ADULT 40-100% MALE 2	1.05	3.93	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	1.41	1.51	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	48.19	59.75	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	11.70	10.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	1.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL	0.58	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	10.10	5.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	1.64	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

4.98	
2.92	
107.94	
22.63	
1.38	
1.35	
15.31	
1.64	

E

E

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016

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

3514	ADULT 40-100% MALE 1	5,324.62	5,467.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,792.34

3515	ADULT 40-100% FEMAL E

5,844.28	5,979.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,823.29

3516	ADULT 40-100% MALE 2	19,365.79	19,627.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,993.73

3517	ADULT 40-100% FEMAL E

15,852.90	16,050.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,902.98

3518	ADULT 40-100% M&F 45	39,856.53	40,435.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,292.45

3519	ADULT 40-100% M&F 65	21.41	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.41

351D	ADULT 40-100% MALE 1	347.75	138.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	486.11

351E	ADULT 40-100% FEMAL E

318.47	148.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	466.81

351F	ADULT 40-100% MALE 2	1,280.29	671.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,951.59

351G	ADULT 40-100% FEMAL E

965.22	464.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,430.04

351H	ADULT 40-100% M&F 45	2,235.88	1,124.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,360.57

351J	ADULT 40-100% M&F 65	22.58	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.58

3526	ADULT 40-100% MALE 2	2.00	3.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.15

3527	ADULT 40-100% FEMAL E

1.00	0.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.19

3528	ADULT 40-100% M&F 45	7.00	6.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.67

3529	ADULT 40-100% M&F 65	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.12

352F	ADULT 40-100% MALE 2	0.00	0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.35

352H	ADULT 40-100% M&F 45	0.00	0.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.32

352J	ADULT 40-100% M&F 65	1.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.87

3704	ADULT <40% EXP MALE	0.00	1.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.22

3706	ADULT <40% EXP MALE	15.41	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32.41

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

9.61	12.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.24

79.34	86.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165.91

3.99	8.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.23

370F	ADULT <40% EXP MALE	0.03	3.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.90

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

7.40	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.52

62.90	4.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67.72

3714	ADULT <40% EXP MALE	12,053.30	11,993.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,046.89

3715	ADULT <40% EXP FEM AL

10,566.05	10,578.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,144.59

3716	ADULT <40% EXP MALE	60,788.30	61,489.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,277.78

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

36,217.95	36,585.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,803.34

76,027.85	76,776.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	152,804.76

46.67	55.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101.67

371D	ADULT <40% EXP MALE	785.47	365.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,150.80

371E	ADULT <40% EXP FEM AL

622.58	343.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	965.60

371F	ADULT <40% EXP MALE	7,431.73	2,823.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,255.25

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016

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

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

3,715.62	1,653.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,369.27

6,450.75	2,546.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,997.18

0.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00

3726	ADULT <40% EXP MALE	3.77	2.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.79

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

1.77	1.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.11

10.87	10.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.36

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

372F	ADULT <40% EXP MALE	2.22	0.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.85

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

1.00	0.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.32

1.64	2.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.39

SUBTOTAL:

306,430.98

295,595.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	602,026.82

A A
SUBTOTAL:

90.00

207.00

297.00

9935	BIRTH SUPP PAYMENT	47.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT	97.00	110.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	144.00	153.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.58	
16.52	
147.39	
12.60	
-0.58	
6.34	
14.03	
4.73	
5,218.02	
6,252.04	
36,867.54	
52,867.08	
54,227.02	
32.00	
250.07	
338.46	
2,425.49	
2,922.43	
2,419.14	
9.00	
1.87	

3906	NEWLY ELIGIBLE MALE	9.99	6.59	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

7.24	9.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

76.38	71.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

6.16	6.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

390F	NEWLY ELIGIBLE MALE	0.00	-0.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

4.73	1.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

12.91	1.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.03	4.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	2,581.12	2,636.90	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

3,107.33	3,144.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	18,434.91	18,432.63	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

26,612.98	26,254.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

27,106.66	27,120.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

15.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391D	NEWLY ELIGIBLE MALE	158.25	91.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391E	NEWLY ELIGIBLE FEMA L

222.94	115.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

391F	NEWLY ELIGIBLE MALE	1,637.68	787.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1,958.63	963.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,626.88	792.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3926	NEWLY ELIGIBLE MALE	1.00	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4

4
SUBTOTAL:

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3928	NEWLY ELIGIBLE M&F	3.00	2.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.92		
392F	NEWLY ELIGIBLE MALE	0.00	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.12		
392H	NEWLY ELIGIBLE M&F	0.00	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.06		
	83,583.82	80,471.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164,054.87		

76.00	105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
76.00	105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9939	BIRTH SUPP PAYMENT N
SUBTOTAL:

181.00

181.00

1.00	
30.33	
93,736.35	
23,672.27	
23,125.04	
7.64	
4,444.54	
929.36	
1,050.63	
146,997.16	

4404	SOBRA 100-133% MALE	0.00	1.00	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

17.33	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

47,099.00	46,637.35	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	11,874.13	11,798.14	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
441B	SOBRA 100-133% M&F
1
441C	SOBRA 100-133% M&F
6

11,579.89	11,545.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

7.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,053.61	1,390.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

441D	SOBRA 100-133% MALE	587.39	341.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

441E	SOBRA 100-133% FEMA L

714.29	336.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

74,933.28

72,063.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

S
SUBTOTAL:

15.00

15.00

9944	BIRTH SUPP PAYMENT	6.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	6.00	9.00	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
451G	BC PATIENT FEMALE 2
1
451H	BC PATIENT FEMALE 4
5
4617	CC PATIENT FEMALE 2
1
4618	CC PATIENT FEMALE 4
5

21.16	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

41.16	
325.83	
0.83	
4.44	
28.00	
16.00	
416.26	

172.08	153.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2.08	2.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

14.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

218.15

198.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

2.00	
3,516.91	
95.30	
544.72	
44.76	
437.04	
5.65	
4,646.38	

1,752.66	1,764.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

76.88	18.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

276.22	268.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

35.37	9.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

214.51	222.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3.47	2.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

2,360.11

2,286.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE CAPITATION - MEMBER MONTHS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	1,621,481.24	1,589,928.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,211,410.04		

LONG TERM CARE CAPITATION - AMOUNTS

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	38,448.73	39,003.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77,452.66

1010	TANF NON-MEDICARE	2,400,462.36	2,421,330.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,821,792.69

1020	TANF WITH QMB	7,060.26	7,046.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,106.99

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

30,800,680.32    35,822,926.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,623,607.23

542,994.93	656,811.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,199,806.74

2,859,005.72	3,112,715.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,971,721.60

4,608.65	22,415.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,024.60

2120	SSI AGED WITH QMB	19,171,298.49    22,384,501.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,555,799.71

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

8,706.14	10,824.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,530.54

14,979,902.29    16,537,185.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,517,088.17

45,197.99	72,772.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	117,970.51

96,668,522.76    98,773,047.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	195,441,569.76

23,471.98	37,264.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,736.04

21,848,759.06    23,184,351.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,033,110.62

717.28	5,025.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,742.66

2300	SSI BLIND WITH MEDIC	66,335.96	72,964.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139,300.61

2310	SSI BLIND NON-MEDIC A

486,146.90	487,621.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	973,768.18

2320	SSI BLIND WITH QMB	137,707.06	142,358.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	280,065.35

232Z	SSI BLIND WITH QMB P	2,187.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,187.82

SUBTOTAL:

190,092,214.70  203,790,167.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	393,882,382.48

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

83,704.76	94,859.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

178,564.61	
245,121.50	
35,587.11	
459,273.22	

118,450.47	126,671.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

17,165.70	18,421.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

190,311,535.63	204,030,120.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

219,320.93

239,952.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

394,341,655.70

LONG TERM CARE MEMBER MONTHS

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.00

1010	TANF NON-MEDICARE	675.51	680.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,356.28

1020	TANF WITH QMB	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00

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

11,265.25	11,234.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,499.33

564.29	677.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,241.65

596.81	592.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,189.19

5.47	24.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.58

2120	SSI AGED WITH QMB	7,455.45	7,481.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,937.08

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

8.97	11.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20.50

4,856.19	4,930.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,786.84

48.42	76.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125.35

26,357.77	26,471.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,828.81

24.77	37.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	62.19

6,861.39	6,872.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,733.96

0.77	4.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.66

2300	SSI BLIND WITH MEDIC	20.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41.00

2310	SSI BLIND NON-MEDIC A

136.44	136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	272.44

2320	SSI BLIND WITH QMB	43.31	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	86.31

232Z	SSI BLIND WITH QMB P	2.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.87

SUBTOTAL:

58,936.68

59,308.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	118,245.04

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

26.00	26.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

52.67	
47.32	
12.00	
111.99	

24.00	23.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

56.00

55.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	58,992.68	59,364.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,357.03		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	2,521,354.40	2,602,767.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,124,121.76

2120	SSI AGED WITH QMB	38.24	38.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.48

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

392,648.32	391,768.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	784,417.12

382.40	344.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	726.56

1,950.24	1,988.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,938.72

497.12	535.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,032.48

21,318,149.92    21,496,616.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,814,765.92

76.48	152.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	229.44

21,988.00	20,879.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,867.04

SUBTOTAL:

24,257,085.12

24,515,090.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,772,175.52

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

9,215.84	8,451.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

17,666.88	
114.72	
38.24	
17,819.84	

76.48	38.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	38.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

9,292.32

8,527.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3710	AHC CARE EXPANDED	76.48	152.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	76.48	152.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

229.44
FO
229.44

F
SUBTOTAL:

152.96

152.96

3910	NEWLY ELIGIBLE FOR	114.72	38.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	114.72	38.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

F F

26,822,721.44	27,053,270.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

38.24

5,085,575.84

5,085,614.08

4400	SOBRA 100-133% FOR	0.00	38.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	2,556,152.80	2,529,423.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,556,152.80	2,529,461.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

53,875,991.84

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	65,935.00	68,064.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133,999.00

2120	SSI AGED WITH QMB	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

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

10,268.00	10,245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,513.00

10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.00

51.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103.00

13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.00

557,483.00	562,150.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,119,633.00

2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

575.00	546.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,121.00

SUBTOTAL:

634,338.00

641,085.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,275,423.00

1110	TANF EXPANDED FOR FI
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

241.00	221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

462.00	
3.00	
1.00	
466.00	

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

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

SUBTOTAL:

243.00

223.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3710	AHC CARE EXPANDED	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6.00
FO
6.00

F

4400	SOBRA 100-133% FOR	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR	66,845.00	66,146.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	66,845.00	66,147.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4.00

4.00

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

F F
SUBTOTAL:

1.00

132,991.00

132,992.00

TOTAL:	701,431.00	707,460.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,408,891.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	113.10	110.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.30

1010	TANF NON-MEDICARE	411,385.30	421,732.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	833,117.80

1020	TANF WITH QMB	52.20	49.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101.50

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

991.80	1,015.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,006.80

15,457.00	15,515.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,972.00

2120	SSI AGED WITH QMB	5,646.30	5,805.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,452.10

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

2,644.80	2,557.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,202.60

109,805.60	109,324.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	219,129.80

8,552.10	8,673.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,226.00

2300	SSI BLIND WITH MEDIC	14.50	17.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31.90

2310	SSI BLIND NON-MEDIC A

1,261.50	1,270.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,531.70

2320	SSI BLIND WITH QMB	110.20	110.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	220.40

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

0.00	2.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.90

53,426.70	55,184.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,610.80

8.70	8.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.40

75,663.90	69,460.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,124.70

11.60	11.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.20

SUBTOTAL:

685,145.30

690,849.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,375,994.90

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
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

1,177.40	1,162.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,340.30	
785,157.60	
910.60	
165.30	
736.60	
5,968.20	
153.70	
8,093.90	
3,633.70	
807,159.90	

390,325.50	394,832.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

437.90	472.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

78.30	87.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

371.20	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,978.30	2,989.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

84.10	69.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4,196.30	3,897.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,861.80	1,771.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

401,510.80

405,649.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

26.10	
512,627.20	
2.90	
46.40	
1,198,268.40	
5.80	
1,710,976.80	

3500	ADULT 40-100% FOR FI	8.70	17.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3510	ADULT 40-100% FOR FI	253,993.60	258,633.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3520	ADULT 40-100% FOR FI	0.00	2.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

26.10	20.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

595,660.00	602,608.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	5.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

849,688.40

861,288.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

F

F
SUBTOTAL:

MENTAL HEALTH CAPITATION AMOUNTS - ADULT

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR	11.60	14.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.10		
3910	NEWLY ELIGIBLE FOR	229,117.40	228,357.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457,475.00		
	229,129.00	228,372.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457,501.10		

4410	SOBRA 100-133% FOR	12,359.80	12,310.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,359.80	12,310.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

24,670.30
F

4510	BC PATIENT FOR FINA	559.70	495.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA	63.80	60.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	623.50	556.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

24,670.30

N N
SUBTOTAL:

1,055.60

124.70

1,180.30

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

63.80	69.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

133.40	
1,258.60	
17.40	
1,409.40	

629.30	629.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8.70	8.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,179,158.60	2,199,734.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

701.80

707.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

4,378,892.70

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	39.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77.00

1010	TANF NON-MEDICARE	141,857.00	145,425.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	287,282.00

1020	TANF WITH QMB	18.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.00

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

342.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	692.00

5,330.00	5,350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,680.00

2120	SSI AGED WITH QMB	1,947.00	2,002.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,949.00

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

912.00	882.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,794.00

37,864.00	37,698.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,562.00

2,949.00	2,991.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,940.00

2300	SSI BLIND WITH MEDIC	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00

2310	SSI BLIND NON-MEDIC A

435.00	438.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	873.00

2320	SSI BLIND WITH QMB	38.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.00

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

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

18,423.00	19,029.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,452.00

3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

26,091.00	23,952.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,043.00

4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

SUBTOTAL:

236,257.00

238,224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	474,481.00

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
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

406.00	401.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

807.00	
270,744.00	
314.00	
57.00	
254.00	
2,058.00	
53.00	
2,791.00	
1,253.00	
278,331.00	

134,595.00	136,149.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

151.00	163.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

27.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

128.00	126.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,027.00	1,031.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

29.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,447.00	1,344.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

642.00	611.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

138,452.00

139,879.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9.00	
176,768.00	
1.00	
16.00	
413,196.00	
2.00	
589,992.00	

3500	ADULT 40-100% FOR FI	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3510	ADULT 40-100% FOR FI	87,584.00	89,184.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3520	ADULT 40-100% FOR FI	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

9.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

205,400.00	207,796.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

292,996.00

296,996.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

F

F
SUBTOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
3910	NEWLY ELIGIBLE FOR	79,006.00	78,744.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,750.00		
	79,010.00	78,749.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,759.00		

4410	SOBRA 100-133% FOR	4,262.00	4,245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,262.00	4,245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,507.00
F

4510	BC PATIENT FOR FINA	193.00	171.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA	22.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	215.00	192.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,507.00

N N
SUBTOTAL:

364.00

43.00

407.00

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

22.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

46.00	
434.00	
6.00	
486.00	

217.00	217.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

242.00

244.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	751,434.00	758,529.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,509,963.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	2,044.77	1,992.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,037.11

1010	TANF NON-MEDICARE	7,437,562.51	7,624,632.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,062,195.26

1020	TANF WITH QMB	943.74	891.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,835.05

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

17,931.06	18,350.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,281.56

279,451.90	280,500.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	559,952.40

2120	SSI AGED WITH QMB	102,081.21	104,964.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	207,046.07

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

47,816.16	46,243.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94,059.42

1,985,209.52	1,976,506.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,961,715.66

154,616.07	156,818.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	311,434.20

2300	SSI BLIND WITH MEDIC	262.15	314.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	576.73

2310	SSI BLIND NON-MEDIC A

22,807.05	22,964.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,771.39

2320	SSI BLIND WITH QMB	1,992.34	1,992.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,984.68

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

0.00	52.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52.43

965,917.89	997,690.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,963,608.36

157.29	157.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314.58

1,367,951.13	1,255,803.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,623,754.49

209.72	209.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419.44

SUBTOTAL:

12,386,954.51

12,490,084.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,877,038.83

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
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

21,286.58	21,024.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

42,311.01	
14,195,107.92	
16,463.02	
2,988.51	
13,317.22	
107,900.94	
2,778.79	
146,332.13	
65,694.79	
14,592,894.33	

7,056,815.85	7,138,292.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

7,916.93	8,546.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,415.61	1,572.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

6,711.04	6,606.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

53,845.61	54,055.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,520.47	1,258.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

75,866.21	70,465.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

33,660.06	32,034.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

7,259,038.36

7,333,855.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

471.87	
9,267,946.24	
52.43	
838.88	
21,663,866.28	
104.86	
30,933,280.56	

3500	ADULT 40-100% FOR FI	157.29	314.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3510	ADULT 40-100% FOR FI	4,592,029.12	4,675,917.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3520	ADULT 40-100% FOR FI	0.00	52.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

471.87	367.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

10,769,122.00    10,894,744.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	104.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

15,361,780.28

15,571,500.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

F

F
SUBTOTAL:

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR	209.72	262.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471.87		
3910	NEWLY ELIGIBLE FOR	4,142,284.58	4,128,547.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,270,832.50		
	4,142,494.30	4,128,810.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,271,304.37		

4410	SOBRA 100-133% FOR	223,456.66	222,565.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	223,456.66	222,565.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

446,022.01
F

4510	BC PATIENT FOR FINA	10,118.99	8,965.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA	1,153.46	1,101.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	11,272.45	10,066.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

446,022.01

N N
SUBTOTAL:

19,084.52

2,254.49

21,339.01

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

1,153.46	1,258.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,411.78	
22,754.62	
314.58	
25,480.98	

11,377.31	11,377.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

157.29	157.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

39,397,684.62	39,769,675.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

12,688.06

12,792.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

79,167,360.09

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	39.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77.00

1010	TANF NON-MEDICARE	141,857.00	145,425.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	287,282.00

1020	TANF WITH QMB	18.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.00

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

342.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	692.00

5,330.00	5,350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,680.00

2120	SSI AGED WITH QMB	1,947.00	2,002.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,949.00

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

912.00	882.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,794.00

37,864.00	37,698.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,562.00

2,949.00	2,991.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,940.00

2300	SSI BLIND WITH MEDIC	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00

2310	SSI BLIND NON-MEDIC A

435.00	438.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	873.00

2320	SSI BLIND WITH QMB	38.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.00

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

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

18,423.00	19,029.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,452.00

3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

26,091.00	23,952.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,043.00

4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

SUBTOTAL:

236,257.00

238,224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	474,481.00

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
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

406.00	401.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

807.00	
270,744.00	
314.00	
57.00	
254.00	
2,058.00	
53.00	
2,791.00	
1,253.00	
278,331.00	

134,595.00	136,149.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

151.00	163.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

27.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

128.00	126.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,027.00	1,031.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

29.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,447.00	1,344.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

642.00	611.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

138,452.00

139,879.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9.00	
176,768.00	
1.00	
16.00	
413,196.00	
2.00	
589,992.00	

3500	ADULT 40-100% FOR FI	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3510	ADULT 40-100% FOR FI	87,584.00	89,184.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3520	ADULT 40-100% FOR FI	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

9.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

205,400.00	207,796.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

292,996.00

296,996.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

F

F
SUBTOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
3910	NEWLY ELIGIBLE FOR	79,006.00	78,744.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,750.00		
	79,010.00	78,749.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,759.00		

4410	SOBRA 100-133% FOR	4,262.00	4,245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,262.00	4,245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,507.00
F

4510	BC PATIENT FOR FINA	193.00	171.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA	22.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	215.00	192.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,507.00

N N
SUBTOTAL:

364.00

43.00

407.00

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

22.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

46.00	
434.00	
6.00	
486.00	

217.00	217.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

242.00

244.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	751,434.00	758,529.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,509,963.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	504,708.56	446,545.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	951,253.68

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

315,208.32	295,507.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	610,716.12

938.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	938.12

0.00	938.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	938.12

15,501,494.88    15,506,185.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,007,680.36

13,133.68	14,071.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,205.48

3710	AHC CARE EXPANDED	938.12	2,814.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	938.12	2,814.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

16,335,483.56

16,263,248.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,598,731.88

FO
SUBTOTAL:

3,752.48

3,752.48

F

16,374,884.60	16,312,968.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

85,368.92

85,368.92

4410	SOBRA 100-133% FOR	38,462.92	46,906.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	38,462.92	46,906.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

32,687,853.28

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	538.00	476.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,014.00

2210	SSI DISABLED NON-ME D
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

336.00	315.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	651.00

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

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

16,524.00	16,529.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,053.00

14.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.00

3710	AHC CARE EXPANDED	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

17,413.00

17,336.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,749.00

FO

4410	SOBRA 100-133% FOR	41.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	41.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4.00

4.00

F
SUBTOTAL:

91.00

91.00

TOTAL:	17,455.00	17,389.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,844.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	3,020.80	3,020.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,041.60

1010	TANF NON-MEDICARE	191,820.80	195,596.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	387,417.60

1011	TANF <1 M & F NON-ME	4,850.24	3,696.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,547.20

1012	TANF 01-05 M & F NON	5,406.40	6,559.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,966.08

1013	TANF 06-13 M & F NON	8,427.20	5,883.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,310.72

1014	TANF 14-20 MALE NON-	4,174.08	3,896.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,070.08

1015	TANF 14-20 FEMALE N O
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

6,281.60	6,281.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,563.20

1,431.36	1,431.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,862.72

26,909.12	26,909.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53,818.24

4,555,037.44	4,547,763.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,102,800.96

60,934.08	63,676.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	124,610.88

2300	SSI BLIND WITH MEDIC	755.20	755.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,510.40

2310	SSI BLIND NON-MEDIC A

44,041.60	44,796.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,838.40

4311	SOBRA CHILD <1 M & F	25,957.76	26,156.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,114.56

4312	SOBRA CHILD 01-05 M	201,787.20	195,069.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	396,856.64

4313	SOBRA CHILD 06-13 M	231,286.72	231,605.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	462,892.48

4314	SOBRA CHILD 14-20 MA	56,885.76	53,744.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110,630.72

4315	SOBRA CHILD 14-20 FE	54,503.04	54,025.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,528.96

5015	SOBRA PREG 14-20 FE M

1,232.32	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,709.44

SUBTOTAL:

5,484,742.72

5,471,348.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,956,090.88

1115	TANF EXPANDED 14-20	477.12	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	477.12	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

954.24

SUBTOTAL:

954.24

4,294.08	
2,862.72	
954.24	
17,653.44	
16,222.08	
3,816.96	
1,908.48	
47,712.00	

3514	ADULT 40-100% MALE 1	1,908.48	2,385.60	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
3517	ADULT 40-100% FEMAL
E

1,431.36	1,431.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

477.12	477.12	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	9,542.40	8,111.04	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

8,588.16	7,633.92	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	1,908.48	1,908.48	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

477.12	1,431.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

24,333.12

23,378.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	954.24	954.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA	477.12	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,431.36	1,431.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,908.48

L
SUBTOTAL:

954.24

2,862.72

4413	SOBRA 100-133% M&F
6

8,588.16	10,496.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,084.80

L

5,524,820.80	5,512,380.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4414	SOBRA 100-133% MALE	2,862.72	2,862.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,725.44		
4415	SOBRA 100-133% FEMA	2,385.60	2,385.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,771.20		
	13,836.48	15,744.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,581.44		

TOTAL:

11,037,201.28

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00

1010	TANF NON-MEDICARE	254.00	259.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	513.00

1011	TANF <1 M & F NON-ME	9.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00

1012	TANF 01-05 M & F NON	9.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.00

1013	TANF 06-13 M & F NON	13.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.00

1014	TANF 14-20 MALE NON-	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00

1015	TANF 14-20 FEMALE N O
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

12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.00

3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

36.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72.00

6,198.00	6,188.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,386.00

84.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	172.00

2300	SSI BLIND WITH MEDIC	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00

2310	SSI BLIND NON-MEDIC A

62.00	63.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	125.00

4311	SOBRA CHILD <1 M & F	41.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83.00

4312	SOBRA CHILD 01-05 M	339.00	329.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	668.00

4313	SOBRA CHILD 06-13 M	395.00	398.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	793.00

4314	SOBRA CHILD 14-20 MA	93.00	87.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	180.00

4315	SOBRA CHILD 14-20 FE	95.00	94.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	189.00

5015	SOBRA PREG 14-20 FE M

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

SUBTOTAL:

7,657.00

7,640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,297.00

1115	TANF EXPANDED 14-20	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00

SUBTOTAL:

2.00

9.00	
6.00	
2.00	
37.00	
34.00	
8.00	
4.00	
100.00	

3514	ADULT 40-100% MALE 1	4.00	5.00	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
3517	ADULT 40-100% FEMAL
E

3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3714	ADULT <40% EXP MALE	20.00	17.00	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

18.00	16.00	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	4.00	4.00	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

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

SUBTOTAL:

51.00

49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00

L
SUBTOTAL:

2.00

6.00

4413	SOBRA 100-133% M&F
6

18.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4414	SOBRA 100-133% MALE	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
4415	SOBRA 100-133% FEMA	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
	29.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		

L
SUBTOTAL:

TOTAL:	7,741.00	7,726.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,467.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

1006	TANF 21-44 MALE WITH	848.42	3,211.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,060.38

1007	TANF 21-44 FEMALE WI	11,505.38	19,187.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,692.47

1008	TANF 45-64 M & F WIT	8,643.75	16,020.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,664.35

1009	TANF 65+ M & F WITH	2,022.37	2,905.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,928.29

1011	TANF <1 M & F NON-ME	997,028.06	1,032,104.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,029,133.01

1012	TANF 01-05 M & F NON	369,557.78	393,193.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	762,751.28

1013	TANF 06-13 M & F NON	342,021.90	307,281.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	649,303.33

1014	TANF 14-20 MALE NON-	88,902.93	72,599.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	161,502.18

1015	TANF 14-20 FEMALE N O

219,214.37	258,354.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	477,568.73

1016	TANF 21-44 MALE NON-	1,794,520.91	1,973,445.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,767,966.12

1017	TANF 21-44 FEMALE N O

6,277,129.24	6,649,032.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,926,161.77

1018	TANF 45-64 M & F NON	2,332,798.20	2,695,114.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,027,913.11

1019	TANF 65+ M & F NON-M	1,488.83	4,276.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,765.31

1026	TANF 21-44 MALE WITH	1,000.95	2,620.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,620.99

1027	TANF 21-44 FEMALE WI	3,449.27	3,490.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,940.09

1028	TANF 45-64 M & F WIT	8,935.11	7,873.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,808.91

1029	TANF 65+ M & F WITH	111.13	364.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	475.46

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

190,983.36	191,970.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	382,953.99

92,974.35	100,505.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	193,479.79

2120	SSI AGED WITH QMB	469,076.56	646,192.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,115,269.27

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

358,598.07	500,225.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	858,823.16

8,751,971.22    10,309,441.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,061,412.59

1,192,013.12	1,702,312.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,894,325.86

2300	SSI BLIND WITH MEDIC	457.17	1,105.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,562.99

2310	SSI BLIND NON-MEDIC A

86,051.54	110,836.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	196,888.10

2320	SSI BLIND WITH QMB	17,562.15	17,561.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,123.77

4303	SOBRA CHILD 06-13 M	441.34	376.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	818.14

4311	SOBRA CHILD <1 M & F	2,788,917.87	2,724,579.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,513,497.76

4312	SOBRA CHILD 01-05 M	3,898,361.36	5,221,614.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,119,975.41

4313	SOBRA CHILD 06-13 M	5,970,382.14	5,908,426.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,878,808.81

4314	SOBRA CHILD 14-20 MA	1,683,601.36	1,670,470.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,354,071.39

4315	SOBRA CHILD 14-20 FE	1,620,045.30	2,013,403.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,633,449.05

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

865.69	2,004.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,870.60

8,701.00	2,702.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,403.26

398,992.68	518,674.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	917,666.87

2,430,613.48	3,015,144.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,445,758.10

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

5018	SOBRA PREG 45-64 FE M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M

4,602.26	5,349.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,951.29

922.96	3,146.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,069.12

408.02	954.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,362.22

8040	SLMB	0.00	16.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.51

SUBTOTAL:

42,425,721.60

48,108,092.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	90,533,813.83

3100	TRANSPLANT OPTION	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,838.51
1
1,838.51

43,485.44	
93,940.26	
255,696.27	
91,716.80	
736.00	
1,943.44	
4,030.00	
16,123.09	
80,185.97	
1,311,354.56	
4,512,034.56	
3,232,543.19	
6,723.30	
37,766.54	
17,903.40	
75,540.15	
43,564.27	
40,287.12	
12,700.10	
648,663.20	
74,043.32	
310,773.19	
777,016.52	
11,688,770.69	

1106	TANF EXPANDED 21-44	19,712.79	23,772.65	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	45,224.17	48,716.09	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	109,148.53	146,547.74	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

43,849.18	47,867.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	736.00	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	1,472.00	471.44	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	1,086.00	2,944.00	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	12,675.95	3,447.14	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	32,925.35	47,260.62	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	603,641.33	707,713.23	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	2,107,615.33	2,404,419.23	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	1,515,661.76	1,716,881.43	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&

3,568.96	3,154.34	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	11,749.81	26,016.73	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	5,757.10	12,146.30	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	33,496.13	42,044.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

17,343.41	26,220.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

17,207.10	23,080.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9,549.32	3,150.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

300,798.06	347,865.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

32,108.52	41,934.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

170,711.55	140,061.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

338,045.21	438,971.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

5,433,347.56

6,255,423.13	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	-107.53	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	-1,335.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-1,442.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-107.53
4
-1,335.43

SUBTOTAL:

-1,442.96

1

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3400	MED ELIGIBILITY W/ M	-128.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-128.19		
3608	AHC CARE/MI M&F 45-6	-10.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-10.16		
3615	AHC CARE/MI FEMALE	0.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-660.00		
3616	AHC CARE/MI MALE 21-	0.00	-4,620.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,620.00		
3618	AHC CARE/MI M&F 45-6	0.00	-2,324.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,324.92		
SUBTOTAL:	-138.35	-7,604.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,743.27		

-172.78	
16,162.20	
8,427.28	
97,496.24	
176,608.12	
1,869,079.78	
1,405,176.09	
4,836,191.60	
32,015.66	
217.07	
64.80	
1,298.11	
480.61	
19,171.60	
5,759.41	
711,246.96	
908,321.05	
14,839,419.80	
7,679,287.89	
20,161,547.96	
9,924.51	
19,935.34	
52,797,659.30	

3506	ADULT 40-100% MALE 2	0.00	-172.78	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	6,729.48	9,432.72	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	2,149.75	6,277.53	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	47,992.72	49,503.52	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

74,897.97	101,710.15	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	875,338.76	993,741.02	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

688,506.80	716,669.29	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	2,164,182.50	2,672,009.10	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	23,988.25	8,027.41	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	217.07	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	64.80	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	8.65	1,289.46	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

112.61	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

10,869.67	8,301.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,326.41	4,433.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	396,349.39	314,897.57	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

466,712.02	441,609.03	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	7,380,948.41	7,458,471.39	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
3728	ADULT <40% EXP M&F
4

3,864,032.81	3,815,255.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9,449,700.09    10,711,847.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4,389.51	5,535.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

579.64	19,355.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

25,459,032.51

27,338,626.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

928.87	
368.00	
21,921.22	
1,094.16	
41,505.76	
87,440.09	

3906	NEWLY ELIGIBLE MALE	600.38	328.49	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	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9,346.79	12,574.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

491.18	602.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	22,978.31	18,527.45	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

41,330.26	46,109.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

3916	NEWLY ELIGIBLE MALE	331,242.92	482,310.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	813,553.62

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3928	NEWLY ELIGIBLE M&F
4

773,121.13	829,594.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,602,715.50

1,108,114.13	1,301,085.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,409,199.13

30.62	360.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	391.18

SUBTOTAL:

2,287,255.72

2,691,861.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,979,117.53

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

0.00	1,436.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,436.00	
994,016.54	
266,770.07	
402,853.79	
1,665,076.40	

435,953.97	558,062.57	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	112,763.49	154,006.58	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

173,477.21	229,376.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

722,194.67

942,881.73	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
4618	CC PATIENT FEMALE 4
5

368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,104.00	
10,733.50	
147.74	
368.00	
12,353.24	

5,535.42	5,198.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	147.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

6,271.42

6,081.82	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

11,347.92	16,496.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

27,844.49	
1,104.00	
3,600.25	
32,548.74	

1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

724.25	2,876.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

76,348,717.42	85,353,274.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

13,176.17

19,372.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

161,701,992.01

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending August 31, 2016

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

1006	TANF 21-44 MALE WITH	24.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.86

1007	TANF 21-44 FEMALE WI	95.75	21.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	117.44

1008	TANF 45-64 M & F WIT	3,001.23	1,005.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,006.69

1009	TANF 65+ M & F WITH	100.93	886.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	987.46

1011	TANF <1 M & F NON-ME	17,325.66	62,411.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,737.39

1012	TANF 01-05 M & F NON	401.51	861.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,263.06

1013	TANF 06-13 M & F NON	1,152.31	-24.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,128.21

1014	TANF 14-20 MALE NON-	714.39	1,253.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,968.17

1015	TANF 14-20 FEMALE N O

3,433.47	1,839.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,273.23

1016	TANF 21-44 MALE NON-	22,396.21	77,167.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,564.00

1017	TANF 21-44 FEMALE N O

52,737.24	131,048.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	183,785.74

1018	TANF 45-64 M & F NON	18,073.82	37,929.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,003.50

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

15,695.91	8,647.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,343.10

28,335.40	43,386.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71,721.87

2120	SSI AGED WITH QMB	0.00	1,048.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,048.56

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

2,033.62	523.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,557.14

16,753.15	7,270.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,023.78

4311	SOBRA CHILD <1 M & F	10,799.03	33,934.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,733.66

4312	SOBRA CHILD 01-05 M	36,145.25	43,168.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,313.88

4313	SOBRA CHILD 06-13 M	35,978.68	63,157.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,136.01

4314	SOBRA CHILD 14-20 MA	18,930.52	12,976.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,906.62

4315	SOBRA CHILD 14-20 FE	12,023.48	33,332.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,356.43

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

214.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	214.11

15,014.16	30,238.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,253.08

74,107.54	80,746.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	154,853.88

0.00	2,069.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,069.35

SUBTOTAL:

385,488.23

674,902.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,060,391.22

1106	TANF EXPANDED 21-44	0.00	16.99	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	48.90	128.09	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	802.19	6,602.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	1,031.42	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	20,881.24	35,996.89	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	25,519.01	79,115.30	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	10,025.87	17,504.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+	55.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.99	
176.99	
7,404.45	
1,031.42	
56,878.13	
104,634.31	
27,530.59	
55.48	

M&

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending August 31, 2016

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

1127	TANF EXPANDED 21-44	0.00	20.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20.04

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

131.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	131.86

9,438.04	7,426.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,864.59

6,357.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,357.74

801.02	279.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,080.32

4,162.15	4,535.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,697.86

2,877.20	578.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,455.29

-21.51	114.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	93.14

SUBTOTAL:

82,110.61

152,318.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	234,429.20

2,087.20	
1,349.25	
6,153.26	
11,477.23	
61,371.28	
38,116.71	
171,800.81	
117.86	
4,675.07	
32,503.13	
24,954.03	
341,356.07	
175,608.02	
407,786.08	
1,305.57	
16.92	
1,280,678.49	

3506	ADULT 40-100% MALE 2	2,064.92	22.28	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	52.59	1,296.66	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	3,554.50	2,598.76	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

2,903.14	8,574.09	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	32,131.34	29,239.94	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

12,275.90	25,840.81	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	62,497.32	109,303.49	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

0.00	117.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

606.80	4,068.27	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	24,159.76	8,343.37	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

14,883.92	10,070.11	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	142,010.48	199,345.59	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

76,836.42	98,771.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

169,251.34	238,534.74	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	1,305.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3728	ADULT <40% EXP M&F
4

0.00	16.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

544,534.00

736,144.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

489.66	
110.07	
3,529.76	
11,580.51	
13,622.13	
138,931.06	
63,477.15	
213,467.11	
445,207.45	

3906	NEWLY ELIGIBLE MALE	0.00	489.66	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

110.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,522.55	2,007.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	5,721.11	5,859.40	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

8,643.80	4,978.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	70,300.31	68,630.75	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

24,423.42	39,053.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

91,934.27	121,532.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

202,655.53

242,551.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

6

L
SUBTOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F	9,276.43	18,205.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,482.22		
4414	SOBRA 100-133% MALE	1,598.02	2,596.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,194.72		
4415	SOBRA 100-133% FEMA	1,645.47	4,875.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,520.58		
	12,519.92	25,677.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,197.52		

78.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
78.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4518	BC PATIENT FEMALE 4
5

8700	SSI DISABLED FREEDO	30.54	591.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	1,065.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,096.24	591.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

78.61

78.61

M M
SUBTOTAL:

621.87

1,065.70

1,687.57

TOTAL:	1,228,483.14	1,832,186.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,060,670.06		

L

0.00	576.29	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 - PRESUMPTIVE ELIGIBILITY - EXC. ES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9000	PRESUMPTIVE ELIGIBI	0.00	576.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		576.29		
	0.00	576.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		576.29		

TOTAL:

576.29

FEDERAL EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

1011	TANF <1 M & F NON-ME	3,451.27	301.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,752.92

1012	TANF 01-05 M & F NON	25,128.76	31,110.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,238.85

1013	TANF 06-13 M & F NON	51,155.97	80,966.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132,122.50

1014	TANF 14-20 MALE NON-	93,392.20	152,861.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	246,253.28

1015	TANF 14-20 FEMALE N O

365,886.79	512,928.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	878,815.24

1016	TANF 21-44 MALE NON-	126,645.84	163,695.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	290,341.64

1017	TANF 21-44 FEMALE N O

2,509,465.83	3,746,506.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,255,972.54

1018	TANF 45-64 M & F NON	232,788.56	309,539.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	542,327.64

1019	TANF 65+ M & F NON-M	4,738.82	9,707.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,446.36

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

12,916.57	12,231.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,148.13

869,141.79	1,485,741.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,354,882.83

2120	SSI AGED WITH QMB	4,041.12	1,462.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,503.49

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

2,921.27	5,139.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,060.93

420,657.34	364,111.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	784,769.24

1,206.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,206.10

SUBTOTAL:

4,723,538.23

6,876,303.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,599,841.69

874.15	
-1,206.23	
1.85	
3,410.44	
26,485.97	
1,144,767.79	
2,244,929.32	
1,126,346.37	
13,402.55	
1,829.25	
3,480.97	
57,241.23	
87.54	
74,650.08	
4,696,301.28	

1106	TANF EXPANDED 21-44	20.66	853.49	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	-1,206.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1109	TANF EXPANDED 65+ M&

0.00	1.85	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	1,720.99	1,689.45	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	9,350.19	17,135.78	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	501,857.98	642,909.81	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	921,767.34	1,323,161.98	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	507,285.08	619,061.29	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&

4,824.90	8,577.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1126	TANF EXPANDED 21-44	0.00	1,829.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2400	SSI AGED EXPANDED WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2610	SSI DISABLED EXPAND
E

2,199.44	1,281.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

17,674.75	39,566.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

62.60	24.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

37,953.48	36,696.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

2,004,717.41

2,691,583.87	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	302.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	144.99	878.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	447.97	878.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

302.98

4
SUBTOTAL:

1,023.72

1,326.70

3906	NEWLY ELIGIBLE MALE	3,658.03	6,533.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,191.34

FEDERAL EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

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

186.74	1,247.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,434.14

190.37	14,378.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,568.95

4,641.95	861.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,503.19

3914	NEWLY ELIGIBLE MALE	-32,353.35	60,696.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,343.55

3915	NEWLY ELIGIBLE FEMA L

47,067.82	74,149.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121,217.71

3916	NEWLY ELIGIBLE MALE	715,851.62	1,156,537.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,872,388.92

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

458,763.46	686,388.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,145,152.13

1,954,928.55	2,512,951.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,467,879.83

4,798.84	29,402.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,200.87

SUBTOTAL:

3,157,734.03

4,543,146.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,700,880.63

TOTAL:	9,886,437.64	14,111,912.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,998,350.30		

SUBTOTAL:

QMB - FEE FOR SERVICE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	400,102.86	462,172.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		862,275.19		
8040	SLMB	4.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.16		
8050	QI1	7.67	86.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94.36		
	400,114.69	462,259.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		862,373.71		

TOTAL:

400,114.69

462,259.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	862,373.71

FFS TRBHA FEE FOR SERVICE

For The Period Ending August 31, 2016

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

1007	TANF 21-44 FEMALE WI	471.71	860.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,332.11

1011	TANF <1 M & F NON-ME	736.00	4,723.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,459.43

1012	TANF 01-05 M & F NON	368.00	6,424.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,792.63

1013	TANF 06-13 M & F NON	16,512.22	58,805.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,317.85

1014	TANF 14-20 MALE NON-	7,533.55	31,068.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,602.52

1015	TANF 14-20 FEMALE N O

17,783.14	60,075.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77,858.30

1016	TANF 21-44 MALE NON-	50,986.98	232,739.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	283,726.22

1017	TANF 21-44 FEMALE N O

127,725.96	724,699.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	852,425.00

1018	TANF 45-64 M & F NON	27,221.83	125,961.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	153,183.80

1019	TANF 65+ M & F NON-M	0.00	1,159.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,159.27

1028	TANF 45-64 M & F WIT	0.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69.00

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

1,846.28	4,349.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,195.36

0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00

2120	SSI AGED WITH QMB	2,129.89	16,890.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,020.44

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

4,943.64	25,786.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,730.23

328,797.09	1,331,576.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,660,373.21

57,352.69	239,617.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	296,970.30

1,641.42	3,896.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,538.24

2320	SSI BLIND WITH QMB	152.56	426.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	578.88

4311	SOBRA CHILD <1 M & F	0.00	4,537.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,537.43

4312	SOBRA CHILD 01-05 M	38,968.43	137,249.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	176,218.29

4313	SOBRA CHILD 06-13 M	681,184.65	2,583,435.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,264,620.35

4314	SOBRA CHILD 14-20 MA	118,686.61	495,250.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	613,937.08

4315	SOBRA CHILD 14-20 FE	99,195.07	477,467.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	576,662.85

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

2,116.23	12,740.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,856.53

13,961.07	87,460.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,421.85

0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00

1106	TANF EXPANDED 21-44	137.75	616.80	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	1,597.76	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	674.27	4,167.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+	0.00	64.80	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	137.44	4,260.77	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	4,744.53	38,555.84	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	35,688.54	179,661.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1,600,315.02

6,668,008.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,268,323.17

754.55	
1,597.76	
4,842.26	
64.80	
4,398.21	
43,300.37	
215,350.08	

M&

FFS TRBHA FEE FOR SERVICE

For The Period Ending August 31, 2016

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

1118	TANF EXPANDED 45-64	12,040.84	94,798.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	106,839.00

1126	TANF EXPANDED 21-44	24.31	48.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72.93

1128	TANF EXPANDED 45-64	0.00	389.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	389.55

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

0.00	87.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87.63

0.00	28.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.43

1,847.24	7,852.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,699.86

340.83	1,313.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,654.64

2,514.49	16,695.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,210.24

7,877.72	36,952.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,829.72

SUBTOTAL:

66,027.96

387,092.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	453,120.03

16,877.85	
12,031.09	
78,414.48	
155,926.48	
46,738.60	
9,094.50	
368.00	
106,545.96	
110,095.01	
1,702,493.29	
837,493.69	
922,331.19	
706.24	
3,999,116.38	

3514	ADULT 40-100% MALE 1	2,919.76	13,958.09	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

1,223.27	10,807.82	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	13,302.02	65,112.46	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

18,532.82	137,393.66	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	9,656.03	37,082.57	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	2,666.95	6,427.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3708	ADULT <40% EXP M&F
4

368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3714	ADULT <40% EXP MALE	25,221.15	81,324.81	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

21,376.36	88,718.65	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	252,385.95	1,450,107.34	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
3728	ADULT <40% EXP M&F
4

121,453.62	716,040.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

133,578.17	788,753.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	706.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

602,684.10

3,396,432.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3908	NEWLY ELIGIBLE M&F
4

252.66	506.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	193.81	2,173.09	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

1,490.91	4,991.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	5,736.39	30,986.85	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

10,182.84	38,280.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,575.13	22,762.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

21,431.74

99,701.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

759.29	
2,366.90	
6,482.43	
36,723.24	
48,463.78	
26,337.63	
121,133.27	

4413	SOBRA 100-133% M&F	21,364.78	93,891.88	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	4,868.73	19,328.03	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	9,747.31	36,201.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

115,256.66
6
24,196.76

45,949.07
L

8700	SSI DISABLED FREEDO	0.00	128.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	128.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

M
SUBTOTAL:

128.25

FFS TRBHA FEE FOR SERVICE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	35,980.82	149,421.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,402.49		

128.25

TOTAL:	2,326,439.64	10,700,783.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,027,223.59		

O

D

1116	TANF EXPANDED 21-44	0.00	6,531.12	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	3,265.56	816.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	8,163.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	11,429.46	7,347.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

STATE ONLY TRBHA FEE FOR SERVICE

For The Period Ending August 31, 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	5,714.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,714.73		
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	0.00	6,440.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,440.00		
	0.00	12,154.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,154.73		

6,531.12	
4,081.95	
8,163.90	
18,776.97	

E
SUBTOTAL:

11,429.46	
9,796.68	
6,888.39	
28,114.53	

AL

4

11,429.46	47,616.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3716	ADULT <40% EXP MALE	0.00	11,429.46	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	0.00	9,796.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	0.00	6,888.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	28,114.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

59,046.23

INPATIENT INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016

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

1016	TANF 21-44 MALE NON-	176.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	176.98

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

62,636.18	7,321.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,957.51

55,431.46	44,621.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100,053.32

2120	SSI AGED WITH QMB	3,240.08	492.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,732.54

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
5017	SOBRA PREG 21-44 FE
M

0.00	-838.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-838.56

1,073.60	164.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,238.32

3,260.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,260.38

8020	QMB ONLY	0.00	1,335.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,335.10

SUBTOTAL:

125,818.68

53,096.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178,915.59

160.42	
0.00	
1,123.14	
1,283.56	

E
SUBTOTAL:

1107	TANF EXPANDED 21-44	0.00	160.42	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	
2620	SSI DISABLED EXPAND	804.92	318.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	804.92	478.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

38,080.35	
303.97	
124,375.90	
16,616.56	
2,416.65	
868,691.34	
87,922.16	
723,904.02	
5,349.86	
85,962.66	
1,953,623.47	

3706	ADULT <40% EXP MALE	26,019.36	12,060.99	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

271.09	32.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

11,908.65	112,467.25	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	353.70	16,262.86	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	2,416.65	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	218,117.82	650,573.52	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

52,156.60	35,765.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

353,809.36	370,094.66	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	5,349.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3728	ADULT <40% EXP M&F
4

139,069.59	-53,106.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	15,999.84	1,846.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA	5,137.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	25,941.69	5,239.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	47,079.35	7,086.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

801,706.17

1,151,917.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

17,846.05	
5,137.82	
31,181.61	
54,165.48	

L

4
SUBTOTAL:

TOTAL:	975,409.12	1,212,578.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,187,988.10		

0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

COCHISE COUNTY INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.17		
	0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.17		

TOTAL:

57.17

COCONINO COUNTY INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	162.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.87		
3717	ADULT <40% EXP FEM	3,420.00	-3,420.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	3,420.00	-3,257.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.87		

AL
SUBTOTAL:

TOTAL:	3,420.00	-3,257.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.87		

5,377.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

GRAHAM COUNTY INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	5,377.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,377.79		
	5,377.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,377.79		

TOTAL:

5,377.79

MARICOPA COUNTY INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016

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

1014	TANF 14-20 MALE NON-	136.74	222.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	359.40

1016	TANF 21-44 MALE NON-	5,818.72	302.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,121.46

1017	TANF 21-44 FEMALE N O
2100	SSI AGED WITH MEDIC
A
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

1,082.48	2,762.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,844.67

7,942.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,942.52

1,309.60	80.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,389.81

1,618.81	30,697.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,315.84

4,268.62	479.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,748.10

0.00	3,613.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,613.61

0.00	470.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	470.90

SUBTOTAL:

22,177.49

38,628.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,806.31

9,884.70	
2,513.74	
31,367.78	
17,181.68	
181.98	
3,944.64	
65,074.52	

1116	TANF EXPANDED 21-44	9,365.91	518.79	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	2,513.74	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	30,975.78	392.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2420	SSI AGED EXPANDED WI
2600	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

17,181.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

173.98	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	3,944.64	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	337.40	9,114.07	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	4,529.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	2,874.75	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	54,620.68	47,911.92	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	10,385.03	11,952.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	13,015.34	65,281.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	78,358.45	141,664.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

57,697.35

7,377.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9,451.47	
4,529.42	
2,874.75	
102,532.60	
22,337.73	
78,296.97	
220,022.94	

AL

4

0.00	8,584.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	8,584.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3916	NEWLY ELIGIBLE MALE

8,584.45

SUBTOTAL:

8,584.45

TOTAL:	158,233.29	196,254.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		354,488.22		

E

D
SUBTOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2200	SSI DISABLED WITH M	0.00	8,322.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,322.27		
2210	SSI DISABLED NON-ME	30.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.82		
	30.82	8,322.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,353.09		

3716	ADULT <40% EXP MALE	962.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	962.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

962.05

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

962.05

TOTAL:

992.87

8,322.27

9,315.14

PIMA COUNTY INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016

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

1016	TANF 21-44 MALE NON-	0.00	11,982.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,982.91

1018	TANF 45-64 M & F NON	0.00	1,058.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,058.42

2210	SSI DISABLED NON-ME D
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

807.17	12,780.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,587.52

470.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	470.90

0.00	415.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	415.50

SUBTOTAL:

1,278.07

26,237.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,515.25

8.00	
114.90	
14,746.48	
8,337.16	
16,885.34	
40,091.88	

3516	ADULT 40-100% MALE 2	0.00	8.00	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

114.90	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	290.46	14,456.02	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

3,587.31	4,749.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

13,647.51	3,237.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

17,640.18

22,451.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	18,918.25	48,688.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,607.13		

PINAL COUNTY INMATES FEE FOR SERVICE

For The Period Ending August 31, 2016

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

2100	SSI AGED WITH MEDIC A
2200	SSI DISABLED WITH M
E
2220	SSI DISABLED WITH Q
M

245.38	3,154.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,399.69

581.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	581.70

3,803.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,803.40

SUBTOTAL:

4,630.48

3,154.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,784.79

2,660.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,660.70	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

2,660.70

SUBTOTAL:

2,660.70

42,847.62	
8.00	
9,572.42	
52,428.04	

AL

4

16,871.60	46,001.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3716	ADULT <40% EXP MALE	0.00	42,847.62	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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	9,572.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	9,580.42	42,847.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

62,873.53

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00

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

2,307,947.16	2,733,144.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,041,092.14

149,727.64	170,783.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	320,511.08

2120	SSI AGED WITH QMB	3,195,618.68	3,951,641.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,147,259.77

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

537,954.02	696,721.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,234,675.41

2,694,953.74	3,287,243.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,982,196.77

764,491.97	940,091.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,704,583.55

12,301.04	21,001.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,302.69

2320	SSI BLIND WITH QMB	7,206.96	7,708.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,914.96

8710	SSI DISABLED FREEDO	653.30	6,631.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	2,765.43	3,427.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,418.73	10,058.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

9,670,201.21

11,808,703.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,478,904.37

M M
SUBTOTAL:

7,284.53

6,192.63

13,477.16

TOTAL:	9,673,619.94	11,818,761.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,492,381.53		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES

For The Period Ending August 31, 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

6,319.24	20,181.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,500.33

200.76	1,334.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,535.31

2120	SSI AGED WITH QMB	3,279.02	110.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,389.43

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

4,355.69	5,162.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,518.41

11,384.31	301.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,685.70

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

25,539.02

27,090.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,629.18

TOTAL:

25,539.02

27,090.16

52,629.18

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending August 31, 2016

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

1012	TANF 01-05 M & F NON	10,026.35	4,936.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,963.17

1013	TANF 06-13 M & F NON	26,843.26	657.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,501.05

1014	TANF 14-20 MALE NON-	2,429.50	605.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,034.62

1015	TANF 14-20 FEMALE N O
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

2,174.10	399.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,573.82

157.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	157.34

136,113.36	80,007.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	216,120.86

800.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	800.49

919.88	782.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,702.87

4305	SOBRA CHILD 14-20 FE	35.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.62

4312	SOBRA CHILD 01-05 M	28,343.38	14,276.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,619.44

4313	SOBRA CHILD 06-13 M	91,660.37	21,444.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	113,105.18

4314	SOBRA CHILD 14-20 MA	6,894.69	11,038.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,933.67

4315	SOBRA CHILD 14-20 FE	2,364.62	747.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,111.86

SUBTOTAL:

308,762.96

134,897.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	443,659.99

83.28	153.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
83.28	153.89	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

237.17

3514	ADULT 40-100% MALE 1	159.17	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	201.78	517.73	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	449.14	125.87	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	41.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	851.49	643.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

237.17

159.17	
719.51	
575.01	
41.40	
1,495.09	

E

AL

3915	NEWLY ELIGIBLE FEMA	0.00	142.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	142.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

L

4413	SOBRA 100-133% M&F	22,760.62	9,243.14	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	1,982.14	551.41	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	706.11	141.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	25,448.87	9,936.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

142.91

142.91

32,003.76	
2,533.55	
847.97	
35,385.28	

6

L
SUBTOTAL:

TOTAL:	335,146.60	145,773.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480,920.44		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	395.88	12.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	408.23

1010	TANF NON-MEDICARE	22,308.73	10,498.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,807.52

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

3,546.21	2,524.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,070.53

797,548.98	458,452.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,256,001.05

1,060.22	728.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,788.63

3,791.67	2,658.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,450.01

828,651.69	474,874.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

828,651.69

474,874.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,303,525.97

TOTAL:

1,303,525.97

ACUTE REINSURANCE

For The Period Ending August 31, 2016

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

1011	TANF <1 M & F NON-ME	644,528.57	538,967.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,183,496.52

1012	TANF 01-05 M & F NON	-5,098.78	50,222.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,123.84

1013	TANF 06-13 M & F NON	127,321.76	319,516.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	446,838.10

1014	TANF 14-20 MALE NON-	13,740.97	54,044.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,785.07

1015	TANF 14-20 FEMALE N O

23,666.42	-77,738.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-54,072.41

1016	TANF 21-44 MALE NON-	217,616.39	157,215.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	374,831.88

1017	TANF 21-44 FEMALE N O

181,478.43	255,820.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	437,299.19

1018	TANF 45-64 M & F NON	234,755.06	169,943.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	404,698.43

1019	TANF 65+ M & F NON-M	4,019.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,019.06

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A

15,498.24	9,837.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,335.66

388,018.03	277,060.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	665,078.74

14,893.21	9,427.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,320.98

5,781,423.00	4,661,832.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,443,255.44

3,144.63	15,144.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,288.92

4311	SOBRA CHILD <1 M & F	1,395,628.58	1,583,427.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,979,056.42

4312	SOBRA CHILD 01-05 M	441,100.37	296,759.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	737,860.19

4313	SOBRA CHILD 06-13 M	263,996.88	399,559.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	663,556.56

4314	SOBRA CHILD 14-20 MA	173,423.73	445,022.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	618,446.26

4315	SOBRA CHILD 14-20 FE	82,494.00	220,990.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	303,484.49

5015	SOBRA PREG 14-20 FE M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

79,849.94	1,849.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,699.68

25,268.07	62,182.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,450.68

0.00	-7,808.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7,808.64

SUBTOTAL:

10,106,766.56

9,443,278.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,550,045.06

3100	TRANSPLANT OPTION	0.00	23.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	23.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

23.10
1
23.10

144.38	
1,108.27	
310,287.98	
495,031.05	
228,007.21	
1,775.50	
2,025.65	
72,547.75	
1,110,927.79	

1106	TANF EXPANDED 21-44	0.00	144.38	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	1,108.27	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	109,137.12	201,150.86	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	367,821.25	127,209.80	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	118,336.16	109,671.05	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&
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E

0.00	1,775.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

850.89	1,174.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

22,124.40	50,423.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

618,269.82

492,657.97	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	13,424.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,424.53

ACUTE REINSURANCE

For The Period Ending August 31, 2016

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

3514	ADULT 40-100% MALE 1	83,948.35	-32,668.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,279.81

3515	ADULT 40-100% FEMAL E

342.52	3,067.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,410.48

3516	ADULT 40-100% MALE 2	208,376.34	237,928.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	446,305.04

3517	ADULT 40-100% FEMAL E

73,314.67	85,173.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	158,488.30

3518	ADULT 40-100% M&F 45	449,226.40	539,517.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	988,743.46

3708	ADULT <40% EXP M&F
4

199,395.77	-259.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	199,136.34

3714	ADULT <40% EXP MALE	46,933.03	4,532.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,465.15

3715	ADULT <40% EXP FEM AL

27,464.33	15,826.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,290.79

3716	ADULT <40% EXP MALE	610,923.36	748,507.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,359,430.61

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

452,359.25	337,121.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	789,480.61

1,050,808.24	2,420,228.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,471,036.80

0.00	5,259.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,259.44

SUBTOTAL:

3,216,516.79

4,364,234.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,580,751.36

67,021.64	
41,972.61	
732,666.71	
55,008.28	
629,338.37	
1,526,007.61	

3914	NEWLY ELIGIBLE MALE	531.22	66,490.42	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	41,972.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3916	NEWLY ELIGIBLE MALE	151,847.06	580,819.65	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

54,472.48	535.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

187,202.54	442,135.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

394,053.30

1,131,954.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

445,743.67	
780,347.52	
51,106.51	
1,277,197.70	

6

L
SUBTOTAL:

4413	SOBRA 100-133% M&F	200,439.17	245,304.50	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	584,170.49	196,177.03	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	37,792.99	13,313.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	822,402.65	454,795.05	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	2,325.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	2,325.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,325.47
5
2,325.47

2,634.47	2,674.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,634.47	2,674.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8710	SSI DISABLED FREEDO M
SUBTOTAL:

5,308.76

5,308.76

TOTAL:	15,160,643.59	15,891,943.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,052,586.85		

LONG TERM CARE REINSURANCE

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	2,240.29	558.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,798.32

2100	SSI AGED WITH MEDIC A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D

427,508.23	354,148.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	781,657.13

109,126.94	168,130.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	277,257.10

922,846.90	607,754.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,530,600.96

3,499,917.78	4,372,697.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,872,615.20

2300	SSI BLIND WITH MEDIC	0.57	43.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44.09

2310	SSI BLIND NON-MEDIC A

5,402.76	5,430.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,833.29

4,967,043.47	5,508,762.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4,967,043.47

5,508,762.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,475,806.09

TOTAL:

10,475,806.09

ACUTE SMIB

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	83,282.60	79,141.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162,424.00

1010	TANF NON-MEDICARE	609.00	852.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,461.60

1020	TANF WITH QMB	24,116.40	24,603.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,720.00

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

103,567.30	146,400.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	249,967.40

493,790.60	499,097.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	992,888.50

2120	SSI AGED WITH QMB	3,316,283.10	3,439,229.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,755,512.60

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

270,428.30	331,956.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	602,384.90

391,130.70	391,601.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	782,731.70

3,666,577.20	3,656,475.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,323,052.70

2300	SSI BLIND WITH MEDIC	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487.20

2310	SSI BLIND NON-MEDIC A

3,288.60	3,288.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,577.20

2320	SSI BLIND WITH QMB	29,962.80	30,084.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,047.40

4300	SOBRA CHILD WITH ME D
4320	SOBRA CHILD WITH Q
MB
5000	SOBRA PREGNANT WO
MAN
5020	SOBRA PREGNANT WO
MAN

121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	243.60

243.60	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	365.40

243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487.20

3,897.60	3,288.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,186.20

8000	SMIB ONLY NOT ELIGIB	-487.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-487.20

8020	QMB ONLY	732,938.50	741,291.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,474,229.70

8040	SLMB	4,230,330.90	4,296,575.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,526,905.90

8888	SMIB ONLY NOT ELIGIB	-149,049.20	-27,293.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-176,342.70

9999	SMIB ONLY NOT ELIGIB	60,444.40	160,788.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	221,233.10

SUBTOTAL:

13,261,964.20

13,778,112.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,040,076.40

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

670,306.70	690,655.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,360,962.30	
1,096.20	
562,950.70	
-609.00	
243.60	
4,498,315.10	
487.20	
-609.00	
3,807,262.20	
10,230,099.30	

730.80	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

277,849.30	285,101.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

-974.40	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,270,888.70	2,227,426.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

121.80	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

-487.20	-121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,918,198.80	1,889,063.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

5,136,756.30

5,093,343.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3520	ADULT 40-100% FOR FI	974.40	1,096.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED	1,339.80	852.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,314.20	1,948.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,070.60

FO
SUBTOTAL:

2,192.40

4,263.00

F

8720	SSI DISABLED FREEDO	26,430.60	25,699.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	26,430.60	25,699.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

M
SUBTOTAL:

52,130.40

ACUTE SMIB

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR	487.20	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852.60		
	487.20	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852.60		

52,130.40

TOTAL:	18,427,952.50	18,899,469.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,327,421.70		

A

M

SUBTOTAL:

FI WI

367,193.50	418,514.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1,356.00

ACUTE HIB

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC	-1,233.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,233.00		
2120	SSI AGED WITH QMB	236,959.20	276,996.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		513,955.50		
2220	SSI DISABLED WITH Q	125,651.90	134,161.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259,813.70		
2320	SSI BLIND WITH QMB	411.00	1,315.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,726.20		
8020	QMB ONLY	2,918.00	3,514.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,432.00		
9999	SMIB ONLY NOT ELIGIB	-3,144.00	-4,377.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,521.10		
	361,563.10	411,610.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		773,173.30		

11,178.80

12,534.80

1120	TANF EXPANDED FOR	1,130.00	226.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED	4,500.40	6,678.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	5,630.40	6,904.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

785,708.10

Q1

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,231,414.30	2,263,375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,494,789.30		
9999	SMIB ONLY NOT ELIGIB	-9,385.60	-5,934.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-15,320.00		
	2,222,028.70	2,257,440.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,479,469.30		

SUBTOTAL:

TOTAL:	2,222,028.70	2,257,440.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,479,469.30		

LTC SMIB

For The Period Ending August 31, 2016

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

1000	TANF WITH MEDICARE	1,339.80	974.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,314.20

1020	TANF WITH QMB	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487.20

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

996,521.00	982,501.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,979,022.00

185,014.20	184,527.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	369,541.20

2120	SSI AGED WITH QMB	904,419.20	906,456.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,810,875.20

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

379,691.30	381,460.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	761,152.00

18,635.40	20,340.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,976.00

835,984.20	830,397.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,666,381.40

2300	SSI BLIND WITH MEDIC	852.60	852.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,705.20

2310	SSI BLIND NON-MEDIC A

365.40	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	609.00

2320	SSI BLIND WITH QMB	5,237.40	5,359.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,596.60

SUBTOTAL:

3,328,304.10

3,313,355.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,641,660.00

M

3,328,913.10	3,313,964.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1,218.00

1,218.00

8720	SSI DISABLED FREEDO	609.00	609.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	609.00	609.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

6,642,878.00

LTC HIB

For The Period Ending August 31, 2016

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

2100	SSI AGED WITH MEDIC A

411.00	-411.00	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	268,654.00	271,962.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	540,616.40

2200	SSI DISABLED WITH M E
2220	SSI DISABLED WITH Q
M

0.00	411.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.00

14,652.00	13,608.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,260.00

SUBTOTAL:

283,717.00

285,570.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	569,287.40

TOTAL:	283,717.00	285,570.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		569,287.40		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

1006	TANF 21-44 MALE WITH	-679.32	1,173.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	494.59

1007	TANF 21-44 FEMALE WI	4,715.31	2,051.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,766.43

1008	TANF 45-64 M & F WIT	2,768.42	8,031.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,800.21

1009	TANF 65+ M & F WITH	1,498.24	2,850.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,349.14

1011	TANF <1 M & F NON-ME	691,179.03	549,687.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,240,866.54

1012	TANF 01-05 M & F NON	300,554.71	309,088.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	609,642.73

1013	TANF 06-13 M & F NON	216,437.47	262,212.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	478,650.05

1014	TANF 14-20 MALE NON-	77,950.03	61,633.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139,583.96

1015	TANF 14-20 FEMALE N O

181,345.66	201,315.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	382,661.14

1016	TANF 21-44 MALE NON-	1,208,018.47	1,095,125.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,303,143.58

1017	TANF 21-44 FEMALE N O

4,782,275.12	4,614,453.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,396,728.48

1018	TANF 45-64 M & F NON	1,536,458.94	1,747,293.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,283,752.75

1019	TANF 65+ M & F NON-M	1,488.83	2,576.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,064.83

1026	TANF 21-44 MALE WITH	736.00	139.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	875.85

1027	TANF 21-44 FEMALE WI	812.39	1,382.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,194.60

1028	TANF 45-64 M & F WIT	3,869.59	788.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,658.17

1029	TANF 65+ M & F WITH	111.13	364.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	475.46

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

66,138.34	96,126.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	162,264.53

53,486.52	61,326.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	114,813.03

2120	SSI AGED WITH QMB	229,795.08	290,274.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	520,069.21

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

138,965.52	205,333.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	344,299.22

4,735,804.13	5,056,810.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,792,615.03

434,350.13	563,385.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	997,735.82

2300	SSI BLIND WITH MEDIC	442.84	1,105.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,548.66

2310	SSI BLIND NON-MEDIC A

59,992.53	44,447.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104,439.54

2320	SSI BLIND WITH QMB	6,629.65	6,866.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,496.06

4303	SOBRA CHILD 06-13 M	441.34	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	809.34

4311	SOBRA CHILD <1 M & F	1,609,122.57	1,747,141.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,356,264.45

4312	SOBRA CHILD 01-05 M	2,972,452.20	3,405,021.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,377,473.35

4313	SOBRA CHILD 06-13 M	4,942,683.63	4,831,514.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,774,198.12

4314	SOBRA CHILD 14-20 MA	1,427,842.79	1,316,616.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,744,459.32

4315	SOBRA CHILD 14-20 FE	1,271,324.45	1,578,662.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,849,987.44

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

378.25	75.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	453.30

8,701.00	2,231.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,932.36

301,972.26	335,882.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	637,854.48

1,648,401.34	1,955,913.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,604,315.04

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

5018	SOBRA PREG 45-64 FE M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M

1,822.00	4,398.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,220.00

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

64.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.80

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

SUBTOTAL:

28,920,351.39

30,363,670.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,284,021.61

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	
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
0.00

15,040.51	
30,242.92	
79,465.98	
54,850.27	
736.00	
1,840.00	
4,030.00	
11,143.08	
55,312.13	
826,419.46	
3,447,046.01	
2,334,608.03	
6,473.14	
6,473.38	
5,742.46	
23,289.69	
18,474.50	
27,604.98	
13,981.28	
321,351.33	
29,193.52	
200,726.56	
273,985.86	
7,788,031.09	

1106	TANF EXPANDED 21-44	8,602.39	6,438.12	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	13,205.53	17,037.39	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	35,277.85	44,188.13	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

25,333.08	29,517.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	736.00	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	1,472.00	368.00	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	1,086.00	2,944.00	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	8,498.36	2,644.72	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	22,839.73	32,472.40	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	391,405.06	435,014.40	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	1,654,146.61	1,792,899.40	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	1,081,476.90	1,253,131.13	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&

3,568.96	2,904.18	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	3,422.37	3,051.01	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	2,367.67	3,374.79	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	9,846.61	13,443.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

8,178.44	10,296.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

11,068.81	16,536.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8,461.28	5,520.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

138,825.20	182,526.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

13,441.47	15,752.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

113,472.90	87,253.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

129,964.16	144,021.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

3,685,961.38

4,102,069.71	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	-1,335.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-1,335.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00
4
-1,335.43

SUBTOTAL:

-1,335.43

1

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		0.00		
3615	AHC CARE/MI FEMALE	0.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-660.00		
3616	AHC CARE/MI MALE 21-	0.00	-4,620.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,620.00		
3618	AHC CARE/MI M&F 45-6	0.00	-2,310.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,310.00		
SUBTOTAL:	0.00	-7,590.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,590.00		

32.05	
7,825.30	
5,141.25	
61,999.59	
144,300.45	
1,077,833.01	
995,295.65	
3,139,224.73	
3,680.00	
0.00	
64.80	
8.65	
406.04	
15,981.90	
4,490.12	
512,357.20	
730,439.87	
8,647,878.84	
5,546,020.34	
12,322,124.40	
7,178.28	
18,205.78	
33,240,488.25	

3506	ADULT 40-100% MALE 2	0.00	32.05	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	5,087.09	2,738.21	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	2,149.75	2,991.50	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	29,860.10	32,139.49	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

58,534.61	85,765.84	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	516,106.88	561,726.13	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

515,712.00	479,583.65	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	1,473,444.90	1,665,779.83	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	1,472.00	2,208.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	64.80	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	8.65	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

38.04	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

10,145.24	5,836.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

386.08	4,104.04	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	296,316.38	216,040.82	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

395,011.00	335,428.87	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	4,559,384.60	4,088,494.24	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
3728	ADULT <40% EXP M&F
4

3,020,325.53	2,525,694.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5,969,277.06	6,352,847.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,190.00	4,988.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	18,205.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

16,855,449.91

16,385,038.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

818.29	
368.00	
15,921.26	
1,094.16	
29,575.39	
74,669.38	

3906	NEWLY ELIGIBLE MALE	565.60	252.69	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	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

6,391.01	9,530.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

491.18	602.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3914	NEWLY ELIGIBLE MALE	15,249.46	14,325.93	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

35,329.67	39,339.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

3916	NEWLY ELIGIBLE MALE	236,860.76	307,117.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	543,978.17

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3928	NEWLY ELIGIBLE M&F
4

595,512.26	613,831.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,209,344.17

774,247.15	944,868.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,719,115.54

0.00	360.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	360.56

SUBTOTAL:

1,664,647.09

1,930,597.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,595,244.92

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

0.00	1,436.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,436.00	
822,101.41	
218,288.49	
336,331.32	
1,378,157.22	

354,893.07	467,208.34	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	98,806.05	119,482.44	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

144,611.95	191,719.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

598,311.07

779,846.15	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
4618	CC PATIENT FEMALE 4
5

368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,104.00	
9,936.00	
147.74	
368.00	
11,555.74	

5,520.00	4,416.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	147.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

6,256.00

5,299.74	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

7,296.44	5,878.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

13,174.77	
1,104.00	
340.87	
14,619.64	

1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	340.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

51,739,377.28	53,563,815.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

8,400.44

6,219.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

105,303,193.04

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016

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

1006	TANF 21-44 MALE WITH	1,472.69	2,038.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,510.74

1007	TANF 21-44 FEMALE WI	6,790.07	16,402.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,192.31

1008	TANF 45-64 M & F WIT	5,745.09	7,583.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,328.10

1009	TANF 65+ M & F WITH	524.13	55.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	579.15

1011	TANF <1 M & F NON-ME	189,983.11	396,902.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	586,885.37

1012	TANF 01-05 M & F NON	63,137.63	76,150.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	139,287.86

1013	TANF 06-13 M & F NON	121,964.92	44,627.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166,592.00

1014	TANF 14-20 MALE NON-	9,809.04	10,160.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,969.23

1015	TANF 14-20 FEMALE N O

33,485.45	46,331.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,817.14

1016	TANF 21-44 MALE NON-	538,720.43	818,731.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,357,451.89

1017	TANF 21-44 FEMALE N O

1,361,290.75	1,890,712.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,252,003.71

1018	TANF 45-64 M & F NON	681,254.62	863,864.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,545,118.98

1019	TANF 65+ M & F NON-M	0.00	1,421.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,421.86

1026	TANF 21-44 MALE WITH	116.86	2,480.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,597.05

1027	TANF 21-44 FEMALE WI	2,636.88	2,108.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,745.49

1028	TANF 45-64 M & F WIT	5,014.97	7,085.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,100.19

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	0.00

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

115,748.46	91,408.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	207,156.96

31,788.57	48,642.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,431.12

2120	SSI AGED WITH QMB	229,484.07	344,087.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	573,571.42

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

210,777.77	283,035.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	493,813.68

3,642,965.31	4,857,725.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,500,690.74

718,446.11	1,087,759.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,806,205.70

2300	SSI BLIND WITH MEDIC	14.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.33

2310	SSI BLIND NON-MEDIC A

25,883.10	61,596.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,479.30

2320	SSI BLIND WITH QMB	9,644.50	10,606.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,251.41

4303	SOBRA CHILD 06-13 M	0.00	8.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.80

4311	SOBRA CHILD <1 M & F	1,068,603.35	839,332.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,907,936.11

4312	SOBRA CHILD 01-05 M	819,475.49	813,753.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,633,228.76

4313	SOBRA CHILD 06-13 M	900,853.80	1,045,600.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,946,454.22

4314	SOBRA CHILD 14-20 MA	235,587.23	343,925.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	579,512.60

4315	SOBRA CHILD 14-20 FE	319,825.62	385,924.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	705,750.41

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

459.90	1,929.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,389.76

0.00	470.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	470.90

66,587.06	139,786.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206,373.74

617,725.42	908,907.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,526,632.72

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016

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

5018	SOBRA PREG 45-64 FE M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M

2,780.26	951.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,731.29

866.28	3,055.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,921.78

262.71	897.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,159.74

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

SUBTOTAL:

12,039,725.98

15,456,060.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,495,786.56

3100	TRANSPLANT OPTION	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,838.51
1
1,838.51

24,324.84	
61,497.58	
170,614.91	
36,327.82	
0.00	
103.44	
0.00	
4,980.01	
23,796.99	
352,009.15	
958,986.13	
851,797.36	
250.16	
28,990.33	
10,545.34	
50,638.77	
24,261.64	
11,236.78	
-728.71	
307,452.37	
43,878.05	
104,693.32	
479,450.60	
3,545,106.88	

1106	TANF EXPANDED 21-44	10,571.52	13,753.32	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	31,189.98	30,307.60	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	72,354.15	98,260.76	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

18,233.09	18,094.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	103.44	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	4,177.59	802.42	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	9,515.12	14,281.87	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	185,416.38	166,592.77	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	416,749.19	542,236.94	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	408,463.01	443,334.35	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	250.16	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	8,136.82	20,853.51	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	2,366.79	8,178.55	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	23,175.10	27,463.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

8,819.97	15,441.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5,234.94	6,001.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,088.04	-1,816.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

151,371.20	156,081.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

18,539.97	25,338.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

56,032.83	48,660.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

197,419.13	282,031.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

1,628,854.82

1,916,252.06	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	-107.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-107.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-107.53
4
0.00

SUBTOTAL:

-107.53

1

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3400	MED ELIGIBILITY W/ M	-128.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-128.19		
3608	AHC CARE/MI M&F 45-6	-10.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-10.16		
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		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		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	-14.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14.92		
SUBTOTAL:	-138.35	-14.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-153.27		

-204.83	
8,237.19	
3,286.03	
29,518.60	
29,568.03	
608,903.57	
350,783.44	
1,393,862.31	
28,335.66	
217.07	
0.00	
648.18	
74.57	
2,654.51	
1,269.29	
167,622.00	
150,153.17	
5,518,392.99	
1,898,747.75	
7,258,750.81	
2,683.63	
1,162.71	
17,454,666.68	

3506	ADULT 40-100% MALE 2	0.00	-204.83	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	1,642.39	6,594.80	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	3,286.03	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	13,795.62	15,722.98	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

14,424.55	15,143.48	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	241,184.19	367,719.38	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

146,713.41	204,070.03	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	609,541.43	784,320.88	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	22,516.25	5,819.41	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	217.07	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

3706	ADULT <40% EXP MALE	0.00	648.18	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

74.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

564.58	2,089.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

940.33	328.96	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	77,551.63	90,070.37	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

64,347.99	85,805.18	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	2,548,960.43	2,969,432.56	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
3728	ADULT <40% EXP M&F
4

765,143.06	1,133,604.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3,295,413.07	3,963,337.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2,136.91	546.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

579.64	583.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

7,805,747.12

9,648,919.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

68.40	
0.00	
5,833.17	
0.00	
10,916.17	
12,770.71	

3906	NEWLY ELIGIBLE MALE	0.00	68.40	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

2,854.42	2,978.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3914	NEWLY ELIGIBLE MALE	6,895.37	4,020.80	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

6,000.59	6,770.12	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-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016

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

3916	NEWLY ELIGIBLE MALE	86,585.35	154,491.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	241,077.04

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3928	NEWLY ELIGIBLE M&F
4

150,672.73	178,002.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	328,675.66

302,477.81	320,499.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	622,977.57

30.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30.62

SUBTOTAL:

555,516.89

666,832.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,222,349.34

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	
155,706.03	
39,441.27	
58,424.38	
253,571.68	

71,542.65	84,163.38	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	13,480.77	25,960.50	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

23,465.33	34,959.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

108,488.75

145,082.93	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
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	
782.08	
0.00	
0.00	
782.08	

0.00	782.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

782.08	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

4,051.48	9,611.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

13,663.00	
0.00	
3,237.84	
16,900.84	

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

724.25	2,513.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

4,775.73

12,125.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	22,144,827.06	27,845,914.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,990,741.77		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

1006	TANF 21-44 MALE WITH	0.00	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	0.00	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	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	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	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	0.00

4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

0.00	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 August 31, 2016

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

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

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

SUBTOTAL:

0.00

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

3100	TRANSPLANT OPTION	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
0.00

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

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1119	TANF EXPANDED 65+ M&

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

1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

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

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

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

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

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

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

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

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	
	0.00	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
0.00

SUBTOTAL:

0.00

1

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		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		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		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

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

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3515	ADULT 40-100% FEMAL E

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

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL E

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

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

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

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

3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3715	ADULT <40% EXP FEM AL

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

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3717	ADULT <40% EXP FEM AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3728	ADULT <40% EXP M&F
4

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

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

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

0.00	0.00	0.00	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	

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

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	0.00

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3928	NEWLY ELIGIBLE M&F
4

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

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

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

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

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
4618	CC PATIENT FEMALE 4
5

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

0.00	
0.00	
0.00	
0.00	
0.00	

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

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

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

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00	
0.00	
0.00	
0.00	

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

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

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

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:

0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

1006	TANF 21-44 MALE WITH	0.00	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	0.00

1008	TANF 45-64 M & F WIT	115.78	373.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	489.59

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	0.00

1011	TANF <1 M & F NON-ME	1,804.59	2,706.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,511.19

1012	TANF 01-05 M & F NON	3,987.61	3,263.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,251.20

1013	TANF 06-13 M & F NON	3,653.62	44.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,697.63

1014	TANF 14-20 MALE NON-	1,143.86	301.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,445.65

1015	TANF 14-20 FEMALE N O

1,333.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,333.07

1016	TANF 21-44 MALE NON-	2,299.03	1,606.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,905.36

1017	TANF 21-44 FEMALE N O

27,040.84	13,143.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,183.87

1018	TANF 45-64 M & F NON	28,071.21	1,484.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,555.27

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	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	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	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	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	0.00

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

596.90	3,497.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,094.18

5,148.07	-9,481.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4,333.58

2120	SSI AGED WITH QMB	242.01	-109.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132.27

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

60.91	-225.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-164.73

27,621.59	22,101.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,722.92

2,632.34	-15.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,617.11

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	0.00	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	0.00

4311	SOBRA CHILD <1 M & F	3,805.82	11,327.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,133.36

4312	SOBRA CHILD 01-05 M	65,933.12	13,197.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,130.47

4313	SOBRA CHILD 06-13 M	104,379.21	2,798.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,177.73

4314	SOBRA CHILD 14-20 MA	11,733.15	2,913.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,646.39

4315	SOBRA CHILD 14-20 FE	7,732.31	6,972.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,705.22

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

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

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

4,124.18	12,367.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,491.59

25,579.26	15,218.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,797.60

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

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

8040	SLMB	0.00	16.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.51

SUBTOTAL:

329,038.48

103,501.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	432,539.87

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	
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
0.00

0.00	
207.00	
1,596.06	
0.00	
0.00	
0.00	
0.00	
0.00	
93.00	
6,231.38	
23,672.41	
1,509.54	
0.00	
0.00	
397.24	
3.33	
191.51	
1,420.17	
0.00	
174.44	
166.07	
3,362.68	
1,665.21	
40,690.04	

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	86.04	120.96	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	698.08	897.98	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	93.00	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	2,328.77	3,902.61	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	13,339.04	10,333.37	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	861.72	647.82	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	64.36	332.88	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	3.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

0.00	191.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

903.35	516.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

174.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	166.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

77.84	3,284.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,647.33	17.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

20,273.97

20,416.07	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	
	0.00	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
0.00

SUBTOTAL:

0.00

1

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		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		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		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	
5,978.05	
497.80	
45,576.26	
3,632.83	
16,262.09	
0.00	
0.00	
0.00	
641.28	
0.00	
425.62	
0.00	
9,998.12	
6,546.29	
132,596.47	
63,674.17	
160,227.07	
0.00	
566.85	
446,622.90	

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

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	4,337.00	1,641.05	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

497.80	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	15,774.69	29,801.57	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

2,768.54	864.29	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	6,879.60	9,382.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3706	ADULT <40% EXP MALE	0.00	641.28	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

107.45	318.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3714	ADULT <40% EXP MALE	9,037.89	960.23	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

6,327.32	218.97	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	26,321.69	106,274.78	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
3728	ADULT <40% EXP M&F
4

14,376.87	49,297.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

39,054.06	121,173.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	566.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

125,482.91

321,139.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

42.18	
0.00	
166.79	
0.00	
0.00	
0.00	

3906	NEWLY ELIGIBLE MALE	34.78	7.40	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

101.36	65.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

3916	NEWLY ELIGIBLE MALE	2,914.09	14,106.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,020.90

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3928	NEWLY ELIGIBLE M&F
4

11,968.55	10,649.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,617.99

12,324.30	13,624.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,948.44

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

SUBTOTAL:

27,343.08

38,453.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,796.30

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	
12,436.21	
0.00	
1,876.24	
14,312.45	

8,378.75	4,057.46	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

901.53	974.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

9,280.28

5,032.17	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
4618	CC PATIENT FEMALE 4
5

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

0.00	
0.00	
0.00	
0.00	
0.00	

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

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

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

SUBTOTAL:

0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

0.00	651.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

651.68	
0.00	
21.54	
673.22	

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	21.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

0.00

673.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	511,418.72	489,216.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,000,634.78		

SUBTOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	36,872.16	53,054.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,926.71		
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		
	36,872.16	53,054.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,926.71		

TOTAL:

36,872.16

53,054.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	89,926.71

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

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

SUBTOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	363,227.79	409,117.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		772,345.57		
8040	SLMB	4.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.16		
8050	QI1	7.67	86.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94.36		
	363,239.62	409,204.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		772,444.09		

TOTAL:

363,239.62

409,204.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	772,444.09

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016

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

1006	TANF 21-44 MALE WITH	55.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55.05

1007	TANF 21-44 FEMALE WI	0.00	733.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	733.73

1008	TANF 45-64 M & F WIT	14.46	31.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.45

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	0.00

1011	TANF <1 M & F NON-ME	114,061.33	82,808.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	196,869.91

1012	TANF 01-05 M & F NON	1,877.83	4,691.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,569.49

1013	TANF 06-13 M & F NON	-34.11	397.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	363.65

1014	TANF 14-20 MALE NON-	0.00	503.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	503.34

1015	TANF 14-20 FEMALE N O

3,050.19	10,707.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,757.38

1016	TANF 21-44 MALE NON-	45,482.98	57,982.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,465.29

1017	TANF 21-44 FEMALE N O

106,522.53	130,723.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	237,245.71

1018	TANF 45-64 M & F NON	87,013.43	82,472.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	169,486.11

1019	TANF 65+ M & F NON-M	0.00	278.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	278.62

1026	TANF 21-44 MALE WITH	148.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148.09

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	0.00

1028	TANF 45-64 M & F WIT	50.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50.55

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	0.00

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

8,499.66	938.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,438.32

2,551.19	18.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,569.22

2120	SSI AGED WITH QMB	9,555.40	11,940.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,496.37

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

8,793.87	12,081.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,874.99

243,889.19	242,188.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	486,077.90

36,584.54	51,182.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,767.23

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

175.91	4,793.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,969.26

2320	SSI BLIND WITH QMB	1,288.00	88.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,376.30

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	0.00

4311	SOBRA CHILD <1 M & F	107,386.13	126,777.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	234,163.84

4312	SOBRA CHILD 01-05 M	31,803.55	53,396.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,200.00

4313	SOBRA CHILD 06-13 M	22,465.50	28,513.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,978.74

4314	SOBRA CHILD 14-20 MA	8,438.19	7,014.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,453.08

4315	SOBRA CHILD 14-20 FE	21,162.92	41,843.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,005.98

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

27.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.54

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

26,309.18	30,637.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,947.06

138,907.46	135,105.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	274,012.74

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016

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

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

56.68	90.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	147.34

80.51	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	137.68

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

SUBTOTAL:

1,026,217.75

1,117,999.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,144,216.96

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	
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
0.00

4,120.09	
1,992.76	
4,019.32	
538.71	
0.00	
0.00	
0.00	
0.00	
983.85	
126,694.57	
82,330.01	
44,628.26	
0.00	
2,302.83	
1,218.36	
1,608.36	
636.62	
25.19	
-552.47	
19,685.06	
805.68	
1,990.63	
21,914.85	
314,942.68	

1106	TANF EXPANDED 21-44	538.88	3,581.21	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	742.62	1,250.14	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	818.45	3,200.87	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

283.01	255.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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	477.50	506.35	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	24,491.12	102,203.45	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	23,380.49	58,949.52	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	24,860.13	19,768.13	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	190.62	2,112.21	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	958.28	260.08	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	474.42	1,133.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1129	TANF EXPANDED 65+ M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

345.00	291.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	25.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	-552.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

10,427.22	9,257.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

127.08	678.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1,127.98	862.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

9,014.59	12,900.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

98,257.39

216,685.29	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	
	0.00	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
0.00

SUBTOTAL:

0.00

1

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		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		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		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	
99.71	
0.00	
0.00	
2,241.84	
136,766.94	
55,464.17	
166,569.47	
0.00	
0.00	
0.00	
0.00	
0.00	
109.57	
0.00	
21,269.64	
21,181.72	
384,562.63	
170,845.63	
420,445.68	
62.60	
0.00	
1,379,619.60	

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

3508	ADULT 40-100% M&F 45	0.00	99.71	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

1,441.01	800.83	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	102,273.00	34,493.94	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

23,312.85	32,151.32	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	74,316.57	92,252.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

52.40	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3714	ADULT <40% EXP MALE	13,443.49	7,826.15	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

1,025.71	20,156.01	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	191,333.82	193,228.81	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
3728	ADULT <40% EXP M&F
4

64,187.35	106,658.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

145,955.90	274,489.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

62.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

SUBTOTAL:

617,404.70

762,214.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	
0.00	
0.00	
0.00	
1,014.20	
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	833.48	180.72	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

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV

For The Period Ending August 31, 2016

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

3916	NEWLY ELIGIBLE MALE	4,882.72	6,594.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,477.51

3917	NEWLY ELIGIBLE FEMA L
3918	NEWLY ELIGIBLE M&F
4
3928	NEWLY ELIGIBLE M&F
4

14,967.59	27,110.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,077.68

19,064.87	22,092.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,157.58

0.00	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:

39,748.66

55,978.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95,726.97

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	
3,772.89	
9,040.31	
6,221.85	
19,035.05	

1,139.50	2,633.39	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	476.67	8,563.64	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

4,498.40	1,723.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

6,114.57

12,920.48	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
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	
15.42	
0.00	
0.00	
15.42	

15.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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:

15.42

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	355.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

355.04	
0.00	
0.00	
355.04	

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

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

355.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

TOTAL:	1,787,758.49	2,166,153.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,953,911.72		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00

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

219,052.35	253,349.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	472,401.60

40,660.18	71,145.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111,805.41

2120	SSI AGED WITH QMB	182,700.41	209,792.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	392,492.71

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

34,869.86	45,426.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,295.91

717,819.30	840,735.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,558,555.19

69,871.55	87,449.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	157,321.30

4,453.28	8,672.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,125.50

2320	SSI BLIND WITH QMB	388.66	676.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,064.78

SUBTOTAL:

1,269,815.59

1,517,614.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,787,430.40

M M

1,270,468.89	1,518,860.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1,898.93

0.00

1,898.93

8710	SSI DISABLED FREEDO	653.30	1,245.63	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	
	653.30	1,245.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

2,789,329.33

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

2,058,486.95	2,374,297.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,432,784.20

108,527.50	93,777.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	202,304.68

2120	SSI AGED WITH QMB	2,980,893.26	3,717,043.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,697,937.05

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

499,603.04	639,287.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,138,890.41

1,864,375.53	2,336,558.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,200,934.30

686,455.43	834,681.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,521,136.66

7,847.76	12,002.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,850.24

2320	SSI BLIND WITH QMB	6,736.52	6,974.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,711.23

8710	SSI DISABLED FREEDO	0.00	5,385.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	2,765.43	3,427.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,765.43	8,812.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

8,212,925.99

10,014,622.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,227,548.77

M M
SUBTOTAL:

5,385.60

6,192.63

11,578.23

TOTAL:	8,215,691.42	10,023,435.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,239,127.00		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

20,107.37	65,824.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85,931.52

321.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	321.97

2120	SSI AGED WITH QMB	16,004.46	3,678.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,683.27

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

859.25	960.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,819.70

65,859.49	70,521.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	136,380.95

304.54	4,059.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,363.76

0.00	326.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	326.95

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

SUBTOTAL:

103,457.08

145,371.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248,828.12

M M

103,457.08	145,371.04	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

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:

248,828.12

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV

For The Period Ending August 31, 2016

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

1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

10,300.49	39,674.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,974.82

217.99	5,861.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,079.02

2120	SSI AGED WITH QMB	16,020.55	21,126.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,146.74

2200	SSI DISABLED WITH M E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

2,621.87	11,047.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,669.39

46,899.42	39,426.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	86,326.33

7,860.45	13,901.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,761.83

0.00	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	81.78	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138.95

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:

84,002.55

131,094.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215,097.08

M M
SUBTOTAL:

0.00

0.00

0.00

TOTAL:	84,002.55	131,094.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,097.08		

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

C

KidsCare - CAPITATION AMOUNTS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	479.18	-557.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-78.31		
6012	KIDS 1-5 M & F NON-M	0.00	-6,189.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6,189.47		
6013	KIDS 6-13 M & F NON-	33,225.63	13,672.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,898.28		
6014	KIDS 14-19 MALE NON-	31,612.49	24,016.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,628.64		
6015	KIDS 14-19 FEMALE NO	40,507.26	29,084.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,591.71		
SUBTOTAL:	105,824.56	60,026.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,850.85		

TOTAL:

105,824.56

60,026.29

165,850.85

KidsCare - CAPITATION MEMBER MONTHS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
6012	KIDS 1-5 M & F NON-M	0.00	0.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.41		
6013	KIDS 6-13 M & F NON-	243.88	228.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		472.29		
6014	KIDS 14-19 MALE NON-	166.11	161.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327.11		
6015	KIDS 14-19 FEMALE NO	138.19	130.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.60		
SUBTOTAL:	549.18	521.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,070.41		

C

TOTAL:	549.18	521.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,070.41		

C

20,727.54	19,967.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	38.24	38.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.48		
6013	KIDS 6-13 M & F NON-	8,948.16	8,489.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,437.44		
6014	KIDS 14-19 MALE NON-	6,415.19	6,262.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,677.42		
6015	KIDS 14-19 FEMALE NO	5,325.95	5,177.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,503.27		
	20,727.54	19,967.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,694.61		

TOTAL:

40,694.61

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
6013	KIDS 6-13 M & F NON-	234.00	222.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		456.00		
6014	KIDS 14-19 MALE NON-	157.00	153.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310.00		
6015	KIDS 14-19 FEMALE NO	130.00	125.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255.00		
	522.00	501.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,023.00		

C

SUBTOTAL:

TOTAL:	522.00	501.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,023.00		

0.00	230.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

KidsCare - FEE FOR SERVICE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6014	KIDS 14-19 MALE NON-	0.00	15.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.43		
6015	KIDS 14-19 FEMALE NO	0.00	214.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214.91		
	0.00	230.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230.34		

TOTAL:

230.34

KidsCare - REINSURANCE

For The Period Ending August 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6014	KIDS 14-19 MALE NON-	82,673.79	198.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,872.74		
	82,673.79	198.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,872.74		

SUBTOTAL:

TOTAL:	82,673.79	198.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,872.74		

0

00

110007 DES-DD - CAP MEMBER MONTHS

For The Period Ending August 31, 2016		
RATE CODE	DESCRIPTION	JULY	AUGUST     SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
		
1000	TANF WITH MEDICARE	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0

0	20.00		
1010	TANF NON-MEDICARE	666.51	671.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,338.28		
1020	TANF WITH QMB	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2100	SSI AGED WITH MEDICA	170.32	172.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343.07		
2110	SSI AGED NON-MEDICAR	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2120	SSI AGED WITH QMB	271.83	271.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		542.85		
2200	SSI DISABLED WITH ME	1,947.34	1,983.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,930.53		
2210	SSI DISABLED NON-MED	22,244.95	22,359.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,604.47		
221Z	SSI DISABLED NON-MED	0.00	1.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.03		
2220	SSI DISABLED WITH QM	4,066.85	4,090.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,156.88		
2300	SSI BLIND WITH MEDIC	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.00		
2310	SSI BLIND NON-MEDICA	118.99	121.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.99		
2320	SSI BLIND WITH QMB	28.19	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.19		
8700	SSI DISABLED FREEDOM	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
8710	SSI DISABLED FREEDOM	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
8720	SSI DISABLED FREEDOM	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
	29,556.98	29,741.31	0.00	0.00	0.00	0.00	0.00	0.00	0.0	0	0.00	0.00	0.0		59,298.29		
	29,556.98	29,741.31	0.00	0.0	0.00	0.00	0.00	0.00	0.0	0	0.	0.00	0.0		59,298.29		

SUBTOTAL: TOTAL:

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending August 31, 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	378,708.42
85,600,877.03	372,091.86
98,791,049.82	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	750,800.28
184,391,926.85	
	85,979,585.45
104,331,950.18	99,163,141.68
104,866,978.39	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	185,142,727.13
209,198,928.57	
	104,331,950.18	104,866,978.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	209,198,928.57	
TOTAL LTC - CAP	190,311,535.63	204,030,120.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	394,341,655.70	

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	
	9,673,619.94
0.00	11,818,761.59
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	21,492,381.53
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	9,673,619.94	11,818,761.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,492,381.53	

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	
	4,453,643.29
513,400.18	5,137,624.64
371,137.98	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	9,591,267.93
884,538.16	
	513,400.18	371,137.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	884,538.16	
TOTAL LTC - REIN	4,967,043.47	5,508,762.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,475,806.09	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	3,612,630.10	3,599,535.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,212,165.40	

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

120

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS

For the Period Ending August 31, 2016

010115	CRS FULLY INTEGRATED PLAN - CAP	14,211,057.11	13,919,274.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,130,331.45	
010145	CRS ACUTE SEMI INTEGRATED - CAP	145,463.25	142,594.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	288,058.10	
999125	CRS SEMI INTEGRATED PLAN - CAP	4,973,747.20	4,959,398.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,933,145.60	
999135	CRS ONLY PLAN - CAP	551,073.60	552,982.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,104,055.68	
	19,881,341.16	19,574,249.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,455,590.83	

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

TOTAL

Friday, September 16, 2016

999155	CRS REINSURANCE ONLY	2,326,263.42	446,456.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,772,720.27	
	2,326,263.42	446,456.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,772,720.27	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC CAP	22,593.49	10,554.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,147.75	
010145	CRS ACUTE SEMI INTEGRATED - KC CAP	0.00	-118.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-118.49	
	22,593.49	10,435.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,029.26	

Subtotal

Subtotal

22,230,198.07	20,031,142.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,261,340.36	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS

For the Period Ending August 31, 2016

010115	CRS FULLY INTEGRATED PLAN - MM	17,102.15	16,990.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,092.65	
010145	CRS ACUTE SEMI INTEGRATED - MM	181.59	179.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	361.57	
999125	CRS SEMI INTEGRATED PLAN - MM	6,586.00	6,567.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,153.00	
999135	CRS ONLY PLAN - MM	1,155.00	1,159.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,314.00	
	25,024.74	24,896.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,921.22	

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

TOTAL

Friday, September 16, 2016

010115	CRS FULLY INTEGRATED PLAN - KC MM	27.18	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.18	
010145	CRS ACUTE SEMI INTEGRATED - KC MM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	27.18	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.18	

Subtotal

Subtotal

25,051.92	24,923.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,975.40	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS

For the Period Ending August 31, 2016

010700	HEALTH CHOICE INTEGRATED - CAP	8,139,817.79	8,143,584.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,283,401.88	
010725	CENPATICO INTEGRATED - CAP	19,718,383.80	19,873,855.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,592,239.48	
078999	MERCY MARICOPA INTEGRATED - CAP	43,908,062.70	44,810,326.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,718,389.44	
	71,766,264.29	72,827,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144,594,030.80	

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

TOTAL

Friday, September 16, 2016

Subtotal

71,766,264.29	72,827,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144,594,030.80	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS

For the Period Ending August 31, 2016

010700	HEALTH CHOICE INTEGRATED - MM	5,434.12	5,436.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,870.25	
010725	CENPATICO INTEGRATED - MM	12,956.97	13,057.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,014.65	
078999	MERCY MARICOPA INTEGRATED - MM	19,855.38	20,248.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,104.26	
	38,246.47	38,742.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,989.16	

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

TOTAL

Friday, September 16, 2016

Subtotal

38,246.47	38,742.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76,989.16	

GRAND TOTAL