October 25, 2016

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

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

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

SUBJECT: FY 2017 Appropriation Status Report for the Period Ended September 30, 2016

Dear President Biggs and Speaker Gowan:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended 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 – September 2016 enrollment is 1,888,006 members, an 18,259 member increase over the prior month. Enrollment for October 2016 increased to 1,900,792 members, a 12,786 member increase.

Major October changes by eligibility category include: 1931 for Families and   Children/SOBRA
– increase of 5,378; Supplemental Security Income – increase of 483; Prop 204 Restoration -

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. October 25, 2016
Page 2

increase of 1,309; Adult Expansion - increase of 232; Medicare Cost Sharing – increase of   756;
and Federal Emerge  cy Services - increase of 1,388.

Tobacco  Funds  Revenue  Update  –  Tobacco  tax  collections  through  September  2016   are
$183,600 more than the AHCCCS monthly projected flows. AHCCCS will monitor the   tobacco

funds revenue collections throughout the appropriations.

year  to  determine  any  impact  on  the    FY

2017

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.

Sincerel ,

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 September 30, 2016

Prepared by: Division of Business and Finance

Appropriation Status Report
Table of Contents
APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 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 September 30, 2016
SUMMARY  OF  APPROPRIATED EXPENDITURES

	

ANNUAL APPROPRIATION		(A)       EXPENDITURE PLAN
YTD		(B)

EXPENDITURES YTD		(A) - (B)

VARIANCE YTD		
PROJECTED ANNUAL EXPENDITURES		

ANNUALIZED VARIANCE		

APPROPRIATIONS:													
ADMINISTRATION													
AHCCCS Operating Lump Sum	$	91,690,700		$	20,049,876		$	16,401,862		$	3,648,014		$	91,690,700		$	-		
AHCCCS Prop 204 Administration	13,666,600		2,822,063		3,292,054		(469,991)		13,666,600		-		
DES Eligibility	54,874,500		14,392,700		8,153,594		6,239,106		54,874,500		-		
DES Prop 204 Eligibility	38,358,700		10,155,900		3,064,457		7,091,444		38,358,700		-		
TOTAL ADMINISTRATION	 	198,590,500 		 	47,420,539 		 	30,911,967 		 	16,508,572 		 	198,590,500 		 	-			

Traditional Medicaid Services	3,835,595,600	951,902,600	977,208,533	(25,305,933)	3,835,595,600	-	
Proposition 204 Services	2,877,688,100	654,053,000	695,530,371	(41,477,371)	2,877,688,100	-	
ACA Adult Expansion	462,284,600	110,624,000	104,629,044	5,994,956	462,284,600	-	
Children's Rehabilitative Services	274,348,100	62,016,900	62,816,704	(799,804)	274,348,100	-	
KidsCare Services	1,955,000	288,300	211,385	76,915	1,955,000	-	
ALTCS Services	1,422,354,600	344,263,600	335,895,900	8,367,700	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	228,473,400	227,649,809	823,591	960,228,100	-	
Behavioral Health Proposition 204 Services	612,844,800	143,349,600	141,037,986	2,311,614	612,844,800	-	
Behavioral Health ACA Adult Expansion	77,702,300	17,779,500	16,615,505	1,163,995	77,702,300	-	
Behavioral Health CMDP	208,027,400	53,194,400	48,161,086	5,033,314	208,027,400	-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900	19,711,800	19,348,180	363,620	78,846,900	-	
Supported Housing	5,324,800	1,331,100	1,309,461	21,639	5,324,800	-	
Crisis Services	16,391,300	4,097,700	4,076,575	21,125	16,391,300	-	

TOTAL PROGRAMMATIC	 	11,181,217,300	 	2,591,826,800	 	2,635,231,446	 	(43,404,646)	 	11,181,217,300	 	-	

TOTAL EXPENDITURES

$	11,379,807,800

$    2,639,247,339

$   2,666,143,413

$	(26,896,074)

$   11,379,807,800	$	-

2

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		
Administrative Expenditures	$	55,399,000	$	13,384,411	$	8,938,131	4,446,280	$	55,399,000	$	-	
Proposition 204 - Administrative Expenditures	21,746,500	5,535,160	1,731,783	3,803,378	21,746,500	-	

Programmatic Expenditures							
Traditional Medicaid Services	782,768,800	214,790,100	202,544,624	12,245,476	782,768,800	-	
Proposition 204 Services	100,000,000	(4,061,900)	19,048,499	(23,110,399)	100,000,000	-	
Children's Rehabilitative Services	84,424,100	19,259,200	17,643,329	1,615,871	84,424,100	-	

KidsCare Services	-	-	(23,942)	23,942	-	-	
ALTCS Services	167,841,100	40,802,800	41,960,275	(1,157,475)	167,841,100	-	
DSH and Rural Hospitals	7,239,300	-	-	-	7,239,300	-	
Behavioral Health Traditional Medicaid Services	259,356,900	62,204,600	62,966,290	(761,690)	259,356,900	-	
Behavioral Health Proposition 204 Services	109,250,500	25,411,600	24,471,212	940,388	109,250,500	-	
Behavioral Health ACA Adult Expansion Behavioral Health CMDP	831,900
63,770,500	- 16,433,000	- 14,921,324	- 1,511,676	831,900
63,770,500	-
-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900	19,711,800	19,348,180	363,620	78,846,900	-	
Supported Housing	5,324,800	1,331,100	1,309,461	21,639	5,324,800	-	
Crisis Services	 	14,141,100 	 	3,535,200 	 	3,514,025 	 	21,175 	 	14,141,100 	 	- 	
TOTAL GF EXPENDITURES	1,750,941,400	436,116,571	418,373,190	(36,118)	1,750,941,400	-	

FEDERAL		
Administrative Expenditures	90,666,200	20,991,263	15,607,570	5,383,693	90,666,200	-	
Proposition 204 - Administrative Expenditures	26,715,500	6,499,202	4,624,728	1,874,475	26,715,500	-	

Programmatic Expenditures							
Traditional Medicaid Services	2,558,500,000	616,907,500	590,149,926	26,757,574	2,558,500,000	-	
Proposition 204 Services	2,375,352,300	559,666,200	600,897,922	(41,231,722)	2,375,352,300	-	
ACA Adult Expansion	456,023,100	110,624,000	104,629,044	5,994,956	456,023,100	-	
Children's Rehabilitative Services	189,924,000	42,757,700	45,173,375	(2,415,675)	189,924,000	-	
KidsCare Services	1,585,000	(16,200)	235,327	(251,527)	1,585,000	-	
ALTCS Services and Nursing Facility Assessment DSH and Rural Hospitals	953,302,500
20,497,800	230,116,700
-	209,620,391
-	20,496,309
-	953,302,500
20,497,800	-
-	
Behavioral Health Traditional Medicaid Services	665,305,400	157,738,700	155,792,069	1,946,631	665,305,400	-	
Behavioral Health Proposition 204 Services	503,594,300	117,938,000	116,566,774	1,371,226	503,594,300	-	
Behavioral Health ACA Adult Expansion	76,870,400	17,779,500	16,615,505	1,163,995	76,870,400	-	
Behavioral Health CMDP	144,256,900	36,761,400	33,239,763	3,521,638	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	1,918,268,165	1,893,656,631	24,611,534	8,213,839,100	-	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,563,300	943,600	-	943,600	3,563,300	-	
Programmatic Expenditures					
Traditional Medicaid Services Acute Care	49,687,700	12,159,100	12,159,100	-	49,687,700	-	
ALTCS Services	 	249,980,000 	 	60,780,100 	 	70,037,025	 	(9,256,925)	 	249,980,000 	 	- 	
TOTAL COUNTY EXPENDITURES	303,231,000	73,882,800	82,196,125	(8,313,325)	303,231,000	-	

	(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	9,160,100	9,358,100	(198,000)	37,432,400	-	
Behavioral Health Traditional Medicaid Services - Medically Needy		35,565,800	8,530,100	8,891,450	(361,350)	35,565,800	-	
Proposition 204 Services - Emergency Health Services		18,747,200	4,430,600	4,686,800	(256,200)	18,747,200	-	
Proposition 204 Services - Proposition 204 Protection		37,521,000	8,867,500	9,380,250	(512,750)	37,521,000	-	
Proposition 204 Services - ATLSF	 	100,000,000 	 	23,633,700 	 	- 	 	23,633,700 	 	100,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	229,266,400	54,622,000	32,316,600	22,305,400	229,266,400	-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	

OTHER

500,000	

66,903	9,755	57,148	500,000	-	
Acute Care - Prescription Drug Rebate Program State Match	105,837,600	25,899,700	42,455,800	(16,556,100)	105,837,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	301,143,200	72,938,500	120,457,280	(47,518,780)	301,143,200	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,441,300	1,812,800	1,860,325	(47,525)	7,441,300	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	21,600,300	5,203,800	7,862,309	(2,658,509)	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	47,600	69,492	(21,892)	194,700	-	
ALTCS Services - TPL	-	-	220,345	(220,345)	-	-	
ALTCS Services - Nursing Facility Assessment	22,189,400	5,547,400	4,335,229	1,212,171	22,189,400	-	
KidsCare Services Premiums	370,000	304,500	-	304,500	370,000	-	
Freedom to Work Premiums	31,200	-	14,211	(14,211)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	562,500	562,550	(50)	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	174,137,303	239,600,866	(65,463,564)	882,529,900	-	

TOTAL		
Administrative Expenditures	198,590,500		47,420,539		30,911,967		16,508,572		198,590,500		-	
Acute Care	9,758,862,700		2,247,563,200		2,299,335,546		(51,772,346)		9,758,862,700		-	
Long Term Care	 	1,422,354,600 		 	344,263,600 		 	335,895,900 		 	8,367,700 		 	1,422,354,600 		 	- 	
TOTAL EXPENDITURES	  $	11,379,807,800 		  $	2,639,247,339 		  $	2,666,143,413 		  $	(26,896,073)		  $	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 September 30, 2016

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	929,831,200	$	247,433,711	$	229,126,084	
Proposition 204 Services & Administrative	121,746,500	1,473,260	45,251,493	
KidsCare Services	-	-	(23,942)	
ALTCS Services	167,841,100	40,802,800	41,960,275	
Behavioral Health Traditional Medicaid Services	 	531,522,600	 	128,627,300	 	102,059,280 	
TOTAL	1,750,941,400	418,337,071	418,373,190	

FEDERAL:
Acute & Administrative	5,868,924,600		1,357,950,065		1,365,924,974	
KidsCare Services	1,585,000		(16,200)		923,559	
ALTCS Services	953,302,500		230,116,700		218,271,249	
Behavioral Health Traditional Medicaid Services	 	1,390,027,000 		 	330,217,600 		 	322,385,321 	
TOTAL	8,213,839,100		1,918,268,165		1,907,505,103	

COUNTY:						
Acute & Administrative	53,251,000		13,102,700		11,473,373	
ALTCS Services	 	249,980,000 		 	60,780,100 		 	62,495,001 	
TOTAL	303,231,000		73,882,800		73,968,374	

TOBACCO FUNDS:						
Traditional Medicaid Services	72,998,200		17,690,200		18,249,550	
Proposition 204 Services	 	156,268,200 		 	36,931,800 		 	14,067,050 	
TOTAL	229,266,400		54,622,000		32,316,600	

OTHER:						
Administrative	500,000		66,903		9,755	
Acute Care - Prescription Drug Rebate Program	406,980,800		98,838,200		162,913,080	
Long Term Care - Prescription Drug Rebate Program	29,041,600		7,016,600		9,722,634	
Hospital Assessment	252,329,100		61,516,900		66,203,791	
ALTCS - Nursing Facility Assessment	22,189,400		5,547,400		5,662,083	
Acute TPL - Note 1	194,700		47,600		69,492	
LTC TPL - Note 1	-		-		220,345	
KidsCare TPL - Note 1	-		-		978	
Member Premiums - CHIP	370,000		304,500		39,806	
Member Premiums - Freedom to Work	31,200		-		14,211	
Behavioral Health Traditional Medicaid Services	2,250,200		562,500		3,314,855	
Voluntary Political Subdivision - State Match	 	168,642,900 		 	236,700 		 	3,630,536 	
TOTAL	882,529,900		174,137,303		251,801,567	

TOTAL REVENUE

$	11,379,807,800

$	2,639,247,339

$	2,683,964,833

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2016	
Note 1:	Third Party Liability Collections:	September 2016		September 2015		July 1, 2016		July 1, 2015	
	Gross Collections:					September 30, 2016		September 30, 2015	
	Acute	$	516,654		$	427,291		$	1,258,616		$	1,247,725	
	LTC	229,483		317,202		1,009,516		905,933	
	KidsCare	4,878		466		4,878		103,981	
	Total TPL Collections	$	751,015		$	744,959		$	2,273,010		$	2,257,639	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	27,813		$	31,857		$	69,492		$	136,662		
LTC	46,440		74,192		220,345		207,634		
KidsCare	980		88		978		20,853		
Total Expenditure Offsets	$	75,233		$	106,137		$	290,815		$	365,149		

FY 17 Total

Note 2:    Authorized Positions	1,141.2
Actual Positions as of September 30, 2016	1,031.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2016

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2016	$	1,933,160	
	Revenues	2,325,004	
	Transfers-In	 	157,342 	
	Total Revenues	 	2,482,346 	
	Expenditures	1,360,918	
	Transfers-out	 	327,536 	
	Total Expenditures	 	1,688,454 	
	Ending Balance September 30, 2016	  $	2,727,052 	

Of the $2,727,052 ending balance, $1,704,235 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through September 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of September 30, 2016

Description		Amount		Type	

School Based Claiming Medicaid Administrative Costs		
18,941,355		
HHS-OIG & AHCCCS Self Reported	
School Based Claiming Direct Services Costs		19,923,489		HHS-OIG	
		 	38,864,844 			

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2016

Note 5:	Summary of Voluntary Political Subdivision Contribution Expenditures:	

State Match	
As of September 30, 2016 Expenditures

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	

Note 6:

Summary of KidsCare non-appropriated administrative and programmatic expenditures in excess of those amounts included in Laws 2016, Chapter 117 that are necessary to implement the legislative intent of Laws 2016, Chapter 112.

	As of September 30, 2016		
	Expenditures		
	Expenditure				Projected	
	Plan YTD	Expenditures YTD	Variance YTD		Annual Expenditures	

AHCCCS Operating CHIP Fund	
$	-	
$	-	
$	-		
$	3,511,900	
DES Eligibility CHIP Fund	-	4,602	(4,602)		3,511,800	
KidsCare Services CHIP Fund	1,728,100	624,435	1,103,665		63,214,800	
Total KidsCare CHIP Type 3 Appropriation Expenditures	$	1,728,100	$	629,037	$	1,099,063		$	70,238,500	

Appropriation Status Report
Caseload and Expenditures by Rate Code

TITLE XIX TRADITIONAL

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

TOTAL

CAPITATION - ACUTE	278,655,778	277,811,900	280,062,197	0	0	0	0	0	0	0	0	0	836,529,875	
CAPITATION - LTC	190,311,536	204,030,120	191,838,793	0	0	0	0	0	0	0	0	0	586,180,449	
MENTAL HEALTH - CHILD	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - ADULT	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - GENERAL	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - CMDP	0	0	0	0	0	0	0	0	0	0	0	0	0	
CHILDREN'S REHAB SERVICES	5,498,579	5,487,093	5,486,973	0	0	0	0	0	0	0	0	0	16,472,645	
FEE FOR SERVICE - ACUTE	43,169,220	49,076,411	38,450,549	0	0	0	0	0	0	0	0	0	130,696,180	
FFS - PRIOR QUARTER COVERAGE	399,183	701,172	353,914	0	0	0	0	0	0	0	0	0	1,454,269	
EMERGENCY SERVICES - FEDERAL	4,723,538	6,876,303	5,487,551	0	0	0	0	0	0	0	0	0	17,087,393	
FFS MEDICAID IN PUBLIC SCHOOLS	334,212	144,833	272,818	0	0	0	0	0	0	0	0	0	751,863	
STATE ONLY TRBHA FFS	0	12,155	22,043	0	0	0	0	0	0	0	0	0	34,197	
FFS TRBHA FEE FOR SERVICE	1,636,296	6,817,558	5,048,877	0	0	0	0	0	0	0	0	0	13,502,731	
QMB - FEE FOR SERVICE	400,115	462,259	326,723	0	0	0	0	0	0	0	0	0	1,189,097	
INPATIENT INMATES FFS	125,819	53,097	229,997	0	0	0	0	0	0	0	0	0	408,913	
PINAL COUNTY INMATES FFS	4,630	3,154	-3,803	0	0	0	0	0	0	0	0	0	3,981	
MARICOPA CTY INMATES FFS	22,177	38,629	14,576	0	0	0	0	0	0	0	0	0	75,382	
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	2,537	0	0	0	0	0	0	0	0	0	30,052	
FEE FOR SERVICE - LTC	9,673,620	11,818,762	10,004,476	0	0	0	0	0	0	0	0	0	31,496,857	
LFFS - PRIOR QUARTER COVERAGE	25,539	27,090	12,241	0	0	0	0	0	0	0	0	0	64,870	
LFFS MEDICAID IN PUBLIC SCHOOLS	828,652	474,874	685,238	0	0	0	0	0	0	0	0	0	1,988,764	
REINSURANCE - ACUTE	10,931,804	9,903,096	8,491,782	0	0	0	0	0	0	0	0	0	29,326,682	
REINSURANCE - LTC	4,967,043	5,508,763	5,025,290	0	0	0	0	0	0	0	0	0	15,501,097	
SMIB - ACUTE	13,288,395	13,803,812	14,079,809	0	0	0	0	0	0	0	0	0	41,172,016	
HIB - ACUTE	361,563	411,610	422,087	0	0	0	0	0	0	0	0	0	1,195,260	
Q1	2,222,029	2,257,441	2,298,793	0	0	0	0	0	0	0	0	0	6,778,262	
SMIB - LTC	3,328,913	3,313,965	3,329,893	0	0	0	0	0	0	0	0	0	9,972,771	
HIB - LTC	283,717	285,570	285,293	0	0	0	0	0	0	0	0	0	854,581	
SUBTOTAL	571,193,666	599,354,227	572,228,646	0	0	0	0	0	0	0	0	0	1,742,776,539	

TITLE XIX PROP 204

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

TOTAL

CAPITATION - ACUTE	212,953,625	204,441,592	206,290,174	0	0	0	0	0	0	0	0	0	623,685,391	
MENTAL HEALTH - CHILD	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - ADULT	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - GENERAL	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - CMDP	0	0	0	0	0	0	0	0	0	0	0	0	0	
CHILDREN'S REHAB SERVICES	24,810	23,856	23,856	0	0	0	0	0	0	0	0	0	72,522	
FEE FOR SERVICE - ACUTE	30,892,242	33,585,002	26,203,618	0	0	0	0	0	0	0	0	0	90,680,862	
FFS - PRIOR QUARTER COVERAGE	626,645	888,463	903,725	0	0	0	0	0	0	0	0	0	2,418,833	
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	2,628,341	0	0	0	0	0	0	0	0	0	7,325,969	
FFS MEDICAID IN PUBLIC SCHOOLS	935	797	636	0	0	0	0	0	0	0	0	0	2,368	
INPATIENT INMATES FFS	802,511	1,152,396	1,098,452	0	0	0	0	0	0	0	0	0	3,053,359	
FFS TRBHA FEE FOR SERVICE	668,712	3,783,524	2,819,057	0	0	0	0	0	0	0	0	0	7,271,293	
STATE ONLY TRBHA FFS	11,429	35,462	16,328	0	0	0	0	0	0	0	0	0	63,219	
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	1,220	0	0	0	0	0	0	0	0	0	56,308	
PIMA COUNTY INMATES FFS	17,640	22,452	328	0	0	0	0	0	0	0	0	0	40,420	
MARICOPA CTY INMATES FFS	136,056	149,042	84,034	0	0	0	0	0	0	0	0	0	369,132	
COCONINO COUNTY INMATES FFS	3,420	-3,257	184	0	0	0	0	0	0	0	0	0	347	
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	4,271,544	0	0	0	0	0	0	0	0	0	12,963,223	
SMIB - ACUTE	5,139,071	5,095,292	5,027,067	0	0	0	0	0	0	0	0	0	15,261,429	
HIB - ACUTE	5,630	6,904	5,363	0	0	0	0	0	0	0	0	0	17,898	
SUBTOTAL	257,141,258	256,774,362	249,373,927	0	0	0	0	0	0	0	0	0	763,289,547	

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

TOTAL

CAPITATION - ACUTE	32,527,702	31,697,577	31,798,297	0	0	0	0	0	0	0	0	0	96,023,576	
MENTAL HEALTH - CHILD	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - ADULT	0	0	0	0	0	0	0	0	0	0	0	0	0	
MENTAL HEALTH - GENERAL	0	0	0	0	0	0	0	0	0	0	0	0	0	
CHILDREN'S REHAB SERVICES	1,431	1,431	1,431	0	0	0	0	0	0	0	0	0	4,294	
FEE FOR SERVICE - ACUTE	2,287,256	2,691,862	2,142,231	0	0	0	0	0	0	0	0	0	7,121,348	
FFS - PRIOR QUARTER COVERAGE	202,656	242,552	172,172	0	0	0	0	0	0	0	0	0	617,379	
EMERGENCY SERVICES - FEDERAL	3,157,734	4,543,147	3,298,138	0	0	0	0	0	0	0	0	0	10,999,019	
FFS MEDICAID IN PUBLIC SCHOOLS	0	143	122	0	0	0	0	0	0	0	0	0	265	
INPATIENT INMATES FFS	47,079	7,086	51,595	0	0	0	0	0	0	0	0	0	105,760	
FFS TRBHA FEE FOR SERVICE	21,432	99,702	78,173	0	0	0	0	0	0	0	0	0	199,306	
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	693,714	0	0	0	0	0	0	0	0	0	2,219,722	
SMIB - ACUTE	487	365	0	0	0	0	0	0	0	0	0	0	853	
	38,639,830	40,424,404	38,235,874	0	0	0	0	0	0	0	0	0	117,300,108	
	866,974,755	896,552,993	859,838,447	0	0	0	0	0	0	0	0	0	2,623,366,194	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
KidsCare - CAPITATION	105,825	60,026	453,014	0	0	0	0	0	0	0	0	0	618,865	
KidsCare - FEE FOR SERVICE	0	230	1,062	0	0	0	0	0	0	0	0	0	1,293	
KidsCare - MENTAL HEALTH	0	0	0	0	0	0	0	0	0	0	0	0	0	
KidsCare - REINSURANCE	82,674	199	63,656	0	0	0	0	0	0	0	0	0	146,529	

188,498	60,456	517,732	0	0	0	0	0	0	0	0	0	766,686	

TOTAL TITLE XXI

867,163,253	896,613,448	860,356,180	0	0	0	0	0	0	0	0	0	2,624,132,881	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1002	TANF 01-05 M & F WIT	0.00	0.00	30.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.83		
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	330.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		991.47		
1005	TANF 14-20 FEMALE WI	4,171.93	2,017.48	2,017.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,206.89		
1006	TANF 21-44 MALE WITH	46,322.50	44,791.85	45,967.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,081.47		
1007	TANF 21-44 FEMALE WI	95,394.39	105,867.62	103,594.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304,856.72		
1008	TANF 45-64 M & F WIT	142,836.05	148,048.76	155,026.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445,911.06		
1009	TANF 65+ M & F WITH	49,195.35	58,493.70	60,090.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,779.32		
100B	TANF 01-05 M & F WIT	0.00	0.00	40.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.03		
100F	TANF 21-44 MALE WITH	2,174.21	932.26	242.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,348.86		
100G	TANF 21-44 FEMALE WI	979.52	875.88	956.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,811.58		
100H	TANF 44-64 M & F WIT	2,819.97	2,677.17	1,834.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,331.32		
100J	TANF 65+ M & F WITH	1,265.56	285.44	454.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,005.14		
1011	TANF <1 M & F NON-ME	5,979,797.90	5,818,316.42	5,667,860.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,465,975.11		
1012	TANF 01-05 M & F NON	1,982,751.29	2,047,597.48	2,192,866.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,223,215.08		
1013	TANF 06-13 M & F NON	3,400,616.72	3,421,770.87	3,534,174.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,356,561.77		
1014	TANF 14-20 MALE NON-	1,438,649.82	1,450,579.41	1,494,737.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,383,966.53		
1015	TANF 14-20 FEMALE N O	2,947,635.53	2,963,712.47	2,982,834.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,894,182.82		
1016	TANF 21-44 MALE NON-	4,500,694.58	4,626,964.05	4,729,641.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,857,300.01		
1017	TANF 21-44 FEMALE N O	21,599,593.38	22,024,671.06	22,380,320.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,004,584.69		
1018	TANF 45-64 M & F NON	9,002,157.42	9,224,599.92	9,390,965.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,617,723.22		
1019	TANF 65+ M & F NON-M	34,981.92	37,207.86	35,682.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,872.47		
101A	TANF < 1 M & F NON-M	1,374,906.97	824,333.81	619,875.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,819,116.77		
101B	TANF 01-05 M & F NON	37,377.77	34,988.09	17,898.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,263.88		
101C	TANF 06-13 M & F NON	31,887.35	38,379.00	14,389.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,655.95		
101D	TANF 14-20 MALE NON-	40,214.75	26,404.71	25,064.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,683.92		
101E	TANF 14-20 FEMALE N O	75,894.61	51,114.86	39,158.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,168.23		
101F	TANF 21-44 MALE NON-	332,694.14	181,172.60	142,480.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		656,347.32		
101G	TANF 21-44 FEMALE N O	1,014,213.65	519,454.48	432,147.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,965,815.56		
101H	TANF 44-64 M & F NON	352,715.91	224,440.64	206,574.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		783,730.73		
101J	TANF 65+ N & F NON-M	2,006.75	449.69	1,257.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,714.43		
1026	TANF 21-44 MALE WITH	9,851.45	9,746.05	9,204.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,801.70		
1027	TANF 21-44 FEMALE WI	37,746.13	34,109.50	35,005.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,860.64		
1028	TANF 45-64 M & F WIT	39,714.64	36,360.22	36,397.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,472.50		
1029	TANF 65+ M & F WITH	11,125.03	11,154.44	10,081.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,360.87		
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		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102G	TANF 21-44 FEMALE WI	0.00	420.35	241.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		662.25		
102H	TANF 44-64 M & F WIT	0.00	1,084.40	2,684.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,768.79		
102J	TANF 65+ M & F WITH	0.00	0.00	403.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403.46		
2100	SSI AGED WITH MEDIC A	842,955.42	868,175.55	898,652.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,609,783.85		
210Z	SSI AGED WITH MEDIC A	28,411.56	21,306.88	29,919.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,638.00		
2110	SSI AGED NON-MEDICA R	4,812,760.61	4,806,493.94	4,896,356.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,515,610.74		
211Z	SSI AGED NON-MEDICA R	127,183.08	147,235.09	133,695.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408,114.05		
2120	SSI AGED WITH QMB	5,230,861.87	5,318,628.79	5,550,430.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,099,921.30		
212Z	SSI AGED WITH QMB P P	4,349.89	5,632.30	8,612.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,594.81		
2200	SSI DISABLED WITH M E	2,492,441.51	2,520,758.68	2,512,167.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,525,367.88		
220Z	SSI DISABLED WITH M E	17,675.35	12,942.73	15,910.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,528.13		
2210	SSI DISABLED NON-ME D	58,494,437.05	58,018,801.11	58,160,271.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,673,509.33		
221Z	SSI DISABLED NON-ME D	433,439.79	419,148.90	538,099.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,390,688.51		
2220	SSI DISABLED WITH Q M	15,152,983.36	15,434,374.34	15,821,632.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,408,990.16		
222Z	SSI DISABLED WITH Q M	3,347.64	4,509.15	6,680.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,536.85		
2300	SSI BLIND WITH MEDIC	6,019.11	6,344.44	6,155.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,518.93		
2310	SSI BLIND NON-MEDIC A	416,766.24	425,608.52	424,789.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,267,164.58		
231Z	SSI BLIND NON-MEDIC A	8,216.96	9,934.43	3,994.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,146.29		
2320	SSI BLIND WITH QMB	48,973.62	48,961.67	49,379.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,315.18		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4301	SOBRA CHILD <1 M & F	0.00	0.00	296.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296.24		
4302	SOBRA CHILD 01-05 M	335.78	335.78	539.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,211.06		
4303	SOBRA CHILD 06-13 M	1,544.93	1,519.86	1,659.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,724.65		
4304	SOBRA CHILD 14-20 MA	453.68	315.45	353.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,122.98		
4305	SOBRA CHILD 14-20 FE	2,687.14	3,209.63	3,132.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,029.50		
430A	SOBRA CHILD < 1 M &	0.00	0.00	467.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		467.78		
430C	SOBRA CHILD 06-13 M	19.65	0.00	91.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.67		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	107.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107.04		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	142.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.68		
4311	SOBRA CHILD <1 M & F	19,199,383.74	19,304,900.69	19,387,265.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,891,549.67		
4312	SOBRA CHILD 01-05 M	23,848,737.73	23,824,566.62	23,927,832.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,601,137.31		
4313	SOBRA CHILD 06-13 M	29,886,460.52	30,038,640.77	30,367,237.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,292,338.66		
4314	SOBRA CHILD 14-20 MA	9,328,457.36	9,454,281.74	9,680,287.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,463,026.17		
4315	SOBRA CHILD 14-20 FE	14,077,063.28	14,260,086.80	14,601,597.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,938,747.43		
431A	SOBRA CHILD < 1 M &	1,177,252.46	693,970.63	867,096.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,738,319.46		
431B	SOBRA CHILD 01-05 M	566,517.45	313,543.99	297,175.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,177,236.63		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431C	SOBRA CHILD 6-13 M& F	721,463.46	331,359.44	312,515.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,365,338.31		
431D	SOBRA CHILD 14-20 MA	521,496.21	233,778.90	223,364.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		978,639.45		
431E	SOBRA CHILD 14-20 FE	561,544.85	276,156.48	306,650.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,144,351.94		
4321	SOBRA CHILD <1 M & F	0.00	507.63	-507.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4322	SOBRA CHILD 01-05 M	230.53	225.94	140.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		596.76		
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	29,492.39	23,326.23	32,995.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,814.22		
5008	SOBRA PREG 45-64 FE M	4,151.82	3,635.38	3,635.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,422.58		
500G	SOBRA PREG 21-44 FE M	621.37	527.22	421.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,569.74		
500H	SOBRA PREG 45-64 FE M	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		
5013	SOBRA PREG 09-13 FE M	1,407.36	911.78	1,029.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,348.97		
5015	SOBRA PREG 14-20 FE M	1,116,187.80	1,054,868.69	1,049,312.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,220,368.93		
5017	SOBRA PREG 21-44 FE M	5,647,435.21	5,224,978.99	5,240,195.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,112,609.52		
5018	SOBRA PREG 45-64 FE M	29,549.66	22,736.94	27,265.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,552.52		
501C	SOBRA PREG 09-13 FE M	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		
501E	SOBRA PREG 14-20 FE M	137,111.91	56,188.00	58,579.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,879.20		
501G	SOBRA PREG 21-44 FE M	501,169.31	249,043.62	241,784.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		991,997.48		
501H	SOBRA PREG 45-64 FE M	2,476.09	1,453.55	2,104.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,033.87		
5027	SOBRA PREG 21-44 FE M	13,528.33	12,323.20	13,443.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,294.53		
5028	SOBRA PREG 45-64 FE M	2,212.75	2,212.75	2,212.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,638.25		
502G	SOBRA PREG 21-44 FE M	163.64	246.72	144.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		555.33		
SUBTOTAL:	250,093,559.53	247,431,996.74	250,079,851.3	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		747,605,407.66		

3100	TRANSPLANT OPTION 1	49.50	49.50	49.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.50	49.50	49.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

148.50	
148.50	

1106	TANF EXPANDED 21-44	282,644.01	293,807.76	299,501.69	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	873,310.21	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	1,655,264.19	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	488,902.31	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	2,589.14	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	11,399.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

875,953.46	
2,598,923.26	
4,906,779.54	
1,452,281.13	
12,962.95	
29,534.13	

9910	TANF & SOBRA CHILDR E	1,823,715.69	2,120,615.87	1,880,550.08	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	43,521.21	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	146,178.87	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	14,622,927.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,085,061.23	17,195,121.06	16,693,178.0	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,824,881.64	
118,213.07	
572,839.63	
42,457,425.96	
48,973,360.30	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110H	TANF EXPANDED 45-64	33,794.96	22,864.73	20,358.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,018.25		
110J	TANF EXPANDED 65+
M&	9,199.74	13,839.05	13,431.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,469.94		
1111	TANF EXPANDED <1 M
&F	557.66	464.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,022.53		
1112	TANF EXPANDED 01-05	4,050.10	1,733.81	2,230.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,014.54		
1113	TANF EXPANDED 06-13	16,864.25	12,083.68	13,812.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,760.03		
1114	TANF EXPANDED 14-20	95,489.34	94,788.46	95,838.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,116.52		
1115	TANF EXPANDED 14-20	534,805.44	532,890.06	531,995.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,599,691.04		
1116	TANF EXPANDED 21-44	5,053,008.48	5,108,578.16	5,172,027.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,333,614.55		
1117	TANF EXPANDED 21-44	18,426,686.32	18,570,201.50	18,914,764.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,911,652.48		
1118	TANF EXPANDED 45-64	11,268,281.74	11,270,199.33	11,461,359.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,999,840.43		
1119	TANF EXPANDED 65+
M&	36,120.95	39,232.95	36,832.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,186.74		
111A	TANF EXPANDED <1 M
&F	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	3,999.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,793.60		
111E	TANF EXPANDED 14-20	27,269.64	15,641.38	9,235.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,146.58		
111F	TANF EXPANDED 21-44	307,744.28	160,720.58	153,918.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		622,383.00		
111G	TANF EXPANDED 21-44	731,144.87	324,566.49	340,720.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,396,431.71		
111H	TANF EXPANDED 45-64	466,357.73	201,524.92	199,655.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		867,538.06		
111J	TANF EXPANDED 65+
M&	8,779.85	4,133.27	202.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,115.77		
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	157,645.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		467,501.68		
1127	TANF EXPANDED 21-44	446,215.59	474,049.46	477,129.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,397,394.36		
1128	TANF EXPANDED 45-64	504,237.50	518,590.37	535,516.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,558,344.52		
1129	TANF EXPANDED 65+
M&	168,961.75	179,353.58	184,855.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		533,171.10		
112F	TANF EXPANDED 21-44	1,973.32	1,569.61	1,040.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,583.13		
112G	TANF EXPANDED 21-44	1,409.59	2,117.93	729.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,256.55		
112H	TANF EXPANDED 45-64	6,149.15	3,315.72	5,472.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,937.73		
112J	TANF EXPANDED 65+
M&	2,268.02	1,088.62	6,118.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,475.06		
2400	SSI AGED EXPANDED WI	79,751.62	88,972.48	94,368.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		263,092.70		
240Z	SSI AGED EXPANDED WI	18,469.11	13,440.92	19,374.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,284.46		
2410	SSI AGED EXPANDED NO	113,134.36	107,329.50	100,424.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320,888.35		
241Z	SSI AGED EXPANDED NO	5,881.63	3,345.40	5,620.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,847.36		
2420	SSI AGED EXPANDED WI	3,821,442.08	3,751,853.32	3,705,430.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,278,725.94		
242Z	SSI AGED EXPANDED WI	8,856.22	3,806.30	10,030.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,693.04		
2500	SSI BLIND EXPANDED W	140.23	140.23	140.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		420.69		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2520

2600	SSI BLIND EXPANDED W
SSI DISABLED EXPAND
E	270.25

254,582.86	113.62

222,372.65	130.02

227,664.21	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

0.00	0.00

0.00	0.00

0.00	513.89

704,619.72	
260Z	SSI DISABLED EXPAND E	10,892.09	7,541.46	10,094.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,528.31	
2610	SSI DISABLED EXPAND E	1,833,932.47	1,565,603.77	1,414,716.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,814,252.61	
261Z	SSI DISABLED EXPAND E	33,726.08	25,186.67	34,152.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,065.64	
2620	SSI DISABLED EXPAND E	8,960,995.29	8,821,264.08	8,606,635.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,388,894.42	
262Z	SSI DISABLED EXPAND E	3,880.96	3,944.92	4,241.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,067.15	
SUBTOTAL:	56,720,391.41	55,619,947.17	55,902,881.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	168,243,219.59	

9911	SB PAYMENT FOR TAN F	1,240,641.58	1,357,800.62	1,384,207.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI E	18,874.52	6,290.91	6,364.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	6,274.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,259,516.10	1,364,091.53	1,396,847.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,982,650.13	
31,530.38	
6,274.24	
4,020,454.75	

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	

-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	

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	
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	

-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	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3506	ADULT 40-100% MALE 2	-1,357.37	3,232.53	3,514.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,389.41		
3507	ADULT 40-100% FEMAL E	655.96	919.44	2,968.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,543.88		
3508	ADULT 40-100% M&F 45	26,030.20	33,829.91	30,003.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,863.64		
3509	ADULT 40-100% M&F 65	5,034.18	4,586.39	5,021.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,642.26		
350F	ADULT 40-100% MALE 2	780.79	0.00	1,767.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,548.18		
350G	ADULT 40-100% FEMAL E	321.93	523.21	450.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,295.68		
350H	ADULT 40-100% M&F 45	6,378.29	3,428.33	180.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,986.84		
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		1,172.03		
3514	ADULT 40-100% MALE 1	2,409,491.88	2,474,191.06	2,493,038.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,376,721.38		
3515	ADULT 40-100% FEMAL E	2,652,207.33	2,709,011.22	2,755,051.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,116,269.79		
3516	ADULT 40-100% MALE 2	9,091,685.89	9,213,419.73	9,339,670.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,644,775.93		
3517	ADULT 40-100% FEMAL E	7,488,728.50	7,584,675.23	7,702,512.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,775,916.19		
3518	ADULT 40-100% M&F 45	18,275,289.94	18,558,142.48	18,724,964.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,558,396.72		
3519	ADULT 40-100% M&F 65	9,481.02	11,136.16	7,516.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,133.36		
351D	ADULT 40-100% MALE 1	230,773.61	92,793.37	78,690.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		402,257.59		
351E	ADULT 40-100% FEMAL E	202,837.35	98,746.64	127,277.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		428,861.88		
351F	ADULT 40-100% MALE 2	854,550.14	446,008.39	470,902.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,771,461.49		
351G	ADULT 40-100% FEMAL E	641,841.39	306,040.86	325,788.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,273,670.92		
351H	ADULT 40-100% M&F 45	1,495,397.19	742,706.24	742,009.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,980,113.27		
351J	ADULT 40-100% M&F 65	15,371.19	2,027.43	6,644.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,043.25		
3526	ADULT 40-100% MALE 2	938.25	2,394.06	3,096.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,428.38		
3527	ADULT 40-100% FEMAL E	489.55	428.27	2,444.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,362.57		
3528	ADULT 40-100% M&F 45	6,566.58	4,703.93	1,851.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,122.14		
3529	ADULT 40-100% M&F 65	59.89	0.00	414.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		474.64		
352F	ADULT 40-100% MALE 2	0.00	239.80	517.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		757.27		
352G	ADULT 40-100% FEMAL E	0.00	0.00	360.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		360.43		
352H	ADULT 40-100% M&F 45	0.00	218.00	733.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		951.84		
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	17,216.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,689.95		
3707	ADULT <40% EXP FEM AL	8,594.39	14,900.87	5,263.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,758.28		
3708	ADULT <40% EXP M&F 4	52,776.27	51,121.40	57,025.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,923.59		
3709	ADULT <40% EXP M&F 6	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	1,914.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,669.14		
370G	ADULT <40% EXP FEM AL	5,014.07	87.20	856.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,957.30		
370H	ADULT <40% EXP M&F 4	41,292.32	3,366.20	7,910.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,569.50		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	5,588,252.13	5,551,951.34	5,502,458.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,642,661.89		
3715	ADULT <40% EXP FEM AL	4,892,572.32	4,914,224.47	4,853,114.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,659,910.86		
3716	ADULT <40% EXP MALE	30,620,225.72	31,120,943.63	31,307,662.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,048,831.76		
3717	ADULT <40% EXP FEM AL	18,697,678.92	18,946,793.84	19,112,832.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,757,305.07		
3718	ADULT <40% EXP M&F 4	37,997,636.85	38,500,400.84	38,797,116.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,295,153.87		
3719	ADULT <40% EXP M&F 6	24,175.96	27,528.55	18,303.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,008.42		
371D	ADULT <40% EXP MALE	527,076.34	241,808.81	265,078.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,033,963.20		
371E	ADULT <40% EXP FEM AL	415,699.52	230,089.36	214,764.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		860,553.28		
371F	ADULT <40% EXP MALE	4,933,492.46	1,889,607.04	2,149,528.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,972,628.41		
371G	ADULT <40% EXP FEM AL	2,488,666.27	1,102,987.94	1,119,521.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,711,175.72		
371H	ADULT <40% EXP M&F 4	4,347,109.87	1,716,162.75	1,833,085.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,896,358.23		
371J	ADULT <40% EXP M&F 6	0.00	1,906.05	554.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,460.48		
3726	ADULT <40% EXP MALE	3,446.36	2,080.08	5,035.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,561.69		
3727	ADULT <40% EXP FEM AL	1,623.77	1,311.51	497.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,432.43		
3728	ADULT <40% EXP M&F 4	7,151.55	6,415.33	4,602.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,169.86		
3729	ADULT <40% EXP M&F 6	475.74	475.74	378.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,330.17		
372F	ADULT <40% EXP MALE	1,504.22	452.54	22.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,979.29		
372G	ADULT <40% EXP FEM AL	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		
372H	ADULT <40% EXP M&F 4	1,005.63	1,712.08	1,509.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,227.02		
SUBTOTAL:	154,087,363.33	146,645,800.61	148,103,646.2	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448,836,810.18		

3906	NEWLY ELIGIBLE MALE	4,896.46	3,633.24	2,121.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	2,726.25	3,437.55	1,624.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	37,160.26	34,294.07	28,140.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	2,216.27	2,338.07	4,878.84	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	149.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1,662.50	511.99	535.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	4,162.37	385.56	3,911.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	11.02	1,310.04	182.13	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	1,036,935.63	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	1,219,383.57	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	7,195,270.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	10,276,450.45	10,168,360.64	10,192,574.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10,651.37	
7,788.50	
99,594.92	
9,433.18	
-87.02	
2,709.62	
8,459.31	
1,503.19	
3,041,070.75	
3,600,155.91	
21,465,890.76	
30,637,385.20	

9935	BIRTH SUPP PAYMENT A	287,840.28	262,331.58	201,591.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT A	598,513.41	678,326.85	685,208.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	886,353.69	940,658.43	886,799.5	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
751,762.86	
1,962,048.80	
2,713,811.66	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3918	NEWLY ELIGIBLE M&F 4	10,565,542.96	10,565,902.98	10,633,336.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,764,782.72		
3919	NEWLY ELIGIBLE M&F 6	5,613.74	6,337.38	4,809.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,761.11		
391D	NEWLY ELIGIBLE MALE	53,561.17	31,001.51	35,796.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,359.10		
391E	NEWLY ELIGIBLE FEMA L	73,185.98	37,874.44	31,818.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,878.78		
391F	NEWLY ELIGIBLE MALE	544,427.88	264,421.24	269,746.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,078,595.40		
391G	NEWLY ELIGIBLE FEMA L	645,279.14	319,627.95	351,282.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,316,190.08		
391H	NEWLY ELIGIBLE M&F 4	535,632.09	262,888.10	263,717.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,062,237.33		
391J	NEWLY ELIGIBLE M&F 6	0.00	3,073.64	1,366.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,439.64		
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		717.46		
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	665.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		665.04		
3928	NEWLY ELIGIBLE M&F 4	1,094.45	1,114.10	2,616.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,825.31		
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		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	87.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.11		
392H	NEWLY ELIGIBLE M&F 4	0.00	384.57	813.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,197.99		
SUBTOTAL:	32,061,907.41	31,054,674.03	31,281,763.8	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,398,345.24		

4404	SOBRA 100-133% MALE	0.00	146.73	290.72	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	1,928.16	1,449.26	1,448.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	5,874,723.53	5,814,953.17	5,863,435.31	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	2,024,655.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	3,005,921.37	2,997,685.23	3,038,508.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	445.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	164,704.59	74,635.99	79,126.77	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	57,787.59	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	72,773.77	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	11,138,027.3	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

437.45	
4,826.32	
17,553,112.01	
6,016,741.86	
9,042,115.30	
445.44	
318,467.35	
194,701.68	
277,205.74	
33,408,053.15	

9944	BIRTH SUPP PAYMENT S	35,856.55	55,987.51	36,542.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	35,856.55	55,987.51	36,542.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

128,386.61	
128,386.61	

4517	BC PATIENT FEMALE 2 1	5,396.74	5,104.69	4,725.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	75,925.22	67,099.18	64,432.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	660.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	163.19	0.00	1,094.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	851.62	879.79	2,962.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15,227.42	
207,456.72	
660.83	
1,257.95	
4,694.06	

9939	BIRTH SUPP PAYMENT N	465,794.15	642,903.37	516,533.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	465,794.15	642,903.37	516,533.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,625,230.69	
1,625,230.69	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4617	CC PATIENT FEMALE 2 1	5,421.52	5,390.70	2,981.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,794.03	
4618	CC PATIENT FEMALE 4 5	3,628.71	3,628.71	3,628.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,886.13	
SUBTOTAL	:	91,387.00	82,103.07	80,487.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	253,977.14	

8600	SSI BLIND FREEDOM/W O	1,497.85	1,497.85	1,497.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,599,503.27	1,594,264.12	1,568,172.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	5,284.74	1,220.33	2,957.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	290,544.03	279,436.17	296,571.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	20,843.53	5,319.97	4,912.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	159,107.87	167,630.72	159,800.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	208.68	121.10	148.84	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	2,034,061.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,493.55	
4,761,940.20	
9,462.68	
866,551.92	
31,075.71	
486,539.05	
478.62	
6,160,541.73	

524,137,104.09	513,951,069.46	518,150,668.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1002	TANF 01-05 M & F WIT	0.00	0.00	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.26		
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1005	TANF 14-20 FEMALE WI	4.99	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.99		
1006	TANF 21-44 MALE WITH	105.64	116.50	122.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345.04		
1007	TANF 21-44 FEMALE WI	181.79	195.90	194.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572.00		
1008	TANF 45-64 M & F WIT	268.21	287.79	294.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		850.87		
1009	TANF 65+ M & F WITH	116.75	130.64	133.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		380.72		
100B	TANF 01-05 M & F WIT	0.00	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.73		
100F	TANF 21-44 MALE WITH	12.95	6.38	1.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.97		
100G	TANF 21-44 FEMALE WI	5.05	4.32	5.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.54		
100H	TANF 44-64 M & F WIT	9.51	7.35	5.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.20		
100J	TANF 65+ M & F WITH	4.22	1.12	1.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1011	TANF <1 M & F NON-ME	12,190.91	11,954.58	11,593.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,738.61		
1012	TANF 01-05 M & F NON	15,922.62	16,925.07	17,709.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,556.87		
1013	TANF 06-13 M & F NON	26,685.75	27,709.65	27,908.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,303.60		
1014	TANF 14-20 MALE NON-	7,849.50	8,080.91	8,195.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,126.26		
1015	TANF 14-20 FEMALE N O	10,947.41	11,170.89	11,082.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,200.98		
1016	TANF 21-44 MALE NON-	25,794.90	26,636.23	27,208.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,640.05		
1017	TANF 21-44 FEMALE N O	78,741.67	80,653.27	81,552.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,947.05		
1018	TANF 45-64 M & F NON	20,054.80	20,572.11	20,890.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,517.27		
1019	TANF 65+ M & F NON-M	82.44	87.95	83.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		254.10		
101A	TANF < 1 M & F NON-M	1,368.89	819.40	613.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,802.16		
101B	TANF 01-05 M & F NON	682.65	652.33	333.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,668.29		
101C	TANF 06-13 M & F NON	588.07	716.90	269.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,574.45		
101D	TANF 14-20 MALE NON-	275.74	179.54	166.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		621.93		
101E	TANF 14-20 FEMALE N O	392.46	264.03	203.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		859.66		
101F	TANF 21-44 MALE NON-	2,233.16	1,246.55	971.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,451.41		
101G	TANF 21-44 FEMALE N O	5,212.42	2,680.13	2,230.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,122.58		
101H	TANF 44-64 M & F NON	1,044.93	668.56	619.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,333.20		
101J	TANF 65+ N & F NON-M	7.16	1.47	3.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.21		
1026	TANF 21-44 MALE WITH	40.21	39.35	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.56		
1027	TANF 21-44 FEMALE WI	55.59	51.12	51.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.37		
1028	TANF 45-64 M & F WIT	75.00	69.96	69.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214.58		
1029	TANF 65+ M & F WITH	27.20	27.00	24.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.76		
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		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102G	TANF 21-44 FEMALE WI	0.00	2.15	1.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.45		
102H	TANF 44-64 M & F WIT	0.00	3.03	7.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.55		
102J	TANF 65+ M & F WITH	0.00	0.00	1.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.43		
2100	SSI AGED WITH MEDIC A	4,687.07	4,820.28	4,932.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,440.02		
210Z	SSI AGED WITH MEDIC A	401.49	304.61	422.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,128.31		
2110	SSI AGED NON-MEDICA R	5,548.22	5,555.50	5,634.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,738.65		
211Z	SSI AGED NON-MEDICA R	216.60	250.09	229.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		695.82		
2120	SSI AGED WITH QMB	27,168.47	27,829.76	28,631.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,629.40		
212Z	SSI AGED WITH QMB P P	67.03	76.42	130.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274.02		
2200	SSI DISABLED WITH M E	5,051.73	5,011.37	5,017.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,080.11		
220Z	SSI DISABLED WITH M E	259.75	180.95	228.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		668.83		
2210	SSI DISABLED NON-ME D	56,419.86	56,072.96	55,978.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168,471.08		
221Z	SSI DISABLED NON-ME D	759.89	735.30	931.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,427.01		
2220	SSI DISABLED WITH Q M	27,588.74	27,999.85	28,560.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,149.15		
222Z	SSI DISABLED WITH Q M	50.54	64.24	90.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205.45		
2300	SSI BLIND WITH MEDIC	27.00	29.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84.00		
2310	SSI BLIND NON-MEDIC A	461.02	472.94	470.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,404.45		
231Z	SSI BLIND NON-MEDIC A	14.08	16.02	6.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.55		
2320	SSI BLIND WITH QMB	208.99	210.04	210.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		629.65		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.60		
4302	SOBRA CHILD 01-05 M	3.00	3.00	4.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.76		
4303	SOBRA CHILD 06-13 M	6.70	6.12	7.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.24		
4304	SOBRA CHILD 14-20 MA	3.00	2.00	2.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.26		
4305	SOBRA CHILD 14-20 FE	6.38	8.49	8.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.13		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.43		
430C	SOBRA CHILD 06-13 M	0.06	0.00	2.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.17		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.73		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.73		
4311	SOBRA CHILD <1 M & F	39,790.63	40,146.76	40,163.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,101.29		
4312	SOBRA CHILD 01-05 M	188,466.60	189,087.15	189,910.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567,464.06		
4313	SOBRA CHILD 06-13 M	233,049.16	235,593.66	237,736.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		706,379.52		
4314	SOBRA CHILD 14-20 MA	54,382.11	55,359.01	56,494.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,235.55		
4315	SOBRA CHILD 14-20 FE	54,106.61	55,018.18	56,134.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,259.40		
431A	SOBRA CHILD < 1 M &	1,208.09	704.71	883.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,796.19		
431B	SOBRA CHILD 01-05 M	9,938.87	5,510.49	5,314.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,764.27		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431C	SOBRA CHILD 6-13 M& F	12,342.03	5,854.58	5,525.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,721.70		
431D	SOBRA CHILD 14-20 MA	3,383.27	1,549.83	1,503.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,436.86		
431E	SOBRA CHILD 14-20 FE	2,833.78	1,413.80	1,559.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,806.79		
4321	SOBRA CHILD <1 M & F	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		
4322	SOBRA CHILD 01-05 M	2.00	2.00	1.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.23		
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	54.43	49.34	63.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.51		
5008	SOBRA PREG 45-64 FE M	5.32	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.32		
500G	SOBRA PREG 21-44 FE M	3.19	2.70	2.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.06		
500H	SOBRA PREG 45-64 FE M	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		
5013	SOBRA PREG 09-13 FE M	6.16	8.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.16		
5015	SOBRA PREG 14-20 FE M	4,337.46	4,046.46	4,011.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,395.80		
5017	SOBRA PREG 21-44 FE M	21,665.43	19,993.98	20,010.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,670.34		
5018	SOBRA PREG 45-64 FE M	69.37	50.47	56.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176.23		
501C	SOBRA PREG 09-13 FE M	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		
501E	SOBRA PREG 14-20 FE M	704.07	289.25	297.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,290.94		
501G	SOBRA PREG 21-44 FE M	2,575.10	1,286.76	1,250.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,112.20		
501H	SOBRA PREG 45-64 FE M	6.61	4.05	6.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.77		
5027	SOBRA PREG 21-44 FE M	22.12	25.35	24.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.40		
5028	SOBRA PREG 45-64 FE M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
502G	SOBRA PREG 21-44 FE M	0.87	1.09	0.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.72		
SUBTOTAL:	968,893.15	957,619.06	965,088.3	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,891,600.54		

3100	TRANSPLANT OPTION 1	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9.00	
9.00	

1106	TANF EXPANDED 21-44	788.67	816.15	831.69	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	1,605.10	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	2,863.87	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	1,112.10	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	18.23	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	59.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,436.51	
4,723.22	
8,510.11	
3,292.32	
88.08	
150.39	

9910	TANF & SOBRA CHILDR E	296.00	348.00	307.00	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	7.00	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	24.00	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	2,398.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,472.00	2,821.00	2,736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
951.00	
19.00	
94.00	
6,965.00	
8,029.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110H	TANF EXPANDED 45-64	104.82	65.06	61.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		231.73		
110J	TANF EXPANDED 65+
M&	27.91	37.48	41.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107.12		
1111	TANF EXPANDED <1 M
&F	1.22	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.22		
1112	TANF EXPANDED 01-05	29.83	22.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.83		
1113	TANF EXPANDED 06-13	131.04	120.00	110.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361.04		
1114	TANF EXPANDED 14-20	576.14	573.34	572.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,722.01		
1115	TANF EXPANDED 14-20	2,070.37	2,092.17	2,076.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,238.94		
1116	TANF EXPANDED 21-44	30,546.64	30,955.38	31,285.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,787.91		
1117	TANF EXPANDED 21-44	70,413.69	71,216.30	72,291.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213,921.53		
1118	TANF EXPANDED 45-64	26,030.37	26,097.67	26,439.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,567.06		
1119	TANF EXPANDED 65+
M&	83.66	90.73	84.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.33		
111A	TANF EXPANDED <1 M
&F	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	27.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.17		
111E	TANF EXPANDED 14-20	140.45	79.30	47.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267.21		
111F	TANF EXPANDED 21-44	2,076.01	1,098.80	1,054.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,229.10		
111G	TANF EXPANDED 21-44	3,752.64	1,672.33	1,755.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,180.89		
111H	TANF EXPANDED 45-64	1,397.05	614.36	610.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,622.15		
111J	TANF EXPANDED 65+
M&	27.62	12.27	0.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.45		
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	310.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		925.19		
1127	TANF EXPANDED 21-44	702.41	738.16	741.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,181.91		
1128	TANF EXPANDED 45-64	861.34	884.40	908.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,653.82		
1129	TANF EXPANDED 65+
M&	379.94	403.85	416.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,200.44		
112F	TANF EXPANDED 21-44	13.19	10.76	7.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00		
112G	TANF EXPANDED 21-44	7.14	11.21	3.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.02		
112H	TANF EXPANDED 45-64	18.32	9.84	16.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.99		
112J	TANF EXPANDED 65+
M&	7.02	3.04	18.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.38		
2400	SSI AGED EXPANDED WI	426.73	443.44	472.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,342.19		
240Z	SSI AGED EXPANDED WI	259.45	185.24	285.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		730.03		
2410	SSI AGED EXPANDED NO	126.95	125.69	114.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		367.29		
241Z	SSI AGED EXPANDED NO	10.56	5.52	10.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.45		
2420	SSI AGED EXPANDED WI	17,593.09	17,259.82	16,957.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,810.35		
242Z	SSI AGED EXPANDED WI	124.19	55.44	148.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327.93		
2500	SSI BLIND EXPANDED W	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2520

2600	SSI BLIND EXPANDED W
SSI DISABLED EXPAND
E	2.00

492.88	1.00

464.34	1.00

445.06	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	4.00

1,402.28	
260Z	SSI DISABLED EXPAND E	161.06	113.94	138.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	413.72	
2610	SSI DISABLED EXPAND E	1,749.60	1,549.45	1,399.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,698.19	
261Z	SSI DISABLED EXPAND E	60.98	43.92	59.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163.91	
2620	SSI DISABLED EXPAND E	14,973.36	14,550.51	14,192.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,716.42	
262Z	SSI DISABLED EXPAND E	57.37	57.71	62.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	177.34	
SUBTOTAL:	182,154.75	178,380.59	179,678.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	540,214.26	

9911	SB PAYMENT FOR TAN F	203.00	222.00	227.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI E	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	206.00	223.00	229.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

652.00	
5.00	
1.00	
658.00	

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	
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	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3506	ADULT 40-100% MALE 2	1.05	3.93	4.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.10		
3507	ADULT 40-100% FEMAL E	1.41	1.51	4.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.25		
3508	ADULT 40-100% M&F 45	48.19	59.75	62.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170.67		
3509	ADULT 40-100% M&F 65	11.70	10.93	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.63		
350F	ADULT 40-100% MALE 2	1.38	0.00	2.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.23		
350G	ADULT 40-100% FEMAL E	0.58	0.77	0.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.01		
350H	ADULT 40-100% M&F 45	10.10	5.21	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.57		
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		1.64		
3514	ADULT 40-100% MALE 1	5,324.62	5,467.72	5,499.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,291.93		
3515	ADULT 40-100% FEMAL E	5,844.28	5,979.01	6,074.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,897.46		
3516	ADULT 40-100% MALE 2	19,365.79	19,627.94	19,910.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,904.13		
3517	ADULT 40-100% FEMAL E	15,852.90	16,050.08	16,295.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,198.25		
3518	ADULT 40-100% M&F 45	39,856.53	40,435.92	40,836.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,128.50		
3519	ADULT 40-100% M&F 65	21.41	25.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.41		
351D	ADULT 40-100% MALE 1	347.75	138.36	119.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		605.53		
351E	ADULT 40-100% FEMAL E	318.47	148.34	190.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		656.87		
351F	ADULT 40-100% MALE 2	1,280.29	671.30	703.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,655.55		
351G	ADULT 40-100% FEMAL E	965.22	464.82	496.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,926.23		
351H	ADULT 40-100% M&F 45	2,235.88	1,124.69	1,123.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,483.79		
351J	ADULT 40-100% M&F 65	22.58	3.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.58		
3526	ADULT 40-100% MALE 2	2.00	3.15	3.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.21		
3527	ADULT 40-100% FEMAL E	1.00	0.19	1.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.65		
3528	ADULT 40-100% M&F 45	7.00	6.67	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.80		
3529	ADULT 40-100% M&F 65	0.12	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.12		
352F	ADULT 40-100% MALE 2	0.00	0.35	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.28		
352G	ADULT 40-100% FEMAL E	0.00	0.00	0.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.53		
352H	ADULT 40-100% M&F 45	0.00	0.32	0.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.18		
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	16.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.65		
3707	ADULT <40% EXP FEM AL	9.61	12.63	3.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.97		
3708	ADULT <40% EXP M&F 4	79.34	86.57	80.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246.56		
3709	ADULT <40% EXP M&F 6	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	2.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.71		
370G	ADULT <40% EXP FEM AL	7.40	0.12	1.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.78		
370H	ADULT <40% EXP M&F 4	62.90	4.82	11.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.66		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	12,053.30	11,993.59	11,889.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,936.06		
3715	ADULT <40% EXP FEM AL	10,566.05	10,578.54	10,458.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,603.40		
3716	ADULT <40% EXP MALE	60,788.30	61,489.48	61,720.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183,998.06		
3717	ADULT <40% EXP FEM AL	36,217.95	36,585.39	36,742.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,545.50		
3718	ADULT <40% EXP M&F 4	76,027.85	76,776.91	77,357.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230,162.71		
3719	ADULT <40% EXP M&F 6	46.67	55.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.67		
371D	ADULT <40% EXP MALE	785.47	365.33	398.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,549.78		
371E	ADULT <40% EXP FEM AL	622.58	343.02	319.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,285.52		
371F	ADULT <40% EXP MALE	7,431.73	2,823.52	3,229.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,485.19		
371G	ADULT <40% EXP FEM AL	3,715.62	1,653.65	1,678.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,047.77		
371H	ADULT <40% EXP M&F 4	6,450.75	2,546.43	2,728.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,725.55		
371J	ADULT <40% EXP M&F 6	0.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
3726	ADULT <40% EXP MALE	3.77	2.02	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.79		
3727	ADULT <40% EXP FEM AL	1.77	1.34	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.11		
3728	ADULT <40% EXP M&F 4	10.87	10.49	6.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.15		
3729	ADULT <40% EXP M&F 6	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
372F	ADULT <40% EXP MALE	2.22	0.63	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.88		
372G	ADULT <40% EXP FEM AL	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		
372H	ADULT <40% EXP M&F 4	1.64	2.75	2.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.61		
SUBTOTAL:	306,430.98	295,595.84	298,069.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		900,095.82		

3906	NEWLY ELIGIBLE MALE	9.99	6.59	5.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	7.24	9.28	4.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	76.38	71.01	65.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	6.16	6.44	13.46	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	0.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	4.73	1.61	1.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	12.91	1.12	10.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.03	4.70	0.53	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	2,704.30	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	3,193.71	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	18,507.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	26,612.98	26,254.10	26,325.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.21	
21.04	
212.54	
26.06	
-0.22	
7.77	
24.90	
5.26	
7,922.32	
9,445.75	
55,374.66	
79,192.93	

9935	BIRTH SUPP PAYMENT A	47.00	43.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT A	97.00	110.00	112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	144.00	153.00	145.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
123.00	
319.00	
442.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3918	NEWLY ELIGIBLE M&F 4	27,106.66	27,120.36	27,282.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,509.12		
3919	NEWLY ELIGIBLE M&F 6	15.00	17.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
391D	NEWLY ELIGIBLE MALE	158.25	91.82	109.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		360.05		
391E	NEWLY ELIGIBLE FEMA L	222.94	115.52	94.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433.33		
391F	NEWLY ELIGIBLE MALE	1,637.68	787.81	817.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,243.32		
391G	NEWLY ELIGIBLE FEMA L	1,958.63	963.80	1,062.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,984.85		
391H	NEWLY ELIGIBLE M&F 4	1,626.88	792.26	797.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,216.92		
391J	NEWLY ELIGIBLE M&F 6	0.00	9.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
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		1.87		
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	1.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.76		
3928	NEWLY ELIGIBLE M&F 4	3.00	2.92	2.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.12		
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		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.23		
392H	NEWLY ELIGIBLE M&F 4	0.00	1.06	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.06		
SUBTOTAL:	83,583.82	80,471.05	81,021.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		245,075.97		

4404	SOBRA 100-133% MALE	0.00	1.00	2.00	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	17.33	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	47,099.00	46,637.35	47,023.52	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	11,976.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	11,579.89	11,545.15	11,686.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	7.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	3,053.61	1,390.93	1,391.31	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	389.46	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	375.30	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	72,858.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
43.33	
140,759.87	
35,648.94	
34,811.88	
7.64	
5,835.85	
1,318.82	
1,425.93	
219,855.26	

9944	BIRTH SUPP PAYMENT S	6.00	9.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6.00	9.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

21.00	
21.00	

4517	BC PATIENT FEMALE 2 1	21.16	20.00	18.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	172.08	153.75	147.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.83	0.00	4.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	2.08	2.36	8.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

59.29	
473.11	
1.73	
5.69	
13.16	

9939	BIRTH SUPP PAYMENT N	76.00	105.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	76.00	105.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
265.00	
265.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4617	CC PATIENT FEMALE 2 1	14.00	14.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40.00	
4618	CC PATIENT FEMALE 4 5	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.00	
SUBTOTAL	:	218.15	198.11	200.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	616.98	

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,752.66	1,764.25	1,749.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	76.88	18.42	45.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	276.22	268.50	283.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	35.37	9.39	8.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	214.51	222.53	207.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	3.47	2.18	2.52	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	2,298.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
5,266.27	
140.63	
828.46	
53.30	
644.99	
8.17	
6,944.82	

1,621,481.24

1,589,928.80

TOTAL:

1,602,417.61

0.00

0.00

0.00

0.00

0.00

4,813,827.65

0.00

0.00

0.00	0.00

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending September 30, 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	38,448.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,901.39		
1010	TANF NON-MEDICARE	2,400,462.36	2,421,330.33	2,419,826.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,241,619.12		
101Z	TANF ALTCS NON-MED IC	0.00	0.00	19,150.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,150.70		
1020	TANF WITH QMB	7,060.26	7,046.73	7,060.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,167.25		
2100	SSI AGED WITH MEDIC A	30,800,680.32	35,822,926.91	30,988,622.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,612,229.34		
210Z	SSI AGED WITH MEDIC A	542,994.93	656,811.81	649,461.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,849,268.25		
2110	SSI AGED NON-MEDICA R	2,859,005.72	3,112,715.88	2,808,352.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,780,074.53		
211Z	SSI AGED NON-MEDICA R	4,608.65	22,415.95	26,737.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,762.14		
2120	SSI AGED WITH QMB	19,171,298.49	22,384,501.22	19,201,118.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,756,918.41		
212Z	SSI AGED WITH QMB P P	8,706.14	10,824.40	15,009.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,539.69		
2200	SSI DISABLED WITH M E	14,979,902.29	16,537,185.88	15,092,965.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,610,053.49		
220Z	SSI DISABLED WITH M E	45,197.99	72,772.52	67,317.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,287.53		
2210	SSI DISABLED NON-ME D	96,668,522.76	98,773,047.00	97,439,687.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292,881,257.70		
221Z	SSI DISABLED NON-ME D	23,471.98	37,264.06	50,403.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,139.98		
2220	SSI DISABLED WITH Q M	21,848,759.06	23,184,351.56	22,097,240.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,130,350.74		
222Z	SSI DISABLED WITH Q M	717.28	5,025.38	3,782.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,525.47		
2300	SSI BLIND WITH MEDIC	66,335.96	72,964.65	79,626.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,927.56		
2310	SSI BLIND NON-MEDIC A	486,146.90	487,621.28	485,314.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,459,082.63		
2320	SSI BLIND WITH QMB	137,707.06	142,358.29	134,795.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414,861.31		
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	191,624,922.5	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		585,507,305.05		

8700	SSI DISABLED FREEDO M	83,704.76	94,859.85	83,565.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	118,450.47	126,671.03	113,138.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	17,165.70	18,421.41	17,165.70	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	213,870.5	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
262,130.58	
358,260.41	
52,752.81	
673,143.80	

191,838,793.15

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

586,180,448.85	

TOTAL:	190,311,535.63  204,030,120.07

LONG TERM CARE MEMBER MONTHS
For The Period Ending September 30, 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	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1010	TANF NON-MEDICARE	675.51	680.77	680.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,036.68		
101Z	TANF ALTCS NON-MED IC	0.00	0.00	5.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.49		
1020	TANF WITH QMB	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2100	SSI AGED WITH MEDIC A	11,265.25	11,234.08	11,290.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,789.90		
210Z	SSI AGED WITH MEDIC A	564.29	677.36	678.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,920.40		
2110	SSI AGED NON-MEDICA R	596.81	592.38	586.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,775.36		
211Z	SSI AGED NON-MEDICA R	5.47	24.11	27.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.84		
2120	SSI AGED WITH QMB	7,455.45	7,481.63	7,490.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,427.62		
212Z	SSI AGED WITH QMB P P	8.97	11.53	14.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.13		
2200	SSI DISABLED WITH M E	4,856.19	4,930.65	4,899.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,686.71		
220Z	SSI DISABLED WITH M E	48.42	76.93	75.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200.59		
2210	SSI DISABLED NON-ME D	26,357.77	26,471.04	26,580.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,409.55		
221Z	SSI DISABLED NON-ME D	24.77	37.42	41.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.43		
2220	SSI DISABLED WITH Q M	6,861.39	6,872.57	6,919.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,653.07		
222Z	SSI DISABLED WITH Q M	0.77	4.89	4.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.81		
2300	SSI BLIND WITH MEDIC	20.00	21.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65.00		
2310	SSI BLIND NON-MEDIC A	136.44	136.00	137.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		409.70		
2320	SSI BLIND WITH QMB	43.31	43.00	42.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129.10		
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	59,511.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,756.25		

8700	SSI DISABLED FREEDO M	26.00	26.67	25.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	24.00	23.32	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	6.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.00	55.99	54.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
78.57	
70.32	
18.00	
166.89	

TOTAL:	58,992.68	59,364.35	59,566.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,923.14		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
4300	SOBRA CHILD WITH ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4320	SOBRA CHILD WITH Q MB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	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		

1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

3910	NEWLY ELIGIBLE FOR 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	
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	

4400	SOBRA 100-133% FOR 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	
4410	SOBRA 100-133% FOR 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	
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	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
4300	SOBRA CHILD WITH ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4320	SOBRA CHILD WITH Q MB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	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		

3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

3910	NEWLY ELIGIBLE FOR 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	
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	

4400	SOBRA 100-133% FOR 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	
4410	SOBRA 100-133% FOR 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	
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	

1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH 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		
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		
1020	TANF 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		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
4300	SOBRA CHILD WITH ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5020	SOBRA PREGNANT WO MAN	0.00	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		

3500	ADULT 40-100% FOR FI	0.00	0.00	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	0.00	0.00	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	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR 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	
3910	NEWLY ELIGIBLE FOR 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	
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	

4410	SOBRA 100-133% FOR 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	
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	

4510	BC PATIENT FOR FINA 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	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH 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		
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		
1020	TANF 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		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
4300	SOBRA CHILD WITH ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5020	SOBRA PREGNANT WO MAN	0.00	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		

3500	ADULT 40-100% FOR FI	0.00	0.00	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	0.00	0.00	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	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending September 30, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR 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	
3910	NEWLY ELIGIBLE FOR 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	
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	

4410	SOBRA 100-133% FOR 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	
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	

4510	BC PATIENT FOR FINA 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	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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

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		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH 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		
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		
1020	TANF 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		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
4300	SOBRA CHILD WITH ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5020	SOBRA PREGNANT WO MAN	0.00	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		

3500	ADULT 40-100% FOR FI	0.00	0.00	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	0.00	0.00	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	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR 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	
3910	NEWLY ELIGIBLE FOR 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	
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	

4410	SOBRA 100-133% FOR 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	
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	

4510	BC PATIENT FOR FINA 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	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH 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		
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		
1020	TANF 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		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
4300	SOBRA CHILD WITH ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5020	SOBRA PREGNANT WO MAN	0.00	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		

3500	ADULT 40-100% FOR FI	0.00	0.00	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	0.00	0.00	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	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3900	NEWLY ELIGIBLE FOR 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	
3910	NEWLY ELIGIBLE FOR 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	
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	

4510	BC PATIENT FOR FINA 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	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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

4410	SOBRA 100-133% FOR 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	
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	

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		

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	
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	
D
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN
SUBTOTAL:	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	

3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

4410	SOBRA 100-133% FOR 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	
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	

TOTAL:

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	
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	
D
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN
SUBTOTAL:	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00	
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 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	
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	

3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending September 30, 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	3,020.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,062.40		
1010	TANF NON-MEDICARE	191,820.80	195,596.80	195,596.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		583,014.40		
1011	TANF <1 M & F NON-ME	4,850.24	3,696.96	4,174.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,721.28		
1012	TANF 01-05 M & F NON	5,406.40	6,559.68	6,837.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,803.84		
1013	TANF 06-13 M & F NON	8,427.20	5,883.52	6,360.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,671.36		
1014	TANF 14-20 MALE NON-	4,174.08	3,896.00	3,617.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,688.00		
1015	TANF 14-20 FEMALE N O	6,281.60	6,281.60	5,327.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,890.56		
1016	TANF 21-44 MALE NON-	0.00	0.00	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		477.12		
1017	TANF 21-44 FEMALE N O	1,431.36	1,431.36	1,908.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,771.20		
2200	SSI DISABLED WITH M E	26,909.12	26,909.12	26,153.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,972.16		
2210	SSI DISABLED NON-ME D	4,555,037.44	4,547,763.52	4,549,511.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,652,312.00		
2220	SSI DISABLED WITH Q M	60,934.08	63,676.80	63,676.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188,287.68		
2300	SSI BLIND WITH MEDIC	755.20	755.20	755.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,265.60		
2310	SSI BLIND NON-MEDIC A	44,041.60	44,796.80	45,552.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,390.40		
4311	SOBRA CHILD <1 M & F	25,957.76	26,156.80	24,646.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,760.96		
4312	SOBRA CHILD 01-05 M	201,787.20	195,069.44	196,857.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		593,714.56		
4313	SOBRA CHILD 06-13 M	231,286.72	231,605.76	228,505.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		691,398.40		
4314	SOBRA CHILD 14-20 MA	56,885.76	53,744.96	52,035.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162,666.24		
4315	SOBRA CHILD 14-20 FE	54,503.04	54,025.92	52,316.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,845.44		
5015	SOBRA PREG 14-20 FE M	1,232.32	477.12	954.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,663.68		
SUBTOTAL:	5,484,742.72	5,471,348.16	5,468,286.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,424,377.28		

3514	ADULT 40-100% MALE 1	1,908.48	2,385.60	2,862.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,431.36	1,431.36	954.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	477.12	477.12	477.12	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	9,065.28	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	7,156.80	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	1,431.36	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	1,431.36	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	23,378.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,156.80	
3,816.96	
1,431.36	
26,718.72	
23,378.88	
5,248.32	
3,339.84	
71,090.88	

3914	NEWLY ELIGIBLE MALE	954.24	954.24	954.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	477.12	477.12	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,431.36	1,431.36	1,431.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,862.72	
1,431.36	
4,294.08	

1115	TANF EXPANDED 14-20	477.12	477.12	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	477.12	477.12	477.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,431.36	
1,431.36	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	8,588.16	10,496.64	12,206.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,290.88		
4414	SOBRA 100-133% MALE	2,862.72	2,862.72	1,908.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,633.92		
4415	SOBRA 100-133% FEMA L	2,385.60	2,385.60	4,572.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,343.36		
SUBTOTAL:	13,836.48	15,744.96	18,686.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,268.16		

0.00

0.00

0.00

0.00

TOTAL:

5,524,820.80

5,512,380.48	5,512,260.48

0.00	0.00	0.00	0.00

0.00

16,549,461.76

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1010	TANF NON-MEDICARE	254.00	259.00	259.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		772.00		
1011	TANF <1 M & F NON-ME	9.00	6.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
1012	TANF 01-05 M & F NON	9.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1013	TANF 06-13 M & F NON	13.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
1014	TANF 14-20 MALE NON-	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1015	TANF 14-20 FEMALE N O	12.00	12.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1017	TANF 21-44 FEMALE N O	3.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
2200	SSI DISABLED WITH M E	36.00	36.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107.00		
2210	SSI DISABLED NON-ME D	6,198.00	6,188.00	6,187.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,573.00		
2220	SSI DISABLED WITH Q M	84.00	88.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2310	SSI BLIND NON-MEDIC A	62.00	63.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189.00		
4311	SOBRA CHILD <1 M & F	41.00	42.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.00		
4312	SOBRA CHILD 01-05 M	339.00	329.00	331.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		999.00		
4313	SOBRA CHILD 06-13 M	395.00	398.00	395.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,188.00		
4314	SOBRA CHILD 14-20 MA	93.00	87.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264.00		
4315	SOBRA CHILD 14-20 FE	95.00	94.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		280.00		
5015	SOBRA PREG 14-20 FE M	2.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
SUBTOTAL:	7,657.00	7,640.00	7,633.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,930.00		

3514	ADULT 40-100% MALE 1	4.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	3.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1.00	1.00	1.00	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	19.00	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	15.00	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	3.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	51.00	49.00	49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15.00	
8.00	
3.00	
56.00	
49.00	
11.00	
7.00	
149.00	

3914	NEWLY ELIGIBLE MALE	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6.00	
3.00	
9.00	

1115	TANF EXPANDED 14-20	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
3.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	18.00	22.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65.00		
4414	SOBRA 100-133% MALE	6.00	6.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
4415	SOBRA 100-133% FEMA L	5.00	5.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
SUBTOTAL:	29.00	33.0	0	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.00		

TOTAL:

7,741.00

7,726.00

7,724.00

0.00

0.00

0.00

0.00

0.00

23,191.00

0.00

0.00

0.00	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	1,839.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,899.53		
1007	TANF 21-44 FEMALE WI	11,505.38	19,187.09	10,505.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,197.66		
1008	TANF 45-64 M & F WIT	8,643.75	16,020.60	11,606.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,271.29		
1009	TANF 65+ M & F WITH	2,022.37	2,905.92	1,922.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,850.47		
1011	TANF <1 M & F NON-ME	997,028.06	1,032,104.95	596,456.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,625,589.81		
1012	TANF 01-05 M & F NON	369,557.78	393,193.50	297,331.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,060,083.00		
1013	TANF 06-13 M & F NON	342,021.90	307,281.43	274,370.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		923,674.06		
1014	TANF 14-20 MALE NON-	88,902.93	72,599.25	62,332.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,834.71		
1015	TANF 14-20 FEMALE N O	219,214.37	258,354.36	254,247.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		731,816.38		
1016	TANF 21-44 MALE NON-	1,794,520.91	1,973,445.21	1,414,952.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,182,918.51		
1017	TANF 21-44 FEMALE N O	6,277,129.24	6,649,032.53	4,945,353.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,871,515.30		
1018	TANF 45-64 M & F NON	2,332,798.20	2,695,114.91	1,952,339.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,980,252.55		
1019	TANF 65+ M & F NON-M	1,488.83	4,276.48	4,454.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,219.60		
1026	TANF 21-44 MALE WITH	1,000.95	2,620.04	1,137.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,758.33		
1027	TANF 21-44 FEMALE WI	3,449.27	3,490.82	1,096.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,036.76		
1028	TANF 45-64 M & F WIT	8,935.11	7,873.80	7,408.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,216.95		
1029	TANF 65+ M & F WITH	111.13	364.33	6.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		482.10		
2100	SSI AGED WITH MEDIC A	190,983.36	191,970.63	82,013.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		464,967.81		
2110	SSI AGED NON-MEDICA R	92,974.35	100,505.44	91,252.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,732.53		
2120	SSI AGED WITH QMB	469,076.56	646,192.71	528,246.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,643,515.34		
2200	SSI DISABLED WITH M E	358,598.07	500,225.09	440,571.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,299,395.09		
2210	SSI DISABLED NON-ME D	8,751,971.22	10,309,441.37	8,095,838.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,157,250.86		
2220	SSI DISABLED WITH Q M	1,192,013.12	1,702,312.74	1,203,802.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,098,128.28		
2300	SSI BLIND WITH MEDIC	457.17	1,105.82	1,395.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,958.48		
2310	SSI BLIND NON-MEDIC A	86,051.54	110,836.56	112,120.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		309,008.28		
2320	SSI BLIND WITH QMB	17,562.15	17,561.62	12,173.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,297.38		
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	2,454,702.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,968,199.85		
4312	SOBRA CHILD 01-05 M	3,898,361.36	5,221,614.05	3,931,751.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,051,726.49		
4313	SOBRA CHILD 06-13 M	5,970,382.14	5,908,426.67	5,257,376.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,136,185.39		
4314	SOBRA CHILD 14-20 MA	1,683,601.36	1,670,470.03	1,196,168.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,550,239.61		
4315	SOBRA CHILD 14-20 FE	1,620,045.30	2,013,403.75	1,845,592.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,479,041.79		
5007	SOBRA PREG 21-44 FE M	865.69	2,004.91	939.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,809.93		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,702.26	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,139.26		
5015	SOBRA PREG 14-20 FE M	398,992.68	518,674.19	387,758.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,305,424.93		
5017	SOBRA PREG 21-44 FE M	2,430,613.48	3,015,144.62	2,238,361.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,684,119.50		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018

5027	SOBRA PREG 45-64 FE M
SOBRA PREG 21-44 FE
M	4,602.26

922.96	5,349.03

3,146.16	5,359.83

1,079.37	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	15,311.12

5,148.49	
5028	SOBRA PREG 45-64 FE M	408.02	954.20	127.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,489.95	
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	37,724,728.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,258,542.02	

1106	TANF EXPANDED 21-44	19,712.79	23,772.65	11,988.70	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	34,116.79	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	90,167.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	43,849.18	47,867.62	36,472.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	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	368.00	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	884.74	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	7,243.61	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	34,831.57	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	545,354.60	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	1,976,732.22	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	1,300,947.76	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	5,023.68	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	11,081.94	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	11,604.05	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	24,285.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	17,343.41	26,220.86	16,100.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	17,207.10	23,080.02	28,399.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	9,549.32	3,150.78	3,153.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	300,798.06	347,865.14	270,900.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	32,108.52	41,934.80	28,768.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	170,711.55	140,061.64	176,457.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	338,045.21	438,971.31	317,520.57	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	4,932,402.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

55,474.14	
128,057.05	
345,863.62	
128,189.20	
736.00	
2,311.44	
4,914.74	
23,366.70	
115,017.54	
1,856,709.16	
6,488,766.78	
4,533,490.95	
11,746.98	
48,848.48	
29,507.45	
99,825.44	
59,665.06	
68,686.75	
15,853.14	
919,563.67	
102,811.69	
487,230.22	
1,094,537.09	
16,621,173.29	

3317	AHC CARE FEMALE 21- 4	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	
SUBTOTAL:	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	
-1,335.43	
-1,442.96	

3100	TRANSPLANT OPTION 1	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	
1,838.51	

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 1	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	-362.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4,982.02	
3618

SUBTOTAL	AHC CARE/MI M&F 45-6

:	0.00

-138.35	-2,324.92

-7,604.92	-463.62

-825.64	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	-2,788.54

-8,568.91	

3906	NEWLY ELIGIBLE MALE	600.38	328.49	29.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	368.00	718.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	9,346.79	12,574.43	4,551.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	491.18	602.98	747.75	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	13,537.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

958.32	
1,086.00	
26,472.90	
1,841.91	
55,043.07	

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	9,045.15	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	10,692.19	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	45,937.98	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	78,047.94	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	812,257.64	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	519,306.11	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	2,054,220.46	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	1,052.67	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	21.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	128.90	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	2,371.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	112.61	368.00	285.98	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	10,869.67	8,301.93	10,834.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	1,326.41	4,433.00	1,431.77	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	319,289.68	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	420,069.14	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	5,814,373.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,864,032.81	3,815,255.08	2,921,267.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	9,449,700.09	10,711,847.87	8,243,352.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	4,389.51	5,535.00	8,073.77	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	579.64	19,355.70	-19.34	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	21,272,041.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-172.78	
25,207.35	
19,119.47	
143,434.22	
254,656.06	
2,681,337.42	
1,924,482.20	
6,890,412.06	
33,068.33	
217.07	
86.34	
128.90	
3,670.09	
766.59	
30,006.32	
7,191.18	
1,030,536.64	
1,328,390.19	
20,653,792.94	
10,600,555.51	
28,404,899.96	
17,998.28	
19,916.00	
74,069,700.34	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	41,330.26	46,109.83	28,638.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116,078.92	
3916	NEWLY ELIGIBLE MALE	331,242.92	482,310.70	341,671.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,155,224.80	
3917	NEWLY ELIGIBLE FEMA L	773,121.13	829,594.37	623,013.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,225,728.75	
3918	NEWLY ELIGIBLE M&F 4	1,108,114.13	1,301,085.00	1,128,587.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,537,786.59	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	736.00	
3928	NEWLY ELIGIBLE M&F 4	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	2,142,230.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,121,348.44	

4412	SOBRA 100-133% M&F
1	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	
4413	SOBRA 100-133% M&F
6	435,953.97	558,062.57	439,608.71	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	88,431.46	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	163,944.58	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	691,984.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,436.00	
1,433,625.25	
355,201.53	
566,798.37	
2,357,061.15	

4517	BC PATIENT FEMALE 2 1	368.00	736.00	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	5,535.42	5,198.08	3,942.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	147.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	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	3,942.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,104.00	
14,676.01	
147.74	
368.00	
16,295.75	

8700	SSI DISABLED FREEDO M	11,347.92	16,496.57	21,239.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	1,104.00	0.00	2,658.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	724.25	2,876.00	5,995.15	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	29,893.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
49,084.00	
3,762.95	
9,595.40	
62,442.35	

76,348,717.42	85,353,274.59	66,796,397.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

1006

1007

1008

1009

1011

1012

1013

1014

1015

1016

1017

1018

2100

2110	TANF 21-44 MALE WITH TANF 21-44 FEMALE WI TANF 45-64 M & F WIT TANF 65+ M & F WITH TANF <1 M & F NON-ME TANF 01-05 M & F NON TANF 06-13 M & F NON TANF 14-20 MALE NON-
TANF 14-20 FEMALE N O
TANF 21-44 MALE NON-

TANF 21-44 FEMALE N O
TANF 45-64 M & F NON

SSI AGED WITH MEDIC A
SSI AGED NON-MEDICA
R	24.86

95.75

3,001.23

100.93

17,325.66

401.51

1,152.31

714.39

3,433.47

22,396.21

52,737.24

18,073.82

15,695.91

28,335.40	0.00

21.69

1,005.46

886.53

62,411.73

861.55

-24.10

1,253.78

1,839.76

77,167.79

131,048.50

37,929.68

8,647.19

43,386.47	90.63

0.00

161.94

87.58

16,655.73

9.55

90.49

2,854.79

17,329.46

17,027.50

51,785.14

10,840.13

17,906.90

18,508.51	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00		115.49

117.44

4,168.63

1,075.04

96,393.12

1,272.61

1,218.70

4,822.96

22,602.69

116,591.50

235,570.88

66,843.63

42,250.00

90,230.38	
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	2,033.62	523.52	3,191.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,748.60	
2210

4311	SSI DISABLED NON-ME D
SOBRA CHILD <1 M & F	16,753.15

10,799.03	7,270.63

33,934.63	7,651.13

1,439.56	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		31,674.91

46,173.22	
4312	SOBRA CHILD 01-05 M	36,145.25	43,168.63	23,886.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,200.64	
4313	SOBRA CHILD 06-13 M	35,978.68	63,157.33	22,075.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,211.21	
4314	SOBRA CHILD 14-20 MA	18,930.52	12,976.10	24,307.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,214.01	
4315	SOBRA CHILD 14-20 FE	12,023.48	33,332.95	16,503.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,859.70	
5007

5015

5017

5018

SUBTOTAL	SOBRA PREG 21-44 FE M
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE
M
:	214.11

15,014.16

74,107.54

0.00

385,488.23	0.00

30,238.92

80,746.34

2,069.35

674,902.99	0.00

17,931.32

74,318.02

0.00

344,652.46	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00		214.11

63,184.40

229,171.90

2,069.35

1,405,043.68	

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	148.39	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	412.43	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	1,190.20	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	1,704.12	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	23,243.00	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	31,651.63	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	19,259.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.99	
325.38	
7,816.88	
1,190.20	
2,735.54	
80,121.13	
136,285.94	
46,790.42	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1119	TANF EXPANDED 65+
M&	55.48	0.00	175.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230.48		
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&	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		
2400	SSI AGED EXPANDED WI	9,438.04	7,426.55	5,904.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,769.49		
2410	SSI AGED EXPANDED NO	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		
2420	SSI AGED EXPANDED WI	801.02	279.30	662.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,742.92		
2600	SSI DISABLED EXPAND E	4,162.15	4,535.71	3,783.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,481.32		
2610	SSI DISABLED EXPAND E	2,877.20	578.09	517.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,973.15		
2620	SSI DISABLED EXPAND E	-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	88,653.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323,082.62		

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	110.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	1,522.55	2,007.21	-130.10	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	1,492.91	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	1,563.70	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	35,919.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	24,423.42	39,053.73	33,070.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	91,934.27	121,532.84	100,254.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

489.66	
110.07	
3,399.66	
13,073.42	
15,185.83	
174,850.71	
96,547.79	
313,721.91	

3506	ADULT 40-100% MALE 2	2,064.92	22.28	907.60	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	249.21	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	350.00	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	1,936.37	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	36,283.29	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	24,340.20	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	156,785.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	117.86	92.24	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	606.80	4,068.27	1,255.40	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	7,413.72	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	9,242.58	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	283,641.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	76,836.42	98,771.60	84,787.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	169,251.34	238,534.74	207,786.84	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	815,071.9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,994.80	
1,598.46	
6,503.26	
13,413.60	
97,654.57	
62,456.91	
328,586.48	
210.10	
5,930.47	
39,916.85	
34,196.61	
624,997.42	
260,395.51	
615,572.92	
1,305.57	
16.92	
2,095,750.45	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	202,655.53	242,551.92	172,171.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617,379.05		

4413	SOBRA 100-133% M&F
6	9,276.43	18,205.79	7,133.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,598.02	2,596.70	398.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,645.47	4,875.11	1,504.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,519.92	25,677.60	9,035.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
34,615.79	
4,592.92	
8,024.67	
47,233.38	

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	

78.61	
78.61	

4518	BC PATIENT FEMALE 4
5
SUBTOTAL:

8700	SSI DISABLED FREEDO M	30.54	591.33	225.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	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	
SUBTOTAL:	1,096.24	591.33	225.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

847.45	
1,065.70	
1,913.15	

TOTAL:	1,228,483.14	1,832,186.92	1,429,810.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,490,480.94		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
9000	PRESUMPTIVE ELIGIBI 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		576.29		
SUBTOTAL:	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	

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 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	83.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,836.62		
1012	TANF 01-05 M & F NON	25,128.76	31,110.09	8,102.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,341.54		
1013	TANF 06-13 M & F NON	51,155.97	80,966.53	57,090.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,213.05		
1014	TANF 14-20 MALE NON-	93,392.20	152,861.08	48,139.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		294,392.52		
1015	TANF 14-20 FEMALE N O	365,886.79	512,928.45	433,985.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,312,800.46		
1016	TANF 21-44 MALE NON-	126,645.84	163,695.80	98,079.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		388,420.67		
1017	TANF 21-44 FEMALE N O	2,509,465.83	3,746,506.71	3,124,913.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,380,885.66		
1018	TANF 45-64 M & F NON	232,788.56	309,539.08	253,785.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796,112.77		
1019	TANF 65+ M & F NON-M	4,738.82	9,707.54	11,164.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,611.10		
2100	SSI AGED WITH MEDIC A	12,916.57	12,231.56	7,221.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,369.98		
2110	SSI AGED NON-MEDICA R	869,141.79	1,485,741.04	1,163,143.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,518,026.42		
2120	SSI AGED WITH QMB	4,041.12	1,462.37	1,946.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,450.45		
2200	SSI DISABLED WITH M E	2,921.27	5,139.66	2,878.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,939.29		
2210	SSI DISABLED NON-ME D	420,657.34	364,111.90	277,016.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,061,786.20		
2220	SSI DISABLED WITH Q M	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	5,487,551.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,087,392.83		

1106	TANF EXPANDED 21-44	20.66	853.49	749.84	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	603.49	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	27,738.74	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	622,298.72	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	1,307,638.53	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	618,832.70	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	11,211.26	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	47.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	2,199.44	1,281.53	561.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	17,674.75	39,566.48	17,817.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	62.60	24.94	383.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	37,953.48	36,696.60	17,335.78	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	2,625,219.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,623.99	
-1,206.23	
1.85	
4,013.93	
54,224.71	
1,767,066.51	
3,552,567.85	
1,745,179.07	
24,613.81	
1,877.16	
4,042.89	
75,058.51	
471.06	
91,985.86	
7,321,520.97	

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 4	144.99	878.73	3,121.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	447.97	878.73	3,121.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
302.98	
4,145.49	
4,448.47	

3906	NEWLY ELIGIBLE MALE	3,658.03	6,533.31	3,679.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,870.43

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3907	NEWLY ELIGIBLE FEMA L	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		
3908	NEWLY ELIGIBLE M&F 4	190.37	14,378.58	4,624.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,193.09		
3909	NEWLY ELIGIBLE M&F 6	4,641.95	861.24	823.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,326.27		
3914	NEWLY ELIGIBLE MALE	-32,353.35	60,696.90	62,912.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,256.30		
3915	NEWLY ELIGIBLE FEMA L	47,067.82	74,149.89	75,387.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196,605.69		
3916	NEWLY ELIGIBLE MALE	715,851.62	1,156,537.30	726,943.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,599,332.53		
3917	NEWLY ELIGIBLE FEMA L	458,763.46	686,388.67	510,747.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,655,900.07		
3918	NEWLY ELIGIBLE M&F 4	1,954,928.55	2,512,951.28	1,912,755.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,380,635.52		
3919	NEWLY ELIGIBLE M&F 6	4,798.84	29,402.03	264.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,464.96		
SUBTOTAL:	3,157,734.03	4,543,146.60	3,298,138.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,999,019.00		

TOTAL:	9,886,437.64	14,111,912.66	11,414,030.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,412,381.27		

QMB - FEE FOR SERVICE
For The Period Ending September 30, 2016

SUBTOTAL:	400,114.69	462,259.02	326,723.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,189,097.06	
															
TOTAL:	400,114.69	462,259.02	326,723.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,189,097.06	

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	326,096.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,188,371.76	
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	626.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	721.14	

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 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	140.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,472.48		
1011	TANF <1 M & F NON-ME	736.00	4,723.43	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,827.43		
1012	TANF 01-05 M & F NON	368.00	6,424.63	12,171.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,964.17		
1013	TANF 06-13 M & F NON	16,512.22	58,805.63	33,851.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,168.99		
1014	TANF 14-20 MALE NON-	7,533.55	31,068.97	43,660.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,262.88		
1015	TANF 14-20 FEMALE N O	17,783.14	60,075.16	52,454.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,312.55		
1016	TANF 21-44 MALE NON-	50,986.98	232,739.24	158,391.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		442,117.61		
1017	TANF 21-44 FEMALE N O	127,725.96	724,699.04	580,736.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,433,161.17		
1018	TANF 45-64 M & F NON	27,221.83	125,961.97	90,380.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243,564.42		
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	1,846.28	4,349.08	4,742.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,938.04		
2110	SSI AGED NON-MEDICA R	0.00	368.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.00		
2120	SSI AGED WITH QMB	2,129.89	16,890.55	8,512.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,533.26		
2200	SSI DISABLED WITH M E	4,943.64	25,786.59	15,182.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,912.48		
2210	SSI DISABLED NON-ME D	328,797.09	1,331,576.12	1,008,275.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,668,649.07		
2220	SSI DISABLED WITH Q M	57,352.69	239,617.61	215,280.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		512,250.89		
2310	SSI BLIND NON-MEDIC A	1,641.42	3,896.82	1,477.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,015.68		
2320	SSI BLIND WITH QMB	152.56	426.32	347.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		925.92		
4311	SOBRA CHILD <1 M & F	0.00	4,537.43	2,034.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,572.16		
4312	SOBRA CHILD 01-05 M	38,968.43	137,249.86	128,098.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304,316.50		
4313	SOBRA CHILD 06-13 M	681,184.65	2,583,435.70	1,681,906.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,946,527.10		
4314	SOBRA CHILD 14-20 MA	118,686.61	495,250.47	412,817.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,026,754.08		
4315	SOBRA CHILD 14-20 FE	99,195.07	477,467.78	386,605.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		963,268.02		
5015	SOBRA PREG 14-20 FE M	2,116.23	12,740.30	13,261.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,118.05		
5017	SOBRA PREG 21-44 FE M	13,961.07	87,460.78	103,132.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204,554.14		
5018	SOBRA PREG 45-64 FE M	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		
SUBTOTAL:	1,600,315.02	6,668,008.15	4,954,196.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,222,519.36		

1106	TANF EXPANDED 21-44	137.75	616.80	613.08	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	374.58	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	4,238.76	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	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	468.71	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	35,932.03	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	169,883.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,367.63	
1,972.34	
9,081.02	
64.80	
4,866.92	
79,232.40	
385,233.76	

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 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	87,530.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194,369.61		
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		
1127	TANF EXPANDED 21-44	0.00	0.00	64.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.80		
1128	TANF EXPANDED 45-64	0.00	389.55	143.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		532.64		
1129	TANF EXPANDED 65+
M&	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		
2400	SSI AGED EXPANDED WI	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		
2420	SSI AGED EXPANDED WI	1,847.24	7,852.62	5,140.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,840.46		
2600	SSI DISABLED EXPAND E	340.83	1,313.81	339.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,993.86		
2610	SSI DISABLED EXPAND E	2,514.49	16,695.75	6,889.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,099.94		
2620	SSI DISABLED EXPAND E	7,877.72	36,952.00	29,165.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,995.71		
SUBTOTAL:	66,027.96	387,092.07	340,784.8	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		793,904.88		

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	2,362.90	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	4,732.31	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	31,836.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	10,182.84	38,280.94	25,210.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	3,575.13	22,762.50	14,030.94	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	78,173.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

759.29	
4,729.80	
11,214.74	
68,560.06	
73,674.02	
40,368.57	
199,306.48	

4413	SOBRA 100-133% M&F
6	21,364.78	93,891.88	53,148.77	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	13,195.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	9,747.31	36,201.76	28,336.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

168,405.43	
37,392.24	
74,285.23	

3514	ADULT 40-100% MALE 1	2,919.76	13,958.09	11,640.18	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	6,809.68	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	52,464.20	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	72,283.71	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	33,975.43	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	1,791.00	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	217.91	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	57,760.73	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	42,372.97	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	1,111,233.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	121,453.62	716,040.07	524,059.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	133,578.17	788,753.02	563,663.21	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	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	2,478,271.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
28,518.03	
18,840.77	
130,878.68	
228,210.19	
80,714.03	
10,885.50	
585.91	
164,306.69	
152,467.98	
2,813,726.57	
1,361,553.10	
1,485,994.40	
706.24	
6,477,388.09	

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	35,980.82	149,421.67	94,680.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		280,082.90		

TOTAL:

2,326,439.64    10,700,783.95	7,946,106.37

0.00

0.00

0.00

0.00

0.00

20,973,329.96

0.00

0.00

0.00	0.00

8700	SSI DISABLED FREEDO M	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:	0.00	128.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
128.25	
128.25	

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2016

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017

2210	TANF 21-44 FEMALE N O
SSI DISABLED NON-ME
D	0.00

0.00	5,714.73

0.00	10,613.08

11,429.46	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	16,327.81

11,429.46	
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	
SUBTOTAL:	0.00	12,154.73	22,042.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,197.27	

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 E	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	
SUBTOTAL:	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	

6,531.12	
4,081.95	
8,163.90	
18,776.97	

3716	ADULT <40% EXP MALE	0.00	11,429.46	12,245.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	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 4	0.00	6,888.39	4,081.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	28,114.53	16,327.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

23,675.31	
9,796.68	
10,970.34	
44,442.33	

11,429.46	47,616.77	38,370.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	62,636.18	7,321.33	10,598.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,555.67		
2110	SSI AGED NON-MEDICA R	55,431.46	44,621.86	210,826.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310,879.44		
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	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		
2210	SSI DISABLED NON-ME D	1,073.60	164.72	7,728.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,967.22		
5017	SOBRA PREG 21-44 FE M	3,260.38	0.00	843.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,104.11		
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	229,996.9	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408,912.50		

3706	ADULT <40% EXP MALE	26,019.36	12,060.99	9,835.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	271.09	32.88	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	11,908.65	112,467.25	35,257.25	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	8,749.29	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	333,067.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	52,156.60	35,765.56	55,821.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	353,809.36	370,094.66	636,761.02	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	18,959.54	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	1,098,452.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

47,916.33	
303.97	
159,633.15	
25,365.85	
2,416.65	
1,201,759.22	
143,743.54	
1,360,665.04	
5,349.86	
104,922.20	
3,052,075.81	

3916	NEWLY ELIGIBLE MALE	15,999.84	1,846.21	8,999.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	5,137.82	0.00	3,260.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	25,941.69	5,239.92	39,335.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	47,079.35	7,086.13	51,594.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

26,845.25	
8,398.20	
70,516.84	
105,760.29	

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 E	804.92	318.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	804.92	478.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
160.42	
0.00	
1,123.14	
1,283.56	

TOTAL:	975,409.12	1,212,578.98	1,380,044.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,568,032.16		

COCHISE COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MALE	0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.17		
SUBTOTAL:	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	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MALE	0.00	162.87	184.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347.24		
3717	ADULT <40% EXP FEM AL	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		
SUBTOTAL:	3,420.00	-3,257.13	184.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347.24		

TOTAL:	3,420.00	-3,257.13	184.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347.24		

GRAHAM COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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		
SUBTOTAL:	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	

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	4,132.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,491.86		
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	1,082.48	2,762.19	4,225.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,070.47		
2100	SSI AGED WITH MEDIC A	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		
2200	SSI DISABLED WITH M E	1,309.60	80.21	289.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,678.81		
2210	SSI DISABLED NON-ME D	1,618.81	30,697.03	892.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,208.08		
2220	SSI DISABLED WITH Q M	4,268.62	479.48	168.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,916.52		
5015	SOBRA PREG 14-20 FE M	0.00	3,613.61	2,433.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,047.41		
5017	SOBRA PREG 21-44 FE M	0.00	470.90	2,433.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,904.70		
SUBTOTAL:	22,177.49	38,628.82	14,575.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,381.83		

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	
3517	ADULT 40-100% FEMAL E	0.00	0.00	80.30	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	1,915.71	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	1,175.42	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	5,014.74	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	34,781.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	10,385.03	11,952.70	8,319.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	13,015.34	65,281.63	32,395.41	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	83,682.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,451.47	
80.30	
6,445.13	
4,050.17	
5,014.74	
137,313.99	
30,656.92	
110,692.38	
303,705.10	

3916	NEWLY ELIGIBLE MALE	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	
SUBTOTAL:	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	

8,584.45	
8,584.45	

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	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	
2600	SSI DISABLED EXPAND E	173.98	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	3,944.64	352.30	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	352.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,884.70	
2,513.74	
31,367.78	
17,181.68	
181.98	
4,296.94	
65,426.82	

TOTAL:	158,233.29	196,254.93	98,609.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453,098.20		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2200	SSI DISABLED WITH M E	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 D	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	
SUBTOTAL	:	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	
962.05	

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

9,315.14	

TOTAL:

992.87

8,322.27

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	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	
5015	SOBRA PREG 14-20 FE M	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	
5017	SOBRA PREG 21-44 FE M	0.00	415.50	2,536.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,952.05	
SUBTOTAL:	1,278.07	26,237.18	2,536.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,051.80	

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	3,587.31	4,749.85	327.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	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	327.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8.00	
114.90	
14,746.48	
8,664.90	
16,885.34	
40,419.62	

TOTAL:	18,918.25	48,688.88	2,864.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,471.42		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	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	
2200	SSI DISABLED WITH M E	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	
2220	SSI DISABLED WITH Q M	3,803.40	0.00	-3,803.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	4,630.48	3,154.31	-3,803.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,981.39	

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	

2,660.70	
2,660.70	

1128	TANF EXPANDED 45-64

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 AL	8.00	0.00	1,076.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	9,572.42	0.00	142.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,580.42	42,847.62	1,219.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

42,847.62	
1,084.63	
9,715.30	
53,647.55	

16,871.60	46,001.93	-2,583.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

60,289.64	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending September 30, 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	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.00		
2100	SSI AGED WITH MEDIC A	2,307,947.16	2,733,144.98	2,326,251.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,367,343.40		
2110	SSI AGED NON-MEDICA R	149,727.64	170,783.44	154,051.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		474,562.55		
2120	SSI AGED WITH QMB	3,195,618.68	3,951,641.09	3,161,445.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,308,705.23		
2200	SSI DISABLED WITH M E	537,954.02	696,721.39	546,649.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,781,325.31		
2210	SSI DISABLED NON-ME D	2,694,953.74	3,287,243.03	2,968,877.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,951,074.30		
2220	SSI DISABLED WITH Q M	764,491.97	940,091.58	815,616.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,520,200.54		
2300	SSI BLIND WITH MEDIC	0.00	0.00	77.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.04		
2310	SSI BLIND NON-MEDIC A	12,301.04	21,001.65	17,655.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,958.66		
2320	SSI BLIND WITH QMB	7,206.96	7,708.00	7,966.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,881.12		
SUBTOTAL:	9,670,201.21	11,808,703.16	9,998,959.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,477,864.15		

8710	SSI DISABLED FREEDO M	653.30	6,631.23	2,774.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	2,765.43	3,427.20	2,741.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,418.73	10,058.43	5,516.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10,058.93	
8,934.39	
18,993.32	

TOTAL:	9,673,619.94	11,818,761.59	10,004,475.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,496,857.47		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100

2110	SSI AGED WITH MEDIC A
SSI AGED NON-MEDICA
R	6,319.24

200.76	20,181.09

1,334.55	10,420.34

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	36,920.67

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

2210

SUBTOTAL	SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
:	4,355.69

11,384.31

25,539.02	5,162.72

301.39

27,090.16	1,056.47

764.10

12,240.91	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	10,574.88

12,449.80

64,870.09	

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2016

12,240.91

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

64,870.09	

TOTAL:

25,539.02

27,090.16

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	10,026.35	4,936.82	11,573.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,536.38		
1013	TANF 06-13 M & F NON	26,843.26	657.79	21,985.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,486.70		
1014	TANF 14-20 MALE NON-	2,429.50	605.12	2,905.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,939.78		
1015	TANF 14-20 FEMALE N O	2,174.10	399.72	505.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,079.15		
2200	SSI DISABLED WITH M E	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		
2210	SSI DISABLED NON-ME D	136,113.36	80,007.50	116,612.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332,732.89		
2220	SSI DISABLED WITH Q M	800.49	0.00	94.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		895.39		
2310	SSI BLIND NON-MEDIC A	919.88	782.99	1,582.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,285.35		
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	26,984.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,604.03		
4313	SOBRA CHILD 06-13 M	91,660.37	21,444.81	62,944.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,049.18		
4314	SOBRA CHILD 14-20 MA	6,894.69	11,038.98	7,338.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,272.04		
4315	SOBRA CHILD 14-20 FE	2,364.62	747.24	2,244.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,356.25		
SUBTOTAL:	308,762.96	134,897.03	254,770.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		698,430.10		

83.28	153.89	635.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
83.28	153.89	635.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

873.13	
873.13	

1113	TANF EXPANDED 06-13	0

SUBTOTAL:

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 E	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 AL	41.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	851.49	643.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

159.17	
719.51	
575.01	
41.40	
1,495.09	

3915	NEWLY ELIGIBLE FEMA L	0.00	142.91	122.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	142.91	122.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

265.40	
265.40	

4413	SOBRA 100-133% M&F
6	22,760.62	9,243.14	15,323.01	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	2,565.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	706.11	141.86	158.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,448.87	9,936.41	18,047.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

47,326.77	
5,099.40	
1,006.51	
53,432.68	

TOTAL:	335,146.60	145,773.84	273,575.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		754,496.40		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	395.88	12.35	86.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	494.59	
1010	TANF NON-MEDICARE	22,308.73	10,498.79	17,933.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,740.86	
2200	SSI DISABLED WITH M E	3,546.21	2,524.32	1,902.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,972.54	
2210	SSI DISABLED NON-ME D	797,548.98	458,452.07	658,852.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,914,853.99	
2220

2310

SUBT	SSI DISABLED WITH Q M
SSI BLIND NON-MEDIC
A
OTAL:	1,060.22

3,791.67

828,651.69	728.41

2,658.34

474,874.28	4,870.69

1,592.64

685,237.98	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

0.00	0.00

0.00

0.00	0.00

0.00

0.00	6,659.32

8,042.65

1,988,763.95	

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 2016

828,651.69	474,874.28	685,237.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,988,763.95	

TOTAL:

ACUTE REINSURANCE
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	100.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.54		
1011	TANF <1 M & F NON-ME	644,528.57	538,967.95	348,193.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,531,689.84		
1012	TANF 01-05 M & F NON	-5,098.78	50,222.62	9,238.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,362.16		
1013	TANF 06-13 M & F NON	127,321.76	319,516.34	87,212.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		534,050.28		
1014	TANF 14-20 MALE NON-	13,740.97	54,044.10	5,286.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,071.76		
1015	TANF 14-20 FEMALE N O	23,666.42	-77,738.83	1,484.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-52,588.15		
1016	TANF 21-44 MALE NON-	217,616.39	157,215.49	54,442.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		429,274.36		
1017	TANF 21-44 FEMALE N O	181,478.43	255,820.76	173,224.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		610,523.31		
1018	TANF 45-64 M & F NON	234,755.06	169,943.37	76,772.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		481,470.96		
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	15,498.24	9,837.42	61,465.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,801.36		
2110	SSI AGED NON-MEDICA R	388,018.03	277,060.71	184,488.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		849,566.77		
2200	SSI DISABLED WITH M E	14,893.21	9,427.77	104,031.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,352.94		
2210	SSI DISABLED NON-ME D	5,781,423.00	4,661,832.44	5,295,002.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,738,258.00		
2310	SSI BLIND NON-MEDIC A	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	916,954.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,896,010.79		
4312	SOBRA CHILD 01-05 M	441,100.37	296,759.82	532,152.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,270,012.69		
4313	SOBRA CHILD 06-13 M	263,996.88	399,559.68	266,337.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		929,894.06		
4314	SOBRA CHILD 14-20 MA	173,423.73	445,022.53	247,300.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		865,747.11		
4315	SOBRA CHILD 14-20 FE	82,494.00	220,990.49	22,217.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		325,701.53		
5015	SOBRA PREG 14-20 FE M	79,849.94	1,849.74	2,876.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,576.39		
5017	SOBRA PREG 21-44 FE M	25,268.07	62,182.61	34,576.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,026.75		
5018	SOBRA PREG 45-64 FE M	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	8,423,357.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,973,402.79		

0.00	23.10	73.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
0.00	23.10	73.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

96.57	
96.57	

3100	TRANSPLANT OPTION	0
1
SUBTOTAL:

1106	TANF EXPANDED 21-44	0.00	144.38	25.63	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	254,276.46	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	142,232.86	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	112,654.35	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	1,775.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	850.89	1,174.76	156.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	22,124.40	50,423.35	87,387.60	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	596,733.8	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

170.01	
1,108.27	
564,564.44	
637,263.91	
340,661.56	
1,775.50	
2,182.55	
159,935.35	
1,707,661.59	

ACUTE REINSURANCE
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
3514	ADULT 40-100% MALE 1	83,948.35	-32,668.54	450.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,729.93		
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	258,705.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		705,010.12		
3517	ADULT 40-100% FEMAL E	73,314.67	85,173.63	80,995.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239,483.33		
3518	ADULT 40-100% M&F 45	449,226.40	539,517.06	402,442.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,391,185.53		
3708	ADULT <40% EXP M&F 4	199,395.77	-259.43	-7,716.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,419.50		
3714	ADULT <40% EXP MALE	46,933.03	4,532.12	33,480.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,945.35		
3715	ADULT <40% EXP FEM AL	27,464.33	15,826.46	21,578.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,869.71		
3716	ADULT <40% EXP MALE	610,923.36	748,507.25	588,904.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,948,334.71		
3717	ADULT <40% EXP FEM AL	452,359.25	337,121.36	388,819.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,178,300.25		
3718	ADULT <40% EXP M&F 4	1,050,808.24	2,420,228.56	1,907,151.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,378,188.38		
3719	ADULT <40% EXP M&F 6	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	3,674,809.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,255,561.26		

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	643.92	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	296,911.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	54,472.48	535.80	28,422.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	187,202.54	442,135.83	367,737.11	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	693,714.3	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
67,021.64	
42,616.53	
1,029,577.87	
83,430.42	
997,075.48	
2,219,721.94	

4413	SOBRA 100-133% M&F
6	200,439.17	245,304.50	51,539.02	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	-15,746.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	37,792.99	13,313.52	6,999.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	822,402.65	454,795.05	42,792.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
497,282.69	
764,601.04	
58,106.37	
1,319,990.10	

0.00	2,325.47	11,583.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
0.00	2,325.47	11,583.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13,908.58	
13,908.58	

4518	BC PATIENT FEMALE 4	0
5
SUBTOTAL:

8710	SSI DISABLED FREEDO M	2,634.47	2,674.29	13,975.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,634.47	2,674.29	13,975.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

19,284.33	
19,284.33	

TOTAL:	15,160,643.59	15,891,943.26	13,457,040.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,509,627.16		

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	12,562.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,360.67	
2100	SSI AGED WITH MEDIC A	427,508.23	354,148.90	316,332.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,097,989.42	
2110	SSI AGED NON-MEDICA R	109,126.94	168,130.16	206,047.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	483,304.55	
2200	SSI DISABLED WITH M E	922,846.90	607,754.06	450,973.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,981,574.87	
2210	SSI DISABLED NON-ME D	3,499,917.78	4,372,697.42	4,032,666.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,905,281.69	
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	6,707.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,541.23	
SUBTOTAL:	4,967,043.47	5,508,762.62	5,025,290.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,501,096.52	

LONG TERM CARE REINSURANCE
For The Period Ending September 30, 2016

4,967,043.47	5,508,762.62	5,025,290.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15,501,096.52	

TOTAL:

ACUTE SMIB
For The Period Ending September 30, 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	88,043.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250,467.10		
1010	TANF NON-MEDICARE	609.00	852.60	609.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,070.60		
1020	TANF WITH QMB	24,116.40	24,603.60	21,315.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,035.00		
2100	SSI AGED WITH MEDIC A	103,567.30	146,400.10	154,520.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		404,487.80		
2110	SSI AGED NON-MEDICA R	493,790.60	499,097.90	531,909.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,524,797.90		
2120	SSI AGED WITH QMB	3,316,283.10	3,439,229.50	3,522,598.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,278,111.20		
2200	SSI DISABLED WITH M E	270,428.30	331,956.60	309,410.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		911,795.70		
2210	SSI DISABLED NON-ME D	391,130.70	391,601.00	388,254.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,170,986.40		
2220	SSI DISABLED WITH Q M	3,666,577.20	3,656,475.50	3,757,730.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,080,783.40		
2300	SSI BLIND WITH MEDIC	243.60	243.60	487.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		974.40		
2310	SSI BLIND NON-MEDIC A	3,288.60	3,288.60	3,410.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,987.60		
2320	SSI BLIND WITH QMB	29,962.80	30,084.60	30,084.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,132.00		
4300	SOBRA CHILD WITH ME D	121.80	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365.40		
4320	SOBRA CHILD WITH Q MB	243.60	121.80	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		609.00		
5000	SOBRA PREGNANT WO MAN	243.60	243.60	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		609.00		
5020	SOBRA PREGNANT WO MAN	3,897.60	3,288.60	3,288.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,474.80		
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	748,193.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,222,422.90		
8040	SLMB	4,230,330.90	4,296,575.00	4,308,851.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,835,757.20		
8888	SMIB ONLY NOT ELIGIB	-149,049.20	-27,293.50	-35,602.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-211,945.60		
9999	SMIB ONLY NOT ELIGIB	60,444.40	160,788.70	220,518.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441,751.40		
SUBTOTAL:	13,261,964.20	13,778,112.20	14,054,109.6	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,094,186.00		

3520	ADULT 40-100% FOR FI	974.40	1,096.20	730.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	1,339.80	852.60	609.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,314.20	1,948.80	1,339.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,801.40	
2,801.40	
5,602.80	

1100	TANF EXPANDED FPR FI	670,306.70	690,655.60	694,042.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	730.80	365.40	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	277,849.30	285,101.40	292,845.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	-974.40	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	121.80	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,270,888.70	2,227,426.40	2,210,062.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	121.80	365.40	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	-487.20	-121.80	-365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,918,198.80	1,889,063.40	1,828,654.60	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	5,025,726.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,055,004.40	
1,339.80	
855,796.60	
-609.00	
365.40	
6,708,377.40	
609.00	
-974.40	
5,635,916.80	
15,255,826.00	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR F	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	
SUBTOTAL	:	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	

8720	SSI DISABLED FREEDO M	26,430.60	25,699.80	25,699.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	26,430.60	25,699.80	25,699.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
77,830.20	
77,830.20	

TOTAL:	18,427,952.50	18,899,469.20	19,106,875.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,434,297.60		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100

2110	SSI AGED WITH MEDIC A
SSI AGED NON-MEDICA
R	-1,233.00

0.00	0.00

0.00	1,233.00

6,165.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

6,165.00	
2120	SSI AGED WITH QMB	236,959.20	276,996.30	277,202.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	791,157.50	
2220	SSI DISABLED WITH Q M	125,651.90	134,161.80	139,747.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	399,561.10	
2320	SSI BLIND WITH QMB	411.00	1,315.20	863.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,589.30	
8020	QMB ONLY	2,918.00	3,514.00	2,281.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,713.00	
9999

SUBT	SMIB ONLY NOT ELIGIB

OTAL:	-3,144.00

361,563.10	-4,377.10

411,610.20	-5,404.80	0.00

422,086.70	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		-12,925.90

1,195,260.00	

1120	TANF EXPANDED FOR FI	1,130.00	226.00	226.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	4,500.40	6,678.40	5,137.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,630.40	6,904.40	5,363.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,582.00	
16,316.20	
17,898.20	

367,193.50	418,514.60	427,450.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,231,414.30	2,263,375.00	2,291,179.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,785,968.50	
9999	SMIB ONLY NOT ELIGIB	-9,385.60	-5,934.40	7,613.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7,706.60	

SUBTOTAL:	
2,222,028.70	
2,257,440.60	
2,298,792.60	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
6,778,261.90	

TOTAL:	2,222,028.70	2,257,440.60	2,298,792.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,778,261.90		

LTC SMIB
For The Period Ending September 30, 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	974.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,288.60		
1020	TANF WITH QMB	243.60	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		730.80		
2100	SSI AGED WITH MEDIC A	996,521.00	982,501.00	980,592.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,959,614.00		
2110	SSI AGED NON-MEDICA R	185,014.20	184,527.00	197,120.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		566,661.90		
2120	SSI AGED WITH QMB	904,419.20	906,456.00	906,658.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,717,534.00		
2200	SSI DISABLED WITH M E	379,691.30	381,460.70	384,735.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,145,887.90		
2210	SSI DISABLED NON-ME D	18,635.40	20,340.60	22,607.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,583.60		
2220	SSI DISABLED WITH Q M	835,984.20	830,397.20	830,017.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,496,399.10		
2300	SSI BLIND WITH MEDIC	852.60	852.60	1,096.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,801.40		
2310	SSI BLIND NON-MEDIC A	365.40	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852.60		
2320	SSI BLIND WITH QMB	5,237.40	5,359.20	5,115.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,712.20		
SUBTOTAL:	3,328,304.10	3,313,355.90	3,329,406.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,971,066.10		

8720	SSI DISABLED FREEDO M	609.00	609.00	487.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	609.00	609.00	487.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,705.20	
1,705.20	

3,328,913.10	3,313,964.90	3,329,893.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,972,771.30	

TOTAL:

LTC HIB
For The Period Ending September 30, 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	452.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	452.10	
2120	SSI AGED WITH QMB	268,654.00	271,962.40	272,059.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	812,675.50	
2200	SSI DISABLED WITH M E	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	
2220	SSI DISABLED WITH Q M	14,652.00	13,608.00	12,782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,042.00	
SUBTOTAL	:	283,717.00	285,570.40	285,293.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	854,580.60	

TOTAL:	283,717.00	285,570.40	285,293.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		854,580.60		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	868.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,363.23		
1007	TANF 21-44 FEMALE WI	4,715.31	2,051.12	1,453.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,219.97		
1008	TANF 45-64 M & F WIT	2,768.42	8,031.79	10,613.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,413.99		
1009	TANF 65+ M & F WITH	1,498.24	2,850.90	1,807.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,156.90		
1011	TANF <1 M & F NON-ME	691,179.03	549,687.51	409,345.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,650,211.55		
1012	TANF 01-05 M & F NON	300,554.71	309,088.02	232,212.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		841,855.45		
1013	TANF 06-13 M & F NON	216,437.47	262,212.58	233,289.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		711,939.54		
1014	TANF 14-20 MALE NON-	77,950.03	61,633.93	49,927.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,511.43		
1015	TANF 14-20 FEMALE N O	181,345.66	201,315.48	195,143.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		577,804.42		
1016	TANF 21-44 MALE NON-	1,208,018.47	1,095,125.11	835,379.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,138,523.22		
1017	TANF 21-44 FEMALE N O	4,782,275.12	4,614,453.36	3,404,247.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,800,975.79		
1018	TANF 45-64 M & F NON	1,536,458.94	1,747,293.81	1,389,507.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,673,260.46		
1019	TANF 65+ M & F NON-M	1,488.83	2,576.00	3,680.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,744.83		
1026	TANF 21-44 MALE WITH	736.00	139.85	1,118.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,994.47		
1027	TANF 21-44 FEMALE WI	812.39	1,382.21	750.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,945.23		
1028	TANF 45-64 M & F WIT	3,869.59	788.58	2,676.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,334.39		
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	66,138.34	96,126.19	56,493.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,757.77		
2110	SSI AGED NON-MEDICA R	53,486.52	61,326.51	50,453.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,266.76		
2120	SSI AGED WITH QMB	229,795.08	290,274.13	250,072.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		770,142.02		
2200	SSI DISABLED WITH M E	138,965.52	205,333.70	184,379.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		528,679.18		
2210	SSI DISABLED NON-ME D	4,735,804.13	5,056,810.90	4,027,055.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,819,670.55		
2220	SSI DISABLED WITH Q M	434,350.13	563,385.69	444,545.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,442,281.10		
2300	SSI BLIND WITH MEDIC	442.84	1,105.82	590.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,139.17		
2310	SSI BLIND NON-MEDIC A	59,992.53	44,447.01	85,286.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,725.85		
2320	SSI BLIND WITH QMB	6,629.65	6,866.41	6,731.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,227.35		
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	1,558,419.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,914,684.12		
4312	SOBRA CHILD 01-05 M	2,972,452.20	3,405,021.15	3,042,802.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,420,275.39		
4313	SOBRA CHILD 06-13 M	4,942,683.63	4,831,514.49	4,120,274.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,894,472.13		
4314	SOBRA CHILD 14-20 MA	1,427,842.79	1,316,616.53	929,242.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,673,701.43		
4315	SOBRA CHILD 14-20 FE	1,271,324.45	1,578,662.99	1,464,172.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,314,159.47		
5007	SOBRA PREG 21-44 FE M	378.25	75.05	453.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906.96		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,231.36	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,668.36		
5015	SOBRA PREG 14-20 FE M	301,972.26	335,882.22	264,018.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901,873.04		
5017	SOBRA PREG 21-44 FE M	1,648,401.34	1,955,913.70	1,441,819.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,046,134.88		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018

5027	SOBRA PREG 45-64 FE M
SOBRA PREG 21-44 FE
M	1,822.00

0.00	4,398.00

0.00	4,828.82

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	11,048.82

0.00	
5028	SOBRA PREG 45-64 FE M	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	24,704,397.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,988,418.82	

1106	TANF EXPANDED 21-44	8,602.39	6,438.12	5,428.43	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	13,237.97	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	42,642.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	25,333.08	29,517.19	24,824.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	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	368.00	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	736.00	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	3,020.07	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	28,496.96	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	388,915.36	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	1,470,759.12	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	972,607.26	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	4,130.43	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	1,984.77	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	4,009.78	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	8,453.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	8,178.44	10,296.06	7,237.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	11,068.81	16,536.17	15,947.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	8,461.28	5,520.00	3,153.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	138,825.20	182,526.13	145,608.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	13,441.47	15,752.05	12,028.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	113,472.90	87,253.66	84,720.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	129,964.16	144,021.70	126,237.55	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	3,364,547.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

20,468.94	
43,480.89	
122,108.52	
79,674.77	
736.00	
2,208.00	
4,766.00	
14,163.15	
83,809.09	
1,215,334.82	
4,917,805.13	
3,307,215.29	
10,603.57	
8,458.15	
9,752.24	
31,743.38	
25,711.80	
43,552.57	
17,134.32	
466,959.59	
41,222.14	
285,446.89	
400,223.41	
11,152,578.66	

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	-1,335.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	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	
-1,335.43	

3100	TRANSPLANT OPTION 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	
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	

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 1	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

SUBTOTAL	AHC CARE/MI M&F 45-6

:	0.00

0.00	-2,310.00

-7,590.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	-2,310.00

-7,590.00	

3906	NEWLY ELIGIBLE MALE	565.60	252.69	29.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	368.00	718.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	6,391.01	9,530.25	3,280.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	491.18	602.98	747.75	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	11,406.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

847.74	
1,086.00	
19,201.39	
1,841.91	
40,982.33	

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	3,620.45	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	337.59	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	31,211.70	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	54,243.11	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	355,787.74	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	372,460.84	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	1,341,815.15	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	1,104.00	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	21.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	128.90	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	1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	38.04	368.00	285.98	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	10,145.24	5,836.66	8,635.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	386.08	4,104.04	1,414.62	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	193,618.06	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	330,646.06	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	3,041,503.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,020,325.53	2,525,694.81	1,840,461.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	5,969,277.06	6,352,847.34	4,996,162.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	2,190.00	4,988.28	4,809.35	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	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	12,579,372.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
32.05	
11,445.75	
5,478.84	
93,211.29	
198,543.56	
1,433,620.75	
1,367,756.49	
4,481,039.88	
4,784.00	
0.00	
86.34	
128.90	
1,112.65	
692.02	
24,617.87	
5,904.74	
705,975.26	
1,061,085.93	
11,689,382.83	
7,386,481.55	
17,318,287.09	
11,987.63	
18,205.78	
45,819,861.20	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	35,329.67	39,339.71	23,671.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,340.38	
3916	NEWLY ELIGIBLE MALE	236,860.76	307,117.41	193,505.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	737,483.85	
3917	NEWLY ELIGIBLE FEMA L	595,512.26	613,831.91	463,222.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,672,566.33	
3918	NEWLY ELIGIBLE M&F 4	774,247.15	944,868.39	770,039.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,489,154.81	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	736.00	
3928	NEWLY ELIGIBLE M&F 4	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	1,467,356.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,062,601.30	

4412	SOBRA 100-133% M&F
1	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	
4413	SOBRA 100-133% M&F
6	354,893.07	467,208.34	376,492.06	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	75,786.40	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	138,585.95	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	590,864.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,436.00	
1,198,593.47	
294,074.89	
474,917.27	
1,969,021.63	

4517	BC PATIENT FEMALE 2 1	368.00	736.00	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	5,520.00	4,416.00	2,284.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	147.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	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	2,284.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,104.00	
12,220.63	
147.74	
368.00	
13,840.37	

8700	SSI DISABLED FREEDO M	7,296.44	5,878.33	16,900.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	1,104.00	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	340.87	4,450.07	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	21,718.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
30,075.15	
1,472.00	
4,790.94	
36,338.09	

51,739,377.28	53,563,815.76	42,730,541.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 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	970.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,481.25		
1007	TANF 21-44 FEMALE WI	6,790.07	16,402.24	8,847.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,039.48		
1008	TANF 45-64 M & F WIT	5,745.09	7,583.01	925.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,253.41		
1009	TANF 65+ M & F WITH	524.13	55.02	114.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		693.57		
1011	TANF <1 M & F NON-ME	189,983.11	396,902.26	166,256.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		753,141.75		
1012	TANF 01-05 M & F NON	63,137.63	76,150.23	60,465.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,753.14		
1013	TANF 06-13 M & F NON	121,964.92	44,627.08	40,421.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,013.31		
1014	TANF 14-20 MALE NON-	9,809.04	10,160.19	11,971.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,940.94		
1015	TANF 14-20 FEMALE N O	33,485.45	46,331.69	52,742.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,560.12		
1016	TANF 21-44 MALE NON-	538,720.43	818,731.46	521,422.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,878,874.72		
1017	TANF 21-44 FEMALE N O	1,361,290.75	1,890,712.96	1,387,455.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,639,459.23		
1018	TANF 45-64 M & F NON	681,254.62	863,864.36	530,664.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,075,783.14		
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	18.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,615.77		
1027	TANF 21-44 FEMALE WI	2,636.88	2,108.61	27.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,773.41		
1028	TANF 45-64 M & F WIT	5,014.97	7,085.22	4,731.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,832.01		
1029	TANF 65+ M & F WITH	0.00	0.00	6.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.64		
2100	SSI AGED WITH MEDIC A	115,748.46	91,408.50	23,387.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230,544.20		
2110	SSI AGED NON-MEDICA R	31,788.57	48,642.55	31,256.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,687.91		
2120	SSI AGED WITH QMB	229,484.07	344,087.35	270,699.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		844,270.70		
2200	SSI DISABLED WITH M E	210,777.77	283,035.91	243,423.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		737,237.64		
2210	SSI DISABLED NON-ME D	3,642,965.31	4,857,725.43	3,800,787.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,301,478.73		
2220	SSI DISABLED WITH Q M	718,446.11	1,087,759.59	730,037.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,536,243.46		
2300	SSI BLIND WITH MEDIC	14.33	0.00	804.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		819.31		
2310	SSI BLIND NON-MEDIC A	25,883.10	61,596.20	26,069.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,548.35		
2320	SSI BLIND WITH QMB	9,644.50	10,606.91	5,210.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,461.80		
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	869,592.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,777,529.07		
4312	SOBRA CHILD 01-05 M	819,475.49	813,753.27	838,457.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,471,686.43		
4313	SOBRA CHILD 06-13 M	900,853.80	1,045,600.42	1,108,540.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,054,994.57		
4314	SOBRA CHILD 14-20 MA	235,587.23	343,925.37	241,039.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		820,552.46		
4315	SOBRA CHILD 14-20 FE	319,825.62	385,924.79	344,546.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,050,296.99		
5007	SOBRA PREG 21-44 FE M	459.90	1,929.86	485.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,875.43		
5013	SOBRA PREG 09-13 FE M	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		
5015	SOBRA PREG 14-20 FE M	66,587.06	139,786.68	101,941.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308,315.53		
5017	SOBRA PREG 21-44 FE M	617,725.42	908,907.30	686,011.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,212,643.93		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018

5027	SOBRA PREG 45-64 FE M
SOBRA PREG 21-44 FE
M	2,780.26

866.28	951.03

3,055.50	531.01

1,079.37	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	4,262.30

5,001.15	
5028	SOBRA PREG 45-64 FE M	262.71	897.03	70.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,230.30	
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	12,111,017.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,606,803.71	

1106	TANF EXPANDED 21-44	10,571.52	13,753.32	6,287.51	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	20,232.01	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	46,200.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	18,233.09	18,094.73	11,324.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	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	148.74	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	4,223.54	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	5,844.39	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	149,895.04	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	401,496.92	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	314,877.56	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	893.25	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	8,953.53	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	7,469.30	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	15,762.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	8,819.97	15,441.67	8,637.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	5,234.94	6,001.84	5,472.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	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	
2420	SSI AGED EXPANDED WI	151,371.20	156,081.17	119,746.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	18,539.97	25,338.08	15,912.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	56,032.83	48,660.49	84,016.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	197,419.13	282,031.47	185,593.40	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	1,412,988.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

30,612.35	
81,729.59	
216,815.79	
47,652.41	
0.00	
103.44	
148.74	
9,203.55	
29,641.38	
501,904.19	
1,360,483.05	
1,166,674.92	
1,143.41	
37,943.86	
18,014.64	
66,401.27	
32,898.81	
16,709.02	
-728.71	
427,198.97	
59,790.75	
188,709.88	
665,044.00	
4,958,095.31	

3317	AHC CARE FEMALE 21- 4	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	
SUBTOTAL:	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	
0.00	
-107.53	

3100	TRANSPLANT OPTION 1	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	
1,838.51	

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 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	
3616	AHC CARE/MI MALE 21-	0.00	0.00	-362.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-362.02	
3618

SUBTOTAL	AHC CARE/MI M&F 45-6

:	0.00

-138.35	-14.92

-14.92	-463.62

-825.64	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	-478.54

-978.91	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	2,854.42	2,978.75	1,020.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	6,895.37	4,020.80	2,130.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

68.40	
0.00	
6,853.62	
0.00	
13,046.54	

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	5,424.70	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	10,354.60	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	10,513.21	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	18,281.48	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	401,745.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	146,713.41	204,070.03	127,918.54	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	571,647.63	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	-51.33	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	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	648.18	1,093.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	74.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	564.58	2,089.93	2,175.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	940.33	328.96	17.15	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	107,660.73	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	82,434.39	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	2,577,851.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	765,143.06	1,133,604.69	998,651.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	3,295,413.07	3,963,337.74	3,047,122.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	2,136.91	546.72	3,264.42	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	579.64	583.07	-19.34	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	7,966,086.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-204.83	
13,661.89	
13,640.63	
40,031.81	
47,849.51	
1,010,649.17	
478,701.98	
1,965,509.94	
28,284.33	
217.07	
0.00	
0.00	
1,741.20	
74.57	
4,830.24	
1,286.44	
275,282.73	
232,587.56	
8,096,244.88	
2,897,398.90	
10,305,873.62	
5,948.05	
1,143.37	
25,420,753.06	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	6,000.59	6,770.12	4,415.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,186.43	
3916	NEWLY ELIGIBLE MALE	86,585.35	154,491.69	129,941.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	371,018.15	
3917	NEWLY ELIGIBLE FEMA L	150,672.73	178,002.93	118,358.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	447,034.65	
3918	NEWLY ELIGIBLE M&F 4	302,477.81	320,499.76	328,674.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	951,651.82	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	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	584,540.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,806,890.23	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	782.08	1,657.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	0.00	782.08	1,657.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
2,439.96	
0.00	
0.00	
2,439.96	

8700	SSI DISABLED FREEDO M	4,051.48	9,611.52	2,832.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	724.25	2,513.59	1,545.08	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	4,377.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,495.06	
0.00	
4,782.92	
21,277.98	

22,144,827.06

27,845,914.71

TOTAL:

22,174,272.47

0.00

0.00

0.00

0.00

0.00

72,165,014.24

0.00

0.00

0.00	0.00

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	71,542.65	84,163.38	60,515.76	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	10,060.39	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	23,854.09	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	94,430.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
216,221.79	
49,501.66	
82,278.47	
348,001.92	

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE 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		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018

5027	SOBRA PREG 45-64 FE M
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	
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	
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	

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

3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

3100	TRANSPLANT OPTION 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	
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	

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 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	
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

SUBTOTAL	AHC CARE/MI M&F 45-6

:	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

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

TOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	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	180.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,691.86		
1012	TANF 01-05 M & F NON	3,987.61	3,263.59	24.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,275.65		
1013	TANF 06-13 M & F NON	3,653.62	44.01	117.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,815.15		
1014	TANF 14-20 MALE NON-	1,143.86	301.79	433.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,879.00		
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	7,315.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,220.60		
1017	TANF 21-44 FEMALE N O	27,040.84	13,143.03	14,720.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,904.56		
1018	TANF 45-64 M & F NON	28,071.21	1,484.06	2,052.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,607.67		
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	596.90	3,497.28	87.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,181.26		
2110	SSI AGED NON-MEDICA R	5,148.07	-9,481.65	7,030.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,697.11		
2120	SSI AGED WITH QMB	242.01	-109.74	3.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.60		
2200	SSI DISABLED WITH M E	60.91	-225.64	2,470.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,305.88		
2210	SSI DISABLED NON-ME D	27,621.59	22,101.33	16,667.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,390.77		
2220	SSI DISABLED WITH Q M	2,632.34	-15.23	394.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,011.52		
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	8,500.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,633.69		
4312	SOBRA CHILD 01-05 M	65,933.12	13,197.35	21,624.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,755.29		
4313	SOBRA CHILD 06-13 M	104,379.21	2,798.52	14,577.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,755.02		
4314	SOBRA CHILD 14-20 MA	11,733.15	2,913.24	6,838.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,484.67		
4315	SOBRA CHILD 14-20 FE	7,732.31	6,972.91	15,121.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,826.95		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	4,124.18	12,367.41	655.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,146.96		
5017	SOBRA PREG 21-44 FE M	25,579.26	15,218.34	29,278.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,076.30		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018

5027	SOBRA PREG 45-64 FE M
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	
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	
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	148,094.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		580,634.68	

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	40.63	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&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	93.00	0.00	235.67	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	1,991.28	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	5,452.56	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	886.54	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	44.84	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&	0.00	191.51	47.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	903.35	516.82	1,276.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	174.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	166.07	666.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	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	
2620	SSI DISABLED EXPAND E	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	10,642.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
247.63	
1,596.06	
0.00	
0.00	
0.00	
0.00	
0.00	
328.67	
8,222.66	
29,124.97	
2,396.08	
0.00	
0.00	
442.08	
3.33	
239.43	
2,696.37	
0.00	
174.44	
832.44	
3,362.68	
1,665.21	
51,332.05	

3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

3100	TRANSPLANT OPTION 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	
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	

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 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	
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

SUBTOTAL	AHC CARE/MI M&F 45-6

:	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	101.36	65.43	251.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

42.18	
0.00	
417.89	
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	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	120.44	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	5,862.77	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	5,076.39	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	19,418.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	641.28	174.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	107.45	318.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	9,037.89	960.23	5,742.48	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	103.21	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	42,777.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	14,376.87	49,297.30	17,351.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	39,054.06	121,173.01	46,890.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	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	143,518.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
5,978.05	
618.24	
51,439.03	
8,709.22	
35,680.81	
0.00	
0.00	
0.00	
0.00	
816.24	
0.00	
425.62	
0.00	
15,740.60	
6,649.50	
175,374.27	
81,025.39	
207,117.30	
0.00	
566.85	
590,141.12	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	76.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.13	
3916	NEWLY ELIGIBLE MALE	2,914.09	14,106.81	6,628.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,649.14	
3917	NEWLY ELIGIBLE FEMA L	11,968.55	10,649.44	3,947.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,564.99	
3918	NEWLY ELIGIBLE M&F 4	12,324.30	13,624.14	7,696.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,644.45	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL	:	27,343.08	38,453.22	18,598.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,394.78	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

8700	SSI DISABLED FREEDO M	0.00	651.68	1,507.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	2,290.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	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	3,798.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,158.75	
2,290.95	
21.54	
4,471.24	

511,418.72

489,216.06

TOTAL:

325,648.49

0.00

0.00

0.00

0.00

0.00

1,326,283.27

0.00

0.00

0.00	0.00

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	8,378.75	4,057.46	579.96	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	272.74	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	144.25	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	996.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
13,016.17	
272.74	
2,020.49	
15,309.40	

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	45,645.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,572.15		
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	41.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.79		
SUBTOTAL:	36,872.16	53,054.5	45,687.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,613.94		

0.00

0.00

0.00

0.00

TOTAL:

36,872.16

53,054.55	45,687.23

0.00	0.00	0.00	0.00

0.00

135,613.94

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending September 30, 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	589.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589.33		
SUBTOTAL:	0.00	0.0	589.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589.33		

TOTAL:

0.00

0.00

589.33

0.00

0.00

0.00

0.00

0.00

589.33

0.00

0.00

0.00	0.00

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	280,451.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052,796.70		
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	-4.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.02		
SUBTOTAL:	363,239.62	409,204.4	7	280,446.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052,890.88		

0.00

0.00

0.00

0.00

TOTAL:

363,239.62

409,204.47	280,446.79

0.00	0.00	0.00	0.00

0.00

1,052,890.88

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 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	204.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938.21		
1008	TANF 45-64 M & F WIT	14.46	31.99	67.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.30		
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	20,674.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217,544.65		
1012	TANF 01-05 M & F NON	1,877.83	4,691.66	4,629.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,198.76		
1013	TANF 06-13 M & F NON	-34.11	397.76	542.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906.06		
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	6,361.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,118.77		
1016	TANF 21-44 MALE NON-	45,482.98	57,982.31	50,834.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,299.97		
1017	TANF 21-44 FEMALE N O	106,522.53	130,723.18	138,930.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		376,175.72		
1018	TANF 45-64 M & F NON	87,013.43	82,472.68	30,115.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,601.28		
1019	TANF 65+ M & F NON-M	0.00	278.62	774.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052.91		
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	318.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318.12		
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	8,499.66	938.66	2,046.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,484.58		
2110	SSI AGED NON-MEDICA R	2,551.19	18.03	2,511.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,080.75		
2120	SSI AGED WITH QMB	9,555.40	11,940.97	7,470.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,967.02		
2200	SSI DISABLED WITH M E	8,793.87	12,081.12	10,297.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,172.39		
2210	SSI DISABLED NON-ME D	243,889.19	242,188.71	228,595.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		714,673.81		
2220	SSI DISABLED WITH Q M	36,584.54	51,182.69	28,824.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,592.20		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	175.91	4,793.35	764.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,734.08		
2320	SSI BLIND WITH QMB	1,288.00	88.30	231.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,608.23		
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	18,189.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252,352.97		
4312	SOBRA CHILD 01-05 M	31,803.55	53,396.45	28,866.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,066.55		
4313	SOBRA CHILD 06-13 M	22,465.50	28,513.24	13,984.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,963.67		
4314	SOBRA CHILD 14-20 MA	8,438.19	7,014.89	19,047.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,501.05		
4315	SOBRA CHILD 14-20 FE	21,162.92	41,843.06	21,752.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,758.38		
5007	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		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	26,309.18	30,637.88	21,142.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,089.40		
5017	SOBRA PREG 21-44 FE M	138,907.46	135,105.28	81,251.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355,264.39		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018

5027	SOBRA PREG 45-64 FE M
SOBRA PREG 21-44 FE
M	0.00

56.68	0.00

90.66	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

147.34	
5028	SOBRA PREG 45-64 FE M	80.51	57.17	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194.85	
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	738,488.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,882,704.98	

1106	TANF EXPANDED 21-44	538.88	3,581.21	272.76	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	606.18	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	1,323.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	283.01	255.70	323.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	477.50	506.35	254.55	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	4,552.92	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	99,023.62	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	12,576.40	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	143.64	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	80.13	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	69.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	345.00	291.62	178.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	25.19	5,703.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	-552.47	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	10,427.22	9,257.84	5,545.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	127.08	678.60	160.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	1,127.98	862.65	7,720.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	9,014.59	12,900.26	5,689.62	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	144,224.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,392.85	
2,598.94	
5,343.25	
862.02	
0.00	
0.00	
0.00	
0.00	
1,238.40	
131,247.49	
181,353.63	
57,204.66	
0.00	
2,446.47	
1,298.49	
1,677.46	
815.02	
5,728.79	
-552.47	
25,230.67	
966.36	
9,710.77	
27,604.47	
459,167.27	

3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

3100	TRANSPLANT OPTION 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	
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	

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 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	
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

SUBTOTAL	AHC CARE/MI M&F 45-6

:	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	833.48	180.72	0.00	0.00	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	

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	4,213.07	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	5,402.91	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	48,861.53	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	13,850.34	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	65,747.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	52.40	57.17	23.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	13,443.49	7,826.15	12,268.41	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	6,885.48	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	152,239.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	64,187.35	106,658.28	64,804.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	145,955.90	274,489.78	153,176.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	62.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	617,404.70	762,214.90	527,472.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
99.71	
0.00	
4,213.07	
7,644.75	
185,628.47	
69,314.51	
232,317.43	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
132.59	
0.00	
33,538.05	
28,067.20	
536,802.09	
235,649.67	
573,621.95	
62.60	
0.00	
1,907,092.09	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	475.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	475.98	
3916	NEWLY ELIGIBLE MALE	4,882.72	6,594.79	11,596.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,073.66	
3917	NEWLY ELIGIBLE FEMA L	14,967.59	27,110.09	37,485.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,562.78	
3918	NEWLY ELIGIBLE M&F 4	19,064.87	22,092.71	22,177.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,335.51	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL	:	39,748.66	55,978.31	71,735.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	167,462.13	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	15.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

0.00	
15.42	
0.00	
0.00	
15.42	

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

355.04	
0.00	
0.00	
355.04	

1,787,758.49

2,166,153.23

TOTAL:

1,487,613.41

0.00

0.00

0.00

0.00

0.00

5,441,525.13

0.00

0.00

0.00	0.00

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	1,139.50	2,633.39	2,020.93	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	2,311.93	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	1,360.29	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	5,693.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
5,793.82	
11,352.24	
7,582.14	
24,728.20	

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.00		
2100	SSI AGED WITH MEDIC A	219,052.35	253,349.25	121,463.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		593,865.24		
2110	SSI AGED NON-MEDICA R	40,660.18	71,145.23	35,038.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,844.31		
2120	SSI AGED WITH QMB	182,700.41	209,792.30	159,732.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		552,224.71		
2200	SSI DISABLED WITH M E	34,869.86	45,426.05	38,471.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,766.93		
2210	SSI DISABLED NON-ME D	717,819.30	840,735.89	669,730.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,228,286.01		
2220	SSI DISABLED WITH Q M	69,871.55	87,449.75	85,703.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243,024.63		
2300	SSI BLIND WITH MEDIC	0.00	0.00	77.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.04		
2310	SSI BLIND NON-MEDIC A	4,453.28	8,672.22	9,443.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,569.31		
2320	SSI BLIND WITH QMB	388.66	676.12	219.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,284.63		
SUBTOTAL:	1,269,815.59	1,517,614.81	1,120,248.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,907,678.81		

8710	SSI DISABLED FREEDO M	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 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	
SUBTOTAL:	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	

 
1,898.93	
0.00	
1,898.93	

1,270,468.89	1,518,860.44	1,120,248.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,909,577.74	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	2,058,486.95	2,374,297.25	2,154,863.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,587,647.55		
2110	SSI AGED NON-MEDICA R	108,527.50	93,777.18	118,373.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320,677.78		
2120	SSI AGED WITH QMB	2,980,893.26	3,717,043.79	2,989,220.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,687,157.88		
2200	SSI DISABLED WITH M E	499,603.04	639,287.37	497,917.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,636,807.93		
2210	SSI DISABLED NON-ME D	1,864,375.53	2,336,558.77	2,196,536.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,397,470.46		
2220	SSI DISABLED WITH Q M	686,455.43	834,681.23	718,107.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,239,244.61		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	7,847.76	12,002.48	8,212.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,062.40		
2320	SSI BLIND WITH QMB	6,736.52	6,974.71	7,689.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,400.37		
SUBTOTAL:	8,212,925.99	10,014,622.78	8,690,920.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,918,468.98		

8710	SSI DISABLED FREEDO M	0.00	5,385.60	2,774.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	2,765.43	3,427.20	2,741.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,765.43	8,812.80	5,516.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,160.00	
8,934.39	
17,094.39	

TOTAL:	8,215,691.42	10,023,435.58	8,696,436.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,935,563.37		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	20,107.37	65,824.15	36,030.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,961.76		
2110	SSI AGED NON-MEDICA R	321.97	0.00	419.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		741.87		
2120	SSI AGED WITH QMB	16,004.46	3,678.81	7,559.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,242.70		
2200	SSI DISABLED WITH M E	859.25	960.45	6,967.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,786.81		
2210	SSI DISABLED NON-ME D	65,859.49	70,521.46	53,975.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190,356.20		
2220	SSI DISABLED WITH Q M	304.54	4,059.22	8,911.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,275.09		
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	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	113,863.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		362,691.38		

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

103,457.08	145,371.04	113,863.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

362,691.38	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	10,300.49	39,674.33	13,894.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,868.85		
2110	SSI AGED NON-MEDICA R	217.99	5,861.03	219.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,298.59		
2120	SSI AGED WITH QMB	16,020.55	21,126.19	4,933.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,079.94		
2200	SSI DISABLED WITH M E	2,621.87	11,047.52	3,294.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,963.64		
2210	SSI DISABLED NON-ME D	46,899.42	39,426.91	48,635.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,961.63		
2220	SSI DISABLED WITH Q M	7,860.45	13,901.38	2,894.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,656.21		
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	81.78	57.17	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196.12		
SUBTOTAL:	84,002.55	131,094.53	73,927.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289,024.98		

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

TOTAL:	84,002.55	131,094.53	73,927.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289,024.98		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011

6012	KIDS <1M&F NON MEDI C
KIDS 1-5 M & F NON-M	479.18

0.00	-557.49

-6,189.47	21,350.80

77,969.11	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	21,272.49

71,779.64	
6013	KIDS 6-13 M & F NON-	33,225.63	13,672.65	183,641.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	230,539.55	
6014	KIDS 14-19 MALE NON-	31,612.49	24,016.15	68,826.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	124,455.16	
6015	KIDS 14-19 FEMALE NO	40,507.26	29,084.45	101,226.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	170,818.32	
SUBTOTAL:	105,824.56	60,026.29	453,014.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		618,865.16	
TOTAL:	105,824.56	60,026.29	453,014.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			

618,865.16	

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	44.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.12	

6012	C
KIDS 1-5 M & F NON-M	
0.00	
0.41	
658.36	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
658.77	
6013	KIDS 6-13 M & F NON-	243.88	228.41	1,455.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,927.42	
6014	KIDS 14-19 MALE NON-	166.11	161.00	387.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	714.87	
6015	KIDS 14-19 FEMALE NO	138.19	130.41	377.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	646.16	

SUBTOTAL:	
549.18	
521.23	
2,922.93	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3,993.34	

TOTAL:	549.18	521.23	2,922.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,993.34		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011

6012	KIDS <1M&F NON MEDI C
KIDS 1-5 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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	
6013	KIDS 6-13 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	
6014	KIDS 14-19 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	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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	
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	

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
6012	KIDS 1-5 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		
6013	KIDS 6-13 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		
6014	KIDS 14-19 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		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		

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		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	0.00	0.00	271.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	271.99	
6013	KIDS 6-13 M & F NON-	0.00	0.00	317.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	317.51	
6014	KIDS 14-19 MALE NON-	0.00	15.43	338.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	354.25	
6015	KIDS 14-19 FEMALE NO	0.00	214.91	133.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	348.81	

SUBTOTAL:	
0.00	
230.34	
1,062.22	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,292.56	

0.00	230.34	1,062.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,292.56	

TOTAL:

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	63,655.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,528.62		
SUBTOTAL:	82,673.79	198.95	63,655.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,528.62		
															
TOTAL:	82,673.79	198.95	63,655.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,528.62		

00

00

89,182.24

89,182.24

30.00

2,008.65

5.49

6.00

518.07

11.00

812.85

5,910.27

67,068.17

5.32

12,279.24

43.00

361.99

83.19

27.00

3.00

9.00

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending September 30, 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	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	666.51	671.77	670.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101Z	TANF ALTCS NON-MEDIC	0.00	0.00	5.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	170.32	172.75	175.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICAR	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	271.83	271.02	270.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH ME	1,947.34	1,983.19	1,979.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-MED	22,244.95	22,359.52	22,463.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
221Z	SSI DISABLED NON-MED	0.00	1.03	4.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH QM	4,066.85	4,090.03	4,122.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	13.00	14.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	118.99	121.00	122.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	28.19	28.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	9.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29,556.98	29,741.31	29,883.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL:	29,556.98	29,741.31	29,883.95	0.	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	

 
ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM
EPD/DD EXPENDITURES
For the Period Ending September 30, 2016

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	378,708.42	372,091.86	377,661.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,128,461.90	
EPD	85,600,877.03	98,791,049.82	85,922,476.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	270,314,403.35	
TOTAL AHCCCS LTC	85,979,585.45	99,163,141.68	86,300,138.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	271,442,865.25	
DES/DD	104,331,950.18	104,866,978.39	105,491,156.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314,690,084.97	
TOTAL DES LTC	104,331,950.18	104,866,978.39	105,491,156.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	314,690,084.97	
TOTAL LTC - CAP	190,311,535.63	204,030,120.07	191,791,294.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	586,132,950.22	

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	10,004,475.94
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	31,496,857.47
0.00	
	0.00	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	10,004,475.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,496,857.47	

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	4,206,734.06
818,556.37	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	13,798,001.99
1,703,094.53	
	513,400.18	371,137.98	818,556.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,703,094.53	
TOTAL LTC - REIN	4,967,043.47	5,508,762.62	5,025,290.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,501,096.52	

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	3,615,186.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,827,351.90	

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

Thursday, October 13, 2016

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

010115	CRS FULLY INTEGRATED PLAN - CAP	14,233,650.60	13,929,828.60	14,183,986.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,347,465.21	
010145	CRS ACUTE SEMI INTEGRATED - CAP	145,463.25	142,476.36	145,562.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	433,501.89	
999125	CRS SEMI INTEGRATED PLAN - CAP	4,973,747.20	4,959,398.40	4,961,664.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,894,809.60	
999135	CRS ONLY PLAN - CAP	551,073.60	552,982.08	550,596.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,654,652.16	
Subtotal	19,903,934.65	19,584,685.44	19,841,808.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,330,428.86	

999155	CRS REINSURANCE ONLY	2,326,263.42	446,456.85	911,431.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,684,151.94	
Subtotal	2,326,263.42	446,456.85	911,431.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,684,151.94	

22,230,198.07	20,031,142.29	20,753,240.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,014,580.80	

GRAND TOTAL

Thursday, October 13, 2016

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

010115	CRS FULLY INTEGRATED PLAN - MM	17,102.15	16,990.50	17,006.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,098.81	
010145	CRS ACUTE SEMI INTEGRATED - MM	181.59	179.98	181.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	543.30	
999125	CRS SEMI INTEGRATED PLAN - MM	6,586.00	6,567.00	6,570.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,723.00	
999135	CRS ONLY PLAN - MM	1,155.00	1,159.00	1,154.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,468.00	
Subtotal	25,024.74	24,896.48	24,911.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,833.11	

25,024.74	24,896.48	24,911.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,833.11	

GRAND TOTAL

Thursday, October 13, 2016

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

010700	HEALTH CHOICE INTEGRATED - CAP	8,139,817.79	8,143,584.09	8,215,936.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,499,338.15	
010725	CENPATICO INTEGRATED - CAP	19,718,383.80	19,873,855.68	19,844,674.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,436,913.79	
078999	MERCY MARICOPA INTEGRATED - CAP	43,908,062.70	44,810,326.74	45,127,647.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133,846,036.99	
Subtotal	71,766,264.29	72,827,766.51	73,188,258.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	217,782,288.93	

71,766,264.29	72,827,766.51	73,188,258.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	217,782,288.93	

GRAND TOTAL

Thursday, October 13, 2016

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

010700	HEALTH CHOICE INTEGRATED - MM	5,434.12	5,436.13	5,482.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,352.55	
010725	CENPATICO INTEGRATED - MM	12,956.97	13,057.68	13,037.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,052.12	
078999	MERCY MARICOPA INTEGRATED - MM	19,855.38	20,248.88	20,392.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,496.61	
Subtotal	38,246.47	38,742.69	38,912.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115,901.28	

38,246.47	38,742.69	38,912.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115,901.28	

GRAND TOTAL