November 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 October 31, 2016

Dear President Biggs and Speaker Gowan:

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

Status Summary – As part of the FY 2018 budget revision submitted 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 $87.2 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 – October 2016 enrollment is 1,900,792 members, a 12,786 member increase over the prior month. Enrollment for November 2016 increased to 1,911,973 members, an 11,181 member increase.

Major November changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 2,676; Supplemental Security Income – decrease of 41; Prop 204

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. November 25, 2016
Page 2

Restoration - increase of 2,486; Adult Expansion - increase of 423; Medicare Cost Sharing – increase of 461; and Federal Emergency Services - increase of 1,755.

Tobacco

Funds Revenue Update – Tobacco tax collections through October 2016 are

$1.4

million less 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 October 31, 2016

Prepared by: Division of Business and Finance

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

FOOTNOTES……………………………………………………………………………………….7 CASELOAD AND EXPENDITURES BY RATE CODE………………………………11

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 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 AHCCCS Prop 204 Administration DES Eligibility
DES Prop 204 Eligibility

TOTAL ADMINISTRATION

Traditional Medicaid Services Proposition 204 Services ACA Adult Expansion
Children's Rehabilitative Services KidsCare Services
ALTCS Services
Disproportionate Share Payments Rural Hospitals
Voluntary Political Subdivision Programs Behavioral Health Traditional Medicaid Services Behavioral Health Proposition 204 Services Behavioral Health ACA Adult Expansion Behavioral Health CMDP
Non Medicaid Seriouslly Mentally Ill Services Supported Housing
Crisis Services

TOTAL PROGRAMMATIC

TOTAL EXPENDITURES	

$

$	

91,690,700
13,666,600
54,874,500
38,358,700

198,590,500

3,835,595,600
2,877,688,100
462,284,600
274,348,100
1,955,000
1,422,354,600
5,087,100
22,650,000
319,888,600
960,228,100
612,844,800
77,702,300
208,027,400
78,846,900
5,324,800
16,391,300

11,181,217,300

11,379,807,800	

$

$	

27,805,028
4,003,134
18,740,900
13,163,800

63,712,862

1,273,859,100
881,652,000
149,617,900
83,173,500
288,300
460,162,900
-
- 3,902,500
309,020,000
195,034,600
24,440,900
69,908,000
26,282,400
1,774,800
5,463,600

3,484,580,500

3,548,293,362	

$	24,306,436
4,953,884
15,129,311
7,793,050

52,182,681

1,294,146,638
900,128,739
141,187,269
84,621,974
(208,314)
447,469,804
-
- 3,902,468
329,331,675
198,187,175
22,582,346
48,161,086
26,319,199
1,745,948
5,435,433

3,503,011,441

$   3,555,194,122	

$

$	

3,498,592
(950,750)
3,611,589
5,370,751

11,530,181

(20,287,538)
(18,476,739)
8,430,631
(1,448,474)
496,614
12,693,096
-
-
32
(20,311,675)
(3,152,575)
1,858,554
21,746,914
(36,799)
28,852
28,167

(18,430,941)

(6,900,759)	

$	91,690,700
13,666,600
54,874,500
38,358,700

198,590,500

3,835,595,600
2,877,688,100
462,284,600
274,348,100
1,955,000
1,422,354,600
5,087,100
22,650,000
319,888,600
960,228,100
612,844,800
77,702,300
208,027,400
78,846,900
5,324,800
16,391,300

11,181,217,300

$   11,379,807,800	

$

$	

-
-
-
-

-

-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

-

-	

2

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

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

STATE - GENERAL FUND

Administrative Expenditures	
$	55,399,000	
$	17,909,911	
$	14,044,181	
3,865,730	
$	55,399,000	
$	-	
Proposition 204 - Administrative Expenditures	21,746,500	7,270,302	3,411,789	3,858,513	21,746,500	-	

Programmatic Expenditures

Traditional Medicaid Services	782,768,800	286,846,600	275,970,177	10,876,423	782,768,800	-	
Proposition 204 Services	100,000,000	47,924,000	39,089,814	8,834,186	100,000,000	-	
Children's Rehabilitative Services	84,424,100	25,761,700	23,725,055	2,036,645	84,424,100	-	
KidsCare Services	-	-	(113,164)	113,164	-	-	
ALTCS Services	167,841,100	55,099,000	55,947,033	(848,033)	167,841,100	-	
DSH and Rural Hospitals	7,239,300	-	-	-	7,239,300	-	
Behavioral Health Traditional Medicaid Services	259,356,900	83,905,300	91,750,640	(7,845,340)	259,356,900	-	
Behavioral Health Proposition 204 Services	109,250,500	34,448,000	34,178,817	269,183	109,250,500	-	
Behavioral Health ACA Adult Expansion	831,900	-	(470)	470	831,900	-	
Behavioral Health CMDP	63,770,500	21,542,900	14,921,324	6,621,576	63,770,500	-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900	26,282,400	26,319,199	(36,799)	78,846,900	-	
Supported Housing	5,324,800	1,774,800	1,745,948	28,852	5,324,800	-	
Crisis Services	14,141,100	4,713,600	4,685,367	28,233	14,141,100	-	
TOTAL GF EXPENDITURES	 	 	 	 	
1,750,941,400	637,919,413	585,675,709	27,802,804	1,750,941,400	-	

	FEDERAL		

Administrative Expenditures		
90,666,200	
28,520,388		
25,301,034		
3,219,354		
90,666,200		
-	
Proposition 204 - Administrative Expenditures		26,715,500	8,673,532		8,444,320		229,212		26,715,500		-	

Programmatic Expenditures Traditional Medicaid Services		

2,558,500,000	

826,267,100		

768,313,784		

57,953,316		

2,558,500,000		

-	
Proposition 204 Services		2,375,352,300	754,376,700		778,288,440		(23,911,740)		2,375,352,300		-	
ACA Adult Expansion		456,023,100	149,617,900		141,187,269		8,430,631		456,023,100		-	
Children's Rehabilitative Services		189,924,000	57,411,800		60,896,919		(3,485,119)		189,924,000		-	
KidsCare Services		1,585,000	(758,700)		(95,149)		(663,551)		1,585,000		-	
ALTCS Services and Nursing Facility Assessment		953,302,500	307,920,800		280,875,831		27,044,969		953,302,500		-	
DSH and Rural Hospitals		20,497,800	-		-		-		20,497,800		-	
Behavioral Health Traditional Medicaid Services	665,305,400	213,608,700	225,626,937	(12,018,237)	665,305,400	-
Behavioral Health Proposition 204 Services	503,594,300	160,586,600	164,008,357	(3,421,757)	503,594,300	-
Behavioral Health ACA Adult Expansion	76,870,400	24,440,900	22,582,816	1,858,084	76,870,400	-
Behavioral Health CMDP	144,256,900	48,365,100	33,239,763	15,125,338	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	2,579,535,020	2,509,174,558	70,360,462	8,213,839,100	-

	COUNTY		

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

49,687,700	
1,223,100

16,224,400		
890,825

16,224,400		
332,275

-		
3,563,300

49,687,700		
-

-	
ALTCS Services		249,980,000	82,081,600		92,663,826		(10,582,226)		249,980,000		-	
TOTAL COUNTY EXPENDITURES		303,231,000	99,529,100		109,779,051		(10,249,951)		303,231,000		-	

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

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

	TOBACCO FUNDS		

Programmatic Expenditures			
Traditional Medicaid Services - Medically Needy		37,432,400	12,222,700	12,581,485	(358,785)	37,432,400		-	
Behavioral Health Traditional Medicaid Services - Medically Needy		35,565,800	11,506,000	11,954,098	(448,098)	35,565,800		-	
Proposition 204 Services - Emergency Health Services		18,747,200	5,942,000	6,853,335	(911,335)	18,747,200		-	
Proposition 204 Services - Proposition 204 Protection		37,521,000	11,892,500	14,380,250	(2,487,750)	37,521,000		-	
Proposition 204 Services - ATLSF	100,000,000		-	-	-	100,000,000		-	
TOTAL TOBACCO EXPENDITURES	229,266,400		41,563,200	45,769,168	(4,205,968)	229,266,400		-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures
Acute Care - Prescription Drug Rebate Program State Match Acute Care - Prescription Drug Rebate Program Federal Authority Long Term Care - Prescription Drug Rebate Program State Match
Long Term Care - Prescription Drug Rebate Program Federal Authority	OTHER		

500,000	

115,629		

90,532		

25,097		

500,000		

-	
		105,837,600	34,558,800		51,300,758		(16,741,958)		105,837,600		-	
		301,143,200	97,676,000		169,630,591		(71,954,591)		301,143,200		-	
		7,441,300	2,450,300		2,480,433		(30,133)		7,441,300		-	
		21,600,300	7,063,800		10,854,866		(3,791,066)		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	63,500		106,427		(42,927)		194,700		-	
ALTCS Services - TPL		-	-		312,585		(312,585)		-		-	
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	1,047,000		-		1,047,000		370,000		-	
Freedom to Work Premiums		31,200	-		19,016		(19,016)		31,200		-	
Crisis Services - Substance Abuse Services Fund		2,250,200	750,000		750,067		(67)		2,250,200		-	
Voluntary Political Subdivision Programs - See Note 5		168,642,900	3,398,200		3,398,231		(31)		168,642,900		-	
TOTAL OTHER EXPENDITURES		882,529,900	214,187,529		304,795,636		(90,608,107)		882,529,900		-	
	TOTAL											

Administrative Expenditures		
198,590,500	
63,712,862		
52,182,681		
11,530,181		
198,590,500		
-	
Acute Care		9,758,862,700	3,024,417,600		3,055,541,637		(31,124,037)		9,758,862,700		-	
Long Term Care		1,422,354,600	460,162,900		447,469,804		12,693,096		1,422,354,600		-	
TOTAL EXPENDITURES	$	11,379,807,800	$	3,548,293,362		$	3,555,194,122		$	(6,900,759)		$	11,379,807,800		$	-	

BUDGET

BUDGET
YTD

RECEIPTS
YTD

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

GENERAL FUND:

FEDERAL:

COUNTY:

TOBACCO FUNDS:

OTHER:

TOTAL REVENUE

$

11,379,807,800

$

3,548,293,362

$

3,568,853,151

Traditional Medicaid Services & Administrative	$	929,831,200	$	330,518,211	$	313,739,413	
Proposition 204 Services & Administrative	121,746,500	55,194,302	76,680,420	
KidsCare Services	-	-	(113,164)	
ALTCS Services	167,841,100	55,099,000	55,947,033	
Behavioral Health Traditional Medicaid Services	 	531,522,600		172,667,000		139,422,477 		
TOTAL	 	1,750,941,400		613,478,513		585,676,179 		

Acute & Administrative	5,868,924,600	1,825,371,620	1,784,690,003	
KidsCare Services	1,585,000	(758,700)	1,765,285	
ALTCS Services	953,302,500	307,920,800	289,526,691	
Behavioral Health Traditional Medicaid Services	 	1,390,027,000 		 	447,001,300 		 	445,633,666 		
TOTAL	 	8,213,839,100 		 	2,579,535,020 		 	2,521,615,645 		

Acute & Administrative	53,251,000	17,447,500	14,929,282	
ALTCS Services	 	249,980,000 		 	82,081,600 		 	83,326,668 		
TOTAL	 	303,231,000 		 	99,529,100 		 	98,255,950 		

Traditional Medicaid Services	72,998,200	23,728,700	24,535,583	
Proposition 204 Services	 	156,268,200 		 	17,834,500 		 	21,233,585 		
TOTAL	 	229,266,400 		 	41,563,200 		 	45,769,168 		

Administrative	500,000	115,629	90,532	
Acute Care - Prescription Drug Rebate Program	406,980,800	132,234,800	220,931,350	
Long Term Care - Prescription Drug Rebate Program	29,041,600	9,514,100	13,335,300	
Hospital Assessment	252,329,100	61,516,900	66,612,111	
ALTCS - Nursing Facility Assessment	22,189,400	5,547,400	5,759,549	
Acute TPL - Note 1	194,700	63,500	106,427	
LTC TPL - Note 1	-	-	312,585	
KidsCare TPL - Note 1	-	-	978	
Member Premiums - CHIP	370,000	1,047,000	104,263	
Member Premiums - Freedom to Work	31,200	-	19,016	
Behavioral Health Traditional Medicaid Services	2,250,200	750,000	3,472,003	
Voluntary Political Subdivision - State Match	 	168,642,900 		 	3,398,200 		 	6,792,096 		
TOTAL	 	882,529,900 		 	214,187,529 		 	317,536,209 		

 	

Appropriation Status Report
Footnotes

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

Note 1:	Third Party Liability Collections: Gross Collections:	October 2016		October 2015		July 1, 2016
October 31, 2016		July 1, 2015
October 31, 2015	
	Acute	$	664,628		$	317,535		$	1,923,244		$	1,565,261	
	LTC	500,064		217,287		1,509,580		1,123,220	
	KidsCare	-		368		4,878		104,349	
	Total TPL Collections	$	1,164,692		$	535,190		$	3,437,702		$	2,792,830	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	36,935		$	31,764		$	106,427		$	168,426	
LTC	92,240		44,695		312,585		252,329	
KidsCare	-		69		978		20,922	
Total Expenditure Offsets	$	129,175		$	76,528		$	419,990		$	441,677	

FY 17 Total

Note 2:	Authorized Positions	1,141.2	
	Actual Positions as of October 31, 2016	1,031.0	

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2016	

$	1,933,160	
	Revenues	2,326,148	
	Transfers-In	 	276,726 		
	Total Revenues	 	2,602,874 		
	Expenditures	2,147,329	
	Transfers-out	 	327,536 		
	Total Expenditures	 	2,474,865 		
	Ending Balance October 31, 2016	  $	2,061,169 		

Of the $2,061,169 ending balance, $918,968 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through October 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of October 31, 2016

 	Description 		 	Amount 		 	Type 		
School Based Claiming Medicaid Administrative Costs	11,716,850	HHS-OIG & CMS Disallowance Letter dated October 20, 2016	
School Based Claiming Direct Services Costs	19,923,489	HHS-OIG	
	31,640,339		

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

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of October 31, 2016 Expenditures

 	State Match			Federal			Total 	

DSH Voluntary

$	236,670	$

504,238	$

740,908

GME Voluntary	3,161,560	-	3,161,560
Safety Net Care Pool	-	-	-

Total Voluntary Political Subdivision Program Expenditures

$	3,398,231	$

504,238	$

3,902,468

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 October 31, 2016 Expenditures

Expenditure	Projected
Plan	Expenditures	Variance	Annual
 	YTD			YTD			YTD	Expenditures 	

AHCCCS Operating CHIP Fund

$	-	$

-	$	-	$

3,511,900

DES Eligibility CHIP Fund	390,200	8,009	382,191	3,511,800
KidsCare Services CHIP Fund	8,167,800	1,712,897	6,454,903	63,214,800

Total KidsCare CHIP Type 3 Appropriation Expenditures

$	8,558,000	$

1,720,906	$

6,837,094	$

70,238,500

Appropriation Status Report
Caseload and Expenditures by Rate Code

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

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	284,152,063	0	0	0	0	0	0	0	0	1,120,681,938	
CAPITATION - LTC	190,311,536	204,030,120	191,838,793	196,146,010	0	0	0	0	0	0	0	0	782,326,459	
MENTAL HEALTH - CHILD	0	0	92,798	40,681,030	0	0	0	0	0	0	0	0	40,773,827	
MENTAL HEALTH - ADULT	0	0	4,710	411,085	0	0	0	0	0	0	0	0	415,795	
MENTAL HEALTH - GENERAL	0	0	47,481	13,592,485	0	0	0	0	0	0	0	0	13,639,965	
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	5,722,113	0	0	0	0	0	0	0	0	22,194,758	
FEE FOR SERVICE - ACUTE	43,169,220	49,076,411	38,450,549	33,852,478	0	0	0	0	0	0	0	0	164,548,657	
FFS - PRIOR QUARTER COVERAGE	399,183	701,172	353,914	449,400	0	0	0	0	0	0	0	0	1,903,668	
EMERGENCY SERVICES - FEDERAL	4,723,538	6,876,303	5,487,551	5,245,641	0	0	0	0	0	0	0	0	22,333,034	
FFS MEDICAID IN PUBLIC SCHOOLS	334,212	144,833	272,818	386,199	0	0	0	0	0	0	0	0	1,138,062	
INPATIENT INMATES FFS	125,819	53,097	229,997	169,499	0	0	0	0	0	0	0	0	578,412	
QMB - FEE FOR SERVICE	400,115	462,259	326,723	359,000	0	0	0	0	0	0	0	0	1,548,097	
STATE ONLY TRBHA FFS	0	12,155	22,043	8,636	0	0	0	0	0	0	0	0	42,833	
FFS TRBHA FEE FOR SERVICE	1,636,296	6,817,558	5,048,877	5,967,130	0	0	0	0	0	0	0	0	19,469,860	
PINAL COUNTY INMATES FFS	4,630	3,154	-3,803	0	0	0	0	0	0	0	0	0	3,981	
PIMA COUNTY INMATES FFS	1,278	26,237	2,537	16,174	0	0	0	0	0	0	0	0	46,226	
MOHAVE COUNTY INMATES FFS	31	8,322	0	0	0	0	0	0	0	0	0	0	8,353	
MARICOPA CTY INMATES FFS	22,177	38,629	14,576	29,601	0	0	0	0	0	0	0	0	104,983	
FEE FOR SERVICE - LTC	9,673,620	11,818,762	10,004,476	9,333,076	0	0	0	0	0	0	0	0	40,829,933	
LFFS - PRIOR QUARTER COVERAGE	25,539	27,090	12,241	20,809	0	0	0	0	0	0	0	0	85,679	
LFFS MEDICAID IN PUBLIC SCHOOLS	828,652	474,874	685,238	912,730	0	0	0	0	0	0	0	0	2,901,494	
REINSURANCE - ACUTE	10,931,804	9,903,096	8,491,782	14,533,814	0	0	0	0	0	0	0	0	43,860,496	
REINSURANCE - LTC	4,967,043	5,508,763	5,025,290	6,016,593	0	0	0	0	0	0	0	0	21,517,690	
SMIB - ACUTE	13,288,395	13,803,812	14,079,809	14,129,644	0	0	0	0	0	0	0	0	55,301,661	
HIB - ACUTE	361,563	411,610	422,087	466,526	0	0	0	0	0	0	0	0	1,661,786	
Q1	2,222,029	2,257,441	2,298,793	2,278,279	0	0	0	0	0	0	0	0	9,056,541	
SMIB - LTC	3,328,913	3,313,965	3,329,893	3,308,977	0	0	0	0	0	0	0	0	13,281,748	
HIB - LTC	283,717	285,570	285,293	289,510	0	0	0	0	0	0	0	0	1,144,090	
	571,193,666	599,354,227	572,373,635	638,478,501	0	0	0	0	0	0	0	0	2,381,400,029	

SUBTOTAL

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

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	215,686,452	0	0	0	0	0	0	0	0	839,371,843	
MENTAL HEALTH - CHILD	0	0	0	7,318	0	0	0	0	0	0	0	0	7,318	
MENTAL HEALTH - ADULT	0	0	9,812	378,170	0	0	0	0	0	0	0	0	387,982	
MENTAL HEALTH - GENERAL	0	0	112,658	21,890,514	0	0	0	0	0	0	0	0	22,003,172	
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	22,815	0	0	0	0	0	0	0	0	95,337	
FEE FOR SERVICE - ACUTE	30,892,242	33,585,002	26,203,618	24,327,724	0	0	0	0	0	0	0	0	115,008,586	
FFS - PRIOR QUARTER COVERAGE	626,645	888,463	903,725	769,131	0	0	0	0	0	0	0	0	3,187,964	
FFS - PRESUMPTIVE ELIGIBILITY	0	576	0	348	0	0	0	0	0	0	0	0	925	
EMERGENCY SERVICES - FEDERAL	2,005,165	2,692,463	2,628,341	2,580,854	0	0	0	0	0	0	0	0	9,906,823	
FFS MEDICAID IN PUBLIC SCHOOLS	935	797	636	479	0	0	0	0	0	0	0	0	2,847	
STATE ONLY TRBHA FFS	11,429	35,462	16,328	45,718	0	0	0	0	0	0	0	0	108,937	
FFS TRBHA FEE FOR SERVICE	668,712	3,783,524	2,819,057	3,584,362	0	0	0	0	0	0	0	0	10,855,655	
INPATIENT INMATES FFS	802,511	1,152,396	1,098,452	742,481	0	0	0	0	0	0	0	0	3,795,841	
GRAHAM COUNTY INMATES FFS	5,378	0	0	194	0	0	0	0	0	0	0	0	5,572	
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	77,666	0	0	0	0	0	0	0	0	118,086	
MOHAVE COUNTY INMATES FFS	962	0	0	0	0	0	0	0	0	0	0	0	962	
MARICOPA CTY INMATES FFS	136,056	149,042	84,034	194,257	0	0	0	0	0	0	0	0	563,389	
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	
REINSURANCE - ACUTE	3,834,787	4,856,893	4,271,544	5,421,175	0	0	0	0	0	0	0	0	18,384,398	
SMIB - ACUTE	5,139,071	5,095,292	5,027,067	4,882,841	0	0	0	0	0	0	0	0	20,144,270	
HIB - ACUTE	5,630	6,904	5,363	5,137	0	0	0	0	0	0	0	0	23,036	
	257,141,258	256,774,362	249,496,397	280,617,638	0	0	0	0	0	0	0	0	1,044,029,655	

SUBTOTAL

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

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	33,390,193	0	0	0	0	0	0	0	0	129,413,769	
MENTAL HEALTH - CHILD	0	0	0	55	0	0	0	0	0	0	0	0	55	
MENTAL HEALTH - ADULT	0	0	6	15,536	0	0	0	0	0	0	0	0	15,542	
MENTAL HEALTH - GENERAL	0	0	15,318	4,075,343	0	0	0	0	0	0	0	0	4,090,661	
CHILDREN'S REHAB SERVICES	1,431	1,431	1,431	1,901	0	0	0	0	0	0	0	0	6,195	
FEE FOR SERVICE - ACUTE	2,287,256	2,691,862	2,142,231	1,981,630	0	0	0	0	0	0	0	0	9,102,979	
FFS - PRIOR QUARTER COVERAGE	202,656	242,552	172,172	168,385	0	0	0	0	0	0	0	0	785,764	
EMERGENCY SERVICES - FEDERAL	3,157,734	4,543,147	3,298,138	3,345,340	0	0	0	0	0	0	0	0	14,344,359	
FFS MEDICAID IN PUBLIC SCHOOLS	0	143	122	154	0	0	0	0	0	0	0	0	419	
FFS TRBHA FEE FOR SERVICE	21,432	99,702	78,173	156,029	0	0	0	0	0	0	0	0	355,335	
STATE ONLY TRBHA FFS	0	0	0	2,449	0	0	0	0	0	0	0	0	2,449	
INPATIENT INMATES FFS	47,079	7,086	51,595	22,751	0	0	0	0	0	0	0	0	128,511	
MARICOPA CTY INMATES FFS	0	8,584	0	8,868	0	0	0	0	0	0	0	0	17,453	
REINSURANCE - ACUTE	394,053	1,131,954	693,714	710,923	0	0	0	0	0	0	0	0	2,930,645	
SMIB - ACUTE	487	365	0	365	0	0	0	0	0	0	0	0	1,218	
	38,639,830	40,424,404	38,251,198	43,879,922	0	0	0	0	0	0	0	0	161,195,354	
	866,974,755	896,552,993	860,121,229	962,976,062	0	0	0	0	0	0	0	0	3,586,625,037	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE

MENTAL HEALTH - CHILD	0	0	2	5,147	0	0	0	0	0	0	0	0	5,149	
MENTAL HEALTH - GENERAL	0	0	0	261	0	0	0	0	0	0	0	0	261	
FFS TRBHA FEE FOR SERVICE	0	30	0	0	0	0	0	0	0	0	0	0	30	
KidsCare - CAPITATION	105,825	60,026	453,014	868,376	0	0	0	0	0	0	0	0	1,487,241	
KidsCare - FEE FOR SERVICE	0	230	1,062	10,448	0	0	0	0	0	0	0	0	11,741	
KidsCare - MENTAL HEALTH	0	0	0	208,753	0	0	0	0	0	0	0	0	208,753	
KidsCare - REINSURANCE	82,674	199	63,656	150	0	0	0	0	0	0	0	0	146,679	

TOTAL TITLE XXI	188,498	60,485	517,734	1,093,134	0	0	0	0	0	0	0	0	1,859,852	
GRAND TOTAL	867,163,253	896,613,478	860,638,963	964,069,196	0	0	0	0	0	0	0	0	3,588,484,890	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	464.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		464.87		
1002	TANF 01-05 M & F WIT	0.00	0.00	30.83	115.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146.63		
1003	TANF 06-13 M & F WIT	0.00	-2.43	0.00	841.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		838.78		
1004	TANF 14-20 MALE WITH	330.49	330.49	330.49	321.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,312.76		
1005	TANF 14-20 FEMALE WI	4,171.93	2,017.48	2,017.48	1,949.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,156.31		
1006	TANF 21-44 MALE WITH	46,322.50	44,791.85	45,967.12	48,079.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,161.00		
1007	TANF 21-44 FEMALE WI	95,394.39	105,867.62	103,594.71	101,741.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406,597.87		
1008	TANF 45-64 M & F WIT	142,836.05	148,048.76	155,026.25	139,573.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		585,484.11		
1009	TANF 65+ M & F WITH	49,195.35	58,493.70	60,090.27	59,039.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		226,818.51		
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	398.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,747.50		
100G	TANF 21-44 FEMALE WI	979.52	875.88	956.18	2,475.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,287.44		
100H	TANF 44-64 M & F WIT	2,819.97	2,677.17	1,834.18	1,521.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,853.03		
100J	TANF 65+ M & F WITH	1,265.56	285.44	454.14	2,354.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,359.92		
1011	TANF <1 M & F NON-ME	5,979,797.90	5,818,316.42	5,667,860.79	5,264,357.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,730,332.41		
1012	TANF 01-05 M & F NON	1,982,751.29	2,047,597.48	2,192,866.31	2,249,311.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,472,526.40		
1013	TANF 06-13 M & F NON	3,400,616.72	3,421,770.87	3,534,174.18	3,620,105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,976,666.77		
1014	TANF 14-20 MALE NON-	1,438,649.82	1,450,579.41	1,494,737.30	1,497,813.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,881,780.40		
1015	TANF 14-20 FEMALE N O	2,947,635.53	2,963,712.47	2,982,834.82	3,056,785.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,950,967.87		
1016	TANF 21-44 MALE NON-	4,500,694.58	4,626,964.05	4,729,641.38	4,653,204.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,510,504.34		
1017	TANF 21-44 FEMALE N O	21,599,593.38	22,024,671.06	22,380,320.25	22,872,264.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,876,848.85		
1018	TANF 45-64 M & F NON	9,002,157.42	9,224,599.92	9,390,965.88	9,650,910.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,268,633.38		
1019	TANF 65+ M & F NON-M	34,981.92	37,207.86	35,682.69	36,767.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,639.90		
101A	TANF < 1 M & F NON-M	1,374,906.97	824,333.81	619,875.99	568,986.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,388,102.84		
101B	TANF 01-05 M & F NON	37,377.77	34,988.09	17,898.02	21,273.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,536.99		
101C	TANF 06-13 M & F NON	31,887.35	38,379.00	14,389.60	17,369.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,024.95		
101D	TANF 14-20 MALE NON-	40,214.75	26,404.71	25,064.46	17,702.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,386.74		
101E	TANF 14-20 FEMALE N O	75,894.61	51,114.86	39,158.76	31,456.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197,624.23		
101F	TANF 21-44 MALE NON-	332,694.14	181,172.60	142,480.58	122,564.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		778,911.45		
101G	TANF 21-44 FEMALE N O	1,014,213.65	519,454.48	432,147.43	353,048.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,318,863.99		
101H	TANF 44-64 M & F NON	352,715.91	224,440.64	206,574.18	154,380.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938,110.98		
101J	TANF 65+ N & F NON-M	2,006.75	449.69	1,257.99	1,285.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,999.82		
1026	TANF 21-44 MALE WITH	9,851.45	9,746.05	9,204.20	12,275.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,077.20		
1027	TANF 21-44 FEMALE WI	37,746.13	34,109.50	35,005.01	42,789.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,649.64		
1028	TANF 45-64 M & F WIT	39,714.64	36,360.22	36,397.64	43,817.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,289.82		
1029	TANF 65+ M & F WITH	11,125.03	11,154.44	10,081.40	13,757.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,118.48		

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	586.66	47.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		633.74		
102G	TANF 21-44 FEMALE WI	0.00	420.35	241.90	946.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,608.26		
102H	TANF 44-64 M & F WIT	0.00	1,084.40	2,684.39	788.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,557.13		
102J	TANF 65+ M & F WITH	0.00	0.00	403.46	1,811.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,214.58		
2100	SSI AGED WITH MEDIC	842,955.42	868,175.55	898,652.88	874,208.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,483,992.76		
210Z	SSI AGED WITH MEDIC A	28,411.56	21,306.88	29,919.56	26,997.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,635.93		
2110	SSI AGED NON-MEDICA	4,812,760.61	4,806,493.94	4,896,356.19	5,249,073.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,764,684.23		
211Z	SSI AGED NON-MEDICA R	127,183.08	147,235.09	133,695.88	151,331.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		559,445.40		
2120	SSI AGED WITH QMB	5,230,861.87	5,318,628.79	5,550,430.64	5,648,335.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,748,256.42		
212Z	SSI AGED WITH QMB P P	4,349.89	5,632.30	8,612.62	3,769.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,364.51		
2200	SSI DISABLED WITH M E	2,492,441.51	2,520,758.68	2,512,167.69	2,556,169.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,081,537.31		
220Z	SSI DISABLED WITH M E	17,675.35	12,942.73	15,910.05	32,865.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,393.58		
2210	SSI DISABLED NON-ME D	58,494,437.05	58,018,801.11	58,160,271.17	61,432,756.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236,106,266.22		
221Z	SSI DISABLED NON-ME D	433,439.79	419,148.90	538,099.82	494,840.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,885,529.48		
2220	SSI DISABLED WITH Q	15,152,983.36	15,434,374.34	15,821,632.46	16,669,682.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,078,672.67		
222Z	SSI DISABLED WITH Q M	3,347.64	4,509.15	6,680.06	8,799.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,336.21		
2300	SSI BLIND WITH MEDIC	6,019.11	6,344.44	6,155.38	6,088.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,607.27		
2310	SSI BLIND NON-MEDIC A	416,766.24	425,608.52	424,789.82	448,406.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,715,571.52		
231Z	SSI BLIND NON-MEDIC A	8,216.96	9,934.43	3,994.90	1,156.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,302.42		
2320	SSI BLIND WITH QMB	48,973.62	48,961.67	49,379.89	45,910.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,225.62		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	7.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.29		
4301	SOBRA CHILD <1 M & F	0.00	0.00	296.24	2,761.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,057.95		
4302	SOBRA CHILD 01-05 M	335.78	335.78	539.50	1,018.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,229.79		
4303	SOBRA CHILD 06-13 M	1,544.93	1,519.86	1,659.86	2,303.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,028.01		
4304	SOBRA CHILD 14-20 MA	453.68	315.45	353.85	728.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,851.37		
4305	SOBRA CHILD 14-20 FE	2,687.14	3,209.63	3,132.73	3,721.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,750.71		
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	341.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		451.71		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	107.04	258.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365.91		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	142.68	126.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269.16		
4311	SOBRA CHILD <1 M & F	19,199,383.74	19,304,900.69	19,387,265.24	18,354,616.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,246,166.21		
4312	SOBRA CHILD 01-05 M	23,848,737.73	23,824,566.62	23,927,832.96	23,969,627.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,570,765.13		
4313	SOBRA CHILD 06-13 M	29,886,460.52	30,038,640.77	30,367,237.37	30,504,380.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,796,719.40		
4314	SOBRA CHILD 14-20 MA	9,328,457.36	9,454,281.74	9,680,287.07	9,625,843.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,088,869.71		
4315	SOBRA CHILD 14-20 FE	14,077,063.28	14,260,086.80	14,601,597.35	15,117,076.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,055,823.79		
431A	SOBRA CHILD < 1 M &	1,177,252.46	693,970.63	867,096.37	887,403.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,625,722.72		

A

R

M

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

RATE CODE	DESCRIPTION		JULY		AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL 431B	SOBRA CHILD 01-05 M	566,517.45	313,543.99	297,175.19	272,088.67		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	1,449,325.30

431C	SOBRA CHILD 6-13 M&
F

721,463.46	331,359.44	312,515.41	256,903.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,622,241.93

431D	SOBRA CHILD 14-20 MA	521,496.21	233,778.90	223,364.34	187,361.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,166,001.22

431E	SOBRA CHILD 14-20 FE	561,544.85	276,156.48	306,650.61	249,415.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,393,767.63
4321	SOBRA CHILD <1 M & F	0.00	507.63	-507.63	456.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	456.79
4322	SOBRA CHILD 01-05 M	230.53	225.94	140.29	115.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	711.85
4323	SOBRA CHILD 06-13 M	0.00	-110.88	0.00	110.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-0.24
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	154.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	154.46
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	841.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	841.21
432D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	9.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.41

5005	SOBRA PREG 14-20 FE
M
5007	SOBRA PREG 21-44 FE
M
5008	SOBRA PREG 45-64 FE
M
500E	SOBRA PREG 14-20 FE
M
500G	SOBRA PREG 21-44 FE
M
500H	SOBRA PREG 45-64 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
502H	SOBRA PREG 45-64 FE
M
SUBTOTAL:

0.00	0.00	0.00	85.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	85.85

29,492.39	23,326.23	32,995.60	25,701.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111,516.09

4,151.82	3,635.38	3,635.38	5,404.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,826.69

0.00	0.00	0.00	521.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	521.94

621.37	527.22	421.15	1,521.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,091.49

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

1,407.36	911.78	1,029.83	909.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,258.83

1,116,187.80	1,054,868.69	1,049,312.44	1,038,713.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,259,082.81

5,647,435.21	5,224,978.99	5,240,195.32	5,315,378.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,427,987.54

29,549.66	22,736.94	27,265.92	27,573.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,125.67

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

137,111.91	56,188.00	58,579.29	46,010.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	297,890.09

501,169.31	249,043.62	241,784.55	223,937.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,215,934.76

2,476.09	1,453.55	2,104.23	1,393.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,427.42

13,528.33	12,323.20	13,443.00	18,199.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,493.63

2,212.75	2,212.75	2,212.75	2,334.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,972.58

163.64	246.72	144.97	283.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	838.43

0.00	0.00	0.00	200.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	200.44

250,093,559.53  247,431,996.74  250,079,851.39  254,460,879.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,002,066,287.65

9910	TANF & SOBRA CHILDR E	1,823,715.69	2,120,615.87	1,880,550.08	1,984,545.39	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	24,794.12	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	184,526.83	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	14,047,224.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	15,085,061.23	17,195,121.06	16,693,178.01	16,241,090.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

7,809,427.03	
143,007.19	
757,366.46	
56,504,650.17	
65,214,450.85	

SUBTOTAL:

198.00

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

1

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	49.50	49.50	49.50	49.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198.00		

SUBTOTAL:

1106	TANF EXPANDED 21-44	282,644.01	293,807.76	299,501.69	277,014.62	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	850,205.50	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	1,640,864.50	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	477,505.63	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	4,234.67	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	9,385.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	33,794.96	22,864.73	20,358.56	24,573.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+
M&	9,199.74	13,839.05	13,431.15	6,856.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1112	TANF EXPANDED 01-05	4,050.10	1,733.81	2,230.63	2,672.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	16,864.25	12,083.68	13,812.10	12,875.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	95,489.34	94,788.46	95,838.72	93,947.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	534,805.44	532,890.06	531,995.54	529,911.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	5,053,008.48	5,108,578.16	5,172,027.91	5,145,531.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	18,426,686.32	18,570,201.50	18,914,764.66	19,599,682.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	11,268,281.74	11,270,199.33	11,461,359.36	11,916,066.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	36,120.95	39,232.95	36,832.84	35,625.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
111C	TANF EXPANDED 06-13	281.75	0.00	0.00	65.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	10,758.18	4,036.30	3,999.12	2,665.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	27,269.64	15,641.38	9,235.56	7,191.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	307,744.28	160,720.58	153,918.14	127,396.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	731,144.87	324,566.49	340,720.35	276,247.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	466,357.73	201,524.92	199,655.41	172,699.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	8,779.85	4,133.27	202.65	2,951.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1126	TANF EXPANDED 21-44	153,790.27	156,066.00	157,645.41	190,040.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	446,215.59	474,049.46	477,129.31	549,846.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	504,237.50	518,590.37	535,516.65	641,276.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	168,961.75	179,353.58	184,855.77	216,186.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112F	TANF EXPANDED 21-44	1,973.32	1,569.61	1,040.20	922.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112G	TANF EXPANDED 21-44	1,409.59	2,117.93	729.03	577.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112H	TANF EXPANDED 45-64	6,149.15	3,315.72	5,472.86	2,754.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
1,152,968.08	
3,449,128.76	
6,547,644.04	
1,929,786.76	
17,197.62	
38,919.50	
101,591.98	
43,326.46	
1,022.53	
10,686.91	
55,635.06	
380,064.32	
2,129,602.82	
20,479,146.11	
75,511,335.24	
45,915,906.87	
147,812.35	
1,927.54	
8.90	
347.74	
21,459.24	
59,337.95	
749,779.27	
1,672,679.05	
1,040,237.80	
16,067.40	
2,212.75	
657,541.82	
1,947,241.32	
2,199,621.12	
749,357.89	
5,505.58	
4,833.86	
17,692.34	

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

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

RATE CODE	DESCRIPTION
112J

JULY
2,268.02

AUGUST	SEPTEMBER
1,088.62	6,118.42

OCTOBER	NOVEMBER	DECEMBER
3,220.68	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

12,695.74

2400

240Z

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

79,751.62

18,469.11

88,972.48

13,440.92

94,368.60

19,374.43

91,017.93

13,803.51

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

354,110.63

65,087.97

2410

113,134.36

107,329.50

100,424.49

104,189.94

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

425,078.29

241Z

5,881.63

3,345.40

5,620.33

5,022.54

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

19,869.90

2420

242Z

3,821,442.08

8,856.22

3,751,853.32

3,806.30

3,705,430.54

10,030.52

3,483,946.60

2,570.04

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

14,762,672.54

2500

140.23

140.23

140.23

132.06

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

25,263.08

552.75

2520

270.25

113.62

130.02

122.42

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

636.31

2600

260Z

254,582.86

10,892.09

222,372.65

7,541.46

227,664.21

10,094.76

204,981.08

34,308.17

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

909,600.80

2610

1,833,932.47

1,565,603.77

1,414,716.37

1,434,111.95

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

62,836.48

6,248,364.56

261Z

33,726.08

25,186.67

34,152.89

26,762.25

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

119,827.89

2620

262Z

8,960,995.29

3,880.96

8,821,264.08

3,944.92

8,606,635.05

4,241.27

8,429,073.96

7,596.05

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

34,817,968.38

E
SUBTOTAL:	56,720,391.41    55,619,947.17    55,902,881.01    56,658,635.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

19,663.20

224,901,855.50

9911	SB PAYMENT FOR TAN F	1,240,641.58	1,357,800.62	1,384,207.93	1,414,042.00	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	
	1,259,516.10	1,364,091.53	1,396,847.12	1,414,042.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

5,396,692.13	
31,530.38	
6,274.24	
5,434,496.75	

SUBTOTAL:

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	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	W
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-	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	2
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-	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	4
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	0.00	-24.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	W													

 	
-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	

 	
-16.83	
-9.23	
-24.92	
-14,265.28	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		-13,424.11		
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		-18,172.03		
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		-14,897.12		
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		-36,015.33		
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		-7.60		
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		-7.60		
	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		-96,840.05		

SUBTOTAL:

3506	ADULT 40-100% MALE 2	-1,357.37	3,232.53	3,514.25	2,792.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	655.96	919.44	2,968.48	3,363.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	26,030.20	33,829.91	30,003.53	26,090.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	5,034.18	4,586.39	5,021.69	5,319.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	780.79	0.00	1,767.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
350H	ADULT 40-100% M&F 45	6,378.29	3,428.33	180.22	391.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	1,172.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	2,409,491.88	2,474,191.06	2,493,038.44	2,664,428.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	2,652,207.33	2,709,011.22	2,755,051.24	2,956,163.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	9,091,685.89	9,213,419.73	9,339,670.31	10,038,892.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	7,488,728.50	7,584,675.23	7,702,512.46	8,328,161.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	18,275,289.94	18,558,142.48	18,724,964.30	20,087,863.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	9,481.02	11,136.16	7,516.18	9,004.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	230,773.61	92,793.37	78,690.61	105,490.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	202,837.35	98,746.64	127,277.89	97,900.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	854,550.14	446,008.39	470,902.96	417,424.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	641,841.39	306,040.86	325,788.67	373,189.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	1,495,397.19	742,706.24	742,009.84	652,231.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	15,371.19	2,027.43	6,644.63	3,216.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	938.25	2,394.06	3,096.07	359.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3528	ADULT 40-100% M&F 45	6,566.58	4,703.93	1,851.63	958.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	59.89	0.00	414.75	423.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352F	ADULT 40-100% MALE 2	0.00	239.80	517.47	77.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
352H	ADULT 40-100% M&F 45	0.00	218.00	733.84	609.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352J	ADULT 40-100% M&F 65	1,264.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
8,182.14	
7,907.24	
115,954.17	
19,961.79	
2,548.18	
1,295.68	
10,378.54	
1,172.03	
10,041,150.31	
11,072,433.39	
37,683,668.39	
31,104,077.77	
75,646,260.00	
37,137.51	
507,747.94	
526,762.19	
2,188,886.25	
1,646,860.03	
3,632,345.26	
27,259.28	
6,787.70	
3,362.57	
14,080.43	
898.04	
835.06	
360.43	
1,561.15	
1,264.42	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2016
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 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	24,670.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,360.32

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

8,594.39	14,900.87	5,263.02	6,423.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35,181.93

52,776.27	51,121.40	57,025.92	45,950.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206,874.00

1,670.61	3,656.59	0.00	1,948.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,275.51

370F	ADULT <40% EXP MALE	23.96	2,730.39	1,914.79	11,055.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,724.25

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

5,014.07	87.20	856.03	464.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,422.07

41,292.32	3,366.20	7,910.98	6,020.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,589.71

3714	ADULT <40% EXP MALE	5,588,252.13	5,551,951.34	5,502,458.42	5,759,882.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,402,544.26

3715	ADULT <40% EXP FEM
AL

4,892,572.32	4,914,224.47	4,853,114.07	5,049,252.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,709,162.89

3716	ADULT <40% EXP MALE    30,620,225.72    31,120,943.63     31,307,662.41     33,361,166.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,409,998.12

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

18,697,678.92    18,946,793.84     19,112,832.31     20,277,539.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	77,034,844.44

37,997,636.85    38,500,400.84     38,797,116.18     41,377,285.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	156,672,438.98

24,175.96	27,528.55	18,303.91	28,413.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,421.93

371D	ADULT <40% EXP MALE	527,076.34	241,808.81	265,078.05	222,838.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,256,801.54

371E	ADULT <40% EXP FEM
AL

415,699.52	230,089.36	214,764.40	182,776.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,043,329.59

371F	ADULT <40% EXP MALE	4,933,492.46	1,889,607.04	2,149,528.91	1,889,147.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,861,775.80

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

2,488,666.27	1,102,987.94	1,119,521.51	1,140,663.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,851,839.40

4,347,109.87	1,716,162.75	1,833,085.61	1,631,801.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,528,159.37

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	4,333.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,895.55

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

1,623.77	1,311.51	497.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,432.43

7,151.55	6,415.33	4,602.98	5,737.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,907.71

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	1,613.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,593.17

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

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

1,005.63	1,712.08	1,509.31	1,669.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,896.39

154,087,363.33  146,645,800.61  148,103,646.24  156,805,005.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	605,641,816.09

9935	BIRTH SUPP PAYMENT A	287,840.28	262,331.58	201,591.00	278,823.61	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	529,944.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	886,353.69	940,658.43	886,799.54	808,768.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,030,586.47	
2,491,993.68	
3,522,580.15	

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	4,896.46	3,633.24	2,121.67	3,220.46	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	1,969.81	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	27,537.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F	2,216.27	2,338.07	4,878.84	3,839.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
13,871.83	
9,758.31	
127,132.91	
13,272.99	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390F	NEWLY ELIGIBLE MALE	0.00	-236.15	149.13	1,045.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		958.23		
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		2,709.62		
390H	NEWLY ELIGIBLE M&F 4	4,162.37	385.56	3,911.38	2,087.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,547.23		
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		1,503.19		
3914	NEWLY ELIGIBLE MALE	993,353.20	1,010,781.92	1,036,935.63	1,098,477.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,139,548.29		
3915	NEWLY ELIGIBLE FEMA L	1,183,692.34	1,197,080.00	1,219,383.57	1,293,607.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,893,763.20		
3916	NEWLY ELIGIBLE MALE	7,130,854.84	7,139,765.29	7,195,270.63	7,612,877.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,078,768.68		
3917	NEWLY ELIGIBLE FEMA L	10,276,450.45	10,168,360.64	10,192,574.11	10,673,216.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,310,601.75		
3918	NEWLY ELIGIBLE M&F 4	10,565,542.96	10,565,902.98	10,633,336.78	11,295,327.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,060,110.12		
3919	NEWLY ELIGIBLE M&F 6	5,613.74	6,337.38	4,809.99	6,649.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,410.73		
391D	NEWLY ELIGIBLE MALE	53,561.17	31,001.51	35,796.42	26,630.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,989.30		
391E	NEWLY ELIGIBLE FEMA L	73,185.98	37,874.44	31,818.36	32,250.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,128.98		
391F	NEWLY ELIGIBLE MALE	544,427.88	264,421.24	269,746.28	231,138.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,309,733.63		
391G	NEWLY ELIGIBLE FEMA L	645,279.14	319,627.95	351,282.99	302,318.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,618,508.24		
391H	NEWLY ELIGIBLE M&F	535,632.09	262,888.10	263,717.14	275,715.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,337,952.95		
391J	NEWLY ELIGIBLE M&F 6	0.00	3,073.64	1,366.00	341.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,781.14		
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	337.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,162.91		
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	1,140.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,338.82		
	32,061,907.41	31,054,674.03	31,281,763.80	32,889,729.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,288,075.14		

4

SUBTOTAL:

2,125,693.70

2,125,693.70

9939	BIRTH SUPP PAYMENT	465,794.15	642,903.37	516,533.17	500,463.01	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	500,463.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

N

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	310.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	146.73	290.72	291.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	138.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440D	SOBRA 100-133% MALE	0.00	0.00	0.00	583.84	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	912.82	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	5,902,856.99	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	1,996,385.26	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	3,125,739.11	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	112.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F	164,704.59	74,635.99	79,126.77	68,697.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
310.51	
729.16	
138.17	
583.84	
5,739.14	
23,455,969.00	
8,013,127.12	
12,167,854.41	
557.99	
387,164.73	

ACUTE CAPITATION - AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
441D	SOBRA 100-133% MALE	86,665.55	50,248.54	57,787.59	46,488.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241,189.84		
441E	SOBRA 100-133% FEMA L	139,238.73	65,193.24	72,773.77	65,282.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342,488.27		
4423	SOBRA 100-133% M&F
6	0.00	0.00	0.00	66.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.90		
	11,272,874.22	10,997,151.60	11,138,027.33	11,207,865.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,615,919.08		

35,856.55	55,987.51	36,542.55	61,327.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
35,856.55	55,987.51	36,542.55	61,327.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

9944	BIRTH SUPP PAYMENT	189,714.40	
S
SUBTOTAL:	

189,714.40	

4517	BC PATIENT FEMALE 2 1	5,396.74	5,104.69	4,725.99	4,457.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	75,925.22	67,099.18	64,432.32	59,300.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4519	5
BC PATIENT FEMALE 6	
0.00	
0.00	
660.83	
355.54	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

451G	5
BC PATIENT FEMALE 2	
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	1
BC PATIENT FEMALE 4	
851.62	
879.79	
2,962.65	
1,358.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4617	5
CC PATIENT FEMALE 2	
5,421.52	
5,390.70	
2,981.81	
2,862.32	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4618	1
CC PATIENT FEMALE 4	
3,628.71	
3,628.71	
3,628.71	
3,226.46	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

461G	5
CC PATIENT FEMALE 2	
0.00	
0.00	
0.00	
293.90	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	1													

91,387.00

82,103.07

80,487.07

71,854.25

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

19,684.56	
266,757.21	
1,016.37	
1,257.95	
6,052.46	
16,656.35	
14,112.59	
293.90	
325,831.39	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W	1,497.85	1,497.85	1,497.85	1,708.04	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	1,595,187.56	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	15,990.73	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	322,599.70	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	18,873.52	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	153,162.80	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	1,472.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,076,989.97	2,049,490.26	2,034,061.50	2,108,995.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

6,201.59	
6,357,127.76	
25,453.41	
1,189,151.62	
49,949.23	
639,701.85	
1,951.36	
8,269,536.82	

O

SUBTOTAL:

TOTAL:

524,137,104.09  513,951,069.46   518,150,668.23  533,228,708.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,089,467,550.10

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1002	TANF 01-05 M & F WIT	0.00	0.00	0.26	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.26		
1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1004	TANF 14-20 MALE WITH	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1005	TANF 14-20 FEMALE WI	4.99	3.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.99		
1006	TANF 21-44 MALE WITH	105.64	116.50	122.90	121.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		466.81		
1007	TANF 21-44 FEMALE WI	181.79	195.90	194.31	186.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		758.27		
1008	TANF 45-64 M & F WIT	268.21	287.79	294.87	260.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,111.04		
1009	TANF 65+ M & F WITH	116.75	130.64	133.33	127.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507.85		
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	2.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.47		
100G	TANF 21-44 FEMALE WI	5.05	4.32	5.17	3.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.38		
100H	TANF 44-64 M & F WIT	9.51	7.35	5.34	4.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.44		
100J	TANF 65+ M & F WITH	4.22	1.12	1.66	7.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.58		
1011	TANF <1 M & F NON-ME	12,190.91	11,954.58	11,593.12	11,243.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,981.78		
1012	TANF 01-05 M & F NON	15,922.62	16,925.07	17,709.18	18,145.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,702.25		
1013	TANF 06-13 M & F NON	26,685.75	27,709.65	27,908.20	28,443.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,747.40		
1014	TANF 14-20 MALE NON-	7,849.50	8,080.91	8,195.85	8,273.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,399.93		
1015	TANF 14-20 FEMALE N O	10,947.41	11,170.89	11,082.68	11,154.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,355.76		
1016	TANF 21-44 MALE NON-	25,794.90	26,636.23	27,208.92	27,085.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,725.61		
1017	TANF 21-44 FEMALE N O	78,741.67	80,653.27	81,552.11	81,259.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322,207.03		
1018	TANF 45-64 M & F NON	20,054.80	20,572.11	20,890.36	20,903.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,420.92		
1019	TANF 65+ M & F NON-M	82.44	87.95	83.71	84.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338.26		
101A	TANF < 1 M & F NON-M	1,368.89	819.40	613.87	559.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,361.42		
101B	TANF 01-05 M & F NON	682.65	652.33	333.31	396.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,064.62		
101C	TANF 06-13 M & F NON	588.07	716.90	269.48	309.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,883.67		
101D	TANF 14-20 MALE NON-	275.74	179.54	166.65	110.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		732.75		
101E	TANF 14-20 FEMALE N O	392.46	264.03	203.17	162.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,021.70		
101F	TANF 21-44 MALE NON-	2,233.16	1,246.55	971.70	792.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,243.44		
101G	TANF 21-44 FEMALE N O	5,212.42	2,680.13	2,230.03	1,744.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,867.56		
101H	TANF 44-64 M & F NON	1,044.93	668.56	619.71	457.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,791.07		
101J	TANF 65+ N & F NON-M	7.16	1.47	3.58	4.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.27		
1026	TANF 21-44 MALE WITH	40.21	39.35	36.00	42.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.26		
1027	TANF 21-44 FEMALE WI	55.59	51.12	51.66	62.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220.78		
1028	TANF 45-64 M & F WIT	75.00	69.96	69.62	81.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295.80		
1029	TANF 65+ M & F WITH	27.20	27.00	24.56	31.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.69		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	3.38	0.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.70		
102G	TANF 21-44 FEMALE WI	0.00	2.15	1.30	0.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.86		
102H	TANF 44-64 M & F WIT	0.00	3.03	7.52	2.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.66		
102J	TANF 65+ M & F WITH	0.00	0.00	1.43	5.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.49		
2100	SSI AGED WITH MEDIC	4,687.07	4,820.28	4,932.67	4,960.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,400.21		
210Z	SSI AGED WITH MEDIC A	401.49	304.61	422.21	299.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,427.87		
2110	SSI AGED NON-MEDICA	5,548.22	5,555.50	5,634.93	5,653.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,391.85		
211Z	SSI AGED NON-MEDICA R	216.60	250.09	229.13	256.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		951.88		
2120	SSI AGED WITH QMB	27,168.47	27,829.76	28,631.17	29,913.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,543.29		
212Z	SSI AGED WITH QMB P P	67.03	76.42	130.57	54.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		328.75		
2200	SSI DISABLED WITH M E	5,051.73	5,011.37	5,017.01	4,955.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,035.37		
220Z	SSI DISABLED WITH M E	259.75	180.95	228.13	199.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		868.32		
2210	SSI DISABLED NON-ME D	56,419.86	56,072.96	55,978.26	55,811.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,282.99		
221Z	SSI DISABLED NON-ME D	759.89	735.30	931.82	815.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,242.34		
2220	SSI DISABLED WITH Q	27,588.74	27,999.85	28,560.56	29,367.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,517.12		
222Z	SSI DISABLED WITH Q M	50.54	64.24	90.67	35.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240.72		
2300	SSI BLIND WITH MEDIC	27.00	29.00	28.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112.00		
2310	SSI BLIND NON-MEDIC A	461.02	472.94	470.49	467.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,871.77		
231Z	SSI BLIND NON-MEDIC A	14.08	16.02	6.45	1.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.47		
2320	SSI BLIND WITH QMB	208.99	210.04	210.62	210.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		840.21		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.12		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.60	4.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.59		
4302	SOBRA CHILD 01-05 M	3.00	3.00	4.76	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.76		
4303	SOBRA CHILD 06-13 M	6.70	6.12	7.42	19.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.90		
4304	SOBRA CHILD 14-20 MA	3.00	2.00	2.26	5.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.32		
4305	SOBRA CHILD 14-20 FE	6.38	8.49	8.26	10.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.48		
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	6.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.53		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.73	1.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.50		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	0.73	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.37		
4311	SOBRA CHILD <1 M & F	39,790.63	40,146.76	40,163.90	39,523.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,624.43		
4312	SOBRA CHILD 01-05 M	188,466.60	189,087.15	189,910.31	189,321.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		756,785.18		
4313	SOBRA CHILD 06-13 M	233,049.16	235,593.66	237,736.70	237,670.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		944,050.37		
4314	SOBRA CHILD 14-20 MA	54,382.11	55,359.01	56,494.43	57,144.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,380.05		
4315	SOBRA CHILD 14-20 FE	54,106.61	55,018.18	56,134.61	56,838.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,098.03		
431A	SOBRA CHILD < 1 M &	1,208.09	704.71	883.39	879.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,675.67		

A

R

M

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

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 431B	SOBRA CHILD 01-05 M	9,938.87	5,510.49		5,314.91		4,820.21		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	25,584.48

431C	SOBRA CHILD 6-13 M&
F

12,342.03	5,854.58	5,525.09	4,454.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,176.67

431D	SOBRA CHILD 14-20 MA	3,383.27	1,549.83	1,503.76	1,251.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,688.17

431E	SOBRA CHILD 14-20 FE	2,833.78	1,413.80	1,559.21	1,256.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,063.34

4321	SOBRA CHILD <1 M & F	0.00	1.00	-1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00
4322	SOBRA CHILD 01-05 M	2.00	2.00	1.23	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.23
4323	SOBRA CHILD 06-13 M	0.00	-1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.93

4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00
432D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.06

5005	SOBRA PREG 14-20 FE
M
5007	SOBRA PREG 21-44 FE
M
5008	SOBRA PREG 45-64 FE
M
500E	SOBRA PREG 14-20 FE
M
500G	SOBRA PREG 21-44 FE
M
500H	SOBRA PREG 45-64 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
502H	SOBRA PREG 45-64 FE
M

0.00	0.00	0.00	0.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.32

54.43	49.34	63.74	53.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	221.47

5.32	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.32

0.00	0.00	0.00	2.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.67

3.19	2.70	2.17	3.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.08

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

6.16	8.00	9.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31.16

4,337.46	4,046.46	4,011.88	3,884.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,280.70

21,665.43	19,993.98	20,010.93	19,866.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,537.05

69.37	50.47	56.39	58.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	234.50

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

704.07	289.25	297.62	231.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,522.59

2,575.10	1,286.76	1,250.34	1,121.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,234.10

6.61	4.05	6.11	4.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.46

22.12	25.35	24.93	29.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101.58

1.00	1.00	1.00	1.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.19

0.87	1.09	0.76	1.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.17

0.00	0.00	0.00	0.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.80

SUBTOTAL:

968,893.15

957,619.06	965,088.33	963,605.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,855,205.71

9910	TANF & SOBRA CHILDR E	296.00	348.00	307.00	319.00	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	4.00	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	30.00	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	2,275.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,472.00	2,821.00	2,736.00	2,628.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,270.00	
23.00	
124.00	
9,240.00	
10,657.00	

SUBTOTAL:

12.00

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

1

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		

SUBTOTAL:

1106	TANF EXPANDED 21-44	788.67	816.15	831.69	763.69	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	1,484.57	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	2,728.23	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	1,059.24	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	23.85	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	39.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	104.82	65.06	61.85	64.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+
M&	27.91	37.48	41.73	22.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1112	TANF EXPANDED 01-05	29.83	22.00	20.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	131.04	120.00	110.00	101.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	576.14	573.34	572.53	565.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	2,070.37	2,092.17	2,076.40	2,012.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	30,546.64	30,955.38	31,285.89	31,482.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	70,413.69	71,216.30	72,291.54	73,064.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	26,030.37	26,097.67	26,439.02	26,767.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	83.66	90.73	84.94	80.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
111C	TANF EXPANDED 06-13	5.16	0.00	0.00	1.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	70.26	26.70	27.21	17.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	140.45	79.30	47.46	37.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	2,076.01	1,098.80	1,054.29	866.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	3,752.64	1,672.33	1,755.92	1,406.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	1,397.05	614.36	610.74	521.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	27.62	12.27	0.56	8.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1126	TANF EXPANDED 21-44	306.62	308.56	310.01	388.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	702.41	738.16	741.34	867.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	861.34	884.40	908.08	1,089.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	379.94	403.85	416.65	478.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112F	TANF EXPANDED 21-44	13.19	10.76	7.05	6.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112G	TANF EXPANDED 21-44	7.14	11.21	3.67	1.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112H	TANF EXPANDED 45-64	18.32	9.84	16.83	8.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
3,200.20	
6,207.79	
11,238.34	
4,351.56	
111.93	
190.38	
296.26	
129.58	
2.22	
95.83	
462.52	
2,287.51	
8,251.64	
124,269.94	
286,985.78	
105,334.23	
339.96	
1.77	
0.16	
6.67	
142.14	
304.26	
5,095.58	
8,587.38	
3,143.78	
48.81	
1.00	
1,313.73	
3,049.39	
3,743.68	
1,678.48	
37.29	
23.93	
53.07	

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

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

RATE CODE	DESCRIPTION
112J

JULY
7.02

AUGUST	SEPTEMBER
3.04	18.32

OCTOBER	NOVEMBER	DECEMBER
8.66	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

37.04

2400

240Z

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

426.73

259.45

443.44

185.24

472.02

285.34

440.67

182.17

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,782.86

912.20

2410

126.95

125.69

114.65

110.10

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

477.39

241Z

10.56

5.52

10.37

8.07

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

34.52

2420

242Z

17,593.09

124.19

17,259.82

55.44

16,957.44

148.30

16,174.97

30.91

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

67,985.32

2500

1.00

1.00

1.00

1.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

358.84

4.00

2520

2.00

1.00

1.00

1.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5.00

2600

260Z

492.88

161.06

464.34

113.94

445.06

138.72

397.48

163.02

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,799.76

2610

1,749.60

1,549.45

1,399.14

1,339.50

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

576.74

6,037.69

261Z

60.98

43.92

59.01

40.76

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

204.67

2620

262Z

14,973.36

57.37

14,550.51

57.71

14,192.55

62.26

13,454.69

22.33

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

57,171.11

E
SUBTOTAL:	182,154.75	178,380.59	179,678.92	178,359.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

199.67

718,573.60

9911	SB PAYMENT FOR TAN F	203.00	222.00	227.00	229.00	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	
	206.00	223.00	229.00	229.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

881.00	
5.00	
1.00	
887.00	

SUBTOTAL:

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	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	W
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-	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	2
AHC CARE MALE 21-44	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3318	4
AHC CARE M&F 45-64 N	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	W													

 	
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	

 	
0.00	
0.00	
0.00	
0.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		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		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

3506	ADULT 40-100% MALE 2	1.05	3.93	4.12	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	1.41	1.51	4.33	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	48.19	59.75	62.73	53.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	11.70	10.93	12.00	11.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	1.38	0.00	2.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
350H	ADULT 40-100% M&F 45	10.10	5.21	0.26	0.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	1.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	5,324.62	5,467.72	5,499.59	5,520.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	5,844.28	5,979.01	6,074.17	6,119.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	19,365.79	19,627.94	19,910.40	20,113.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	15,852.90	16,050.08	16,295.27	16,563.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	39,856.53	40,435.92	40,836.05	40,979.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	21.41	25.00	17.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	347.75	138.36	119.42	158.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	318.47	148.34	190.06	144.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	1,280.29	671.30	703.96	627.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	965.22	464.82	496.19	554.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	2,235.88	1,124.69	1,123.22	967.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	22.58	3.00	9.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	2.00	3.15	3.06	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3528	ADULT 40-100% M&F 45	7.00	6.67	4.13	2.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.12	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352F	ADULT 40-100% MALE 2	0.00	0.35	0.93	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
352H	ADULT 40-100% M&F 45	0.00	0.32	0.86	0.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 	
15.10	
14.25	
224.66	
46.04	
4.23	
2.01	
16.14	
1.64	
21,812.17	
24,016.78	
79,017.38	
64,761.30	
162,107.59	
82.41	
764.39	
801.53	
3,283.44	
2,480.70	
5,451.35	
38.58	
9.08	
2.65	
19.89	
2.12	
1.40	
0.53	
2.07	
1.87	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2016
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 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	24.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73.58

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

9.61	12.63	3.73	7.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.13

79.34	86.57	80.65	72.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	318.97

3.99	8.24	0.00	4.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.68

370F	ADULT <40% EXP MALE	0.03	3.87	2.81	14.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.02

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

7.40	0.12	1.26	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.61

62.90	4.82	11.94	8.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88.02

3714	ADULT <40% EXP MALE	12,053.30	11,993.59	11,889.17	11,702.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,638.86

3715	ADULT <40% EXP FEM
AL

10,566.05	10,578.54	10,458.81	10,259.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,862.68

3716	ADULT <40% EXP MALE	60,788.30	61,489.48	61,720.28	61,704.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	245,702.62

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

36,217.95	36,585.39	36,742.16	36,721.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,267.32

76,027.85	76,776.91	77,357.95	77,642.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	307,804.85

46.67	55.00	38.00	56.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	196.05

371D	ADULT <40% EXP MALE	785.47	365.33	398.98	325.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,875.36

371E	ADULT <40% EXP FEM
AL

622.58	343.02	319.92	267.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,553.15

371F	ADULT <40% EXP MALE	7,431.73	2,823.52	3,229.94	2,724.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,210.08

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

3,715.62	1,653.65	1,678.50	1,655.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,703.13

6,450.75	2,546.43	2,728.37	2,354.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,079.99

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	6.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.02

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

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

10.87	10.49	6.79	5.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.30

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	2.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.39

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

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

1.64	2.75	2.22	2.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.18

SUBTOTAL:

306,430.98

295,595.84	298,069.00	297,419.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,197,514.94

9935	BIRTH SUPP PAYMENT A	47.00	43.00	33.00	45.00	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	86.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	144.00	153.00	145.00	131.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

168.00	
405.00	
573.00	

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	9.99	6.59	5.63	7.18	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	5.00	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	62.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F	6.16	6.44	13.46	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
29.39	
26.04	
275.22	
36.06	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390F	NEWLY ELIGIBLE MALE	0.00	-0.58	0.36	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.42		
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		7.77		
390H	NEWLY ELIGIBLE M&F 4	12.91	1.12	10.87	5.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.82		
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		5.26		
3914	NEWLY ELIGIBLE MALE	2,581.12	2,636.90	2,704.30	2,731.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,653.33		
3915	NEWLY ELIGIBLE FEMA L	3,107.33	3,144.71	3,193.71	3,228.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,674.70		
3916	NEWLY ELIGIBLE MALE	18,434.91	18,432.63	18,507.12	18,595.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,970.08		
3917	NEWLY ELIGIBLE FEMA L	26,612.98	26,254.10	26,325.85	26,195.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,388.53		
3918	NEWLY ELIGIBLE M&F 4	27,106.66	27,120.36	27,282.10	27,501.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,010.54		
3919	NEWLY ELIGIBLE M&F 6	15.00	17.00	13.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		
391D	NEWLY ELIGIBLE MALE	158.25	91.82	109.98	82.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		442.75		
391E	NEWLY ELIGIBLE FEMA L	222.94	115.52	94.87	97.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		530.51		
391F	NEWLY ELIGIBLE MALE	1,637.68	787.81	817.83	674.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,917.49		
391G	NEWLY ELIGIBLE FEMA L	1,958.63	963.80	1,062.42	891.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,876.64		
391H	NEWLY ELIGIBLE M&F	1,626.88	792.26	797.78	827.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,044.80		
391J	NEWLY ELIGIBLE M&F 6	0.00	9.00	4.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
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	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.05		
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	4.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.12		
	83,583.82	80,471.05	81,021.10	80,940.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		326,016.50		

4

SUBTOTAL:

346.00

346.00

9939	BIRTH SUPP PAYMENT	76.00	105.00	84.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	76.00	105.00	84.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

N

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	2.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	3.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440D	SOBRA 100-133% MALE	0.00	0.00	0.00	4.00	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	8.12	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	47,096.41	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	12,103.73	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	11,741.62	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	1.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F	3,053.61	1,390.93	1,391.31	1,278.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
2.80	
5.00	
3.19	
4.00	
51.45	
187,856.28	
47,752.67	
46,553.50	
9.51	
7,113.89	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
441D	SOBRA 100-133% MALE	587.39	341.97	389.46	313.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,631.92		
441E	SOBRA 100-133% FEMA L	714.29	336.34	375.30	334.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,760.67		
4423	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.58		
	74,933.28	72,063.88	72,858.10	72,890.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292,745.46		

SUBTOTAL:

31.00

31.00

6.00	9.00	6.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6.00	9.00	6.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9944	BIRTH SUPP PAYMENT
S
SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	21.16	20.00	18.13	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	172.08	153.75	147.28	130.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4519	5
BC PATIENT FEMALE 6	
0.00	
0.00	
1.73	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

451G	5
BC PATIENT FEMALE 2	
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	1
BC PATIENT FEMALE 4	
2.08	
2.36	
8.72	
5.17	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4617	5
CC PATIENT FEMALE 2	
14.00	
14.00	
12.00	
11.45	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4618	1
CC PATIENT FEMALE 4	
8.00	
8.00	
8.00	
7.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

461G	5
CC PATIENT FEMALE 2	
0.00	
0.00	
0.00	
1.54	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	1													

218.15

198.11

200.72

173.28

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

76.29	
603.23	
2.73	
5.69	
18.33	
51.45	
31.00	
1.54	
790.26	

SUBTOTAL:

8600	SSI BLIND FREEDOM/W	1.00	1.00	1.00	1.00	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	1,760.86	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	128.23	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	286.43	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	31.38	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	207.33	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	7.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,360.11	2,286.27	2,298.44	2,422.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4.00	
7,027.13	
268.86	
1,114.89	
84.68	
852.32	
15.56	
9,367.44	

O

SUBTOTAL:

TOTAL:	1,621,481.24	1,589,928.80	1,602,417.61	1,598,892.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,412,719.91		

1000	TANF WITH MEDICARE	38,448.73	39,003.93	38,448.73	42,377.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	158,279.20	
1010	TANF NON-MEDICARE	2,400,462.36	2,421,330.33	2,419,826.43	2,447,259.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,688,878.55	
101Z	TANF ALTCS NON-MED	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	IC
TANF WITH QMB	7,060.26	7,046.73	7,060.26	7,100.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
28,267.47	
2100	SSI AGED WITH MEDIC	30,800,680.32	35,822,926.91	30,988,622.11	31,576,930.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	129,189,160.20	
210Z	A
SSI AGED WITH MEDIC	542,994.93	656,811.81	649,461.51	680,788.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,530,056.80	
2110	A
SSI AGED NON-MEDICA	2,859,005.72	3,112,715.88	2,808,352.93	3,098,256.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
11,878,331.18	

211Z	R
SSI AGED NON-MEDICA	
4,608.65	
22,415.95	
26,737.54	
17,364.42	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
71,126.56	
2120	R
SSI AGED WITH QMB	19,171,298.49	22,384,501.22	19,201,118.70	19,593,122.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
80,350,040.69	
212Z	SSI AGED WITH QMB P	8,706.14	10,824.40	15,009.15	7,377.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,917.38	
2200	P
SSI DISABLED WITH M	14,979,902.29	16,537,185.88	15,092,965.32	15,230,886.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
61,840,940.25	

220Z	E
SSI DISABLED WITH M	
45,197.99	
72,772.52	
67,317.02	
87,641.17	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
272,928.70	
2210	E
SSI DISABLED NON-ME	96,668,522.76	98,773,047.00	97,439,687.94	100,080,369.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392,961,627.32	
221Z	D
SSI DISABLED NON-ME	23,471.98	37,264.06	50,403.94	25,347.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
136,487.04	
2220	D
SSI DISABLED WITH Q	21,848,759.06	23,184,351.56	22,097,240.12	22,312,110.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
89,442,461.52	
222Z	M
SSI DISABLED WITH Q	717.28	5,025.38	3,782.81	2,796.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
12,322.17	
2300	M
SSI BLIND WITH MEDIC	66,335.96	72,964.65	79,626.95	80,592.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
299,519.91	
2310	SSI BLIND NON-MEDIC	486,146.90	487,621.28	485,314.45	484,339.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,943,421.93	
2320	A
SSI BLIND WITH QMB	137,707.06	142,358.29	134,795.96	136,620.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
551,482.01	
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	

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

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

190,092,214.70  203,790,167.78  191,624,922.57  195,911,282.35

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

781,418,587.40

8700	SSI DISABLED FREEDO M	83,704.76	94,859.85	83,565.97	89,541.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	118,450.47	126,671.03	113,138.91	128,196.90	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	16,989.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	219,320.93	239,952.29	213,870.58	234,728.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

351,671.72	
0.00	
486,457.31	
69,742.77	
0.00	
907,871.80	

M

M

782,326,459.20

190,311,535.63	204,030,120.07	191,838,793.15	196,146,010.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

1000	TANF WITH MEDICARE	11.00	11.00	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45.00	
1010	TANF NON-MEDICARE	675.51	680.77	680.40	683.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,720.58	
101Z	TANF ALTCS NON-MED	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	IC
TANF WITH QMB	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8.00	
2100	SSI AGED WITH MEDIC	11,265.25	11,234.08	11,290.57	11,351.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,141.32	
210Z	A
SSI AGED WITH MEDIC	564.29	677.36	678.75	693.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,614.37	
2110	A
SSI AGED NON-MEDICA	596.81	592.38	586.17	582.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,358.20	

211Z	R
SSI AGED NON-MEDICA	
5.47	
24.11	
27.26	
18.19	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
75.03	
2120	R
SSI AGED WITH QMB	7,455.45	7,481.63	7,490.54	7,498.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
29,926.24	
212Z	SSI AGED WITH QMB P	8.97	11.53	14.63	7.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42.20	
2200	P
SSI DISABLED WITH M	4,856.19	4,930.65	4,899.87	4,874.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
19,561.11	

220Z	E
SSI DISABLED WITH M	
48.42	
76.93	
75.24	
85.66	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
286.25	
2210	E
SSI DISABLED NON-ME	26,357.77	26,471.04	26,580.74	26,594.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
106,004.17	
221Z	D
SSI DISABLED NON-ME	24.77	37.42	41.24	26.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
129.45	
2220	D
SSI DISABLED WITH Q	6,861.39	6,872.57	6,919.11	6,913.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
27,566.16	
222Z	M
SSI DISABLED WITH Q	0.77	4.89	4.15	2.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
12.77	
2300	M
SSI BLIND WITH MEDIC	20.00	21.00	24.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
89.00	
2310	SSI BLIND NON-MEDIC	136.44	136.00	137.26	133.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	543.18	
2320	A
SSI BLIND WITH QMB	43.31	43.00	42.79	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
172.10	
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	

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

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

58,936.68

59,308.36

59,511.21

59,547.24

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

237,303.49

8700	SSI DISABLED FREEDO M	26.00	26.67	25.90	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO	24.00	23.32	23.00	23.00	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	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.00	55.99	54.90	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

105.57	
0.00	
93.32	
24.00	
0.00	
222.89	

M

237,526.38

TOTAL:

M

58,992.68	59,364.35	59,566.11	59,603.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending October 31, 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	56.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.90	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	2,972,808.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,972,808.05	
1011	TANF <1 M & F NON-ME	0.00	0.00	4,780.98	27,888.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,669.81	
1012	TANF 01-05 M & F NON	0.00	0.00	-999.24	6,087.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,088.44	
1013	TANF 06-13 M & F NON	0.00	0.00	982.48	10,237.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,219.78	
1014	TANF 14-20 MALE NON-	0.00	0.00	274.85	4,661.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,936.82	
1015	TANF 14-20 FEMALE N	0.00	0.00	276.04	5,084.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,360.13	

1017	O
TANF 21-44 FEMALE N	
0.00	
0.00	
0.00	
22.03	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
22.03	
101A	O
TANF < 1 M & F NON-M	0.00	0.00	0.00	2,757.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,757.79	
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	2,330.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,330.99	
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	2,949.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,949.36	
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	591.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	591.34	
101E	TANF 14-20 FEMALE N	0.00	0.00	0.00	1,210.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,210.60	
2120	O
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	0.00	0.00	0.00	110.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110.98	
2210	E
SSI DISABLED NON-ME	0.00	0.00	6,042.11	1,893,541.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1,899,583.76	
221Z	D
SSI DISABLED NON-ME	0.00	0.00	0.00	736.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
736.55	

2220	D
SSI DISABLED WITH Q	
0.00	
0.00	
0.00	
977.78	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
977.78	
2310	M
SSI BLIND NON-MEDIC	0.00	0.00	0.00	2,252.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,252.75	

4300	A
SOBRA CHILD WITH ME	
0.00	
0.00	
0.00	
1,998.89	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,998.89	
4303	D
SOBRA CHILD 06-13 M	0.00	0.00	0.00	94.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
94.54	
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	10.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.10	
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	47.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47.71	
430E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	18.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.35	
4310	SOBRA CHILD NON-ME	0.00	0.00	0.00	32,582,791.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,582,791.23	
4311	DI
SOBRA CHILD <1 M & F	0.00	0.00	16,585.12	101,558.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
118,144.05	
4312	SOBRA CHILD 01-05 M	0.00	0.00	9,176.08	134,775.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143,951.10	
4313	SOBRA CHILD 06-13 M	0.00	0.00	28,671.34	129,554.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	158,225.42	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	1,802.52	37,478.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,281.02	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	16,681.14	21,239.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37,921.13	
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	12,551.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,551.84	
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	52,870.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,870.33	
431C	SOBRA CHILD 6-13 M&	0.00	0.00	0.00	57,860.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57,860.11	
431D	F
SOBRA CHILD 14-20 MA	0.00	0.00	0.00	16,103.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
16,103.43	
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	13,430.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,430.13	
4320	SOBRA CHILD WITH Q	0.00	0.00	0.00	112.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	112.39	
	MB														

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	26.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.61		
432D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	1.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.84		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	29,326.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,326.53		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	310.77	1,029.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,340.76		
501E	SOBRA PREG 14-20 FE	0.00	0.00	0.00	360.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		360.58		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	-55.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-55.49		
7000	CMHS	0.00	0.00	0.00	62,616.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,616.60		
	0.00	0.00	84,584.19	38,190,108.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,274,693.06		

M

SUBTOTAL:

1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	6,425.42	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	87.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	28.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	6,541.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

6,425.42	
87.72	
28.64	
0.00	
0.00	
6,541.78	

SUBTOTAL:

776.66

776.66

3710	AHC CARE EXPANDED	0.00	0.00	0.00	776.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	776.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

FO

55.49

55.49

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	55.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	55.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	83.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4403	SOBRA 100-133% M&F	0.00	0.00	0.00	155.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

440C	6
SOBRA 100-133% M&F	
0.00	
0.00	
0.00	
10.74	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4410	6
SOBRA 100-133% FOR	
0.00	
0.00	
0.00	
2,430,724.38	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4413	F
SOBRA 100-133% M&F	
0.00	
0.00	
5,553.54	
32,585.38	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4414	6
SOBRA 100-133% MALE	
0.00	
0.00	
1,555.12	
6,025.82	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4415	SOBRA 100-133% FEMA	0.00	0.00	1,105.03	5,327.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

441C	L
SOBRA 100-133% M&F	
0.00	
0.00	
0.00	
10,898.27	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

441D	6
SOBRA 100-133% MALE	
0.00	
0.00	
0.00	
2,372.99	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
441E	SOBRA 100-133% FEMA	0.00	0.00	0.00	2,691.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4420	L
SOBRA 100-133% FOR	
0.00	
0.00	
0.00	
28.45	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4423	F
SOBRA 100-133% M&F	
0.00	
0.00	
0.00	
-11.93	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	6													

 	
83.94	
155.73	
10.74	
2,430,724.38	
38,138.92	
7,580.94	
6,432.03	
10,898.27	
2,372.99	
2,691.47	
28.45	
-11.93	
2,499,105.93	

SUBTOTAL:

0.00

0.00

8,213.69	2,490,892.24

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

10.10

18.35

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	10.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO	0.00	0.00	0.00	18.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

M

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	28.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.45		

SUBTOTAL:

6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	75.25	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	1,331.48	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	2,606.11	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	594.99	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	1.85	538.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	1.85	5,146.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
75.25	
1,331.48	
2,606.11	
594.99	
540.82	
5,148.65	

40,786,350.02

0.00	0.00	92,799.73	40,693,550.29	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 October 31, 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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	68,480.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,480.00	
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	0.00	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	O
TANF 21-44 FEMALE N	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
101A	O
TANF < 1 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	
101B	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	
101C	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	
101D	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	
101E	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	O
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	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	
2210	E
SSI DISABLED NON-ME	0.00	0.00	0.00	19,129.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
19,129.00	
221Z	D
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	

2220	D
SSI DISABLED WITH Q	
0.00	
0.00	
0.00	
11.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
11.00	
2310	M
SSI BLIND NON-MEDIC	0.00	0.00	0.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
52.00	

4300	A
SOBRA CHILD WITH ME	
0.00	
0.00	
0.00	
35.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
35.00	
4303	D
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	
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
430C	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	
430E	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	
4310	SOBRA CHILD NON-ME	0.00	0.00	0.00	550,197.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	550,197.00	
4311	DI
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	
431A	SOBRA CHILD < 1 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	
431B	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	
431C	SOBRA CHILD 6-13 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	
431D	F
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	
431E	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	
4320	SOBRA CHILD WITH Q	0.00	0.00	0.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	
	MB														

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4324	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		
432D	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		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	489.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		489.00		
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		
501E	SOBRA PREG 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		
501G	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		
7000	CMHS	0.00	0.00	0.00	659.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		659.00		
	0.00	0.00	0.00	639,059.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		639,059.00		

M

SUBTOTAL:

1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	180.00	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	
111C	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	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	180.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

180.00	
0.00	
0.00	
0.00	
0.00	
180.00	

SUBTOTAL:

2.00

2.00

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

FO

1.00

1.00

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

SUBTOTAL:

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4403	SOBRA 100-133% 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	

440C	6
SOBRA 100-133% 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	

4410	6
SOBRA 100-133% FOR	
0.00	
0.00	
0.00	
64,550.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4413	F
SOBRA 100-133% 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	

4414	6
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

441C	L
SOBRA 100-133% 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	

441D	6
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	
441E	SOBRA 100-133% FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4420	L
SOBRA 100-133% FOR	
0.00	
0.00	
0.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4423	F
SOBRA 100-133% 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	
	6													

 	
2.00	
0.00	
0.00	
64,550.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1.00	
0.00	
64,553.00	

SUBTOTAL:

0.00

0.00

0.00

64,553.00

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	
871Z	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

M

703,795.00

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

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	
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	
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	
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	
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	
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	703,795.00	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 October 31, 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	1,780.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,780.48	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	36,591.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,591.46	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	565.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	565.66	
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	295.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295.97	
1016	O
TANF 21-44 MALE NON-	0.00	0.00	0.00	2,354.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,354.77	
1017	TANF 21-44 FEMALE N	0.00	0.00	1,407.35	7,975.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,382.54	
1018	O
TANF 45-64 M & F NON	0.00	0.00	0.00	2,024.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,024.76	
1020	TANF WITH QMB	0.00	0.00	0.00	611.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	611.68	
2100	SSI AGED 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	

210Z	A
SSI AGED WITH MEDIC	
0.00	
0.00	
0.00	
3.23	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3.23	
2110	A
SSI AGED NON-MEDICA	0.00	0.00	0.00	611.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
611.68	

2120	R
SSI AGED WITH QMB	
0.00	
0.00	
0.00	
4,970.51	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4,970.51	
2200	SSI DISABLED WITH M	0.00	0.00	4.04	11,736.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,740.66	
220Z	E
SSI DISABLED WITH M	0.00	0.00	0.00	796.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
796.92	
2210	E
SSI DISABLED NON-ME	0.00	0.00	1,099.38	217,351.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
218,450.67	
221Z	D
SSI DISABLED NON-ME	0.00	0.00	0.00	1,815.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1,815.46	
2220	D
SSI DISABLED WITH Q	0.00	0.00	784.40	67,465.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
68,250.33	

2300	M
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	0.00	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	A
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	0.00	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	D
SOBRA CHILD NON-ME	
0.00	
0.00	
0.00	
5,115.99	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
5,115.99	
4314	DI
SOBRA CHILD 14-20 MA	0.00	0.00	0.00	1,163.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1,163.24	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	490.36	2,128.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,618.96	
5000	SOBRA PREGNANT WO	0.00	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	MAN
SOBRA PREGNANT WO	0.00	0.00	0.00	3,015.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,015.70	
5017	MAN
SOBRA PREG 21-44 FE	0.00	0.00	632.12	597.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1,229.81	

5020	M
SOBRA PREGNANT WO	
0.00	
0.00	
0.00	
1,168.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,168.80	
7100	MAN SMI	0.00	0.00	0.00	35,808.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
35,808.23	

SUBTOTAL:

0.00

0.00	4,417.65	405,949.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	410,367.51

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	7,932.86	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	1,058.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	6.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	0.00	0.00	0.00	16,128.53	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	2,254.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,932.86	
1,058.92	
6.46	
16,128.53	
2,254.49	

FI

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

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1117	TANF EXPANDED 21-44		0.00		0.00		0.00		3,396.13		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	3,396.13
1118	TANF EXPANDED 45-64	0.00	0.00	5.96	414.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	420.70
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	876.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	876.61

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

0.00	0.00	0.00	1,235.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,235.22

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

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

0.00	0.00	8.76	4,796.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,804.94

0.00	0.00	0.00	980.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	980.28

0.00	0.00	0.00	1,659.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,659.70

0.00	0.00	284.40	28,081.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,366.29

SUBTOTAL:

0.00

0.00	299.12	68,822.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,121.13

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	
3508	ADULT 40-100% M&F 45	0.00	0.00	2.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	0.00	0.00	2.92	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	40,358.79	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	11.10	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	1,168.91	565.55	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	1,462.52	2,672.54	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	14.60	1,916.12	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	274.74	4,796.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	754.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	12.37	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	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	3.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED	0.00	0.00	0.00	177,719.03	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	1,739.25	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	2,226.07	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	3,147.79	26,230.54	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	1,291.54	16,371.03	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	2,137.68	21,035.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	716.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	8,364.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEM	0.00	0.00	5.84	2,530.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F	0.00	0.00	0.00	1,329.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
2.92	
2.92	
40,358.79	
11.10	
1,734.46	
4,135.06	
1,930.72	
5,070.79	
754.06	
12.37	
0.00	
0.00	
3.23	
177,719.03	
1,739.25	
2,226.07	
29,378.33	
17,662.57	
23,173.10	
716.36	
8,364.62	
2,536.23	
1,329.05	

F

FO

AL

4

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
	0.00	0.00	9,512.69	309,348.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318,861.03		

SUBTOTAL:

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	
3910	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	7,969.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3916	F
NEWLY ELIGIBLE MALE	
0.00	
0.00	
0.00	
1,394.59	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3917	NEWLY ELIGIBLE FEMA	0.00	0.00	5.84	1,330.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3918	L
NEWLY ELIGIBLE M&F	
0.00	
0.00	
0.00	
4,841.64	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

0.00

0.00

5.84

15,535.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
7,969.37	
1,394.59	
1,335.90	
4,841.64	
15,541.50	

4
SUBTOTAL:

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	1,432.70	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	2.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	1,434.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,432.70	
2.04	
1,434.74	

SUBTOTAL:

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

0.00	
0.00	
0.00	

SUBTOTAL:

8700	SSI DISABLED FREEDO	0.00	0.00	283.50	2,946.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	8.76	452.44	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	150.80	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	150.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	292.26	3,700.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3,230.25	
461.20	
150.80	
150.80	
3,993.05	

M

SUBTOTAL:

819,318.96

0.00	0.00	14,527.56	804,791.40	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 October 31, 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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39.00	
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	0.00	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	O
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	0.00	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	O
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	
1020	TANF WITH QMB	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
2100	SSI AGED 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	

210Z	A
SSI AGED 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	
2110	A
SSI AGED NON-MEDICA	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1.00	

2120	R
SSI AGED WITH QMB	
0.00	
0.00	
0.00	
4.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4.00	
2200	SSI DISABLED WITH M	0.00	0.00	0.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00	
220Z	E
SSI DISABLED WITH 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	
2210	E
SSI DISABLED NON-ME	0.00	0.00	0.00	200.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
200.00	
221Z	D
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	
2220	D
SSI DISABLED WITH Q	0.00	0.00	0.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
69.00	

2300	M
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	0.00	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	A
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	0.00	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	D
SOBRA CHILD NON-ME	
0.00	
0.00	
0.00	
3.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3.00	
4314	DI
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	
5000	SOBRA PREGNANT WO	0.00	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	MAN
SOBRA PREGNANT WO	0.00	0.00	0.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3.00	
5017	MAN
SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	

5020	M
SOBRA PREGNANT WO	
0.00	
0.00	
0.00	
1.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1.00	
7100	MAN SMI	0.00	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	335.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	335.00

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	9.00	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	
110F	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	
1110	TANF EXPANDED FOR	0.00	0.00	0.00	16.00	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	

9.00	
0.00	
0.00	
16.00	
0.00	

FI

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

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

111G	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	0.00

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

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

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

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

0.00	0.00	0.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00

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

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

0.00	0.00	0.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.00

SUBTOTAL:

0.00

0.00	0.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.00

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	
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	
350H	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	
3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	38.00	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	
351E	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	
351F	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	
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	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	
3710	AHC CARE EXPANDED	0.00	0.00	0.00	168.00	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	
371E	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	
371F	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	
371G	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
38.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
168.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

F

FO

AL

4

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
	0.00	0.00	0.00	206.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206.00		

SUBTOTAL:

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	
3910	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3916	F
NEWLY ELIGIBLE MALE	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3917	NEWLY ELIGIBLE FEMA	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	L
NEWLY ELIGIBLE M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

0.00

0.00

0.00

6.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
6.00	
0.00	
0.00	
0.00	
6.00	

4
SUBTOTAL:

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1.00	
0.00	
1.00	

SUBTOTAL:

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

0.00	
0.00	
0.00	

SUBTOTAL:

8700	SSI DISABLED FREEDO	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2.00	
0.00	
0.00	
0.00	
2.00	

M

606.00

TOTAL:

SUBTOTAL:

0.00	0.00	0.00	606.00	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 October 31, 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	1,105.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,105.02		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	104.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.23		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	7,004,854.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,004,854.69		
1014	TANF 14-20 MALE NON-	0.00	0.00	438.29	2,321.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,759.40		
1015	TANF 14-20 FEMALE N	0.00	0.00	813.01	4,947.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,760.06		
1016	TANF 21-44 MALE NON-	0.00	0.00	7,154.15	29,902.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,056.94		
1017	TANF 21-44 FEMALE N	0.00	0.00	13,453.05	67,144.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,597.73		
1018	TANF 45-64 M & F NON	0.00	0.00	3,879.61	18,566.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,446.43		
1019	TANF 65+ M & F NON-M	0.00	0.00	150.96	119.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270.57		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	677.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		677.04		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	1,580.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,580.58		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	11,521.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,521.99		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	26,112.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,112.50		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	6,264.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,264.39		
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	118.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118.92		
1020	TANF WITH QMB	0.00	0.00	0.00	394.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394.08		
2100	SSI AGED WITH MEDIC	0.00	0.00	-58.75	31,686.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,627.51		
2110	SSI AGED NON-MEDICA R	0.00	0.00	1,993.26	285,686.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287,680.09		
211Z	SSI AGED NON-MEDICA R	0.00	0.00	0.00	2,554.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,554.39		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	69,158.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,158.76		
2200	SSI DISABLED WITH M E	0.00	0.00	59.00	261,948.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,007.03		
2210	SSI DISABLED NON-ME D	0.00	0.00	2,749.04	2,519,626.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,522,375.78		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	4,633.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,633.84		
2220	SSI DISABLED WITH Q M	0.00	0.00	760.15	559,624.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		560,384.48		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	1,928.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,928.79		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	53.70	25,178.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,232.38		
231Z	SSI BLIND NON-MEDIC	0.00	0.00	0.00	41.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.18		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	4,118.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,118.66		
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	1,021,211.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,021,211.35		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.82		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	-54.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-54.96		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	1,928.61	8,967.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,896.11		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	2,872.42	10,293.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,166.15		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	3,393.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,393.32		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	3,902.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,902.74		

O

O

A

A

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

RATE CODE	DESCRIPTION
5000

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

0.00

5007

5010

SOBRA PREGNANT WO
MAN
SOBRA PREG 21-44 FE
M
SOBRA PREGNANT WO
MAN
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE
M
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE
M
SOBRA PREGNANT WO
MAN
GENERAL MENTAL HEA

0.00

0.00

0.00

0.00

0.00	42.23

0.00	1,169,673.33

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

42.23

1,169,673.33

5015

0.00

0.00

1,377.52

5,703.57

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

7,081.09

5017

0.00

0.00

8,698.21

35,078.16

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

43,776.37

5018

501E

0.00

0.00

0.00

0.00

53.70

0.00

118.58

3,306.29

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

172.28

501G

0.00

0.00

0.00

18,026.07

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3,306.29

18,026.07

501H

0.00

0.00

0.00

49.27

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

49.27

5020

7400

0.00

0.00

0.00

0.00

0.00

0.00

50.35

113,385.42

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

50.35

LT
SUBTOTAL:	0.00	0.00	46,375.93    13,335,069.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

113,385.42

13,381,445.69

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	6,241.38	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	42.23	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	93.76	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	179.85	249.59	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	482.60	280.76	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	6,862,244.15	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	168.21	845.99	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	444.50	1,269.51	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	5,565.84	28,124.43	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	11,320.08	49,834.87	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	4,231.64	21,544.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+	0.00	0.00	150.96	51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	0.00	0.00	0.00	269.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	0.00	0.00	0.00	643.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	11,460.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	21,282.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	8,128.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	0.00	0.00	0.00	29.74	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	3,294.54	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	943.32	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	5,224.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
241Z	SSI AGED EXPANDED	0.00	0.00	0.00	91.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED	0.00	0.00	0.00	15,821.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,241.38	
42.23	
93.76	
429.44	
763.36	
6,862,244.15	
1,014.20	
1,714.01	
33,690.27	
61,154.95	
25,776.61	
202.87	
269.52	
643.22	
11,460.35	
21,282.94	
8,128.89	
29.74	
3,294.54	
943.32	
5,224.40	
91.77	
15,821.03	

M&

NO

WI

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	784.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		784.67		
2610	SSI DISABLED EXPAND E	0.00	0.00	380.15	59,038.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,418.31		
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	582.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		582.67		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	10,692.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,692.84		
	0.00	0.00	22,923.83	7,109,111.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,132,035.44		

89.91	
56.86	
24.36	
4,521,352.89	
4,946.81	
4,625.05	
26,220.31	
19,484.28	
37,985.48	
1,819.41	
1,765.77	
8,609.41	
7,091.78	
14,388.14	
0.00	
58.75	
24.36	
44.19	
9,810,302.35	
11,816.57	
8,525.59	
121,300.12	
59,144.86	
100,106.64	
-165.67	
4,626.58	
3,568.66	
42,355.82	
21,484.21	
39,427.87	

SUBTOTAL:

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	89.91	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	56.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3507	ADULT 40-100% FEMAL	0.00	0.00	0.00	24.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3510	E
ADULT 40-100% FOR FI	
0.00	
0.00	
0.00	
4,521,352.89	
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	992.40	3,954.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3515	ADULT 40-100% FEMAL	0.00	0.00	1,013.93	3,611.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3516	E
ADULT 40-100% MALE 2	
0.00	
0.00	
5,546.63	
20,673.68	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
3517	ADULT 40-100% FEMAL	0.00	0.00	4,253.41	15,230.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3518	E
ADULT 40-100% M&F 45	
0.00	
0.00	
8,630.54	
29,354.94	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
351D	ADULT 40-100% MALE 1	0.00	0.00	0.00	1,819.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
351E	ADULT 40-100% FEMAL	0.00	0.00	0.00	1,765.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

351F	E
ADULT 40-100% MALE 2	
0.00	
0.00	
0.00	
8,609.41	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
351G	ADULT 40-100% FEMAL	0.00	0.00	0.00	7,091.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

351H	E
ADULT 40-100% M&F 45	
0.00	
0.00	
0.00	
14,388.14	
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	0.00	0.00	0.00	58.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3706	F
ADULT <40% EXP MALE	
0.00	
0.00	
0.00	
24.36	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
3708	ADULT <40% EXP M&F	0.00	0.00	0.00	44.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3710	4
AHC CARE EXPANDED	
0.00	
0.00	
0.00	
9,810,302.35	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

3714	FO
ADULT <40% EXP MALE	
0.00	
0.00	
2,784.91	
9,031.66	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
3715	ADULT <40% EXP FEM	0.00	0.00	2,062.31	6,463.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3716	AL
ADULT <40% EXP MALE	
0.00	
0.00	
30,342.83	
90,957.29	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
3717	ADULT <40% EXP FEM	0.00	0.00	12,585.50	46,559.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3718	AL
ADULT <40% EXP M&F	
0.00	
0.00	
21,561.45	
78,545.19	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

3719	4
ADULT <40% EXP M&F	
0.00	
0.00	
-50.35	
-115.32	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

371D	6
ADULT <40% EXP MALE	
0.00	
0.00	
0.00	
4,626.58	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
371E	ADULT <40% EXP FEM	0.00	0.00	0.00	3,568.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

371F	AL
ADULT <40% EXP MALE	
0.00	
0.00	
0.00	
42,355.82	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
371G	ADULT <40% EXP FEM	0.00	0.00	0.00	21,484.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

371H	AL
ADULT <40% EXP M&F	
0.00	
0.00	
10.38	
39,417.49	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	4														
														48	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3720	AHC CARE EXPANDED FO	0.00	0.00	0.00	50.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.35		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	4.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.87		
	0.00	0.00	89,733.94	14,781,402.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,871,136.58		

SUBTOTAL:

3900	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	58.75	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	3,958,586.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	356.72	2,527.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	560.21	2,239.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	4,502.59	21,386.48	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	5,869.16	29,093.80	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	4,087.72	24,383.29	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	-58.75	-49.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1,051.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	1,325.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	9,509.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	12,843.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	12,386.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	15,317.65	4,075,342.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

58.75	
3,958,586.24	
2,883.89	
2,799.53	
25,889.07	
34,962.96	
28,471.01	
-108.02	
1,051.69	
1,325.96	
9,509.18	
12,843.37	
12,386.88	
4,090,660.51	

F

4

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	229,236.70	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	235.04	2,109.94	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	585.00	1,639.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	643.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	712.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	820.04	234,341.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

229,236.70	
2,344.98	
2,224.15	
643.05	
712.30	
235,161.18	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	0.00	0.00	0.00	8,193.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	0.00	0.00	116.49	139.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

451H	5
BC PATIENT FEMALE 4	
0.00	
0.00	
0.00	
67.64	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4610	5
CC PATIENT FOR FINA	
0.00	
0.00	
0.00	
875.16	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4617	N
CC PATIENT FEMALE 2	
0.00	
0.00	
0.00	
17.87	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

461G	1
CC PATIENT FEMALE 2	
0.00	
0.00	
0.00	
21.69	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	1													

 	
8,193.19	
256.26	
67.64	
875.16	
17.87	
21.69	
9,431.81	

SUBTOTAL:

0.00

0.00

116.49

9,315.32

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	1,641.69	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	168.21	11,600.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO	0.00	0.00	0.00	119.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	0.00	0.00	0.00	397.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,641.69	
11,768.57	
119.35	
397.16	

M

M

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	168.21	13,758.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,926.77		

SUBTOTAL:

6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	260.15	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	1.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	261.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

260.15	
1.08	
261.23	

SUBTOTAL:

39,734,059.21

0.00	0.00	175,456.09	39,558,603.12	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 October 31, 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	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
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		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	135,295.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,295.00		
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	0.00	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	0.00	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		
101D	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		
101E	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		
101F	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		
101G	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		
101H	TANF 44-64 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		
101J	TANF 65+ N & 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		
1020	TANF WITH QMB	0.00	0.00	0.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2100	SSI AGED WITH MEDIC	0.00	0.00	0.00	285.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285.00		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	5,398.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,398.00		
211Z	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	861.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		861.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	2,141.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,141.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	40,232.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,232.00		
221Z	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	4,732.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,732.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	422.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		422.00		
231Z	SSI BLIND NON-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		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
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	19,737.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,737.00		
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		
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		
431D	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		
431E	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		

O

O

A

A

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

RATE CODE	DESCRIPTION
5000

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

0.00

5007

5010

SOBRA PREGNANT WO
MAN
SOBRA PREG 21-44 FE
M
SOBRA PREGNANT WO
MAN
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE
M
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE
M
SOBRA PREGNANT WO
MAN
GENERAL MENTAL HEA

0.00

0.00

0.00

0.00

0.00

0.00

0.00

22,659.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

22,659.00

5015

0.00

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5018

501E

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

501G

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

501H

0.00

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

7400

0.00

0.00

0.00

0.00

0.00

0.00

1.00

832.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1.00

LT
SUBTOTAL:	0.00	0.00	0.00	232,672.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

832.00

232,672.00

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	125.00	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	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	132,307.00	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+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	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	
111E	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	
111F	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	
111G	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	
111H	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	
111J	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	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	65.00	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	11.00	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	101.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
241Z	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED	0.00	0.00	0.00	321.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

125.00	
0.00	
0.00	
0.00	
0.00	
132,307.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
65.00	
11.00	
101.00	
0.00	
321.00	

M&

NO

WI

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	1,134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,134.00		
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	203.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203.00		
	0.00	0.00	0.00	134,274.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,274.00		

2.00	
0.00	
0.00	
87,606.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1.00	
0.00	
0.00	
190,536.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3507	ADULT 40-100% FEMAL	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	E
ADULT 40-100% FOR FI	
0.00	
0.00	
0.00	
87,606.00	
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	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	E
ADULT 40-100% MALE 2	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3518	E
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		
351D	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		
351E	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

351F	E
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		
351G	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

351H	E
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		
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	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3706	F
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		
3708	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3710	4
AHC CARE EXPANDED	
0.00	
0.00	
0.00	
190,536.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

3714	FO
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	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	AL
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	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	AL
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

3719	4
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

371D	6
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		
371E	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

371F	AL
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		
371G	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

371H	AL
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	4														
														53	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3720	AHC CARE EXPANDED FO	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	278,146.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278,146.00		

SUBTOTAL:

3900	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	1.00	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	76,644.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	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	
391E	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	
391F	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	
391G	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	
391H	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	76,645.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1.00	
76,644.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
76,645.00	

F

4

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	4,438.00	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	
441D	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	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	4,438.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4,438.00	
0.00	
0.00	
0.00	
0.00	
4,438.00	

SUBTOTAL:

4510	BC PATIENT FOR FINA N	0.00	0.00	0.00	159.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

451H	5
BC PATIENT FEMALE 4	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4610	5
CC PATIENT FOR FINA	
0.00	
0.00	
0.00	
18.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4617	N
CC PATIENT 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	

461G	1
CC PATIENT 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	
	1													

 	
159.00	
0.00	
0.00	
18.00	
0.00	
0.00	
177.00	

SUBTOTAL:

0.00

0.00

0.00

177.00

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	18.00	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	224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	0.00	0.00	0.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18.00	
224.00	
0.00	
4.00	

M

M

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	246.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246.00		

SUBTOTAL:

726,598.00

TOTAL:

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	
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	0.00	0.00	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	726,598.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1010	TANF NON-MEDICARE		0.00		0.00		0.00		0.00		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00		0.00

2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

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

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

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

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

0.00	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

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	
	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

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	
	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:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1010	TANF NON-MEDICARE		0.00		0.00		0.00		0.00		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00		0.00

2210	SSI DISABLED NON-ME
D
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH ME
D
4310	SOBRA CHILD NON-ME
DI
5010	SOBRA PREGNANT WO
MAN

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

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

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

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

0.00	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

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	
	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

TOTAL:

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	
	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	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3,020.80	3,020.80	3,020.80	3,966.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,028.40		
1010	TANF NON-MEDICARE	191,820.80	195,596.80	195,596.80	202,266.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785,280.40		
1011	TANF <1 M & F NON-ME	4,850.24	3,696.96	4,174.08	4,280.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,002.12		
1012	TANF 01-05 M & F NON	5,406.40	6,559.68	6,837.76	7,450.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,254.43		
1013	TANF 06-13 M & F NON	8,427.20	5,883.52	6,360.64	6,975.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,646.64		
1014	TANF 14-20 MALE NON-	4,174.08	3,896.00	3,617.92	2,376.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,064.55		
1015	TANF 14-20 FEMALE N	6,281.60	6,281.60	5,327.36	5,864.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,754.75		
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	1,425.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,197.13		
2200	SSI DISABLED WITH M E	26,909.12	26,909.12	26,153.92	25,857.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,829.87		
2210	SSI DISABLED NON-ME D	4,555,037.44	4,547,763.52	4,549,511.04	4,770,193.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,422,505.82		
2220	SSI DISABLED WITH Q M	60,934.08	63,676.80	63,676.80	69,002.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257,289.98		
2300	SSI BLIND WITH MEDIC	755.20	755.20	755.20	793.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,058.80		
2310	SSI BLIND NON-MEDIC A	44,041.60	44,796.80	45,552.00	46,317.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,707.79		
4311	SOBRA CHILD <1 M & F	25,957.76	26,156.80	24,646.40	21,722.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,483.05		
4312	SOBRA CHILD 01-05 M	201,787.20	195,069.44	196,857.92	198,822.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		792,537.49		
4313	SOBRA CHILD 06-13 M	231,286.72	231,605.76	228,505.92	229,397.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		920,795.54		
4314	SOBRA CHILD 14-20 MA	56,885.76	53,744.96	52,035.52	56,132.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,798.57		
4315	SOBRA CHILD 14-20 FE	54,503.04	54,025.92	52,316.48	51,046.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,891.53		
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		
	5,484,742.72	5,471,348.16	5,468,286.40	5,703,890.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,128,267.66		

O

SUBTOTAL:

1,906.67

1,906.67

1115	TANF EXPANDED 14-20	477.12	477.12	477.12	475.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	477.12	477.12	477.12	475.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

3514	ADULT 40-100% MALE 1	1,908.48	2,385.60	2,862.72	2,851.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	1,431.36	1,431.36	954.24	950.62	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	475.31	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	8,555.58	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	6,654.34	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	1,425.93	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	1,425.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	24,333.12	23,378.88	23,378.88	22,339.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

10,008.66	
4,767.58	
1,906.67	
35,274.30	
30,033.22	
6,674.25	
4,765.77	
93,430.45	

E

SUBTOTAL:

3914	NEWLY ELIGIBLE MALE	954.24	954.24	954.24	1,425.93	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	475.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,431.36	1,431.36	1,431.36	1,901.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

4,288.65	
1,906.67	
6,195.32	

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	8,588.16	10,496.64	12,206.08	13,151.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,442.14		
4414	SOBRA 100-133% MALE	2,862.72	2,862.72	1,908.48	1,425.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,059.85		
4415	SOBRA 100-133% FEMA L	2,385.60	2,385.60	4,572.16	3,645.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,988.42		
	13,836.48	15,744.96	18,686.72	18,222.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,490.41		

SUBTOTAL:

TOTAL:

5,524,820.80

5,512,380.48	5,512,260.48	5,746,828.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,296,290.51

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	4.00	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1010	TANF NON-MEDICARE	254.00	259.00	259.00	255.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,027.00		
1011	TANF <1 M & F NON-ME	9.00	6.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
1012	TANF 01-05 M & F NON	9.00	12.00	12.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46.00		
1013	TANF 06-13 M & F NON	13.00	10.00	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46.00		
1014	TANF 14-20 MALE NON-	7.00	7.00	7.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
1015	TANF 14-20 FEMALE N	12.00	12.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
2200	SSI DISABLED WITH M E	36.00	36.00	35.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140.00		
2210	SSI DISABLED NON-ME D	6,198.00	6,188.00	6,187.00	6,191.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,764.00		
2220	SSI DISABLED WITH Q M	84.00	88.00	88.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		351.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2310	SSI BLIND NON-MEDIC A	62.00	63.00	64.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251.00		
4311	SOBRA CHILD <1 M & F	41.00	42.00	40.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.00		
4312	SOBRA CHILD 01-05 M	339.00	329.00	331.00	324.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,323.00		
4313	SOBRA CHILD 06-13 M	395.00	398.00	395.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,579.00		
4314	SOBRA CHILD 14-20 MA	93.00	87.00	84.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		352.00		
4315	SOBRA CHILD 14-20 FE	95.00	94.00	91.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368.00		
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		
	7,657.00	7,640.00	7,633.00	7,615.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,545.00		

O

SUBTOTAL:

4.00

4.00

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

SUBTOTAL:

3514	ADULT 40-100% MALE 1	4.00	5.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	3.00	3.00	2.00	2.00	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	1.00	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	18.00	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	14.00	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	3.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	51.00	49.00	49.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

21.00	
10.00	
4.00	
74.00	
63.00	
14.00	
10.00	
196.00	

E

SUBTOTAL:

3914	NEWLY ELIGIBLE MALE	2.00	2.00	2.00	3.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3.00	3.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

9.00	
4.00	
13.00	

SUBTOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	18.00	22.00	25.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.00		
4414	SOBRA 100-133% MALE	6.00	6.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
4415	SOBRA 100-133% FEMA L	5.00	5.00	9.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
	29.00	33.00	38.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137.00		

SUBTOTAL:

TOTAL:	7,741.00	7,726.00	7,724.00	7,704.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,895.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	848.42	3,211.96	1,839.15	1,556.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,455.66		
1007	TANF 21-44 FEMALE WI	11,505.38	19,187.09	10,505.19	13,081.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,278.80		
1008	TANF 45-64 M & F WIT	8,643.75	16,020.60	11,606.94	2,469.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,740.34		
1009	TANF 65+ M & F WITH	2,022.37	2,905.92	1,922.18	3,376.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,227.45		
1011	TANF <1 M & F NON-ME	997,028.06	1,032,104.95	596,456.80	985,043.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,610,632.88		
1012	TANF 01-05 M & F NON	369,557.78	393,193.50	297,331.72	298,111.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,358,194.08		
1013	TANF 06-13 M & F NON	342,021.90	307,281.43	274,370.73	269,534.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,193,208.29		
1014	TANF 14-20 MALE NON-	88,902.93	72,599.25	62,332.53	62,617.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,452.35		
1015	TANF 14-20 FEMALE N O	219,214.37	258,354.36	254,247.65	217,864.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		949,680.44		
1016	TANF 21-44 MALE NON-	1,794,520.91	1,973,445.21	1,414,952.39	1,367,761.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,550,680.32		
1017	TANF 21-44 FEMALE N O	6,277,129.24	6,649,032.53	4,945,353.53	4,531,316.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,402,831.43		
1018	TANF 45-64 M & F NON	2,332,798.20	2,695,114.91	1,952,339.44	1,894,566.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,874,819.06		
1019	TANF 65+ M & F NON-M	1,488.83	4,276.48	4,454.29	39,419.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,639.45		
1026	TANF 21-44 MALE WITH	1,000.95	2,620.04	1,137.34	2,285.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,043.83		
1027	TANF 21-44 FEMALE WI	3,449.27	3,490.82	1,096.67	4,139.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,176.66		
1028	TANF 45-64 M & F WIT	8,935.11	7,873.80	7,408.04	7,634.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,851.01		
1029	TANF 65+ M & F WITH	111.13	364.33	6.64	1,438.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,920.61		
2100	SSI AGED WITH MEDIC A	190,983.36	191,970.63	82,013.82	76,365.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		541,333.20		
2110	SSI AGED NON-MEDICA R	92,974.35	100,505.44	91,252.74	187,019.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,752.04		
2120	SSI AGED WITH QMB	469,076.56	646,192.71	528,246.07	449,589.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,093,104.90		
2200	SSI DISABLED WITH M E	358,598.07	500,225.09	440,571.93	338,158.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,637,554.08		
2210	SSI DISABLED NON-ME D	8,751,971.22	10,309,441.37	8,095,838.27	6,773,265.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,930,516.06		
2220	SSI DISABLED WITH Q M	1,192,013.12	1,702,312.74	1,203,802.42	1,061,781.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,159,910.26		
2300	SSI BLIND WITH MEDIC	457.17	1,105.82	1,395.49	132.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,090.49		
2310	SSI BLIND NON-MEDIC	86,051.54	110,836.56	112,120.18	81,513.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390,521.68		
2320	SSI BLIND WITH QMB	17,562.15	17,561.62	12,173.61	7,949.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,246.48		
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	2,154,608.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,122,808.00		
4312	SOBRA CHILD 01-05 M	3,898,361.36	5,221,614.05	3,931,751.08	3,374,005.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,425,731.55		
4313	SOBRA CHILD 06-13 M	5,970,382.14	5,908,426.67	5,257,376.58	4,250,756.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,386,941.59		
4314	SOBRA CHILD 14-20 MA	1,683,601.36	1,670,470.03	1,196,168.22	1,038,419.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,588,659.41		
4315	SOBRA CHILD 14-20 FE	1,620,045.30	2,013,403.75	1,845,592.74	1,401,643.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,880,684.79		
5007	SOBRA PREG 21-44 FE M	865.69	2,004.91	939.33	151.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,961.01		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,702.26	736.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,875.26		
5015	SOBRA PREG 14-20 FE	398,992.68	518,674.19	387,758.06	314,539.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,619,964.22		
5017	SOBRA PREG 21-44 FE	2,430,613.48	3,015,144.62	2,238,361.40	1,945,980.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,630,099.63		

A

M

M

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	4,602.26	5,349.03	5,359.83	10,691.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,002.37		
5027	SOBRA PREG 21-44 FE M	922.96	3,146.16	1,079.37	1,402.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,551.39		
5028	SOBRA PREG 45-64 FE M	408.02	954.20	127.73	1,184.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,674.88		
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		
	42,425,721.60	48,108,092.23	37,724,728.19	33,172,108.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,430,650.60		

SUBTOTAL:

1,838.51

3100	TRANSPLANT OPTION	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

	1,838.51	
1106	TANF EXPANDED 21-44	19,712.79	23,772.65	11,988.70	17,140.04	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	24,200.83	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	88,440.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1109	TANF EXPANDED 65+	43,849.18	47,867.62	36,472.40	38,131.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1111	M&
TANF EXPANDED <1 M	
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	&F
TANF EXPANDED 01-05	
1,472.00	
471.44	
368.00	
1,481.59	
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	1,104.00	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	2,915.95	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	34,793.85	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	459,197.90	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	1,783,563.40	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	1,157,507.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1119	TANF EXPANDED 65+	3,568.96	3,154.34	5,023.68	4,365.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1126	M&
TANF EXPANDED 21-44	
11,749.81	
26,016.73	
11,081.94	
11,382.54	
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	12,135.98	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	24,892.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1129	TANF EXPANDED 65+	17,343.41	26,220.86	16,100.79	9,815.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2400	M&
SSI AGED EXPANDED	
17,207.10	
23,080.02	
28,399.63	
13,700.77	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2410	WI
SSI AGED EXPANDED	
9,549.32	
3,150.78	
3,153.04	
2,208.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2420	NO
SSI AGED EXPANDED	
300,798.06	
347,865.14	
270,900.47	
216,331.04	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2600	WI
SSI DISABLED EXPAND	
32,108.52	
41,934.80	
28,768.37	
14,158.05	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2610	E
SSI DISABLED EXPAND	
170,711.55	
140,061.64	
176,457.03	
173,409.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2620	E
SSI DISABLED EXPAND	
338,045.21	
438,971.31	
317,520.57	
254,535.17	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	E														

1

72,614.18	
152,257.88	
434,303.86	
166,320.38	
736.00	
3,793.03	
6,018.74	
26,282.65	
149,811.39	
2,315,907.06	
8,272,330.18	
5,690,998.35	
16,112.63	
60,231.02	
41,643.43	
124,718.31	
69,480.14	
82,387.52	
18,061.14	
1,135,894.71	
116,969.74	
660,639.22	
1,349,072.26	
20,966,583.82	

SUBTOTAL:

5,433,347.56	6,255,423.13	4,932,402.60	4,345,410.53

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3317	AHC CARE FEMALE 21- 4	0.00	-107.53	0.00	-56.48	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	-1,782.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-1,442.96	0.00	-1,838.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

-164.01	
-3,117.77	
-3,281.78	

SUBTOTAL:

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3400	MED ELIGIBILITY W/ M	-128.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-128.19		
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	-3,081.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,081.67		
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	-610.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,592.02		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-660.00		
3618	AHC CARE/MI M&F 45-6	0.00	-2,324.92	-463.62	-995.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,784.02		
	-138.35	-7,604.92	-825.64	-5,347.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-13,916.06		

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	-172.78	0.00	-25.53	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	4,133.80	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	6,300.41	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	32,546.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	74,897.97	101,710.15	78,047.94	61,982.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
875,338.76	
993,741.02	
812,257.64	
811,955.65	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	688,506.80	716,669.29	519,306.11	481,552.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
2,164,182.50	
2,672,009.10	
2,054,220.46	
1,818,577.48	
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	2,889.62	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	837.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	112.61	368.00	285.98	5,924.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3708	AL
ADULT <40% EXP M&F	
10,869.67	
8,301.93	
10,834.72	
9,262.41	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3709	4
ADULT <40% EXP M&F	
1,326.41	
4,433.00	
1,431.77	
64.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3714	6
ADULT <40% EXP MALE	
396,349.39	
314,897.57	
319,289.68	
238,842.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3715	ADULT <40% EXP FEM	466,712.02	441,609.03	420,069.14	280,751.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	AL
ADULT <40% EXP MALE	
7,380,948.41	
7,458,471.39	
5,814,373.14	
5,938,761.42	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEM	3,864,032.81	3,815,255.08	2,921,267.62	2,735,105.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
9,449,700.09	
10,711,847.87	
8,243,352.00	
7,558,809.96	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
4,389.51	
5,535.00	
8,073.77	
924.43	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3728	6
ADULT <40% EXP M&F	
579.64	
19,355.70	
-19.34	
301.11	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	4													

 	
-198.31	
29,341.15	
25,419.88	
175,980.31	
316,638.79	
3,493,293.07	
2,406,035.12	
8,708,989.54	
35,957.95	
217.07	
86.34	
128.90	
4,508.00	
6,690.70	
39,268.73	
7,255.98	
1,269,379.04	
1,609,141.91	
26,592,554.36	
13,335,661.39	
35,963,709.92	
18,922.71	
20,217.11	
94,059,199.66	

SUBTOTAL:

25,459,032.51    27,338,626.79    21,272,041.04    19,989,499.32

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3906	NEWLY ELIGIBLE MALE	600.38	328.49	29.45	209.59	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	9,346.79	12,574.43	4,551.68	837.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,167.91	
1,086.00	
27,310.03	

4

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

RATE CODE	DESCRIPTION
3909

JULY
491.18

AUGUST	SEPTEMBER
602.98	747.75

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

1,841.91

3914

3915

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

22,978.31

41,330.26

18,527.45

46,109.83

13,537.31

28,638.83

13,309.33

27,897.16

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

68,352.40

143,976.08

3916

331,242.92

482,310.70

341,671.18

331,691.73

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,486,916.53

3917

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE M&F

773,121.13

829,594.37

623,013.25

503,865.22

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,729,593.97

3918

3919

1,108,114.13

0.00

1,301,085.00

0.00

1,128,587.46

736.00

1,103,452.24

368.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4,641,238.83

3928

30.62

360.56

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,104.00

391.18

4
SUBTOTAL:	2,287,255.72	2,691,861.81	2,142,230.91	1,981,630.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,102,978.84

4412	SOBRA 100-133% M&F
1	0.00	1,436.00	0.00	700.00	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	403,538.35	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	104,916.12	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	157,332.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	722,194.67	942,881.73	691,984.75	666,487.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2,136.00	
1,837,163.60	
460,117.65	
724,131.21	
3,023,548.46	

SUBTOTAL:

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	5,535.42	5,198.08	3,942.51	1,151.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4519	5
BC PATIENT FEMALE 6	
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	5
CC PATIENT FEMALE 4	
368.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	5													

 	
1,104.00	
15,827.04	
147.74	
368.00	
17,446.78	

SUBTOTAL:

6,271.42

6,081.82

3,942.51

1,151.03

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8700	SSI DISABLED FREEDO M	11,347.92	16,496.57	21,239.51	9,895.47	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	2,835.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	13,176.17	19,372.57	29,893.61	12,730.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

58,979.47	
3,762.95	
12,430.66	
75,173.08	

SUBTOTAL:

TOTAL:

76,348,717.42

85,353,274.59    66,796,397.97    60,161,831.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	288,660,221.91

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2016
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1006	TANF 21-44 MALE WITH	24.86		0.00		90.63		0.00		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00		115.49
1007	TANF 21-44 FEMALE WI	95.75	21.69	0.00	20.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138.00
1008	TANF 45-64 M & F WIT	3,001.23	1,005.46	161.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,168.63
1009	TANF 65+ M & F WITH	100.93	886.53	87.58	99.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,174.35
1011	TANF <1 M & F NON-ME	17,325.66	62,411.73	16,655.73	16,367.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	112,760.83
1012	TANF 01-05 M & F NON	401.51	861.55	9.55	87.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,360.09
1013	TANF 06-13 M & F NON	1,152.31	-24.10	90.49	1,646.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,865.02
1014	TANF 14-20 MALE NON-	714.39	1,253.78	2,854.79	1,212.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,035.25

1015	TANF 14-20 FEMALE N
O

3,433.47	1,839.76	17,329.46	1,737.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,340.47

1016	TANF 21-44 MALE NON-	22,396.21	77,167.79	17,027.50	30,769.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	147,361.41

1017	TANF 21-44 FEMALE N
O

52,737.24	131,048.50	51,785.14	68,373.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	303,944.20

1018	TANF 45-64 M & F NON	18,073.82	37,929.68	10,840.13	21,323.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	88,166.74

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

15,695.91	8,647.19	17,906.90	4,577.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,827.58

28,335.40	43,386.47	18,508.51	14,354.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104,584.90

2120	SSI AGED WITH QMB	0.00	1,048.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,048.56

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

2,033.62	523.52	3,191.46	2,136.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,884.82

16,753.15	7,270.63	7,651.13	14,824.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,499.33

4311	SOBRA CHILD <1 M & F	10,799.03	33,934.63	1,439.56	27,420.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,593.71

4312	SOBRA CHILD 01-05 M	36,145.25	43,168.63	23,886.76	53,151.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	156,352.42

4313	SOBRA CHILD 06-13 M	35,978.68	63,157.33	22,075.20	27,013.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	148,224.35

4314	SOBRA CHILD 14-20 MA	18,930.52	12,976.10	24,307.39	12,958.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,172.70

4315	SOBRA CHILD 14-20 FE	12,023.48	33,332.95	16,503.27	18,974.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,834.20

5007	SOBRA PREG 21-44 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M

214.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	214.11

15,014.16	30,238.92	17,931.32	21,033.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,218.27

74,107.54	80,746.34	74,318.02	80,279.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	309,451.03

0.00	2,069.35	0.00	-47.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,021.47

0.00	0.00	0.00	22.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.85

SUBTOTAL:

385,488.23

674,902.99	344,652.46	418,337.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,823,380.78

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	275.17	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	1,163.33	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	93.00	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	93.00	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	23,284.36	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	22,755.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
16.99	
600.55	
8,980.21	
1,283.20	
2,828.54	
103,405.49	
159,041.60	

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

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1118	TANF EXPANDED 45-64	10,025.87	17,504.72		19,259.83	34,282.55		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	81,072.97

1119	TANF EXPANDED 65+
M&

55.48	0.00	175.00	813.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,044.29

1127	TANF EXPANDED 21-44	0.00	20.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20.04

1129	TANF EXPANDED 65+
M&
2400	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E

131.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	131.86

9,438.04	7,426.55	5,904.90	3,506.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,276.20

6,357.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,357.74

801.02	279.30	662.60	137.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,880.78

4,162.15	4,535.71	3,783.46	647.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,129.24

2,877.20	578.09	517.86	37.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,010.42

-21.51	114.65	0.00	418.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	511.55

SUBTOTAL:

82,110.61

152,318.59	88,653.42	87,509.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	410,591.67

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	5,951.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	2,903.14	8,574.09	1,936.37	3,155.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
32,131.34	
29,239.94	
36,283.29	
34,693.65	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	12,275.90	25,840.81	24,340.20	16,047.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
62,497.32	
109,303.49	
156,785.67	
67,687.05	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3707	ADULT <40% EXP FEM	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	AL
ADULT <40% EXP M&F	
606.80	
4,068.27	
1,255.40	
106.83	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3714	4
ADULT <40% EXP MALE	
24,159.76	
8,343.37	
7,413.72	
6,490.79	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3715	ADULT <40% EXP FEM	14,883.92	10,070.11	9,242.58	8,071.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	AL
ADULT <40% EXP MALE	
142,010.48	
199,345.59	
283,641.35	
208,398.59	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEM	76,836.42	98,771.60	84,787.49	72,456.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
169,251.34	
238,534.74	
207,786.84	
258,564.20	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3726	4
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	0.00	16.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	4													

544,534.00

736,144.49

815,071.96

681,622.29

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,994.80	
1,598.46	
12,454.83	
16,568.74	
132,348.22	
78,504.19	
396,273.53	
210.10	
6,037.30	
46,407.64	
42,267.76	
833,396.01	
332,851.55	
874,137.12	
1,305.57	
16.92	
2,777,372.74	

SUBTOTAL:

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	441.86	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	47.46	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	2,289.17	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	2,092.87	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	13,892.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA	24,423.42	39,053.73	33,070.64	21,577.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

489.66	
551.93	
3,447.12	
15,362.59	
17,278.70	
188,743.12	
118,125.65	

L

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3918	NEWLY ELIGIBLE M&F 4	91,934.27	121,532.84	100,254.80	128,043.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441,765.24		
	202,655.53	242,551.92	172,171.60	168,384.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785,764.01		

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	9,276.43	18,205.79	7,133.57	16,656.45	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	11,438.45	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	2,652.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	12,519.92	25,677.60	9,035.86	30,747.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

51,272.24	
16,031.37	
10,676.93	
77,980.54	

SUBTOTAL:

78.61

78.61

4518	BC PATIENT FEMALE 4	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		

5
SUBTOTAL:

5,877,396.82

TOTAL:

8700	SSI DISABLED FREEDO M	30.54	591.33	225.58	25.00	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	290.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	1,096.24	591.33	225.58	315.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

872.45	
1,356.02	
2,228.47	

SUBTOTAL:

1,228,483.14	1,832,186.92	1,429,810.88	1,386,915.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending October 31, 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	348.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		924.68		
	0.00	576.29	0.00	348.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		924.68		

SUBTOTAL:

924.68

0.00	576.29	0.00	348.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION		JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1011	TANF <1 M & F NON-ME	3,451.27		301.65		83.70		377.87		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	4,214.49
1012	TANF 01-05 M & F NON	25,128.76	31,110.09	8,102.69	164,581.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	228,922.55

1013	TANF 06-13 M & F NON	51,155.97	80,966.53	57,090.55	57,009.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	246,223.02

1014	TANF 14-20 MALE NON-	93,392.20	152,861.08	48,139.24	75,194.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	369,587.05

1015	TANF 14-20 FEMALE N
O

365,886.79	512,928.45	433,985.22	437,748.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,750,548.49

1016	TANF 21-44 MALE NON-	126,645.84	163,695.80	98,079.03	56,898.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	445,318.94

1017	TANF 21-44 FEMALE N
O

2,509,465.83	3,746,506.71	3,124,913.12	3,032,934.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,413,820.48

1018	TANF 45-64 M & F NON	232,788.56	309,539.08	253,785.13	187,921.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	984,033.86

1019	TANF 65+ M & F NON-M	4,738.82	9,707.54	11,164.74	323.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,934.50

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

12,916.57	12,231.56	7,221.85	7,793.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,163.68

869,141.79	1,485,741.04	1,163,143.59	971,963.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,489,990.23

2120	SSI AGED WITH QMB	4,041.12	1,462.37	1,946.96	191.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,642.07

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

2,921.27	5,139.66	2,878.36	3,669.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,609.26

420,657.34	364,111.90	277,016.96	249,032.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,310,818.95

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	5,245,640.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,333,033.67

1106	TANF EXPANDED 21-44	20.66	853.49	749.84	779.40	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	10,205.32	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	29,449.07	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	505,974.04	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	1,146,845.50	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	825,574.05	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	10,693.84	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	46,964.75	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	319.20	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	3,809.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,004,717.41	2,691,583.87	2,625,219.69	2,580,614.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2,403.39	
-1,206.23	
1.85	
14,219.25	
83,673.78	
2,273,040.55	
4,699,413.35	
2,570,753.12	
35,307.65	
1,877.16	
4,042.89	
122,023.26	
790.26	
95,795.02	
9,902,135.30	

SUBTOTAL:

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	239.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	447.97	878.73	3,121.77	239.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

302.98	
4,384.78	
4,687.76	

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	3,658.03	6,533.31	3,679.09	3,982.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,853.02

TOTAL:

46,584,215.89

FEDERAL EMERGENCY SERVICES
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION
3907

JULY
186.74

AUGUST	SEPTEMBER
1,247.40	0.00

OCTOBER	NOVEMBER	DECEMBER
545.96	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

1,980.10

3908

3909

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

190.37

4,641.95

14,378.58

861.24

4,624.14

823.08

668.06

871.77

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

19,861.15

7,198.04

3914

-32,353.35

60,696.90

62,912.75

148,618.75

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

239,875.05

3915

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6

47,067.82

74,149.89

75,387.98

171,140.37

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

367,746.06

3916

3917

715,851.62

458,763.46

1,156,537.30

686,388.67

726,943.61

510,747.94

721,640.46

437,479.68

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3,320,972.99

3918

1,954,928.55

2,512,951.28

1,912,755.69

1,855,944.26

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,093,379.75

8,236,579.78

3919

4,798.84

29,402.03

264.09

4,448.26

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

38,913.22

SUBTOTAL:	3,157,734.03	4,543,146.60	3,298,138.37	3,345,340.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,344,359.16

9,886,437.64	14,111,912.66	11,414,030.97	11,171,834.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

QMB - FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	400,102.86	462,172.33	326,096.57	359,000.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,547,372.19		
8040	SLMB	4.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.16		
8050	QI1	7.67	86.69	626.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		721.14		
	400,114.69	462,259.02	326,723.35	359,000.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,548,097.49		

SUBTOTAL:

TOTAL:

400,114.69

462,259.02	326,723.35	359,000.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,548,097.49

FFS TRBHA FEE FOR SERVICE
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1007	TANF 21-44 FEMALE WI	471.71		860.40		140.37		24.31		0.00		0.00		0.00		0.00		0.00	0.00	0.00	0.00	1,496.79
1011	TANF <1 M & F NON-ME	736.00	4,723.43	368.00	425.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,252.88

1012	TANF 01-05 M & F NON	368.00	6,424.63	12,171.54	6,859.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,823.95

1013	TANF 06-13 M & F NON	16,512.22	58,805.63	33,851.14	31,350.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140,519.61

1014	TANF 14-20 MALE NON-	7,533.55	31,068.97	43,660.36	19,685.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,948.08

1015	TANF 14-20 FEMALE N
O

17,783.14	60,075.16	52,454.25	37,141.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	167,454.45

1016	TANF 21-44 MALE NON-	50,986.98	232,739.24	158,391.39	238,145.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	680,263.53

1017	TANF 21-44 FEMALE N
O

127,725.96	724,699.04	580,736.17	781,083.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,214,244.51

1018	TANF 45-64 M & F NON	27,221.83	125,961.97	90,380.62	113,702.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	357,266.54

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
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	242.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	242.02

1028	TANF 45-64 M & F WIT	0.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69.00

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

1,846.28	4,349.08	4,742.68	9,243.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,181.88

0.00	368.00	368.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,104.00

2120	SSI AGED WITH QMB	2,129.89	16,890.55	8,512.82	13,797.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,330.83

2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A

4,943.64	25,786.59	15,182.25	15,394.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,306.91

328,797.09	1,331,576.12	1,008,275.86	1,224,180.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,892,829.85

57,352.69	239,617.61	215,280.59	218,399.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	730,650.56

1,641.42	3,896.82	1,477.44	1,960.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,976.13

2320	SSI BLIND WITH QMB	152.56	426.32	347.04	441.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,367.78

4311	SOBRA CHILD <1 M & F	0.00	4,537.43	2,034.73	1,426.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,998.50

4312	SOBRA CHILD 01-05 M	38,968.43	137,249.86	128,098.21	121,728.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	426,045.04

4313	SOBRA CHILD 06-13 M	681,184.65	2,583,435.70	1,681,906.75	1,873,899.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,820,426.54

4314	SOBRA CHILD 14-20 MA	118,686.61	495,250.47	412,817.00	484,576.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,511,330.63

4315	SOBRA CHILD 14-20 FE	99,195.07	477,467.78	386,605.17	499,195.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,462,463.76

5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M

2,116.23	12,740.30	13,261.52	9,943.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,061.61

13,961.07	87,460.78	103,132.29	142,374.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	346,928.90

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	5,845,592.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,068,111.55

1106	TANF EXPANDED 21-44	137.75	616.80	613.08	272.99	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	275.22	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	2,252.40	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	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	736.00	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	2,643.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 	
1,640.62	
2,247.56	
11,333.42	
64.80	
736.00	
7,510.42	

FFS TRBHA FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	4,744.53	38,555.84	35,932.03	37,022.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,254.69		
1117	TANF EXPANDED 21-44	35,688.54	179,661.54	169,883.68	176,677.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		561,910.99		
1118	TANF EXPANDED 45-64	12,040.84	94,798.16	87,530.61	76,865.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271,234.61		
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	295.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		359.92		
1128	TANF EXPANDED 45-64	0.00	389.55	143.09	11.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		544.38		
1129	TANF EXPANDED 65+	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	3,311.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,152.17		
2600	SSI DISABLED EXPAND E	340.83	1,313.81	339.22	88.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,082.23		
2610	SSI DISABLED EXPAND E	2,514.49	16,695.75	6,889.70	9,071.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,171.50		
2620	SSI DISABLED EXPAND E	7,877.72	36,952.00	29,165.99	31,985.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,980.91		
	66,027.96	387,092.07	340,784.85	341,508.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,135,413.21		

M&

SUBTOTAL:

3514	ADULT 40-100% MALE 1	2,919.76	13,958.09	11,640.18	12,833.20	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	4,497.67	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	73,682.25	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	77,823.96	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	65,334.58	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	543.50	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	83.70	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	78,653.88	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	59,317.92	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	1,475,308.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM	121,453.62	716,040.07	524,059.41	692,762.19	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	702,012.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	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	3,242,853.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

41,351.23	
23,338.44	
204,560.93	
306,034.15	
146,048.61	
11,429.00	
669.61	
242,960.57	
211,785.90	
4,289,035.28	
2,054,315.29	
2,188,006.44	
706.24	
9,720,241.69	

AL

4

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	6,476.92	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	10,105.65	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	76,473.72	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	40,302.32	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	22,670.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	21,431.74	99,701.53	78,173.21	156,028.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

759.29	
11,206.72	
21,320.39	
145,033.78	
113,976.34	
63,038.81	
355,335.33	

SUBTOTAL:

4413	SOBRA 100-133% M&F
6

21,364.78	93,891.88	53,148.77	66,966.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	235,371.98

FFS TRBHA FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4414	SOBRA 100-133% MALE	4,868.73	19,328.03	13,195.48	16,884.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,276.52		
4415	SOBRA 100-133% FEMA L	9,747.31	36,201.76	28,336.16	37,423.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,708.46		
	35,980.82	149,421.67	94,680.41	121,274.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		401,356.96		

SUBTOTAL:

391.58

391.58

8700	SSI DISABLED FREEDO	0.00	128.25	0.00	263.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	128.25	0.00	263.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

M

29.62

29.62

0.00	29.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	29.62	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

30,680,879.94

TOTAL:

SUBTOTAL:

2,326,439.64	10,700,813.57	7,946,106.37	9,707,520.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	0.00	5,714.73	10,613.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,327.81		
2210	SSI DISABLED NON-ME D	0.00	0.00	11,429.46	7,347.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,776.97		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	1,288.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,288.00		
8020	QMB ONLY	0.00	6,440.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,440.00		
	0.00	12,154.73	22,042.54	8,635.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,832.78		

SUBTOTAL:

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	
	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	

SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	5,714.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	11,429.46	12,245.85	40,003.11	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	45,717.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
5,714.73	
63,678.42	
9,796.68	
10,970.34	
90,160.17	

3917	NEWLY ELIGIBLE FEMA	2,449.17	
L
SUBTOTAL:	

2,449.17	

154,219.09

0.00	0.00	0.00	2,449.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	2,449.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,429.46	47,616.77	38,370.34	56,802.52	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 October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	176.98	0.00	0.00	3,999.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,176.58		
2100	SSI AGED WITH MEDIC A	62,636.18	7,321.33	10,598.16	63,394.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,949.87		
2110	SSI AGED NON-MEDICA R	55,431.46	44,621.86	210,826.12	50,715.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361,595.28		
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	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	3,785.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,752.85		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	47,529.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,529.94		
5017	SOBRA PREG 21-44 FE M	3,260.38	0.00	843.73	74.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,178.26		
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		
	125,818.68	53,096.91	229,996.91	169,499.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		578,411.86		

E

SUBTOTAL:

1107	TANF EXPANDED 21-44	0.00	160.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	2,468.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	804.92	318.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	804.92	478.64	0.00	2,468.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

160.42	
2,468.86	
0.00	
1,123.14	
3,752.42	

E

3706	ADULT <40% EXP MALE	26,019.36	12,060.99	9,835.98	6,683.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	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	60,092.24	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	199,077.83	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	13,814.93	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	448,492.46	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	139,069.59	-53,106.93	18,959.54	11,851.11	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	740,012.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

54,600.29	
303.97	
219,725.39	
25,365.85	
2,416.65	
1,400,837.05	
157,558.47	
1,809,157.50	
5,349.86	
116,773.31	
3,792,088.34	

AL

4

4,502,763.43

TOTAL:

3916	NEWLY ELIGIBLE MALE	15,999.84	1,846.21	8,999.20	7,227.69	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	15,522.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	47,079.35	7,086.13	51,594.81	22,750.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

34,072.94	
8,398.20	
86,039.67	
128,510.81	

SUBTOTAL:

975,409.12	1,212,578.98	1,380,044.06	934,731.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

COCHISE COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.17		
	0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.17		

SUBTOTAL:

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:

347.24

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	162.87	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		
	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		

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	

GRAHAM COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	5,377.79	0.00	0.00	193.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,571.69		
	5,377.79	0.00	0.00	193.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,571.69		

SUBTOTAL:

5,571.69

5,377.79	0.00	0.00	193.90	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 October 31, 2016

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL 1014	TANF 14-20 MALE NON-	136.74		222.66		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
2100	SSI AGED WITH MEDIC
A
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M

1,082.48	2,762.19	4,225.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,070.47

7,942.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,942.52

1,309.60	80.21	289.00	7,325.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,004.48

1,618.81	30,697.03	892.24	8,800.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,008.59

4,268.62	479.48	168.42	4,913.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,830.17

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

0.00	470.90	2,433.80	8,561.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,466.16

SUBTOTAL:

22,177.49

38,628.82	14,575.52	29,601.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	104,983.12

1116	TANF EXPANDED 21-44	9,365.91	518.79	0.00	45.28	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	17,181.68	0.00	0.00	39.63	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	0.00	3,944.64	352.30	1,959.29	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	2,044.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

9,929.98	
2,513.74	
31,367.78	
17,221.31	
181.98	
6,256.23	
67,471.02	

WI

E

3516	ADULT 40-100% MALE 2	337.40	9,114.07	0.00	9,805.62	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	32,619.72	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	12,793.05	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	1,866.63	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	78,899.54	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	10,052.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	13,015.34	65,281.63	32,395.41	46,175.47	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	192,212.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

19,257.09	
80.30	
39,064.85	
16,843.22	
6,881.37	
216,213.53	
40,709.82	
156,867.85	
495,918.03	

4

685,824.87

TOTAL:

3916	NEWLY ELIGIBLE MALE	0.00	8,584.45	0.00	3,933.53	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	4,934.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	8,584.45	0.00	8,868.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

12,517.98	
4,934.72	
17,452.70	

SUBTOTAL:

158,233.29	196,254.93	98,609.98	232,726.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

SUBTOTAL:

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

TOTAL:

992.87

9,315.14

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,322.27

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	11,982.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,982.91		
1018	TANF 45-64 M & F NON	0.00	1,058.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,058.42		
2210	SSI DISABLED NON-ME D	807.17	12,780.35	0.00	7,126.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,714.14		
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	0.00	415.50	2,536.55	9,047.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,999.71		
SUBTOTAL:	1,278.07	26,237.18	2,536.55	16,174.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,226.08		

M

164,311.91

TOTAL:

3516	ADULT 40-100% MALE 2	0.00	8.00	0.00	773.04	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	13,385.02	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	41,091.10	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	22,417.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	17,640.18	22,451.70	327.74	77,666.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

781.04	
114.90	
28,131.50	
49,756.00	
39,302.39	
118,085.83	

SUBTOTAL:

18,918.25	48,688.88	2,864.29	93,840.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2016	
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		
	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		

SUBTOTAL:

2,660.70

2,660.70

2,660.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,660.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1128	TANF EXPANDED 45-64

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	
	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	

SUBTOTAL:

60,289.64

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	

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	2,307,947.16	2,733,144.98	2,326,251.26	2,120,800.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,488,144.06	
2110	A
SSI AGED NON-MEDICA	149,727.64	170,783.44	154,051.47	181,595.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
656,157.60	
2120	R
SSI AGED WITH QMB	3,195,618.68	3,951,641.09	3,161,445.46	3,070,261.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
13,378,966.76	
2200	SSI DISABLED WITH M	537,954.02	696,721.39	546,649.90	536,933.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,318,259.30	
2210	E
SSI DISABLED NON-ME	2,694,953.74	3,287,243.03	2,968,877.53	2,680,189.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
11,631,263.93	
2220	D
SSI DISABLED WITH Q	764,491.97	940,091.58	815,616.99	716,604.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3,236,804.96	

2300	M
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	12,301.04	21,001.65	17,655.97	15,184.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,143.58	

2320	A
SSI BLIND WITH QMB	
7,206.96	
7,708.00	
7,966.16	
6,133.72	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
29,014.84	

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

9,670,201.21    11,808,703.16	9,998,959.78	9,327,703.92

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

40,805,568.07

40,829,933.07

TOTAL:

8710	SSI DISABLED FREEDO M	653.30	6,631.23	2,774.40	2,603.04	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	2,768.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,418.73	10,058.43	5,516.16	5,371.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

12,661.97	
11,703.03	
24,365.00	

SUBTOTAL:

9,673,619.94	11,818,761.59	10,004,475.94	9,333,075.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

85,679.39

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	6,319.24	20,181.09	10,420.34	11,053.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,974.42		
2110	SSI AGED NON-MEDICA R	200.76	1,334.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,535.31		
2120	SSI AGED WITH QMB	3,279.02	110.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,389.43		
2200	SSI DISABLED WITH M E	4,355.69	5,162.72	1,056.47	2,523.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,098.70		
2210	SSI DISABLED NON-ME	11,384.31	301.39	764.10	7,231.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,681.53		
SUBTOTAL:	25,539.02	27,090.16	12,240.91	20,809.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,679.39		

12,240.91	20,809.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

D

TOTAL:

25,539.02

27,090.16

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

308,762.96

134,897.03

254,770.11

355,503.99

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,053,934.09

83.28	153.89	635.96	150.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
83.28	153.89	635.96	150.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	28.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.52	
1012	TANF 01-05 M & F NON	10,026.35	4,936.82	11,573.21	12,343.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,880.13	
1013	TANF 06-13 M & F NON	26,843.26	657.79	21,985.65	28,689.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	78,176.18	
1014	TANF 14-20 MALE NON-	2,429.50	605.12	2,905.16	3,211.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,151.24	
1015	TANF 14-20 FEMALE N	2,174.10	399.72	505.33	2,371.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,450.21	
1016	O
TANF 21-44 MALE NON-	0.00	0.00	0.00	35.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
35.48	
2200	SSI DISABLED WITH M	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	E
SSI DISABLED NON-ME	
136,113.36	
80,007.50	
116,612.03	
161,945.69	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
494,678.58	
2220	D
SSI DISABLED WITH Q	800.49	0.00	94.90	187.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1,083.33	

2310	M
SSI BLIND NON-MEDIC	
919.88	
782.99	
1,582.48	
1,994.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
5,280.15	
4305	A
SOBRA CHILD 14-20 FE	35.62	0.00	0.00	14.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
49.86	
4312	SOBRA CHILD 01-05 M	28,343.38	14,276.06	26,984.59	32,321.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,925.44	
4313	SOBRA CHILD 06-13 M	91,660.37	21,444.81	62,944.00	102,084.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	278,134.14	
4314	SOBRA CHILD 14-20 MA	6,894.69	11,038.98	7,338.37	7,172.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,444.54	
4315	SOBRA CHILD 14-20 FE	2,364.62	747.24	2,244.39	3,102.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,458.95	

1113	TANF EXPANDED 06-13	1,023.80	
SUBTOTAL:	1,023.80	

3514	ADULT 40-100% MALE 1	159.17	0.00	0.00	57.88	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	49.15	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	207.92	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	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	851.49	643.60	0.00	328.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 	
217.05	
719.51	
624.16	
249.32	
13.60	
1,823.64	

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	73.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA	0.00	142.91	122.49	79.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	142.91	122.49	153.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

73.89	
345.20	
419.09	

L
SUBTOTAL:

1,141,328.12

TOTAL:

4413	SOBRA 100-133% M&F
6	22,760.62	9,243.14	15,323.01	22,503.30	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	7,418.53	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	772.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	25,448.87	9,936.41	18,047.40	30,694.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

69,830.07	
12,517.93	
1,779.50	
84,127.50	

SUBTOTAL:

335,146.60	145,773.84	273,575.96	386,831.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	395.88	12.35	86.36	136.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		631.54		
1010	TANF NON-MEDICARE	22,308.73	10,498.79	17,933.34	30,369.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,109.93		
1020	TANF WITH QMB	0.00	0.00	0.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
2200	SSI DISABLED WITH M E	3,546.21	2,524.32	1,902.01	1,501.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,473.67		
2210	SSI DISABLED NON-ME	797,548.98	458,452.07	658,852.94	873,666.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,788,520.95		
2220	SSI DISABLED WITH Q M	1,060.22	728.41	4,870.69	2,137.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,797.11		
2310	SSI BLIND NON-MEDIC	3,791.67	2,658.34	1,592.64	4,892.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,935.46		
	828,651.69	474,874.28	685,237.98	912,729.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,901,493.66		

D

A
SUBTOTAL:

2,901,493.66

828,651.69	474,874.28	685,237.98	912,729.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE REINSURANCE
For The Period Ending October 31, 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	594,119.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,125,809.26		
1012	TANF 01-05 M & F NON	-5,098.78	50,222.62	9,238.32	34,486.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,848.96		
1013	TANF 06-13 M & F NON	127,321.76	319,516.34	87,212.18	77,045.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611,095.97		
1014	TANF 14-20 MALE NON-	13,740.97	54,044.10	5,286.69	14.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,086.43		
1015	TANF 14-20 FEMALE N O	23,666.42	-77,738.83	1,484.26	5,630.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-46,957.72		
1016	TANF 21-44 MALE NON-	217,616.39	157,215.49	54,442.48	268,465.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697,739.66		
1017	TANF 21-44 FEMALE N O	181,478.43	255,820.76	173,224.12	319,873.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		930,396.35		
1018	TANF 45-64 M & F NON	234,755.06	169,943.37	76,772.53	258,308.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		739,779.93		
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	12,512.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,313.88		
2110	SSI AGED NON-MEDICA R	388,018.03	277,060.71	184,488.03	54,193.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		903,760.65		
2200	SSI DISABLED WITH M E	14,893.21	9,427.77	104,031.96	-62,585.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,767.50		
2210	SSI DISABLED NON-ME D	5,781,423.00	4,661,832.44	5,295,002.56	9,420,683.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,158,941.20		
2310	SSI BLIND NON-MEDIC	3,144.63	15,144.29	0.00	1,933.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,222.21		
4311	SOBRA CHILD <1 M & F	1,395,628.58	1,583,427.84	916,954.37	1,555,892.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,451,903.14		
4312	SOBRA CHILD 01-05 M	441,100.37	296,759.82	532,152.50	544,706.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,814,718.80		
4313	SOBRA CHILD 06-13 M	263,996.88	399,559.68	266,337.50	410,303.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,340,197.49		
4314	SOBRA CHILD 14-20 MA	173,423.73	445,022.53	247,300.85	263,469.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,129,216.23		
4315	SOBRA CHILD 14-20 FE	82,494.00	220,990.49	22,217.04	183,110.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		508,812.30		
5015	SOBRA PREG 14-20 FE M	79,849.94	1,849.74	2,876.71	25,606.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,183.08		
5017	SOBRA PREG 21-44 FE M	25,268.07	62,182.61	34,576.07	39,775.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,801.93		
5018	SOBRA PREG 45-64 FE M	0.00	-7,808.64	0.00	7,808.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	10,106,766.56	9,443,278.50	8,423,357.73	14,015,354.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,988,756.85		

A

SUBTOTAL:

295.58

295.58

0.00	23.10	73.47	199.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	23.10	73.47	199.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3100	TRANSPLANT OPTION
1
SUBTOTAL:

1106	TANF EXPANDED 21-44	0.00	144.38	25.63	53.22	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	154,835.84	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	283,957.47	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	146,667.89	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	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	3,001.34	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	64.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	22,124.40	50,423.35	87,387.60	59,323.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

223.23	
1,108.27	
719,400.28	
921,221.38	
487,329.45	
1,775.50	
3,001.34	
2,247.47	
219,259.31	

E

ACUTE REINSURANCE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	618,269.82	492,657.97	596,733.80	647,904.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,355,566.23		

SUBTOTAL:

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	
3514	ADULT 40-100% MALE 1	83,948.35	-32,668.54	450.12	27,965.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	342.52	3,067.96	0.00	6,164.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
208,376.34	
237,928.70	
258,705.08	
238,397.88	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	73,314.67	85,173.63	80,995.03	104,916.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
449,226.40	
539,517.06	
402,442.07	
655,747.53	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3708	ADULT <40% EXP M&F	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	

3714	4
ADULT <40% EXP MALE	
46,933.03	
4,532.12	
33,480.20	
43,030.95	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3715	ADULT <40% EXP FEM	27,464.33	15,826.46	21,578.92	14,289.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	AL
ADULT <40% EXP MALE	
610,923.36	
748,507.25	
588,904.10	
1,279,758.58	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEM	452,359.25	337,121.36	388,819.64	398,887.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
1,050,808.24	
2,420,228.56	
1,907,151.58	
2,004,111.73	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
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	
	6													

 	
13,424.53	
79,695.44	
9,574.81	
943,408.00	
344,399.97	
2,046,933.06	
191,419.50	
127,976.30	
79,159.41	
3,228,093.29	
1,577,187.52	
7,382,300.11	
5,259.44	
16,028,831.38	

SUBTOTAL:

3,216,516.79	4,364,234.57	3,674,809.90	4,773,270.12

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3914	NEWLY ELIGIBLE MALE	531.22	66,490.42	0.00	70,551.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA	0.00	41,972.61	643.92	12,518.17	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	140,940.47	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	23,346.54	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	463,566.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	394,053.30	1,131,954.31	693,714.33	710,922.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

137,572.65	
55,134.70	
1,170,518.34	
106,776.96	
1,460,642.08	
2,930,644.73	

L

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	200,439.17	245,304.50	51,539.02	159,641.83	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	318,516.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA	37,792.99	13,313.52	6,999.86	21,783.34	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	499,941.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

656,924.52	
1,083,117.75	
79,889.71	
1,819,931.98	

L

13,908.58

13,908.58

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	
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	

4518	BC PATIENT FEMALE 4
5
SUBTOTAL:

37,603.02

37,603.02

TOTAL:

65,175,538.35

8710	SSI DISABLED FREEDO M	2,634.47	2,674.29	13,975.57	18,318.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,634.47	2,674.29	13,975.57	18,318.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

15,160,643.59	15,891,943.26	13,457,040.31	20,665,911.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

LONG TERM CARE REINSURANCE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	2,240.29	558.03	12,562.35	50.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,410.73		
2100	SSI AGED WITH MEDIC A	427,508.23	354,148.90	316,332.29	325,278.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,423,268.30		
2110	SSI AGED NON-MEDICA R	109,126.94	168,130.16	206,047.45	305,444.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		788,749.00		
2200	SSI DISABLED WITH M E	922,846.90	607,754.06	450,973.91	607,692.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,589,267.81		
2210	SSI DISABLED NON-ME	3,499,917.78	4,372,697.42	4,032,666.49	4,727,568.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,632,850.27		
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	5,402.76	5,430.53	6,707.94	50,558.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,099.66		
	4,967,043.47	5,508,762.62	5,025,290.43	6,016,593.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,517,689.86		

D

A
SUBTOTAL:

21,517,689.86

4,967,043.47	5,508,762.62	5,025,290.43	6,016,593.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE SMIB
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

13,261,964.20    13,778,112.20    14,054,109.60    14,105,406.20

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

55,199,592.20

1000	TANF WITH MEDICARE	83,282.60	79,141.40	88,043.10	86,501.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	336,968.90	
1010	TANF NON-MEDICARE	609.00	852.60	609.00	487.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,557.80	
1020	TANF WITH QMB	24,116.40	24,603.60	21,315.00	22,167.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92,202.60	
2100	SSI AGED WITH MEDIC	103,567.30	146,400.10	154,520.40	148,789.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	553,277.00	
2110	A
SSI AGED NON-MEDICA	493,790.60	499,097.90	531,909.40	527,915.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,052,713.70	
2120	R
SSI AGED WITH QMB	3,316,283.10	3,439,229.50	3,522,598.60	3,636,418.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
13,914,529.20	
2200	SSI DISABLED WITH M	270,428.30	331,956.60	309,410.80	300,387.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,212,183.30	

2210	E
SSI DISABLED NON-ME	
391,130.70	
391,601.00	
388,254.70	
391,651.10	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,562,637.50	
2220	D
SSI DISABLED WITH Q	3,666,577.20	3,656,475.50	3,757,730.70	3,825,877.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
14,906,661.20	

2300	M
SSI BLIND WITH MEDIC	
243.60	
243.60	
487.20	
365.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,339.80	
2310	SSI BLIND NON-MEDIC	3,288.60	3,288.60	3,410.40	3,532.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,519.80	

2320	A
SSI BLIND WITH QMB	
29,962.80	
30,084.60	
30,084.60	
30,693.60	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
120,825.60	
4300	SOBRA CHILD WITH ME	121.80	121.80	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487.20	
4320	D
SOBRA CHILD WITH Q	243.60	121.80	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
852.60	
5000	MB
SOBRA PREGNANT WO	243.60	243.60	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
730.80	
5020	MAN
SOBRA PREGNANT WO	3,897.60	3,288.60	3,288.60	4,506.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
14,981.40	
8000	MAN
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	736,917.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,959,340.70	
8040	SLMB	4,230,330.90	4,296,575.00	4,308,851.30	4,252,296.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,088,053.70	
8888	SMIB ONLY NOT ELIGIB	-149,049.20	-27,293.50	-35,602.90	-25,963.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-237,909.00	
9999	SMIB ONLY NOT ELIGIB	60,444.40	160,788.70	220,518.30	162,374.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	604,125.60	

1100	TANF EXPANDED FPR FI	670,306.70	690,655.60	694,042.10	689,258.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR	730.80	365.40	243.60	121.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1120	FI
TANF EXPANDED FOR	
277,849.30	
285,101.40	
292,845.90	
302,501.90	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2400	FI
SSI AGED EXPANDED	
-974.40	
365.40	
0.00	
365.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2410	WI
SSI AGED EXPANDED	
121.80	
121.80	
121.80	
121.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2420	NO
SSI AGED EXPANDED	
2,270,888.70	
2,227,426.40	
2,210,062.30	
2,133,197.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2520	WI
SSI BLIND EXPANDED	
121.80	
365.40	
121.80	
121.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2600	W
SSI DISABLED EXPAND	
-487.20	
-121.80	
-365.40	
243.60	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

2620	E
SSI DISABLED EXPAND	
1,918,198.80	
1,889,063.40	
1,828,654.60	
1,755,447.20	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	E													

 	
2,744,263.20	
1,461.60	
1,158,298.50	
-243.60	
487.20	
8,841,574.40	
730.80	
-730.80	
7,391,364.00	
20,137,205.30	

SUBTOTAL:

5,136,756.30	5,093,343.00	5,025,726.70	4,881,379.30

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3520	ADULT 40-100% FOR FI	974.40	1,096.20	730.80	974.40	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	487.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,314.20	1,948.80	1,339.80	1,461.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

3,775.80	
3,288.60	
7,064.40	

SUBTOTAL:

ACUTE SMIB
For The Period Ending October 31, 2016	
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	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,218.00		
	487.20	365.40	0.00	365.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,218.00		

SUBTOTAL:

102,068.40

102,068.40

TOTAL:

75,447,148.30

8720	SSI DISABLED FREEDO M	26,430.60	25,699.80	25,699.80	24,238.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	26,430.60	25,699.80	25,699.80	24,238.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

SUBTOTAL:

18,427,952.50	18,899,469.20	19,106,875.90	19,012,850.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

ACUTE HIB
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	-1,233.00	0.00	1,233.00	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	6,165.00	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	318,010.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,109,168.20		
2220	SSI DISABLED WITH Q M	125,651.90	134,161.80	139,747.40	146,768.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		546,329.90		
2320	SSI BLIND WITH QMB	411.00	1,315.20	863.10	863.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,452.40		
8020	QMB ONLY	2,918.00	3,514.00	2,281.00	2,281.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,994.00		
9999	SMIB ONLY NOT ELIGIB	-3,144.00	-4,377.10	-5,404.80	-1,397.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14,323.20		
	361,563.10	411,610.20	422,086.70	466,526.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,661,786.30		

SUBTOTAL:

1120	TANF EXPANDED FOR FI	1,130.00	226.00	226.00	226.00	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	4,911.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	5,630.40	6,904.40	5,363.40	5,137.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1,808.00	
21,227.60	
23,035.60	

SUBTOTAL:

1,684,821.90

367,193.50	418,514.60	427,450.10	471,663.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

9,056,541.10

TOTAL:

Q1
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,231,414.30	2,263,375.00	2,291,179.20	2,282,238.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,068,207.10		
9999	SMIB ONLY NOT ELIGIB	-9,385.60	-5,934.40	7,613.40	-3,959.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11,666.00		
	2,222,028.70	2,257,440.60	2,298,792.60	2,278,279.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,056,541.10		

SUBTOTAL:

2,222,028.70	2,257,440.60	2,298,792.60	2,278,279.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

LTC SMIB
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,339.80	974.40	974.40	974.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,263.00		
1020	TANF WITH QMB	243.60	243.60	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		974.40		
2100	SSI AGED WITH MEDIC A	996,521.00	982,501.00	980,592.00	984,002.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,943,616.40		
2110	SSI AGED NON-MEDICA R	185,014.20	184,527.00	197,120.70	175,537.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		742,198.90		
2120	SSI AGED WITH QMB	904,419.20	906,456.00	906,658.80	901,435.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,618,969.80		
2200	SSI DISABLED WITH M E	379,691.30	381,460.70	384,735.90	383,791.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,529,679.70		
2210	SSI DISABLED NON-ME	18,635.40	20,340.60	22,607.60	20,097.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,680.60		
2220	SSI DISABLED WITH Q M	835,984.20	830,397.20	830,017.70	835,586.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,331,985.80		
2300	SSI BLIND WITH MEDIC	852.60	852.60	1,096.20	1,096.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,897.60		
2310	SSI BLIND NON-MEDIC A	365.40	243.60	243.60	609.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,461.60		
2320	SSI BLIND WITH QMB	5,237.40	5,359.20	5,115.60	5,115.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,827.80		
	3,328,304.10	3,313,355.90	3,329,406.10	3,308,489.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,279,555.60		

D

SUBTOTAL:

2,192.40

2,192.40

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

SUBTOTAL:

13,281,748.00

3,328,913.10	3,313,964.90	3,329,893.30	3,308,976.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

1,144,090.30

TOTAL:

LTC HIB
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	411.00	-411.00	452.10	-41.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		411.00		
2120	SSI AGED WITH QMB	268,654.00	271,962.40	272,059.10	272,658.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,085,334.30		
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	16,892.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,934.00		
	283,717.00	285,570.40	285,293.20	289,509.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,144,090.30		

SUBTOTAL:

283,717.00	285,570.40	285,293.20	289,509.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	-679.32	1,173.91	868.64	392.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,755.49		
1007	TANF 21-44 FEMALE WI	4,715.31	2,051.12	1,453.54	1,749.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,969.77		
1008	TANF 45-64 M & F WIT	2,768.42	8,031.79	10,613.78	1,364.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,778.04		
1009	TANF 65+ M & F WITH	1,498.24	2,850.90	1,807.76	2,387.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,543.90		
1011	TANF <1 M & F NON-ME	691,179.03	549,687.51	409,345.01	353,570.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,003,782.53		
1012	TANF 01-05 M & F NON	300,554.71	309,088.02	232,212.72	239,296.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,081,151.59		
1013	TANF 06-13 M & F NON	216,437.47	262,212.58	233,289.49	222,822.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		934,761.71		
1014	TANF 14-20 MALE NON-	77,950.03	61,633.93	49,927.47	46,564.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236,076.13		
1015	TANF 14-20 FEMALE N O	181,345.66	201,315.48	195,143.28	161,871.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		739,676.09		
1016	TANF 21-44 MALE NON-	1,208,018.47	1,095,125.11	835,379.64	706,242.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,844,765.37		
1017	TANF 21-44 FEMALE N O	4,782,275.12	4,614,453.36	3,404,247.31	3,052,363.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,853,339.75		
1018	TANF 45-64 M & F NON	1,536,458.94	1,747,293.81	1,389,507.71	1,271,142.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,944,402.76		
1019	TANF 65+ M & F NON-M	1,488.83	2,576.00	3,680.00	33,017.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,762.52		
1026	TANF 21-44 MALE WITH	736.00	139.85	1,118.62	562.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,556.87		
1027	TANF 21-44 FEMALE WI	812.39	1,382.21	750.63	132.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,077.95		
1028	TANF 45-64 M & F WIT	3,869.59	788.58	2,676.22	2,442.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,776.49		
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	20,977.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239,735.45		
2110	SSI AGED NON-MEDICA R	53,486.52	61,326.51	50,453.73	46,591.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,857.95		
2120	SSI AGED WITH QMB	229,795.08	290,274.13	250,072.81	131,217.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901,359.34		
2200	SSI DISABLED WITH M E	138,965.52	205,333.70	184,379.96	67,124.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		595,803.47		
2210	SSI DISABLED NON-ME D	4,735,804.13	5,056,810.90	4,027,055.52	3,272,331.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,092,002.49		
2220	SSI DISABLED WITH Q M	434,350.13	563,385.69	444,545.28	262,116.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,704,397.93		
2300	SSI BLIND WITH MEDIC	442.84	1,105.82	590.51	117.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,256.85		
2310	SSI BLIND NON-MEDIC	59,992.53	44,447.01	85,286.31	35,040.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,765.93		
2320	SSI BLIND WITH QMB	6,629.65	6,866.41	6,731.29	3,117.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,345.24		
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	1,126,001.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,040,685.54		
4312	SOBRA CHILD 01-05 M	2,972,452.20	3,405,021.15	3,042,802.04	2,617,151.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,037,427.29		
4313	SOBRA CHILD 06-13 M	4,942,683.63	4,831,514.49	4,120,274.01	3,397,274.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,291,746.55		
4314	SOBRA CHILD 14-20 MA	1,427,842.79	1,316,616.53	929,242.11	726,349.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,400,051.36		
4315	SOBRA CHILD 14-20 FE	1,271,324.45	1,578,662.99	1,464,172.03	1,028,446.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,342,605.91		
5007	SOBRA PREG 21-44 FE M	378.25	75.05	453.66	151.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,058.04		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,231.36	736.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,404.36		
5015	SOBRA PREG 14-20 FE	301,972.26	335,882.22	264,018.56	177,300.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,079,174.02		
5017	SOBRA PREG 21-44 FE	1,648,401.34	1,955,913.70	1,441,819.84	1,128,207.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,174,342.65		

A

M

M

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	1,822.00	4,398.00	4,828.82	2,944.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,992.82		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
	28,920,351.39	30,363,670.22	24,704,397.21	20,139,120.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,127,539.75		

SUBTOTAL:

0.00

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

	0.00	
1106	TANF EXPANDED 21-44	8,602.39	6,438.12	5,428.43	1,485.85	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	9,185.60	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	19,595.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1109	TANF EXPANDED 65+	25,333.08	29,517.19	24,824.50	13,286.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1111	M&
TANF EXPANDED <1 M	
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	&F
TANF EXPANDED 01-05	
1,472.00	
368.00	
368.00	
1,481.59	
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	1,104.00	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	2,637.47	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	26,050.92	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	311,681.85	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	1,346,560.39	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	786,294.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1119	TANF EXPANDED 65+	3,568.96	2,904.18	4,130.43	3,680.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1126	M&
TANF EXPANDED 21-44	
3,422.37	
3,051.01	
1,984.77	
757.45	
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	2,548.55	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	5,509.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1129	TANF EXPANDED 65+	8,178.44	10,296.06	7,237.30	2,808.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2400	M&
SSI AGED EXPANDED	
11,068.81	
16,536.17	
15,947.59	
8,607.12	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2410	WI
SSI AGED EXPANDED	
8,461.28	
5,520.00	
3,153.04	
2,208.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2420	NO
SSI AGED EXPANDED	
138,825.20	
182,526.13	
145,608.26	
74,183.12	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2600	WI
SSI DISABLED EXPAND	
13,441.47	
15,752.05	
12,028.62	
8,513.03	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2610	E
SSI DISABLED EXPAND	
113,472.90	
87,253.66	
84,720.33	
86,173.05	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2620	E
SSI DISABLED EXPAND	
129,964.16	
144,021.70	
126,237.55	
70,602.13	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	E														

1

21,954.79	
52,666.49	
141,704.39	
92,961.59	
736.00	
3,689.59	
5,870.00	
16,800.62	
109,860.01	
1,527,016.67	
6,264,365.52	
4,093,509.33	
14,283.57	
9,215.60	
12,300.79	
37,252.67	
28,520.16	
52,159.69	
19,342.32	
541,142.71	
49,735.17	
371,619.94	
470,825.54	
13,937,533.16	

SUBTOTAL:

3,685,961.38	4,102,069.71	3,364,547.57	2,784,954.50

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	-56.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	-1,335.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-1,335.43	0.00	-56.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

-56.48	
-1,335.43	
-1,391.91	

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	-610.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,230.00		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-660.00		
3618	AHC CARE/MI M&F 45-6	0.00	-2,310.00	0.00	-940.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,250.00		
	0.00	-7,590.00	0.00	-2,210.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-9,800.00		

SUBTOTAL:

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	2,223.50	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	166.06	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	22,730.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	58,534.61	85,765.84	54,243.11	45,388.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
516,106.88	
561,726.13	
355,787.74	
408,976.15	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	515,712.00	479,583.65	372,460.84	314,271.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
1,473,444.90	
1,665,779.83	
1,341,815.15	
1,191,743.61	
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	2,208.00	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	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	38.04	368.00	285.98	5,742.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3708	AL
ADULT <40% EXP M&F	
10,145.24	
5,836.66	
8,635.97	
4,989.41	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3709	4
ADULT <40% EXP M&F	
386.08	
4,104.04	
1,414.62	
64.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3714	6
ADULT <40% EXP MALE	
296,316.38	
216,040.82	
193,618.06	
151,960.71	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3715	ADULT <40% EXP FEM	395,011.00	335,428.87	330,646.06	218,101.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	AL
ADULT <40% EXP MALE	
4,559,384.60	
4,088,494.24	
3,041,503.99	
2,662,433.62	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEM	3,020,325.53	2,525,694.81	1,840,461.21	1,560,503.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
5,969,277.06	
6,352,847.34	
4,996,162.69	
3,927,219.57	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
2,190.00	
4,988.28	
4,809.35	
761.87	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3728	6
ADULT <40% EXP M&F	
0.00	
18,205.78	
0.00	
301.11	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	4													

 	
32.05	
13,669.25	
5,644.90	
115,941.69	
243,932.11	
1,842,596.90	
1,682,028.06	
5,672,783.49	
6,992.00	
0.00	
86.34	
128.90	
1,480.65	
6,434.82	
29,607.28	
5,969.54	
857,935.97	
1,279,187.27	
14,351,816.45	
8,946,984.77	
21,245,506.66	
12,749.50	
18,506.89	
56,340,015.49	

SUBTOTAL:

16,855,449.91    16,385,038.34    12,579,372.95    10,520,154.29

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3906	NEWLY ELIGIBLE MALE	565.60	252.69	29.45	69.53	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	6,391.01	9,530.25	3,280.13	877.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

917.27	
1,086.00	
20,079.10	

4

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

RATE CODE	DESCRIPTION
3909

JULY
491.18

AUGUST	SEPTEMBER
602.98	747.75

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

1,841.91

3914

3915

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

15,249.46

35,329.67

14,325.93

39,339.71

11,406.94

23,671.00

10,046.14

13,093.41

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

51,028.47

111,433.79

3916

236,860.76

307,117.41

193,505.68

173,818.34

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

911,302.19

3917

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE M&F

595,512.26

613,831.91

463,222.16

384,839.40

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,057,405.73

3918

3919

774,247.15

0.00

944,868.39

0.00

770,039.27

736.00

643,515.20

368.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3,132,670.01

3928

0.00

360.56

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,104.00

360.56

4
SUBTOTAL:	1,664,647.09	1,930,597.83	1,467,356.38	1,226,627.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,289,229.03

4412	SOBRA 100-133% M&F
1	0.00	1,436.00	0.00	700.00	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	325,353.20	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	78,855.73	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	115,672.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	598,311.07	779,846.15	590,864.41	520,580.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2,136.00	
1,523,946.67	
372,930.62	
590,589.33	
2,489,602.62	

SUBTOTAL:

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	5,520.00	4,416.00	2,284.63	1,533.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4519	5
BC PATIENT FEMALE 6	
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	5
CC PATIENT FEMALE 4	
368.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	5													

 	
1,104.00	
13,754.29	
147.74	
368.00	
15,374.03	

SUBTOTAL:

6,256.00

5,299.74

2,284.63

1,533.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8700	SSI DISABLED FREEDO M	7,296.44	5,878.33	16,900.38	5,411.35	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	213.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	8,400.44	6,219.20	21,718.45	5,624.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

35,486.50	
1,472.00	
5,004.09	
41,962.59	

SUBTOTAL:

TOTAL:

51,739,377.28

53,563,815.76    42,730,541.60    35,196,330.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	183,230,064.76

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,472.69	2,038.05	970.51	1,038.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,520.02		
1007	TANF 21-44 FEMALE WI	6,790.07	16,402.24	8,847.17	10,787.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,827.19		
1008	TANF 45-64 M & F WIT	5,745.09	7,583.01	925.31	1,105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,358.41		
1009	TANF 65+ M & F WITH	524.13	55.02	114.42	854.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,548.12		
1011	TANF <1 M & F NON-ME	189,983.11	396,902.26	166,256.38	614,840.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,367,982.23		
1012	TANF 01-05 M & F NON	63,137.63	76,150.23	60,465.28	57,381.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257,134.92		
1013	TANF 06-13 M & F NON	121,964.92	44,627.08	40,421.31	44,209.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,222.79		
1014	TANF 14-20 MALE NON-	9,809.04	10,160.19	11,971.71	14,277.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,218.39		
1015	TANF 14-20 FEMALE N O	33,485.45	46,331.69	52,742.98	45,433.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,993.76		
1016	TANF 21-44 MALE NON-	538,720.43	818,731.46	521,422.83	594,944.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,473,819.59		
1017	TANF 21-44 FEMALE N O	1,361,290.75	1,890,712.96	1,387,455.52	1,361,156.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,000,616.14		
1018	TANF 45-64 M & F NON	681,254.62	863,864.36	530,664.16	577,401.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,653,184.97		
1019	TANF 65+ M & F NON-M	0.00	1,421.86	0.00	6,402.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,824.02		
1026	TANF 21-44 MALE WITH	116.86	2,480.19	18.72	1,723.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,338.87		
1027	TANF 21-44 FEMALE WI	2,636.88	2,108.61	27.92	3,528.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,302.16		
1028	TANF 45-64 M & F WIT	5,014.97	7,085.22	4,731.82	5,191.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,023.97		
1029	TANF 65+ M & F WITH	0.00	0.00	6.64	1,438.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,445.15		
2100	SSI AGED WITH MEDIC A	115,748.46	91,408.50	23,387.24	52,926.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283,470.72		
2110	SSI AGED NON-MEDICA R	31,788.57	48,642.55	31,256.79	125,559.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237,247.14		
2120	SSI AGED WITH QMB	229,484.07	344,087.35	270,699.28	303,353.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,147,623.74		
2200	SSI DISABLED WITH M E	210,777.77	283,035.91	243,423.96	176,967.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		914,205.08		
2210	SSI DISABLED NON-ME D	3,642,965.31	4,857,725.43	3,800,787.99	3,208,089.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,509,567.95		
2220	SSI DISABLED WITH Q M	718,446.11	1,087,759.59	730,037.76	771,043.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,307,286.98		
2300	SSI BLIND WITH MEDIC	14.33	0.00	804.98	14.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		833.64		
2310	SSI BLIND NON-MEDIC	25,883.10	61,596.20	26,069.05	45,729.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,278.32		
2320	SSI BLIND WITH QMB	9,644.50	10,606.91	5,210.39	4,646.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,108.32		
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	949,458.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,726,987.30		
4312	SOBRA CHILD 01-05 M	819,475.49	813,753.27	838,457.67	700,737.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,172,424.13		
4313	SOBRA CHILD 06-13 M	900,853.80	1,045,600.42	1,108,540.35	810,562.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,865,556.91		
4314	SOBRA CHILD 14-20 MA	235,587.23	343,925.37	241,039.86	292,752.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,113,304.95		
4315	SOBRA CHILD 14-20 FE	319,825.62	385,924.79	344,546.58	352,532.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,402,829.30		
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	66,587.06	139,786.68	101,941.79	122,415.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430,731.13		
5017	SOBRA PREG 21-44 FE	617,725.42	908,907.30	686,011.21	679,176.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,891,820.12		

A

M

M

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	2,780.26	951.03	531.01	7,747.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,009.55		
5027	SOBRA PREG 21-44 FE M	866.28	3,055.50	1,079.37	1,331.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,332.42		
5028	SOBRA PREG 45-64 FE M	262.71	897.03	70.56	1,184.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,415.23		
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		
	12,039,725.98	15,456,060.58	12,111,017.15	11,947,945.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,554,748.76		

SUBTOTAL:

1,838.51

3100	TRANSPLANT OPTION	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,856.12	-17.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

	1,838.51	
1106	TANF EXPANDED 21-44	10,571.52	13,753.32	6,287.51	14,369.57	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	14,438.40	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	67,375.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1109	TANF EXPANDED 65+	18,233.09	18,094.73	11,324.59	22,653.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1111	M&
TANF EXPANDED <1 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		

1112	&F
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	278.48	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	8,742.93	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	136,159.53	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	388,547.35	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	351,875.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1119	TANF EXPANDED 65+	0.00	250.16	893.25	685.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1126	M&
TANF EXPANDED 21-44	
8,136.82	
20,853.51	
8,953.53	
10,479.17	
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	9,524.55	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	18,695.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1129	TANF EXPANDED 65+	8,819.97	15,441.67	8,637.17	6,934.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2400	M&
SSI AGED EXPANDED	
5,234.94	
6,001.84	
5,472.24	
4,592.07	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2410	WI
SSI AGED EXPANDED	
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	NO
SSI AGED EXPANDED	
151,371.20	
156,081.17	
119,746.60	
130,287.12	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2600	WI
SSI DISABLED EXPAND	
18,539.97	
25,338.08	
15,912.70	
4,857.82	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2610	E
SSI DISABLED EXPAND	
56,032.83	
48,660.49	
84,016.56	
84,064.52	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2620	E
SSI DISABLED EXPAND	
197,419.13	
282,031.47	
185,593.40	
176,414.17	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	E														

1

44,981.92	
96,167.99	
284,191.35	
70,306.21	
0.00	
103.44	
148.74	
9,482.03	
38,384.31	
638,063.72	
1,749,030.40	
1,518,550.66	
1,829.06	
48,423.03	
27,539.19	
85,096.97	
39,833.24	
21,301.09	
-728.71	
557,486.09	
64,648.57	
272,774.40	
841,458.17	
6,409,071.87	

SUBTOTAL:

1,628,854.82	1,916,252.06	1,412,988.43	1,450,976.56

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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	-1,782.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	-107.53	0.00	-1,782.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

-107.53	
-1,782.34	
-1,889.87	

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SE
For The Period Ending October 31, 2016	RV	
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		
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	-3,081.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,081.67		
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		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	-14.92	-463.62	-55.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-534.02		
	-138.35	-14.92	-825.64	-3,137.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,116.06		

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	-204.83	0.00	-25.53	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	1,897.45	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	6,134.35	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	9,422.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	14,424.55	15,143.48	18,281.48	11,841.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
241,184.19	
367,719.38	
401,745.60	
338,432.53	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	146,713.41	204,070.03	127,918.54	150,332.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
609,541.43	
784,320.88	
571,647.63	
533,624.93	
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	681.62	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	337.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	74.57	0.00	0.00	181.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3708	AL
ADULT <40% EXP M&F	
564.58	
2,089.93	
2,175.73	
4,273.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3709	4
ADULT <40% EXP M&F	
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	6
ADULT <40% EXP MALE	
77,551.63	
90,070.37	
107,660.73	
84,080.97	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3715	ADULT <40% EXP FEM	64,347.99	85,805.18	82,434.39	53,957.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	AL
ADULT <40% EXP MALE	
2,548,960.43	
2,969,432.56	
2,577,851.89	
2,971,415.37	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEM	765,143.06	1,133,604.69	998,651.15	1,100,450.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
3,295,413.07	
3,963,337.74	
3,047,122.81	
3,278,706.11	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
2,136.91	
546.72	
3,264.42	
162.56	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3728	6
ADULT <40% EXP M&F	
579.64	
583.07	
-19.34	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	4													

 	
-230.36	
15,559.34	
19,774.98	
49,454.27	
59,690.99	
1,349,081.70	
629,034.50	
2,499,134.87	
28,965.95	
217.07	
0.00	
0.00	
2,078.51	
255.88	
9,103.24	
1,286.44	
359,363.70	
286,544.95	
11,067,660.25	
3,997,849.70	
13,584,579.73	
6,110.61	
1,143.37	
33,966,659.69	

SUBTOTAL:

7,805,747.12	9,648,919.56	7,966,086.38	8,545,906.63

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3906	NEWLY ELIGIBLE MALE	0.00	68.40	0.00	128.60	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	2,854.42	2,978.75	1,020.45	-40.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

197.00	
0.00	
6,813.04	

4

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

RATE CODE	DESCRIPTION
3909

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

0.00

3914

3915

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

6,895.37

6,000.59

4,020.80

6,770.12

2,130.37

4,415.72

3,263.19

14,631.01

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

16,309.73

31,817.44

3916

86,585.35

154,491.69

129,941.11

92,209.11

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

463,227.26

3917

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE M&F

150,672.73

178,002.93

118,358.99

104,012.75

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

551,047.40

3918

3919

302,477.81

0.00

320,499.76

0.00

328,674.25

0.00

338,201.99

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1,289,853.81

3928

30.62

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

30.62

4
SUBTOTAL:	555,516.89	666,832.45	584,540.89	552,406.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,359,296.30

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	62,261.45	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	22,963.22	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	40,308.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	108,488.75	145,082.93	94,430.24	125,533.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
278,483.24	
72,464.88	
122,587.36	
473,535.48	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	0.00	782.08	1,657.88	-402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4519	5
BC PATIENT FEMALE 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	

4618	5
CC PATIENT FEMALE 4	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	5													

 	
0.00	
2,037.96	
0.00	
0.00	
2,037.96	

SUBTOTAL:

0.00

782.08

1,657.88

-402.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8700	SSI DISABLED FREEDO M	4,051.48	9,611.52	2,832.06	4,024.33	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	2,622.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	4,775.73	12,125.11	4,377.14	6,646.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

20,519.39	
0.00	
7,405.03	
27,924.42	

SUBTOTAL:

TOTAL:	22,144,827.06	27,845,914.71	22,174,272.47    22,624,092.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	94,789,107.06		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	0.00	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	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

A

M

M

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

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1111	M&
TANF EXPANDED <1 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		

1112	&F
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+	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	M&
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+	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	M&
SSI AGED EXPANDED	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2410	WI
SSI AGED EXPANDED	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2420	NO
SSI AGED EXPANDED	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2600	WI
SSI DISABLED EXPAND	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2610	E
SSI DISABLED EXPAND	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2620	E
SSI DISABLED EXPAND	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	E														

1

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

SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3317	AHC CARE FEMALE 21- 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	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
0.00	

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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	E
ADULT 40-100% MALE 2	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
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	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	AL
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3709	4
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3714	6
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	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	AL
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	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	AL
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3728	6
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	4													

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

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

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	0.00	0.00	0.00	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

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

RATE CODE	DESCRIPTION
3909

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

0.00

3914

3915

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3916

0.00

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3918

3919

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4
SUBTOTAL:	0.00	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	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

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

4618	5
CC PATIENT FEMALE 4	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	5													

 	
0.00	
0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

TOTAL:

0.00

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

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	93.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93.00		
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	3,089.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,781.46		
1012	TANF 01-05 M & F NON	3,987.61	3,263.59	24.45	74.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,349.75		
1013	TANF 06-13 M & F NON	3,653.62	44.01	117.52	1,337.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,152.19		
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	272.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,605.74		
1016	TANF 21-44 MALE NON-	2,299.03	1,606.33	7,315.24	3,093.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,314.37		
1017	TANF 21-44 FEMALE N O	27,040.84	13,143.03	14,720.69	12,353.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,258.26		
1018	TANF 45-64 M & F NON	28,071.21	1,484.06	2,052.40	1,175.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,783.06		
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	2,183.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,364.26		
2110	SSI AGED NON-MEDICA R	5,148.07	-9,481.65	7,030.69	14,677.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,375.09		
2120	SSI AGED WITH QMB	242.01	-109.74	3.33	-104.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.25		
2200	SSI DISABLED WITH M E	60.91	-225.64	2,470.61	-272.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,033.84		
2210	SSI DISABLED NON-ME D	27,621.59	22,101.33	16,667.85	687.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,078.68		
2220	SSI DISABLED WITH Q M	2,632.34	-15.23	394.41	608.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,620.02		
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	0.00	0.00	0.00	167.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.54		
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	3,139.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,773.49		
4312	SOBRA CHILD 01-05 M	65,933.12	13,197.35	21,624.82	5,408.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,163.78		
4313	SOBRA CHILD 06-13 M	104,379.21	2,798.52	14,577.29	2,003.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,758.77		
4314	SOBRA CHILD 14-20 MA	11,733.15	2,913.24	6,838.28	4,514.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,999.19		
4315	SOBRA CHILD 14-20 FE	7,732.31	6,972.91	15,121.73	3,090.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,917.66		
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	4,124.18	12,367.41	655.37	135.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,282.01		
5017	SOBRA PREG 21-44 FE	25,579.26	15,218.34	29,278.70	40,492.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,568.44		

A

M

M

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
	329,038.48	103,501.39	148,094.81	98,222.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		678,856.95		

SUBTOTAL:

0.00

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

	0.00	
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	38.33	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	38.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1111	M&
TANF EXPANDED <1 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		

1112	&F
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	1,056.47	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	2,949.92	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	1,515.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1119	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1126	M&
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+	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	M&
SSI AGED EXPANDED	
903.35	
516.82	
1,276.20	
471.14	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2410	WI
SSI AGED EXPANDED	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2420	NO
SSI AGED EXPANDED	
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	WI
SSI DISABLED EXPAND	
0.00	
166.07	
666.37	
196.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2610	E
SSI DISABLED EXPAND	
77.84	
3,284.84	
0.00	
637.94	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2620	E
SSI DISABLED EXPAND	
1,647.33	
17.88	
0.00	
53.93	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	E														

1

0.00	
285.96	
1,634.60	
0.00	
0.00	
0.00	
0.00	
0.00	
328.67	
9,279.13	
32,074.89	
3,911.45	
0.00	
0.00	
442.08	
3.33	
239.43	
3,167.51	
0.00	
174.44	
1,029.24	
4,000.62	
1,719.14	
58,290.49	

SUBTOTAL:

20,273.97

20,416.07

10,642.01

6,958.44

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

0.00	
0.00	
0.00	

SUBTOTAL:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	12.85	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	497.80	0.00	120.44	403.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
15,774.69	
29,801.57	
5,862.77	
21,712.35	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	2,768.54	864.29	5,076.39	9,985.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
6,879.60	
9,382.49	
19,418.72	
32,529.53	
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	132.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3708	AL
ADULT <40% EXP M&F	
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	4
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3714	6
ADULT <40% EXP MALE	
9,037.89	
960.23	
5,742.48	
1,218.60	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3715	ADULT <40% EXP FEM	6,327.32	218.97	103.21	444.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	AL
ADULT <40% EXP MALE	
26,321.69	
106,274.78	
42,777.80	
88,481.16	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEM	14,376.87	49,297.30	17,351.22	22,570.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
39,054.06	
121,173.01	
46,890.23	
113,580.58	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3728	6
ADULT <40% EXP M&F	
0.00	
566.85	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	4													

 	
0.00	
12.85	
0.00	
5,978.05	
1,022.20	
73,151.38	
18,695.09	
68,210.34	
0.00	
0.00	
0.00	
0.00	
948.84	
0.00	
425.62	
0.00	
16,959.20	
7,094.22	
263,855.43	
103,595.61	
320,697.88	
0.00	
566.85	
881,213.56	

SUBTOTAL:

125,482.91

321,139.99

143,518.22

291,072.44

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	11.46	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	101.36	65.43	251.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

53.64	
0.00	
417.89	

4

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

RATE CODE	DESCRIPTION
3909

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

0.00

3914

3915

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

0.00

0.00

0.00

0.00

0.00

76.13

0.00

172.74

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

248.87

3916

2,914.09

14,106.81

6,628.24

15,285.71

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

38,934.85

3917

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE M&F

11,968.55

10,649.44

3,947.00

10,034.39

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

36,599.38

3918

3919

12,324.30

0.00

13,624.14

0.00

7,696.01

0.00

-2,853.79

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

30,790.66

3928

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4
SUBTOTAL:	27,343.08	38,453.22	18,598.48	22,650.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,045.29

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	7,690.74	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	2,945.35	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	19.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	9,280.28	5,032.17	996.95	10,655.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
20,706.91	
3,218.09	
2,039.59	
25,964.59	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	0.00	0.00	0.00	19.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4519	5
BC PATIENT FEMALE 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	

4618	5
CC PATIENT FEMALE 4	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	5													

 	
0.00	
19.37	
0.00	
0.00	
19.37	

SUBTOTAL:

0.00

0.00

0.00

19.37

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	438.25	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	
	0.00	673.22	3,798.02	438.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2,597.00	
2,290.95	
21.54	
4,909.49	

SUBTOTAL:

TOTAL:	511,418.72	489,216.06	325,648.49	430,016.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,756,299.74		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	36,872.16	53,054.55	45,645.44	31,004.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,577.05		
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		
	36,872.16	53,054.55	45,687.23	31,004.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,618.84		

SUBTOTAL:

TOTAL:

36,872.16

53,054.55	45,687.23	31,004.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166,618.84

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	0.00	589.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589.33		
	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:

TOTAL:

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

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	363,227.79	409,117.78	280,451.13	327,995.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,380,792.23		
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		
	363,239.62	409,204.47	280,446.79	327,995.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,380,886.41		

SUBTOTAL:

TOTAL:

363,239.62

409,204.47	280,446.79	327,995.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,380,886.41

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	55.05	0.00	0.00	125.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180.15		
1007	TANF 21-44 FEMALE WI	0.00	733.73	204.48	450.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,388.84		
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	135.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.43		
1011	TANF <1 M & F NON-ME	114,061.33	82,808.58	20,674.74	13,542.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		231,086.66		
1012	TANF 01-05 M & F NON	1,877.83	4,691.66	4,629.27	1,359.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,557.82		
1013	TANF 06-13 M & F NON	-34.11	397.76	542.41	1,165.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,071.60		
1014	TANF 14-20 MALE NON-	0.00	503.34	0.00	1,775.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,278.83		
1015	TANF 14-20 FEMALE N O	3,050.19	10,707.19	6,361.39	10,286.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,404.85		
1016	TANF 21-44 MALE NON-	45,482.98	57,982.31	50,834.68	63,481.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217,780.99		
1017	TANF 21-44 FEMALE N O	106,522.53	130,723.18	138,930.01	105,441.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		481,617.28		
1018	TANF 45-64 M & F NON	87,013.43	82,472.68	30,115.17	44,846.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,448.27		
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	478.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796.55		
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	278.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,762.77		
2110	SSI AGED NON-MEDICA R	2,551.19	18.03	2,511.53	191.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,271.86		
2120	SSI AGED WITH QMB	9,555.40	11,940.97	7,470.65	15,123.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,090.57		
2200	SSI DISABLED WITH M E	8,793.87	12,081.12	10,297.40	5,147.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,319.69		
2210	SSI DISABLED NON-ME D	243,889.19	242,188.71	228,595.91	178,902.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		893,575.94		
2220	SSI DISABLED WITH Q M	36,584.54	51,182.69	28,824.97	28,013.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,605.33		
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	175.91	4,793.35	764.82	575.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,309.89		
2320	SSI BLIND WITH QMB	1,288.00	88.30	231.93	184.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,792.92		
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	76,008.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		328,361.67		
4312	SOBRA CHILD 01-05 M	31,803.55	53,396.45	28,866.55	50,706.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164,773.52		
4313	SOBRA CHILD 06-13 M	22,465.50	28,513.24	13,984.93	40,915.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,879.36		
4314	SOBRA CHILD 14-20 MA	8,438.19	7,014.89	19,047.97	14,802.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,303.91		
4315	SOBRA CHILD 14-20 FE	21,162.92	41,843.06	21,752.40	17,573.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,331.92		
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	26,309.18	30,637.88	21,142.34	14,687.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,777.06		
5017	SOBRA PREG 21-44 FE	138,907.46	135,105.28	81,251.65	98,104.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453,368.42		

A

M

M

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	56.68	90.66	0.00	71.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218.97		
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		
	1,026,217.75	1,117,999.21	738,488.02	784,374.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,667,079.31		

SUBTOTAL:

0.00

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

	0.00	
1106	TANF EXPANDED 21-44	538.88	3,581.21	272.76	1,284.62	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	538.50	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	1,430.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1109	TANF EXPANDED 65+	283.01	255.70	323.31	2,190.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1111	M&
TANF EXPANDED <1 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		

1112	&F
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	10,300.05	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	41,265.74	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	17,822.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1119	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

1126	M&
TANF EXPANDED 21-44	
190.62	
2,112.21	
143.64	
145.92	
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	62.88	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	687.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
1129	TANF EXPANDED 65+	345.00	291.62	178.40	72.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

2400	M&
SSI AGED EXPANDED	
0.00	
25.19	
5,703.60	
30.44	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2410	WI
SSI AGED EXPANDED	
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	NO
SSI AGED EXPANDED	
10,427.22	
9,257.84	
5,545.61	
11,860.80	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2600	WI
SSI DISABLED EXPAND	
127.08	
678.60	
160.68	
590.40	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2610	E
SSI DISABLED EXPAND	
1,127.98	
862.65	
7,720.14	
2,533.49	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		

2620	E
SSI DISABLED EXPAND	
9,014.59	
12,900.26	
5,689.62	
7,464.94	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
	E														

1

5,677.47	
3,137.44	
6,773.52	
3,052.58	
0.00	
0.00	
0.00	
0.00	
1,238.40	
141,547.54	
222,619.37	
75,026.91	
0.00	
2,592.39	
1,361.37	
2,365.34	
887.31	
5,759.23	
-552.47	
37,091.47	
1,556.76	
12,244.26	
35,069.41	
557,448.30	

SUBTOTAL:

98,257.39

216,685.29

144,224.59

98,281.03

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

0.00	
0.00	
0.00	

SUBTOTAL:

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	393.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	1,441.01	800.83	5,402.91	4,348.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
102,273.00	
34,493.94	
48,861.53	
42,834.62	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	23,312.85	32,151.32	13,850.34	6,962.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
74,316.57	
92,252.90	
65,747.96	
32,884.41	
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	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	AL
ADULT <40% EXP M&F	
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	4
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3714	6
ADULT <40% EXP MALE	
13,443.49	
7,826.15	
12,268.41	
1,582.12	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3715	ADULT <40% EXP FEM	1,025.71	20,156.01	6,885.48	8,248.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	AL
ADULT <40% EXP MALE	
191,333.82	
193,228.81	
152,239.46	
216,431.27	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEM	64,187.35	106,658.28	64,804.04	51,581.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	AL
ADULT <40% EXP M&F	
145,955.90	
274,489.78	
153,176.27	
239,303.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3719	4
ADULT <40% EXP M&F	
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	6
ADULT <40% EXP M&F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	4													

 	
0.00	
99.71	
0.00	
4,606.30	
11,993.49	
228,463.09	
76,277.47	
265,201.84	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
132.59	
0.00	
35,120.17	
36,315.47	
753,233.36	
287,231.31	
812,925.65	
62.60	
0.00	
2,511,663.05	

SUBTOTAL:

617,404.70

762,214.90

527,472.49

604,570.96

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	0.00	0.00	0.00	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

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

RATE CODE	DESCRIPTION
3909

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER	NOVEMBER	DECEMBER
0.00	0.00	0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

0.00

3914

3915

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

833.48

0.00

180.72

0.00

0.00

475.98

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

1,014.20

475.98

3916

4,882.72

6,594.79

11,596.15

50,378.57

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

73,452.23

3917

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE M&F

14,967.59

27,110.09

37,485.10

4,978.68

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

84,541.46

3918

3919

19,064.87

0.00

22,092.71

0.00

22,177.93

0.00

124,588.84

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

187,924.35

3928

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4
SUBTOTAL:	39,748.66	55,978.31	71,735.16	179,946.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	347,408.22

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	8,232.96	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	151.82	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	1,332.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	6,114.57	12,920.48	5,693.15	9,717.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

0.00	
14,026.78	
11,504.06	
8,914.93	
34,445.77	

SUBTOTAL:

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

4618	5
CC PATIENT FEMALE 4	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	5													

 	
0.00	
15.42	
0.00	
0.00	
15.42	

SUBTOTAL:

15.42

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

8700	SSI DISABLED FREEDO M	0.00	355.04	0.00	21.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	355.04	0.00	21.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

376.58	
0.00	
0.00	
376.58	

SUBTOTAL:

TOTAL:	1,787,758.49	2,166,153.23	1,487,613.41	1,676,911.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,118,436.65		

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	219,052.35	253,349.25	121,463.64	90,376.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	684,241.55	
2110	A
SSI AGED NON-MEDICA	40,660.18	71,145.23	35,038.90	71,771.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
218,615.42	
2120	R
SSI AGED WITH QMB	182,700.41	209,792.30	159,732.00	109,007.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
661,231.88	
2200	SSI DISABLED WITH M	34,869.86	45,426.05	38,471.02	26,683.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,450.86	
2210	E
SSI DISABLED NON-ME	717,819.30	840,735.89	669,730.82	575,860.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,804,146.19	
2220	D
SSI DISABLED WITH Q	69,871.55	87,449.75	85,703.33	53,253.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
296,278.57	

2300	M
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	4,453.28	8,672.22	9,443.81	6,895.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,464.31	

2320	A
SSI BLIND WITH QMB	
388.66	
676.12	
219.85	
166.47	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,451.10	

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION

JULY	AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

1,269,815.59	1,517,614.81	1,120,248.41

934,014.11

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4,841,692.92

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	
	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	

SUBTOTAL:

4,843,591.85

1,270,468.89	1,518,860.44	1,120,248.41	934,014.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	2,058,486.95	2,374,297.25	2,154,863.35	1,996,107.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,583,755.54	
2110	A
SSI AGED NON-MEDICA	108,527.50	93,777.18	118,373.10	98,203.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
418,881.45	
2120	R
SSI AGED WITH QMB	2,980,893.26	3,717,043.79	2,989,220.83	2,951,777.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
12,638,935.41	
2200	SSI DISABLED WITH M	499,603.04	639,287.37	497,917.52	493,961.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,130,769.29	
2210	E
SSI DISABLED NON-ME	1,864,375.53	2,336,558.77	2,196,536.16	1,991,658.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8,389,129.17	
2220	D
SSI DISABLED WITH Q	686,455.43	834,681.23	718,107.95	654,700.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2,893,945.56	

2300	M
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	7,847.76	12,002.48	8,212.16	8,289.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,352.32	

2320	A
SSI BLIND WITH QMB	
6,736.52	
6,974.71	
7,689.14	
5,785.34	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
27,185.71	

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

8,212,925.99    10,014,622.78	8,690,920.21	8,200,485.47

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

35,118,954.45

35,141,420.52

TOTAL:

8710	SSI DISABLED FREEDO M	0.00	5,385.60	2,774.40	2,603.04	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	2,768.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,765.43	8,812.80	5,516.16	5,371.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

10,763.04	
11,703.03	
22,466.07	

SUBTOTAL:

8,215,691.42	10,023,435.58	8,696,436.37	8,205,857.15	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	
2100	SSI AGED WITH MEDIC	20,107.37	65,824.15	36,030.24	23,726.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	145,688.32	
2110	A
SSI AGED NON-MEDICA	321.97	0.00	419.90	11,620.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
12,362.14	
2120	R
SSI AGED WITH QMB	16,004.46	3,678.81	7,559.43	-86.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
27,156.47	
2200	SSI DISABLED WITH M	859.25	960.45	6,967.11	7,944.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,731.60	
2210	E
SSI DISABLED NON-ME	65,859.49	70,521.46	53,975.25	80,967.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
271,324.05	
2220	D
SSI DISABLED WITH Q	304.54	4,059.22	8,911.33	3,935.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
17,210.99	

2300	M
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	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	A
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	

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

103,457.08

145,371.04

113,863.26

128,109.14

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

490,800.52

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

0.00	
0.00	
0.00	

SUBTOTAL:

490,800.52

103,457.08	145,371.04	113,863.26	128,109.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	10,300.49	39,674.33	13,894.03	10,589.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,458.65	
2110	A
SSI AGED NON-MEDICA	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	R
SSI AGED WITH QMB	16,020.55	21,126.19	4,933.20	9,563.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
51,643.00	
2200	SSI DISABLED WITH M	2,621.87	11,047.52	3,294.25	8,343.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,307.55	
2210	E
SSI DISABLED NON-ME	46,899.42	39,426.91	48,635.30	31,702.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
166,664.52	
2220	D
SSI DISABLED WITH Q	7,860.45	13,901.38	2,894.38	4,713.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
29,369.84	

2300	M
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	0.00	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	A
SSI BLIND WITH QMB	
81.78	
57.17	
57.17	
181.91	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
378.03	

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending October 31, 2016

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

SUBTOTAL:

84,002.55

131,094.53

73,927.90

65,095.20

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

354,120.18

354,120.18

TOTAL:

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

0.00	
0.00	
0.00	

SUBTOTAL:

84,002.55	131,094.53	73,927.90	65,095.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

KidsCare - CAPITATION AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	479.18	-557.49	21,350.80	37,417.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,690.09		
6012	KIDS 1-5 M & F NON-M	0.00	-6,189.47	77,969.11	170,721.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242,500.78		
6013	KIDS 6-13 M & F NON-	33,225.63	13,672.65	183,641.27	347,351.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		577,891.19		
6014	KIDS 14-19 MALE NON-	31,612.49	24,016.15	68,826.52	122,434.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246,889.73		
6015	KIDS 14-19 FEMALE NO	40,507.26	29,084.45	101,226.61	190,450.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361,268.93		
SUBTOTAL:	105,824.56	60,026.29	453,014.31	868,375.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,487,240.72		

TOTAL:

105,824.56

1,487,240.72

453,014.31	868,375.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

60,026.29

9,776.83

TOTAL:

549.18

521.23

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	1.00	1.00	44.12	80.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126.69		
6012	KIDS 1-5 M & F NON-M	0.00	0.41	658.36	1,428.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,087.19		
6013	KIDS 6-13 M & F NON-	243.88	228.41	1,455.13	2,839.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,766.71		
6014	KIDS 14-19 MALE NON-	166.11	161.00	387.76	725.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,440.37		
6015	KIDS 14-19 FEMALE NO	138.19	130.41	377.56	709.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,355.87		
SUBTOTAL:	549.18	521.23	2,922.93	5,783.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,776.83		

2,922.93	5,783.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	2,852.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,852.17		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	50,985.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,985.55		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	101,202.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,202.62		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	26,413.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,413.11		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	27,299.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,299.09		
SUBTOTAL:	0.00	0.00	0.00	208,752.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,752.54		

TOTAL:

0.00

208,752.54

0.00	208,752.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

5,568.00

TOTAL:

0.00

0.00

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	79.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.00		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	1,383.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,383.00		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	2,738.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,738.00		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	687.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		687.00		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	681.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		681.00		
SUBTOTAL:	0.00	0.00	0.00	5,568.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,568.00		

0.00	5,568.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

KidsCare - FEE FOR SERVICE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	0.00	0.00	271.99	2,214.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,486.22		
6013	KIDS 6-13 M & F NON-	0.00	0.00	317.51	3,907.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,224.58		
6014	KIDS 14-19 MALE NON-	0.00	15.43	338.82	399.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		753.29		
6015	KIDS 14-19 FEMALE NO	0.00	214.91	133.90	3,927.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,276.58		
	0.00	230.34	1,062.22	10,448.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,740.67		

SUBTOTAL:

11,740.67

0.00	230.34	1,062.22	10,448.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

146,678.80

TOTAL:

KidsCare - REINSURANCE
For The Period Ending October 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6014	KIDS 14-19 MALE NON-	82,673.79	198.95	63,655.88	150.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,678.80		
	82,673.79	198.95	63,655.88	150.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,678.80		

SUBTOTAL:

82,673.79	198.95	63,655.88	150.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4

00

110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending October 31, 2016		
RATE CODE	DESCRIPTION	JULY	AUGUST     SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
		
1000	TANF WITH MEDICARE	10.00	10.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			41.00		
1010	TANF NON-MEDICARE	666.51	671.77	670.37	675.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			2,684.58		
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			5.49		
1020	TANF WITH QMB	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			8.00		
2100	SSI AGED WITH MEDICA	170.32	172.75	175.00	184.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			702.12		
2110	SSI AGED NON-MEDICAR	4.00	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			14.00		
2120	SSI AGED WITH QMB	271.83	271.02	270.00	270.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1,083.33		
2200	SSI DISABLED WITH ME	1,947.34	1,983.19	1,979.74	1,970.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			7,881.11		
2210	SSI DISABLED NON-MED	22,244.95	22,359.52	22,463.70	22,462.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			89,530.74		
221Z	SSI DISABLED NON-MED	0.00	1.03	4.29	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			5.35		
2220	SSI DISABLED WITH QM	4,066.85	4,090.03	4,122.36	4,129.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			16,408.40		
2300	SSI BLIND WITH MEDIC	13.00	14.00	16.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			59.00		
2310	SSI BLIND NON-MEDICA	118.99	121.00	122.00	116.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			478.47		
2320	SSI BLIND WITH QMB	28.19	28.00	27.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			110.19		
8700	SSI DISABLED FREEDOM	9.00	9.00	9.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			37.00		
8710	SSI DISABLED FREEDOM	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			4.00		
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			12.00		
	29,556.98
29,556.98	29,741.31
29,741.31	29,883.95
29,883.95	29,882.54
29,882.5	0.00		0.00
0.00	0.00	0.00
0.00	0.00	0.00
0.	0.00	0.00		119,064.78		
					0.00		0.00		0.00		0.00	0.00		119,064.78		

SUBTOTAL: TOTAL:

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD  EXPENDITURES
For the Period Ending October 31, 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	392,869.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,521,330.96	
EPD	85,600,877.03	98,791,049.82	85,922,476.50	89,715,562.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	360,029,965.38	
TOTAL AHCCCS LTC	85,979,585.45	99,163,141.68	86,300,138.12	90,108,431.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	361,551,296.34	
DES/DD	104,331,950.18	104,866,978.39	105,491,156.40	106,085,077.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	420,775,162.86	
TOTAL DES LTC	104,331,950.18	104,866,978.39	105,491,156.40	106,085,077.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	420,775,162.86	
TOTAL LTC - CAP	190,311,535.63	204,030,120.07	191,791,294.52	196,193,508.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	782,326,459.20	

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	11,818,761.59	10,004,475.94	9,333,075.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,829,933.07	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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	9,333,075.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,829,933.07	

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	5,137,624.64	4,206,734.06	5,494,838.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,292,840.13	
	513,400.18	371,137.98	818,556.37	521,755.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,224,849.73	
	513,400.18	371,137.98	818,556.37	521,755.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,224,849.73	
TOTAL LTC - REIN	4,967,043.47	5,508,762.62	5,025,290.43	6,016,593.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,517,689.86	

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	3,598,486.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,425,838.30	

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

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

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

TOTAL

Thursday, November 17, 2016

010115	CRS FULLY INTEGRATED PLAN - CAP	14,233,650.60	13,929,828.60	14,183,986.01	14,337,196.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,684,661.97	
010145	CRS ACUTE SEMI INTEGRATED - CAP	145,463.25	142,476.36	145,562.28	109,407.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	542,909.24	
999125	CRS SEMI INTEGRATED PLAN - CAP	4,973,747.20	4,959,398.40	4,961,664.00	5,202,598.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,097,408.40	
999135	CRS ONLY PLAN - CAP	551,073.60	552,982.08	550,596.48	544,229.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,198,882.11	
	19,903,934.65	19,584,685.44	19,841,808.77	20,193,432.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,523,861.72	

Subtotal

999155	CRS REINSURANCE ONLY	2,326,263.42	446,456.85	911,431.67	1,717,829.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,401,981.82	
	2,326,263.42	446,456.85	911,431.67	1,717,829.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,401,981.82	

Subtotal

22,230,198.07	20,031,142.29	20,753,240.44	21,911,262.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84,925,843.54	

GRAND TOTAL

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

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

TOTAL

Thursday, November 17, 2016

010115	CRS FULLY INTEGRATED PLAN - MM	17,102.15	16,990.50	17,006.16	16,948.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,047.74	
010145	CRS ACUTE SEMI INTEGRATED - MM	181.59	179.98	181.73	184.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	728.15	
999125	CRS SEMI INTEGRATED PLAN - MM	6,586.00	6,567.00	6,570.00	6,559.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,282.00	
999135	CRS ONLY PLAN - MM	1,155.00	1,159.00	1,154.00	1,145.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,613.00	
	25,024.74	24,896.48	24,911.89	24,837.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,670.89	

Subtotal

25,024.74	24,896.48	24,911.89	24,837.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	99,670.89	

GRAND TOTAL

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

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

TOTAL

Thursday, November 17, 2016

010700	HEALTH CHOICE INTEGRATED - CAP	8,139,817.79	8,143,584.09	8,215,936.27	9,455,259.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,954,597.96	
010725	CENPATICO INTEGRATED - CAP	19,718,383.80	19,873,855.68	19,844,674.31	21,352,168.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	80,789,082.42	
078999	MERCY MARICOPA INTEGRATED - CAP	43,908,062.70	44,810,326.74	45,127,647.55	46,563,901.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	180,409,938.15	
	71,766,264.29	72,827,766.51	73,188,258.13	77,371,329.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295,153,618.53	

Subtotal

71,766,264.29	72,827,766.51	73,188,258.13	77,371,329.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295,153,618.53	

GRAND TOTAL

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

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

TOTAL

Thursday, November 17, 2016

010700	HEALTH CHOICE INTEGRATED - MM	5,434.12	5,436.13	5,482.30	5,531.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,883.67	
010725	CENPATICO INTEGRATED - MM	12,956.97	13,057.68	13,037.47	13,175.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,227.30	
078999	MERCY MARICOPA INTEGRATED - MM	19,855.38	20,248.88	20,392.35	20,636.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,133.21	
	38,246.47	38,742.69	38,912.12	39,342.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	155,244.18	

Subtotal

38,246.47	38,742.69	38,912.12	39,342.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	155,244.18	

GRAND TOTAL