January 27, 2016

The Honorable Steve Yarbrough Arizona State Senate
1700 W. Washington
Phoenix, AZ 85007

The Honorable J.D. Mesnard Speaker of the House
Arizona House of Representatives 1700 W. Washington
Phoenix, AZ 85007

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

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

Dear President Yarbrough and Speaker Mesnard:

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 December 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. Based on that revision and administrative adjustment activity through December, AHCCCS is currently forecasting a FY 2017 Total Fund shortfall of $12.9 million. The total fund shortfall is comprised of Hospital Assessment Expenditure Authority and represents the difference between the current assessment rate and the appropriated amount.

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

In December, AHCCCS administratively adjusted $322.2 million Total Fund of Fiscal Year 2017 date of service expenditures back to the Fiscal Year 2016 appropriation. These administrative adjustments have been taken into account in projecting the shortfalls described above. The line item detail for these transactions is included in Note 7 of this report.

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

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov

The Honorable Steve Yarbrough The Honorable J.D. Mesnard January 27, 2017
Page 2

Enrollment Update

–  December  2016  enrollment is

1,916,671

members,

a  4,698 member

increase over the prior month. 3,044 member decrease.

Enrollment for January 2017 decreased to 1,913,629 members,  a

Major January changes by eligibility category include: 1931 for Families and Children/SOBRA –

decrease

of 2,266;

Supplemental Security

Income  –  increase of

208;  Prop  204  Restoration -

decrease of 2,232; Adult Expansion - decrease of 187; Medicare 2,168; and Federal Emergency Services - decrease of 226.

Cost Sharing – decrease   of

Tobacco Funds Revenue Update – Tobacco tax collections through December 2016 are $8.1 million more than the AHCCCS monthly projected flows. AHCCCS will monitor the tobacco

funds revenue collections throughout the appropriations.

year  to  determine  any  impact  on  the    FY

2017

If you have any questions about this report, please do not hesitate to call me at (602) 417-4111 or Jeffery Tegen at (602) 417-4705.

Sincerel ,

Thomas J. Betlach Director

Enclosure

cc:	The Honorable Douglas A. Ducey, Governor
The Honorable, Debbie Lesko, Chairman, Senate Appropriations Committee The Honorable Don Shooter, 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 December 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 December 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 

3,689,969,100
2,786,105,800
455,159,400
274,348,100
1,955,000
1,422,354,600
5,087,100
22,650,000
445,609,000
1,105,854,600
704,427,100
84,827,500
208,027,400
78,846,900
5,324,800
16,391,300

 	11,306,937,700 

$	11,505,528,200	

$	39,313,296
5,625,147
27,437,300
19,179,600

 	91,555,343 

1,803,376,100
1,369,025,100
224,050,100
138,572,900
603,800
697,171,300
- 5,244,300
81,273,800
543,965,100
358,877,700
42,399,200
108,033,200
39,423,600
2,662,200
8,195,400

 	5,422,873,800 

$    5,514,429,143	

$	38,896,325
5,968,929
29,326,040
16,850,915

 	91,042,209 

1,756,669,743
1,274,331,631
197,740,940
116,637,406
(278,664)
649,459,278
- 5,244,302
81,273,849
540,061,340
268,632,886
26,536,023
96,969,703
38,732,333
2,618,922
8,153,150

 	5,062,782,842 

$   5,153,825,051	

$	416,971
(343,782)
(1,888,740)
2,328,685

 	513,135 

46,706,357
94,693,469
26,309,160
21,935,494
882,464
47,712,022
-
(2)
(49)
3,903,760
90,244,814
15,863,177
11,063,497
691,267
43,278
42,250

 	360,090,958 

$	360,604,092	

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

 	198,590,500 

3,689,969,100
2,786,105,800
455,159,400
274,348,100
1,955,000
1,422,354,600
5,087,100
22,650,000
445,609,000
1,105,854,600
704,427,100
84,827,500
208,027,400
78,846,900
5,324,800
16,391,300

 	11,306,937,700 

$   11,505,528,200	

$	-
-
-
-

 	-	

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

 	-	

$	-	

2

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		
Administrative Expenditures	$	55,399,000	$	25,792,428	$	24,456,068	1,336,360	$	55,399,000	$	-	
Proposition 204 - Administrative Expenditures	21,746,500	10,530,903	6,079,009	4,451,894	21,746,500	-	

Programmatic Expenditures							
Traditional Medicaid Services	737,857,600	361,306,500	373,307,609	(12,001,109)	737,857,600	-	
Proposition 204 Services	100,000,000	91,801,600	26,408,294	65,393,306	100,000,000	-	
Children's Rehabilitative Services KidsCare Services	84,424,100
-	42,696,400
-	33,008,890
(24,398)	9,687,510
24,398	84,424,100
-	-
-	
ALTCS Services	167,841,100	82,254,100	83,920,550	(1,666,450)	167,841,100	-	
DSH and Rural Hospitals	7,239,300	1,613,100	1,613,147	(47)	7,239,300	-	
Behavioral Health Traditional Medicaid Services	304,268,100	149,973,500	153,522,125	(3,548,625)	304,268,100	-	
Behavioral Health Proposition 204 Services	109,250,500	61,035,200	40,826,139	20,209,061	109,250,500	-	
Behavioral Health ACA Adult Expansion	831,900	-	(11,335)	11,335	831,900	-	
Behavioral Health CMDP	63,770,500	33,205,900	30,046,561	3,159,339	63,770,500	-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900	39,423,600	38,732,333	691,267	78,846,900	-	
Supported Housing	5,324,800	2,662,200	2,618,922	43,278	5,324,800	-	
Crisis Services	 	14,141,100 	 	7,070,400 	 	7,028,050 	 	42,350 	 	14,141,100 	 	- 	
TOTAL GF EXPENDITURES	1,750,941,400	951,765,031	821,531,963	87,833,868	1,750,941,400	-	

FEDERAL		
Administrative Expenditures	90,666,200	40,803,561	43,631,196	(2,827,634)	90,666,200	-	
Proposition 204 - Administrative Expenditures	26,715,500	12,491,744	15,850,009	(3,358,266)	26,715,500	-	

Programmatic Expenditures	
Traditional Medicaid Services	2,457,784,700	1,199,986,700	1,014,901,612	185,085,088	2,457,784,700	-	
Proposition 204 Services	2,283,770,000	1,130,564,400	1,102,072,837	28,491,563	2,283,770,000	-	
ACA Adult Expansion	448,897,900	224,050,100	197,740,940	26,309,160	448,897,900	-	
Children's Rehabilitative Services	189,924,000	95,876,500	83,628,516	12,247,984	189,924,000	-	
KidsCare Services	1,585,000	(2,367,800)	(254,265)	(2,113,535)	1,585,000	-	
ALTCS Services and Nursing Facility Assessment	953,302,500	467,066,000	434,498,204	32,567,796	953,302,500	-	
DSH and Rural Hospitals	20,497,800	3,631,200	3,631,155	45	20,497,800	-	
Behavioral Health Traditional Medicaid Services	766,020,700	376,461,200	369,105,941	7,355,259	766,020,700	-	
Behavioral Health Proposition 204 Services	595,176,600	294,803,900	222,489,347	72,314,553	595,176,600	-	
Behavioral Health ACA Adult Expansion	83,995,600	42,399,200	26,547,358	15,851,842	83,995,600	-	
Behavioral Health CMDP	144,256,900	74,827,300	66,923,142	7,904,158	144,256,900	-	
Voluntary Political Subdivision Programs - See Note 5	 	299,477,800 	 	55,930,200 	 	55,930,162 	 	38 	 	299,477,800 	 	- 	
TOTAL FEDERAL EXPENDITURES	8,362,071,200	4,016,524,205	3,636,696,153	379,828,052	8,362,071,200	-	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,563,300	1,782,100	890,825	891,275	3,563,300	-	
Traditional Medicaid Services Acute Care	49,687,700	24,381,000	24,381,000	-	49,687,700	-	
ALTCS Services	 	249,980,000 	 	122,529,600 	 	105,541,987 	 	16,987,613 	 	249,980,000 	 	- 	
TOTAL COUNTY EXPENDITURES	303,231,000	148,692,700	130,813,812	17,878,888	303,231,000	-	

Programmatic Expenditures

	(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	18,367,500	18,348,225	19,275	37,432,400	-	
Behavioral Health Traditional Medicaid Services - Medically Needy		35,565,800	17,530,400	17,433,274	97,126	35,565,800	-	
Proposition 204 Services - Emergency Health Services		18,747,200	9,244,900	8,436,450	808,450	18,747,200	-	
Proposition 204 Services - Proposition 204 Protection		16,251,400	14,380,300	14,380,250	50	16,251,400	-	
Behavioral Health Proposition 204 Services - Proposition 204 Protection		21,269,600	3,038,600	5,317,400	(2,278,800)	21,269,600	-	
Proposition 204 Services - ATLSF	 	100,000,000 	 	- 	 	- 	 	- 	 	100,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	229,266,400	62,561,700	63,915,599	(1,353,899)	229,266,400	-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	

OTHER

500,000	

154,607	135,102	19,505	500,000	-	
Acute Care - Prescription Drug Rebate Program State Match	105,837,600	51,932,700	84,609,700	(32,677,000)	105,837,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	301,143,200	147,306,000	240,914,560	(93,608,560)	301,143,200	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,441,300	3,655,800	3,720,650	(64,850)	7,441,300	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	21,600,300	10,571,000	16,476,538	(5,905,538)	21,600,300	-	
Proposition 204 Services - Hospital Assessment	246,067,600	123,033,800	123,033,800	-	246,067,600	-	
ACA Adult Expansion - Hospital Assessment	6,261,500	-	-	-	6,261,500	-	
Traditional Medicaid Services - TPL	194,700	95,700	177,959	(82,259)	194,700	-	
ALTCS Services - TPL	-	-	571,489	(571,489)	-	-	
ALTCS Services - Nursing Facility Assessment	22,189,400	11,094,800	4,729,861	6,364,939	22,189,400	-	
KidsCare Services Premiums	370,000	2,971,600	-	2,971,600	370,000	-	
Freedom to Work Premiums	31,200	-	29,078	(29,078)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	1,125,000	1,125,100	(100)	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	146,131,200 	 	25,343,700 	 	25,343,687 	 	13 	 	146,131,200 	 	- 	
TOTAL OTHER EXPENDITURES	860,018,200	377,284,707	500,867,523	(123,582,817)	860,018,200	-	

TOTAL		
Administrative Expenditures	198,590,500		91,555,343		91,042,209		513,135		198,590,500		-	
Acute Care	9,884,583,100		4,725,702,500		4,413,323,564		312,378,936		9,884,583,100		-	
Long Term Care	 	1,422,354,600 		 	697,171,300 		 	649,459,279 		 	47,712,021 		 	1,422,354,600 		 	- 	
TOTAL EXPENDITURES	  $	11,505,528,200 		  $	5,514,429,143 		  $	5,153,825,051 		  $	360,604,092 		  $	11,505,528,200 		  $	- 	

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

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:		
Traditional Medicaid Services & Administrative	$	884,920,000	$	431,408,428	$	432,385,714	
Proposition 204 Services & Administrative	121,746,500	102,332,503	78,630,843	
KidsCare Services	-	-	(24,398)	
ALTCS Services	167,841,100	82,254,100	83,920,550	
Behavioral Health Traditional Medicaid Services	 	576,433,800 	 	293,370,800 	 	231,947,990 	
TOTAL	 	1,750,941,400 	 	909,365,831 	 	826,860,698 	

FEDERAL:
Acute & Administrative	5,817,733,900	2,763,334,405	2,751,715,167	
KidsCare Services	1,585,000	(2,367,800)	5,701,492	
ALTCS Services	953,302,500	467,066,000	443,149,068	
Behavioral Health Traditional Medicaid Services	 	1,589,449,800 	 	788,491,600 	 	685,388,593 	
TOTAL	 	8,362,071,200 	 	4,016,524,205 	 	3,885,954,320 	

COUNTY:				
Acute & Administrative	53,251,000	26,163,100	24,903,387	
ALTCS Services	 	249,980,000 	 	122,529,600 	 	124,990,002 	
TOTAL	 	303,231,000 	 	148,692,700 	 	149,893,389 	

TOBACCO FUNDS:				
Traditional Medicaid Services	72,998,200	35,897,900	35,781,499	
Proposition 204 Services	 	156,268,200 	 	26,663,800 	 	22,816,700 	
TOTAL	 	229,266,400 	 	62,561,700 	 	58,598,199 	

OTHER:

Administrative	500,000	154,607	135,102	
Acute Care - Prescription Drug Rebate Program	406,980,800	199,238,700	325,524,260	
Long Term Care - Prescription Drug Rebate Program	29,041,600	14,226,800	20,197,188	
Hospital Assessment	252,329,100	123,033,800	132,312,796	
ALTCS - Nursing Facility Assessment	22,189,400	11,094,800	9,717,103	
Acute TPL - Note 1	194,700	95,700	177,959	
LTC TPL - Note 1	-	-	571,489	
KidsCare TPL - Note 1	-	-	978	
Member Premiums - CHIP	370,000	2,971,600	429,974	
Member Premiums - Freedom to Work	31,200	-	29,078	
Behavioral Health Traditional Medicaid Services	2,250,200	1,125,000	3,770,077	
Voluntary Political Subdivision - State Match	 	146,131,200 	 	25,343,700 	 	34,862,319 	
TOTAL	 	860,018,200 	 	377,284,707 	 	527,728,322 	

TOTAL REVENUE

  $	11,505,528,200 

  $	5,514,429,143 

  $	5,449,034,929 

 	

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending December 31, 2016	
Note 1:    Third Party Liability Collections:	December 2016		December 2015		July 1, 2016		July 1, 2015	
Gross Collections:					December 31, 2016		December 31, 2015	
Acute	$	425,715		$	373,701		$	2,819,026		$	2,130,346	
LTC	698,558		248,546		2,672,729		1,590,590	
KidsCare	-		-		4,878		104,447	
Total TPL Collections	$	1,124,273		$	622,247		$	5,496,633		$	3,825,383	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	50,519		$	41,813		$	177,959		$	236,856		
LTC	162,206		58,782		571,489		361,752		
KidsCare	-		-		978		20,942		
Total Expenditure Offsets	$	212,725		$	100,595		$	750,426		$	619,550		

FY 17 Total

Note 2:    Authorized Positions	1,141.2
Actual Positions as of December 31, 2016	1,009.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2016	$	1,933,160	
	Revenues	3,349,509	
	Transfers-In	 	372,293 	
	Total Revenues	 	3,721,802 	
	Expenditures	2,862,391	
	Transfers-out	 	1,287,163 	
	Total Expenditures	 	4,149,554 	
	Ending Balance December 31, 2016	  $	1,505,408 	
Of the $1,505,408 ending balance, $1,227,267 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through December 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.
Schedule of Outstanding Liabilities As of December 31, 2016
 	Description		 	Amount	

 	Type	

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

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of December 31, 2016 Expenditures

     State Match		 	Federal	 	Total	

DSH Voluntary	$	367,113	$	688,426	$	1,055,538	
GME Voluntary	7,319,575	15,663,626	22,983,200	
Safety Net Care Pool	17,657,000	39,578,110	57,235,110	

Total Voluntary Political Subdivision Program Expenditure $	25,343,687	$	55,930,162    $	81,273,849 

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

Note 6:

Note 7:

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 December 31, 2016		
	Expenditures		
Expenditure				Projected	
Plan YTD	Expenditures YTD	Variance YTD		Annual Expenditures	

AHCCCS Operating CHIP Fund	$	-	
$	-	
$	-		
$	3,511,900	
DES Eligibility CHIP Fund	1,170,600		21,072		1,149,528		3,511,800	
KidsCare Services CHIP Fund	21,762,000		5,231,705		16,530,295		63,214,800	
Total KidsCare CHIP Type 3 Appropriation Expenditures	$	22,932,600		$	5,252,778		$	17,679,822		$	70,238,500	

The following is a summary of $322,230,579 Total Fund ($52,943,687 General Fund/ALTCS Fund state match and $12,797,628 Hospital Assessment Fund) administrative adjustment transactions for medical service claims processed through December 2016 that either pay for or transfer expenditures with dates of service prior to June 30, 2016. Additionally, the $11,716,850 questioned cost previously reported in Note 4 was officially disallowed by CMS and administratively adjusted against the FY 2016 surplus General  Fund.

FY 2016 YTD December 31, 2016	
State Match	Expenditure	ALTCS	Total	
Funds	Authority Funds	Fund	Fund	

Traditional Medicaid Services	$	28,379,022	$	134,920,254	$	-	$	163,299,276	
Proposition 204 Services	12,797,628	69,990,802	-	82,788,430	
ACA Adult Expansion	-	21,164,951	-	21,164,951	
KidsCare - Children Services	-	146,990	-	146,990	
Children's Rehabilitative Services	2,702,559	7,769,127	-	10,471,686	
Long Term Care	-	-	32,642,396	32,642,396	
SBC Medicaid Administrative Costs CMS  Disallowance	11,716,850	11,716,850	

Total

$	55,596,059	$

233,992,124	$

32,642,396	$

322,230,579

Appropriation Status Report
Caseload and Expenditures by Rate Code

TITLE XIX TRADITIONAL

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

TOTAL

CAPITATION - ACUTE	278,655,778	277,811,900	280,062,197	284,152,063	282,661,012	329,277,191	0	0	0	0	0	0	1,732,620,140	
CAPITATION - LTC	190,311,536	204,030,120	191,838,793	196,146,010	209,487,257	202,049,311	0	0	0	0	0	0	1,193,863,028	
MENTAL HEALTH - CHILD	0	0	92,798	40,826,707	39,495,084	39,842,165	0	0	0	0	0	0	120,256,754	
MENTAL HEALTH - ADULT	0	0	4,710	413,272	837,527	996,821	0	0	0	0	0	0	2,252,329	
MENTAL HEALTH - GENERAL	0	0	47,481	13,777,916	38,472,152	38,742,203	0	0	0	0	0	0	91,039,752	
MENTAL HEALTH - CMDP	0	0	0	0	0	122,513	0	0	0	0	0	0	122,513	
MENTAL HEALTH - DD	0	0	0	0	0	11,832	0	0	0	0	0	0	11,832	
CHILDREN'S REHAB SERVICES	5,498,579	5,487,093	5,486,973	5,722,113	5,724,020	5,710,536	0	0	0	0	0	0	33,629,314	
FEE FOR SERVICE - ACUTE	43,169,220	49,076,411	38,450,549	33,852,478	42,186,889	38,478,867	0	0	0	0	0	0	245,214,414	
FFS - PRIOR QUARTER COVERAGE	399,183	701,172	353,914	449,400	558,100	496,870	0	0	0	0	0	0	2,958,639	
EMERGENCY SERVICES - FEDERAL	4,723,538	6,876,303	5,487,551	5,245,641	6,844,880	4,467,826	0	0	0	0	0	0	33,645,740	
FFS MEDICAID IN PUBLIC SCHOOLS	334,212	144,833	272,818	386,199	709,765	605,747	0	0	0	0	0	0	2,453,574	
STATE ONLY TRBHA FFS	0	12,155	22,043	8,636	4,898	0	0	0	0	0	0	0	47,731	
QMB - FEE FOR SERVICE	400,115	462,259	326,723	359,000	531,370	353,079	0	0	0	0	0	0	2,432,546	
INPATIENT INMATES FFS	125,819	53,097	229,997	169,499	209,214	227,846	0	0	0	0	0	0	1,015,473	
FFS TRBHA FEE FOR SERVICE	1,636,296	6,817,558	5,048,877	5,967,130	9,664,772	6,557,074	0	0	0	0	0	0	35,691,705	
PINAL COUNTY INMATES FFS	4,630	3,154	-3,803	0	136	339	0	0	0	0	0	0	4,457	
MARICOPA CTY INMATES FFS	22,177	38,629	14,576	29,601	80,815	53,553	0	0	0	0	0	0	239,351	
MOHAVE COUNTY INMATES FFS	31	8,322	0	0	0	0	0	0	0	0	0	0	8,353	
PIMA COUNTY INMATES FFS	1,278	26,237	2,537	16,174	1,551	17,023	0	0	0	0	0	0	64,800	
FEE FOR SERVICE - LTC	9,673,620	11,818,762	10,004,476	9,333,076	11,165,207	10,203,811	0	0	0	0	0	0	62,198,951	
LFFS - PRIOR QUARTER COVERAGE	25,539	27,090	12,241	20,809	12,995	21,149	0	0	0	0	0	0	119,823	
LFFS MEDICAID IN PUBLIC SCHOOLS	828,652	474,874	685,238	912,730	1,643,386	1,363,964	0	0	0	0	0	0	5,908,844	
REINSURANCE - ACUTE	10,931,804	9,903,096	8,491,782	14,533,814	7,715,454	9,779,160	0	0	0	0	0	0	61,355,110	
REINSURANCE - LTC	4,967,043	5,508,763	5,025,290	6,016,593	4,491,726	3,989,491	0	0	0	0	0	0	29,998,906	
SMIB - ACUTE	13,288,395	13,803,812	14,079,809	14,129,644	14,330,128	14,490,148	0	0	0	0	0	0	84,121,937	
HIB - ACUTE	361,563	411,610	422,087	466,526	462,666	487,547	0	0	0	0	0	0	2,612,000	
Q1	2,222,029	2,257,441	2,298,793	2,278,279	2,348,519	2,380,274	0	0	0	0	0	0	13,785,334	
SMIB - LTC	3,328,913	3,313,965	3,329,893	3,308,977	3,330,340	3,335,593	0	0	0	0	0	0	19,947,681	
HIB - LTC	283,717	285,570	285,293	289,510	282,009	281,043	0	0	0	0	0	0	1,707,143	
KidsCare - MENTAL HEALTH	0	0	0	0	325,271	344,109	0	0	0	0	0	0	669,380	
SUBTOTAL	571,193,666	599,354,227	572,373,635	638,811,797	683,577,144	714,687,084	0	0	0	0	0	0	3,779,997,553	

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	215,435,155	250,525,359	0	0	0	0	0	0	1,305,332,356	
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	8,463	0	0	0	0	0	0	396,445	
MENTAL HEALTH - GENERAL	0	0	112,658	21,890,514	0	152,235	0	0	0	0	0	0	22,155,407	
CHILDREN'S REHAB SERVICES	24,810	23,856	23,856	22,815	21,864	21,389	0	0	0	0	0	0	138,590	
FEE FOR SERVICE - ACUTE	30,892,242	33,585,002	26,203,618	24,327,724	29,526,359	27,383,554	0	0	0	0	0	0	171,918,498	
FFS - PRIOR QUARTER COVERAGE	626,645	888,463	903,725	769,131	981,486	808,163	0	0	0	0	0	0	4,977,613	
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	3,218,819	2,435,868	0	0	0	0	0	0	15,561,511	
FFS MEDICAID IN PUBLIC SCHOOLS	935	797	636	479	704	522	0	0	0	0	0	0	4,074	
INPATIENT INMATES FFS	802,511	1,152,396	1,098,452	742,481	527,347	561,320	0	0	0	0	0	0	4,884,509	
FFS TRBHA FEE FOR SERVICE	668,712	3,783,524	2,819,057	3,584,362	4,058,941	3,430,687	0	0	0	0	0	0	18,345,283	
STATE ONLY TRBHA FFS	11,429	35,462	16,328	45,718	31,474	1,633	0	0	0	0	0	0	142,044	
COCONINO COUNTY INMATES FFS	3,420	-3,257	184	0	4,937	0	0	0	0	0	0	0	5,284	
PINAL COUNTY INMATES FFS	12,241	42,848	1,220	0	39,116	30	0	0	0	0	0	0	95,454	
PIMA COUNTY INMATES FFS	17,640	22,452	328	77,666	35,488	17,393	0	0	0	0	0	0	170,966	
MOHAVE COUNTY INMATES FFS	962	0	0	0	103	0	0	0	0	0	0	0	1,065	
GRAHAM COUNTY INMATES FFS	5,378	0	0	194	0	0	0	0	0	0	0	0	5,572	
COCHISE COUNTY INMATES FFS	0	57	0	0	0	0	0	0	0	0	0	0	57	
MARICOPA CTY INMATES FFS	136,056	149,042	84,034	194,257	148,296	283,764	0	0	0	0	0	0	995,450	
REINSURANCE - ACUTE	3,834,787	4,856,893	4,271,544	5,421,175	4,319,577	4,761,721	0	0	0	0	0	0	27,465,695	
SMIB - ACUTE	5,139,071	5,095,292	5,027,067	4,882,841	4,731,222	4,730,634	0	0	0	0	0	0	29,606,125	
HIB - ACUTE	5,630	6,904	5,363	5,137	4,274	5,733	0	0	0	0	0	0	33,043	
SUBTOTAL	257,141,258	256,774,362	249,496,397	280,617,638	263,085,161	295,128,469	0	0	0	0	0	0	1,602,243,285	

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	33,277,987	39,484,545	0	0	0	0	0	0	202,176,301	
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	48	0	0	0	0	0	0	15,590	
MENTAL HEALTH - GENERAL	0	0	15,318	4,075,343	0	29,953	0	0	0	0	0	0	4,120,613	
CHILDREN'S REHAB SERVICES	1,431	1,431	1,431	1,901	1,901	1,426	0	0	0	0	0	0	9,522	
FEE FOR SERVICE - ACUTE	2,287,256	2,691,862	2,142,231	1,981,630	2,199,736	2,072,337	0	0	0	0	0	0	13,375,052	
FFS - PRIOR QUARTER COVERAGE	202,656	242,552	172,172	168,385	251,444	168,159	0	0	0	0	0	0	1,205,366	
EMERGENCY SERVICES - FEDERAL	3,157,734	4,543,147	3,298,138	3,345,340	4,224,989	3,425,218	0	0	0	0	0	0	21,994,567	
FFS MEDICAID IN PUBLIC SCHOOLS	0	143	122	154	155	209	0	0	0	0	0	0	783	
INPATIENT INMATES FFS	47,079	7,086	51,595	22,751	37,922	31,158	0	0	0	0	0	0	197,591	
STATE ONLY TRBHA FFS	0	0	0	2,449	0	0	0	0	0	0	0	0	2,449	
FFS TRBHA FEE FOR SERVICE	21,432	99,702	78,173	156,029	165,931	129,909	0	0	0	0	0	0	651,175	
MARICOPA CTY INMATES FFS	0	8,584	0	8,868	0	4,324	0	0	0	0	0	0	21,777	
REINSURANCE - ACUTE	394,053	1,131,954	693,714	710,923	877,023	572,747	0	0	0	0	0	0	4,380,414	
SMIB - ACUTE	487	365	0	365	0	122	0	0	0	0	0	0	1,340	
	38,639,830	40,424,404	38,251,198	43,879,922	41,037,088	45,920,155	0	0	0	0	0	0	248,152,596	
	866,974,755	896,552,993	860,121,229	963,309,357	987,699,392	1,055,735,708	0	0	0	0	0	0	5,630,393,434	

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	1,313,240	1,495,618	0	0	0	0	0	0	4,296,099	
KidsCare - FEE FOR SERVICE	0	230	1,062	10,448	32,270	38,910	0	0	0	0	0	0	82,921	
KidsCare - MENTAL HEALTH	0	0	0	208,753	0	-86	0	0	0	0	0	0	208,666	
KidsCare - REINSURANCE	82,674	199	63,656	150	0	0	0	0	0	0	0	0	146,679	
KidsCare - CHILD REHAB SERVICES	0	0	0	0	1,426	1,901	0	0	0	0	0	0	3,327	

867,116838,,245938	896,66103,,448758	860,653187,,976334	9641,,400932,,413924	9891,,034466,,392368	1,0571,,257326,,035413	00	00	00	00	00	00	5,6354,,173463,,516315	

TGORTAANLDTTIOTLTEALXXI

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 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	604.33	634.60	0.00	0.00	0.00	0.00	0.00	0.00		1,703.80		
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	40.46	0.00	0.00	0.00	0.00	0.00	0.00		879.24		
1004	TANF 14-20 MALE WITH	330.49	330.49	330.49	321.29	321.29	321.29	0.00	0.00	0.00	0.00	0.00	0.00		1,955.34		
1005	TANF 14-20 FEMALE WI	4,171.93	2,017.48	2,017.48	1,949.42	1,949.42	1,949.42	0.00	0.00	0.00	0.00	0.00	0.00		14,055.15		
1006	TANF 21-44 MALE WITH	46,322.50	44,791.85	45,967.12	48,079.53	47,522.03	47,061.91	0.00	0.00	0.00	0.00	0.00	0.00		279,744.94		
1007	TANF 21-44 FEMALE WI	95,394.39	105,867.62	103,594.71	101,741.15	92,114.31	88,694.68	0.00	0.00	0.00	0.00	0.00	0.00		587,406.86		
1008	TANF 45-64 M & F WIT	142,836.05	148,048.76	155,026.25	139,573.05	133,200.64	145,189.70	0.00	0.00	0.00	0.00	0.00	0.00		863,874.45		
1009	TANF 65+ M & F WITH	49,195.35	58,493.70	60,090.27	59,039.19	54,968.63	58,038.42	0.00	0.00	0.00	0.00	0.00	0.00		339,825.56		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	7,370.41	1,767.37	0.00	0.00	0.00	0.00	0.00	0.00		9,137.78		
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	159.78	6,286.41	0.00	0.00	0.00	0.00	0.00	0.00		10,193.69		
100G	TANF 21-44 FEMALE WI	979.52	875.88	956.18	2,475.86	4,188.11	2,247.92	0.00	0.00	0.00	0.00	0.00	0.00		11,723.47		
100H	TANF 44-64 M & F WIT	2,819.97	2,677.17	1,834.18	1,521.71	790.81	3,372.56	0.00	0.00	0.00	0.00	0.00	0.00		13,016.40		
100J	TANF 65+ M & F WITH	1,265.56	285.44	454.14	2,354.78	606.53	4,192.00	0.00	0.00	0.00	0.00	0.00	0.00		9,158.45		
1011	TANF <1 M & F NON-ME	5,979,797.90	5,818,316.42	5,667,860.79	5,264,357.30	5,238,796.13	6,667,979.20	0.00	0.00	0.00	0.00	0.00	0.00		34,637,107.74		
1012	TANF 01-05 M & F NON	1,982,751.29	2,047,597.48	2,192,866.31	2,249,311.32	2,307,392.92	3,139,622.31	0.00	0.00	0.00	0.00	0.00	0.00		13,919,541.63		
1013	TANF 06-13 M & F NON	3,400,616.72	3,421,770.87	3,534,174.18	3,620,105.00	3,691,889.62	5,064,058.92	0.00	0.00	0.00	0.00	0.00	0.00		22,732,615.31		
1014	TANF 14-20 MALE NON-	1,438,649.82	1,450,579.41	1,494,737.30	1,497,813.87	1,504,698.09	1,967,644.60	0.00	0.00	0.00	0.00	0.00	0.00		9,354,123.09		
1015	TANF 14-20 FEMALE N O	2,947,635.53	2,963,712.47	2,982,834.82	3,056,785.05	3,049,939.84	3,887,878.75	0.00	0.00	0.00	0.00	0.00	0.00		18,888,786.46		
1016	TANF 21-44 MALE NON-	4,500,694.58	4,626,964.05	4,729,641.38	4,653,204.33	4,660,635.41	5,465,529.66	0.00	0.00	0.00	0.00	0.00	0.00		28,636,669.41		
1017	TANF 21-44 FEMALE N O	21,599,593.38	22,024,671.06	22,380,320.25	22,872,264.16	22,944,498.02	27,041,452.63	0.00	0.00	0.00	0.00	0.00	0.00		138,862,799.50		
1018	TANF 45-64 M & F NON	9,002,157.42	9,224,599.92	9,390,965.88	9,650,910.16	9,680,286.24	11,395,064.44	0.00	0.00	0.00	0.00	0.00	0.00		58,343,984.06		
1019	TANF 65+ M & F NON-M	34,981.92	37,207.86	35,682.69	36,767.43	37,806.68	44,420.37	0.00	0.00	0.00	0.00	0.00	0.00		226,866.95		
101A	TANF < 1 M & F NON-M	1,374,906.97	824,333.81	619,875.99	568,986.07	853,162.61	1,639,938.42	0.00	0.00	0.00	0.00	0.00	0.00		5,881,203.87		
101B	TANF 01-05 M & F NON	37,377.77	34,988.09	17,898.02	21,273.11	19,327.94	26,498.52	0.00	0.00	0.00	0.00	0.00	0.00		157,363.45		
101C	TANF 06-13 M & F NON	31,887.35	38,379.00	14,389.60	17,369.00	14,533.97	10,118.95	0.00	0.00	0.00	0.00	0.00	0.00		126,677.87		
101D	TANF 14-20 MALE NON-	40,214.75	26,404.71	25,064.46	17,702.82	15,421.37	23,296.40	0.00	0.00	0.00	0.00	0.00	0.00		148,104.51		
101E	TANF 14-20 FEMALE N O	75,894.61	51,114.86	39,158.76	31,456.00	26,405.58	26,674.76	0.00	0.00	0.00	0.00	0.00	0.00		250,704.57		
101F	TANF 21-44 MALE NON-	332,694.14	181,172.60	142,480.58	122,564.13	125,386.70	122,533.93	0.00	0.00	0.00	0.00	0.00	0.00		1,026,832.08		
101G	TANF 21-44 FEMALE N O	1,014,213.65	519,454.48	432,147.43	353,048.43	322,246.49	381,070.67	0.00	0.00	0.00	0.00	0.00	0.00		3,022,181.15		
101H	TANF 44-64 M & F NON	352,715.91	224,440.64	206,574.18	154,380.25	135,951.78	131,149.27	0.00	0.00	0.00	0.00	0.00	0.00		1,205,212.03		
101J	TANF 65+ N & F NON-M	2,006.75	449.69	1,257.99	1,285.39	1,332.45	1,160.97	0.00	0.00	0.00	0.00	0.00	0.00		7,493.24		
1026	TANF 21-44 MALE WITH	9,851.45	9,746.05	9,204.20	12,275.50	9,559.38	11,275.00	0.00	0.00	0.00	0.00	0.00	0.00		61,911.58		
1027	TANF 21-44 FEMALE WI	37,746.13	34,109.50	35,005.01	42,789.00	43,224.39	55,840.93	0.00	0.00	0.00	0.00	0.00	0.00		248,714.96		
1028	TANF 45-64 M & F WIT	39,714.64	36,360.22	36,397.64	43,817.32	41,125.45	54,047.68	0.00	0.00	0.00	0.00	0.00	0.00		251,462.95		

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1029	TANF 65+ M & F WITH	11,125.03	11,154.44	10,081.40	13,757.61	16,159.29	23,545.55	0.00	0.00	0.00	0.00	0.00	0.00		85,823.32		
102F	TANF 21-44 MALE WITH	586.66	47.08	0.00	0.00	79.00	38.55	0.00	0.00	0.00	0.00	0.00	0.00		751.29		
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	1,620.14	57.55	0.00	0.00	0.00	0.00	0.00	0.00		6,234.82		
102J	TANF 65+ M & F WITH	0.00	0.00	403.46	1,811.12	202.18	1,069.19	0.00	0.00	0.00	0.00	0.00	0.00		3,485.95		
2100	SSI AGED WITH MEDIC A	842,955.42	868,175.55	898,652.88	874,208.91	889,564.98	997,567.98	0.00	0.00	0.00	0.00	0.00	0.00		5,371,125.72		
210Z	SSI AGED WITH MEDIC A	28,411.56	21,306.88	29,919.56	26,997.93	33,316.23	20,125.60	0.00	0.00	0.00	0.00	0.00	0.00		160,077.76		
2110	SSI AGED NON-MEDIC AR	4,812,760.61	4,806,493.94	4,896,356.19	5,249,073.49	5,316,138.47	6,256,315.66	0.00	0.00	0.00	0.00	0.00	0.00		31,337,138.36		
211Z	SSI AGED NON-MEDIC AR	127,183.08	147,235.09	133,695.88	151,331.35	125,347.45	140,553.26	0.00	0.00	0.00	0.00	0.00	0.00		825,346.11		
2120	SSI AGED WITH QMB	5,230,861.87	5,318,628.79	5,550,430.64	5,648,335.12	5,672,717.59	6,666,515.40	0.00	0.00	0.00	0.00	0.00	0.00		34,087,489.41		
212Z	SSI AGED WITH QMB P P	4,349.89	5,632.30	8,612.62	3,769.70	5,489.56	4,117.50	0.00	0.00	0.00	0.00	0.00	0.00		31,971.57		
2200	SSI DISABLED WITH M E	2,492,441.51	2,520,758.68	2,512,167.69	2,556,169.43	2,493,359.25	2,585,610.23	0.00	0.00	0.00	0.00	0.00	0.00		15,160,506.79		
220Z	SSI DISABLED WITH M E	17,675.35	12,942.73	15,910.05	32,865.45	38,733.87	79,796.07	0.00	0.00	0.00	0.00	0.00	0.00		197,923.52		
2210	SSI DISABLED NON-ME D	58,494,437.05	58,018,801.11	58,160,271.17	61,432,756.89	61,396,508.54	69,753,176.02	0.00	0.00	0.00	0.00	0.00	0.00		367,255,950.78		
221Z	SSI DISABLED NON-ME D	433,439.79	419,148.90	538,099.82	494,840.97	471,406.12	446,507.00	0.00	0.00	0.00	0.00	0.00	0.00		2,803,442.60		
2220	SSI DISABLED WITH Q M	15,152,983.36	15,434,374.34	15,821,632.46	16,669,682.51	16,659,904.21	17,647,601.63	0.00	0.00	0.00	0.00	0.00	0.00		97,386,178.51		
222Z	SSI DISABLED WITH Q M	3,347.64	4,509.15	6,680.06	8,799.36	18,045.88	28,908.73	0.00	0.00	0.00	0.00	0.00	0.00		70,290.82		
2300	SSI BLIND WITH MEDIC	6,019.11	6,344.44	6,155.38	6,088.34	5,983.02	6,897.85	0.00	0.00	0.00	0.00	0.00	0.00		37,488.14		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	290.29	0.00	0.00	0.00	0.00	0.00	0.00		290.29		
2310	SSI BLIND NON-MEDIC A	416,766.24	425,608.52	424,789.82	448,406.94	455,856.96	531,029.94	0.00	0.00	0.00	0.00	0.00	0.00		2,702,458.42		
231Z	SSI BLIND NON-MEDIC A	8,216.96	9,934.43	3,994.90	1,156.13	9,959.35	4,956.96	0.00	0.00	0.00	0.00	0.00	0.00		38,218.73		
2320	SSI BLIND WITH QMB	48,973.62	48,961.67	49,379.89	45,910.44	31,177.50	52,726.05	0.00	0.00	0.00	0.00	0.00	0.00		277,129.17		
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	2,616.24	3,414.91	0.00	0.00	0.00	0.00	0.00	0.00		9,089.10		
4302	SOBRA CHILD 01-05 M	335.78	335.78	539.50	1,018.73	1,096.85	1,899.47	0.00	0.00	0.00	0.00	0.00	0.00		5,226.11		
4303	SOBRA CHILD 06-13 M	1,544.93	1,519.86	1,659.86	2,303.36	2,801.95	1,628.46	0.00	0.00	0.00	0.00	0.00	0.00		11,458.42		
4304	SOBRA CHILD 14-20 MA	453.68	315.45	353.85	728.39	1,278.19	1,000.27	0.00	0.00	0.00	0.00	0.00	0.00		4,129.83		
4305	SOBRA CHILD 14-20 FE	2,687.14	3,209.63	3,132.73	3,721.21	2,857.51	3,080.11	0.00	0.00	0.00	0.00	0.00	0.00		18,688.33		
430A	SOBRA CHILD < 1 M &	0.00	0.00	467.78	0.00	340.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		808.61		
430B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	-203.90	23.11	0.00	0.00	0.00	0.00	0.00	0.00		-180.79		
430C	SOBRA CHILD 06-13 M	19.65	0.00	91.02	341.04	95.52	-303.68	0.00	0.00	0.00	0.00	0.00	0.00		243.55		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	107.04	258.87	252.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		618.70		
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	18,294,595.80	21,621,494.17	0.00	0.00	0.00	0.00	0.00	0.00		116,162,256.18		
4312	SOBRA CHILD 01-05 M	23,848,737.73	23,824,566.62	23,927,832.96	23,969,627.82	23,700,421.28	28,297,919.77	0.00	0.00	0.00	0.00	0.00	0.00		147,569,106.18		
4313	SOBRA CHILD 06-13 M	29,886,460.52	30,038,640.77	30,367,237.37	30,504,380.74	30,473,626.73	36,245,124.74	0.00	0.00	0.00	0.00	0.00	0.00		187,515,470.87		

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4314	SOBRA CHILD 14-20 MA	9,328,457.36	9,454,281.74	9,680,287.07	9,625,843.54	9,765,658.28	11,628,439.62	0.00	0.00	0.00	0.00	0.00	0.00		59,482,967.61		
4315	SOBRA CHILD 14-20 FE	14,077,063.28	14,260,086.80	14,601,597.35	15,117,076.36	15,314,970.13	18,231,821.06	0.00	0.00	0.00	0.00	0.00	0.00		91,602,614.98		
431A	SOBRA CHILD < 1 M &	1,177,252.46	693,970.63	867,096.37	887,403.26	188,046.92	124,120.40	0.00	0.00	0.00	0.00	0.00	0.00		3,937,890.04		
431B	SOBRA CHILD 01-05 M	566,517.45	313,543.99	297,175.19	272,088.67	197,833.20	278,397.78	0.00	0.00	0.00	0.00	0.00	0.00		1,925,556.28		
431C	SOBRA CHILD 6-13 M& F	721,463.46	331,359.44	312,515.41	256,903.62	209,162.78	240,393.88	0.00	0.00	0.00	0.00	0.00	0.00		2,071,798.59		
431D	SOBRA CHILD 14-20 MA	521,496.21	233,778.90	223,364.34	187,361.77	159,838.31	161,002.45	0.00	0.00	0.00	0.00	0.00	0.00		1,486,841.98		
431E	SOBRA CHILD 14-20 FE	561,544.85	276,156.48	306,650.61	249,415.69	203,761.63	211,908.27	0.00	0.00	0.00	0.00	0.00	0.00		1,809,437.53		
4321	SOBRA CHILD <1 M & F	0.00	507.63	-507.63	456.79	456.79	456.79	0.00	0.00	0.00	0.00	0.00	0.00		1,370.37		
4322	SOBRA CHILD 01-05 M	230.53	225.94	140.29	115.09	115.09	189.42	0.00	0.00	0.00	0.00	0.00	0.00		1,016.36		
4323	SOBRA CHILD 06-13 M	0.00	-110.88	0.00	110.64	115.09	70.14	0.00	0.00	0.00	0.00	0.00	0.00		184.99		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	154.46	0.00	45.62	0.00	0.00	0.00	0.00	0.00	0.00		200.08		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	841.21	841.21	841.21	0.00	0.00	0.00	0.00	0.00	0.00		2,523.63		
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	0.00	0.00	0.00	85.85	266.13	266.13	0.00	0.00	0.00	0.00	0.00	0.00		618.11		
5007	SOBRA PREG 21-44 FE M	29,492.39	23,326.23	32,995.60	25,701.87	24,041.71	21,600.95	0.00	0.00	0.00	0.00	0.00	0.00		157,158.75		
5008	SOBRA PREG 45-64 FE M	4,151.82	3,635.38	3,635.38	5,404.11	5,404.11	6,398.24	0.00	0.00	0.00	0.00	0.00	0.00		28,629.04		
500E	SOBRA PREG 14-20 FE M	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		
500G	SOBRA PREG 21-44 FE M	621.37	527.22	421.15	1,521.75	1,483.48	859.89	0.00	0.00	0.00	0.00	0.00	0.00		5,434.86		
500H	SOBRA PREG 45-64 FE M	242.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242.26		
5013	SOBRA PREG 09-13 FE M	1,407.36	911.78	1,029.83	909.86	905.20	974.43	0.00	0.00	0.00	0.00	0.00	0.00		6,138.46		
5015	SOBRA PREG 14-20 FE M	1,116,187.80	1,054,868.69	1,049,312.44	1,038,713.88	984,770.34	1,217,082.66	0.00	0.00	0.00	0.00	0.00	0.00		6,460,935.81		
5017	SOBRA PREG 21-44 FE M	5,647,435.21	5,224,978.99	5,240,195.32	5,315,378.02	5,139,266.89	6,230,214.69	0.00	0.00	0.00	0.00	0.00	0.00		32,797,469.12		
5018	SOBRA PREG 45-64 FE M	29,549.66	22,736.94	27,265.92	27,573.15	30,400.52	36,560.26	0.00	0.00	0.00	0.00	0.00	0.00		174,086.45		
501C	SOBRA PREG 09-13 FE M	33.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.46		
501E	SOBRA PREG 14-20 FE M	137,111.91	56,188.00	58,579.29	46,010.89	47,323.53	53,280.95	0.00	0.00	0.00	0.00	0.00	0.00		398,494.57		
501G	SOBRA PREG 21-44 FE M	501,169.31	249,043.62	241,784.55	223,937.28	202,877.40	237,060.93	0.00	0.00	0.00	0.00	0.00	0.00		1,655,873.09		
501H	SOBRA PREG 45-64 FE M	2,476.09	1,453.55	2,104.23	1,393.55	211.23	491.83	0.00	0.00	0.00	0.00	0.00	0.00		8,130.48		
5027	SOBRA PREG 21-44 FE M	13,528.33	12,323.20	13,443.00	18,199.10	24,727.05	32,629.74	0.00	0.00	0.00	0.00	0.00	0.00		114,850.42		
5028	SOBRA PREG 45-64 FE M	2,212.75	2,212.75	2,212.75	2,334.33	2,661.28	405.42	0.00	0.00	0.00	0.00	0.00	0.00		12,039.28		
502G	SOBRA PREG 21-44 FE M	163.64	246.72	144.97	283.10	71.88	145.54	0.00	0.00	0.00	0.00	0.00	0.00		1,055.85		
502H	SOBRA PREG 45-64 FE M	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		
SUBTOTAL:	250,093,559.53	247,431,996.74	250,079,851.3	9  254,460,879.99	253,693,976.91	297,655,399.76	0.00	0.00	0.00	0.00	0.00	0.00		1,553,415,664.32		

9910	TANF & SOBRA CHILDR E	1,823,715.69	2,120,615.87	1,880,550.08	1,984,545.39	1,786,184.79	1,702,172.89	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	36,132.84	68,606.36	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	190,093.86	236,566.90	146,178.87	184,526.83	178,796.57	217,366.98	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,297,784.71	
247,746.39	
1,153,530.01	

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

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9950	S.O.B.R.A. KICK PAYM	13,033,453.67	14,801,044.44	14,622,927.85	14,047,224.21	13,562,906.17	13,638,342.01	0.00	0.00	0.00	0.00	0.00	0.00	83,705,898.35	
SUBTOTAL:	15,085,061.23	17,195,121.06	16,693,178.01	16,241,090.55	15,564,020.37	15,626,488.24	0.00	0.00	0.00	0.00	0.00	0.00	96,404,959.46	

3100	TRANSPLANT OPTION 1	49.50	49.50	49.50	49.50	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.50	49.50	49.50	49.50	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	

264.00	
264.00	

1106	TANF EXPANDED 21-44	282,644.01	293,807.76	299,501.69	277,014.62	268,149.29	275,700.50	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	803,584.94	786,830.31	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	1,565,454.05	1,731,799.86	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	469,313.74	549,864.62	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	6,261.97	3,322.16	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	11,070.94	12,119.57	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	19,087.28	14,444.80	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	9,711.19	7,486.03	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	322.99	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	1,898.32	8,140.07	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	11,827.50	30,696.33	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	93,989.59	115,114.05	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	526,094.80	625,527.48	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	5,160,601.35	6,082,756.37	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	19,904,407.77	23,230,590.87	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	12,064,807.64	14,246,489.77	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	33,409.10	42,210.57	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	34.90	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	1,669.50	1,501.50	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	8,603.79	8,002.30	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	104,345.89	107,174.44	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	243,533.39	296,843.66	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	130,369.36	190,961.64	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	315.38	804.86	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	209,459.95	235,445.96	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	612,274.47	686,379.35	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	756,936.29	889,763.00	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	257,449.40	314,120.09	0.00	0.00	0.00	0.00	0.00	0.00	

1,696,817.87	
5,039,544.01	
9,844,897.95	
2,948,965.12	
26,781.75	
62,110.01	
135,124.06	
60,523.68	
1,345.52	
20,725.30	
98,158.89	
589,167.96	
3,281,225.10	
31,722,503.83	
118,646,333.88	
72,227,204.28	
223,432.02	
1,927.54	
8.90	
382.64	
24,630.24	
75,944.04	
961,299.60	
2,213,056.10	
1,361,568.80	
17,187.64	
2,212.75	
1,102,447.73	
3,245,895.14	
3,846,320.41	
1,320,927.38	

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
112F	TANF EXPANDED 21-44	1,973.32	1,569.61	1,040.20	922.45	232.14	627.15	0.00	0.00	0.00	0.00	0.00	0.00		6,364.87		
112G	TANF EXPANDED 21-44	1,409.59	2,117.93	729.03	577.31	276.98	1,857.64	0.00	0.00	0.00	0.00	0.00	0.00		6,968.48		
112H	TANF EXPANDED 45-64	6,149.15	3,315.72	5,472.86	2,754.61	1,419.99	4,864.61	0.00	0.00	0.00	0.00	0.00	0.00		23,976.94		
112J	TANF EXPANDED 65+
M&	2,268.02	1,088.62	6,118.42	3,220.68	1,119.22	125.85	0.00	0.00	0.00	0.00	0.00	0.00		13,940.81		
2400	SSI AGED EXPANDED WI	79,751.62	88,972.48	94,368.60	91,017.93	90,743.11	101,158.12	0.00	0.00	0.00	0.00	0.00	0.00		546,011.86		
240Z	SSI AGED EXPANDED WI	18,469.11	13,440.92	19,374.43	13,803.51	15,940.39	15,301.77	0.00	0.00	0.00	0.00	0.00	0.00		96,330.13		
2410	SSI AGED EXPANDED NO	113,134.36	107,329.50	100,424.49	104,189.94	96,726.54	159,654.45	0.00	0.00	0.00	0.00	0.00	0.00		681,459.28		
241Z	SSI AGED EXPANDED NO	5,881.63	3,345.40	5,620.33	5,022.54	10,604.36	4,682.55	0.00	0.00	0.00	0.00	0.00	0.00		35,156.81		
2420	SSI AGED EXPANDED WI	3,821,442.08	3,751,853.32	3,705,430.54	3,483,946.60	3,328,627.31	4,030,494.09	0.00	0.00	0.00	0.00	0.00	0.00		22,121,793.94		
242Z	SSI AGED EXPANDED WI	8,856.22	3,806.30	10,030.52	2,570.04	3,942.59	4,471.07	0.00	0.00	0.00	0.00	0.00	0.00		33,676.74		
2500	SSI BLIND EXPANDED W	140.23	140.23	140.23	132.06	132.06	132.06	0.00	0.00	0.00	0.00	0.00	0.00		816.87		
2520	SSI BLIND EXPANDED W	270.25	113.62	130.02	122.42	122.42	164.64	0.00	0.00	0.00	0.00	0.00	0.00		923.37		
2600	SSI DISABLED EXPAND E	254,582.86	222,372.65	227,664.21	204,981.08	183,819.53	195,144.58	0.00	0.00	0.00	0.00	0.00	0.00		1,288,564.91		
260Z	SSI DISABLED EXPAND E	10,892.09	7,541.46	10,094.76	34,308.17	34,711.64	42,168.34	0.00	0.00	0.00	0.00	0.00	0.00		139,716.46		
2610	SSI DISABLED EXPAND E	1,833,932.47	1,565,603.77	1,414,716.37	1,434,111.95	1,366,957.30	1,659,024.25	0.00	0.00	0.00	0.00	0.00	0.00		9,274,346.11		
261Z	SSI DISABLED EXPAND E	33,726.08	25,186.67	34,152.89	26,762.25	21,901.27	28,933.10	0.00	0.00	0.00	0.00	0.00	0.00		170,662.26		
2620	SSI DISABLED EXPAND E	8,960,995.29	8,821,264.08	8,606,635.05	8,429,073.96	8,340,750.91	8,633,717.87	0.00	0.00	0.00	0.00	0.00	0.00		51,792,437.16		
262Z	SSI DISABLED EXPAND E	3,880.96	3,944.92	4,241.27	7,596.05	8,545.54	16,312.05	0.00	0.00	0.00	0.00	0.00	0.00		44,520.79		
SUBTOTAL:	56,720,391.41	55,619,947.17	55,902,881.0	1    56,658,635.91	56,781,235.09	65,393,247.34	0.00	0.00	0.00	0.00	0.00	0.00		347,076,337.93		

9911	SB PAYMENT FOR TAN F	1,240,641.58	1,357,800.62	1,384,207.93	1,414,042.00	1,256,317.58	1,217,357.70	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	6,295.68	6,425.30	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	6,274.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,259,516.10	1,364,091.53	1,396,847.12	1,414,042.00	1,262,613.26	1,223,783.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,870,367.41	
44,251.36	
6,274.24	
7,920,893.01	

3306	AHC CARE MALE 21-44	0.00	-18.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3308	AHC CARE M&F 45-64 W	0.00	-43.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3309	AHC CARE M&F 65+ W/	0.00	-24.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3314	AHC CARE MALE 14-20	0.00	-2,158.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3315	AHC CARE FEMALE 14- 2	0.00	-3,005.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	-4,860.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	-5,400.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	-16,486.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3326	AHC CARE MALE 21-44	0.00	-42.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3328	AHC CARE M&F 45-64 W	0.00	-24.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-32,065.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

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

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		-9.23		
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		-24.92		
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		-14,265.28		
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		
SUBTOTAL:	0.00	-96,840.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-96,840.05		

3506	ADULT 40-100% MALE
2	-1,357.37	3,232.53	3,514.25	2,792.73	2,557.08	3,835.22	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	1,147.56	4,094.51	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	27,957.92	29,657.56	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	3,374.47	9,627.01	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	961.21	1,818.24	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	572.62	6,442.73	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	6,089.14	1,620.14	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	2,679,734.54	3,066,598.71	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	2,944,277.06	3,359,308.01	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	10,229,817.74	12,015,104.51	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	8,515,585.02	10,023,923.14	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	20,226,019.25	23,766,092.64	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	8,607.35	14,085.53	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	68,625.54	80,777.13	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	57,829.81	90,964.14	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	299,835.84	436,734.43	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	291,851.74	365,226.24	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	602,011.16	850,806.55	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	596.31	-946.13	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	660.99	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	121.31	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	1,624.94	4,972.99	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	1,503.29	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	314.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14,574.44	
13,149.31	
173,569.65	
32,963.27	
5,327.63	
8,311.03	
18,087.82	
1,172.03	
15,787,483.56	
17,376,018.46	
59,928,590.64	
49,643,585.93	
119,638,371.89	
59,830.39	
657,150.61	
675,556.14	
2,925,456.52	
2,303,938.01	
5,085,162.97	
26,909.46	
7,448.69	
3,483.88	
20,678.36	
2,401.33	
1,149.87	

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
352G	ADULT 40-100% FEMAL E	0.00	0.00	360.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		360.43		
352H	ADULT 40-100% M&F 45	0.00	218.00	733.84	609.31	256.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,817.30		
352J	ADULT 40-100% M&F 65	1,264.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,264.42		
3704	ADULT <40% EXP MAL E	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 MAL E	13,532.14	18,941.00	17,216.81	24,670.37	19,392.65	9,537.39	0.00	0.00	0.00	0.00	0.00	0.00		103,290.36		
3707	ADULT <40% EXP FEM AL	8,594.39	14,900.87	5,263.02	6,423.65	7,134.62	2,389.39	0.00	0.00	0.00	0.00	0.00	0.00		44,705.94		
3708	ADULT <40% EXP M&F 4	52,776.27	51,121.40	57,025.92	45,950.41	46,351.35	44,925.65	0.00	0.00	0.00	0.00	0.00	0.00		298,151.00		
3709	ADULT <40% EXP M&F 6	1,670.61	3,656.59	0.00	1,948.31	2,400.09	3,408.73	0.00	0.00	0.00	0.00	0.00	0.00		13,084.33		
370F	ADULT <40% EXP MAL E	23.96	2,730.39	1,914.79	11,055.11	6,234.81	4,229.76	0.00	0.00	0.00	0.00	0.00	0.00		26,188.82		
370G	ADULT <40% EXP FEM AL	5,014.07	87.20	856.03	464.77	936.45	1,487.75	0.00	0.00	0.00	0.00	0.00	0.00		8,846.27		
370H	ADULT <40% EXP M&F 4	41,292.32	3,366.20	7,910.98	6,020.21	697.07	1,392.78	0.00	0.00	0.00	0.00	0.00	0.00		60,679.56		
3714	ADULT <40% EXP MAL E	5,588,252.13	5,551,951.34	5,502,458.42	5,759,882.37	5,647,657.89	6,561,511.56	0.00	0.00	0.00	0.00	0.00	0.00		34,611,713.71		
3715	ADULT <40% EXP FEM AL	4,892,572.32	4,914,224.47	4,853,114.07	5,049,252.03	4,963,023.23	5,783,463.79	0.00	0.00	0.00	0.00	0.00	0.00		30,455,649.91		
3716	ADULT <40% EXP MAL E	30,620,225.72	31,120,943.63	31,307,662.41	33,361,166.36	33,620,279.22	39,213,040.90	0.00	0.00	0.00	0.00	0.00	0.00		199,243,318.24		
3717	ADULT <40% EXP FEM AL	18,697,678.92	18,946,793.84	19,112,832.31	20,277,539.37	20,527,144.97	23,859,107.37	0.00	0.00	0.00	0.00	0.00	0.00		121,421,096.78		
3718	ADULT <40% EXP M&F 4	37,997,636.85	38,500,400.84	38,797,116.18	41,377,285.11	41,621,184.87	48,401,298.11	0.00	0.00	0.00	0.00	0.00	0.00		246,694,921.96		
3719	ADULT <40% EXP M&F 6	24,175.96	27,528.55	18,303.91	28,413.51	22,584.55	29,933.96	0.00	0.00	0.00	0.00	0.00	0.00		150,940.44		
371D	ADULT <40% EXP MAL E	527,076.34	241,808.81	265,078.05	222,838.34	176,484.70	183,566.85	0.00	0.00	0.00	0.00	0.00	0.00		1,616,853.09		
371E	ADULT <40% EXP FEM AL	415,699.52	230,089.36	214,764.40	182,776.31	141,258.86	154,392.19	0.00	0.00	0.00	0.00	0.00	0.00		1,338,980.64		
371F	ADULT <40% EXP MAL E	4,933,492.46	1,889,607.04	2,149,528.91	1,889,147.39	1,502,047.44	1,758,047.87	0.00	0.00	0.00	0.00	0.00	0.00		14,121,871.11		
371G	ADULT <40% EXP FEM AL	2,488,666.27	1,102,987.94	1,119,521.51	1,140,663.68	907,211.02	1,059,797.93	0.00	0.00	0.00	0.00	0.00	0.00		7,818,848.35		
371H	ADULT <40% EXP M&F 4	4,347,109.87	1,716,162.75	1,833,085.61	1,631,801.14	1,412,503.64	1,778,289.60	0.00	0.00	0.00	0.00	0.00	0.00		12,718,952.61		
371J	ADULT <40% EXP M&F 6	0.00	1,906.05	554.43	0.00	0.00	5,406.48	0.00	0.00	0.00	0.00	0.00	0.00		7,866.96		
3726	ADULT <40% EXP MAL E	3,446.36	2,080.08	5,035.25	4,333.86	5,684.84	6,290.68	0.00	0.00	0.00	0.00	0.00	0.00		26,871.07		
3727	ADULT <40% EXP FEM AL	1,623.77	1,311.51	497.15	0.00	90.00	3,186.06	0.00	0.00	0.00	0.00	0.00	0.00		6,708.49		
3728	ADULT <40% EXP M&F 4	7,151.55	6,415.33	4,602.98	5,737.85	3,360.98	9,026.93	0.00	0.00	0.00	0.00	0.00	0.00		36,295.62		
3729	ADULT <40% EXP M&F 6	475.74	475.74	378.69	0.00	0.00	468.79	0.00	0.00	0.00	0.00	0.00	0.00		1,798.96		
372F	ADULT <40% EXP MAL E	1,504.22	452.54	22.53	1,613.88	2,418.90	4,535.06	0.00	0.00	0.00	0.00	0.00	0.00		10,547.13		
372G	ADULT <40% EXP FEM AL	675.81	218.00	0.00	0.00	494.70	2,765.25	0.00	0.00	0.00	0.00	0.00	0.00		4,153.76		
372H	ADULT <40% EXP M&F 4	1,005.63	1,712.08	1,509.31	1,669.37	3,454.24	2,604.03	0.00	0.00	0.00	0.00	0.00	0.00		11,954.66		
SUBTOTAL:	154,087,363.33	146,645,800.61	148,103,646.2	4  156,805,005.91	156,610,339.34	183,016,472.76	0.00	0.00	0.00	0.00	0.00	0.00		945,268,628.19		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	129.91	0.00	0.00	0.00	0.00	0.00	0.00	

129.91	

9935	BIRTH SUPP PAYMENT A	287,840.28	262,331.58	201,591.00	278,823.61	241,562.08	333,303.14	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	539,404.91	558,552.39	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	886,353.69	940,658.43	886,799.5	4	808,768.49	780,966.99	891,855.53	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,605,451.69	
3,589,950.98	
5,195,402.67	

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3906	NEWLY ELIGIBLE MALE	4,896.46	3,633.24	2,121.67	3,220.46	569.79	2,399.56	0.00	0.00	0.00	0.00	0.00	0.00		16,841.18		
3907	NEWLY ELIGIBLE FEMA L	2,726.25	3,437.55	1,624.70	1,969.81	1,586.87	2,479.22	0.00	0.00	0.00	0.00	0.00	0.00		13,824.40		
3908	NEWLY ELIGIBLE M&F 4	37,160.26	34,294.07	28,140.59	27,537.99	23,080.17	32,646.74	0.00	0.00	0.00	0.00	0.00	0.00		182,859.82		
3909	NEWLY ELIGIBLE M&F 6	2,216.27	2,338.07	4,878.84	3,839.81	4,250.06	6,298.52	0.00	0.00	0.00	0.00	0.00	0.00		23,821.57		
390F	NEWLY ELIGIBLE MALE	0.00	-236.15	149.13	1,045.25	0.00	798.46	0.00	0.00	0.00	0.00	0.00	0.00		1,756.69		
390G	NEWLY ELIGIBLE FEMA L	1,662.50	511.99	535.13	0.00	0.00	102.15	0.00	0.00	0.00	0.00	0.00	0.00		2,811.77		
390H	NEWLY ELIGIBLE M&F 4	4,162.37	385.56	3,911.38	2,087.92	273.38	618.88	0.00	0.00	0.00	0.00	0.00	0.00		11,439.49		
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	1,098,114.35	1,301,276.48	0.00	0.00	0.00	0.00	0.00	0.00		6,538,939.12		
3915	NEWLY ELIGIBLE FEMA L	1,183,692.34	1,197,080.00	1,219,383.57	1,293,607.29	1,304,366.86	1,507,060.97	0.00	0.00	0.00	0.00	0.00	0.00		7,705,191.03		
3916	NEWLY ELIGIBLE MALE	7,130,854.84	7,139,765.29	7,195,270.63	7,612,877.92	7,638,531.67	9,161,153.44	0.00	0.00	0.00	0.00	0.00	0.00		45,878,453.79		
3917	NEWLY ELIGIBLE FEMA L	10,276,450.45	10,168,360.64	10,192,574.11	10,673,216.55	10,631,442.38	12,591,666.15	0.00	0.00	0.00	0.00	0.00	0.00		64,533,710.28		
3918	NEWLY ELIGIBLE M&F 4	10,565,542.96	10,565,902.98	10,633,336.78	11,295,327.40	11,400,992.17	13,558,092.09	0.00	0.00	0.00	0.00	0.00	0.00		68,019,194.38		
3919	NEWLY ELIGIBLE M&F 6	5,613.74	6,337.38	4,809.99	6,649.62	5,089.92	9,131.94	0.00	0.00	0.00	0.00	0.00	0.00		37,632.59		
391D	NEWLY ELIGIBLE MALE	53,561.17	31,001.51	35,796.42	26,630.20	17,981.79	22,666.66	0.00	0.00	0.00	0.00	0.00	0.00		187,637.75		
391E	NEWLY ELIGIBLE FEMA L	73,185.98	37,874.44	31,818.36	32,250.20	35,979.77	32,467.58	0.00	0.00	0.00	0.00	0.00	0.00		243,576.33		
391F	NEWLY ELIGIBLE MALE	544,427.88	264,421.24	269,746.28	231,138.23	173,322.60	264,546.70	0.00	0.00	0.00	0.00	0.00	0.00		1,747,602.93		
391G	NEWLY ELIGIBLE FEMA L	645,279.14	319,627.95	351,282.99	302,318.16	244,905.13	293,343.48	0.00	0.00	0.00	0.00	0.00	0.00		2,156,756.85		
391H	NEWLY ELIGIBLE M&F 4	535,632.09	262,888.10	263,717.14	275,715.62	210,221.06	318,108.73	0.00	0.00	0.00	0.00	0.00	0.00		1,866,282.74		
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	343.12	0.00	0.00	0.00	0.00	0.00	0.00		1,060.58		
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	665.04	0.00	0.00	253.40	0.00	0.00	0.00	0.00	0.00	0.00		918.44		
3928	NEWLY ELIGIBLE M&F 4	1,094.45	1,114.10	2,616.76	337.60	0.00	682.52	0.00	0.00	0.00	0.00	0.00	0.00		5,845.43		
3929	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	254.57	0.00	0.00	0.00	0.00	0.00	0.00		254.57		
392F	NEWLY ELIGIBLE MALE	0.00	52.48	0.00	0.00	0.00	910.29	0.00	0.00	0.00	0.00	0.00	0.00		962.77		
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		
SUBTOTAL:	32,061,907.41	31,054,674.03	31,281,763.8	0    32,889,729.90	32,790,707.97	39,107,431.56	0.00	0.00	0.00	0.00	0.00	0.00		199,186,214.67		

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	310.51	331.92	117.78	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	291.71	361.75	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	254.04	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	141.29	0.00	0.00	0.00	0.00	0.00	0.00	

760.21	
1,382.62	
138.17	
837.88	
141.29	

9939	BIRTH SUPP PAYMENT N	465,794.15	642,903.37	516,533.17	500,463.01	487,279.13	377,113.93	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	487,279.13	377,113.93	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,990,086.76	
2,990,086.76	

ACUTE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4412	SOBRA 100-133% M&F
1	1,928.16	1,449.26	1,448.90	912.82	1,202.09	1,334.87	0.00	0.00	0.00	0.00	0.00	0.00		8,276.10		
4413	SOBRA 100-133% M&F
6	5,874,723.53	5,814,953.17	5,863,435.31	5,902,856.99	5,881,704.32	7,175,783.61	0.00	0.00	0.00	0.00	0.00	0.00		36,513,456.93		
4414	SOBRA 100-133% MALE	1,999,246.85	1,992,839.44	2,024,655.57	1,996,385.26	1,999,638.82	2,500,078.60	0.00	0.00	0.00	0.00	0.00	0.00		12,512,844.54		
4415	SOBRA 100-133% FEM AL	3,005,921.37	2,997,685.23	3,038,508.70	3,125,739.11	3,151,559.69	3,855,733.32	0.00	0.00	0.00	0.00	0.00	0.00		19,175,147.42		
441B	SOBRA 100-133% M&F
1	445.44	0.00	0.00	112.55	14.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572.69		
441C	SOBRA 100-133% M&F
6	164,704.59	74,635.99	79,126.77	68,697.38	45,342.58	56,788.39	0.00	0.00	0.00	0.00	0.00	0.00		489,295.70		
441D	SOBRA 100-133% MALE	86,665.55	50,248.54	57,787.59	46,488.16	35,388.26	46,682.47	0.00	0.00	0.00	0.00	0.00	0.00		323,260.57		
441E	SOBRA 100-133% FEM AL	139,238.73	65,193.24	72,773.77	65,282.53	38,391.66	50,108.66	0.00	0.00	0.00	0.00	0.00	0.00		430,988.59		
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		
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	165.11	222.71	0.00	0.00	0.00	0.00	0.00	0.00		387.82		
SUBTOTAL:	11,272,874.22	10,997,151.60	11,138,027.3	3    11,207,865.93	11,154,030.86	13,687,607.49	0.00	0.00	0.00	0.00	0.00	0.00		69,457,557.43		

9944	BIRTH SUPP PAYMENT S	35,856.55	55,987.51	36,542.55	61,327.79	50,782.96	12,517.40	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	35,856.55	55,987.51	36,542.55	61,327.79	50,782.96	12,517.40	0.00	0.00	0.00	0.00	0.00	0.00	

 
253,014.76	
253,014.76	

4517	BC PATIENT FEMALE 2 1	5,396.74	5,104.69	4,725.99	4,457.14	4,429.66	5,368.23	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	75,925.22	67,099.18	64,432.32	59,300.49	63,587.19	74,293.66	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	660.83	355.54	2,175.25	5,612.45	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	163.19	0.00	1,094.76	0.00	182.97	559.32	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	851.62	879.79	2,962.65	1,358.40	1,969.77	1,609.77	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	5,421.52	5,390.70	2,981.81	2,862.32	2,226.07	2,838.37	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	3,628.71	3,628.71	3,628.71	3,226.46	2,784.34	3,779.49	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	293.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	91,387.00	82,103.07	80,487.07	71,854.25	77,355.25	94,061.29	0.00	0.00	0.00	0.00	0.00	0.00	

 
29,482.45	
404,638.06	
8,804.07	
2,000.24	
9,632.00	
21,720.79	
20,676.42	
293.90	
497,247.93	

8600	SSI BLIND FREEDOM/W O	1,497.85	1,497.85	1,497.85	1,708.04	1,708.04	1,708.04	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	1,600,200.67	1,623,285.27	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	26,433.56	28,153.26	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	330,179.81	367,845.00	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	6,396.23	18,038.23	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	155,734.00	160,033.82	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	159.84	2,019.87	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,076,989.97	2,049,490.26	2,034,061.50	2,108,995.09	2,120,812.15	2,201,083.49	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,617.67	
9,580,613.70	
80,040.23	
1,887,176.43	
74,383.69	
955,469.67	
4,131.07	
12,591,432.46	

524,137,104.09	513,951,069.46	518,150,668.23	533,228,708.32	531,374,153.28	619,287,094.79	0.00	0.00	0.00	0.00	0.00	0.00	

3,240,128,798.17	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending December 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	1.30	1.35	0.00	0.00	0.00	0.00	0.00	0.00		3.65		
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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1005	TANF 14-20 FEMALE WI	4.99	3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		16.99		
1006	TANF 21-44 MALE WITH	105.64	116.50	122.90	121.77	112.58	103.11	0.00	0.00	0.00	0.00	0.00	0.00		682.50		
1007	TANF 21-44 FEMALE WI	181.79	195.90	194.31	186.27	171.61	156.02	0.00	0.00	0.00	0.00	0.00	0.00		1,085.90		
1008	TANF 45-64 M & F WIT	268.21	287.79	294.87	260.17	251.14	238.36	0.00	0.00	0.00	0.00	0.00	0.00		1,600.54		
1009	TANF 65+ M & F WITH	116.75	130.64	133.33	127.13	117.54	110.88	0.00	0.00	0.00	0.00	0.00	0.00		736.27		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	7.23	1.60	0.00	0.00	0.00	0.00	0.00	0.00		8.83		
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	1.09	5.24	0.00	0.00	0.00	0.00	0.00	0.00		29.80		
100G	TANF 21-44 FEMALE WI	5.05	4.32	5.17	3.84	11.40	5.00	0.00	0.00	0.00	0.00	0.00	0.00		34.78		
100H	TANF 44-64 M & F WIT	9.51	7.35	5.34	4.24	0.81	9.97	0.00	0.00	0.00	0.00	0.00	0.00		37.22		
100J	TANF 65+ M & F WITH	4.22	1.12	1.66	7.58	1.68	12.77	0.00	0.00	0.00	0.00	0.00	0.00		29.03		
1011	TANF <1 M & F NON-ME	12,190.91	11,954.58	11,593.12	11,243.17	11,181.60	11,429.77	0.00	0.00	0.00	0.00	0.00	0.00		69,593.15		
1012	TANF 01-05 M & F NON	15,922.62	16,925.07	17,709.18	18,145.38	18,604.32	19,030.15	0.00	0.00	0.00	0.00	0.00	0.00		106,336.72		
1013	TANF 06-13 M & F NON	26,685.75	27,709.65	27,908.20	28,443.80	28,921.29	29,578.35	0.00	0.00	0.00	0.00	0.00	0.00		169,247.04		
1014	TANF 14-20 MALE NON-	7,849.50	8,080.91	8,195.85	8,273.67	8,323.39	8,492.84	0.00	0.00	0.00	0.00	0.00	0.00		49,216.16		
1015	TANF 14-20 FEMALE N O	10,947.41	11,170.89	11,082.68	11,154.78	11,146.76	11,240.12	0.00	0.00	0.00	0.00	0.00	0.00		66,742.64		
1016	TANF 21-44 MALE NON-	25,794.90	26,636.23	27,208.92	27,085.56	27,212.69	27,492.79	0.00	0.00	0.00	0.00	0.00	0.00		161,431.09		
1017	TANF 21-44 FEMALE N O	78,741.67	80,653.27	81,552.11	81,259.98	81,592.89	82,186.25	0.00	0.00	0.00	0.00	0.00	0.00		485,986.17		
1018	TANF 45-64 M & F NON	20,054.80	20,572.11	20,890.36	20,903.65	20,956.43	21,262.34	0.00	0.00	0.00	0.00	0.00	0.00		124,639.69		
1019	TANF 65+ M & F NON-M	82.44	87.95	83.71	84.16	87.04	88.37	0.00	0.00	0.00	0.00	0.00	0.00		513.67		
101A	TANF < 1 M & F NON-M	1,368.89	819.40	613.87	559.26	852.99	1,643.54	0.00	0.00	0.00	0.00	0.00	0.00		5,857.95		
101B	TANF 01-05 M & F NON	682.65	652.33	333.31	396.33	345.82	490.50	0.00	0.00	0.00	0.00	0.00	0.00		2,900.94		
101C	TANF 06-13 M & F NON	588.07	716.90	269.48	309.22	272.45	188.98	0.00	0.00	0.00	0.00	0.00	0.00		2,345.10		
101D	TANF 14-20 MALE NON-	275.74	179.54	166.65	110.82	101.75	109.00	0.00	0.00	0.00	0.00	0.00	0.00		943.50		
101E	TANF 14-20 FEMALE N O	392.46	264.03	203.17	162.04	121.91	123.04	0.00	0.00	0.00	0.00	0.00	0.00		1,266.65		
101F	TANF 21-44 MALE NON-	2,233.16	1,246.55	971.70	792.03	795.69	776.19	0.00	0.00	0.00	0.00	0.00	0.00		6,815.32		
101G	TANF 21-44 FEMALE N O	5,212.42	2,680.13	2,230.03	1,744.98	1,557.77	1,743.02	0.00	0.00	0.00	0.00	0.00	0.00		15,168.35		
101H	TANF 44-64 M & F NON	1,044.93	668.56	619.71	457.87	378.53	377.29	0.00	0.00	0.00	0.00	0.00	0.00		3,546.89		
101J	TANF 65+ N & F NON-M	7.16	1.47	3.58	4.06	4.24	3.32	0.00	0.00	0.00	0.00	0.00	0.00		23.83		
1026	TANF 21-44 MALE WITH	40.21	39.35	36.00	42.70	38.83	42.76	0.00	0.00	0.00	0.00	0.00	0.00		239.85		
1027	TANF 21-44 FEMALE WI	55.59	51.12	51.66	62.41	66.63	77.48	0.00	0.00	0.00	0.00	0.00	0.00		364.89		
1028	TANF 45-64 M & F WIT	75.00	69.96	69.62	81.22	81.00	92.83	0.00	0.00	0.00	0.00	0.00	0.00		469.63		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1029	TANF 65+ M & F WITH	27.20	27.00	24.56	31.93	38.43	46.54	0.00	0.00	0.00	0.00	0.00	0.00		195.66		
102F	TANF 21-44 MALE WITH	3.38	0.32	0.00	0.00	0.60	0.22	0.00	0.00	0.00	0.00	0.00	0.00		4.52		
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	1.00	0.16	0.00	0.00	0.00	0.00	0.00	0.00		13.82		
102J	TANF 65+ M & F WITH	0.00	0.00	1.43	5.06	0.56	3.45	0.00	0.00	0.00	0.00	0.00	0.00		10.50		
2100	SSI AGED WITH MEDIC A	4,687.07	4,820.28	4,932.67	4,960.19	4,993.69	4,950.86	0.00	0.00	0.00	0.00	0.00	0.00		29,344.76		
210Z	SSI AGED WITH MEDIC A	401.49	304.61	422.21	299.56	324.48	244.26	0.00	0.00	0.00	0.00	0.00	0.00		1,996.61		
2110	SSI AGED NON-MEDIC AR	5,548.22	5,555.50	5,634.93	5,653.20	5,723.40	5,738.02	0.00	0.00	0.00	0.00	0.00	0.00		33,853.27		
211Z	SSI AGED NON-MEDIC AR	216.60	250.09	229.13	256.06	209.31	234.95	0.00	0.00	0.00	0.00	0.00	0.00		1,396.14		
2120	SSI AGED WITH QMB	27,168.47	27,829.76	28,631.17	29,913.89	29,919.48	30,922.62	0.00	0.00	0.00	0.00	0.00	0.00		174,385.39		
212Z	SSI AGED WITH QMB P P	67.03	76.42	130.57	54.73	35.88	46.57	0.00	0.00	0.00	0.00	0.00	0.00		411.20		
2200	SSI DISABLED WITH M E	5,051.73	5,011.37	5,017.01	4,955.26	4,862.22	4,826.30	0.00	0.00	0.00	0.00	0.00	0.00		29,723.89		
220Z	SSI DISABLED WITH M E	259.75	180.95	228.13	199.49	211.99	217.73	0.00	0.00	0.00	0.00	0.00	0.00		1,298.04		
2210	SSI DISABLED NON-ME D	56,419.86	56,072.96	55,978.26	55,811.91	55,691.20	55,489.08	0.00	0.00	0.00	0.00	0.00	0.00		335,463.27		
221Z	SSI DISABLED NON-ME D	759.89	735.30	931.82	815.33	751.41	666.76	0.00	0.00	0.00	0.00	0.00	0.00		4,660.51		
2220	SSI DISABLED WITH Q M	27,588.74	27,999.85	28,560.56	29,367.97	29,376.90	30,014.18	0.00	0.00	0.00	0.00	0.00	0.00		172,908.20		
222Z	SSI DISABLED WITH Q M	50.54	64.24	90.67	35.27	62.39	49.98	0.00	0.00	0.00	0.00	0.00	0.00		353.09		
2300	SSI BLIND WITH MEDIC	27.00	29.00	28.00	28.00	27.50	26.98	0.00	0.00	0.00	0.00	0.00	0.00		166.48		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	4.09	0.00	0.00	0.00	0.00	0.00	0.00		4.09		
2310	SSI BLIND NON-MEDIC A	461.02	472.94	470.49	467.32	475.67	472.18	0.00	0.00	0.00	0.00	0.00	0.00		2,819.62		
231Z	SSI BLIND NON-MEDIC A	14.08	16.02	6.45	1.92	16.88	7.60	0.00	0.00	0.00	0.00	0.00	0.00		62.95		
2320	SSI BLIND WITH QMB	208.99	210.04	210.62	210.56	206.15	210.00	0.00	0.00	0.00	0.00	0.00	0.00		1,256.36		
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	4.66	6.38	0.00	0.00	0.00	0.00	0.00	0.00		16.63		
4302	SOBRA CHILD 01-05 M	3.00	3.00	4.76	9.00	6.20	16.40	0.00	0.00	0.00	0.00	0.00	0.00		42.36		
4303	SOBRA CHILD 06-13 M	6.70	6.12	7.42	19.66	24.26	12.70	0.00	0.00	0.00	0.00	0.00	0.00		76.86		
4304	SOBRA CHILD 14-20 MA	3.00	2.00	2.26	5.06	8.26	6.12	0.00	0.00	0.00	0.00	0.00	0.00		26.70		
4305	SOBRA CHILD 14-20 FE	6.38	8.49	8.26	10.35	7.03	6.41	0.00	0.00	0.00	0.00	0.00	0.00		46.92		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.43	0.00	0.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.76		
430B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	-3.74	0.41	0.00	0.00	0.00	0.00	0.00	0.00		-3.33		
430C	SOBRA CHILD 06-13 M	0.06	0.00	2.11	6.36	1.73	-5.54	0.00	0.00	0.00	0.00	0.00	0.00		4.72		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.73	1.77	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.23		
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	39,368.27	38,933.42	0.00	0.00	0.00	0.00	0.00	0.00		237,926.12		
4312	SOBRA CHILD 01-05 M	188,466.60	189,087.15	189,910.31	189,321.12	187,168.96	187,945.84	0.00	0.00	0.00	0.00	0.00	0.00		1,131,899.98		
4313	SOBRA CHILD 06-13 M	233,049.16	235,593.66	237,736.70	237,670.85	237,504.09	237,478.64	0.00	0.00	0.00	0.00	0.00	0.00		1,419,033.10		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4314	SOBRA CHILD 14-20 MA	54,382.11	55,359.01	56,494.43	57,144.50	57,962.23	58,222.49	0.00	0.00	0.00	0.00	0.00	0.00		339,564.77		
4315	SOBRA CHILD 14-20 FE	54,106.61	55,018.18	56,134.61	56,838.63	57,549.93	57,955.59	0.00	0.00	0.00	0.00	0.00	0.00		337,603.55		
431A	SOBRA CHILD < 1 M &	1,208.09	704.71	883.39	879.48	228.79	222.46	0.00	0.00	0.00	0.00	0.00	0.00		4,126.92		
431B	SOBRA CHILD 01-05 M	9,938.87	5,510.49	5,314.91	4,820.21	3,433.09	4,103.06	0.00	0.00	0.00	0.00	0.00	0.00		33,120.63		
431C	SOBRA CHILD 6-13 M& F	12,342.03	5,854.58	5,525.09	4,454.97	3,593.92	3,794.89	0.00	0.00	0.00	0.00	0.00	0.00		35,565.48		
431D	SOBRA CHILD 14-20 MA	3,383.27	1,549.83	1,503.76	1,251.31	1,054.40	1,059.81	0.00	0.00	0.00	0.00	0.00	0.00		9,802.38		
431E	SOBRA CHILD 14-20 FE	2,833.78	1,413.80	1,559.21	1,256.55	1,028.70	1,064.42	0.00	0.00	0.00	0.00	0.00	0.00		9,156.46		
4321	SOBRA CHILD <1 M & F	0.00	1.00	-1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4322	SOBRA CHILD 01-05 M	2.00	2.00	1.23	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		8.23		
4323	SOBRA CHILD 06-13 M	0.00	-1.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
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	0.00	0.00	0.00	0.32	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.32		
5007	SOBRA PREG 21-44 FE M	54.43	49.34	63.74	53.96	45.22	43.53	0.00	0.00	0.00	0.00	0.00	0.00		310.22		
5008	SOBRA PREG 45-64 FE M	5.32	4.00	4.00	5.00	5.00	4.99	0.00	0.00	0.00	0.00	0.00	0.00		28.31		
500E	SOBRA PREG 14-20 FE M	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		
500G	SOBRA PREG 21-44 FE M	3.19	2.70	2.17	3.02	5.05	4.53	0.00	0.00	0.00	0.00	0.00	0.00		20.66		
500H	SOBRA PREG 45-64 FE M	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.67		
5013	SOBRA PREG 09-13 FE M	6.16	8.00	9.00	8.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00		46.16		
5015	SOBRA PREG 14-20 FE M	4,337.46	4,046.46	4,011.88	3,884.90	3,684.54	3,542.55	0.00	0.00	0.00	0.00	0.00	0.00		23,507.79		
5017	SOBRA PREG 21-44 FE M	21,665.43	19,993.98	20,010.93	19,866.71	19,187.42	18,568.75	0.00	0.00	0.00	0.00	0.00	0.00		119,293.22		
5018	SOBRA PREG 45-64 FE M	69.37	50.47	56.39	58.27	58.19	54.32	0.00	0.00	0.00	0.00	0.00	0.00		347.01		
501C	SOBRA PREG 09-13 FE M	0.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.61		
501E	SOBRA PREG 14-20 FE M	704.07	289.25	297.62	231.65	223.26	260.87	0.00	0.00	0.00	0.00	0.00	0.00		2,006.72		
501G	SOBRA PREG 21-44 FE M	2,575.10	1,286.76	1,250.34	1,121.90	986.61	1,133.73	0.00	0.00	0.00	0.00	0.00	0.00		8,354.44		
501H	SOBRA PREG 45-64 FE M	6.61	4.05	6.11	4.69	0.80	1.54	0.00	0.00	0.00	0.00	0.00	0.00		23.80		
5027	SOBRA PREG 21-44 FE M	22.12	25.35	24.93	29.18	41.23	48.92	0.00	0.00	0.00	0.00	0.00	0.00		191.73		
5028	SOBRA PREG 45-64 FE M	1.00	1.00	1.00	1.19	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		7.19		
502G	SOBRA PREG 21-44 FE M	0.87	1.09	0.76	1.45	0.36	0.06	0.00	0.00	0.00	0.00	0.00	0.00		4.59		
502H	SOBRA PREG 45-64 FE M	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	965,088.3	3	963,605.17	959,449.06	965,789.05	0.00	0.00	0.00	0.00	0.00	0.00		5,780,443.82		

9910	TANF & SOBRA CHILDR E	296.00	348.00	307.00	319.00	288.00	275.00	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	6.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	31.00	39.00	24.00	30.00	29.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,833.00	
40.00	
188.00	

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

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9950	S.O.B.R.A. KICK PAYM	2,139.00	2,428.00	2,398.00	2,275.00	2,193.00	2,205.00	0.00	0.00	0.00	0.00	0.00	0.00	13,638.00	
SUBTOTAL:	2,472.00	2,821.00	2,736.00	2,628.00	2,516.00	2,526.00	0.00	0.00	0.00	0.00	0.00	0.00	15,699.00	

3100	TRANSPLANT OPTION 1	3.00	3.00	3.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.00	
16.00	

1106	TANF EXPANDED 21-44	788.67	816.15	831.69	763.69	714.36	650.05	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	1,390.31	1,263.68	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	2,610.04	2,484.55	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	1,038.85	993.03	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	15.67	11.80	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	24.10	44.79	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	46.32	37.01	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	32.67	21.52	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	17.00	17.00	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	91.92	86.00	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	561.62	542.08	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	2,003.79	2,009.41	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	31,637.05	31,562.05	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	74,067.95	74,402.29	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	27,071.00	27,064.81	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	75.48	73.72	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	0.63	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	11.76	10.01	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	37.74	40.86	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	667.86	727.15	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	1,207.45	1,420.51	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	393.72	564.42	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	0.92	2.09	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	459.24	547.43	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	989.15	1,094.54	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	1,273.31	1,427.48	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	571.50	664.28	0.00	0.00	0.00	0.00	0.00	0.00	

4,564.61	
8,861.78	
16,332.93	
6,383.44	
139.40	
259.27	
379.59	
183.77	
2.22	
129.83	
640.44	
3,391.21	
12,264.84	
187,469.04	
435,456.02	
159,470.04	
489.16	
1.77	
0.16	
7.30	
163.91	
382.86	
6,490.59	
11,215.34	
4,101.92	
51.82	
1.00	
2,320.40	
5,133.08	
6,444.47	
2,914.26	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
112F	TANF EXPANDED 21-44	13.19	10.76	7.05	6.29	1.46	0.38	0.00	0.00	0.00	0.00	0.00	0.00		39.13		
112G	TANF EXPANDED 21-44	7.14	11.21	3.67	1.91	1.04	6.87	0.00	0.00	0.00	0.00	0.00	0.00		31.84		
112H	TANF EXPANDED 45-64	18.32	9.84	16.83	8.08	4.33	10.13	0.00	0.00	0.00	0.00	0.00	0.00		67.53		
112J	TANF EXPANDED 65+
M&	7.02	3.04	18.32	8.66	3.52	0.51	0.00	0.00	0.00	0.00	0.00	0.00		41.07		
2400	SSI AGED EXPANDED WI	426.73	443.44	472.02	440.67	421.28	416.03	0.00	0.00	0.00	0.00	0.00	0.00		2,620.17		
240Z	SSI AGED EXPANDED WI	259.45	185.24	285.34	182.17	156.25	182.04	0.00	0.00	0.00	0.00	0.00	0.00		1,250.49		
2410	SSI AGED EXPANDED NO	126.95	125.69	114.65	110.10	102.07	100.93	0.00	0.00	0.00	0.00	0.00	0.00		680.39		
241Z	SSI AGED EXPANDED NO	10.56	5.52	10.37	8.07	18.00	8.21	0.00	0.00	0.00	0.00	0.00	0.00		60.73		
2420	SSI AGED EXPANDED WI	17,593.09	17,259.82	16,957.44	16,174.97	15,572.31	15,222.85	0.00	0.00	0.00	0.00	0.00	0.00		98,780.48		
242Z	SSI AGED EXPANDED WI	124.19	55.44	148.30	30.91	27.11	61.83	0.00	0.00	0.00	0.00	0.00	0.00		447.78		
2500	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2520	SSI BLIND EXPANDED W	2.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2600	SSI DISABLED EXPAND E	492.88	464.34	445.06	397.48	316.87	354.84	0.00	0.00	0.00	0.00	0.00	0.00		2,471.47		
260Z	SSI DISABLED EXPAND E	161.06	113.94	138.72	163.02	133.69	175.63	0.00	0.00	0.00	0.00	0.00	0.00		886.06		
2610	SSI DISABLED EXPAND E	1,749.60	1,549.45	1,399.14	1,339.50	1,277.70	1,221.60	0.00	0.00	0.00	0.00	0.00	0.00		8,536.99		
261Z	SSI DISABLED EXPAND E	60.98	43.92	59.01	40.76	37.50	49.05	0.00	0.00	0.00	0.00	0.00	0.00		291.22		
2620	SSI DISABLED EXPAND E	14,973.36	14,550.51	14,192.55	13,454.69	13,193.27	12,672.31	0.00	0.00	0.00	0.00	0.00	0.00		83,036.69		
262Z	SSI DISABLED EXPAND E	57.37	57.71	62.26	22.33	26.27	49.90	0.00	0.00	0.00	0.00	0.00	0.00		275.84		
SUBTOTAL:	182,154.75	178,380.59	179,678.9	2	178,359.34	178,306.08	178,297.67	0.00	0.00	0.00	0.00	0.00	0.00		1,075,177.35		

9911	SB PAYMENT FOR TAN F	203.00	222.00	227.00	229.00	202.00	196.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	206.00	223.00	229.00	229.00	203.00	197.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,279.00	
7.00	
1.00	
1,287.00	

3306	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3308	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3309	AHC CARE M&F 65+ W/	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3314	AHC CARE MALE 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3315	AHC CARE FEMALE 14- 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3326	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3328	AHC CARE M&F 45-64 W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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

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

3506	ADULT 40-100% MALE
2	1.05	3.93	4.12	6.00	2.70	2.93	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	2.96	2.67	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	47.58	29.17	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	7.00	6.00	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	1.30	1.06	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	1.03	3.43	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	6.39	1.00	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	5,556.86	5,702.56	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	6,093.36	6,188.83	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	20,476.59	20,844.55	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	16,934.26	17,295.93	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	41,302.01	41,872.93	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	18.00	20.00	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	103.73	121.24	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	88.26	135.84	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	448.47	641.91	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	423.34	540.27	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	880.18	1,248.63	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	1.00	-1.40	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	1.53	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	3.63	7.00	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	0.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
20.73	
19.88	
301.41	
59.04	
6.59	
6.47	
23.53	
1.64	
33,071.59	
36,298.97	
120,338.52	
98,991.49	
245,282.53	
120.41	
989.36	
1,025.63	
4,373.82	
3,444.31	
7,580.16	
38.18	
10.61	
2.65	
30.52	
2.12	
1.86	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
352G	ADULT 40-100% FEMAL E	0.00	0.00	0.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.53		
352H	ADULT 40-100% M&F 45	0.00	0.32	0.86	0.89	0.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.43		
352J	ADULT 40-100% M&F 65	1.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.87		
3704	ADULT <40% EXP MAL E	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 MAL E	15.41	17.00	16.24	24.93	27.77	14.52	0.00	0.00	0.00	0.00	0.00	0.00		115.87		
3707	ADULT <40% EXP FEM AL	9.61	12.63	3.73	7.16	7.66	2.54	0.00	0.00	0.00	0.00	0.00	0.00		43.33		
3708	ADULT <40% EXP M&F 4	79.34	86.57	80.65	72.41	83.25	56.35	0.00	0.00	0.00	0.00	0.00	0.00		458.57		
3709	ADULT <40% EXP M&F 6	3.99	8.24	0.00	4.45	5.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		22.68		
370F	ADULT <40% EXP MAL E	0.03	3.87	2.81	14.31	5.59	3.91	0.00	0.00	0.00	0.00	0.00	0.00		30.52		
370G	ADULT <40% EXP FEM AL	7.40	0.12	1.26	0.83	1.32	0.91	0.00	0.00	0.00	0.00	0.00	0.00		11.84		
370H	ADULT <40% EXP M&F 4	62.90	4.82	11.94	8.36	1.02	1.75	0.00	0.00	0.00	0.00	0.00	0.00		90.79		
3714	ADULT <40% EXP MAL E	12,053.30	11,993.59	11,889.17	11,702.80	11,433.43	11,404.82	0.00	0.00	0.00	0.00	0.00	0.00		70,477.11		
3715	ADULT <40% EXP FEM AL	10,566.05	10,578.54	10,458.81	10,259.28	10,054.16	10,056.84	0.00	0.00	0.00	0.00	0.00	0.00		61,973.68		
3716	ADULT <40% EXP MAL E	60,788.30	61,489.48	61,720.28	61,704.56	62,203.68	62,733.33	0.00	0.00	0.00	0.00	0.00	0.00		370,639.63		
3717	ADULT <40% EXP FEM AL	36,217.95	36,585.39	36,742.16	36,721.82	37,041.08	37,387.97	0.00	0.00	0.00	0.00	0.00	0.00		220,696.37		
3718	ADULT <40% EXP M&F 4	76,027.85	76,776.91	77,357.95	77,642.14	78,016.68	78,564.14	0.00	0.00	0.00	0.00	0.00	0.00		464,385.67		
3719	ADULT <40% EXP M&F 6	46.67	55.00	38.00	56.38	44.03	38.16	0.00	0.00	0.00	0.00	0.00	0.00		278.24		
371D	ADULT <40% EXP MAL E	785.47	365.33	398.98	325.58	262.69	270.65	0.00	0.00	0.00	0.00	0.00	0.00		2,408.70		
371E	ADULT <40% EXP FEM AL	622.58	343.02	319.92	267.63	210.79	224.26	0.00	0.00	0.00	0.00	0.00	0.00		1,988.20		
371F	ADULT <40% EXP MAL E	7,431.73	2,823.52	3,229.94	2,724.89	2,157.68	2,538.66	0.00	0.00	0.00	0.00	0.00	0.00		20,906.42		
371G	ADULT <40% EXP FEM AL	3,715.62	1,653.65	1,678.50	1,655.36	1,276.43	1,523.11	0.00	0.00	0.00	0.00	0.00	0.00		11,502.67		
371H	ADULT <40% EXP M&F 4	6,450.75	2,546.43	2,728.37	2,354.44	2,020.25	2,567.87	0.00	0.00	0.00	0.00	0.00	0.00		18,668.11		
371J	ADULT <40% EXP M&F 6	0.00	3.00	1.00	0.00	0.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
3726	ADULT <40% EXP MAL E	3.77	2.02	5.00	6.23	6.79	5.57	0.00	0.00	0.00	0.00	0.00	0.00		29.38		
3727	ADULT <40% EXP FEM AL	1.77	1.34	1.00	0.00	0.26	2.77	0.00	0.00	0.00	0.00	0.00	0.00		7.14		
3728	ADULT <40% EXP M&F 4	10.87	10.49	6.79	5.15	7.15	8.11	0.00	0.00	0.00	0.00	0.00	0.00		48.56		
3729	ADULT <40% EXP M&F 6	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
372F	ADULT <40% EXP MAL E	2.22	0.63	0.03	2.51	3.29	7.75	0.00	0.00	0.00	0.00	0.00	0.00		16.43		
372G	ADULT <40% EXP FEM AL	1.00	0.32	0.00	0.00	0.73	1.22	0.00	0.00	0.00	0.00	0.00	0.00		3.27		
372H	ADULT <40% EXP M&F 4	1.64	2.75	2.22	2.57	5.47	3.39	0.00	0.00	0.00	0.00	0.00	0.00		18.04		
SUBTOTAL:	306,430.98	295,595.84	298,069.0	0	297,419.12	297,277.20	302,092.15	0.00	0.00	0.00	0.00	0.00	0.00		1,796,884.29		

3904	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	

9935	BIRTH SUPP PAYMENT A	47.00	43.00	33.00	45.00	39.00	54.00	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	87.00	90.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	144.00	153.00	145.00	131.00	126.00	144.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
261.00	
582.00	
843.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3906	NEWLY ELIGIBLE MALE	9.99	6.59	5.63	7.18	1.50	1.89	0.00	0.00	0.00	0.00	0.00	0.00		32.78		
3907	NEWLY ELIGIBLE FEMA L	7.24	9.28	4.52	5.00	4.00	4.74	0.00	0.00	0.00	0.00	0.00	0.00		34.78		
3908	NEWLY ELIGIBLE M&F 4	76.38	71.01	65.15	62.68	56.05	57.26	0.00	0.00	0.00	0.00	0.00	0.00		388.53		
3909	NEWLY ELIGIBLE M&F 6	6.16	6.44	13.46	10.00	11.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00		57.06		
390F	NEWLY ELIGIBLE MALE	0.00	-0.58	0.36	0.64	0.00	1.09	0.00	0.00	0.00	0.00	0.00	0.00		1.51		
390G	NEWLY ELIGIBLE FEMA L	4.73	1.61	1.43	0.00	0.00	0.25	0.00	0.00	0.00	0.00	0.00	0.00		8.02		
390H	NEWLY ELIGIBLE M&F 4	12.91	1.12	10.87	5.92	0.79	1.71	0.00	0.00	0.00	0.00	0.00	0.00		33.32		
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	2,760.99	2,874.35	0.00	0.00	0.00	0.00	0.00	0.00		16,288.67		
3915	NEWLY ELIGIBLE FEMA L	3,107.33	3,144.71	3,193.71	3,228.95	3,256.44	3,327.84	0.00	0.00	0.00	0.00	0.00	0.00		19,258.98		
3916	NEWLY ELIGIBLE MALE	18,434.91	18,432.63	18,507.12	18,595.42	18,621.41	18,933.68	0.00	0.00	0.00	0.00	0.00	0.00		111,525.17		
3917	NEWLY ELIGIBLE FEMA L	26,612.98	26,254.10	26,325.85	26,195.60	26,108.59	26,484.47	0.00	0.00	0.00	0.00	0.00	0.00		157,981.59		
3918	NEWLY ELIGIBLE M&F 4	27,106.66	27,120.36	27,282.10	27,501.42	27,719.53	28,047.40	0.00	0.00	0.00	0.00	0.00	0.00		164,777.47		
3919	NEWLY ELIGIBLE M&F 6	15.00	17.00	13.00	17.00	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00		89.00		
391D	NEWLY ELIGIBLE MALE	158.25	91.82	109.98	82.70	53.83	68.82	0.00	0.00	0.00	0.00	0.00	0.00		565.40		
391E	NEWLY ELIGIBLE FEMA L	222.94	115.52	94.87	97.18	111.84	96.79	0.00	0.00	0.00	0.00	0.00	0.00		739.14		
391F	NEWLY ELIGIBLE MALE	1,637.68	787.81	817.83	674.17	504.08	759.81	0.00	0.00	0.00	0.00	0.00	0.00		5,181.38		
391G	NEWLY ELIGIBLE FEMA L	1,958.63	963.80	1,062.42	891.79	711.85	867.99	0.00	0.00	0.00	0.00	0.00	0.00		6,456.48		
391H	NEWLY ELIGIBLE M&F 4	1,626.88	792.26	797.78	827.88	609.56	922.35	0.00	0.00	0.00	0.00	0.00	0.00		5,576.71		
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	0.54	0.00	0.00	0.00	0.00	0.00	0.00		2.41		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00		10.05		
3929	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
392F	NEWLY ELIGIBLE MALE	0.00	0.12	0.00	0.00	0.00	3.45	0.00	0.00	0.00	0.00	0.00	0.00		3.57		
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		
SUBTOTAL:	83,583.82	80,471.05	81,021.10	80,940.53	80,544.46	82,479.43	0.00	0.00	0.00	0.00	0.00	0.00		489,040.39		

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	2.80	3.00	1.06	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	2.00	2.25	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	1.74	0.00	0.00	0.00	0.00	0.00	0.00	
4411	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	

6.86	
9.25	
3.19	
5.74	
0.00	

9939	BIRTH SUPP PAYMENT N	76.00	105.00	84.00	81.00	78.00	61.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	76.00	105.00	84.00	81.00	78.00	61.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
485.00	
485.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4412	SOBRA 100-133% M&F
1	17.33	13.00	13.00	8.12	10.73	7.77	0.00	0.00	0.00	0.00	0.00	0.00		69.95		
4413	SOBRA 100-133% M&F
6	47,099.00	46,637.35	47,023.52	47,096.41	47,000.04	47,324.31	0.00	0.00	0.00	0.00	0.00	0.00		282,180.63		
4414	SOBRA 100-133% MALE	11,874.13	11,798.14	11,976.67	12,103.73	12,124.08	12,300.60	0.00	0.00	0.00	0.00	0.00	0.00		72,177.35		
4415	SOBRA 100-133% FEM AL	11,579.89	11,545.15	11,686.84	11,741.62	11,839.97	11,924.67	0.00	0.00	0.00	0.00	0.00	0.00		70,318.14		
441B	SOBRA 100-133% M&F
1	7.64	0.00	0.00	1.87	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.77		
441C	SOBRA 100-133% M&F
6	3,053.61	1,390.93	1,391.31	1,278.04	838.85	1,052.35	0.00	0.00	0.00	0.00	0.00	0.00		9,005.09		
441D	SOBRA 100-133% MALE	587.39	341.97	389.46	313.10	244.45	321.17	0.00	0.00	0.00	0.00	0.00	0.00		2,197.54		
441E	SOBRA 100-133% FEM AL	714.29	336.34	375.30	334.74	195.86	257.25	0.00	0.00	0.00	0.00	0.00	0.00		2,213.78		
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		
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
SUBTOTAL:	74,933.28	72,063.88	72,858.10	72,890.20	72,260.24	73,194.17	0.00	0.00	0.00	0.00	0.00	0.00		438,199.87		

4517	BC PATIENT FEMALE 2 1	21.16	20.00	18.13	17.00	17.06	17.05	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	172.08	153.75	147.28	130.12	140.39	134.75	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	1.73	1.00	5.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.83	0.00	4.86	0.00	0.93	2.93	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	2.08	2.36	8.72	5.17	5.59	5.20	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	14.00	14.00	12.00	11.45	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	8.00	8.00	8.00	7.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	1.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	218.15	198.11	200.72	173.28	183.97	187.93	0.00	0.00	0.00	0.00	0.00	0.00	

110.40	
878.37	
20.73	
9.55	
29.12	
69.45	
43.00	
1.54	
1,162.16	

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	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	1,758.82	1,788.45	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	67.61	79.60	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	291.76	289.63	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	10.91	31.21	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	215.49	205.03	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	2.49	6.95	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,360.11	2,286.27	2,298.44	2,422.62	2,348.08	2,401.87	0.00	0.00	0.00	0.00	0.00	0.00	

6.00	
10,574.40	
416.07	
1,696.28	
126.80	
1,272.84	
25.00	
14,117.39	

9944	BIRTH SUPP PAYMENT S	6.00	9.00	6.00	10.00	8.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6.00	9.00	6.00	10.00	8.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
41.00	
41.00	

TOTAL:	1,621,481.24	1,589,928.80	1,602,417.61	1,598,892.26	1,593,302.09	1,607,374.27	0.00	0.00	0.00	0.00	0.00	0.00		9,613,396.27		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	38,448.73	39,003.93	38,448.73	42,377.81	42,937.52	42,549.47	0.00	0.00	0.00	0.00	0.00	0.00		243,766.19		
1010	TANF NON-MEDICARE	2,400,462.36	2,421,330.33	2,419,826.43	2,447,259.43	2,497,914.21	2,524,942.57	0.00	0.00	0.00	0.00	0.00	0.00		14,711,735.33		
101Z	TANF ALTCS NON-MED IC	0.00	0.00	19,150.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,150.70		
1020	TANF WITH QMB	7,060.26	7,046.73	7,060.26	7,100.22	7,100.22	7,186.05	0.00	0.00	0.00	0.00	0.00	0.00		42,553.74		
2100	SSI AGED WITH MEDIC A	30,800,680.32	35,822,926.91	30,988,622.11	31,576,930.86	36,627,792.26	31,957,175.42	0.00	0.00	0.00	0.00	0.00	0.00		197,774,127.88		
210Z	SSI AGED WITH MEDIC A	542,994.93	656,811.81	649,461.51	680,788.55	579,080.36	649,230.44	0.00	0.00	0.00	0.00	0.00	0.00		3,758,367.60		
2110	SSI AGED NON-MEDIC AR	2,859,005.72	3,112,715.88	2,808,352.93	3,098,256.65	3,322,036.03	3,357,441.94	0.00	0.00	0.00	0.00	0.00	0.00		18,557,809.15		
211Z	SSI AGED NON-MEDIC AR	4,608.65	22,415.95	26,737.54	17,364.42	13,461.95	28,385.40	0.00	0.00	0.00	0.00	0.00	0.00		112,973.91		
2120	SSI AGED WITH QMB	19,171,298.49	22,384,501.22	19,201,118.70	19,593,122.28	22,662,904.64	19,825,191.27	0.00	0.00	0.00	0.00	0.00	0.00		122,838,136.60		
212Z	SSI AGED WITH QMB P P	8,706.14	10,824.40	15,009.15	7,377.69	9,418.21	19,442.54	0.00	0.00	0.00	0.00	0.00	0.00		70,778.13		
2200	SSI DISABLED WITH M E	14,979,902.29	16,537,185.88	15,092,965.32	15,230,886.76	16,570,209.92	15,474,036.91	0.00	0.00	0.00	0.00	0.00	0.00		93,885,187.08		
220Z	SSI DISABLED WITH M E	45,197.99	72,772.52	67,317.02	87,641.17	92,231.69	85,603.01	0.00	0.00	0.00	0.00	0.00	0.00		450,763.40		
2210	SSI DISABLED NON-ME D	96,668,522.76	98,773,047.00	97,439,687.94	100,080,369.62	102,448,594.96	104,269,518.78	0.00	0.00	0.00	0.00	0.00	0.00		599,679,741.06		
221Z	SSI DISABLED NON-ME D	23,471.98	37,264.06	50,403.94	25,347.06	33,325.75	29,238.39	0.00	0.00	0.00	0.00	0.00	0.00		199,051.18		
2220	SSI DISABLED WITH Q M	21,848,759.06	23,184,351.56	22,097,240.12	22,312,110.78	23,597,301.80	22,803,817.34	0.00	0.00	0.00	0.00	0.00	0.00		135,843,580.66		
222Z	SSI DISABLED WITH Q M	717.28	5,025.38	3,782.81	2,796.70	227.54	2,252.69	0.00	0.00	0.00	0.00	0.00	0.00		14,802.40		
2300	SSI BLIND WITH MEDIC	66,335.96	72,964.65	79,626.95	80,592.35	84,285.15	78,663.84	0.00	0.00	0.00	0.00	0.00	0.00		462,468.90		
2310	SSI BLIND NON-MEDIC A	486,146.90	487,621.28	485,314.45	484,339.30	492,101.69	518,525.80	0.00	0.00	0.00	0.00	0.00	0.00		2,954,049.42		
2320	SSI BLIND WITH QMB	137,707.06	142,358.29	134,795.96	136,620.70	140,028.19	137,497.66	0.00	0.00	0.00	0.00	0.00	0.00		829,007.86		
232Z	SSI BLIND WITH QMB P	2,187.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,187.82		
SUBTOTAL:	190,092,214.70	203,790,167.78	191,624,922.5	7  195,911,282.35	209,220,952.09	201,810,699.52	0.00	0.00	0.00	0.00	0.00	0.00		1,192,450,239.01		

8700	SSI DISABLED FREEDO M	83,704.76	94,859.85	83,565.97	89,541.14	99,604.56	89,231.29	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	5,331.26	-5,331.26	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	118,450.47	126,671.03	113,138.91	128,196.90	143,111.02	137,432.42	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	18,258.18	17,279.26	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	219,320.93	239,952.29	213,870.5	8	234,728.00	266,305.02	238,611.71	0.00	0.00	0.00	0.00	0.00	0.00	

 
540,507.57	
0.00	
767,000.75	
105,280.21	
0.00	
1,412,788.53	

190,311,535.63	204,030,120.07	191,838,793.15	196,146,010.35	209,487,257.11	202,049,311.23	0.00	0.00	0.00	0.00	0.00	0.00	

1,193,863,027.54	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	11.00	11.00	11.00	12.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00		69.00		
1010	TANF NON-MEDICARE	675.51	680.77	680.40	683.90	696.26	688.51	0.00	0.00	0.00	0.00	0.00	0.00		4,105.35		
101Z	TANF ALTCS NON-MED IC	0.00	0.00	5.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.49		
1020	TANF WITH QMB	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
2100	SSI AGED WITH MEDIC A	11,265.25	11,234.08	11,290.57	11,351.42	11,348.68	11,346.72	0.00	0.00	0.00	0.00	0.00	0.00		67,836.72		
210Z	SSI AGED WITH MEDIC A	564.29	677.36	678.75	693.97	591.76	657.08	0.00	0.00	0.00	0.00	0.00	0.00		3,863.21		
2110	SSI AGED NON-MEDIC AR	596.81	592.38	586.17	582.84	573.54	568.51	0.00	0.00	0.00	0.00	0.00	0.00		3,500.25		
211Z	SSI AGED NON-MEDIC AR	5.47	24.11	27.26	18.19	14.30	30.73	0.00	0.00	0.00	0.00	0.00	0.00		120.06		
2120	SSI AGED WITH QMB	7,455.45	7,481.63	7,490.54	7,498.62	7,494.32	7,489.53	0.00	0.00	0.00	0.00	0.00	0.00		44,910.09		
212Z	SSI AGED WITH QMB P P	8.97	11.53	14.63	7.07	10.30	19.95	0.00	0.00	0.00	0.00	0.00	0.00		72.45		
2200	SSI DISABLED WITH M E	4,856.19	4,930.65	4,899.87	4,874.40	4,878.01	4,884.09	0.00	0.00	0.00	0.00	0.00	0.00		29,323.21		
220Z	SSI DISABLED WITH M E	48.42	76.93	75.24	85.66	93.51	85.23	0.00	0.00	0.00	0.00	0.00	0.00		464.99		
2210	SSI DISABLED NON-ME D	26,357.77	26,471.04	26,580.74	26,594.62	26,756.31	26,836.23	0.00	0.00	0.00	0.00	0.00	0.00		159,596.71		
221Z	SSI DISABLED NON-ME D	24.77	37.42	41.24	26.02	33.61	28.98	0.00	0.00	0.00	0.00	0.00	0.00		192.04		
2220	SSI DISABLED WITH Q M	6,861.39	6,872.57	6,919.11	6,913.09	6,938.65	6,937.12	0.00	0.00	0.00	0.00	0.00	0.00		41,441.93		
222Z	SSI DISABLED WITH Q M	0.77	4.89	4.15	2.96	0.23	2.77	0.00	0.00	0.00	0.00	0.00	0.00		15.77		
2300	SSI BLIND WITH MEDIC	20.00	21.00	24.00	24.00	24.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00		136.00		
2310	SSI BLIND NON-MEDIC A	136.44	136.00	137.26	133.48	133.00	137.06	0.00	0.00	0.00	0.00	0.00	0.00		813.24		
2320	SSI BLIND WITH QMB	43.31	43.00	42.79	43.00	42.00	42.41	0.00	0.00	0.00	0.00	0.00	0.00		256.51		
232Z	SSI BLIND WITH QMB P	2.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.87		
SUBTOTAL:	58,936.68	59,308.36	59,511.21	59,547.24	59,642.48	59,791.92	0.00	0.00	0.00	0.00	0.00	0.00		356,737.89		

8700	SSI DISABLED FREEDO M	26.00	26.67	25.90	27.00	27.33	26.67	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	5.66	-5.66	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	24.00	23.32	23.00	23.00	24.00	24.00	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	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.00	55.99	54.90	56.00	62.99	51.01	0.00	0.00	0.00	0.00	0.00	0.00	

 
159.57	
0.00	
141.32	
36.00	
0.00	
336.89	

TOTAL:	58,992.68	59,364.35	59,566.11	59,603.24	59,705.47	59,842.93	0.00	0.00	0.00	0.00	0.00	0.00		357,074.78		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending December 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	4,816.59	0.00	0.00	0.00	0.00	0.00	0.00		37,486.40		
1012	TANF 01-05 M & F NON	0.00	0.00	-999.24	6,087.68	0.00	628.68	0.00	0.00	0.00	0.00	0.00	0.00		5,717.12		
1013	TANF 06-13 M & F NON	0.00	0.00	982.48	10,237.30	0.00	541.96	0.00	0.00	0.00	0.00	0.00	0.00		11,761.74		
1014	TANF 14-20 MALE NON-	0.00	0.00	274.85	4,661.97	0.00	76.23	0.00	0.00	0.00	0.00	0.00	0.00		5,013.05		
1015	TANF 14-20 FEMALE N O	0.00	0.00	276.04	5,084.09	0.00	27.92	0.00	0.00	0.00	0.00	0.00	0.00		5,388.05		
1017	TANF 21-44 FEMALE N O	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	TANF < 1 M & F NON-M	0.00	0.00	0.00	2,757.79	0.00	5,116.77	0.00	0.00	0.00	0.00	0.00	0.00		7,874.56		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	2,330.99	0.00	1,108.34	0.00	0.00	0.00	0.00	0.00	0.00		3,439.33		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	2,949.36	0.00	1,028.59	0.00	0.00	0.00	0.00	0.00	0.00		3,977.95		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	591.34	0.00	151.55	0.00	0.00	0.00	0.00	0.00	0.00		742.89		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	1,210.60	0.00	145.55	0.00	0.00	0.00	0.00	0.00	0.00		1,356.15		
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	110.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.98		
2210	SSI DISABLED NON-ME D	0.00	0.00	6,042.11	1,893,541.65	0.00	-52.10	0.00	0.00	0.00	0.00	0.00	0.00		1,899,531.66		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	736.55	0.00	542.99	0.00	0.00	0.00	0.00	0.00	0.00		1,279.54		
2220	SSI DISABLED WITH Q M	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	SSI BLIND NON-MEDIC A	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	SOBRA CHILD WITH M ED	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	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 DI	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	SOBRA CHILD <1 M & F	0.00	0.00	16,585.12	101,558.93	0.00	8,744.64	0.00	0.00	0.00	0.00	0.00	0.00		126,888.69		
4312	SOBRA CHILD 01-05 M	0.00	0.00	9,176.08	134,775.02	0.00	13,665.99	0.00	0.00	0.00	0.00	0.00	0.00		157,617.09		
4313	SOBRA CHILD 06-13 M	0.00	0.00	28,671.34	129,554.08	0.00	12,744.26	0.00	0.00	0.00	0.00	0.00	0.00		170,969.68		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	1,802.52	37,478.50	0.00	2,823.44	0.00	0.00	0.00	0.00	0.00	0.00		42,104.46		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	16,681.14	21,239.99	0.00	3,630.18	0.00	0.00	0.00	0.00	0.00	0.00		41,551.31		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	12,551.84	0.00	897.80	0.00	0.00	0.00	0.00	0.00	0.00		13,449.64		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	52,870.33	0.00	16,353.14	0.00	0.00	0.00	0.00	0.00	0.00		69,223.47		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	57,860.11	0.00	14,673.16	0.00	0.00	0.00	0.00	0.00	0.00		72,533.27		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	16,103.43	0.00	3,889.25	0.00	0.00	0.00	0.00	0.00	0.00		19,992.68		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	13,430.13	0.00	4,260.71	0.00	0.00	0.00	0.00	0.00	0.00		17,690.84		
4320	SOBRA CHILD WITH Q MB	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		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending December 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	233.51	0.00	0.00	0.00	0.00	0.00	0.00		1,574.27		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	360.58	0.00	274.66	0.00	0.00	0.00	0.00	0.00	0.00		635.24		
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	25,443,521.50	25,493,930.17	0.00	0.00	0.00	0.00	0.00	0.00		51,000,068.27		
7050	CMHS PPC	0.00	0.00	0.00	82,735.48	337,510.99	352,547.23	0.00	0.00	0.00	0.00	0.00	0.00		772,793.70		
7800	CMDP	0.00	0.00	0.00	32,195.01	13,570,187.70	13,609,630.66	0.00	0.00	0.00	0.00	0.00	0.00		27,212,013.37		
7850	CMDP PPC	0.00	0.00	0.00	30,747.31	143,863.39	277,657.30	0.00	0.00	0.00	0.00	0.00	0.00		452,268.00		
SUBTOTAL:	0.00	0.00	84,584.19	38,335,786.67	39,495,083.58	39,830,089.17	0.00	0.00	0.00	0.00	0.00	0.00		117,745,543.61		

3710	AHC CARE EXPANDED FO	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	

776.66	
776.66	

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	
SUBTOTAL:	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	
55.49	

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
6	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	SOBRA 100-133% M&F
6	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	SOBRA 100-133% FOR F	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	SOBRA 100-133% M&F
6	0.00	0.00	5,553.54	32,585.38	0.00	3,847.34	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	1,555.12	6,025.82	0.00	674.67	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	1,105.03	5,327.00	0.00	639.31	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	10,898.27	0.00	4,919.04	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	2,372.99	0.00	1,117.24	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	2,691.47	0.00	878.61	0.00	0.00	0.00	0.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	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	SOBRA 100-133% M&F
6	0.00	0.00	0.00	-11.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	8,213.69	2,490,892.24	0.00	12,076.21	0.00	0.00	0.00	0.00	0.00	0.00	

83.94	
155.73	
10.74	
2,430,724.38	
41,986.26	
8,255.61	
7,071.34	
15,817.31	
3,490.23	
3,570.08	
28.45	
-11.93	
2,511,182.14	

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	
SUBTOTAL:	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	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	10.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.10	
871Z	SSI DISABLED FREEDO M	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	
SUBTOTAL	:	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	

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	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending December 31, 2016

0.00	0.00	92,799.73	40,839,228.09	39,495,083.58	39,842,165.38	0.00	0.00	0.00	0.00	0.00	0.00	

120,269,276.78	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending December 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	4,081.00	0.00	0.00	0.00	0.00	0.00	0.00		4,081.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	523.00	0.00	0.00	0.00	0.00	0.00	0.00		523.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	516.00	0.00	0.00	0.00	0.00	0.00	0.00		516.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	68.00	0.00	0.00	0.00	0.00	0.00	0.00		68.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	59.00	0.00	0.00	0.00	0.00	0.00	0.00		59.00		
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		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	4,359.00	0.00	0.00	0.00	0.00	0.00	0.00		4,359.00		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	985.00	0.00	0.00	0.00	0.00	0.00	0.00		985.00		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	982.00	0.00	0.00	0.00	0.00	0.00	0.00		982.00		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	149.00	0.00	0.00	0.00	0.00	0.00	0.00		149.00		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	117.00	0.00	0.00	0.00	0.00	0.00	0.00		117.00		
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	19,129.00	0.00	-85.00	0.00	0.00	0.00	0.00	0.00	0.00		19,044.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	446.00	0.00	0.00	0.00	0.00	0.00	0.00		446.00		
2220	SSI DISABLED WITH Q M	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	SSI BLIND NON-MEDIC A	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	SOBRA CHILD WITH M ED	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	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 DI	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	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	7,659.00	0.00	0.00	0.00	0.00	0.00	0.00		7,659.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	11,720.00	0.00	0.00	0.00	0.00	0.00	0.00		11,720.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	11,001.00	0.00	0.00	0.00	0.00	0.00	0.00		11,001.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	2,512.00	0.00	0.00	0.00	0.00	0.00	0.00		2,512.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	2,899.00	0.00	0.00	0.00	0.00	0.00	0.00		2,899.00		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	705.00	0.00	0.00	0.00	0.00	0.00	0.00		705.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	14,224.00	0.00	0.00	0.00	0.00	0.00	0.00		14,224.00		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	13,249.00	0.00	0.00	0.00	0.00	0.00	0.00		13,249.00		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	3,483.00	0.00	0.00	0.00	0.00	0.00	0.00		3,483.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	3,492.00	0.00	0.00	0.00	0.00	0.00	0.00		3,492.00		
4320	SOBRA CHILD WITH Q MB	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		

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending December 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	163.00	0.00	0.00	0.00	0.00	0.00	0.00		163.00		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	212.00	0.00	0.00	0.00	0.00	0.00	0.00		212.00		
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	677,635.00	678,509.00	0.00	0.00	0.00	0.00	0.00	0.00		1,356,803.00		
7050	CMHS PPC	0.00	0.00	0.00	0.00	3,847.00	5,397.00	0.00	0.00	0.00	0.00	0.00	0.00		9,244.00		
7800	CMDP	0.00	0.00	0.00	-95.00	15,560.00	15,637.00	0.00	0.00	0.00	0.00	0.00	0.00		31,102.00		
7850	CMDP PPC	0.00	0.00	0.00	0.00	74.00	221.00	0.00	0.00	0.00	0.00	0.00	0.00		295.00		
SUBTOTAL:	0.00	0.00	0.00	638,964.00	697,116.00	783,283.00	0.00	0.00	0.00	0.00	0.00	0.00		2,119,363.00		

3710	AHC CARE EXPANDED FO	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	

2.00	
2.00	

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	
SUBTOTAL:	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	
1.00	

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
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	
440C	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	
4410	SOBRA 100-133% FOR F	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	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	3,287.00	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	485.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	535.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	4,261.00	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	868.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	730.00	0.00	0.00	0.00	0.00	0.00	0.00	
4420	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	
4423	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	
SUBTOTAL:	0.00	0.00	0.00	64,553.00	0.00	10,166.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
0.00	
0.00	
64,550.00	
3,287.00	
485.00	
535.00	
4,261.00	
868.00	
730.00	
1.00	
0.00	
74,719.00	

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	
SUBTOTAL:	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	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending December 31, 2016

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	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	
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	

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	

TOTAL:	0.00	0.00	0.00	703,700.00	697,116.00	793,449.00	0.00	0.00	0.00	0.00	0.00	0.00		2,194,265.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending December 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 O	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	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 O	0.00	0.00	1,407.35	7,975.19	0.00	387.75	0.00	0.00	0.00	0.00	0.00	0.00		9,770.29		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	2,024.76	0.00	295.97	0.00	0.00	0.00	0.00	0.00	0.00		2,320.73		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	2,470.44	0.00	0.00	0.00	0.00	0.00	0.00		2,470.44		
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 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		
210Z	SSI AGED WITH MEDIC A	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	SSI AGED NON-MEDIC AR	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	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 E	0.00	0.00	4.04	11,736.62	0.00	1,395.02	0.00	0.00	0.00	0.00	0.00	0.00		13,135.68		
220Z	SSI DISABLED WITH M E	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	SSI DISABLED NON-ME D	0.00	0.00	1,099.38	217,351.29	0.00	4,311.82	0.00	0.00	0.00	0.00	0.00	0.00		222,762.49		
221Z	SSI DISABLED NON-ME D	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	SSI DISABLED WITH Q M	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	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4300	SOBRA CHILD WITH M ED	0.00	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	5,115.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,115.99		
4314	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 MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	3,015.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,015.70		
5017	SOBRA PREG 21-44 FE M	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	SOBRA PREGNANT WO MAN	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	SMI	0.00	0.00	0.00	35,808.23	829,447.25	966,698.59	0.00	0.00	0.00	0.00	0.00	0.00		1,831,954.07		
7150	SMI PPC	0.00	0.00	0.00	2,186.78	8,079.27	18,659.46	0.00	0.00	0.00	0.00	0.00	0.00		28,925.51		
SUBTOTAL:	0.00	0.00	4,417.65	408,136.64	837,526.52	994,219.05	0.00	0.00	0.00	0.00	0.00	0.00		2,244,299.86		

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	

 
7,932.86	
1,058.92	
6.46	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1110	TANF EXPANDED FOR FI	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		16,128.53		
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		2,254.49		
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	3,396.13	0.00	1,093.39	0.00	0.00	0.00	0.00	0.00	0.00		4,489.52		
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	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		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2420	SSI AGED EXPANDED WI	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		
2600	SSI DISABLED EXPAND E	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		
2610	SSI DISABLED EXPAND E	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		
2620	SSI DISABLED EXPAND E	0.00	0.00	284.40	28,081.89	0.00	150.81	0.00	0.00	0.00	0.00	0.00	0.00		28,517.10		
SUBTOTAL:	0.00	0.00	299.12	68,822.01	0.00	1,244.20	0.00	0.00	0.00	0.00	0.00	0.00		70,365.33		

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	188.52	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 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	
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 FO	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 MAL E	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	297.89	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	3,147.79	26,230.54	0.00	3,503.43	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	884.87	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	2,344.08	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 MAL E	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	

 
0.00	
2.92	
2.92	
40,358.79	
11.10	
1,734.46	
4,135.06	
1,930.72	
5,259.31	
754.06	
12.37	
0.00	
0.00	
3.23	
177,719.03	
1,739.25	
2,523.96	
32,881.76	
18,547.44	
25,517.18	
716.36	
8,364.62	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEM AL	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	2,536.23	
371H	ADULT <40% EXP M&F 4	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	1,329.05	
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	
SUBTOTAL	:	0.00	0.00	9,512.69	309,348.34	0.00	7,218.79	0.00	0.00	0.00	0.00	0.00	0.00	326,079.82	

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 F	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	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	-150.81	0.00	0.00	0.00	0.00	0.00	0.00	
3916	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 L	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	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	4,841.64	0.00	199.23	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	5.84	15,535.66	0.00	48.42	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
7,969.37	
-150.81	
1,394.59	
1,335.90	
5,040.87	
15,589.92	

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	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	2,601.52	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	2.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	1,434.74	0.00	2,601.52	0.00	0.00	0.00	0.00	0.00	0.00	

1,432.70	
2,601.52	
2.04	
4,036.26	

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

0.00	
0.00	
0.00	

8700	SSI DISABLED FREEDO M	0.00	0.00	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	
SUBTOTAL:	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	

0.00	0.00	14,527.56	806,978.18	837,526.52	1,005,331.98	0.00	0.00	0.00	0.00	0.00	0.00	

2,664,364.24	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending December 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 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	10.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	61.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
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 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		
210Z	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-MEDIC AR	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	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 E	0.00	0.00	0.00	12.00	0.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00		49.00		
220Z	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	200.00	0.00	144.00	0.00	0.00	0.00	0.00	0.00	0.00		344.00		
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	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4300	SOBRA CHILD WITH M ED	0.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
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		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5020	SOBRA PREGNANT WO MAN	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	SMI	0.00	0.00	0.00	0.00	599.00	722.00	0.00	0.00	0.00	0.00	0.00	0.00		1,321.00		
7150	SMI PPC	0.00	0.00	0.00	0.00	4.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
SUBTOTAL:	0.00	0.00	0.00	335.00	603.00	997.00	0.00	0.00	0.00	0.00	0.00	0.00		1,935.00		

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	

 
9.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
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		0.00		
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
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	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		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2420	SSI AGED EXPANDED WI	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		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	25.00	0.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
SUBTOTAL:	0.00	0.00	0.00	56.00	0.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00		89.00		

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	5.00	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 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	
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 FO	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 MAL 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	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	91.00	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	25.00	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	70.00	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 MAL 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	
38.00	
0.00	
0.00	
0.00	
0.00	
5.00	
0.00	
0.00	
0.00	
0.00	
0.00	
168.00	
0.00	
10.00	
91.00	
25.00	
70.00	
0.00	
0.00	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL	:	0.00	0.00	0.00	206.00	0.00	201.00	0.00	0.00	0.00	0.00	0.00	0.00	407.00	

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 F	0.00	0.00	0.00	6.00	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	-4.00	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	5.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	6.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
6.00	
-4.00	
0.00	
0.00	
5.00	
7.00	

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	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	68.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% 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	
SUBTOTAL:	0.00	0.00	0.00	1.00	0.00	68.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
68.00	
0.00	
69.00	

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

0.00	
0.00	
0.00	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	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	
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	

2.00	
0.00	
0.00	
0.00	
2.00	

TOTAL:	0.00	0.00	0.00	606.00	603.00	1,300.00	0.00	0.00	0.00	0.00	0.00	0.00		2,509.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending December 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	86.48	0.00	0.00	0.00	0.00	0.00	0.00		2,845.88		
1015	TANF 14-20 FEMALE N O	0.00	0.00	813.01	4,947.05	0.00	535.22	0.00	0.00	0.00	0.00	0.00	0.00		6,295.28		
1016	TANF 21-44 MALE NON-	0.00	0.00	7,154.15	29,902.79	0.00	4,071.65	0.00	0.00	0.00	0.00	0.00	0.00		41,128.59		
1017	TANF 21-44 FEMALE N O	0.00	0.00	13,453.05	67,144.68	0.00	9,357.18	0.00	0.00	0.00	0.00	0.00	0.00		89,954.91		
1018	TANF 45-64 M & F NON	0.00	0.00	3,879.61	18,566.82	0.00	2,049.22	0.00	0.00	0.00	0.00	0.00	0.00		24,495.65		
1019	TANF 65+ M & F NON-M	0.00	0.00	150.96	119.61	0.00	51.97	0.00	0.00	0.00	0.00	0.00	0.00		322.54		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	677.04	0.00	269.27	0.00	0.00	0.00	0.00	0.00	0.00		946.31		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	1,580.58	0.00	426.47	0.00	0.00	0.00	0.00	0.00	0.00		2,007.05		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	11,521.99	0.00	4,561.96	0.00	0.00	0.00	0.00	0.00	0.00		16,083.95		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	26,112.50	0.00	10,793.83	0.00	0.00	0.00	0.00	0.00	0.00		36,906.33		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	6,264.39	0.00	2,457.99	0.00	0.00	0.00	0.00	0.00	0.00		8,722.38		
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	118.92	0.00	48.73	0.00	0.00	0.00	0.00	0.00	0.00		167.65		
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 A	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-MEDIC AR	0.00	0.00	1,993.26	285,686.83	0.00	625.01	0.00	0.00	0.00	0.00	0.00	0.00		288,305.10		
211Z	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	2,554.39	0.00	1,036.30	0.00	0.00	0.00	0.00	0.00	0.00		3,590.69		
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	-7.58	0.00	0.00	0.00	0.00	0.00	0.00		261,999.45		
2210	SSI DISABLED NON-ME D	0.00	0.00	2,749.04	2,519,626.74	0.00	1,146.84	0.00	0.00	0.00	0.00	0.00	0.00		2,523,522.62		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	4,633.84	0.00	2,218.07	0.00	0.00	0.00	0.00	0.00	0.00		6,851.91		
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	-1.63	0.00	0.00	0.00	0.00	0.00	0.00		25,230.75		
231Z	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	41.18	0.00	48.73	0.00	0.00	0.00	0.00	0.00	0.00		89.91		
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 M ED	0.00	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	989.30	0.00	0.00	0.00	0.00	0.00	0.00		11,885.41		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	2,872.42	10,293.73	0.00	1,491.07	0.00	0.00	0.00	0.00	0.00	0.00		14,657.22		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	3,393.32	0.00	1,518.51	0.00	0.00	0.00	0.00	0.00	0.00		4,911.83		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	3,902.74	0.00	1,808.52	0.00	0.00	0.00	0.00	0.00	0.00		5,711.26		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	42.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.23		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	1,169,673.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,169,673.33		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	1,377.52	5,703.57	0.00	1,503.71	0.00	0.00	0.00	0.00	0.00	0.00		8,584.80		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	8,698.21	35,078.16	0.00	8,739.41	0.00	0.00	0.00	0.00	0.00	0.00		52,515.78		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	53.70	118.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172.28		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	3,306.29	0.00	1,450.51	0.00	0.00	0.00	0.00	0.00	0.00		4,756.80		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	18,026.07	0.00	8,826.87	0.00	0.00	0.00	0.00	0.00	0.00		26,852.94		
501H	SOBRA PREG 45-64 FE M	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	SOBRA PREGNANT WO MAN	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		
7400	GENERAL MENTAL HE ALT	0.00	0.00	0.00	113,385.42	37,740,591.19	37,852,313.24	0.00	0.00	0.00	0.00	0.00	0.00		75,706,289.85		
7450	GENERAL MENTAL HE ALT	0.00	0.00	0.00	185,431.35	731,560.62	821,889.23	0.00	0.00	0.00	0.00	0.00	0.00		1,738,881.20		
SUBTOTAL:	0.00	0.00	46,375.93	13,520,501.11	38,472,151.81	38,740,306.08	0.00	0.00	0.00	0.00	0.00	0.00		90,779,334.93		

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	56.04	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	298.06	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	4,741.49	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	7,957.06	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	2,414.63	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	150.96	51.91	0.00	58.75	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	54.96	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	423.69	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	5,044.39	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	8,823.94	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	2,899.43	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 NO	0.00	0.00	0.00	91.77	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	
1,070.24	
2,012.07	
38,431.76	
69,112.01	
28,191.24	
261.62	
324.48	
1,066.91	
16,504.74	
30,106.88	
11,028.32	
29.74	
3,294.54	
943.32	
5,224.40	
91.77	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED WI	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	15,821.03	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	784.67	0.00	100.70	0.00	0.00	0.00	0.00	0.00	0.00	885.37	
2610	SSI DISABLED EXPAND E	0.00	0.00	380.15	59,038.16	0.00	290.38	0.00	0.00	0.00	0.00	0.00	0.00	59,708.69	
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	582.67	0.00	341.56	0.00	0.00	0.00	0.00	0.00	0.00	924.23	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	10,692.84	0.00	236.09	0.00	0.00	0.00	0.00	0.00	0.00	10,928.93	
SUBTOTAL	:	0.00	0.00	22,923.83	7,109,111.61	0.00	33,741.17	0.00	0.00	0.00	0.00	0.00	0.00	7,165,776.61	

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 E	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	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	755.25	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	1,013.93	3,611.12	0.00	639.26	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	5,546.63	20,673.68	0.00	2,757.30	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	4,253.41	15,230.87	0.00	1,811.16	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	8,630.54	29,354.94	0.00	6,462.02	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	869.84	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1,765.77	0.00	877.05	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE
2	0.00	0.00	0.00	8,609.41	0.00	3,253.72	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	7,091.78	0.00	2,330.99	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	14,388.14	0.00	7,192.13	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	58.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	24.36	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	109.38	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	44.19	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	9,810,302.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	2,784.91	9,031.66	0.00	1,005.28	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	2,062.31	6,463.28	0.00	1,055.50	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	30,342.83	90,957.29	0.00	20,334.09	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	12,585.50	46,559.36	0.00	8,844.57	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	21,561.45	78,545.19	0.00	17,183.22	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	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	ADULT <40% EXP MAL E	0.00	0.00	0.00	4,626.58	0.00	1,285.85	0.00	0.00	0.00	0.00	0.00	0.00	
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	3,568.66	0.00	1,337.49	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	42,355.82	0.00	16,783.10	0.00	0.00	0.00	0.00	0.00	0.00	

 
89.91	
56.86	
24.36	
4,521,352.89	
5,702.06	
5,264.31	
28,977.61	
21,295.44	
44,447.50	
2,689.25	
2,642.82	
11,863.13	
9,422.77	
21,580.27	
0.00	
58.75	
24.36	
109.38	
44.19	
9,810,302.35	
12,821.85	
9,581.09	
141,634.21	
67,989.43	
117,289.86	
-165.67	
5,912.43	
4,906.15	
59,138.92	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	21,484.21	0.00	7,786.59	0.00	0.00	0.00	0.00	0.00	0.00	29,270.80	
371H	ADULT <40% EXP M&F 4	0.00	0.00	10.38	39,417.49	0.00	15,820.09	0.00	0.00	0.00	0.00	0.00	0.00	55,247.96	
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 MAL E	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	
SUBTOTAL	:	0.00	0.00	89,733.94	14,781,402.64	0.00	118,493.88	0.00	0.00	0.00	0.00	0.00	0.00	14,989,630.46	

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	563.09	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	585.00	1,639.15	0.00	77.72	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	620.21	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	712.30	0.00	98.81	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	820.04	234,341.14	0.00	1,359.83	0.00	0.00	0.00	0.00	0.00	0.00	

229,236.70	
2,908.07	
2,301.87	
1,263.26	
811.11	
236,521.01	

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 5	0.00	0.00	116.49	139.77	0.00	51.97	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	67.64	0.00	48.73	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	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	CC PATIENT FEMALE 2 1	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	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	21.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	116.49	9,315.32	0.00	100.70	0.00	0.00	0.00	0.00	0.00	0.00	

8,193.19	
308.23	
116.37	
875.16	
17.87	
21.69	
9,532.51	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	1,641.69	0.00	117.50	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	114.25	0.00	0.00	0.00	0.00	0.00	0.00	

1,759.19	
11,882.82	

3900	NEWLY ELIGIBLE FOR F	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	200.75	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	445.05	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	3,092.41	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	3,965.29	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	5,714.75	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	213.98	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	444.50	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	4,196.13	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	5,346.42	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	12,386.88	0.00	6,333.68	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	29,952.96	0.00	0.00	0.00	0.00	0.00	0.00	

 
58.75	
3,958,586.24	
3,084.64	
3,244.58	
28,981.48	
38,928.25	
34,185.76	
-108.02	
1,265.67	
1,770.46	
13,705.31	
18,189.79	
18,720.56	
4,120,613.47	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	119.35	0.00	204.65	0.00	0.00	0.00	0.00	0.00	0.00	324.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	397.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	397.16	
SUBTOTAL	:	0.00	0.00	168.21	13,758.56	0.00	436.40	0.00	0.00	0.00	0.00	0.00	0.00	14,363.17	

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	
SUBTOTAL:	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	

0.00	0.00	175,456.09	39,744,034.47	38,472,151.81	38,924,391.02	0.00	0.00	0.00	0.00	0.00	0.00	

117,316,033.39	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending December 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	40.00	0.00	0.00	0.00	0.00	0.00	0.00		40.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	332.00	0.00	0.00	0.00	0.00	0.00	0.00		332.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	2,462.00	0.00	0.00	0.00	0.00	0.00	0.00		2,462.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	5,683.00	0.00	0.00	0.00	0.00	0.00	0.00		5,683.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	1,216.00	0.00	0.00	0.00	0.00	0.00	0.00		1,216.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00		32.00		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	154.00	0.00	0.00	0.00	0.00	0.00	0.00		154.00		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	252.00	0.00	0.00	0.00	0.00	0.00	0.00		252.00		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	2,723.00	0.00	0.00	0.00	0.00	0.00	0.00		2,723.00		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	6,401.00	0.00	0.00	0.00	0.00	0.00	0.00		6,401.00		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	1,493.00	0.00	0.00	0.00	0.00	0.00	0.00		1,493.00		
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	0.00	0.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
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 A	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-MEDIC AR	0.00	0.00	0.00	5,398.00	0.00	398.00	0.00	0.00	0.00	0.00	0.00	0.00		5,796.00		
211Z	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	662.00	0.00	0.00	0.00	0.00	0.00	0.00		662.00		
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	-4.00	0.00	0.00	0.00	0.00	0.00	0.00		2,137.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	40,232.00	0.00	652.00	0.00	0.00	0.00	0.00	0.00	0.00		40,884.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	1,350.00	0.00	0.00	0.00	0.00	0.00	0.00		1,350.00		
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	-1.00	0.00	0.00	0.00	0.00	0.00	0.00		421.00		
231Z	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
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 M ED	0.00	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	594.00	0.00	0.00	0.00	0.00	0.00	0.00		594.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	882.00	0.00	0.00	0.00	0.00	0.00	0.00		882.00		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	922.00	0.00	0.00	0.00	0.00	0.00	0.00		922.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	1,069.00	0.00	0.00	0.00	0.00	0.00	0.00		1,069.00		

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
5010	SOBRA PREGNANT WO MAN	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		22,659.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	891.00	0.00	0.00	0.00	0.00	0.00	0.00		891.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	5,277.00	0.00	0.00	0.00	0.00	0.00	0.00		5,277.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	882.00	0.00	0.00	0.00	0.00	0.00	0.00		882.00		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	5,391.00	0.00	0.00	0.00	0.00	0.00	0.00		5,391.00		
501H	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		
5020	SOBRA PREGNANT WO MAN	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		
7400	GENERAL MENTAL HE ALT	0.00	0.00	0.00	832.00	716,469.00	717,493.00	0.00	0.00	0.00	0.00	0.00	0.00		1,434,794.00		
7450	GENERAL MENTAL HE ALT	0.00	0.00	0.00	0.00	5,734.00	8,674.00	0.00	0.00	0.00	0.00	0.00	0.00		14,408.00		
SUBTOTAL:	0.00	0.00	0.00	232,672.00	722,203.00	765,980.00	0.00	0.00	0.00	0.00	0.00	0.00		1,720,855.00		

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	29.00	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	167.00	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	2,850.00	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	4,746.00	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	1,501.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	30.00	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	29.00	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	235.00	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	3,080.00	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	5,382.00	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	1,813.00	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 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	

 
125.00	
0.00	
0.00	
0.00	
0.00	
132,307.00	
29.00	
167.00	
2,850.00	
4,746.00	
1,501.00	
30.00	
29.00	
235.00	
3,080.00	
5,382.00	
1,813.00	
0.00	
65.00	
11.00	
101.00	
0.00	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	321.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	321.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	7.00	0.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	69.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	1,134.00	0.00	188.00	0.00	0.00	0.00	0.00	0.00	0.00	1,322.00	
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	206.00	0.00	0.00	0.00	0.00	0.00	0.00	206.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	203.00	0.00	182.00	0.00	0.00	0.00	0.00	0.00	0.00	385.00	
SUBTOTAL	:	0.00	0.00	0.00	134,274.00	0.00	20,500.00	0.00	0.00	0.00	0.00	0.00	0.00	154,774.00	

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 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	
3510	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	465.00	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	360.00	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	1,625.00	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	1,093.00	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	3,967.00	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	549.00	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	498.00	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	1,909.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	1,350.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	4,446.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL 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	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	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	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	599.00	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	616.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	12,247.00	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	5,374.00	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	10,390.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371D	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	764.00	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	793.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	10,078.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
0.00	
0.00	
87,606.00	
465.00	
360.00	
1,625.00	
1,093.00	
3,967.00	
549.00	
498.00	
1,909.00	
1,350.00	
4,446.00	
0.00	
1.00	
0.00	
62.00	
0.00	
190,536.00	
599.00	
616.00	
12,247.00	
5,374.00	
10,390.00	
0.00	
764.00	
793.00	
10,078.00	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	4,707.00	0.00	0.00	0.00	0.00	0.00	0.00	4,707.00	
371H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	9,538.00	0.00	0.00	0.00	0.00	0.00	0.00	9,538.00	
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 MAL 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	
SUBTOTAL	:	0.00	0.00	0.00	278,146.00	0.00	71,430.00	0.00	0.00	0.00	0.00	0.00	0.00	349,576.00	

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	325.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	37.00	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	355.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	4,438.00	0.00	773.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,438.00	
325.00	
37.00	
355.00	
56.00	
5,211.00	

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 5	0.00	0.00	0.00	0.00	0.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	177.00	0.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	

159.00	
32.00	
30.00	
18.00	
0.00	
0.00	
239.00	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	18.00	0.00	61.00	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	65.00	0.00	0.00	0.00	0.00	0.00	0.00	

79.00	
289.00	

3900	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	
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	126.00	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	263.00	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	1,785.00	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	2,366.00	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	3,440.00	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	121.00	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	263.00	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	2,429.00	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	3,186.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	3,718.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	76,645.00	0.00	17,697.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
76,644.00	
126.00	
263.00	
1,785.00	
2,366.00	
3,440.00	
0.00	
121.00	
263.00	
2,429.00	
3,186.00	
3,718.00	
94,342.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	120.00	0.00	0.00	0.00	0.00	0.00	0.00		120.00		
8720	SSI DISABLED FREEDO M	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		
SUBTOTAL:	0.00	0.00	0.00	246.00	0.00	246.00	0.00	0.00	0.00	0.00	0.00	0.00		492.00		

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	

TOTAL:	0.00	0.00	0.00	726,598.00	722,203.00	876,688.00	0.00	0.00	0.00	0.00	0.00	0.00		2,325,489.00		

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

1012

TANF 01-05 M & F NON

0.00

0.00

0.00

0.00

0.00

594.88

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

69.78

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

957.15

0.00

0.00

0.00

0.00

0.00

0.00

101A

TANF < 1 M & F NON-M

0.00

0.00

0.00

0.00

0.00

4,140.92

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

163.22

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

20,509.77

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

13,327.75

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

16,266.40

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

2,499.16

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

6,061.86

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

19,420.01

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

17,215.59

0.00

0.00

0.00

0.00

0.00

0.00

431C

SOBRA CHILD 6-13 M& F

0.00

0.00

0.00

0.00

0.00

10,385.58

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

790.96

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4,034.63

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

120,233.00

0.00

0.00

0.00

0.00

0.00

0.00

431E

SOBRA CHILD 14-20 FE

SUBTOTAL:

594.88

69.78

957.15

4,140.92

163.22

20,509.77

13,327.75

16,266.40

2,499.16

6,061.86

19,420.01

17,215.59

10,385.58

790.96

4,034.63

120,233.00

1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	3,795.34	0.00	0.00	0.00	0.00	0.00	0.00	3,795.34

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	1,535.40	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	744.43	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	2,279.83	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,535.40	
744.43	
2,279.83	

0.00	0.00	0.00	0.00	0.00	122,512.83	0.00	0.00	0.00	0.00	0.00	0.00	

122,512.83	

TOTAL:

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

1012

TANF 01-05 M & F NON

0.00

0.00

0.00

0.00

0.00

27.00

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

3.00

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

32.00

0.00

0.00

0.00

0.00

0.00

0.00

101A

TANF < 1 M & F NON-M

0.00

0.00

0.00

0.00

0.00

176.00

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

4.00

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

748.00

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

524.00

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

617.00

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

110.00

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

232.00

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

716.00

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

683.00

0.00

0.00

0.00

0.00

0.00

0.00

431C

SOBRA CHILD 6-13 M& F

0.00

0.00

0.00

0.00

0.00

416.00

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

34.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

146.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4,604.00

0.00

0.00

0.00

0.00

0.00

0.00

431E

SOBRA CHILD 14-20 FE

SUBTOTAL:

27.00

3.00

32.00

176.00

4.00

748.00

524.00

617.00

110.00

232.00

716.00

683.00

416.00

34.00

146.00

4,604.00

1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	136.00	0.00	0.00	0.00	0.00	0.00	0.00	136.00

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	66.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	98.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
66.00	
32.00	
98.00	

TOTAL:	0.00	0.00	0.00	0.00	0.00	4,702.00	0.00	0.00	0.00	0.00	0.00	0.00		4,702.00		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	-25.99	0.00	0.00	0.00	0.00	0.00	0.00	-25.99	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	1,977.97	0.00	0.00	0.00	0.00	0.00	0.00	1,977.97	
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	9,879.89	0.00	0.00	0.00	0.00	0.00	0.00	9,879.89	
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	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	11,831.87	0.00	0.00	0.00	0.00	0.00	0.00	11,831.87	

0.00	0.00	0.00	0.00	0.00	11,831.87	0.00	0.00	0.00	0.00	0.00	0.00	

11,831.87	

TOTAL:

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	-8.00	0.00	0.00	0.00	0.00	0.00	0.00	-8.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	407.00	0.00	0.00	0.00	0.00	0.00	0.00	407.00	
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	2,047.00	0.00	0.00	0.00	0.00	0.00	0.00	2,047.00	
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	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	2,446.00	0.00	0.00	0.00	0.00	0.00	0.00	2,446.00	

TOTAL:	0.00	0.00	0.00	0.00	0.00	2,446.00	0.00	0.00	0.00	0.00	0.00	0.00		2,446.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending December 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	3,966.00	3,172.80	0.00	0.00	0.00	0.00	0.00	0.00		20,167.20		
1010	TANF NON-MEDICARE	191,820.80	195,596.80	195,596.80	202,266.00	205,438.80	203,852.40	0.00	0.00	0.00	0.00	0.00	0.00		1,194,571.60		
1011	TANF <1 M & F NON-ME	4,850.24	3,696.96	4,174.08	4,280.84	4,598.73	4,123.42	0.00	0.00	0.00	0.00	0.00	0.00		25,724.27		
1012	TANF 01-05 M & F NON	5,406.40	6,559.68	6,837.76	7,450.59	5,388.88	8,243.79	0.00	0.00	0.00	0.00	0.00	0.00		39,887.10		
1013	TANF 06-13 M & F NON	8,427.20	5,883.52	6,360.64	6,975.28	4,913.57	6,182.08	0.00	0.00	0.00	0.00	0.00	0.00		38,742.29		
1014	TANF 14-20 MALE NON-	4,174.08	3,896.00	3,617.92	2,376.55	2,376.55	2,376.55	0.00	0.00	0.00	0.00	0.00	0.00		18,817.65		
1015	TANF 14-20 FEMALE N O	6,281.60	6,281.60	5,327.36	5,864.19	5,388.88	4,120.37	0.00	0.00	0.00	0.00	0.00	0.00		33,264.00		
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	1,901.24	1,901.24	0.00	0.00	0.00	0.00	0.00	0.00		9,999.61		
2200	SSI DISABLED WITH M E	26,909.12	26,909.12	26,153.92	25,857.71	26,650.91	29,030.51	0.00	0.00	0.00	0.00	0.00	0.00		161,511.29		
2210	SSI DISABLED NON-ME D	4,555,037.44	4,547,763.52	4,549,511.04	4,770,193.82	4,767,659.85	4,752,749.52	0.00	0.00	0.00	0.00	0.00	0.00		27,942,915.19		
2220	SSI DISABLED WITH Q M	60,934.08	63,676.80	63,676.80	69,002.30	69,002.30	70,588.70	0.00	0.00	0.00	0.00	0.00	0.00		396,880.98		
2300	SSI BLIND WITH MEDIC	755.20	755.20	755.20	793.20	793.20	793.20	0.00	0.00	0.00	0.00	0.00	0.00		4,645.20		
2310	SSI BLIND NON-MEDIC A	44,041.60	44,796.80	45,552.00	46,317.39	45,842.08	47,428.48	0.00	0.00	0.00	0.00	0.00	0.00		273,978.35		
4311	SOBRA CHILD <1 M & F	25,957.76	26,156.80	24,646.40	21,722.09	26,320.82	23,623.33	0.00	0.00	0.00	0.00	0.00	0.00		148,427.20		
4312	SOBRA CHILD 01-05 M	201,787.20	195,069.44	196,857.92	198,822.93	192,005.07	190,100.78	0.00	0.00	0.00	0.00	0.00	0.00		1,174,643.34		
4313	SOBRA CHILD 06-13 M	231,286.72	231,605.76	228,505.92	229,397.14	231,619.32	230,350.81	0.00	0.00	0.00	0.00	0.00	0.00		1,382,765.67		
4314	SOBRA CHILD 14-20 MA	56,885.76	53,744.96	52,035.52	56,132.33	56,607.64	57,558.26	0.00	0.00	0.00	0.00	0.00	0.00		332,964.47		
4315	SOBRA CHILD 14-20 FE	54,503.04	54,025.92	52,316.48	51,046.09	52,947.33	54,215.84	0.00	0.00	0.00	0.00	0.00	0.00		319,054.70		
5015	SOBRA PREG 14-20 FE M	1,232.32	477.12	954.24	0.00	0.00	475.31	0.00	0.00	0.00	0.00	0.00	0.00		3,138.99		
SUBTOTAL:	5,484,742.72	5,471,348.16	5,468,286.40	5,703,890.38	5,703,421.17	5,690,887.39	0.00	0.00	0.00	0.00	0.00	0.00		33,522,576.22		

3514	ADULT 40-100% MALE
1	1,908.48	2,385.60	2,862.72	2,851.86	3,327.17	3,327.17	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,431.36	1,431.36	954.24	950.62	475.31	475.31	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	475.31	475.31	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	9,542.40	8,111.04	9,065.28	8,555.58	6,654.34	6,179.03	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	7,129.65	6,654.34	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	1,908.48	1,908.48	1,431.36	1,425.93	2,376.55	2,376.55	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	1,425.93	1,901.24	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	24,333.12	23,378.88	23,378.88	22,339.57	21,864.26	21,388.95	0.00	0.00	0.00	0.00	0.00	0.00	

16,663.00	
5,718.20	
2,857.29	
48,107.67	
43,817.21	
11,427.35	
8,092.94	
136,683.66	

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

7,140.51	
2,381.98	
9,522.49	

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	
SUBTOTAL:	477.12	477.12	477.12	475.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,906.67	
1,906.67	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending December 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	14,577.19	13,626.57	0.00	0.00	0.00	0.00	0.00	0.00		72,645.90		
4414	SOBRA 100-133% MALE	2,862.72	2,862.72	1,908.48	1,425.93	1,901.24	2,376.55	0.00	0.00	0.00	0.00	0.00	0.00		13,337.64		
4415	SOBRA 100-133% FEM AL	2,385.60	2,385.60	4,572.16	3,645.06	4,120.37	3,645.06	0.00	0.00	0.00	0.00	0.00	0.00		20,753.85		
SUBTOTAL:	13,836.48	15,744.96	18,686.72	18,222.25	20,598.80	19,648.18	0.00	0.00	0.00	0.00	0.00	0.00		106,737.39		

5,746,828.75

0.00

0.00

0.00

TOTAL:

5,524,820.80

5,512,380.48	5,512,260.48

5,747,785.47	5,733,350.45	0.00	0.00

0.00

33,777,426.43

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending December 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	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
1010	TANF NON-MEDICARE	254.00	259.00	259.00	255.00	259.00	257.00	0.00	0.00	0.00	0.00	0.00	0.00		1,543.00		
1011	TANF <1 M & F NON-ME	9.00	6.00	7.00	7.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
1012	TANF 01-05 M & F NON	9.00	12.00	12.00	13.00	10.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00		70.00		
1013	TANF 06-13 M & F NON	13.00	10.00	11.00	12.00	9.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00		66.00		
1014	TANF 14-20 MALE NON-	7.00	7.00	7.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00		36.00		
1015	TANF 14-20 FEMALE N O	12.00	12.00	10.00	11.00	10.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00		63.00		
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	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
2200	SSI DISABLED WITH M E	36.00	36.00	35.00	33.00	34.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00		211.00		
2210	SSI DISABLED NON-ME D	6,198.00	6,188.00	6,187.00	6,191.00	6,185.00	6,165.00	0.00	0.00	0.00	0.00	0.00	0.00		37,114.00		
2220	SSI DISABLED WITH Q M	84.00	88.00	88.00	91.00	91.00	93.00	0.00	0.00	0.00	0.00	0.00	0.00		535.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2310	SSI BLIND NON-MEDIC A	62.00	63.00	64.00	62.00	61.00	63.00	0.00	0.00	0.00	0.00	0.00	0.00		375.00		
4311	SOBRA CHILD <1 M & F	41.00	42.00	40.00	35.00	42.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00		239.00		
4312	SOBRA CHILD 01-05 M	339.00	329.00	331.00	324.00	313.00	311.00	0.00	0.00	0.00	0.00	0.00	0.00		1,947.00		
4313	SOBRA CHILD 06-13 M	395.00	398.00	395.00	391.00	393.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00		2,363.00		
4314	SOBRA CHILD 14-20 MA	93.00	87.00	84.00	88.00	89.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00		532.00		
4315	SOBRA CHILD 14-20 FE	95.00	94.00	91.00	88.00	92.00	94.00	0.00	0.00	0.00	0.00	0.00	0.00		554.00		
5015	SOBRA PREG 14-20 FE M	2.00	1.00	2.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	7,657.00	7,640.00	7,633.00	7,615.00	7,610.00	7,595.00	0.00	0.00	0.00	0.00	0.00	0.00		45,750.00		

3514	ADULT 40-100% MALE
1	4.00	5.00	6.00	6.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	3.00	3.00	2.00	2.00	1.00	1.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	20.00	17.00	19.00	18.00	14.00	13.00	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	15.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	4.00	4.00	3.00	3.00	5.00	5.00	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	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	51.00	49.00	49.00	47.00	46.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	

35.00	
12.00	
6.00	
101.00	
92.00	
24.00	
17.00	
287.00	

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

15.00	
5.00	
20.00	

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	
SUBTOTAL:	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	
4.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending December 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	30.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00		150.00		
4414	SOBRA 100-133% MALE	6.00	6.00	4.00	3.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00		28.00		
4415	SOBRA 100-133% FEM AL	5.00	5.00	9.00	7.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
SUBTOTAL:	29.00	33.0	0	38.00	37.00	42.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00		219.00		

TOTAL:

7,741.00

7,726.00

7,724.00

7,702.00

7,683.00

0.00

0.00

0.00

46,280.00

7,704.00

0.00

0.00	0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 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	4,208.35	1,206.95	0.00	0.00	0.00	0.00	0.00	0.00		12,870.96		
1007	TANF 21-44 FEMALE WI	11,505.38	19,187.09	10,505.19	13,081.14	12,255.21	5,857.34	0.00	0.00	0.00	0.00	0.00	0.00		72,391.35		
1008	TANF 45-64 M & F WIT	8,643.75	16,020.60	11,606.94	2,469.05	14,211.66	6,056.21	0.00	0.00	0.00	0.00	0.00	0.00		59,008.21		
1009	TANF 65+ M & F WITH	2,022.37	2,905.92	1,922.18	3,376.98	5,415.68	4,221.49	0.00	0.00	0.00	0.00	0.00	0.00		19,864.62		
1011	TANF <1 M & F NON-ME	997,028.06	1,032,104.95	596,456.80	985,043.07	762,247.89	778,844.36	0.00	0.00	0.00	0.00	0.00	0.00		5,151,725.13		
1012	TANF 01-05 M & F NON	369,557.78	393,193.50	297,331.72	298,111.08	340,248.24	297,806.62	0.00	0.00	0.00	0.00	0.00	0.00		1,996,248.94		
1013	TANF 06-13 M & F NON	342,021.90	307,281.43	274,370.73	269,534.23	332,186.83	340,367.47	0.00	0.00	0.00	0.00	0.00	0.00		1,865,762.59		
1014	TANF 14-20 MALE NON-	88,902.93	72,599.25	62,332.53	62,617.64	90,941.50	84,475.92	0.00	0.00	0.00	0.00	0.00	0.00		461,869.77		
1015	TANF 14-20 FEMALE N O	219,214.37	258,354.36	254,247.65	217,864.06	248,268.11	224,437.51	0.00	0.00	0.00	0.00	0.00	0.00		1,422,386.06		
1016	TANF 21-44 MALE NON-	1,794,520.91	1,973,445.21	1,414,952.39	1,367,761.81	1,741,771.82	1,612,356.94	0.00	0.00	0.00	0.00	0.00	0.00		9,904,809.08		
1017	TANF 21-44 FEMALE N O	6,277,129.24	6,649,032.53	4,945,353.53	4,531,316.13	5,499,752.98	5,171,885.74	0.00	0.00	0.00	0.00	0.00	0.00		33,074,470.15		
1018	TANF 45-64 M & F NON	2,332,798.20	2,695,114.91	1,952,339.44	1,894,566.51	2,216,914.32	2,294,592.10	0.00	0.00	0.00	0.00	0.00	0.00		13,386,325.48		
1019	TANF 65+ M & F NON-M	1,488.83	4,276.48	4,454.29	39,419.85	11,908.51	5,893.98	0.00	0.00	0.00	0.00	0.00	0.00		67,441.94		
1026	TANF 21-44 MALE WITH	1,000.95	2,620.04	1,137.34	2,285.50	955.88	180.71	0.00	0.00	0.00	0.00	0.00	0.00		8,180.42		
1027	TANF 21-44 FEMALE WI	3,449.27	3,490.82	1,096.67	4,139.90	2,045.11	510.96	0.00	0.00	0.00	0.00	0.00	0.00		14,732.73		
1028	TANF 45-64 M & F WIT	8,935.11	7,873.80	7,408.04	7,634.06	6,284.82	4,614.87	0.00	0.00	0.00	0.00	0.00	0.00		42,750.70		
1029	TANF 65+ M & F WITH	111.13	364.33	6.64	1,438.51	195.66	525.26	0.00	0.00	0.00	0.00	0.00	0.00		2,641.53		
2100	SSI AGED WITH MEDIC A	190,983.36	191,970.63	82,013.82	76,365.39	91,088.43	84,485.74	0.00	0.00	0.00	0.00	0.00	0.00		716,907.37		
2110	SSI AGED NON-MEDIC AR	92,974.35	100,505.44	91,252.74	187,019.51	212,617.39	73,413.33	0.00	0.00	0.00	0.00	0.00	0.00		757,782.76		
2120	SSI AGED WITH QMB	469,076.56	646,192.71	528,246.07	449,589.56	450,826.87	348,768.55	0.00	0.00	0.00	0.00	0.00	0.00		2,892,700.32		
2200	SSI DISABLED WITH M E	358,598.07	500,225.09	440,571.93	338,158.99	391,009.98	311,665.78	0.00	0.00	0.00	0.00	0.00	0.00		2,340,229.84		
2210	SSI DISABLED NON-ME D	8,751,971.22	10,309,441.37	8,095,838.27	6,773,265.20	8,806,294.76	8,542,596.89	0.00	0.00	0.00	0.00	0.00	0.00		51,279,407.71		
2220	SSI DISABLED WITH Q M	1,192,013.12	1,702,312.74	1,203,802.42	1,061,781.98	1,370,268.80	958,676.06	0.00	0.00	0.00	0.00	0.00	0.00		7,488,855.12		
2300	SSI BLIND WITH MEDIC	457.17	1,105.82	1,395.49	132.01	491.84	428.26	0.00	0.00	0.00	0.00	0.00	0.00		4,010.59		
2310	SSI BLIND NON-MEDIC A	86,051.54	110,836.56	112,120.18	81,513.40	82,935.27	81,079.47	0.00	0.00	0.00	0.00	0.00	0.00		554,536.42		
2320	SSI BLIND WITH QMB	17,562.15	17,561.62	12,173.61	7,949.10	17,096.45	11,085.52	0.00	0.00	0.00	0.00	0.00	0.00		83,428.45		
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	2,747,010.01	2,481,215.34	0.00	0.00	0.00	0.00	0.00	0.00		15,351,033.35		
4312	SOBRA CHILD 01-05 M	3,898,361.36	5,221,614.05	3,931,751.08	3,374,005.06	4,010,212.14	4,301,630.58	0.00	0.00	0.00	0.00	0.00	0.00		24,737,574.27		
4313	SOBRA CHILD 06-13 M	5,970,382.14	5,908,426.67	5,257,376.58	4,250,756.20	5,669,522.10	4,391,163.44	0.00	0.00	0.00	0.00	0.00	0.00		31,447,627.13		
4314	SOBRA CHILD 14-20 MA	1,683,601.36	1,670,470.03	1,196,168.22	1,038,419.80	1,585,180.68	1,265,644.69	0.00	0.00	0.00	0.00	0.00	0.00		8,439,484.78		
4315	SOBRA CHILD 14-20 FE	1,620,045.30	2,013,403.75	1,845,592.74	1,401,643.00	1,810,729.95	1,566,327.85	0.00	0.00	0.00	0.00	0.00	0.00		10,257,742.59		
5007	SOBRA PREG 21-44 FE M	865.69	2,004.91	939.33	151.08	459.33	261.99	0.00	0.00	0.00	0.00	0.00	0.00		4,682.33		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,702.26	736.00	736.00	0.00	815.73	0.00	0.00	0.00	0.00	0.00	0.00		13,690.99		
5015	SOBRA PREG 14-20 FE M	398,992.68	518,674.19	387,758.06	314,539.29	350,898.88	334,012.06	0.00	0.00	0.00	0.00	0.00	0.00		2,304,875.16		
5017	SOBRA PREG 21-44 FE M	2,430,613.48	3,015,144.62	2,238,361.40	1,945,980.13	2,386,665.71	2,139,041.97	0.00	0.00	0.00	0.00	0.00	0.00		14,155,807.31		

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

RATE COD	E	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	27,596.10	12,701.46	0.00	0.00	0.00	0.00	0.00	0.00	66,299.93	
5027	SOBRA PREG 21-44 FE M	922.96	3,146.16	1,079.37	1,402.90	3,204.61	2,735.48	0.00	0.00	0.00	0.00	0.00	0.00	12,491.48	
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	
SUBTOTAL	:	42,425,721.60	48,108,092.23	37,724,728.19	33,172,108.58	41,303,921.87	37,741,584.62	0.00	0.00	0.00	0.00	0.00	0.00	240,476,157.09	

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

1,838.51	
1,838.51	

1106	TANF EXPANDED 21-44	19,712.79	23,772.65	11,988.70	17,140.04	22,040.16	16,937.89	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	35,218.74	19,784.01	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	95,032.02	59,533.27	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	43,849.18	47,867.62	36,472.40	38,131.18	36,818.64	24,274.38	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	1,472.00	471.44	368.00	1,481.59	2,806.93	368.00	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	736.00	1,472.00	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	4,356.53	2,015.96	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	50,425.28	46,391.53	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	559,699.80	611,284.24	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	2,185,538.90	2,133,031.44	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	1,633,132.51	1,360,274.98	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	3,568.96	3,154.34	5,023.68	4,365.65	4,739.79	10,389.44	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	11,749.81	26,016.73	11,081.94	11,382.54	17,326.99	20,943.95	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	27,164.38	22,630.71	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	54,020.94	40,899.35	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	17,343.41	26,220.86	16,100.79	9,815.08	17,818.86	16,868.11	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	17,207.10	23,080.02	28,399.63	13,700.77	12,869.20	14,537.07	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	9,549.32	3,150.78	3,153.04	2,208.00	6,394.47	3,262.70	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	300,798.06	347,865.14	270,900.47	216,331.04	264,977.28	198,503.35	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	32,108.52	41,934.80	28,768.37	14,158.05	25,178.04	11,813.77	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	170,711.55	140,061.64	176,457.03	173,409.00	189,119.12	126,144.75	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	338,045.21	438,971.31	317,520.57	254,535.17	307,286.68	236,404.15	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,433,347.56	6,255,423.13	4,932,402.60	4,345,410.53	5,552,701.26	4,977,765.05	0.00	0.00	0.00	0.00	0.00	0.00	

111,592.23	
207,260.63	
588,869.15	
227,413.40	
736.00	
6,967.96	
8,226.74	
32,655.14	
246,628.20	
3,486,891.10	
12,590,900.52	
8,684,405.84	
31,241.86	
98,501.96	
91,438.52	
219,638.60	
104,167.11	
109,793.79	
27,718.31	
1,599,375.34	
153,961.55	
975,903.09	
1,892,763.09	
31,497,050.13	

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	-294.00	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	-899.00	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	-61.97	-1,161.00	0.00	0.00	0.00	0.00	0.00	0.00	

-294.00	
-1,063.01	
-4,340.74	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	-1,442.96	0.00	-1,838.82	-61.97	-2,354.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,697.75		

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	
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	
3608	AHC CARE/MI M&F 45-6	-10.16	0.00	0.00	0.00	-13.47	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	
3616	AHC CARE/MI MALE 21-	0.00	-4,620.00	-362.02	-610.00	-294.00	-2,381.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	-660.00	-294.00	-1,766.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	-2,324.92	-463.62	-995.48	-739.76	-3,299.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-138.35	-7,604.92	-825.64	-5,347.15	-1,341.23	-7,446.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-128.19	
-3,081.67	
-23.63	
-660.00	
-8,267.02	
-2,720.00	
-7,822.78	
-22,703.29	

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	-1,166.66	1,264.78	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	6,327.79	15,866.14	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	56,060.43	44,818.62	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	74,897.97	101,710.15	78,047.94	61,982.73	76,779.04	88,818.48	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	875,338.76	993,741.02	812,257.64	811,955.65	914,132.12	757,098.06	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	688,506.80	716,669.29	519,306.11	481,552.92	559,184.06	482,437.75	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	2,164,182.50	2,672,009.10	2,054,220.46	1,818,577.48	2,332,481.43	2,275,223.23	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	7,494.50	-73.00	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	143.93	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	-128.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	8.65	1,289.46	2,371.98	837.91	2,418.85	257.39	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	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	ADULT <40% EXP M&F 4	10,869.67	8,301.93	10,834.72	9,262.41	23,458.38	2,494.65	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	1,326.41	4,433.00	1,431.77	64.80	197.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	396,349.39	314,897.57	319,289.68	238,842.40	301,110.30	276,678.41	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	466,712.02	441,609.03	420,069.14	280,751.72	338,144.22	263,371.91	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	7,380,948.41	7,458,471.39	5,814,373.14	5,938,761.42	6,755,844.39	6,330,402.78	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,864,032.81	3,815,255.08	2,921,267.62	2,735,105.88	3,344,580.99	3,059,428.82	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	9,449,700.09	10,711,847.87	8,243,352.00	7,558,809.96	9,253,995.87	8,809,856.30	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	4,389.51	5,535.00	8,073.77	924.43	2,245.03	3,407.52	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	45.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	579.64	19,355.70	-19.34	301.11	1,712.05	4,236.80	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,459,032.51	27,338,626.79	21,272,041.0	19,989,499.32	23,975,060.56	22,415,588.64	0.00	0.00	0.00	0.00	0.00	0.00	

 
-198.31	
29,439.27	
47,613.81	
276,859.36	
482,236.31	
5,164,523.25	
3,447,656.93	
13,316,694.20	
43,379.45	
217.07	
230.27	
0.00	
7,184.24	
6,690.70	
65,221.76	
7,453.58	
1,847,167.75	
2,210,658.04	
39,678,801.53	
19,739,671.20	
54,027,562.09	
24,575.26	
45.14	
26,165.96	
140,449,848.86	

3906	NEWLY ELIGIBLE MALE	600.38	328.49	29.45	209.59	411.24	590.08	0.00	0.00	0.00	0.00	0.00	0.00	2,169.23

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3907	NEWLY ELIGIBLE FEMA L	0.00	368.00	718.00	0.00	0.00	72.94	0.00	0.00	0.00	0.00	0.00	0.00		1,158.94		
3908	NEWLY ELIGIBLE M&F 4	9,346.79	12,574.43	4,551.68	837.13	2,803.98	3,984.00	0.00	0.00	0.00	0.00	0.00	0.00		34,098.01		
3909	NEWLY ELIGIBLE M&F 6	491.18	602.98	747.75	0.00	1,943.80	166.29	0.00	0.00	0.00	0.00	0.00	0.00		3,952.00		
3914	NEWLY ELIGIBLE MALE	22,978.31	18,527.45	13,537.31	13,309.33	31,539.02	32,825.23	0.00	0.00	0.00	0.00	0.00	0.00		132,716.65		
3915	NEWLY ELIGIBLE FEMA L	41,330.26	46,109.83	28,638.83	27,897.16	30,273.25	31,443.93	0.00	0.00	0.00	0.00	0.00	0.00		205,693.26		
3916	NEWLY ELIGIBLE MALE	331,242.92	482,310.70	341,671.18	331,691.73	336,188.43	356,055.85	0.00	0.00	0.00	0.00	0.00	0.00		2,179,160.81		
3917	NEWLY ELIGIBLE FEMA L	773,121.13	829,594.37	623,013.25	503,865.22	576,970.36	489,415.96	0.00	0.00	0.00	0.00	0.00	0.00		3,795,980.29		
3918	NEWLY ELIGIBLE M&F 4	1,108,114.13	1,301,085.00	1,128,587.46	1,103,452.24	1,218,789.25	1,157,414.84	0.00	0.00	0.00	0.00	0.00	0.00		7,017,442.92		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	736.00	368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,840.00		
3928	NEWLY ELIGIBLE M&F 4	30.62	360.56	0.00	0.00	80.90	368.00	0.00	0.00	0.00	0.00	0.00	0.00		840.08		
SUBTOTAL:	2,287,255.72	2,691,861.81	2,142,230.91	1,981,630.40	2,199,736.23	2,072,337.12	0.00	0.00	0.00	0.00	0.00	0.00		13,375,052.19		

4412	SOBRA 100-133% M&F
1	0.00	1,436.00	0.00	700.00	350.00	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	533,221.30	439,686.09	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	123,911.42	118,885.22	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	173,477.21	229,376.58	163,944.58	157,332.84	206,060.33	161,551.54	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	722,194.67	942,881.73	691,984.7	5	666,487.31	863,543.05	720,122.85	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,486.00	
2,810,070.99	
702,914.29	
1,091,743.08	
4,607,214.36	

4517	BC PATIENT FEMALE 2 1	368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	5,535.42	5,198.08	3,942.51	1,151.03	1,104.00	1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	147.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,271.42	6,081.82	3,942.51	1,151.03	1,104.00	1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,104.00	
18,035.04	
147.74	
368.00	
19,654.78	

8700	SSI DISABLED FREEDO M	11,347.92	16,496.57	21,239.51	9,895.47	12,006.69	10,563.56	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	1,984.49	2,170.38	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	4,329.16	3,321.72	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,176.17	19,372.57	29,893.61	12,730.73	18,320.34	16,055.66	0.00	0.00	0.00	0.00	0.00	0.00	

 
81,549.72	
7,917.82	
20,081.54	
109,549.08	

66,796,397.97

73,912,984.11    67,934,757.94

0.00

0.00

0.00

60,161,831.93

0.00

0.00	0.00

430,507,963.96	

TOTAL:

76,348,717.42

85,353,274.59

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending December 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	1,619.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,757.87		
1008	TANF 45-64 M & F WIT	3,001.23	1,005.46	161.94	0.00	437.60	1,300.91	0.00	0.00	0.00	0.00	0.00	0.00		5,907.14		
1009	TANF 65+ M & F WITH	100.93	886.53	87.58	99.31	0.00	121.78	0.00	0.00	0.00	0.00	0.00	0.00		1,296.13		
1011	TANF <1 M & F NON-ME	17,325.66	62,411.73	16,655.73	16,367.71	-4,482.71	24,568.77	0.00	0.00	0.00	0.00	0.00	0.00		132,846.89		
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	9,527.66	471.14	0.00	0.00	0.00	0.00	0.00	0.00		12,863.82		
1014	TANF 14-20 MALE NON-	714.39	1,253.78	2,854.79	1,212.29	1,317.94	1,063.58	0.00	0.00	0.00	0.00	0.00	0.00		8,416.77		
1015	TANF 14-20 FEMALE N O	3,433.47	1,839.76	17,329.46	1,737.78	4,834.68	13,551.37	0.00	0.00	0.00	0.00	0.00	0.00		42,726.52		
1016	TANF 21-44 MALE NON-	22,396.21	77,167.79	17,027.50	30,769.91	19,582.98	74,267.10	0.00	0.00	0.00	0.00	0.00	0.00		241,211.49		
1017	TANF 21-44 FEMALE N O	52,737.24	131,048.50	51,785.14	68,373.32	75,889.86	95,839.19	0.00	0.00	0.00	0.00	0.00	0.00		475,673.25		
1018	TANF 45-64 M & F NON	18,073.82	37,929.68	10,840.13	21,323.11	29,738.22	7,585.42	0.00	0.00	0.00	0.00	0.00	0.00		125,490.38		
2100	SSI AGED WITH MEDIC A	15,695.91	8,647.19	17,906.90	4,577.58	24,850.76	12,624.23	0.00	0.00	0.00	0.00	0.00	0.00		84,302.57		
2110	SSI AGED NON-MEDIC AR	28,335.40	43,386.47	18,508.51	14,354.52	14,326.40	10,091.55	0.00	0.00	0.00	0.00	0.00	0.00		129,002.85		
2120	SSI AGED WITH QMB	0.00	1,048.56	0.00	0.00	0.00	388.95	0.00	0.00	0.00	0.00	0.00	0.00		1,437.51		
2200	SSI DISABLED WITH M E	2,033.62	523.52	3,191.46	2,136.22	337.95	867.18	0.00	0.00	0.00	0.00	0.00	0.00		9,089.95		
2210	SSI DISABLED NON-ME D	16,753.15	7,270.63	7,651.13	14,824.42	5,039.25	322.18	0.00	0.00	0.00	0.00	0.00	0.00		51,860.76		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	1.71	0.00	0.00	0.00	0.00	0.00	0.00		1.71		
4311	SOBRA CHILD <1 M & F	10,799.03	33,934.63	1,439.56	27,420.49	47,618.22	15,364.31	0.00	0.00	0.00	0.00	0.00	0.00		136,576.24		
4312	SOBRA CHILD 01-05 M	36,145.25	43,168.63	23,886.76	53,151.78	93,538.03	55,433.49	0.00	0.00	0.00	0.00	0.00	0.00		305,323.94		
4313	SOBRA CHILD 06-13 M	35,978.68	63,157.33	22,075.20	27,013.14	18,490.93	31,425.00	0.00	0.00	0.00	0.00	0.00	0.00		198,140.28		
4314	SOBRA CHILD 14-20 MA	18,930.52	12,976.10	24,307.39	12,958.69	48,135.67	14,354.58	0.00	0.00	0.00	0.00	0.00	0.00		131,662.95		
4315	SOBRA CHILD 14-20 FE	12,023.48	33,332.95	16,503.27	18,974.50	34,815.87	26,678.69	0.00	0.00	0.00	0.00	0.00	0.00		142,328.76		
5007	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		
5015	SOBRA PREG 14-20 FE M	15,014.16	30,238.92	17,931.32	21,033.87	24,921.06	15,629.11	0.00	0.00	0.00	0.00	0.00	0.00		124,768.44		
5017	SOBRA PREG 21-44 FE M	74,107.54	80,746.34	74,318.02	80,279.13	96,045.85	79,809.71	0.00	0.00	0.00	0.00	0.00	0.00		485,306.59		
5018	SOBRA PREG 45-64 FE M	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		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	22.85	92.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.90		
SUBTOTAL:	385,488.23	674,902.99	344,652.4	6	418,337.10	546,678.14	481,759.95	0.00	0.00	0.00	0.00	0.00	0.00		2,851,818.87		

1106	TANF EXPANDED 21-44	0.00	16.99	0.00	0.00	64.90	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	401.97	414.56	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	2,050.54	1,037.17	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	49.92	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	1,317.36	1,900.33	0.00	0.00	0.00	0.00	0.00	0.00	

 
81.89	
1,417.08	
12,067.92	
49.92	
1,283.20	
6,046.23	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	20,881.24	35,996.89	23,243.00	23,284.36	32,455.03	19,904.42	0.00	0.00	0.00	0.00	0.00	0.00		155,764.94		
1117	TANF EXPANDED 21-44	25,519.01	79,115.30	31,651.63	22,755.66	43,409.59	32,204.44	0.00	0.00	0.00	0.00	0.00	0.00		234,655.63		
1118	TANF EXPANDED 45-64	10,025.87	17,504.72	19,259.83	34,282.55	9,735.71	23,483.52	0.00	0.00	0.00	0.00	0.00	0.00		114,292.20		
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	79.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.85		
1129	TANF EXPANDED 65+
M&	131.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131.86		
2400	SSI AGED EXPANDED WI	9,438.04	7,426.55	5,904.90	3,506.71	7,040.86	4,584.98	0.00	0.00	0.00	0.00	0.00	0.00		37,902.04		
2410	SSI AGED EXPANDED NO	6,357.74	0.00	0.00	0.00	2,137.03	533.72	0.00	0.00	0.00	0.00	0.00	0.00		9,028.49		
2420	SSI AGED EXPANDED WI	801.02	279.30	662.60	137.86	393.70	1,206.34	0.00	0.00	0.00	0.00	0.00	0.00		3,480.82		
2600	SSI DISABLED EXPAND E	4,162.15	4,535.71	3,783.46	647.92	3,387.25	1,809.57	0.00	0.00	0.00	0.00	0.00	0.00		18,326.06		
2610	SSI DISABLED EXPAND E	2,877.20	578.09	517.86	37.27	692.45	3,699.97	0.00	0.00	0.00	0.00	0.00	0.00		8,402.84		
2620	SSI DISABLED EXPAND E	-21.51	114.65	0.00	418.41	0.00	90.00	0.00	0.00	0.00	0.00	0.00	0.00		601.55		
SUBTOTAL:	82,110.61	152,318.59	88,653.42	87,509.05	103,166.20	90,918.94	0.00	0.00	0.00	0.00	0.00	0.00		604,676.81		

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	348.62	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	

489.66	
900.55	
3,447.12	

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	1,000.22	84.96	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	6,324.82	1,707.84	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	2,903.14	8,574.09	1,936.37	3,155.14	3,556.90	4,675.16	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	32,131.34	29,239.94	36,283.29	34,693.65	80,459.91	41,099.62	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	12,275.90	25,840.81	24,340.20	16,047.28	28,690.15	22,565.90	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	62,497.32	109,303.49	156,785.67	67,687.05	108,693.55	104,440.83	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	369.84	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	16.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	117.86	92.24	0.00	551.21	68.47	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	606.80	4,068.27	1,255.40	106.83	227.01	493.24	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	24,159.76	8,343.37	7,413.72	6,490.79	14,009.99	5,965.65	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	14,883.92	10,070.11	9,242.58	8,071.15	20,160.49	9,102.45	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	142,010.48	199,345.59	283,641.35	208,398.59	205,186.06	149,427.69	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	76,836.42	98,771.60	84,787.49	72,456.04	129,112.24	111,438.52	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	169,251.34	238,534.74	207,786.84	258,564.20	279,920.82	266,036.10	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL E	1,305.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	16.92	0.00	0.00	39.29	137.25	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	544,534.00	736,144.49	815,071.9	681,622.29	878,319.49	717,243.68	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,994.80	
2,683.64	
20,487.49	
24,800.80	
253,907.75	
129,760.24	
609,407.91	
369.84	
16.99	
829.78	
6,757.55	
66,383.28	
71,530.70	
1,188,009.76	
573,402.31	
1,420,094.04	
1,305.57	
193.46	
4,372,935.91	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	5,721.11	5,859.40	1,492.91	2,289.17	4,340.03	5,511.27	0.00	0.00	0.00	0.00	0.00	0.00	25,213.89	
3915	NEWLY ELIGIBLE FEMA L	8,643.80	4,978.33	1,563.70	2,092.87	236.71	468.25	0.00	0.00	0.00	0.00	0.00	0.00	17,983.66	
3916	NEWLY ELIGIBLE MALE	70,300.31	68,630.75	35,919.65	13,892.41	58,542.71	28,479.75	0.00	0.00	0.00	0.00	0.00	0.00	275,765.58	
3917	NEWLY ELIGIBLE FEMA L	24,423.42	39,053.73	33,070.64	21,577.86	34,563.12	45,340.29	0.00	0.00	0.00	0.00	0.00	0.00	198,029.06	
3918	NEWLY ELIGIBLE M&F 4	91,934.27	121,532.84	100,254.80	128,043.33	153,412.32	88,359.26	0.00	0.00	0.00	0.00	0.00	0.00	683,536.82	
SUBTOTAL	:	202,655.53	242,551.92	172,171.60	168,384.96	251,443.51	168,158.82	0.00	0.00	0.00	0.00	0.00	0.00	1,205,366.34	

4413	SOBRA 100-133% M&F
6	9,276.43	18,205.79	7,133.57	16,656.45	4,408.10	4,315.12	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	1,661.45	4,384.49	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	1,645.47	4,875.11	1,504.09	2,652.26	5,044.71	4,347.44	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,519.92	25,677.60	9,035.86	30,747.16	11,114.26	13,047.05	0.00	0.00	0.00	0.00	0.00	0.00	

59,995.46	
22,077.31	
20,069.08	
102,141.85	

4518	BC PATIENT FEMALE 4 5	78.61	0.00	0.00	0.00	152.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	78.61	0.00	0.00	0.00	152.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

230.99	
230.99	

8700	SSI DISABLED FREEDO M	30.54	591.33	225.58	25.00	155.36	1,799.54	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	237.08	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	26.70	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,096.24	591.33	225.58	315.32	155.36	2,063.32	0.00	0.00	0.00	0.00	0.00	0.00	

2,827.35	
1,593.10	
26.70	
4,447.15	

TOTAL:	1,228,483.14	1,832,186.92	1,429,810.88	1,386,915.88	1,791,029.34	1,473,191.76	0.00	0.00	0.00	0.00	0.00	0.00		9,141,617.92		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending December 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		
SUBTOTAL:	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	

TOTAL:

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	37.96	0.00	0.00	0.00	0.00	0.00	0.00	37.96	
1011	TANF <1 M & F NON-ME	3,451.27	301.65	83.70	377.87	2,556.41	204.21	0.00	0.00	0.00	0.00	0.00	0.00	6,975.11	
1012	TANF 01-05 M & F NON	25,128.76	31,110.09	8,102.69	164,581.01	17,355.47	31,680.25	0.00	0.00	0.00	0.00	0.00	0.00	277,958.27	
1013	TANF 06-13 M & F NON	51,155.97	80,966.53	57,090.55	57,009.97	85,394.15	57,902.60	0.00	0.00	0.00	0.00	0.00	0.00	389,519.77	
1014	TANF 14-20 MALE NON-	93,392.20	152,861.08	48,139.24	75,194.53	324,931.57	107,296.76	0.00	0.00	0.00	0.00	0.00	0.00	801,815.38	
1015	TANF 14-20 FEMALE N O	365,886.79	512,928.45	433,985.22	437,748.03	526,093.75	496,187.13	0.00	0.00	0.00	0.00	0.00	0.00	2,772,829.37	
1016	TANF 21-44 MALE NON-	126,645.84	163,695.80	98,079.03	56,898.27	58,334.35	39,877.67	0.00	0.00	0.00	0.00	0.00	0.00	543,530.96	
1017	TANF 21-44 FEMALE N O	2,509,465.83	3,746,506.71	3,124,913.12	3,032,934.82	3,531,096.65	2,233,122.35	0.00	0.00	0.00	0.00	0.00	0.00	18,178,039.48	
1018	TANF 45-64 M & F NON	232,788.56	309,539.08	253,785.13	187,921.09	266,690.04	207,749.11	0.00	0.00	0.00	0.00	0.00	0.00	1,458,473.01	
1019	TANF 65+ M & F NON-M	4,738.82	9,707.54	11,164.74	323.40	5,875.39	2,871.88	0.00	0.00	0.00	0.00	0.00	0.00	34,681.77	
2100	SSI AGED WITH MEDIC A	12,916.57	12,231.56	7,221.85	7,793.70	12,148.63	9,089.59	0.00	0.00	0.00	0.00	0.00	0.00	61,401.90	
2110	SSI AGED NON-MEDIC AR	869,141.79	1,485,741.04	1,163,143.59	971,963.81	1,535,124.58	987,744.35	0.00	0.00	0.00	0.00	0.00	0.00	7,012,859.16	
2120	SSI AGED WITH QMB	4,041.12	1,462.37	1,946.96	191.62	1,089.89	471.22	0.00	0.00	0.00	0.00	0.00	0.00	9,203.18	
2200	SSI DISABLED WITH M E	2,921.27	5,139.66	2,878.36	3,669.97	3,512.16	4,895.49	0.00	0.00	0.00	0.00	0.00	0.00	23,016.91	
2210	SSI DISABLED NON-ME D	420,657.34	364,111.90	277,016.96	249,032.75	474,676.82	288,695.61	0.00	0.00	0.00	0.00	0.00	0.00	2,074,191.38	
2220	SSI DISABLED WITH Q M	1,206.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,206.10	
SUBTOTAL	:	4,723,538.23	6,876,303.46	5,487,551.14	5,245,640.84	6,844,879.86	4,467,826.18	0.00	0.00	0.00	0.00	0.00	0.00	33,645,739.71	

3716	ADULT <40% EXP MAL E	302.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

302.98	

1106	TANF EXPANDED 21-44	20.66	853.49	749.84	779.40	4,811.37	1,707.88	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	-710.00	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	25.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	8.00	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	144.99	137.60	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	462.03	264.88	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	28,375.30	12,335.76	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	718,653.36	595,860.22	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	1,513,289.03	1,145,924.52	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	899,557.28	624,584.72	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	8,302.55	32,722.38	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	25,920.48	15,971.63	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	354.11	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	18,923.40	7,060.82	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,004,717.41	2,691,583.87	2,625,219.69	2,580,614.33	3,218,819.18	2,435,868.41	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,922.64	
-1,916.23	
27.13	
8.00	
282.59	
14,946.16	
124,384.84	
3,587,554.13	
7,358,626.90	
4,094,895.12	
76,332.58	
1,877.16	
4,042.89	
163,915.37	
1,144.37	
121,779.24	
15,556,822.89	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	4,384.78	
SUBTOTAL	:	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	4,687.76	

TOTAL:

9,886,437.64     14,111,912.66    11,414,030.97

14,288,688.22    10,328,912.85

0.00

0.00

0.00

71,201,816.96

11,171,834.62

0.00

0.00	0.00

3906	NEWLY ELIGIBLE MALE	3,658.03	6,533.31	3,679.09	3,982.59	6,269.15	3,584.44	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	186.74	1,247.40	0.00	545.96	172.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	190.37	14,378.58	4,624.14	668.06	2,168.21	1,466.79	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	4,641.95	861.24	823.08	871.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	-32,353.35	60,696.90	62,912.75	148,618.75	94,029.72	52,481.49	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	47,067.82	74,149.89	75,387.98	171,140.37	62,563.67	117,456.88	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	715,851.62	1,156,537.30	726,943.61	721,640.46	1,028,293.82	900,973.25	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	458,763.46	686,388.67	510,747.94	437,479.68	672,376.28	452,233.25	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	1,954,928.55	2,512,951.28	1,912,755.69	1,855,944.26	2,352,174.12	1,892,387.69	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	4,798.84	29,402.03	264.09	4,448.26	6,941.96	4,634.47	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,157,734.03	4,543,146.60	3,298,138.37	3,345,340.16	4,224,989.18	3,425,218.26	0.00	0.00	0.00	0.00	0.00	0.00	

 
27,706.61	
2,152.35	
23,496.15	
7,198.04	
386,386.26	
547,766.61	
5,250,240.06	
3,217,989.28	
12,481,141.59	
50,489.65	
21,994,566.60	

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	531,290.47	353,070.67	0.00	0.00	0.00	0.00	0.00	0.00	2,431,733.33	
8040	SLMB	4.16	0.00	0.00	0.00	4.29	7.91	0.00	0.00	0.00	0.00	0.00	0.00	16.36	
8050	QI1	7.67	86.69	626.78	0.00	75.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	796.76	

SUBTOTAL:	400,114.69	462,259.02	326,723.35	359,000.43	531,370.38	353,078.58	0.00	0.00	0.00	0.00	0.00	0.00		2,432,546.45	
															
TOTAL:	400,114.69	462,259.02	326,723.35	359,000.43	531,370.38	353,078.58	0.00	0.00	0.00	0.00	0.00	0.00		2,432,546.45	

FFS TRBHA FEE FOR SERVICE
For The Period Ending December 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	368.00	4,560.13	0.00	0.00	0.00	0.00	0.00	0.00		11,181.01		
1012	TANF 01-05 M & F NON	368.00	6,424.63	12,171.54	6,859.78	9,788.83	9,203.67	0.00	0.00	0.00	0.00	0.00	0.00		44,816.45		
1013	TANF 06-13 M & F NON	16,512.22	58,805.63	33,851.14	31,350.62	74,857.22	45,625.82	0.00	0.00	0.00	0.00	0.00	0.00		261,002.65		
1014	TANF 14-20 MALE NON-	7,533.55	31,068.97	43,660.36	19,685.20	17,281.74	15,695.59	0.00	0.00	0.00	0.00	0.00	0.00		134,925.41		
1015	TANF 14-20 FEMALE N O	17,783.14	60,075.16	52,454.25	37,141.90	89,701.85	41,636.73	0.00	0.00	0.00	0.00	0.00	0.00		298,793.03		
1016	TANF 21-44 MALE NON-	50,986.98	232,739.24	158,391.39	238,145.92	268,947.55	213,560.11	0.00	0.00	0.00	0.00	0.00	0.00		1,162,771.19		
1017	TANF 21-44 FEMALE N O	127,725.96	724,699.04	580,736.17	781,083.34	802,036.54	664,977.53	0.00	0.00	0.00	0.00	0.00	0.00		3,681,258.58		
1018	TANF 45-64 M & F NON	27,221.83	125,961.97	90,380.62	113,702.12	175,425.74	108,458.73	0.00	0.00	0.00	0.00	0.00	0.00		641,151.01		
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	605.22	592.54	0.00	0.00	0.00	0.00	0.00	0.00		1,439.78		
1028	TANF 45-64 M & F WIT	0.00	69.00	0.00	0.00	1,364.85	191.10	0.00	0.00	0.00	0.00	0.00	0.00		1,624.95		
2100	SSI AGED WITH MEDIC A	1,846.28	4,349.08	4,742.68	9,243.84	8,974.21	5,444.39	0.00	0.00	0.00	0.00	0.00	0.00		34,600.48		
2110	SSI AGED NON-MEDIC AR	0.00	368.00	368.00	368.00	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00		1,472.00		
2120	SSI AGED WITH QMB	2,129.89	16,890.55	8,512.82	13,797.57	24,489.11	27,241.34	0.00	0.00	0.00	0.00	0.00	0.00		93,061.28		
2200	SSI DISABLED WITH M E	4,943.64	25,786.59	15,182.25	15,394.43	21,736.34	19,832.03	0.00	0.00	0.00	0.00	0.00	0.00		102,875.28		
2210	SSI DISABLED NON-ME D	328,797.09	1,331,576.12	1,008,275.86	1,224,180.78	1,745,413.36	1,340,142.17	0.00	0.00	0.00	0.00	0.00	0.00		6,978,385.38		
2220	SSI DISABLED WITH Q M	57,352.69	239,617.61	215,280.59	218,399.67	280,370.96	270,585.46	0.00	0.00	0.00	0.00	0.00	0.00		1,281,606.98		
2310	SSI BLIND NON-MEDIC A	1,641.42	3,896.82	1,477.44	1,960.45	3,267.86	7,135.91	0.00	0.00	0.00	0.00	0.00	0.00		19,379.90		
2320	SSI BLIND WITH QMB	152.56	426.32	347.04	441.86	184.29	699.38	0.00	0.00	0.00	0.00	0.00	0.00		2,251.45		
4311	SOBRA CHILD <1 M & F	0.00	4,537.43	2,034.73	1,426.34	6,580.12	7,003.95	0.00	0.00	0.00	0.00	0.00	0.00		21,582.57		
4312	SOBRA CHILD 01-05 M	38,968.43	137,249.86	128,098.21	121,728.54	162,096.34	91,097.20	0.00	0.00	0.00	0.00	0.00	0.00		679,238.58		
4313	SOBRA CHILD 06-13 M	681,184.65	2,583,435.70	1,681,906.75	1,873,899.44	4,038,697.57	2,282,137.04	0.00	0.00	0.00	0.00	0.00	0.00		13,141,261.15		
4314	SOBRA CHILD 14-20 MA	118,686.61	495,250.47	412,817.00	484,576.55	753,609.47	528,879.93	0.00	0.00	0.00	0.00	0.00	0.00		2,793,820.03		
4315	SOBRA CHILD 14-20 FE	99,195.07	477,467.78	386,605.17	499,195.74	754,614.07	576,811.53	0.00	0.00	0.00	0.00	0.00	0.00		2,793,889.36		
5015	SOBRA PREG 14-20 FE M	2,116.23	12,740.30	13,261.52	9,943.56	21,201.36	19,030.59	0.00	0.00	0.00	0.00	0.00	0.00		78,293.56		
5017	SOBRA PREG 21-44 FE M	13,961.07	87,460.78	103,132.29	142,374.76	133,317.49	103,801.36	0.00	0.00	0.00	0.00	0.00	0.00		584,047.75		
5018	SOBRA PREG 45-64 FE M	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368.00		
SUBTOTAL:	1,600,315.02	6,668,008.15	4,954,196.19	5,845,592.19	9,394,930.09	6,384,712.23	0.00	0.00	0.00	0.00	0.00	0.00		34,847,753.87		

1106	TANF EXPANDED 21-44	137.75	616.80	613.08	272.99	532.97	486.29	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	407.11	636.48	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	965.63	2,424.52	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	167.36	84.46	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	912.14	1,874.36	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,659.88	
3,291.15	
14,723.57	
316.62	
736.00	
10,296.92	

FFS TRBHA FEE FOR SERVICE
For The Period Ending December 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	79,859.99	37,359.82	0.00	0.00	0.00	0.00	0.00	0.00		233,474.50		
1117	TANF EXPANDED 21-44	35,688.54	179,661.54	169,883.68	176,677.23	386,454.55	193,784.64	0.00	0.00	0.00	0.00	0.00	0.00		1,142,150.18		
1118	TANF EXPANDED 45-64	12,040.84	94,798.16	87,530.61	76,865.00	142,804.48	62,357.25	0.00	0.00	0.00	0.00	0.00	0.00		476,396.34		
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	187.16	733.08	0.00	0.00	0.00	0.00	0.00	0.00		1,280.16		
1128	TANF EXPANDED 45-64	0.00	389.55	143.09	11.74	75.11	909.56	0.00	0.00	0.00	0.00	0.00	0.00		1,529.05		
1129	TANF EXPANDED 65+
M&	0.00	87.63	0.00	0.00	0.00	98.19	0.00	0.00	0.00	0.00	0.00	0.00		185.82		
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	1,221.35	958.95	0.00	0.00	0.00	0.00	0.00	0.00		20,332.47		
2600	SSI DISABLED EXPAND E	340.83	1,313.81	339.22	88.37	0.00	6,254.71	0.00	0.00	0.00	0.00	0.00	0.00		8,336.94		
2610	SSI DISABLED EXPAND E	2,514.49	16,695.75	6,889.70	9,071.56	8,556.05	4,361.11	0.00	0.00	0.00	0.00	0.00	0.00		48,088.66		
2620	SSI DISABLED EXPAND E	7,877.72	36,952.00	29,165.99	31,985.20	31,811.60	23,669.04	0.00	0.00	0.00	0.00	0.00	0.00		161,461.55		
SUBTOTAL:	66,027.96	387,092.07	340,784.8	5	341,508.33	653,955.50	335,992.46	0.00	0.00	0.00	0.00	0.00	0.00		2,125,361.17		

3514	ADULT 40-100% MALE
1	2,919.76	13,958.09	11,640.18	12,833.20	8,641.72	7,019.65	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	4,321.80	3,072.41	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	99,796.75	95,139.96	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	69,427.82	39,094.51	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	69,587.75	53,019.40	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	2,301.13	993.52	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 MAL E	25,221.15	81,324.81	57,760.73	78,653.88	96,344.55	80,464.86	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	76,077.76	122,671.59	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	252,385.95	1,450,107.34	1,111,233.28	1,475,308.71	1,430,139.06	1,317,522.43	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	121,453.62	716,040.07	524,059.41	692,762.19	903,744.18	769,187.70	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	644,603.18	606,508.54	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	706.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	602,684.10	3,396,432.28	2,478,271.71	3,242,853.60	3,404,985.70	3,094,694.57	0.00	0.00	0.00	0.00	0.00	0.00	

 
57,012.60	
30,732.65	
399,497.64	
414,556.48	
268,655.76	
14,723.65	
669.61	
419,769.98	
410,535.25	
7,036,696.77	
3,727,247.17	
3,439,118.16	
706.24	
16,219,921.96	

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	3,904.93	3,701.03	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	10,263.47	8,977.14	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	74,020.49	62,367.63	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	41,986.09	32,774.04	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	35,755.93	22,088.97	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	21,431.74	99,701.53	78,173.21	156,028.85	165,930.91	129,908.81	0.00	0.00	0.00	0.00	0.00	0.00	

 
759.29	
18,812.68	
40,561.00	
281,421.90	
188,736.47	
120,883.71	
651,175.05	

4413	SOBRA 100-133% M&F
6

21,364.78	93,891.88	53,148.77	66,966.55	178,392.22	112,957.89	0.00	0.00	0.00	0.00	0.00	0.00	526,722.09

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	44,153.42	22,515.31	0.00	0.00	0.00	0.00	0.00	0.00	120,945.25	
4415	SOBRA 100-133% FEM AL	9,747.31	36,201.76	28,336.16	37,423.23	47,203.48	36,724.97	0.00	0.00	0.00	0.00	0.00	0.00	195,636.91	
SUBTOTAL:	35,980.82	149,421.67	94,680.41	121,274.06	269,749.12	172,198.17	0.00	0.00	0.00	0.00	0.00	0.00	843,304.25	

6015	KIDS 14-19 FEMALE NO	0.00	29.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	29.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

29.62	
29.62	

8700	SSI DISABLED FREEDO M	0.00	128.25	0.00	263.33	92.35	68.72	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	94.52	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	128.25	0.00	263.33	92.35	163.24	0.00	0.00	0.00	0.00	0.00	0.00	

 
552.65	
94.52	
647.17	

TOTAL:	2,326,439.64	10,700,813.57	7,946,106.37	9,707,520.36	13,889,643.67	10,117,669.48	0.00	0.00	0.00	0.00	0.00	0.00		54,688,193.09		

RATE COD	E	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	4,898.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,675.31	
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	
SUBTOTAL	:	0.00	12,154.73	22,042.54	8,635.51	4,898.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	47,731.12	

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	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	1,288.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,429.46	7,347.51	0.00	0.00	1,288.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,531.12	
4,081.95	
8,163.90	
1,288.00	
20,064.97	

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	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	1,632.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	11,429.46	12,245.85	40,003.11	15,511.41	1,632.78	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	13,042.02	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	30,186.21	1,632.78	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,714.73	
1,632.78	
80,822.61	
22,838.70	
10,970.34	
121,979.16	

3917	NEWLY ELIGIBLE FEMA L	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	
SUBTOTAL:	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	

 
2,449.17	
2,449.17	

11,429.46	47,616.77	38,370.34	56,802.52	36,372.55	1,632.78	0.00	0.00	0.00	0.00	0.00	0.00	

192,224.42	

TOTAL:

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending December 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	57.73	8.00	0.00	0.00	0.00	0.00	0.00	0.00		4,242.31		
2100	SSI AGED WITH MEDIC A	62,636.18	7,321.33	10,598.16	63,394.20	68,198.13	90,939.08	0.00	0.00	0.00	0.00	0.00	0.00		303,087.08		
2110	SSI AGED NON-MEDIC AR	55,431.46	44,621.86	210,826.12	50,715.84	137,219.27	120,845.17	0.00	0.00	0.00	0.00	0.00	0.00		619,659.72		
2120	SSI AGED WITH QMB	3,240.08	492.46	0.00	0.00	0.00	4,464.46	0.00	0.00	0.00	0.00	0.00	0.00		8,197.00		
2200	SSI DISABLED WITH M E	0.00	-838.56	0.00	0.00	872.06	9,596.98	0.00	0.00	0.00	0.00	0.00	0.00		9,630.48		
2210	SSI DISABLED NON-ME D	1,073.60	164.72	7,728.90	3,785.63	2,867.26	306.67	0.00	0.00	0.00	0.00	0.00	0.00		15,926.78		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	47,529.94	0.00	842.95	0.00	0.00	0.00	0.00	0.00	0.00		48,372.89		
5017	SOBRA PREG 21-44 FE M	3,260.38	0.00	843.73	74.15	0.00	842.95	0.00	0.00	0.00	0.00	0.00	0.00		5,021.21		
8020	QMB ONLY	0.00	1,335.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,335.10		
SUBTOTAL:	125,818.68	53,096.91	229,996.9	1	169,499.36	209,214.45	227,846.26	0.00	0.00	0.00	0.00	0.00	0.00		1,015,472.57		

3706	ADULT <40% EXP MAL E	26,019.36	12,060.99	9,835.98	6,683.96	3,092.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	271.09	32.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	11,908.65	112,467.25	35,257.25	60,092.24	7,505.91	28,864.16	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	353.70	16,262.86	8,749.29	0.00	3,615.67	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 MAL E	218,117.82	650,573.52	333,067.88	199,077.83	182,374.64	188,359.76	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	47,185.16	8,554.58	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	285,922.93	321,041.96	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL E	0.00	5,349.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	139,069.59	-53,106.93	18,959.54	11,851.11	-4,035.60	14,499.96	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	525,660.76	561,320.42	0.00	0.00	0.00	0.00	0.00	0.00	

57,692.34	
303.97	
256,095.46	
28,981.52	
2,416.65	
1,771,571.45	
213,298.21	
2,416,122.39	
5,349.86	
127,237.67	
4,879,069.52	

3916	NEWLY ELIGIBLE MALE	15,999.84	1,846.21	8,999.20	7,227.69	30,094.45	13,399.98	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	47.75	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	7,779.78	17,757.79	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	47,079.35	7,086.13	51,594.81	22,750.52	37,921.98	31,157.77	0.00	0.00	0.00	0.00	0.00	0.00	

77,567.37	
8,445.95	
111,577.24	
197,590.56	

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	1,686.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	804.92	318.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	804.92	478.64	0.00	2,468.86	1,686.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
160.42	
4,155.54	
0.00	
1,123.14	
5,439.10	

TOTAL:	975,409.12	1,212,578.98	1,380,044.06	934,731.27	774,483.87	820,324.45	0.00	0.00	0.00	0.00	0.00	0.00		6,097,571.75		

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

0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MAL E	0.00	162.87	184.37	0.00	4,937.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,284.43		
3717	ADULT <40% EXP FEM AL	3,420.00	-3,420.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	3,420.00	-3,257.13	184.37	0.00	4,937.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,284.43		

TOTAL:	3,420.00	-3,257.13	184.37	0.00	4,937.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,284.43		

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

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending December 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		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	166.72	0.00	0.00	0.00	0.00	0.00	0.00		166.72		
1016	TANF 21-44 MALE NON-	5,818.72	302.74	0.00	0.00	0.00	3,018.41	0.00	0.00	0.00	0.00	0.00	0.00		9,139.87		
1017	TANF 21-44 FEMALE N O	1,082.48	2,762.19	4,225.80	0.00	9,835.12	577.75	0.00	0.00	0.00	0.00	0.00	0.00		18,483.34		
2100	SSI AGED WITH MEDIC A	7,942.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,942.52		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	153.61	14,914.58	0.00	0.00	0.00	0.00	0.00	0.00		15,068.19		
2200	SSI DISABLED WITH M E	1,309.60	80.21	289.00	7,325.67	5,634.60	15,516.38	0.00	0.00	0.00	0.00	0.00	0.00		30,155.46		
2210	SSI DISABLED NON-ME D	1,618.81	30,697.03	892.24	8,800.51	49,300.03	11,607.05	0.00	0.00	0.00	0.00	0.00	0.00		102,915.67		
2220	SSI DISABLED WITH Q M	4,268.62	479.48	168.42	4,913.65	175.20	1,987.39	0.00	0.00	0.00	0.00	0.00	0.00		11,992.76		
5015	SOBRA PREG 14-20 FE M	0.00	3,613.61	2,433.80	0.00	0.00	787.10	0.00	0.00	0.00	0.00	0.00	0.00		6,834.51		
5017	SOBRA PREG 21-44 FE M	0.00	470.90	2,433.80	8,561.46	15,716.18	4,977.27	0.00	0.00	0.00	0.00	0.00	0.00		32,159.61		
SUBTOTAL:	22,177.49	38,628.82	14,575.52	29,601.29	80,814.74	53,552.65	0.00	0.00	0.00	0.00	0.00	0.00		239,350.51		

3516	ADULT 40-100% MALE
2	337.40	9,114.07	0.00	9,805.62	160.42	152.18	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	8,645.56	-332.40	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	114.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	2,874.75	1,175.42	12,793.05	337.54	336.50	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	57.17	3,707.36	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	54,620.68	47,911.92	34,781.39	78,899.54	63,825.60	211,916.03	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	21,655.33	17,899.83	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	13,015.34	65,281.63	32,395.41	46,175.47	39,793.33	46,479.66	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	134,589.29	280,159.16	0.00	0.00	0.00	0.00	0.00	0.00	

19,569.69	
8,393.46	
39,179.19	
17,517.26	
10,645.90	
491,955.16	
80,264.98	
243,140.84	
910,666.48	

3916	NEWLY ELIGIBLE MALE	0.00	8,584.45	0.00	3,933.53	0.00	389.61	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	3,934.26	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	8,584.45	0.00	8,868.25	0.00	4,323.87	0.00	0.00	0.00	0.00	0.00	0.00	

12,907.59	
8,868.98	
21,776.57	

158,233.29

196,254.93

TOTAL:

98,609.98

229,111.22

341,640.84

0.00

0.00

0.00

1,256,576.93

232,726.67

0.00

0.00	0.00

1116	TANF EXPANDED 21-44	9,365.91	518.79	0.00	45.28	2,092.94	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	82.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	17,181.68	0.00	0.00	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	217.71	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	3,944.64	352.30	1,959.29	11,531.89	3,387.45	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	57,697.35	7,377.17	352.30	2,044.20	13,707.19	3,605.16	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,022.92	
2,513.74	
31,450.14	
17,221.31	
399.69	
21,175.57	
84,783.37	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2200	SSI DISABLED WITH M E	0.00	8,322.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,322.27	
2210	SSI DISABLED NON-ME D	30.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30.82	
SUBTOTAL	:	30.82	8,322.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,353.09	

3716	ADULT <40% EXP MAL E	962.05	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	102.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	962.05	0.00	0.00	0.00	102.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
962.05	
102.64	
1,064.69	

992.87	8,322.27	0.00	0.00	102.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,417.78	

TOTAL:

RATE COD	E	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	166.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,149.11	
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	1,385.08	16,374.92	0.00	0.00	0.00	0.00	0.00	0.00	38,474.14	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	176.95	0.00	0.00	0.00	0.00	0.00	0.00	176.95	
5015	SOBRA PREG 14-20 FE M	470.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	470.90	
5017	SOBRA PREG 21-44 FE M	0.00	415.50	2,536.55	9,047.66	0.00	470.90	0.00	0.00	0.00	0.00	0.00	0.00	12,470.61	
SUBTOTAL	:	1,278.07	26,237.18	2,536.55	16,174.28	1,551.28	17,022.77	0.00	0.00	0.00	0.00	0.00	0.00	64,800.13	

TOTAL:

18,918.25

48,688.88

2,864.29

93,840.49

37,038.84

34,415.36

0.00

0.00

0.00

0.00

0.00

0.00

235,766.11

3516	ADULT 40-100% MALE
2	0.00	8.00	0.00	773.04	3,200.23	6,747.78	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 MAL E	290.46	14,456.02	0.00	13,385.02	5,585.00	1,553.42	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	12,894.74	5,974.66	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	13,807.59	3,116.73	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	17,640.18	22,451.70	327.74	77,666.21	35,487.56	17,392.59	0.00	0.00	0.00	0.00	0.00	0.00	

 
10,729.05	
114.90	
35,269.92	
68,625.40	
56,226.71	
170,965.98	

RATE COD	E	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	136.25	277.00	0.00	0.00	0.00	0.00	0.00	0.00	3,812.94	
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	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	62.32	0.00	0.00	0.00	0.00	0.00	0.00	62.32	
SUBTOTAL	:	4,630.48	3,154.31	-3,803.40	0.00	136.25	339.32	0.00	0.00	0.00	0.00	0.00	0.00	4,456.96	

1128	TANF EXPANDED 45-64	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	
SUBTOTAL:	2,660.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,660.70	
2,660.70	

3716	ADULT <40% EXP MAL E	0.00	42,847.62	0.00	0.00	36,297.71	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	2,817.83	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	30.39	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,580.42	42,847.62	1,219.51	0.00	39,115.54	30.39	0.00	0.00	0.00	0.00	0.00	0.00	

 
79,145.33	
3,902.46	
9,745.69	
92,793.48	

16,871.60	46,001.93	-2,583.89	0.00	39,251.79	369.71	0.00	0.00	0.00	0.00	0.00	0.00	

99,911.14	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	368.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.00		
2100	SSI AGED WITH MEDIC A	2,307,947.16	2,733,144.98	2,326,251.26	2,120,800.66	2,659,932.99	2,448,945.08	0.00	0.00	0.00	0.00	0.00	0.00		14,597,022.13		
2110	SSI AGED NON-MEDIC AR	149,727.64	170,783.44	154,051.47	181,595.05	188,692.42	151,634.95	0.00	0.00	0.00	0.00	0.00	0.00		996,484.97		
2120	SSI AGED WITH QMB	3,195,618.68	3,951,641.09	3,161,445.46	3,070,261.53	3,609,364.19	3,243,888.46	0.00	0.00	0.00	0.00	0.00	0.00		20,232,219.41		
2200	SSI DISABLED WITH M E	537,954.02	696,721.39	546,649.90	536,933.99	658,981.77	584,706.59	0.00	0.00	0.00	0.00	0.00	0.00		3,561,947.66		
2210	SSI DISABLED NON-ME D	2,694,953.74	3,287,243.03	2,968,877.53	2,680,189.63	3,123,107.99	2,960,139.61	0.00	0.00	0.00	0.00	0.00	0.00		17,714,511.53		
2220	SSI DISABLED WITH Q M	764,491.97	940,091.58	815,616.99	716,604.42	883,677.47	782,712.79	0.00	0.00	0.00	0.00	0.00	0.00		4,903,195.22		
2300	SSI BLIND WITH MEDIC	0.00	0.00	77.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.04		
2310	SSI BLIND NON-MEDIC A	12,301.04	21,001.65	17,655.97	15,184.92	26,557.19	18,174.70	0.00	0.00	0.00	0.00	0.00	0.00		110,875.47		
2320	SSI BLIND WITH QMB	7,206.96	7,708.00	7,966.16	6,133.72	8,669.95	7,946.81	0.00	0.00	0.00	0.00	0.00	0.00		45,631.60		
SUBTOTAL:	9,670,201.21	11,808,703.16	9,998,959.78	9,327,703.92	11,158,983.97	10,198,148.99	0.00	0.00	0.00	0.00	0.00	0.00		62,162,701.03		

8710	SSI DISABLED FREEDO M	653.30	6,631.23	2,774.40	2,603.04	2,728.96	2,866.56	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	3,494.40	2,795.52	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,418.73	10,058.43	5,516.16	5,371.68	6,223.36	5,662.08	0.00	0.00	0.00	0.00	0.00	0.00	

 
18,257.49	
17,992.95	
36,250.44	

TOTAL:	9,673,619.94	11,818,761.59	10,004,475.94	9,333,075.60	11,165,207.33	10,203,811.07	0.00	0.00	0.00	0.00	0.00	0.00		62,198,951.47		

2100

SSI AGED WITH MEDIC A

6,319.24

20,181.09

10,420.34

11,053.75

7,720.14

5,511.39

0.00

0.00

0.00

0.00

0.00

0.00

61,205.95

2110

SSI AGED NON-MEDIC AR

200.76

1,334.55

0.00

0.00

0.00

362.78

0.00

0.00

0.00

0.00

0.00

0.00

1,898.09

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

723.87

3,810.52

0.00

0.00

0.00

0.00

0.00

0.00

17,633.09

2210

SSI DISABLED NON-ME D

11,384.31

301.39

764.10

7,231.73

4,550.79

11,463.96

0.00

0.00

0.00

0.00

0.00

0.00

35,696.28

SUBTOTAL:

25,539.02

27,090.16

12,240.91

20,809.30

12,994.80

21,148.65

0.00

0.00

0.00

0.00

0.00

0.00

119,822.84

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

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

12,240.91

12,994.80

21,148.65

0.00

0.00

0.00

20,809.30

0.00

0.00	0.00

119,822.84	

TOTAL:

25,539.02

27,090.16

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	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	25,873.56	19,010.65	0.00	0.00	0.00	0.00	0.00	0.00		83,764.34		
1013	TANF 06-13 M & F NON	26,843.26	657.79	21,985.65	28,689.48	63,946.81	58,560.80	0.00	0.00	0.00	0.00	0.00	0.00		200,683.79		
1014	TANF 14-20 MALE NON-	2,429.50	605.12	2,905.16	3,211.46	5,545.19	6,425.15	0.00	0.00	0.00	0.00	0.00	0.00		21,121.58		
1015	TANF 14-20 FEMALE N O	2,174.10	399.72	505.33	2,371.06	2,491.16	3,929.49	0.00	0.00	0.00	0.00	0.00	0.00		11,870.86		
1016	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 E	157.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.34		
2210	SSI DISABLED NON-ME D	136,113.36	80,007.50	116,612.03	161,945.69	300,838.41	248,858.18	0.00	0.00	0.00	0.00	0.00	0.00		1,044,375.17		
2220	SSI DISABLED WITH Q M	800.49	0.00	94.90	187.94	342.48	127.08	0.00	0.00	0.00	0.00	0.00	0.00		1,552.89		
2310	SSI BLIND NON-MEDIC A	919.88	782.99	1,582.48	1,994.80	2,667.60	1,082.22	0.00	0.00	0.00	0.00	0.00	0.00		9,029.97		
4305	SOBRA CHILD 14-20 FE	35.62	0.00	0.00	14.24	0.00	28.64	0.00	0.00	0.00	0.00	0.00	0.00		78.50		
4312	SOBRA CHILD 01-05 M	28,343.38	14,276.06	26,984.59	32,321.41	49,958.69	42,807.75	0.00	0.00	0.00	0.00	0.00	0.00		194,691.88		
4313	SOBRA CHILD 06-13 M	91,660.37	21,444.81	62,944.00	102,084.96	188,317.16	174,938.30	0.00	0.00	0.00	0.00	0.00	0.00		641,389.60		
4314	SOBRA CHILD 14-20 MA	6,894.69	11,038.98	7,338.37	7,172.50	14,161.79	19,417.16	0.00	0.00	0.00	0.00	0.00	0.00		66,023.49		
4315	SOBRA CHILD 14-20 FE	2,364.62	747.24	2,244.39	3,102.70	6,215.23	6,428.15	0.00	0.00	0.00	0.00	0.00	0.00		21,102.33		
SUBTOTAL:	308,762.96	134,897.03	254,770.1	1	355,503.99	660,358.08	581,613.57	0.00	0.00	0.00	0.00	0.00	0.00		2,295,905.74		

83.28	153.89	635.96	150.67	154.27	218.23	0.00	0.00	0.00	0.00	0.00	0.0	
83.28	153.89	635.96	150.67	154.27	218.23	0.00	0.00	0.00	0.00	0.00	0.00	

1,396.30	
1,396.30	

1113	TANF EXPANDED 06-13	0

SUBTOTAL:

3514	ADULT 40-100% MALE
1	159.17	0.00	0.00	57.88	28.94	57.94	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	19.66	66.42	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	37.40	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	449.14	125.87	0.00	49.15	48.62	77.21	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	452.45	65.27	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	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	549.67	304.24	0.00	0.00	0.00	0.00	0.00	0.00	

303.93	
805.59	
37.40	
749.99	
767.04	
13.60	
2,677.55	

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	73.89	58.98	145.40	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	142.91	122.49	79.80	95.76	63.84	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	142.91	122.49	153.69	154.74	209.24	0.00	0.00	0.00	0.00	0.00	0.00	

278.27	
504.80	
783.07	

4413	SOBRA 100-133% M&F
6	22,760.62	9,243.14	15,323.01	22,503.30	45,692.54	20,626.56	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	2,617.26	2,896.62	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	706.11	141.86	158.54	772.99	1,097.52	609.98	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,448.87	9,936.41	18,047.40	30,694.82	49,407.32	24,133.16	0.00	0.00	0.00	0.00	0.00	0.00	

136,149.17	
18,031.81	
3,487.00	
157,667.98	

TOTAL:

335,146.60

145,773.84

273,575.96

710,624.08

606,478.44

0.00

0.00

0.00

2,458,430.64

386,831.72

0.00

0.00	0.00

RATE COD	E	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	913.77	216.07	0.00	0.00	0.00	0.00	0.00	0.00	1,761.38	
1010	TANF NON-MEDICARE	22,308.73	10,498.79	17,933.34	30,369.07	43,022.68	34,536.06	0.00	0.00	0.00	0.00	0.00	0.00	158,668.67	
1020	TANF WITH QMB	0.00	0.00	0.00	25.00	37.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	62.50	
2200	SSI DISABLED WITH M E	3,546.21	2,524.32	1,902.01	1,501.13	3,846.51	3,910.34	0.00	0.00	0.00	0.00	0.00	0.00	17,230.52	
2210	SSI DISABLED NON-ME D	797,548.98	458,452.07	658,852.94	873,666.96	1,576,731.69	1,314,408.38	0.00	0.00	0.00	0.00	0.00	0.00	5,679,661.02	
2220	SSI DISABLED WITH Q M	1,060.22	728.41	4,870.69	2,137.79	7,316.49	3,833.69	0.00	0.00	0.00	0.00	0.00	0.00	19,947.29	
2310	SSI BLIND NON-MEDIC A	3,791.67	2,658.34	1,592.64	4,892.81	11,517.68	7,059.71	0.00	0.00	0.00	0.00	0.00	0.00	31,512.85	
SUBTOTAL	:	828,651.69	474,874.28	685,237.98	912,729.71	1,643,386.32	1,363,964.25	0.00	0.00	0.00	0.00	0.00	0.00	5,908,844.23	

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending December 31, 2016

828,651.69	474,874.28	685,237.98	912,729.71	1,643,386.32	1,363,964.25	0.00	0.00	0.00	0.00	0.00	0.00	

5,908,844.23	

TOTAL:

ACUTE REINSURANCE
For The Period Ending December 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	127.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.55		
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	262,182.68	160,880.45	0.00	0.00	0.00	0.00	0.00	0.00		2,548,872.39		
1012	TANF 01-05 M & F NON	-5,098.78	50,222.62	9,238.32	34,486.80	19,865.57	98,483.47	0.00	0.00	0.00	0.00	0.00	0.00		207,198.00		
1013	TANF 06-13 M & F NON	127,321.76	319,516.34	87,212.18	77,045.69	306,258.56	70,270.02	0.00	0.00	0.00	0.00	0.00	0.00		987,624.55		
1014	TANF 14-20 MALE NON-	13,740.97	54,044.10	5,286.69	14.67	26,047.98	366,701.18	0.00	0.00	0.00	0.00	0.00	0.00		465,835.59		
1015	TANF 14-20 FEMALE N O	23,666.42	-77,738.83	1,484.26	5,630.43	0.00	3,121.92	0.00	0.00	0.00	0.00	0.00	0.00		-43,835.80		
1016	TANF 21-44 MALE NON-	217,616.39	157,215.49	54,442.48	268,465.30	45,836.45	309,861.85	0.00	0.00	0.00	0.00	0.00	0.00		1,053,437.96		
1017	TANF 21-44 FEMALE N O	181,478.43	255,820.76	173,224.12	319,873.04	208,881.31	417,038.38	0.00	0.00	0.00	0.00	0.00	0.00		1,556,316.04		
1018	TANF 45-64 M & F NON	234,755.06	169,943.37	76,772.53	258,308.97	242,618.15	137,654.01	0.00	0.00	0.00	0.00	0.00	0.00		1,120,052.09		
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	2,199.67	-31,198.64	0.00	0.00	0.00	0.00	0.00	0.00		70,314.91		
2110	SSI AGED NON-MEDIC AR	388,018.03	277,060.71	184,488.03	54,193.88	121,989.09	4,331.92	0.00	0.00	0.00	0.00	0.00	0.00		1,030,081.66		
2200	SSI DISABLED WITH M E	14,893.21	9,427.77	104,031.96	-62,585.44	18,091.83	145,523.65	0.00	0.00	0.00	0.00	0.00	0.00		229,382.98		
2210	SSI DISABLED NON-ME D	5,781,423.00	4,661,832.44	5,295,002.56	9,420,683.20	4,724,515.62	4,868,206.07	0.00	0.00	0.00	0.00	0.00	0.00		34,751,662.89		
2310	SSI BLIND NON-MEDIC A	3,144.63	15,144.29	0.00	1,933.29	0.00	38,010.74	0.00	0.00	0.00	0.00	0.00	0.00		58,232.95		
4311	SOBRA CHILD <1 M & F	1,395,628.58	1,583,427.84	916,954.37	1,555,892.35	304,214.20	1,295,822.13	0.00	0.00	0.00	0.00	0.00	0.00		7,051,939.47		
4312	SOBRA CHILD 01-05 M	441,100.37	296,759.82	532,152.50	544,706.11	615,576.52	304,644.90	0.00	0.00	0.00	0.00	0.00	0.00		2,734,940.22		
4313	SOBRA CHILD 06-13 M	263,996.88	399,559.68	266,337.50	410,303.43	234,978.54	755,527.86	0.00	0.00	0.00	0.00	0.00	0.00		2,330,703.89		
4314	SOBRA CHILD 14-20 MA	173,423.73	445,022.53	247,300.85	263,469.12	242,015.11	477,731.60	0.00	0.00	0.00	0.00	0.00	0.00		1,848,962.94		
4315	SOBRA CHILD 14-20 FE	82,494.00	220,990.49	22,217.04	183,110.77	107,887.03	159,428.33	0.00	0.00	0.00	0.00	0.00	0.00		776,127.66		
5015	SOBRA PREG 14-20 FE M	79,849.94	1,849.74	2,876.71	25,606.69	256.98	684.85	0.00	0.00	0.00	0.00	0.00	0.00		111,124.91		
5017	SOBRA PREG 21-44 FE M	25,268.07	62,182.61	34,576.07	39,775.18	34,615.69	160,955.85	0.00	0.00	0.00	0.00	0.00	0.00		357,373.47		
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		
SUBTOTAL:	10,106,766.56	9,443,278.50	8,423,357.73	14,015,354.06	7,518,158.53	9,743,680.54	0.00	0.00	0.00	0.00	0.00	0.00		59,250,595.92		

1106	TANF EXPANDED 21-44	0.00	144.38	25.63	53.22	289.54	181.94	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	302.90	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	17,070.38	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	482,747.69	246,018.72	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	130,215.39	181,514.90	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	59,392.47	60,802.30	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	

694.71	
302.90	
17,070.38	
1,108.27	
1,448,166.69	
1,232,951.67	
607,524.22	
1,775.50	

3100	TRANSPLANT OPTION 1	0.00	23.10	73.47	199.01	64.18	4.61	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	23.10	73.47	199.01	64.18	4.61	0.00	0.00	0.00	0.00	0.00	0.00	

 
364.37	
364.37	

ACUTE REINSURANCE
For The Period Ending December 31, 2016

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	5.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.49	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	3,001.34	1,600.02	1,270.23	0.00	0.00	0.00	0.00	0.00	0.00	5,871.59	
2600	SSI DISABLED EXPAND E	850.89	1,174.76	156.90	64.92	64.94	4,087.33	0.00	0.00	0.00	0.00	0.00	0.00	6,399.74	
2610	SSI DISABLED EXPAND E	22,124.40	50,423.35	87,387.60	59,323.96	153,256.28	171,187.32	0.00	0.00	0.00	0.00	0.00	0.00	543,702.91	
SUBTOTAL	:	618,269.82	492,657.97	596,733.80	647,904.64	844,945.10	665,062.74	0.00	0.00	0.00	0.00	0.00	0.00	3,865,574.07	

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	3,565.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	342.52	3,067.96	0.00	6,164.33	0.00	6,947.30	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	208,376.34	237,928.70	258,705.08	238,397.88	129,157.35	112,700.43	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	73,314.67	85,173.63	80,995.03	104,916.64	35,362.38	16,958.50	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	449,226.40	539,517.06	402,442.07	655,747.53	582,757.87	650,508.95	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	11,548.22	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	9,118.38	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	199,395.77	-259.43	-7,716.84	0.00	0.00	48,862.73	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	46,933.03	4,532.12	33,480.20	43,030.95	178,033.59	14,666.13	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	27,464.33	15,826.46	21,578.92	14,289.70	2,382.00	409.49	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	610,923.36	748,507.25	588,904.10	1,279,758.58	790,915.44	595,898.14	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	452,359.25	337,121.36	388,819.64	398,887.27	144,349.09	313,087.05	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	1,050,808.24	2,420,228.56	1,907,151.58	2,004,111.73	1,605,724.79	2,315,857.71	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	5,259.44	0.00	0.00	2,383.77	95.02	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,216,516.79	4,364,234.57	3,674,809.90	4,773,270.12	3,474,631.52	4,096,658.05	0.00	0.00	0.00	0.00	0.00	0.00	

13,424.53	
83,260.68	
16,522.11	
1,185,265.78	
396,720.85	
3,280,199.88	
11,548.22	
9,118.38	
240,282.23	
320,676.02	
81,950.90	
4,614,906.87	
2,034,623.66	
11,303,882.61	
7,738.23	
23,600,120.95	

3914	NEWLY ELIGIBLE MALE	531.22	66,490.42	0.00	70,551.01	47,248.50	53,533.32	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	41,972.61	643.92	12,518.17	10,313.00	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	415,003.66	40,175.54	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	11,013.78	88,432.96	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	393,443.68	390,605.17	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	394,053.30	1,131,954.31	693,714.3	3	710,922.79	877,022.62	572,746.99	0.00	0.00	0.00	0.00	0.00	0.00	

238,354.47	
65,447.70	
1,625,697.54	
206,223.70	
2,244,690.93	
4,380,414.34	

4413	SOBRA 100-133% M&F
6	200,439.17	245,304.50	51,539.02	159,641.83	95,364.54	1,706.68	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	74,478.95	20,491.33	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	37,792.99	13,313.52	6,999.86	21,783.34	27,001.46	10,642.72	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	196,844.95	32,840.73	0.00	0.00	0.00	0.00	0.00	0.00	

753,995.74	
1,178,088.03	
117,533.89	
2,049,617.66	

4518	BC PATIENT FEMALE 4 5	0.00	2,325.47	11,583.11	0.00	386.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	2,325.47	11,583.11	0.00	386.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14,294.81	
14,294.81	

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

40,237.49	

ACUTE REINSURANCE
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,634.47	2,674.29	13,975.57	18,318.69	0.00	2,634.47	0.00	0.00	0.00	0.00	0.00	0.00		40,237.49		

TOTAL:	15,160,643.59	15,891,943.26	13,457,040.31	20,665,911.19	12,912,053.13	15,113,628.13	0.00	0.00	0.00	0.00	0.00	0.00		93,201,219.61		

RATE COD	E	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	26,622.42	-3,094.69	0.00	0.00	0.00	0.00	0.00	0.00	38,938.46	
2100	SSI AGED WITH MEDIC A	427,508.23	354,148.90	316,332.29	325,278.88	180,913.05	-32,402.61	0.00	0.00	0.00	0.00	0.00	0.00	1,571,778.74	
2110	SSI AGED NON-MEDIC AR	109,126.94	168,130.16	206,047.45	305,444.45	145,747.56	196,635.86	0.00	0.00	0.00	0.00	0.00	0.00	1,131,132.42	
2200	SSI DISABLED WITH M E	922,846.90	607,754.06	450,973.91	607,692.94	398,167.22	439,850.36	0.00	0.00	0.00	0.00	0.00	0.00	3,427,285.39	
2210	SSI DISABLED NON-ME D	3,499,917.78	4,372,697.42	4,032,666.49	4,727,568.58	3,737,256.62	3,385,823.11	0.00	0.00	0.00	0.00	0.00	0.00	23,755,930.00	
2300	SSI BLIND WITH MEDIC	0.57	43.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44.09	
2310	SSI BLIND NON-MEDIC A	5,402.76	5,430.53	6,707.94	50,558.43	3,018.68	2,678.53	0.00	0.00	0.00	0.00	0.00	0.00	73,796.87	
SUBTOTAL	:	4,967,043.47	5,508,762.62	5,025,290.43	6,016,593.34	4,491,725.55	3,989,490.56	0.00	0.00	0.00	0.00	0.00	0.00	29,998,905.97	

LONG TERM CARE REINSURANCE
For The Period Ending December 31, 2016

4,967,043.47	5,508,762.62	5,025,290.43	6,016,593.34	4,491,725.55	3,989,490.56	0.00	0.00	0.00	0.00	0.00	0.00	

29,998,905.97	

TOTAL:

ACUTE SMIB
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	83,282.60	79,141.40	88,043.10	86,501.80	76,636.00	68,962.60	0.00	0.00	0.00	0.00	0.00	0.00		482,567.50		
1010	TANF NON-MEDICARE	609.00	852.60	609.00	487.20	487.20	609.00	0.00	0.00	0.00	0.00	0.00	0.00		3,654.00		
1020	TANF WITH QMB	24,116.40	24,603.60	21,315.00	22,167.60	27,648.60	25,578.00	0.00	0.00	0.00	0.00	0.00	0.00		145,429.20		
2100	SSI AGED WITH MEDIC A	103,567.30	146,400.10	154,520.40	148,789.20	144,933.70	147,264.80	0.00	0.00	0.00	0.00	0.00	0.00		845,475.50		
2110	SSI AGED NON-MEDIC AR	493,790.60	499,097.90	531,909.40	527,915.80	509,066.30	521,344.80	0.00	0.00	0.00	0.00	0.00	0.00		3,083,124.80		
2120	SSI AGED WITH QMB	3,316,283.10	3,439,229.50	3,522,598.60	3,636,418.00	3,766,394.10	3,837,370.00	0.00	0.00	0.00	0.00	0.00	0.00		21,518,293.30		
2200	SSI DISABLED WITH M E	270,428.30	331,956.60	309,410.80	300,387.60	292,142.60	275,734.80	0.00	0.00	0.00	0.00	0.00	0.00		1,780,060.70		
2210	SSI DISABLED NON-ME D	391,130.70	391,601.00	388,254.70	391,651.10	389,445.30	392,074.20	0.00	0.00	0.00	0.00	0.00	0.00		2,344,157.00		
2220	SSI DISABLED WITH Q M	3,666,577.20	3,656,475.50	3,757,730.70	3,825,877.80	3,892,827.30	3,914,275.10	0.00	0.00	0.00	0.00	0.00	0.00		22,713,763.60		
2300	SSI BLIND WITH MEDIC	243.60	243.60	487.20	365.40	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00		1,583.40		
2310	SSI BLIND NON-MEDIC A	3,288.60	3,288.60	3,410.40	3,532.20	3,532.20	3,532.20	0.00	0.00	0.00	0.00	0.00	0.00		20,584.20		
2320	SSI BLIND WITH QMB	29,962.80	30,084.60	30,084.60	30,693.60	30,328.20	29,597.40	0.00	0.00	0.00	0.00	0.00	0.00		180,751.20		
4300	SOBRA CHILD WITH M ED	121.80	121.80	121.80	121.80	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00		730.80		
4320	SOBRA CHILD WITH Q MB	243.60	121.80	243.60	243.60	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00		1,339.80		
5000	SOBRA PREGNANT WO MAN	243.60	243.60	121.80	121.80	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00		974.40		
5020	SOBRA PREGNANT WO MAN	3,897.60	3,288.60	3,288.60	4,506.60	3,897.60	6,211.80	0.00	0.00	0.00	0.00	0.00	0.00		25,090.80		
8000	SMIB ONLY NOT ELIGIB	-487.20	0.00	0.00	0.00	-730.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,218.00		
8020	QMB ONLY	732,938.50	741,291.20	748,193.20	736,917.80	737,989.80	749,169.90	0.00	0.00	0.00	0.00	0.00	0.00		4,446,500.40		
8040	SLMB	4,230,330.90	4,296,575.00	4,308,851.30	4,252,296.50	4,325,351.40	4,361,433.10	0.00	0.00	0.00	0.00	0.00	0.00		25,774,838.20		
8888	SMIB ONLY NOT ELIGIB	-149,049.20	-27,293.50	-35,602.90	-25,963.40	-24,461.80	-13,173.60	0.00	0.00	0.00	0.00	0.00	0.00		-275,544.40		
9999	SMIB ONLY NOT ELIGIB	60,444.40	160,788.70	220,518.30	162,374.20	129,062.70	143,733.40	0.00	0.00	0.00	0.00	0.00	0.00		876,921.70		
SUBTOTAL:	13,261,964.20	13,778,112.20	14,054,109.6	0    14,105,406.20	14,305,159.40	14,464,326.50	0.00	0.00	0.00	0.00	0.00	0.00		83,969,078.10		

3520	ADULT 40-100% FOR FI	974.40	1,096.20	730.80	974.40	243.60	487.20	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	365.40	243.60	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,314.20	1,948.80	1,339.80	1,461.60	609.00	730.80	0.00	0.00	0.00	0.00	0.00	0.00	

4,506.60	
3,897.60	
8,404.20	

1100	TANF EXPANDED FPR FI	670,306.70	690,655.60	694,042.10	689,258.80	619,093.20	571,816.50	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	730.80	365.40	243.60	121.80	365.40	974.40	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	277,849.30	285,101.40	292,845.90	302,501.90	381,912.10	432,876.90	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	-974.40	365.40	0.00	365.40	121.80	-121.80	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	121.80	121.80	121.80	121.80	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,270,888.70	2,227,426.40	2,210,062.30	2,133,197.00	2,061,349.50	2,053,921.10	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	121.80	365.40	121.80	121.80	121.80	121.80	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	-487.20	-121.80	-365.40	243.60	121.80	-121.80	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,918,198.80	1,889,063.40	1,828,654.60	1,755,447.20	1,667,405.10	1,670,314.50	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,136,756.30	5,093,343.00	5,025,726.70	4,881,379.30	4,730,612.50	4,729,903.40	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,935,172.90	
2,801.40	
1,973,087.50	
-243.60	
730.80	
12,956,845.00	
974.40	
-730.80	
10,729,083.60	
29,597,721.20	

RATE COD	E	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	121.80	0.00	0.00	0.00	0.00	0.00	0.00	1,339.80	
SUBTOTAL	:	487.20	365.40	0.00	365.40	0.00	121.80	0.00	0.00	0.00	0.00	0.00	0.00	1,339.80	

8720	SSI DISABLED FREEDO M	26,430.60	25,699.80	25,699.80	24,238.20	24,969.00	25,821.60	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	26,430.60	25,699.80	25,699.80	24,238.20	24,969.00	25,821.60	0.00	0.00	0.00	0.00	0.00	0.00	

 
152,859.00	
152,859.00	

TOTAL:	18,427,952.50	18,899,469.20	19,106,875.90	19,012,850.70	19,061,349.90	19,220,904.10	0.00	0.00	0.00	0.00	0.00	0.00		113,729,402.30		

RATE COD	E	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	1,233.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,233.00	
2110	SSI AGED NON-MEDIC AR	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	327,113.80	330,125.20	0.00	0.00	0.00	0.00	0.00	0.00	1,766,407.20	
2220	SSI DISABLED WITH Q M	125,651.90	134,161.80	139,747.40	146,768.80	143,036.60	156,332.60	0.00	0.00	0.00	0.00	0.00	0.00	845,699.10	
2320	SSI BLIND WITH QMB	411.00	1,315.20	863.10	863.10	863.10	863.10	0.00	0.00	0.00	0.00	0.00	0.00	5,178.60	
8020	QMB ONLY	2,918.00	3,514.00	2,281.00	2,281.00	2,281.00	3,514.00	0.00	0.00	0.00	0.00	0.00	0.00	16,789.00	
9999	SMIB ONLY NOT ELIGIB	-3,144.00	-4,377.10	-5,404.80	-1,397.30	-11,861.10	-3,288.00	0.00	0.00	0.00	0.00	0.00	0.00	-29,472.30	
SUBTOTAL	:	361,563.10	411,610.20	422,086.70	466,526.30	462,666.40	487,546.90	0.00	0.00	0.00	0.00	0.00	0.00	2,611,999.60	

1120	TANF EXPANDED FOR FI	1,130.00	226.00	226.00	226.00	226.00	2,137.00	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	4,048.30	3,596.20	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,630.40	6,904.40	5,363.40	5,137.40	4,274.30	5,733.20	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,171.00	
28,872.10	
33,043.10	

367,193.50	418,514.60	427,450.10	471,663.70	466,940.70	493,280.10	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,231,414.30	2,263,375.00	2,291,179.20	2,282,238.60	2,355,461.40	2,382,222.50	0.00	0.00	0.00	0.00	0.00	0.00	13,805,891.00	
9999	SMIB ONLY NOT ELIGIB	-9,385.60	-5,934.40	7,613.40	-3,959.40	-6,942.60	-1,948.80	0.00	0.00	0.00	0.00	0.00	0.00	-20,557.40	

SUBTOTAL:	
2,222,028.70	
2,257,440.60	
2,298,792.60	
2,278,279.20	
2,348,518.80	
2,380,273.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
13,785,333.60	

TOTAL:	2,222,028.70	2,257,440.60	2,298,792.60	2,278,279.20	2,348,518.80	2,380,273.70	0.00	0.00	0.00	0.00	0.00	0.00		13,785,333.60		

LTC SMIB
For The Period Ending December 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	974.40	1,705.20	0.00	0.00	0.00	0.00	0.00	0.00		6,942.60		
1020	TANF WITH QMB	243.60	243.60	243.60	243.60	243.60	243.60	0.00	0.00	0.00	0.00	0.00	0.00		1,461.60		
2100	SSI AGED WITH MEDIC A	996,521.00	982,501.00	980,592.00	984,002.40	994,372.30	1,001,923.90	0.00	0.00	0.00	0.00	0.00	0.00		5,939,912.60		
2110	SSI AGED NON-MEDIC AR	185,014.20	184,527.00	197,120.70	175,537.00	184,648.80	187,450.20	0.00	0.00	0.00	0.00	0.00	0.00		1,114,297.90		
2120	SSI AGED WITH QMB	904,419.20	906,456.00	906,658.80	901,435.80	903,262.80	906,916.80	0.00	0.00	0.00	0.00	0.00	0.00		5,429,149.40		
2200	SSI DISABLED WITH M E	379,691.30	381,460.70	384,735.90	383,791.80	382,086.60	379,894.20	0.00	0.00	0.00	0.00	0.00	0.00		2,291,660.50		
2210	SSI DISABLED NON-ME D	18,635.40	20,340.60	22,607.60	20,097.00	19,366.20	20,218.80	0.00	0.00	0.00	0.00	0.00	0.00		121,265.60		
2220	SSI DISABLED WITH Q M	835,984.20	830,397.20	830,017.70	835,586.70	838,198.70	829,932.60	0.00	0.00	0.00	0.00	0.00	0.00		5,000,117.10		
2300	SSI BLIND WITH MEDIC	852.60	852.60	1,096.20	1,096.20	974.40	1,096.20	0.00	0.00	0.00	0.00	0.00	0.00		5,968.20		
2310	SSI BLIND NON-MEDIC A	365.40	243.60	243.60	609.00	487.20	487.20	0.00	0.00	0.00	0.00	0.00	0.00		2,436.00		
2320	SSI BLIND WITH QMB	5,237.40	5,359.20	5,115.60	5,115.60	5,237.40	5,237.40	0.00	0.00	0.00	0.00	0.00	0.00		31,302.60		
SUBTOTAL:	3,328,304.10	3,313,355.90	3,329,406.10	3,308,489.50	3,329,852.40	3,335,106.10	0.00	0.00	0.00	0.00	0.00	0.00		19,944,514.10		

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

 
3,166.80	
3,166.80	

3,328,913.10	3,313,964.90	3,329,893.30	3,308,976.70	3,330,339.60	3,335,593.30	0.00	0.00	0.00	0.00	0.00	0.00	

19,947,680.90	

TOTAL:

LTC HIB
For The Period Ending December 31, 2016

RATE COD	E	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	411.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	822.00	
2120	SSI AGED WITH QMB	268,654.00	271,962.40	272,059.10	272,658.80	267,768.20	266,802.20	0.00	0.00	0.00	0.00	0.00	0.00	1,619,904.70	
2200	SSI DISABLED WITH M E	0.00	411.00	0.00	0.00	0.00	822.00	0.00	0.00	0.00	0.00	0.00	0.00	1,233.00	
2220	SSI DISABLED WITH Q M	14,652.00	13,608.00	12,782.00	16,892.00	13,830.00	13,419.00	0.00	0.00	0.00	0.00	0.00	0.00	85,183.00	
SUBTOTAL	:	283,717.00	285,570.40	285,293.20	289,509.70	282,009.20	281,043.20	0.00	0.00	0.00	0.00	0.00	0.00	1,707,142.70	

TOTAL:	283,717.00	285,570.40	285,293.20	289,509.70	282,009.20	281,043.20	0.00	0.00	0.00	0.00	0.00	0.00		1,707,142.70		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 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	1,480.58	550.77	0.00	0.00	0.00	0.00	0.00	0.00		3,786.84		
1007	TANF 21-44 FEMALE WI	4,715.31	2,051.12	1,453.54	1,749.80	2,271.89	356.42	0.00	0.00	0.00	0.00	0.00	0.00		12,598.08		
1008	TANF 45-64 M & F WIT	2,768.42	8,031.79	10,613.78	1,364.05	2,685.34	3,248.95	0.00	0.00	0.00	0.00	0.00	0.00		28,712.33		
1009	TANF 65+ M & F WITH	1,498.24	2,850.90	1,807.76	2,387.00	677.41	1,262.43	0.00	0.00	0.00	0.00	0.00	0.00		10,483.74		
1011	TANF <1 M & F NON-ME	691,179.03	549,687.51	409,345.01	353,570.98	412,427.30	523,704.75	0.00	0.00	0.00	0.00	0.00	0.00		2,939,914.58		
1012	TANF 01-05 M & F NON	300,554.71	309,088.02	232,212.72	239,296.14	261,351.77	230,271.22	0.00	0.00	0.00	0.00	0.00	0.00		1,572,774.58		
1013	TANF 06-13 M & F NON	216,437.47	262,212.58	233,289.49	222,822.17	274,483.27	218,355.18	0.00	0.00	0.00	0.00	0.00	0.00		1,427,600.16		
1014	TANF 14-20 MALE NON-	77,950.03	61,633.93	49,927.47	46,564.70	65,284.20	71,787.12	0.00	0.00	0.00	0.00	0.00	0.00		373,147.45		
1015	TANF 14-20 FEMALE N O	181,345.66	201,315.48	195,143.28	161,871.67	179,987.24	187,584.91	0.00	0.00	0.00	0.00	0.00	0.00		1,107,248.24		
1016	TANF 21-44 MALE NON-	1,208,018.47	1,095,125.11	835,379.64	706,242.15	1,003,909.01	1,040,637.66	0.00	0.00	0.00	0.00	0.00	0.00		5,889,312.04		
1017	TANF 21-44 FEMALE N O	4,782,275.12	4,614,453.36	3,404,247.31	3,052,363.96	3,502,754.53	3,473,975.61	0.00	0.00	0.00	0.00	0.00	0.00		22,830,069.89		
1018	TANF 45-64 M & F NON	1,536,458.94	1,747,293.81	1,389,507.71	1,271,142.30	1,354,779.78	1,489,644.47	0.00	0.00	0.00	0.00	0.00	0.00		8,788,827.01		
1019	TANF 65+ M & F NON-M	1,488.83	2,576.00	3,680.00	33,017.69	5,152.00	2,944.00	0.00	0.00	0.00	0.00	0.00	0.00		48,858.52		
1026	TANF 21-44 MALE WITH	736.00	139.85	1,118.62	562.40	467.90	40.06	0.00	0.00	0.00	0.00	0.00	0.00		3,064.83		
1027	TANF 21-44 FEMALE WI	812.39	1,382.21	750.63	132.72	488.34	112.61	0.00	0.00	0.00	0.00	0.00	0.00		3,678.90		
1028	TANF 45-64 M & F WIT	3,869.59	788.58	2,676.22	2,442.10	1,744.89	703.12	0.00	0.00	0.00	0.00	0.00	0.00		12,224.50		
1029	TANF 65+ M & F WITH	111.13	364.33	0.00	0.00	59.22	22.64	0.00	0.00	0.00	0.00	0.00	0.00		557.32		
2100	SSI AGED WITH MEDIC A	66,138.34	96,126.19	56,493.24	20,977.68	23,692.13	22,233.45	0.00	0.00	0.00	0.00	0.00	0.00		285,661.03		
2110	SSI AGED NON-MEDIC AR	53,486.52	61,326.51	50,453.73	46,591.19	78,692.57	47,031.71	0.00	0.00	0.00	0.00	0.00	0.00		337,582.23		
2120	SSI AGED WITH QMB	229,795.08	290,274.13	250,072.81	131,217.32	132,033.60	101,985.96	0.00	0.00	0.00	0.00	0.00	0.00		1,135,378.90		
2200	SSI DISABLED WITH M E	138,965.52	205,333.70	184,379.96	67,124.29	62,539.48	68,301.93	0.00	0.00	0.00	0.00	0.00	0.00		726,644.88		
2210	SSI DISABLED NON-ME D	4,735,804.13	5,056,810.90	4,027,055.52	3,272,331.94	3,983,070.19	4,207,984.32	0.00	0.00	0.00	0.00	0.00	0.00		25,283,057.00		
2220	SSI DISABLED WITH Q M	434,350.13	563,385.69	444,545.28	262,116.83	263,873.74	218,711.29	0.00	0.00	0.00	0.00	0.00	0.00		2,186,982.96		
2300	SSI BLIND WITH MEDIC	442.84	1,105.82	590.51	117.68	384.15	343.70	0.00	0.00	0.00	0.00	0.00	0.00		2,984.70		
2310	SSI BLIND NON-MEDIC A	59,992.53	44,447.01	85,286.31	35,040.08	36,650.66	45,641.81	0.00	0.00	0.00	0.00	0.00	0.00		307,058.40		
2320	SSI BLIND WITH QMB	6,629.65	6,866.41	6,731.29	3,117.89	4,640.91	2,420.45	0.00	0.00	0.00	0.00	0.00	0.00		30,406.60		
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	1,526,164.79	1,583,838.11	0.00	0.00	0.00	0.00	0.00	0.00		9,150,688.44		
4312	SOBRA CHILD 01-05 M	2,972,452.20	3,405,021.15	3,042,802.04	2,617,151.90	2,934,194.77	2,837,648.14	0.00	0.00	0.00	0.00	0.00	0.00		17,809,270.20		
4313	SOBRA CHILD 06-13 M	4,942,683.63	4,831,514.49	4,120,274.01	3,397,274.42	4,306,423.43	3,362,972.16	0.00	0.00	0.00	0.00	0.00	0.00		24,961,142.14		
4314	SOBRA CHILD 14-20 MA	1,427,842.79	1,316,616.53	929,242.11	726,349.93	1,182,767.84	898,272.47	0.00	0.00	0.00	0.00	0.00	0.00		6,481,091.67		
4315	SOBRA CHILD 14-20 FE	1,271,324.45	1,578,662.99	1,464,172.03	1,028,446.44	1,377,326.52	1,124,631.52	0.00	0.00	0.00	0.00	0.00	0.00		7,844,563.95		
5007	SOBRA PREG 21-44 FE M	378.25	75.05	453.66	151.08	459.33	214.55	0.00	0.00	0.00	0.00	0.00	0.00		1,731.92		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,231.36	736.00	736.00	0.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00		13,140.36		
5015	SOBRA PREG 14-20 FE M	301,972.26	335,882.22	264,018.56	177,300.98	219,235.25	227,474.86	0.00	0.00	0.00	0.00	0.00	0.00		1,525,884.13		
5017	SOBRA PREG 21-44 FE M	1,648,401.34	1,955,913.70	1,441,819.84	1,128,207.77	1,413,744.83	1,363,319.48	0.00	0.00	0.00	0.00	0.00	0.00		8,951,406.96		

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

RATE COD	E	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	2,558.00	4,067.51	0.00	0.00	0.00	0.00	0.00	0.00	20,618.33	
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	64.80	278.14	0.00	0.00	0.00	0.00	0.00	0.00	342.94	
5028	SOBRA PREG 45-64 FE M	64.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.80	
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	28,920,351.39	30,363,670.22	24,704,397.21	20,139,120.93	24,618,521.66	23,363,309.48	0.00	0.00	0.00	0.00	0.00	0.00	152,109,370.89	

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

0.00	
0.00	

1106	TANF EXPANDED 21-44	8,602.39	6,438.12	5,428.43	1,485.85	2,545.01	1,682.43	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	6,481.61	8,125.47	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	14,176.79	14,100.25	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	25,333.08	29,517.19	24,824.50	13,286.82	14,209.93	10,666.79	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	1,472.00	368.00	368.00	1,481.59	368.00	368.00	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	736.00	1,472.00	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	4,306.54	1,840.00	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	26,153.72	26,595.23	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	364,621.76	421,768.05	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	1,430,852.73	1,493,620.41	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	1,029,786.10	984,628.59	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	3,568.96	2,904.18	4,130.43	3,680.00	4,290.51	4,416.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	3,422.37	3,051.01	1,984.77	757.45	948.46	449.08	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	1,190.66	1,849.89	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	11,091.35	9,056.93	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	8,178.44	10,296.06	7,237.30	2,808.36	4,333.94	4,034.18	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	11,068.81	16,536.17	15,947.59	8,607.12	7,047.52	3,351.62	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	8,461.28	5,520.00	3,153.04	2,208.00	6,314.39	2,952.04	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	138,825.20	182,526.13	145,608.26	74,183.12	73,655.07	61,324.82	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	13,441.47	15,752.05	12,028.62	8,513.03	9,538.97	6,753.78	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	113,472.90	87,253.66	84,720.33	86,173.05	65,822.43	74,897.21	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	129,964.16	144,021.70	126,237.55	70,602.13	74,220.83	55,156.88	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,685,961.38	4,102,069.71	3,364,547.57	2,784,954.50	3,152,692.32	3,189,109.65	0.00	0.00	0.00	0.00	0.00	0.00	

26,182.23	
67,273.57	
169,981.43	
117,838.31	
736.00	
4,425.59	
8,078.00	
22,947.16	
162,608.96	
2,313,406.48	
9,188,838.66	
6,107,924.02	
22,990.08	
10,613.14	
15,341.34	
57,400.95	
36,888.28	
62,558.83	
28,608.75	
676,122.60	
66,027.92	
512,339.58	
600,203.25	
20,279,335.13	

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	-294.00	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	-899.00	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	-1,161.00	0.00	0.00	0.00	0.00	0.00	0.00	

-294.00	
-955.48	
-2,496.43	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	-1,335.43	0.00	-56.48	0.00	-2,354.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,745.91		

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3616	AHC CARE/MI MALE 21-	0.00	-4,620.00	0.00	-610.00	-294.00	-2,381.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	-660.00	-294.00	-1,766.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	-2,310.00	0.00	-940.00	-646.00	-3,292.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-7,590.00	0.00	-2,210.00	-1,234.00	-7,439.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
-660.00	
-7,905.00	
-2,720.00	
-7,188.00	
-18,473.00	

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	295.56	1,179.51	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	71.33	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	16,936.80	29,309.34	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	58,534.61	85,765.84	54,243.11	45,388.55	61,949.79	69,558.16	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	516,106.88	561,726.13	355,787.74	408,976.15	389,520.06	460,213.52	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	515,712.00	479,583.65	372,460.84	314,271.57	343,885.37	335,106.65	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	1,473,444.90	1,665,779.83	1,341,815.15	1,191,743.61	1,355,243.56	1,310,623.03	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	3,312.00	-350.00	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	53.30	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	-128.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	8.65	0.00	1,104.00	368.00	1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	38.04	368.00	285.98	5,742.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	10,145.24	5,836.66	8,635.97	4,989.41	17,376.31	1,532.71	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	386.08	4,104.04	1,414.62	64.80	197.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	296,316.38	216,040.82	193,618.06	151,960.71	152,019.52	190,434.63	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	395,011.00	335,428.87	330,646.06	218,101.34	220,030.12	200,036.14	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	4,559,384.60	4,088,494.24	3,041,503.99	2,662,433.62	3,157,279.80	2,987,355.08	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,020,325.53	2,525,694.81	1,840,461.21	1,560,503.22	2,011,635.38	2,051,622.23	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	5,969,277.06	6,352,847.34	4,996,162.69	3,927,219.57	4,880,203.45	5,054,403.07	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	2,190.00	4,988.28	4,809.35	761.87	2,095.00	2,540.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	45.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	18,205.78	0.00	301.11	543.95	746.04	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,855,449.91	16,385,038.34	12,579,372.95	10,520,154.29	12,613,669.14	12,694,310.11	0.00	0.00	0.00	0.00	0.00	0.00	

 
32.05	
15,144.32	
5,716.23	
162,187.83	
375,440.06	
2,692,330.48	
2,361,020.08	
8,338,650.08	
9,954.00	
0.00	
139.64	
0.00	
2,584.65	
6,434.82	
48,516.30	
6,167.14	
1,200,390.12	
1,699,253.53	
20,496,451.33	
13,010,242.38	
31,180,113.18	
17,384.50	
45.14	
19,796.88	
81,647,994.74	

3906	NEWLY ELIGIBLE MALE	565.60	252.69	29.45	69.53	8.54	136.64	0.00	0.00	0.00	0.00	0.00	0.00	1,062.45

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3907	NEWLY ELIGIBLE FEMA L	0.00	368.00	718.00	0.00	0.00	72.94	0.00	0.00	0.00	0.00	0.00	0.00		1,158.94		
3908	NEWLY ELIGIBLE M&F 4	6,391.01	9,530.25	3,280.13	877.71	1,922.94	2,626.26	0.00	0.00	0.00	0.00	0.00	0.00		24,628.30		
3909	NEWLY ELIGIBLE M&F 6	491.18	602.98	747.75	0.00	167.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,009.38		
3914	NEWLY ELIGIBLE MALE	15,249.46	14,325.93	11,406.94	10,046.14	14,291.58	17,730.71	0.00	0.00	0.00	0.00	0.00	0.00		83,050.76		
3915	NEWLY ELIGIBLE FEMA L	35,329.67	39,339.71	23,671.00	13,093.41	25,444.20	23,475.47	0.00	0.00	0.00	0.00	0.00	0.00		160,353.46		
3916	NEWLY ELIGIBLE MALE	236,860.76	307,117.41	193,505.68	173,818.34	229,297.35	213,031.74	0.00	0.00	0.00	0.00	0.00	0.00		1,353,631.28		
3917	NEWLY ELIGIBLE FEMA L	595,512.26	613,831.91	463,222.16	384,839.40	412,589.35	380,208.75	0.00	0.00	0.00	0.00	0.00	0.00		2,850,203.83		
3918	NEWLY ELIGIBLE M&F 4	774,247.15	944,868.39	770,039.27	643,515.20	818,844.64	740,490.30	0.00	0.00	0.00	0.00	0.00	0.00		4,692,004.95		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	736.00	368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,840.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	360.56	0.00	0.00	28.43	368.00	0.00	0.00	0.00	0.00	0.00	0.00		756.99		
SUBTOTAL:	1,664,647.09	1,930,597.83	1,467,356.38	1,226,627.73	1,503,330.50	1,378,140.81	0.00	0.00	0.00	0.00	0.00	0.00		9,170,700.34		

4412	SOBRA 100-133% M&F
1	0.00	1,436.00	0.00	700.00	350.00	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	383,277.18	369,186.18	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	96,394.47	86,618.72	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	144,611.95	191,719.37	138,585.95	115,672.06	157,084.99	122,553.75	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	598,311.07	779,846.15	590,864.41	520,580.99	637,106.64	578,358.65	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,486.00	
2,276,410.03	
555,943.81	
870,228.07	
3,705,067.91	

4517	BC PATIENT FEMALE 2 1	368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	5,520.00	4,416.00	2,284.63	1,533.66	1,104.00	1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	147.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,256.00	5,299.74	2,284.63	1,533.66	1,104.00	1,104.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,104.00	
15,962.29	
147.74	
368.00	
17,582.03	

8700	SSI DISABLED FREEDO M	7,296.44	5,878.33	16,900.38	5,411.35	4,232.74	5,639.92	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	1,840.00	1,104.00	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	
SUBTOTAL:	8,400.44	6,219.20	21,718.45	5,624.50	6,072.74	6,743.92	0.00	0.00	0.00	0.00	0.00	0.00	

 
45,359.16	
4,416.00	
5,004.09	
54,779.25	

42,730,541.60

42,531,263.00    41,201,283.62

0.00

0.00

0.00

35,196,330.12

0.00

0.00	0.00

266,962,611.38	

TOTAL:

51,739,377.28

53,563,815.76

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending December 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	2,727.77	656.18	0.00	0.00	0.00	0.00	0.00	0.00		8,903.97		
1007	TANF 21-44 FEMALE WI	6,790.07	16,402.24	8,847.17	10,787.71	9,830.33	5,500.92	0.00	0.00	0.00	0.00	0.00	0.00		58,158.44		
1008	TANF 45-64 M & F WIT	5,745.09	7,583.01	925.31	1,105.00	11,490.06	1,594.05	0.00	0.00	0.00	0.00	0.00	0.00		28,442.52		
1009	TANF 65+ M & F WITH	524.13	55.02	114.42	854.55	4,017.07	2,959.06	0.00	0.00	0.00	0.00	0.00	0.00		8,524.25		
1011	TANF <1 M & F NON-ME	189,983.11	396,902.26	166,256.38	614,840.48	277,979.85	221,769.76	0.00	0.00	0.00	0.00	0.00	0.00		1,867,731.84		
1012	TANF 01-05 M & F NON	63,137.63	76,150.23	60,465.28	57,381.78	74,635.31	64,605.36	0.00	0.00	0.00	0.00	0.00	0.00		396,375.59		
1013	TANF 06-13 M & F NON	121,964.92	44,627.08	40,421.31	44,209.48	47,042.15	121,226.96	0.00	0.00	0.00	0.00	0.00	0.00		419,491.90		
1014	TANF 14-20 MALE NON-	9,809.04	10,160.19	11,971.71	14,277.45	24,852.99	12,379.65	0.00	0.00	0.00	0.00	0.00	0.00		83,451.03		
1015	TANF 14-20 FEMALE N O	33,485.45	46,331.69	52,742.98	45,433.64	62,896.47	34,741.71	0.00	0.00	0.00	0.00	0.00	0.00		275,631.94		
1016	TANF 21-44 MALE NON-	538,720.43	818,731.46	521,422.83	594,944.87	672,217.52	511,299.05	0.00	0.00	0.00	0.00	0.00	0.00		3,657,336.16		
1017	TANF 21-44 FEMALE N O	1,361,290.75	1,890,712.96	1,387,455.52	1,361,156.91	1,833,174.27	1,567,796.12	0.00	0.00	0.00	0.00	0.00	0.00		9,401,586.53		
1018	TANF 45-64 M & F NON	681,254.62	863,864.36	530,664.16	577,401.83	768,464.05	777,939.23	0.00	0.00	0.00	0.00	0.00	0.00		4,199,588.25		
1019	TANF 65+ M & F NON-M	0.00	1,421.86	0.00	6,402.16	6,756.51	2,856.98	0.00	0.00	0.00	0.00	0.00	0.00		17,437.51		
1026	TANF 21-44 MALE WITH	116.86	2,480.19	18.72	1,723.10	487.98	140.65	0.00	0.00	0.00	0.00	0.00	0.00		4,967.50		
1027	TANF 21-44 FEMALE WI	2,636.88	2,108.61	27.92	3,528.75	1,556.77	398.35	0.00	0.00	0.00	0.00	0.00	0.00		10,257.28		
1028	TANF 45-64 M & F WIT	5,014.97	7,085.22	4,731.82	5,191.96	4,539.93	3,742.23	0.00	0.00	0.00	0.00	0.00	0.00		30,306.13		
1029	TANF 65+ M & F WITH	0.00	0.00	6.64	1,438.51	136.44	502.62	0.00	0.00	0.00	0.00	0.00	0.00		2,084.21		
2100	SSI AGED WITH MEDIC A	115,748.46	91,408.50	23,387.24	52,926.52	63,459.66	60,447.58	0.00	0.00	0.00	0.00	0.00	0.00		407,377.96		
2110	SSI AGED NON-MEDIC AR	31,788.57	48,642.55	31,256.79	125,559.23	108,863.17	18,844.60	0.00	0.00	0.00	0.00	0.00	0.00		364,954.91		
2120	SSI AGED WITH QMB	229,484.07	344,087.35	270,699.28	303,353.04	306,132.68	229,783.12	0.00	0.00	0.00	0.00	0.00	0.00		1,683,539.54		
2200	SSI DISABLED WITH M E	210,777.77	283,035.91	243,423.96	176,967.44	315,518.68	234,425.64	0.00	0.00	0.00	0.00	0.00	0.00		1,464,149.40		
2210	SSI DISABLED NON-ME D	3,642,965.31	4,857,725.43	3,800,787.99	3,208,089.22	4,567,276.71	4,019,881.27	0.00	0.00	0.00	0.00	0.00	0.00		24,096,725.93		
2220	SSI DISABLED WITH Q M	718,446.11	1,087,759.59	730,037.76	771,043.52	1,063,813.53	704,305.79	0.00	0.00	0.00	0.00	0.00	0.00		5,075,406.30		
2300	SSI BLIND WITH MEDIC	14.33	0.00	804.98	14.33	107.69	84.56	0.00	0.00	0.00	0.00	0.00	0.00		1,025.89		
2310	SSI BLIND NON-MEDIC A	25,883.10	61,596.20	26,069.05	45,729.97	39,652.49	35,017.47	0.00	0.00	0.00	0.00	0.00	0.00		233,948.28		
2320	SSI BLIND WITH QMB	9,644.50	10,606.91	5,210.39	4,646.52	12,453.83	7,366.51	0.00	0.00	0.00	0.00	0.00	0.00		49,928.66		
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	1,096,580.56	817,887.45	0.00	0.00	0.00	0.00	0.00	0.00		5,641,455.31		
4312	SOBRA CHILD 01-05 M	819,475.49	813,753.27	838,457.67	700,737.70	1,003,751.57	1,351,572.53	0.00	0.00	0.00	0.00	0.00	0.00		5,527,748.23		
4313	SOBRA CHILD 06-13 M	900,853.80	1,045,600.42	1,108,540.35	810,562.34	1,331,591.98	990,383.38	0.00	0.00	0.00	0.00	0.00	0.00		6,187,532.27		
4314	SOBRA CHILD 14-20 MA	235,587.23	343,925.37	241,039.86	292,752.49	340,091.21	338,149.49	0.00	0.00	0.00	0.00	0.00	0.00		1,791,545.65		
4315	SOBRA CHILD 14-20 FE	319,825.62	385,924.79	344,546.58	352,532.31	415,333.28	417,725.77	0.00	0.00	0.00	0.00	0.00	0.00		2,235,888.35		
5007	SOBRA PREG 21-44 FE M	459.90	1,929.86	485.67	0.00	0.00	47.44	0.00	0.00	0.00	0.00	0.00	0.00		2,922.87		
5013	SOBRA PREG 09-13 FE M	0.00	470.90	0.00	0.00	0.00	79.73	0.00	0.00	0.00	0.00	0.00	0.00		550.63		
5015	SOBRA PREG 14-20 FE M	66,587.06	139,786.68	101,941.79	122,415.60	104,526.79	78,341.89	0.00	0.00	0.00	0.00	0.00	0.00		613,599.81		
5017	SOBRA PREG 21-44 FE M	617,725.42	908,907.30	686,011.21	679,176.19	845,381.47	675,635.51	0.00	0.00	0.00	0.00	0.00	0.00		4,412,837.10		

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

RATE COD	E	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	24,921.44	8,633.95	0.00	0.00	0.00	0.00	0.00	0.00	45,564.94	
5027	SOBRA PREG 21-44 FE M	866.28	3,055.50	1,079.37	1,331.27	3,041.80	2,429.88	0.00	0.00	0.00	0.00	0.00	0.00	11,804.10	
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	
SUBTOTAL	:	12,039,725.98	15,456,060.58	12,111,017.15	11,947,945.05	15,445,304.01	13,321,152.44	0.00	0.00	0.00	0.00	0.00	0.00	80,321,205.21	

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

1,838.51	
1,838.51	

1106	TANF EXPANDED 21-44	10,571.52	13,753.32	6,287.51	14,369.57	17,466.25	14,663.13	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	26,491.47	11,365.54	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	75,035.75	44,332.03	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	18,233.09	18,094.73	11,324.59	22,653.80	21,544.62	12,050.95	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	103.44	0.00	0.00	2,438.93	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	49.99	175.96	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	19,538.17	18,474.01	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	185,333.66	180,275.36	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	667,495.16	589,653.78	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	559,174.22	358,773.71	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	250.16	893.25	685.65	449.28	5,973.44	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	8,136.82	20,853.51	8,953.53	10,479.17	16,314.64	20,415.31	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	25,131.54	20,122.12	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	40,567.85	30,794.61	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	8,819.97	15,441.67	8,637.17	6,934.43	13,087.29	12,806.28	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	5,234.94	6,001.84	5,472.24	4,592.07	5,203.82	10,332.32	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	1,088.04	-1,816.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	151,371.20	156,081.17	119,746.60	130,287.12	181,202.28	134,328.38	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	18,539.97	25,338.08	15,912.70	4,857.82	14,012.73	4,916.98	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	56,032.83	48,660.49	84,016.56	84,064.52	119,792.12	41,421.37	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	197,419.13	282,031.47	185,593.40	176,414.17	224,507.97	172,804.43	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,628,854.82	1,916,252.06	1,412,988.43	1,450,976.56	2,214,837.74	1,683,679.71	0.00	0.00	0.00	0.00	0.00	0.00	

77,111.30	
134,025.00	
403,559.13	
103,901.78	
0.00	
2,542.37	
148.74	
9,707.98	
76,396.49	
1,003,672.74	
3,006,179.34	
2,436,498.59	
8,251.78	
85,152.98	
72,792.85	
156,459.43	
65,726.81	
36,837.23	
-728.71	
873,016.75	
83,578.28	
433,987.89	
1,238,770.57	
10,307,589.32	

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	-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	-61.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
-107.53	
-1,844.31	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	-107.53	0.00	-1,782.34	-61.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,951.84		

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	
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	
3608	AHC CARE/MI M&F 45-6	-10.16	0.00	0.00	0.00	-13.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	-362.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	-14.92	-463.62	-55.48	-93.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-138.35	-14.92	-825.64	-3,137.15	-107.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-128.19	
-3,081.67	
-23.63	
0.00	
-362.02	
0.00	
-627.78	
-4,223.29	

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	-1,472.47	58.76	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	6,256.46	15,866.14	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	38,985.39	15,244.90	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	14,424.55	15,143.48	18,281.48	11,841.48	12,513.50	18,187.10	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	241,184.19	367,719.38	401,745.60	338,432.53	459,199.81	280,779.81	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	146,713.41	204,070.03	127,918.54	150,332.52	171,683.81	129,396.86	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	609,541.43	784,320.88	571,647.63	533,624.93	801,465.85	864,994.06	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	2,622.48	277.00	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	90.63	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 MAL E	0.00	648.18	1,093.02	337.31	689.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	74.57	0.00	0.00	181.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	564.58	2,089.93	2,175.73	4,273.00	6,082.07	961.94	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	940.33	328.96	17.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	77,551.63	90,070.37	107,660.73	84,080.97	135,239.42	82,324.99	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	64,347.99	85,805.18	82,434.39	53,957.39	113,258.10	55,943.22	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	2,548,960.43	2,969,432.56	2,577,851.89	2,971,415.37	3,390,279.99	3,101,884.87	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	765,143.06	1,133,604.69	998,651.15	1,100,450.80	1,124,053.51	923,562.85	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	3,295,413.07	3,963,337.74	3,047,122.81	3,278,706.11	4,030,606.31	3,444,326.98	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	2,136.91	546.72	3,264.42	162.56	67.37	867.52	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL 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	
3728	ADULT <40% EXP M&F 4	579.64	583.07	-19.34	0.00	16.55	2,000.27	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,805,747.12	9,648,919.56	7,966,086.38	8,545,906.63	10,291,638.54	8,936,677.27	0.00	0.00	0.00	0.00	0.00	0.00	

 
-230.36	
14,145.63	
41,897.58	
103,684.56	
90,391.59	
2,089,061.32	
930,115.17	
4,165,594.78	
31,865.43	
217.07	
90.63	
0.00	
2,768.27	
255.88	
16,147.25	
1,286.44	
576,928.11	
455,746.27	
17,559,825.11	
6,045,466.06	
21,059,513.02	
7,045.50	
0.00	
3,160.19	
53,194,975.50	

3906	NEWLY ELIGIBLE MALE	0.00	68.40	0.00	128.60	154.69	432.24	0.00	0.00	0.00	0.00	0.00	0.00	783.93

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3908	NEWLY ELIGIBLE M&F 4	2,854.42	2,978.75	1,020.45	-40.58	881.04	1,357.74	0.00	0.00	0.00	0.00	0.00	0.00		9,051.82		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	1,776.33	150.63	0.00	0.00	0.00	0.00	0.00	0.00		1,926.96		
3914	NEWLY ELIGIBLE MALE	6,895.37	4,020.80	2,130.37	3,263.19	16,838.11	14,476.85	0.00	0.00	0.00	0.00	0.00	0.00		47,624.69		
3915	NEWLY ELIGIBLE FEMA L	6,000.59	6,770.12	4,415.72	14,631.01	3,996.59	7,835.28	0.00	0.00	0.00	0.00	0.00	0.00		43,649.31		
3916	NEWLY ELIGIBLE MALE	86,585.35	154,491.69	129,941.11	92,209.11	96,904.07	82,937.24	0.00	0.00	0.00	0.00	0.00	0.00		643,068.57		
3917	NEWLY ELIGIBLE FEMA L	150,672.73	178,002.93	118,358.99	104,012.75	150,614.67	94,760.95	0.00	0.00	0.00	0.00	0.00	0.00		796,423.02		
3918	NEWLY ELIGIBLE M&F 4	302,477.81	320,499.76	328,674.25	338,201.99	340,449.66	383,639.65	0.00	0.00	0.00	0.00	0.00	0.00		2,013,943.12		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	30.62	0.00	0.00	0.00	52.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.09		
SUBTOTAL:	555,516.89	666,832.45	584,540.89	552,406.07	611,667.63	585,590.58	0.00	0.00	0.00	0.00	0.00	0.00		3,556,554.51		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	782.08	1,657.88	-402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	782.08	1,657.88	-402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
2,037.96	
0.00	
0.00	
2,037.96	

8700	SSI DISABLED FREEDO M	4,051.48	9,611.52	2,832.06	4,024.33	5,669.59	2,234.13	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	1,664.74	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	4,329.16	3,321.72	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,775.73	12,125.11	4,377.14	6,646.44	9,998.75	7,220.59	0.00	0.00	0.00	0.00	0.00	0.00	

28,423.11	
1,664.74	
15,055.91	
45,143.76	

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	139,595.48	67,884.81	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	23,529.15	25,466.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	23,465.33	34,959.05	23,854.09	40,308.89	45,244.29	36,181.05	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	108,488.75	145,082.93	94,430.24	125,533.56	208,368.92	129,531.86	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
485,963.53	
121,460.03	
204,012.70	
811,436.26	

TOTAL:	22,144,827.06	27,845,914.71	22,174,272.47	22,624,092.82	28,781,646.39	24,663,852.45	0.00	0.00	0.00	0.00	0.00	0.00		148,234,605.90		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 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-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

RATE COD	E	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	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

0.00	
0.00	

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

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

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

0.00	
0.00	
0.00	

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

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL 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	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL 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	
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 MAL 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	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL 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	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

 
0.00	
0.00	
0.00	
0.00	
0.00	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	

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

 
0.00	
0.00	
0.00	
0.00	

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	

TOTAL:

0.00

0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 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	1,275.12	0.00	0.00	0.00	0.00	0.00	0.00		1,764.71		
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	2,238.40	888.35	0.00	0.00	0.00	0.00	0.00	0.00		10,908.21		
1012	TANF 01-05 M & F NON	3,987.61	3,263.59	24.45	74.10	74.84	51.54	0.00	0.00	0.00	0.00	0.00	0.00		7,476.13		
1013	TANF 06-13 M & F NON	3,653.62	44.01	117.52	1,337.04	470.18	44.01	0.00	0.00	0.00	0.00	0.00	0.00		5,666.38		
1014	TANF 14-20 MALE NON-	1,143.86	301.79	433.35	0.00	430.90	-33.55	0.00	0.00	0.00	0.00	0.00	0.00		2,276.35		
1015	TANF 14-20 FEMALE N O	1,333.07	0.00	0.00	272.67	55.05	775.37	0.00	0.00	0.00	0.00	0.00	0.00		2,436.16		
1016	TANF 21-44 MALE NON-	2,299.03	1,606.33	7,315.24	3,093.77	642.56	6,843.53	0.00	0.00	0.00	0.00	0.00	0.00		21,800.46		
1017	TANF 21-44 FEMALE N O	27,040.84	13,143.03	14,720.69	12,353.70	11,802.29	16,893.31	0.00	0.00	0.00	0.00	0.00	0.00		95,953.86		
1018	TANF 45-64 M & F NON	28,071.21	1,484.06	2,052.40	1,175.39	3,789.68	4,898.72	0.00	0.00	0.00	0.00	0.00	0.00		41,471.46		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	93.00	0.00	0.00	0.00	0.00	0.00	0.00		93.00		
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	1,149.14	-7.98	0.00	0.00	0.00	0.00	0.00	0.00		7,505.42		
2110	SSI AGED NON-MEDIC AR	5,148.07	-9,481.65	7,030.69	14,677.98	22,927.47	7,360.07	0.00	0.00	0.00	0.00	0.00	0.00		47,662.63		
2120	SSI AGED WITH QMB	242.01	-109.74	3.33	-104.35	108.19	-1,169.48	0.00	0.00	0.00	0.00	0.00	0.00		-1,030.04		
2200	SSI DISABLED WITH M E	60.91	-225.64	2,470.61	-272.04	1,010.07	461.97	0.00	0.00	0.00	0.00	0.00	0.00		3,505.88		
2210	SSI DISABLED NON-ME D	27,621.59	22,101.33	16,667.85	687.91	1,579.78	2,985.98	0.00	0.00	0.00	0.00	0.00	0.00		71,644.44		
2220	SSI DISABLED WITH Q M	2,632.34	-15.23	394.41	608.50	3,385.69	683.16	0.00	0.00	0.00	0.00	0.00	0.00		7,688.87		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	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	3,201.48	3,119.55	0.00	0.00	0.00	0.00	0.00	0.00		33,094.52		
4312	SOBRA CHILD 01-05 M	65,933.12	13,197.35	21,624.82	5,408.49	6,709.04	6,772.19	0.00	0.00	0.00	0.00	0.00	0.00		119,645.01		
4313	SOBRA CHILD 06-13 M	104,379.21	2,798.52	14,577.29	2,003.75	-104.06	2,493.05	0.00	0.00	0.00	0.00	0.00	0.00		126,147.76		
4314	SOBRA CHILD 14-20 MA	11,733.15	2,913.24	6,838.28	4,514.52	6,851.42	5,692.98	0.00	0.00	0.00	0.00	0.00	0.00		38,543.59		
4315	SOBRA CHILD 14-20 FE	7,732.31	6,972.91	15,121.73	3,090.71	-857.41	1,558.35	0.00	0.00	0.00	0.00	0.00	0.00		33,618.60		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	4,124.18	12,367.41	655.37	135.05	689.42	1,649.35	0.00	0.00	0.00	0.00	0.00	0.00		19,620.78		
5017	SOBRA PREG 21-44 FE M	25,579.26	15,218.34	29,278.70	40,492.14	41,383.08	15,565.70	0.00	0.00	0.00	0.00	0.00	0.00		167,517.22		

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

RATE COD	E	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	
SUBTOTAL	:	329,038.48	103,501.39	148,094.81	98,222.27	107,537.21	78,894.29	0.00	0.00	0.00	0.00	0.00	0.00	865,288.45	

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

0.00	
0.00	

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	644.00	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	43.92	93.36	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	93.00	0.00	235.67	0.00	0.00	-93.00	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	3,015.80	3,778.06	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	11,851.52	6,661.39	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	3,446.49	163.09	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	64.36	332.88	44.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	3.33	0.00	0.00	4.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	0.00	191.51	47.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	903.35	516.82	1,276.20	471.14	605.69	714.99	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	80.08	310.66	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	174.44	0.00	0.00	0.00	0.00	38.59	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	166.07	666.37	196.80	1,060.18	143.01	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	77.84	3,284.84	0.00	637.94	1,480.72	8,439.15	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,647.33	17.88	0.00	53.93	21.16	189.60	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,273.97	20,416.07	10,642.01	6,958.44	22,254.55	20,438.90	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
929.96	
1,771.88	
0.00	
0.00	
0.00	
0.00	
0.00	
235.67	
16,072.99	
50,587.80	
7,521.03	
0.00	
0.00	
442.08	
8.32	
239.43	
4,488.19	
390.74	
213.03	
2,232.43	
13,920.49	
1,929.90	
100,983.94	

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

0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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	175.96	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	497.80	0.00	120.44	403.96	336.96	82.82	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	15,774.69	29,801.57	5,862.77	21,712.35	27,227.91	6,665.66	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	2,768.54	864.29	5,076.39	9,985.87	4,313.84	552.81	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	6,879.60	9,382.49	19,418.72	32,529.53	27,547.41	6,554.45	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 MAL E	0.00	641.28	174.96	132.60	625.09	257.39	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	107.45	318.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	9,037.89	960.23	5,742.48	1,218.60	456.47	442.41	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	6,327.32	218.97	103.21	444.72	2,863.82	611.63	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	26,321.69	106,274.78	42,777.80	88,481.16	25,940.01	45,589.03	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	14,376.87	49,297.30	17,351.22	22,570.22	12,658.03	20,579.76	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	39,054.06	121,173.01	46,890.23	113,580.58	62,608.03	53,603.33	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL 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	
3728	ADULT <40% EXP M&F 4	0.00	566.85	0.00	0.00	1,151.55	1,490.49	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	125,482.91	321,139.99	143,518.22	291,072.44	165,729.12	136,605.74	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
12.85	
0.00	
6,154.01	
1,441.98	
107,044.95	
23,561.74	
102,312.20	
0.00	
0.00	
0.00	
0.00	
1,831.32	
0.00	
425.62	
0.00	
17,858.08	
10,569.67	
335,384.47	
136,833.40	
436,909.24	
0.00	
0.00	
3,208.89	
1,183,548.42	

3906	NEWLY ELIGIBLE MALE	34.78	7.40	0.00	11.46	0.00	21.20	0.00	0.00	0.00	0.00	0.00	0.00	74.84

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3908	NEWLY ELIGIBLE M&F 4	101.36	65.43	251.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417.89		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	617.67	0.00	0.00	0.00	0.00	0.00	0.00		617.67		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	76.13	172.74	776.01	29.89	0.00	0.00	0.00	0.00	0.00	0.00		1,054.77		
3916	NEWLY ELIGIBLE MALE	2,914.09	14,106.81	6,628.24	15,285.71	5,946.75	50,306.73	0.00	0.00	0.00	0.00	0.00	0.00		95,188.33		
3917	NEWLY ELIGIBLE FEMA L	11,968.55	10,649.44	3,947.00	10,034.39	5,485.50	5,480.40	0.00	0.00	0.00	0.00	0.00	0.00		47,565.28		
3918	NEWLY ELIGIBLE M&F 4	12,324.30	13,624.14	7,696.01	-2,853.79	15,897.06	8,064.83	0.00	0.00	0.00	0.00	0.00	0.00		54,752.55		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	27,343.08	38,453.22	18,598.48	22,650.51	28,105.32	64,520.72	0.00	0.00	0.00	0.00	0.00	0.00		199,671.33		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	19.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	19.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
19.37	
0.00	
0.00	
19.37	

8700	SSI DISABLED FREEDO M	0.00	651.68	1,507.07	438.25	175.38	182.62	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	144.49	-598.36	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	21.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	673.22	3,798.02	438.25	319.87	-415.74	0.00	0.00	0.00	0.00	0.00	0.00	

2,955.00	
1,837.08	
21.54	
4,813.62	

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	1,688.40	540.50	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	3,894.78	1,340.14	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	901.53	974.71	144.25	19.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,280.28	5,032.17	996.95	10,655.19	5,583.18	1,880.64	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
22,935.81	
8,453.01	
2,039.59	
33,428.41	

TOTAL:	511,418.72	489,216.06	325,648.49	430,016.47	329,529.25	301,924.55	0.00	0.00	0.00	0.00	0.00	0.00		2,387,753.54		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 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	33,976.76	21,371.45	0.00	0.00	0.00	0.00	0.00	0.00		221,925.26		
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	75.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117.41		
SUBTOTAL:	36,872.16	53,054.55	45,687.23	31,004.90	34,052.38	21,371.45	0.00	0.00	0.00	0.00	0.00	0.00		222,042.67		

31,004.90

0.00

0.00

0.00

TOTAL:

36,872.16

53,054.55	45,687.23

34,052.38	21,371.45	0.00	0.00

0.00

222,042.67

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending December 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		
SUBTOTAL:	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		

TOTAL:

0.00

0.00

589.33

0.00

0.00

0.00

0.00

0.00

589.33

0.00

0.00

0.00	0.00

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 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	497,313.71	331,637.09	0.00	0.00	0.00	0.00	0.00	0.00		2,209,743.03		
8040	SLMB	4.16	0.00	0.00	0.00	4.29	7.91	0.00	0.00	0.00	0.00	0.00	0.00		16.36		
8050	QI1	7.67	86.69	-4.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.02		
SUBTOTAL:	363,239.62	409,204.4	7	280,446.79	327,995.53	497,318.00	331,645.00	0.00	0.00	0.00	0.00	0.00	0.00		2,209,849.41		

327,995.53

0.00

0.00

0.00

TOTAL:

363,239.62

409,204.47	280,446.79

497,318.00	331,645.00	0.00	0.00

0.00

2,209,849.41

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending December 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	152.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,541.83		
1008	TANF 45-64 M & F WIT	14.46	31.99	67.85	0.00	36.26	-61.91	0.00	0.00	0.00	0.00	0.00	0.00		88.65		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	135.43	721.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		856.63		
1011	TANF <1 M & F NON-ME	114,061.33	82,808.58	20,674.74	13,542.01	69,602.34	32,481.50	0.00	0.00	0.00	0.00	0.00	0.00		333,170.50		
1012	TANF 01-05 M & F NON	1,877.83	4,691.66	4,629.27	1,359.06	4,186.32	2,878.50	0.00	0.00	0.00	0.00	0.00	0.00		19,622.64		
1013	TANF 06-13 M & F NON	-34.11	397.76	542.41	1,165.54	10,191.23	741.32	0.00	0.00	0.00	0.00	0.00	0.00		13,004.15		
1014	TANF 14-20 MALE NON-	0.00	503.34	0.00	1,775.49	373.41	342.70	0.00	0.00	0.00	0.00	0.00	0.00		2,994.94		
1015	TANF 14-20 FEMALE N O	3,050.19	10,707.19	6,361.39	10,286.08	5,329.35	1,335.52	0.00	0.00	0.00	0.00	0.00	0.00		37,069.72		
1016	TANF 21-44 MALE NON-	45,482.98	57,982.31	50,834.68	63,481.02	65,002.73	53,576.70	0.00	0.00	0.00	0.00	0.00	0.00		336,360.42		
1017	TANF 21-44 FEMALE N O	106,522.53	130,723.18	138,930.01	105,441.56	152,021.89	108,980.70	0.00	0.00	0.00	0.00	0.00	0.00		742,619.87		
1018	TANF 45-64 M & F NON	87,013.43	82,472.68	30,115.17	44,846.99	89,880.81	22,109.68	0.00	0.00	0.00	0.00	0.00	0.00		356,438.76		
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	169.52	0.00	0.00	0.00	0.00	0.00	0.00		220.07		
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	2,787.50	1,812.69	0.00	0.00	0.00	0.00	0.00	0.00		16,362.96		
2110	SSI AGED NON-MEDIC AR	2,551.19	18.03	2,511.53	191.11	2,134.18	176.95	0.00	0.00	0.00	0.00	0.00	0.00		7,582.99		
2120	SSI AGED WITH QMB	9,555.40	11,940.97	7,470.65	15,123.55	12,552.40	18,168.95	0.00	0.00	0.00	0.00	0.00	0.00		74,811.92		
2200	SSI DISABLED WITH M E	8,793.87	12,081.12	10,297.40	5,147.30	11,941.75	4,236.24	0.00	0.00	0.00	0.00	0.00	0.00		52,497.68		
2210	SSI DISABLED NON-ME D	243,889.19	242,188.71	228,595.91	178,902.13	254,368.08	181,654.32	0.00	0.00	0.00	0.00	0.00	0.00		1,329,598.34		
2220	SSI DISABLED WITH Q M	36,584.54	51,182.69	28,824.97	28,013.13	39,195.84	34,975.82	0.00	0.00	0.00	0.00	0.00	0.00		218,776.99		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	175.91	4,793.35	764.82	575.81	6,632.12	420.19	0.00	0.00	0.00	0.00	0.00	0.00		13,362.20		
2320	SSI BLIND WITH QMB	1,288.00	88.30	231.93	184.69	1.71	1,298.56	0.00	0.00	0.00	0.00	0.00	0.00		3,093.19		
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	121,063.18	76,370.23	0.00	0.00	0.00	0.00	0.00	0.00		525,795.08		
4312	SOBRA CHILD 01-05 M	31,803.55	53,396.45	28,866.55	50,706.97	65,556.76	44,433.72	0.00	0.00	0.00	0.00	0.00	0.00		274,764.00		
4313	SOBRA CHILD 06-13 M	22,465.50	28,513.24	13,984.93	40,915.69	31,610.75	35,314.85	0.00	0.00	0.00	0.00	0.00	0.00		172,804.96		
4314	SOBRA CHILD 14-20 MA	8,438.19	7,014.89	19,047.97	14,802.86	55,470.21	23,529.75	0.00	0.00	0.00	0.00	0.00	0.00		128,303.87		
4315	SOBRA CHILD 14-20 FE	21,162.92	41,843.06	21,752.40	17,573.54	18,927.56	22,412.21	0.00	0.00	0.00	0.00	0.00	0.00		143,671.69		
5007	SOBRA PREG 21-44 FE M	27.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.54		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	26,309.18	30,637.88	21,142.34	14,687.66	26,447.42	26,545.96	0.00	0.00	0.00	0.00	0.00	0.00		145,770.44		
5017	SOBRA PREG 21-44 FE M	138,907.46	135,105.28	81,251.65	98,104.03	86,156.33	84,521.28	0.00	0.00	0.00	0.00	0.00	0.00		624,046.03		

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

RATE COD	E	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	116.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116.66	
5027	SOBRA PREG 21-44 FE M	56.68	90.66	0.00	71.63	98.01	27.46	0.00	0.00	0.00	0.00	0.00	0.00	344.44	
5028	SOBRA PREG 45-64 FE M	80.51	57.17	57.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194.85	
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	1,026,217.75	1,117,999.21	738,488.02	784,374.33	1,132,558.99	778,453.41	0.00	0.00	0.00	0.00	0.00	0.00	5,578,091.71	

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

0.00	
0.00	

1106	TANF EXPANDED 21-44	538.88	3,581.21	272.76	1,284.62	2,028.90	592.33	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	1,601.66	293.00	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	5,775.56	1,007.63	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	283.01	255.70	323.31	2,190.56	1,064.09	1,556.64	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	477.50	506.35	254.55	0.00	4,733.39	1,415.29	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	6,728.58	5,462.77	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	75,339.49	43,095.86	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	40,725.70	16,709.59	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	190.62	2,112.21	143.64	145.92	63.89	79.56	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	842.18	658.70	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	2,356.75	1,047.81	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	345.00	291.62	178.40	72.29	397.63	27.65	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	25.19	5,703.60	30.44	12.17	138.14	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	-552.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	10,427.22	9,257.84	5,545.61	11,860.80	10,119.93	2,811.56	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	127.08	678.60	160.68	590.40	566.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	1,127.98	862.65	7,720.14	2,533.49	2,023.85	1,387.02	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	9,014.59	12,900.26	5,689.62	7,464.94	8,536.72	8,253.24	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	98,257.39	216,685.29	144,224.59	98,281.03	162,916.65	84,536.79	0.00	0.00	0.00	0.00	0.00	0.00	

8,298.70	
5,032.10	
13,556.71	
5,673.31	
0.00	
0.00	
0.00	
0.00	
7,387.08	
153,738.89	
341,054.72	
132,462.20	
0.00	
2,735.84	
2,862.25	
5,769.90	
1,312.59	
5,909.54	
-552.47	
50,022.96	
2,122.92	
15,655.13	
51,859.37	
804,901.74	

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

0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	-7.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	-7.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
-7.00	
-7.00	

3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	99.71	0.00	0.00	10.25	26.51	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	138.24	88.42	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,441.01	800.83	5,402.91	4,348.74	1,978.79	990.40	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	102,273.00	34,493.94	48,861.53	42,834.62	38,184.34	9,439.07	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	23,312.85	32,151.32	13,850.34	6,962.96	39,301.04	17,381.43	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	74,316.57	92,252.90	65,747.96	32,884.41	148,224.61	93,051.69	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	1,560.02	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 MAL 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	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	52.40	57.17	23.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	13,443.49	7,826.15	12,268.41	1,582.12	13,394.89	3,476.38	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	1,025.71	20,156.01	6,885.48	8,248.27	1,992.18	6,780.92	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	191,333.82	193,228.81	152,239.46	216,431.27	174,373.59	195,573.80	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	64,187.35	106,658.28	64,804.04	51,581.64	196,234.07	63,663.98	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	145,955.90	274,489.78	153,176.27	239,303.70	280,578.08	257,522.92	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	62.60	0.00	0.00	0.00	82.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MAL 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	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	617,404.70	762,214.90	527,472.49	604,570.96	896,052.76	647,995.52	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
136.47	
0.00	
4,832.96	
14,962.68	
276,086.50	
132,959.94	
506,478.14	
1,560.02	
0.00	
0.00	
0.00	
0.00	
0.00	
132.59	
0.00	
51,991.44	
45,088.57	
1,123,180.75	
547,129.36	
1,351,026.65	
145.26	
0.00	
0.00	
4,055,711.33	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	248.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.01

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	15.66	0.00	0.00	0.00	0.00	0.00	0.00		15.66		
3914	NEWLY ELIGIBLE MALE	833.48	180.72	0.00	0.00	409.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,423.53		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	475.98	0.00	56.45	103.29	0.00	0.00	0.00	0.00	0.00	0.00		635.72		
3916	NEWLY ELIGIBLE MALE	4,882.72	6,594.79	11,596.15	50,378.57	4,040.26	9,780.14	0.00	0.00	0.00	0.00	0.00	0.00		87,272.63		
3917	NEWLY ELIGIBLE FEMA L	14,967.59	27,110.09	37,485.10	4,978.68	8,280.84	8,965.86	0.00	0.00	0.00	0.00	0.00	0.00		101,788.16		
3918	NEWLY ELIGIBLE M&F 4	19,064.87	22,092.71	22,177.93	124,588.84	43,597.89	25,220.06	0.00	0.00	0.00	0.00	0.00	0.00		256,742.30		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	39,748.66	55,978.31	71,735.16	179,946.09	56,632.78	44,085.01	0.00	0.00	0.00	0.00	0.00	0.00		448,126.01		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	15.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
15.42	
0.00	
0.00	
15.42	

8700	SSI DISABLED FREEDO M	0.00	355.04	0.00	21.54	1,928.98	2,506.89	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	355.04	0.00	21.54	1,928.98	2,506.89	0.00	0.00	0.00	0.00	0.00	0.00	

4,812.45	
0.00	
0.00	
4,812.45	

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	8,660.24	2,074.60	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	93.02	5,460.36	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	4,498.40	1,723.45	1,360.29	1,332.79	3,731.05	2,816.74	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,114.57	12,920.48	5,693.15	9,717.57	12,484.31	10,351.70	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
24,761.62	
17,057.44	
15,462.72	
57,281.78	

TOTAL:	1,787,758.49	2,166,153.23	1,487,613.41	1,676,911.52	2,262,574.47	1,567,922.32	0.00	0.00	0.00	0.00	0.00	0.00		10,948,933.44		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	368.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.00		
2100	SSI AGED WITH MEDIC A	219,052.35	253,349.25	121,463.64	90,376.31	64,358.63	118,343.68	0.00	0.00	0.00	0.00	0.00	0.00		866,943.86		
2110	SSI AGED NON-MEDIC AR	40,660.18	71,145.23	35,038.90	71,771.11	42,485.37	34,633.59	0.00	0.00	0.00	0.00	0.00	0.00		295,734.38		
2120	SSI AGED WITH QMB	182,700.41	209,792.30	159,732.00	109,007.17	110,830.05	95,397.85	0.00	0.00	0.00	0.00	0.00	0.00		867,459.78		
2200	SSI DISABLED WITH M E	34,869.86	45,426.05	38,471.02	26,683.93	20,108.19	15,168.82	0.00	0.00	0.00	0.00	0.00	0.00		180,727.87		
2210	SSI DISABLED NON-ME D	717,819.30	840,735.89	669,730.82	575,860.18	624,054.60	683,828.40	0.00	0.00	0.00	0.00	0.00	0.00		4,112,029.19		
2220	SSI DISABLED WITH Q M	69,871.55	87,449.75	85,703.33	53,253.94	51,148.27	45,343.15	0.00	0.00	0.00	0.00	0.00	0.00		392,769.99		
2300	SSI BLIND WITH MEDIC	0.00	0.00	77.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.04		
2310	SSI BLIND NON-MEDIC A	4,453.28	8,672.22	9,443.81	6,895.00	15,806.00	8,697.81	0.00	0.00	0.00	0.00	0.00	0.00		53,968.12		
2320	SSI BLIND WITH QMB	388.66	676.12	219.85	166.47	64.80	64.80	0.00	0.00	0.00	0.00	0.00	0.00		1,580.70		
SUBTOTAL:	1,269,815.59	1,517,614.81	1,120,248.41	934,014.11	928,855.91	1,001,478.10	0.00	0.00	0.00	0.00	0.00	0.00		6,772,026.93		

8710	SSI DISABLED FREEDO M	653.30	1,245.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	653.30	1,245.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,898.93	
0.00	
1,898.93	

1,270,468.89	1,518,860.44	1,120,248.41	934,014.11	928,855.91	1,001,478.10	0.00	0.00	0.00	0.00	0.00	0.00	

6,773,925.86	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	2,058,486.95	2,374,297.25	2,154,863.35	1,996,107.99	2,497,653.43	2,295,382.33	0.00	0.00	0.00	0.00	0.00	0.00		13,376,791.30		
2110	SSI AGED NON-MEDIC AR	108,527.50	93,777.18	118,373.10	98,203.67	145,392.38	113,770.05	0.00	0.00	0.00	0.00	0.00	0.00		678,043.88		
2120	SSI AGED WITH QMB	2,980,893.26	3,717,043.79	2,989,220.83	2,951,777.53	3,472,269.24	3,101,971.18	0.00	0.00	0.00	0.00	0.00	0.00		19,213,175.83		
2200	SSI DISABLED WITH M E	499,603.04	639,287.37	497,917.52	493,961.36	627,636.13	566,146.99	0.00	0.00	0.00	0.00	0.00	0.00		3,324,552.41		
2210	SSI DISABLED NON-ME D	1,864,375.53	2,336,558.77	2,196,536.16	1,991,658.71	2,260,634.42	2,177,481.88	0.00	0.00	0.00	0.00	0.00	0.00		12,827,245.47		
2220	SSI DISABLED WITH Q M	686,455.43	834,681.23	718,107.95	654,700.95	825,634.11	732,198.97	0.00	0.00	0.00	0.00	0.00	0.00		4,451,778.64		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	7,847.76	12,002.48	8,212.16	8,289.92	10,751.19	9,476.89	0.00	0.00	0.00	0.00	0.00	0.00		56,580.40		
2320	SSI BLIND WITH QMB	6,736.52	6,974.71	7,689.14	5,785.34	8,605.15	7,858.67	0.00	0.00	0.00	0.00	0.00	0.00		43,649.53		
SUBTOTAL:	8,212,925.99	10,014,622.78	8,690,920.21	8,200,485.47	9,848,576.05	9,004,286.96	0.00	0.00	0.00	0.00	0.00	0.00		53,971,817.46		

8710	SSI DISABLED FREEDO M	0.00	5,385.60	2,774.40	2,603.04	2,728.96	2,866.56	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	3,494.40	2,795.52	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,765.43	8,812.80	5,516.16	5,371.68	6,223.36	5,662.08	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,358.56	
17,992.95	
34,351.51	

TOTAL:	8,215,691.42	10,023,435.58	8,696,436.37	8,205,857.15	9,854,799.41	9,009,949.04	0.00	0.00	0.00	0.00	0.00	0.00		54,006,168.97		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	20,107.37	65,824.15	36,030.24	23,726.56	90,996.84	28,789.22	0.00	0.00	0.00	0.00	0.00	0.00		265,474.38		
2110	SSI AGED NON-MEDIC AR	321.97	0.00	419.90	11,620.27	326.31	2,893.78	0.00	0.00	0.00	0.00	0.00	0.00		15,582.23		
2120	SSI AGED WITH QMB	16,004.46	3,678.81	7,559.43	-86.23	16,376.35	33,532.66	0.00	0.00	0.00	0.00	0.00	0.00		77,065.48		
2200	SSI DISABLED WITH M E	859.25	960.45	6,967.11	7,944.79	2,533.01	1,144.21	0.00	0.00	0.00	0.00	0.00	0.00		20,408.82		
2210	SSI DISABLED NON-ME D	65,859.49	70,521.46	53,975.25	80,967.85	145,314.60	45,760.55	0.00	0.00	0.00	0.00	0.00	0.00		462,399.20		
2220	SSI DISABLED WITH Q M	304.54	4,059.22	8,911.33	3,935.90	2,353.48	777.30	0.00	0.00	0.00	0.00	0.00	0.00		20,341.77		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	326.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		326.95		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	103,457.08	145,371.04	113,863.26	128,109.14	257,900.59	112,897.72	0.00	0.00	0.00	0.00	0.00	0.00		861,598.83		

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	

103,457.08	145,371.04	113,863.26	128,109.14	257,900.59	112,897.72	0.00	0.00	0.00	0.00	0.00	0.00	

861,598.83	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending December 31, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	10,300.49	39,674.33	13,894.03	10,589.80	6,924.09	6,429.85	0.00	0.00	0.00	0.00	0.00	0.00		87,812.59		
2110	SSI AGED NON-MEDIC AR	217.99	5,861.03	219.57	0.00	488.36	337.53	0.00	0.00	0.00	0.00	0.00	0.00		7,124.48		
2120	SSI AGED WITH QMB	16,020.55	21,126.19	4,933.20	9,563.06	9,888.55	12,986.77	0.00	0.00	0.00	0.00	0.00	0.00		74,518.32		
2200	SSI DISABLED WITH M E	2,621.87	11,047.52	3,294.25	8,343.91	8,704.44	2,246.57	0.00	0.00	0.00	0.00	0.00	0.00		36,258.56		
2210	SSI DISABLED NON-ME D	46,899.42	39,426.91	48,635.30	31,702.89	93,104.37	53,068.78	0.00	0.00	0.00	0.00	0.00	0.00		312,837.67		
2220	SSI DISABLED WITH Q M	7,860.45	13,901.38	2,894.38	4,713.63	4,541.61	4,393.37	0.00	0.00	0.00	0.00	0.00	0.00		38,304.82		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	81.78	57.17	57.17	181.91	0.00	23.34	0.00	0.00	0.00	0.00	0.00	0.00		401.37		
SUBTOTAL:	84,002.55	131,094.53	73,927.90	65,095.20	123,651.42	79,486.21	0.00	0.00	0.00	0.00	0.00	0.00		557,257.81		

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	

TOTAL:	84,002.55	131,094.53	73,927.90	65,095.20	123,651.42	79,486.21	0.00	0.00	0.00	0.00	0.00	0.00		557,257.81		

RATE COD	E	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	55,947.22	65,109.08	0.00	0.00	0.00	0.00	0.00	0.00	179,746.39	
6012	KIDS 1-5 M & F NON-M	0.00	-6,189.47	77,969.11	170,721.14	269,206.40	300,425.01	0.00	0.00	0.00	0.00	0.00	0.00	812,132.19	
6013	KIDS 6-13 M & F NON-	33,225.63	13,672.65	183,641.27	347,351.64	527,182.78	606,701.83	0.00	0.00	0.00	0.00	0.00	0.00	1,711,775.80	
6014	KIDS 14-19 MALE NON-	31,612.49	24,016.15	68,826.52	122,434.57	176,702.06	203,272.99	0.00	0.00	0.00	0.00	0.00	0.00	626,864.78	
6015	KIDS 14-19 FEMALE NO	40,507.26	29,084.45	101,226.61	190,450.61	278,101.35	320,109.20	0.00	0.00	0.00	0.00	0.00	0.00	959,479.48	
9960	KIDSCARE KICK PAYM EN	0.00	0.00	0.00	0.00	6,100.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,100.23	
SUBTOTAL	:	105,824.56	60,026.29	453,014.31	868,375.56	1,313,240.04	1,495,618.11	0.00	0.00	0.00	0.00	0.00	0.00	4,296,098.87	

105,824.56	60,026.29	453,014.31	868,375.56	1,313,240.04	1,495,618.11	0.00	0.00	0.00	0.00	0.00	0.00	

4,296,098.87	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	1.00	1.00	44.12	80.57	120.31	138.90	0.00	0.00	0.00	0.00	0.00	0.00	385.90	

6012	C
KIDS 1-5 M & F NON-M	
0.00	
0.41	
658.36	
1,428.42	
2,256.23	
2,527.97	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
6,871.39	
6013	KIDS 6-13 M & F NON-	243.88	228.41	1,455.13	2,839.29	4,347.22	4,881.76	0.00	0.00	0.00	0.00	0.00	0.00	13,995.69	
6014	KIDS 14-19 MALE NON-	166.11	161.00	387.76	725.50	1,065.03	1,171.24	0.00	0.00	0.00	0.00	0.00	0.00	3,676.64	
6015	KIDS 14-19 FEMALE NO	138.19	130.41	377.56	709.71	1,046.78	1,134.25	0.00	0.00	0.00	0.00	0.00	0.00	3,536.90	
9960	KIDSCARE KICK PAYM EN	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
SUBTOTAL:	549.18	521.23	2,922.93	5,783.49	8,836.57	9,854.12	0.00	0.00	0.00	0.00	0.00	0.00	28,467.52	

TOTAL:	549.18	521.23	2,922.93	5,783.49	8,836.57	9,854.12	0.00	0.00	0.00	0.00	0.00	0.00		28,467.52		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
7000	CMHS	0.00	0.00	0.00	0.00	307,934.36	325,711.46	0.00	0.00	0.00	0.00	0.00	0.00	633,645.82	
7400	GENERAL MENTAL HE ALT	0.00	0.00	0.00	0.00	17,336.80	18,397.82	0.00	0.00	0.00	0.00	0.00	0.00	35,734.62	
SUBTOTAL:	0.00	0.00	0.00	0.00	325,271.16	344,109.28	0.00	0.00	0.00	0.00	0.00	0.00	669,380.44	

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	
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	50,985.55	0.00	-28.78	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	101,202.62	0.00	-57.56	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
SUBTOTAL:	0.00	0.00	0.00	208,752.54	0.00	-86.34	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,852.17	
50,956.77	
101,145.06	
26,413.11	
27,299.09	
208,666.20	

0.00	0.00	0.00	208,752.54	325,271.16	344,022.94	0.00	0.00	0.00	0.00	0.00	0.00	

878,046.64	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
7000	CMHS	0.00	0.00	0.00	0.00	8,346.00	8,810.00	0.00	0.00	0.00	0.00	0.00	0.00	17,156.00	
7400	GENERAL MENTAL HE ALT	0.00	0.00	0.00	0.00	333.00	353.00	0.00	0.00	0.00	0.00	0.00	0.00	686.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	8,679.00	9,163.00	0.00	0.00	0.00	0.00	0.00	0.00	17,842.00	

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	
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	
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	
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	
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	
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	

 
79.00	
1,383.00	
2,738.00	
687.00	
681.00	
5,568.00	

TOTAL:	0.00	0.00	0.00	5,568.00	8,679.00	9,163.00	0.00	0.00	0.00	0.00	0.00	0.00		23,410.00		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending December 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	0.00	475.31	475.31	0.00	0.00	0.00	0.00	0.00	0.00		950.62		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	475.31	475.31	0.00	0.00	0.00	0.00	0.00	0.00		950.62		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	475.31	475.31	0.00	0.00	0.00	0.00	0.00	0.00		950.62		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	475.31	0.00	0.00	0.00	0.00	0.00	0.00		475.31		
SUBTOTAL:	0.00	0.0	0	0.00	0.00	1,425.93	1,901.24	0.00	0.00	0.00	0.00	0.00	0.00		3,327.17		

0.00	0.00	0.00	0.00	1,425.93	1,901.24	0.00	0.00	0.00	0.00	0.00	0.00	

3,327.17	

TOTAL:

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending December 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	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	0.00	0.0	0	0.00	0.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		

TOTAL:	0.00	0.00	0.00	0.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		

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

6012	KIDS <1M&F NON MEDI C
KIDS 1-5 M & F NON-M	0.00

0.00	0.00

0.00	0.00

271.99	0.00

2,214.23	167.63

14,593.88	301.30

18,380.56	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	468.93

35,460.66	
6013	KIDS 6-13 M & F NON-	0.00	0.00	317.51	3,907.07	6,662.69	7,261.75	0.00	0.00	0.00	0.00	0.00	0.00	18,149.02	
6014	KIDS 14-19 MALE NON-	0.00	15.43	338.82	399.04	9,728.06	1,853.73	0.00	0.00	0.00	0.00	0.00	0.00	12,335.08	
6015	KIDS 14-19 FEMALE NO	0.00	214.91	133.90	3,927.77	1,118.06	11,112.33	0.00	0.00	0.00	0.00	0.00	0.00	16,506.97	
SUBTOTAL:	0.00	230.34	1,062.22	10,448.11	32,270.32	38,909.67	0.00	0.00	0.00	0.00	0.00	0.00		82,920.66	
TOTAL:	0.00	230.34	1,062.22	10,448.11	32,270.32	38,909.67	0.00	0.00	0.00	0.00	0.00	0.00			

82,920.66	

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	-0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,678.79		
SUBTOTAL:	82,673.79	198.95	63,655.88	150.18	-0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,678.79		
															
TOTAL:	82,673.79	198.95	63,655.88	150.18	-0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	146,678.79		

4

00

179,295.78

179,295.78

63.00

4,051.35

5.49

12.00

1,071.29

22.00

1,621.09

11,828.26

134,869.92

5.35

24,698.37

91.00

709.47

164.19

57.00

8.00

18.00

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending December 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	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	666.51	671.77	670.37	675.93	687.26	679.51	0.00	0.00	0.00	0.00	0.00	0.00	
101Z	TANF ALTCS NON-MEDIC	0.00	0.00	5.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	170.32	172.75	175.00	184.05	188.99	180.18	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICAR	4.00	4.00	3.00	3.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	271.83	271.02	270.00	270.48	268.86	268.90	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH ME	1,947.34	1,983.19	1,979.74	1,970.84	1,966.98	1,980.17	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-MED	22,244.95	22,359.52	22,463.70	22,462.57	22,623.68	22,715.50	0.00	0.00	0.00	0.00	0.00	0.00	
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	
2220	SSI DISABLED WITH QM	4,066.85	4,090.03	4,122.36	4,129.16	4,142.64	4,147.33	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	13.00	14.00	16.00	16.00	16.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	118.99	121.00	122.00	116.48	114.00	117.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	28.19	28.00	27.00	27.00	27.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	9.00	9.00	9.00	10.00	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	1.00	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29,556.98	29,741.31	29,883.95	29,882.54	30,067.41	30,163.59	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL:	29,556.98	29,741.31	29,883.95	29,882.	5	30,067.41	30,163.59	0.00	0.00	0.00	0.	0.00	0.00	

 
ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM
EPD/DD EXPENDITURES
For the Period Ending December 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	390,833.38	395,654.95	0.00	0.00	0.00	0.00	0.00	0.00	2,307,819.29	
EPD	85,600,877.03	98,791,049.82	85,969,975.13	89,668,063.40	102,355,061.38	92,101,502.50	0.00	0.00	0.00	0.00	0.00	0.00	554,486,529.26	
TOTAL AHCCCS LTC	85,979,585.45	99,163,141.68	86,347,636.75	90,060,932.46	102,745,894.76	92,497,157.45	0.00	0.00	0.00	0.00	0.00	0.00	556,794,348.55	
DES/DD	104,331,950.18	104,866,978.39	105,491,156.40	106,085,077.89	106,741,362.35	109,552,153.78	0.00	0.00	0.00	0.00	0.00	0.00	637,068,678.99	
TOTAL DES LTC	104,331,950.18	104,866,978.39	105,491,156.40	106,085,077.89	106,741,362.35	109,552,153.78	0.00	0.00	0.00	0.00	0.00	0.00	637,068,678.99	
TOTAL LTC - CAP	190,311,535.63	204,030,120.07	191,838,793.15	196,146,010.35	209,487,257.11	202,049,311.23	0.00	0.00	0.00	0.00	0.00	0.00	1,193,863,027.54	

EPD/DD FEE-FOR-SERVICE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	9,673,619.94
0.00	11,818,761.59
0.00	10,004,475.94
0.00	9,333,075.60
0.00	11,165,207.33
0.00	10,203,811.07
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	62,198,951.47
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	9,673,619.94	11,818,761.59	10,004,475.94	9,333,075.60	11,165,207.33	10,203,811.07	0.00	0.00	0.00	0.00	0.00	0.00	62,198,951.47	

EPD/DD REINSURANCE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	4,453,643.29
513,400.18	5,137,624.64
371,137.98	4,206,734.06
818,556.37	5,494,838.14
521,755.20	3,432,440.40
1,059,285.15	3,687,593.77
301,896.79	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	26,412,874.30
3,586,031.67	
	513,400.18	371,137.98	818,556.37	521,755.20	1,059,285.15	301,896.79	0.00	0.00	0.00	0.00	0.00	0.00	3,586,031.67	
TOTAL LTC - REIN	4,967,043.47	5,508,762.62	5,025,290.43	6,016,593.34	4,491,725.55	3,989,490.56	0.00	0.00	0.00	0.00	0.00	0.00	29,998,905.97	

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	3,612,348.80	3,616,636.50	0.00	0.00	0.00	0.00	0.00	0.00	21,654,823.60	

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.

Tuesday, January 24, 2017

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

010115	CRS FULLY INTEGRATED PLAN - CAP	14,233,650.60	13,929,828.60	14,183,986.01	14,337,196.76	14,347,791.47	20,412,180.12	0.00	0.00	0.00	0.00	0.00	0.00	91,444,633.56	
010145	CRS ACUTE SEMI INTEGRATED - CAP	145,463.25	142,476.36	145,562.28	109,407.35	109,309.61	169,789.77	0.00	0.00	0.00	0.00	0.00	0.00	822,008.62	
999125	CRS SEMI INTEGRATED PLAN - CAP	4,973,747.20	4,959,398.40	4,961,664.00	5,202,598.80	5,207,358.00	5,193,873.60	0.00	0.00	0.00	0.00	0.00	0.00	30,498,640.00	
999135	CRS ONLY PLAN - CAP	551,073.60	552,982.08	550,596.48	544,229.95	541,853.40	541,378.09	0.00	0.00	0.00	0.00	0.00	0.00	3,282,113.60	
Subtotal	19,903,934.65	19,584,685.44	19,841,808.77	20,193,432.86	20,206,312.48	26,317,221.58	0.00	0.00	0.00	0.00	0.00	0.00	126,047,395.78	

999155	CRS REINSURANCE ONLY	2,326,263.42	446,456.85	911,431.67	1,717,829.88	1,131,339.38	1,162,365.46	0.00	0.00	0.00	0.00	0.00	0.00	7,695,686.66	
Subtotal	2,326,263.42	446,456.85	911,431.67	1,717,829.88	1,131,339.38	1,162,365.46	0.00	0.00	0.00	0.00	0.00	0.00	7,695,686.66	

22,230,198.07	20,031,142.29	20,753,240.44	21,911,262.74	21,337,651.86	27,479,587.04	0.00	0.00	0.00	0.00	0.00	0.00	133,743,082.44	

GRAND TOTAL

Tuesday, January 24, 2017

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

010115	CRS FULLY INTEGRATED PLAN - MM	17,102.15	16,990.50	17,006.16	16,948.93	16,928.08	16,949.90	0.00	0.00	0.00	0.00	0.00	0.00	101,925.72	
010145	CRS ACUTE SEMI INTEGRATED - MM	181.59	179.98	181.73	184.85	185.14	190.54	0.00	0.00	0.00	0.00	0.00	0.00	1,103.83	
999125	CRS SEMI INTEGRATED PLAN - MM	6,586.00	6,567.00	6,570.00	6,559.00	6,565.00	6,548.00	0.00	0.00	0.00	0.00	0.00	0.00	39,395.00	
999135	CRS ONLY PLAN - MM	1,155.00	1,159.00	1,154.00	1,145.00	1,137.00	1,135.00	0.00	0.00	0.00	0.00	0.00	0.00	6,885.00	
Subtotal	25,024.74	24,896.48	24,911.89	24,837.78	24,815.22	24,823.44	0.00	0.00	0.00	0.00	0.00	0.00	149,309.55	

25,024.74	24,896.48	24,911.89	24,837.78	24,815.22	24,823.44	0.00	0.00	0.00	0.00	0.00	0.00	149,309.55	

GRAND TOTAL

Tuesday, January 24, 2017

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

010700	HEALTH CHOICE INTEGRATED - CAP	8,139,817.79	8,143,584.09	8,215,936.27	9,455,259.81	9,593,036.06	9,666,569.26	0.00	0.00	0.00	0.00	0.00	0.00	53,214,203.28	
010725	CENPATICO INTEGRATED - CAP	19,718,383.80	19,873,855.68	19,844,674.31	21,352,168.63	21,376,211.96	21,458,505.12	0.00	0.00	0.00	0.00	0.00	0.00	123,623,799.50	
078999	MERCY MARICOPA INTEGRATED - CAP	43,908,062.70	44,810,326.74	45,127,647.55	46,563,901.16	46,879,070.47	47,010,920.91	0.00	0.00	0.00	0.00	0.00	0.00	274,299,929.53	
Subtotal	71,766,264.29	72,827,766.51	73,188,258.13	77,371,329.60	77,848,318.49	78,135,995.29	0.00	0.00	0.00	0.00	0.00	0.00	451,137,932.31	

71,766,264.29	72,827,766.51	73,188,258.13	77,371,329.60	77,848,318.49	78,135,995.29	0.00	0.00	0.00	0.00	0.00	0.00	451,137,932.31	

GRAND TOTAL

Tuesday, January 24, 2017

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

010700	HEALTH CHOICE INTEGRATED - MM	5,434.12	5,436.13	5,482.30	5,531.12	5,613.21	5,656.73	0.00	0.00	0.00	0.00	0.00	0.00	33,153.61	
010725	CENPATICO INTEGRATED - MM	12,956.97	13,057.68	13,037.47	13,175.18	13,188.37	13,241.02	0.00	0.00	0.00	0.00	0.00	0.00	78,656.69	
078999	MERCY MARICOPA INTEGRATED - MM	19,855.38	20,248.88	20,392.35	20,636.60	20,777.74	20,835.63	0.00	0.00	0.00	0.00	0.00	0.00	122,746.58	
Subtotal	38,246.47	38,742.69	38,912.12	39,342.90	39,579.32	39,733.38	0.00	0.00	0.00	0.00	0.00	0.00	234,556.88	

38,246.47	38,742.69	38,912.12	39,342.90	39,579.32	39,733.38	0.00	0.00	0.00	0.00	0.00	0.00	234,556.88	

GRAND TOTAL