May 25, 2017

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 April 30, 2017

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 April 30, 2017.

Status Summary – Laws 2017, Chapter 305, included the following FY 2017 appropriation adjustments/balance transfers:

Section 106(A) – CHIP Fund increase of $63,225,800
Section 106(B1) – Federal Medicaid Authority decrease of $70,854,300
Section 106(B2) – Federal Prescription Drug Rebate Fund increase of $137,309,100 Section 138(1) – State Prescription Drug Rebate Fund balance transfer of $30,000,000

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

There are several issues this fiscal year that have the potential to affect the 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 May 25, 2017
Page 2

Enrollment Update – April 2017 enrollment is 1,917,836 members, an 85 member increase

over the

prior month.	Enrollment  for  May  2017  increased  to  1,924,391  members, a

6,555

member increase.

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

increase

of 2,165;

Supplemental Security

Income  –  increase of

29;  Prop  204  Restoration -

increase of 190; Adult Expansion - increase of 126; Medicare Cost Sharing – increase of 308; KidsCare – increase of 2,551; and Federal Emergency Services - increase of 982.

Tobacco Funds Revenue Update – Tobac less than the AHCCCS monthly    projected

o tax collections through March 2017 are $900,000 flows. In April, AHCCCS received    approximately

$101.5 million in Tobacco Litigation Settlement funding which is about $1.5 million more   than

the FY17 appropriation of   $100,000,000.

AHCCCS

will monitor the tobacco funds    revenue

collections throughout the year to determine any impact on the FY 2017 appropriations.

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

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 April 30, 2017

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 April 30, 2017
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	$	106,048,900		$	71,329,205		$	69,902,837		$	1,426,367		$	106,048,900		$	-		
AHCCCS Prop 204 Administration	13,666,600		10,407,033		11,109,716		(702,683)		13,666,600		-		
DES Eligibility	88,874,500		46,178,200		52,188,735		(6,010,535)		88,874,500		-		
DES Prop 204 Eligibility	44,358,700		32,343,400		26,992,834		5,350,566		44,358,700		-		
TOTAL ADMINISTRATION	 	252,948,700 		 	160,257,837 		 	160,194,122 		 	63,715 		 	252,948,700 		 	-			

Traditional Medicaid Services	3,684,394,400	3,086,103,600	3,020,884,965	65,218,635	3,684,394,400	-	
Proposition 204 Services	2,799,798,900	2,283,731,900	2,195,597,126	88,134,774	2,799,798,900	-	
ACA Adult Expansion	436,402,900	376,442,200	358,451,349	17,990,851	436,402,900	-	
Children's Rehabilitative Services	280,814,200	228,951,600	215,203,478	13,748,122	280,814,200	-	
KidsCare Services	61,180,800	1,473,500	(241,339)	1,714,839	61,180,800	-	
ALTCS Services	1,434,138,200	1,172,474,500	1,119,774,555	52,699,945	1,434,138,200	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	22,650,000	5,244,300	10,488,754	(5,244,454)	22,650,000	-	
Voluntary Political Subdivision Programs	445,609,000	167,972,100	167,972,058	42	445,609,000	-	
Behavioral Health Traditional Medicaid Services	1,111,571,200	916,939,900	908,012,737	8,927,163	1,111,571,200	-	
Behavioral Health Proposition 204 Services	707,640,500	602,841,400	581,109,907	21,731,493	707,640,500	-	
Behavioral Health ACA Adult Expansion	81,143,500	70,549,300	62,609,888	7,939,412	81,143,500	-	
Behavioral Health CMDP	211,266,400	174,696,000	145,939,231	28,756,769	211,266,400	-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900	65,706,000	65,506,751	199,249	78,846,900	-	
Supported Housing	5,324,800	4,437,000	4,364,870	72,130	5,324,800	-	
Crisis Services	16,391,300	13,659,000	13,600,913	58,087	16,391,300	-	

TOTAL PROGRAMMATIC	 	11,382,260,100	 	9,171,222,300	 	8,869,275,242	 	301,947,058	 	11,382,260,100	 	-	

TOTAL EXPENDITURES

$	11,635,208,800

$    9,331,480,137

$   9,029,469,364

$	302,010,773

$   11,635,208,800	$	-

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2017 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		
Administrative Expenditures	$	58,901,000	$	44,931,799	$	41,473,338	3,458,462	$	58,901,000	$	-	
Proposition 204 - Administrative Expenditures	21,746,500	18,021,829	10,317,304	7,704,525	21,746,500	-	

Programmatic Expenditures							
Traditional Medicaid Services	749,355,600	627,154,700	671,089,900	(43,935,200)	749,355,600	-	
Proposition 204 Services	85,000,000	71,417,700	(18,136,064)	89,553,764	85,000,000	-	
Children's Rehabilitative Services KidsCare Services	84,424,100
-	70,472,400
-	60,730,628
(13,188)	9,741,772
13,188	84,424,100
-	-
-	
ALTCS Services	167,841,100	138,991,000	139,867,499	(876,499)	167,841,100	-	
DSH and Rural Hospitals	7,239,300	1,613,100	3,226,341	(1,613,241)	7,239,300	-	
Behavioral Health Traditional Medicaid Services	304,268,100	252,383,200	255,059,292	(2,676,092)	304,268,100	-	
Behavioral Health Proposition 204 Services	108,150,500	93,071,600	79,893,526	13,178,074	108,150,500	-	
Behavioral Health ACA Adult Expansion	1,931,900	551,900	857,856	(305,956)	1,931,900	-	
Behavioral Health CMDP	63,770,500	53,582,300	46,104,179	7,478,121	63,770,500	-	
Non Medicaid Seriouslly Mentally Ill Services	78,846,900	65,706,000	65,506,751	199,249	78,846,900	-	
Supported Housing	5,324,800	4,437,000	4,364,870	72,130	5,324,800	-	
Crisis Services	 	14,141,100 	 	11,784,000 	 	11,725,746 	 	58,254 	 	14,141,100 	 	- 	
TOTAL GF EXPENDITURES	1,750,941,400	1,524,667,828	1,372,067,977	82,050,551	1,750,941,400	-	

FEDERAL		
Administrative Expenditures	135,522,400	72,243,844	80,275,615	(8,031,771)	135,522,400	-	
Proposition 204 - Administrative Expenditures	32,715,500	21,723,404	26,003,596	(4,280,192)	32,715,500	-	

Programmatic Expenditures	
Traditional Medicaid Services	2,197,740,600	1,946,092,100	1,753,046,064	193,046,036	2,197,740,600	-	
Proposition 204 Services	2,312,463,100	1,896,574,100	1,894,932,759	1,641,341	2,312,463,100	-	
ACA Adult Expansion	430,324,100	373,311,400	352,430,340	20,881,060	430,324,100	-	
Children's Rehabilitative Services	196,390,100	158,479,200	154,472,850	4,006,350	196,390,100	-	
KidsCare Services	60,810,800	1,194,700	(506,951)	1,701,651	60,810,800	-	
ALTCS Services and Nursing Facility Assessment	894,587,700	780,450,800	741,221,951	39,228,849	894,587,700	-	
DSH and Rural Hospitals	20,497,800	3,631,200	7,262,413	(3,631,213)	20,497,800	-	
Behavioral Health Traditional Medicaid Services	771,737,300	635,055,600	624,544,219	10,511,381	771,737,300	-	
Behavioral Health Proposition 204 Services	599,490,000	494,577,200	482,026,753	12,550,447	599,490,000	-	
Behavioral Health ACA Adult Expansion	79,028,900	69,997,400	61,615,007	8,382,393	79,028,900	-	
Behavioral Health CMDP	147,495,900	121,113,700	99,835,052	21,278,648	147,495,900	-	
Voluntary Political Subdivision Programs - See Note 5	 	299,477,800 	 	115,558,800 	 	115,558,800 	 	0 	 	299,477,800 	 	- 	
TOTAL FEDERAL EXPENDITURES	8,178,282,000	6,690,003,448	6,392,718,469	297,284,978	8,178,282,000	-	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,563,300	3,005,200	1,781,650	1,223,550	3,563,300	-	
Programmatic Expenditures							
Traditional Medicaid Services Acute Care	49,687,700	41,508,400	41,508,400	-	49,687,700	-	
ALTCS Services	 	249,980,000 	 	207,027,900 	 	186,160,963 	 	20,866,937 	 	249,980,000 	 	- 	
TOTAL COUNTY EXPENDITURES	303,231,000	251,541,500	229,451,013	22,090,487	303,231,000	-	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2017 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

	TOBACCO FUNDS		

Programmatic Expenditures			
Traditional Medicaid Services - Medically Needy		37,432,400	31,270,500	29,900,227	1,370,273	37,432,400	-	
Behavioral Health Traditional Medicaid Services - Medically Needy		35,565,800	29,501,100	28,409,226	1,091,874	35,565,800	-	
Proposition 204 Services - Emergency Health Services		18,747,200	15,561,800	16,121,043	(559,243)	18,747,200	-	
Proposition 204 Services - Proposition 204 Protection		16,251,400	15,627,600	14,662,162	965,438	16,251,400	-	
Behavioral Health Proposition 204 Services - Proposition 204 Protection		21,269,600	15,192,600	19,189,628	(3,997,028)	21,269,600	-	
Proposition 204 Services - ATLSF	 	100,000,000 	 	100,000,000 	 	100,000,000 	 	- 	 	100,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	229,266,400	207,153,600	208,282,286	(1,128,686)	229,266,400	-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	

OTHER

500,000	

331,762	342,619	(10,857)	500,000	-	
Acute Care - Prescription Drug Rebate Program State Match	105,837,600	88,415,100	104,043,450	(15,628,350)	105,837,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	544,114,600	351,499,900	420,840,743	(69,340,843)	544,114,600	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,441,300	6,169,200	6,201,083	(31,883)	7,441,300	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	42,338,000	23,193,400	28,000,300	(4,806,900)	42,338,000	-	
Proposition 204 Services - Hospital Assessment	246,067,600	184,550,700	188,017,227	(3,466,527)	246,067,600	-	
ACA Adult Expansion - Hospital Assessment	6,078,800	3,130,800	6,021,009	(2,890,209)	6,078,800	-	
Behavioral Health ACA Adult Expansion - Hospital Assessment	182,700	-	137,025	(137,025)	182,700	-	
Traditional Medicaid Services - TPL	194,700	162,900	404,817	(241,917)	194,700	-	
ALTCS Services - TPL	-	-	1,026,241	(1,026,241)	-	-	
ALTCS Services - Nursing Facility Assessment	71,950,100	16,642,200	17,296,518	(654,318)	71,950,100	-	
KidsCare Services Premiums	370,000	278,800	278,800	-	370,000	-	
Freedom to Work Premiums	31,200	-	51,363	(51,363)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	1,875,000	1,875,167	(167)	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	146,131,200 	 	52,413,300 	 	52,413,258 	 	42 	 	146,131,200 	 	- 	
TOTAL OTHER EXPENDITURES	1,173,488,000	728,663,062	826,949,619	(98,286,558)	1,173,488,000	-	

TOTAL		
Administrative Expenditures	252,948,700		160,257,837		160,194,122		63,715		252,948,700		-	
Acute Care	9,948,121,900		7,998,747,800		7,749,500,687		249,247,113		9,948,121,900		-	
Long Term Care	 	1,434,138,200 		 	1,172,474,500 		 	1,119,774,555 		 	52,699,945 		 	1,434,138,200 		 	- 	
TOTAL EXPENDITURES	  $	11,635,208,800 		  $	9,331,480,137 		  $	9,029,469,364 		  $	302,010,773 		  $	11,635,208,800 		  $	- 	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending April 30, 2017

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	899,920,000	$	744,171,999	$	776,520,207	
Proposition 204 Services & Administrative	106,746,500	89,439,529	91,264,393	
KidsCare Services	-	-	(13,188)	
ALTCS Services	167,841,100	138,991,000	139,867,499	
Behavioral Health Traditional Medicaid Services	 	576,433,800	 	481,516,000	 	382,760,838 	
TOTAL	1,750,941,400	1,454,118,528	1,390,399,749	

FEDERAL:
Acute & Administrative	5,625,131,400		4,587,614,048		4,639,912,869	
KidsCare Services	60,810,800		1,194,700		17,140,251	
ALTCS Services	894,587,700		780,450,800		749,872,989	
Behavioral Health Traditional Medicaid Services	 	1,597,752,100 		 	1,320,743,900 		 	1,268,260,010 	
TOTAL	8,178,282,000		6,690,003,448		6,675,186,119	

COUNTY:						
Acute & Administrative	53,251,000		44,513,600		42,731,762	
ALTCS Services	 	249,980,000 		 	207,027,900 		 	208,316,670 	
TOTAL	303,231,000		251,541,500		251,048,432	

TOBACCO FUNDS:						
Traditional Medicaid Services	72,998,200		60,771,600		58,309,453	
Proposition 204 Services	 	156,268,200 		 	146,382,000 		 	130,783,205 	
TOTAL	229,266,400		207,153,600		189,092,658	

OTHER:

Administrative	500,000		331,762		342,619	
Acute Care - Prescription Drug Rebate Program	649,952,200		439,915,000		524,884,193	
Long Term Care - Prescription Drug Rebate Program	49,779,300		29,362,600		34,201,383	
Hospital Assessment	252,329,100		187,681,500		198,421,800	
ALTCS - Nursing Facility Assessment	71,950,100		16,642,200		16,592,451	
Acute TPL - Note 1	194,700		162,900		404,817	
LTC TPL - Note 1	-		-		1,026,241	
KidsCare TPL - Note 1	-		-		976	
Member Premiums - CHIP	370,000		278,800		1,710,870	
Member Premiums - Freedom to Work	31,200		-		51,363	
Behavioral Health Traditional Medicaid Services	2,250,200		1,875,000		4,460,456	
Voluntary Political Subdivision - State Match	 	146,131,200 		 	52,413,300 		 	123,825,914 	
TOTAL	1,173,488,000		728,663,062		905,923,083	

TOTAL REVENUE

$	11,635,208,800

$	9,331,480,137

$	9,411,650,041

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2017 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2017	
Note 1:	Third Party Liability Collections:	April 2017		April 2016		July 1, 2016		July 1, 2015	
	Gross Collections:					April 30, 2017		April 30, 2016	
	Acute	$	284,711		$	858,861		$	4,438,254		$	4,698,251	
	LTC	735,377		417,909		4,508,151		2,633,546	
	KidsCare	-		27,655		4,878		132,102	
	Total TPL Collections	$	1,020,088		$	1,304,425		$	8,951,283		$	7,463,899	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	80,535		$	26,930		$	404,817		$	377,384		
LTC	202,169		123,251		1,026,241		644,346		
KidsCare	-		5,422		976		26,362		
Total Expenditure Offsets	$	282,704		$	155,603		$	1,432,034		$	1,048,092		

FY 17 Total		
Note 2:	Authorized Positions	1,141.2		
	Actual Positions as of April 30, 2017	1,058.0		

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2016	$	1,933,160	
	Revenues	5,745,481	
	Transfers-In	 	2,015,827 	
	Total Revenues	 	7,761,308 	
	Expenditures	5,241,692	
	Transfers-out	 	2,035,461 	
	Total Expenditures	 	7,277,153 	
	Ending Balance April 30, 2017	  $	2,417,314 	

Of the $2,417,314 ending balance, $1,023,073 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through April 2017.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.
Schedule of Outstanding Liabilities As of April 30, 2017
Description	Amount

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

Type

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of April 30, 2017 Expenditures

State Match	Federal	Total

DSH Voluntary	$	2,567,113	$	5,463,695	$	8,030,808	
GME Voluntary	32,189,146	70,516,994	102,706,140	
Safety Net Care Pool	17,657,000	39,578,110	57,235,110	

Total Voluntary Political Subdivision Program Expenditure $

52,413,258	$

115,558,800    $

167,972,058

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

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 April 30, 2017		
	Expenditures		
	Expenditure						Projected	
	Plan YTD		Expenditures YTD		Variance YTD		Annual Expenditures	

AHCCCS Operating CHIP Fund	
$	2,341,200		
$	-		
$	2,341,200		
$	3,511,900	
DES Eligibility CHIP Fund	2,731,400		129,309		2,602,091		3,511,800	
KidsCare Services CHIP Fund	44,884,600		15,278,539		29,606,061		53,962,800	
KidsCare AHCCCS Premiums	6,973,300		1,432,070		5,541,230		9,252,000	
Total KidsCare CHIP Type 3 Appropriation Expenditures	$	56,930,500		$	16,839,918		$	40,090,582		$	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 April 30, 2017	
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	286,919,278	284,617,214	291,611,661	288,440,222	0	0	2,884,208,516	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	7,129,252	0	0	7,129,252	
CAPITATION - LTC	190,311,536	204,030,120	191,838,793	196,146,010	209,487,257	202,049,311	197,378,148	209,839,656	199,019,378	202,137,892	0	0	2,002,238,102	
MENTAL HEALTH - CHILD	0	0	92,798	40,826,707	39,495,084	39,842,165	25,864,885	27,609,357	27,742,870	27,649,298	0	0	229,123,163	
MENTAL HEALTH - ADULT	0	0	4,710	413,272	837,527	996,821	485,827	811,923	947,569	977,247	0	0	5,474,895	
MENTAL HEALTH - GENERAL	0	0	47,481	13,777,916	38,472,152	38,742,203	12,163,646	12,856,359	12,974,671	12,937,767	0	0	141,972,194	
MENTAL HEALTH - CMDP	0	0	0	0	0	122,513	14,160,067	13,895,319	13,587,988	13,421,352	0	0	55,187,238	
MENTAL HEALTH - DD	0	0	0	0	0	11,832	3,034,462	4,031,001	4,073,316	4,191,142	0	0	15,341,753	
CHILDREN'S REHAB SERVICES	5,498,579	5,487,093	5,486,973	5,722,113	5,724,020	5,710,536	5,767,013	5,771,027	5,772,457	6,180,199	0	0	57,120,009	
FEE FOR SERVICE - ACUTE	43,169,220	49,076,411	38,450,549	33,852,478	42,186,889	38,478,867	33,536,590	45,607,298	50,958,719	37,649,869	0	0	412,966,889	
FFS - PRIOR QUARTER COVERAGE	399,183	701,172	353,914	449,400	558,100	496,870	515,193	523,285	598,776	696,660	0	0	5,292,553	
EMERGENCY SERVICES - FEDERAL	4,723,538	6,876,303	5,487,551	5,245,641	6,844,880	4,467,826	4,177,346	5,200,704	6,814,164	5,235,220	0	0	55,073,174	
FFS MEDICAID IN PUBLIC SCHOOLS	334,212	144,833	272,818	386,199	709,765	605,747	297,095	401,722	810,165	486,907	0	0	4,449,462	
STATE ONLY TRBHA FFS	0	12,155	22,043	8,636	4,898	0	0	13,879	1,316	0	0	0	62,926	
QMB - FEE FOR SERVICE	400,115	462,259	326,723	359,000	531,370	353,079	365,354	486,176	584,922	437,844	0	0	4,306,842	
INPATIENT INMATES FFS	125,819	53,097	229,997	169,499	209,214	227,846	319,020	200,028	126,222	123,441	0	0	1,784,184	
FFS TRBHA FEE FOR SERVICE	1,636,296	6,817,558	5,048,877	5,967,130	9,664,772	6,557,074	6,317,784	9,031,965	10,595,549	8,722,504	0	0	70,359,507	
PIMA COUNTY INMATES FFS	1,278	26,237	2,537	16,174	1,551	17,023	33,891	4,254	3,194	2,060	0	0	108,199	
MARICOPA CTY INMATES FFS	22,177	38,629	14,576	29,601	80,815	53,553	30,364	58,189	25,995	37,919	0	0	391,816	
MOHAVE COUNTY INMATES FFS	31	8,322	0	0	0	0	0	167	0	2,984	0	0	11,505	
PINAL COUNTY INMATES FFS	4,630	3,154	-3,803	0	136	339	-62	0	0	0	0	0	4,395	
FEE FOR SERVICE - LTC	9,673,620	11,818,762	10,004,476	9,333,076	11,165,207	10,203,811	9,384,275	10,683,278	12,748,002	9,747,538	0	0	104,762,044	
LFFS - PRIOR QUARTER COVERAGE	25,539	27,090	12,241	20,809	12,995	21,149	20,276	31,240	8,769	67,770	0	0	247,878	
COCONINO COUNTY INMATES LTC FFS	0	0	0	436	53	0	5,326	332	0	0	0	0	6,148	
INPATIENT INMATES LTC FFS	160	0	0	0	0	0	0	0	0	0	0	0	160	
MARICOPA CTY INMATES LTC FFS	0	0	0	0	279	4,800	0	0	57	0	0	0	5,136	
LFFS MEDICAID IN PUBLIC SCHOOLS	828,652	474,874	685,238	912,730	1,643,386	1,363,964	916,125	1,049,967	2,084,312	1,675,026	0	0	11,634,274	
REINSURANCE - ACUTE	10,931,804	9,903,096	8,491,782	14,533,814	7,715,454	9,779,160	8,327,159	10,840,423	11,365,535	8,832,910	0	0	100,721,137	
REINSURANCE - LTC	4,967,043	5,508,763	5,025,290	6,016,593	4,491,726	3,989,491	2,972,427	2,652,623	2,673,302	2,617,998	0	0	40,915,256	
SMIB - ACUTE	13,288,395	13,803,812	14,079,809	14,129,644	14,330,128	14,490,148	16,253,860	16,413,504	16,658,668	17,982,170	0	0	151,430,139	
HIB - ACUTE	361,563	411,610	422,087	466,526	462,666	487,547	488,373	500,496	492,404	528,156	0	0	4,621,428	
Q1	2,222,029	2,257,441	2,298,793	2,278,279	2,348,519	2,380,274	2,522,242	2,484,010	2,225,693	2,521,966	0	0	23,539,244	
SMIB - LTC	3,328,913	3,313,965	3,329,893	3,308,977	3,330,340	3,335,593	3,666,808	3,642,643	3,638,137	3,664,301	0	0	34,559,569	
HIB - LTC	283,717	285,570	285,293	289,510	282,009	281,043	290,103	286,466	284,140	279,971	0	0	2,847,822	
KidsCare - MENTAL HEALTH	0	0	0	0	325,271	344,109	0	0	0	0	0	0	669,380	
SUBTOTAL	571,193,827	599,354,227	572,373,635	638,812,233	683,577,476	714,691,884	636,212,874	669,544,504	678,427,949	664,377,582	0	0	6,428,566,190	

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	219,094,843	218,573,577	217,037,620	213,605,883	0	0	2,173,644,279	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	1,773,829	0	0	1,773,829	
MENTAL HEALTH - CHILD	0	0	0	7,318	0	0	5,299	4,777	4,299	3,690	0	0	25,384	
MENTAL HEALTH - ADULT	0	0	9,812	378,170	0	8,463	515,039	783,190	1,170,688	1,232,517	0	0	4,097,880	
MENTAL HEALTH - GENERAL	0	0	112,658	21,890,514	0	152,235	22,647,652	23,879,213	23,997,368	23,742,113	0	0	116,421,752	
MENTAL HEALTH - CMDP	0	0	0	0	0	0	1,117	725	725	925	0	0	3,491	
CHILDREN'S REHAB SERVICES	24,810	23,856	23,856	22,815	21,864	21,389	18,289	18,770	18,770	21,504	0	0	215,923	
FEE FOR SERVICE - ACUTE	30,892,242	33,585,002	26,203,618	24,327,724	29,526,359	27,383,554	25,175,883	30,811,052	34,467,965	27,255,282	0	0	289,628,680	
FFS - PRIOR QUARTER COVERAGE	626,645	888,463	903,725	769,131	981,486	808,163	633,971	1,038,440	1,221,302	991,317	0	0	8,862,643	
FFS - PRESUMPTIVE ELIGIBILITY	0	576	0	348	0	0	550	0	0	0	0	0	1,475	
EMERGENCY SERVICES - FEDERAL	2,005,165	2,692,463	2,628,341	2,580,854	3,218,819	2,435,868	2,469,182	2,981,868	3,540,254	2,741,415	0	0	27,294,229	
FEDERAL ESP CHRONIC SERVICES	0	0	0	0	0	0	6,982	0	0	0	0	0	6,982	
FFS MEDICAID IN PUBLIC SCHOOLS	935	797	636	479	704	522	1,851	772	1,188	792	0	0	8,677	
INPATIENT INMATES FFS	802,511	1,152,396	1,098,452	742,481	527,347	561,320	899,703	700,314	633,109	710,797	0	0	7,828,432	
FFS TRBHA FEE FOR SERVICE	668,712	3,783,524	2,819,057	3,584,362	4,058,941	3,430,687	3,062,117	5,519,274	6,772,716	5,163,196	0	0	38,862,586	
STATE ONLY TRBHA FFS	11,429	35,462	16,328	45,718	31,474	1,633	14,695	6,186	8,715	3,266	0	0	174,906	
GRAHAM COUNTY INMATES FFS	5,378	0	0	194	0	0	-194	0	0	0	0	0	5,378	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	0	0	935	159	2,251	0	0	0	3,345	
PINAL COUNTY INMATES FFS	12,241	42,848	1,220	0	39,116	30	0	0	1,190	8,329	0	0	104,973	
PIMA COUNTY INMATES FFS	17,640	22,452	328	77,666	35,488	17,393	21,677	15,175	49,868	26,339	0	0	284,025	
MARICOPA CTY INMATES FFS	136,056	149,042	84,034	194,257	148,296	283,764	188,348	166,222	211,345	159,189	0	0	1,720,555	
COCONINO COUNTY INMATES FFS	3,420	-3,257	184	0	4,937	0	0	0	7	0	0	0	5,292	
MOHAVE COUNTY INMATES FFS	962	0	0	0	103	0	0	0	0	8,712	0	0	9,776	
COCHISE COUNTY INMATES LTC FFS	0	57	0	0	0	0	0	0	166	0	0	0	223	
REINSURANCE - ACUTE	3,834,787	4,856,893	4,271,544	5,421,175	4,319,577	4,761,721	2,983,387	4,284,397	2,573,728	4,481,428	0	0	41,788,635	
SMIB - ACUTE	5,139,071	5,095,292	5,027,067	4,882,841	4,731,222	4,730,634	4,924,286	4,969,311	4,858,855	3,695,167	0	0	48,053,745	
HIB - ACUTE	5,630	6,904	5,363	5,137	4,274	5,733	4,935	9,468	7,762	5,781	0	0	60,989	
SUBTOTAL	257,141,258	256,774,362	249,496,397	280,617,638	263,085,161	295,128,469	282,670,548	293,762,890	296,579,890	285,631,471	0	0	2,760,888,084	

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	34,127,342	33,954,707	34,329,737	34,656,648	0	0	339,244,736	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	2,773,504	0	0	2,773,504	
MENTAL HEALTH - CHILD	0	0	0	55	0	0	0	0	0	12	0	0	68	
MENTAL HEALTH - ADULT	0	0	6	15,536	0	48	26,409	57,051	57,388	84,633	0	0	241,070	
MENTAL HEALTH - GENERAL	0	0	15,318	4,075,343	0	29,953	4,253,662	4,473,216	4,512,748	4,474,669	0	0	21,834,909	
CHILDREN'S REHAB SERVICES	1,431	1,431	1,431	1,901	1,901	1,426	963	963	1,444	2,000	0	0	14,892	
FEE FOR SERVICE - ACUTE	2,287,256	2,691,862	2,142,231	1,981,630	2,199,736	2,072,337	1,962,984	2,509,778	2,798,883	2,137,376	0	0	22,784,073	
FFS - PRIOR QUARTER COVERAGE	202,656	242,552	172,172	168,385	251,444	168,159	156,412	185,075	294,992	275,455	0	0	2,117,300	
EMERGENCY SERVICES - FEDERAL	3,157,734	4,543,147	3,298,138	3,345,340	4,224,989	3,425,218	3,728,688	3,619,005	5,017,046	3,886,326	0	0	38,245,631	
FFS MEDICAID IN PUBLIC SCHOOLS	0	143	122	154	155	209	117	150	62	286	0	0	1,398	
INPATIENT INMATES FFS	47,079	7,086	51,595	22,751	37,922	31,158	13,896	14,549	11,516	6,104	0	0	243,655	
STATE ONLY TRBHA FFS	0	0	0	2,449	0	0	0	6,786	1,633	2,449	0	0	13,318	
FFS TRBHA FEE FOR SERVICE	21,432	99,702	78,173	156,029	165,931	129,909	117,936	149,823	162,431	73,542	0	0	1,154,908	
PINAL COUNTY INMATES FFS	0	0	0	0	0	0	0	0	0	10	0	0	10	
PIMA COUNTY INMATES FFS	0	0	0	0	0	0	0	0	1,001	0	0	0	1,001	
MARICOPA CTY INMATES FFS	0	8,584	0	8,868	0	4,324	0	0	0	285	0	0	22,062	
REINSURANCE - ACUTE	394,053	1,131,954	693,714	710,923	877,023	572,747	343,615	510,239	487,083	692,497	0	0	6,413,848	
SMIB - ACUTE	487	365	0	365	0	122	0	0	0	378	0	0	1,717	
	38,639,830	40,424,404	38,251,198	43,879,922	41,037,088	45,920,155	44,732,024	45,481,342	47,675,963	49,066,174	0	0	435,108,100	
	866,974,915	896,552,993	860,121,229	963,309,794	987,699,724	1,055,740,508	963,615,445	1,008,788,737	1,022,683,802	999,075,228	0	0	9,624,562,373	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - CHILD	0	0	2	5,147	0	0	0	-57	-63	-116	0	0	4,913	
MENTAL HEALTH - ADULT	0	0	0	0	0	0	0	0	1,871	0	0	0	1,871	
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	1,945,235	2,024,840	2,255,866	2,561,353	0	0	13,083,393	
KidsCare - FEE FOR SERVICE	0	230	1,062	10,448	32,270	38,910	43,842	29,601	37,625	38,654	0	0	232,643	
KidsCare - MENTAL HEALTH	0	0	0	208,753	0	-86	485,905	542,155	606,775	704,079	0	0	2,547,580	
KidsCare - REINSURANCE	82,674	199	63,656	150	0	0	30	0	47,722	115,216	0	0	309,647	
KidsCare - CHILD REHAB SERVICES	0	0	0	0	1,426	1,901	1,444	1,444	1,925	2,500	0	0	10,640	

188,498	60,485	517,734	1,093,134	1,346,936	1,536,343	2,476,457	2,597,983	2,951,721	3,421,686	0	0	16,190,978	

TOTAL TITLE XXI

867,163,413	896,613,478	860,638,963	964,402,928	989,046,661	1,057,276,850	966,091,902	1,011,386,719	1,025,635,523	1,002,496,914	0	0	9,640,753,351	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017	
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	948.70	1,526.47	1,568.46	1,253.40	0.00	0.00		7,000.83		
1002	TANF 01-05 M & F WIT	0.00	0.00	30.83	115.80	0.00	0.00	232.58	232.58	456.30	463.76	0.00	0.00		1,531.85		
1003	TANF 06-13 M & F WIT	0.00	-2.43	0.00	841.21	0.00	40.46	192.16	231.88	578.65	578.65	0.00	0.00		2,460.58		
1004	TANF 14-20 MALE WITH	330.49	330.49	330.49	321.29	321.29	321.29	322.76	322.76	307.60	166.11	0.00	0.00		3,074.57		
1005	TANF 14-20 FEMALE WI	4,171.93	2,017.48	2,017.48	1,949.42	1,949.42	1,949.42	664.76	2,253.61	2,253.61	295.03	0.00	0.00		19,522.16		
1006	TANF 21-44 MALE WITH	46,322.50	44,791.85	45,967.12	48,079.53	47,522.03	47,061.91	38,947.61	32,494.21	33,928.16	33,251.50	0.00	0.00		418,366.42		
1007	TANF 21-44 FEMALE WI	95,394.39	105,867.62	103,594.71	101,741.15	92,114.31	88,694.68	82,350.17	89,688.83	86,068.00	94,621.84	0.00	0.00		940,135.70		
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	108,880.19	113,791.21	106,660.85	99,366.14	0.00	0.00		1,292,572.84		
1009	TANF 65+ M & F WITH	49,195.35	58,493.70	60,090.27	59,039.19	54,968.63	58,038.42	46,812.51	48,868.34	43,651.21	39,574.66	0.00	0.00		518,732.28		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	7,370.41	1,767.37	1,187.42	0.00	9,198.03	-9,198.03	0.00	0.00		10,325.20		
100B	TANF 01-05 M & F WIT	0.00	0.00	40.03	0.00	0.00	0.00	0.00	0.00	3.56	0.00	0.00	0.00		43.59		
100C	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	16.00	0.00	0.00	0.00	0.00	0.00		16.00		
100F	TANF 21-44 MALE WITH	2,174.21	932.26	242.39	398.64	159.78	6,286.41	857.76	192.72	933.23	369.69	0.00	0.00		12,547.09		
100G	TANF 21-44 FEMALE WI	979.52	875.88	956.18	2,475.86	4,188.11	2,247.92	1,641.53	5,171.86	879.96	2,339.99	0.00	0.00		21,756.81		
100H	TANF 44-64 M & F WIT	2,819.97	2,677.17	1,834.18	1,521.71	790.81	3,372.56	3,070.43	1,584.88	2,591.21	2,045.39	0.00	0.00		22,308.31		
100J	TANF 65+ M & F WITH	1,265.56	285.44	454.14	2,354.78	606.53	4,192.00	1,564.55	395.01	745.57	1,201.16	0.00	0.00		13,064.74		
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	5,522,465.34	5,704,427.34	5,880,297.44	5,895,668.93	0.00	0.00		57,639,966.79		
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	2,449,866.47	2,433,786.02	2,472,987.15	2,529,914.76	0.00	0.00		23,806,096.03		
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	3,911,996.69	3,987,080.06	4,002,141.23	4,048,456.19	0.00	0.00		38,682,289.48		
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	1,574,461.67	1,611,527.66	1,540,071.19	1,542,062.14	0.00	0.00		15,622,245.75		
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	3,138,102.41	3,172,343.50	3,092,037.27	3,120,476.22	0.00	0.00		31,411,745.86		
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	4,712,956.47	4,773,717.72	4,783,099.14	4,740,718.70	0.00	0.00		47,647,161.44		
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	23,037,568.69	23,346,053.97	23,420,398.72	23,365,433.02	0.00	0.00		232,032,253.90		
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	9,827,960.64	10,020,498.24	10,052,209.45	9,983,063.36	0.00	0.00		98,227,715.75		
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	34,417.21	35,489.31	37,481.67	36,184.29	0.00	0.00		370,439.43		
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	1,954,247.03	1,223,255.31	1,501,212.89	1,310,561.54	0.00	0.00		11,870,480.64		
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	17,467.31	19,051.59	26,988.69	17,085.26	0.00	0.00		237,956.30		
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	15,870.40	11,701.70	19,162.62	16,701.99	0.00	0.00		190,114.58		
101D	TANF 14-20 MALE NON-	40,214.75	26,404.71	25,064.46	17,702.82	15,421.37	23,296.40	19,323.30	7,649.89	21,634.37	19,403.04	0.00	0.00		216,115.11		
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	31,476.13	27,003.10	48,477.35	33,240.68	0.00	0.00		390,901.83		
101F	TANF 21-44 MALE NON-	332,694.14	181,172.60	142,480.58	122,564.13	125,386.70	122,533.93	158,648.87	110,602.36	138,297.71	118,516.31	0.00	0.00		1,552,897.33		
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	404,104.92	337,912.91	420,205.17	381,275.53	0.00	0.00		4,565,679.68		
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	168,769.28	145,340.58	174,367.37	146,039.96	0.00	0.00		1,839,729.22		
101J	TANF 65+ N & F NON-M	2,006.75	449.69	1,257.99	1,285.39	1,332.45	1,160.97	661.77	566.77	460.36	249.75	0.00	0.00		9,431.89		
1026	TANF 21-44 MALE WITH	9,851.45	9,746.05	9,204.20	12,275.50	9,559.38	11,275.00	12,018.59	15,249.34	15,857.11	15,336.57	0.00	0.00		120,373.19		
1027	TANF 21-44 FEMALE WI	37,746.13	34,109.50	35,005.01	42,789.00	43,224.39	55,840.93	53,507.38	55,699.77	54,335.48	58,504.66	0.00	0.00		470,762.25		

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	52,775.79	61,710.05	70,504.91	70,615.31	0.00	0.00		507,069.01		
1029	TANF 65+ M & F WITH	11,125.03	11,154.44	10,081.40	13,757.61	16,159.29	23,545.55	18,949.08	19,510.21	19,044.88	19,865.50	0.00	0.00		163,192.99		
102F	TANF 21-44 MALE WITH	586.66	47.08	0.00	0.00	79.00	38.55	0.00	0.00	127.42	0.00	0.00	0.00		878.71		
102G	TANF 21-44 FEMALE WI	0.00	420.35	241.90	946.01	0.00	0.00	77.98	286.89	190.44	603.58	0.00	0.00		2,767.15		
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	71.36	0.00	0.00		6,306.18		
102J	TANF 65+ M & F WITH	0.00	0.00	403.46	1,811.12	202.18	1,069.19	0.00	0.00	1,024.30	118.93	0.00	0.00		4,629.18		
2100	SSI AGED WITH MEDIC A	842,955.42	868,175.55	898,652.88	874,208.91	889,564.98	997,567.98	888,162.12	891,065.19	893,664.81	875,819.79	0.00	0.00		8,919,837.63		
210Z	SSI AGED WITH MEDIC A	28,411.56	21,306.88	29,919.56	26,997.93	33,316.23	20,125.60	21,193.72	29,180.53	26,951.05	19,571.83	0.00	0.00		256,974.89		
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	5,369,227.33	5,450,439.45	5,367,874.51	5,398,745.50	0.00	0.00		52,923,425.15		
211Z	SSI AGED NON-MEDIC AR	127,183.08	147,235.09	133,695.88	151,331.35	125,347.45	140,553.26	153,633.36	138,231.72	185,804.70	135,437.40	0.00	0.00		1,438,453.29		
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	6,021,251.03	6,253,546.30	7,640,672.96	7,635,670.18	0.00	0.00		61,638,629.88		
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	3,411.51	2,302.74	3,133.72	2,409.43	0.00	0.00		43,228.97		
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	2,485,392.53	2,532,461.22	2,512,168.72	2,493,852.19	0.00	0.00		25,184,381.45		
220Z	SSI DISABLED WITH M E	17,675.35	12,942.73	15,910.05	32,865.45	38,733.87	79,796.07	64,447.43	87,602.31	147,304.90	76,734.13	0.00	0.00		574,012.29		
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	61,155,071.07	61,877,746.37	61,691,029.75	62,082,626.64	0.00	0.00		614,062,424.61		
221Z	SSI DISABLED NON-ME D	433,439.79	419,148.90	538,099.82	494,840.97	471,406.12	446,507.00	620,204.35	685,412.92	624,883.80	605,667.89	0.00	0.00		5,339,611.56		
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	17,004,733.28	17,542,704.01	20,347,549.76	20,663,820.21	0.00	0.00		172,944,985.77		
222Z	SSI DISABLED WITH Q M	3,347.64	4,509.15	6,680.06	8,799.36	18,045.88	28,908.73	38,477.57	28,839.70	36,160.43	41,406.56	0.00	0.00		215,175.08		
2300	SSI BLIND WITH MEDIC	6,019.11	6,344.44	6,155.38	6,088.34	5,983.02	6,897.85	7,827.35	7,686.03	7,712.91	7,956.83	0.00	0.00		68,671.26		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	290.29	0.00	43.00	141.64	0.00	0.00	0.00		474.93		
2310	SSI BLIND NON-MEDIC A	416,766.24	425,608.52	424,789.82	448,406.94	455,856.96	531,029.94	455,972.23	460,180.32	468,949.33	476,653.18	0.00	0.00		4,564,213.48		
231Z	SSI BLIND NON-MEDIC A	8,216.96	9,934.43	3,994.90	1,156.13	9,959.35	4,956.96	4,028.67	3,895.07	13,398.54	14,570.44	0.00	0.00		74,111.45		
2320	SSI BLIND WITH QMB	48,973.62	48,961.67	49,379.89	45,910.44	31,177.50	52,726.05	45,767.09	46,516.72	46,816.60	49,753.50	0.00	0.00		465,983.08		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	7.29	0.00	0.00	0.00	0.00	93.67	0.00	0.00	0.00		100.96		
4301	SOBRA CHILD <1 M & F	0.00	0.00	296.24	2,761.71	2,616.24	3,414.91	2,792.94	1,941.12	1,841.22	1,841.22	0.00	0.00		17,505.60		
4302	SOBRA CHILD 01-05 M	335.78	335.78	539.50	1,018.73	1,096.85	1,899.47	2,368.68	3,853.99	5,299.56	6,047.43	0.00	0.00		22,795.77		
4303	SOBRA CHILD 06-13 M	1,544.93	1,519.86	1,659.86	2,303.36	2,801.95	1,628.46	3,265.29	4,380.77	5,644.75	6,537.06	0.00	0.00		31,286.29		
4304	SOBRA CHILD 14-20 MA	453.68	315.45	353.85	728.39	1,278.19	1,000.27	1,557.83	1,891.35	2,176.96	2,364.26	0.00	0.00		12,120.23		
4305	SOBRA CHILD 14-20 FE	2,687.14	3,209.63	3,132.73	3,721.21	2,857.51	3,080.11	2,813.44	2,347.30	661.71	1,423.43	0.00	0.00		25,934.21		
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	120.57	0.00	99.55	59.79	0.00	0.00		99.12		
430C	SOBRA CHILD 06-13 M	19.65	0.00	91.02	341.04	95.52	-303.68	0.00	41.33	-4.29	134.44	0.00	0.00		415.03		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	107.04	258.87	252.79	0.00	0.00	151.05	0.00	87.50	0.00	0.00		857.25		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	142.68	126.48	0.00	0.00	0.00	0.00	0.00	215.64	0.00	0.00		484.80		
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	18,102,974.43	17,558,427.51	17,420,419.36	17,155,701.36	0.00	0.00		186,399,778.84		
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	23,702,627.58	23,735,754.92	23,661,851.93	23,441,535.68	0.00	0.00		242,110,876.29		

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	30,379,594.10	30,290,604.03	30,180,016.89	29,961,155.36	0.00	0.00		308,326,841.25		
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	9,841,444.78	9,915,454.08	10,070,462.66	10,010,332.77	0.00	0.00		99,320,661.90		
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	15,453,046.13	15,564,339.68	15,756,307.61	15,654,214.78	0.00	0.00		154,030,523.18		
431A	SOBRA CHILD < 1 M &	1,177,252.46	693,970.63	867,096.37	887,403.26	188,046.92	124,120.40	464,171.64	132,161.10	384,105.66	298,882.18	0.00	0.00		5,217,210.62		
431B	SOBRA CHILD 01-05 M	566,517.45	313,543.99	297,175.19	272,088.67	197,833.20	278,397.78	341,064.71	235,020.85	285,896.22	239,739.32	0.00	0.00		3,027,277.38		
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	306,841.86	231,139.33	274,788.94	219,219.23	0.00	0.00		3,103,787.95		
431D	SOBRA CHILD 14-20 MA	521,496.21	233,778.90	223,364.34	187,361.77	159,838.31	161,002.45	212,047.27	163,222.77	182,927.59	159,275.45	0.00	0.00		2,204,315.06		
431E	SOBRA CHILD 14-20 FE	561,544.85	276,156.48	306,650.61	249,415.69	203,761.63	211,908.27	262,360.41	201,555.85	246,429.38	207,845.53	0.00	0.00		2,727,628.70		
4321	SOBRA CHILD <1 M & F	0.00	507.63	-507.63	456.79	456.79	456.79	922.56	460.39	460.39	460.39	0.00	0.00		3,674.10		
4322	SOBRA CHILD 01-05 M	230.53	225.94	140.29	115.09	115.09	189.42	115.59	105.19	115.59	0.00	0.00	0.00		1,352.73		
4323	SOBRA CHILD 06-13 M	0.00	-110.88	0.00	110.64	115.09	70.14	0.00	0.00	0.00	103.70	0.00	0.00		288.69		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	154.46	0.00	45.62	0.00	0.00	0.00	158.73	0.00	0.00		358.81		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	841.21	841.21	841.21	2,236.28	2,236.28	2,236.28	3,142.91	0.00	0.00		12,375.38		
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	504.99	0.00	156.81	0.00	0.00	0.00		1,279.91		
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	24,167.99	28,269.73	27,584.97	28,332.54	0.00	0.00		265,513.98		
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	5,467.99	5,471.33	5,623.20	6,164.24	0.00	0.00		51,355.80		
500E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	521.94	0.00	0.00	0.00	0.00	215.24	0.00	0.00	0.00		737.18		
500G	SOBRA PREG 21-44 FE M	621.37	527.22	421.15	1,521.75	1,483.48	859.89	2,458.06	1,817.74	1,239.36	2,707.22	0.00	0.00		13,657.24		
500H	SOBRA PREG 45-64 FE M	242.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	241.69	0.00	0.00	0.00		483.95		
5013	SOBRA PREG 09-13 FE M	1,407.36	911.78	1,029.83	909.86	905.20	974.43	1,115.96	671.41	1,018.18	1,470.32	0.00	0.00		10,414.33		
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	926,941.64	932,290.12	944,999.92	942,363.48	0.00	0.00		10,207,530.97		
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	5,006,426.01	5,037,181.72	5,030,486.97	5,113,382.66	0.00	0.00		52,984,946.48		
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	28,795.83	27,166.39	27,682.26	28,765.18	0.00	0.00		286,496.11		
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	54.59	0.00	0.00		88.05		
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	51,097.81	42,452.18	55,526.34	45,181.39	0.00	0.00		592,752.29		
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	243,036.02	201,067.83	259,035.35	198,521.40	0.00	0.00		2,557,533.69		
501H	SOBRA PREG 45-64 FE M	2,476.09	1,453.55	2,104.23	1,393.55	211.23	491.83	805.34	1,324.46	4,188.65	107.34	0.00	0.00		14,556.27		
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	36,569.46	36,344.75	35,874.90	33,849.14	0.00	0.00		257,488.67		
5028	SOBRA PREG 45-64 FE M	2,212.75	2,212.75	2,212.75	2,334.33	2,661.28	405.42	405.42	405.42	405.42	405.42	0.00	0.00		13,660.96		
502G	SOBRA PREG 21-44 FE M	163.64	246.72	144.97	283.10	71.88	145.54	0.00	483.76	0.00	0.00	0.00	0.00		1,539.61		
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	257,154,341.80	257,815,107.98	262,972,767.75	262,088,975.65	0.00	0.00		2,593,446,857.50		

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	1,874,936.71	1,678,045.58	1,742,410.54	1,442,984.93	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	24,896.52	18,034.99	37,695.04	49,631.15	0.00	0.00	

 
18,036,162.47	
378,004.09	

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9921	SSI W/O MEDICARE KI	190,093.86	236,566.90	146,178.87	184,526.83	178,796.57	217,366.98	165,442.30	150,340.49	85,726.94	137,627.71	0.00	0.00	1,692,667.45	

9950	C
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	
14,129,690.50	
11,390,451.48	
13,003,982.47	
10,952,510.94	
0.00	
0.00	
133,182,533.74	

SUBTOTAL:	
15,085,061.23	
17,195,121.06	
16,693,178.0	
1    16,241,090.55	
15,564,020.37	
15,626,488.24	
16,194,966.03	
13,236,872.54	
14,869,814.99	
12,582,754.73	
0.00	
0.00	
153,289,367.75	

3100	TRANSPLANT OPTION 1	49.50	49.50	49.50	49.50	33.00	33.00	16.50	16.50	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.50	49.50	49.50	49.50	33.00	33.00	16.50	16.50	0.00	0.00	0.00	0.00	

297.00	
297.00	

1106	TANF EXPANDED 21-44	282,644.01	293,807.76	299,501.69	277,014.62	268,149.29	275,700.50	214,241.54	191,700.71	183,997.02	167,723.42	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	649,986.58	582,957.77	511,646.09	477,454.90	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	1,389,917.05	1,323,913.19	1,237,046.19	1,167,042.31	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	417,074.12	387,446.57	369,983.80	347,511.91	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	4,824.21	5,167.10	6,037.89	3,214.96	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	15,897.55	23,254.42	6,700.61	16,191.25	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	23,646.74	13,114.86	17,467.43	21,842.76	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	10,426.11	7,395.41	12,696.95	4,316.05	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	1,800.06	1,684.70	1,685.22	1,244.11	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	10,864.67	8,754.66	7,938.92	7,300.12	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	88,087.11	83,498.52	79,918.25	78,440.65	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	516,423.59	514,918.55	500,565.76	496,412.58	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	5,181,886.23	5,177,540.49	5,199,695.22	5,158,027.81	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	19,995,512.30	20,072,393.94	20,105,209.70	20,015,586.25	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	12,073,525.04	12,092,042.86	12,103,933.46	11,989,774.37	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	33,922.10	34,374.15	37,595.90	36,377.90	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	56.89	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	1,997.18	1,751.25	2,166.04	3,896.35	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	10,644.96	8,416.14	11,599.08	6,727.59	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	153,055.71	128,919.24	166,988.15	121,215.74	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	291,512.58	290,957.48	340,282.93	275,155.03	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	222,060.27	189,305.19	213,567.39	178,663.01	0.00	0.00	
111J	TANF EXPANDED 65+
M&	8,779.85	4,133.27	202.65	2,951.63	315.38	804.86	840.80	1,312.45	1,116.38	1,080.46	0.00	0.00	
1125	TANF EXPANDED 14-20	0.00	2,212.75	0.00	0.00	0.00	0.00	-2,212.75	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	260,407.99	284,551.58	307,927.16	329,941.22	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	727,192.07	808,720.89	853,001.73	911,822.11	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	964,367.49	1,052,869.18	1,148,347.31	1,237,972.52	0.00	0.00	

2,454,480.56	
7,261,589.35	
14,962,816.69	
4,470,981.52	
46,025.91	
124,153.84	
211,195.85	
95,358.20	
1,345.52	
27,139.39	
133,017.26	
919,112.49	
5,309,545.58	
52,439,653.58	
198,835,036.07	
120,486,480.01	
365,702.07	
1,927.54	
8.90	
439.53	
34,441.06	
113,331.81	
1,531,478.44	
3,410,964.12	
2,165,164.66	
21,537.73	
0.00	
2,285,275.68	
6,546,631.94	
8,249,876.91	

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1129	TANF EXPANDED 65+
M&	168,961.75	179,353.58	184,855.77	216,186.79	257,449.40	314,120.09	337,638.85	387,633.92	437,680.29	455,079.14	0.00	0.00		2,938,959.58		
112F	TANF EXPANDED 21-44	1,973.32	1,569.61	1,040.20	922.45	232.14	627.15	135.08	1,597.18	458.48	1,645.36	0.00	0.00		10,200.97		
112G	TANF EXPANDED 21-44	1,409.59	2,117.93	729.03	577.31	276.98	1,857.64	595.28	4,690.51	5,552.88	3,070.26	0.00	0.00		20,877.41		
112H	TANF EXPANDED 45-64	6,149.15	3,315.72	5,472.86	2,754.61	1,419.99	4,864.61	12,430.61	4,056.36	1,547.75	1,289.39	0.00	0.00		43,301.05		
112J	TANF EXPANDED 65+
M&	2,268.02	1,088.62	6,118.42	3,220.68	1,119.22	125.85	1,124.27	2,208.11	1,984.55	912.27	0.00	0.00		20,170.01		
2400	SSI AGED EXPANDED WI	79,751.62	88,972.48	94,368.60	91,017.93	90,743.11	101,158.12	85,144.90	89,474.75	88,341.71	77,196.26	0.00	0.00		886,169.48		
240Z	SSI AGED EXPANDED WI	18,469.11	13,440.92	19,374.43	13,803.51	15,940.39	15,301.77	16,191.98	24,019.19	28,870.23	8,777.67	0.00	0.00		174,189.20		
2410	SSI AGED EXPANDED NO	113,134.36	107,329.50	100,424.49	104,189.94	96,726.54	159,654.45	97,478.92	101,472.26	94,943.89	96,201.93	0.00	0.00		1,071,556.28		
241Z	SSI AGED EXPANDED NO	5,881.63	3,345.40	5,620.33	5,022.54	10,604.36	4,682.55	10,973.87	3,143.25	5,609.63	2,417.92	0.00	0.00		57,301.48		
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	3,270,920.49	3,187,612.03	1,995,935.97	2,126,437.18	0.00	0.00		32,702,699.61		
242Z	SSI AGED EXPANDED WI	8,856.22	3,806.30	10,030.52	2,570.04	3,942.59	4,471.07	3,892.39	4,292.95	7,104.02	5,932.71	0.00	0.00		54,898.81		
2500	SSI BLIND EXPANDED W	140.23	140.23	140.23	132.06	132.06	132.06	132.08	167.67	167.67	167.67	0.00	0.00		1,451.96		
2520	SSI BLIND EXPANDED W	270.25	113.62	130.02	122.42	122.42	164.64	122.44	0.00	0.00	0.00	0.00	0.00		1,045.81		
2600	SSI DISABLED EXPAND E	254,582.86	222,372.65	227,664.21	204,981.08	183,819.53	195,144.58	183,000.18	196,101.57	177,980.16	163,679.40	0.00	0.00		2,009,326.22		
260Z	SSI DISABLED EXPAND E	10,892.09	7,541.46	10,094.76	34,308.17	34,711.64	42,168.34	71,232.06	84,828.64	60,844.02	70,947.84	0.00	0.00		427,569.02		
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	1,230,108.69	1,225,747.24	1,167,651.23	1,207,222.08	0.00	0.00		14,105,075.35		
261Z	SSI DISABLED EXPAND E	33,726.08	25,186.67	34,152.89	26,762.25	21,901.27	28,933.10	44,081.74	35,725.09	38,143.13	24,219.77	0.00	0.00		312,831.99		
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	7,964,122.67	7,915,610.63	5,204,608.75	5,328,359.04	0.00	0.00		78,205,138.25		
262Z	SSI DISABLED EXPAND E	3,880.96	3,944.92	4,241.27	7,596.05	8,545.54	16,312.05	19,735.25	28,416.63	24,870.54	19,311.95	0.00	0.00		136,855.16		
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	56,607,019.94	56,583,759.28	52,769,409.48	52,647,803.22	0.00	0.00		565,684,329.85		

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	

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	1,318,562.43	1,048,164.06	1,373,981.71	1,038,641.38	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	6,425.30	6,425.30	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	1,324,987.73	1,054,589.36	1,373,981.71	1,038,641.38	0.00	0.00	

 
12,649,716.99	
57,101.96	
6,274.24	
12,713,093.19	

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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	79.09	296.70	1,664.14	2,498.40	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	4,654.08	1,299.80	395.95	1,111.25	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	13,144.26	23,530.79	12,669.39	10,539.79	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	1,907.64	1,409.51	647.68	953.14	0.00	0.00	
350F	ADULT 40-100% MALE
2	780.79	0.00	1,767.39	0.00	961.21	1,818.24	565.79	915.52	944.19	394.77	0.00	0.00	
350G	ADULT 40-100% FEMAL E	321.93	523.21	450.54	0.00	572.62	6,442.73	1,827.92	1,421.46	152.33	1,259.23	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	8,643.79	3,384.62	7,283.31	4,664.37	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	435.22	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	2,804,170.55	2,847,155.07	2,881,475.81	2,920,868.66	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	3,021,504.28	3,064,899.08	3,070,144.13	3,103,601.18	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	10,403,380.07	10,605,150.67	10,519,002.71	10,586,796.21	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	8,747,646.97	8,819,474.23	8,777,783.16	8,851,686.15	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	20,530,281.26	20,725,865.23	20,593,619.83	20,477,040.40	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	8,972.53	7,064.28	8,370.08	9,486.09	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	90,121.81	79,426.76	127,217.69	75,699.07	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	110,154.36	103,161.58	120,799.86	93,085.12	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	597,311.00	470,941.68	640,925.78	350,579.69	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	482,266.88	350,362.28	480,587.86	325,684.57	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	1,129,371.71	752,451.27	978,509.90	676,159.51	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	3,690.44	1,349.18	960.77	4,047.54	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	1,603.45	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	479.35	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	1,850.83	2,353.98	1,878.80	314.74	0.00	0.00	
3529	ADULT 40-100% M&F 65	59.89	0.00	414.75	423.40	0.00	1,503.29	412.55	0.00	0.00	0.00	0.00	0.00	

 
19,112.77	
20,610.39	
233,453.88	
37,881.24	
8,147.90	
12,971.97	
42,063.91	
1,607.25	
27,241,153.65	
29,636,167.13	
102,042,920.30	
84,840,176.44	
201,965,178.61	
93,723.37	
1,029,615.94	
1,102,757.06	
4,985,214.67	
3,942,839.60	
8,621,655.36	
36,957.39	
9,052.14	
3,963.23	
27,076.71	
2,813.88	

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
352F	ADULT 40-100% MALE
2	0.00	239.80	517.47	77.79	314.81	0.00	0.00	0.00	1,092.35	0.00	0.00	0.00		2,242.22		
352G	ADULT 40-100% FEMAL E	0.00	0.00	360.43	0.00	0.00	0.00	3,745.69	0.00	0.00	0.00	0.00	0.00		4,106.12		
352H	ADULT 40-100% M&F 45	0.00	218.00	733.84	609.31	256.15	0.00	6,187.43	657.77	24.95	269.84	0.00	0.00		8,957.29		
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		
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	461.54	0.00	0.00		461.54		
3706	ADULT <40% EXP MAL E	13,532.14	18,941.00	17,216.81	24,670.37	19,392.65	9,537.39	7,386.49	12,582.30	13,788.64	13,473.98	0.00	0.00		150,521.77		
3707	ADULT <40% EXP FEM AL	8,594.39	14,900.87	5,263.02	6,423.65	7,134.62	2,389.39	2,314.27	5,357.75	3,397.48	4,443.01	0.00	0.00		60,218.45		
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	22,693.11	27,155.39	24,570.17	20,533.25	0.00	0.00		393,102.92		
3709	ADULT <40% EXP M&F 6	1,670.61	3,656.59	0.00	1,948.31	2,400.09	3,408.73	1,877.13	0.00	0.00	1,014.92	0.00	0.00		15,976.38		
370F	ADULT <40% EXP MAL E	23.96	2,730.39	1,914.79	11,055.11	6,234.81	4,229.76	5,166.53	3,838.87	13,081.80	7,177.50	0.00	0.00		55,453.52		
370G	ADULT <40% EXP FEM AL	5,014.07	87.20	856.03	464.77	936.45	1,487.75	565.78	1,166.87	1,998.55	1,898.33	0.00	0.00		14,475.80		
370H	ADULT <40% EXP M&F 4	41,292.32	3,366.20	7,910.98	6,020.21	697.07	1,392.78	4,157.73	3,112.73	4,811.22	5,570.41	0.00	0.00		78,331.65		
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	5,579,305.62	5,556,425.70	5,463,125.57	5,433,335.15	0.00	0.00		56,643,905.75		
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	4,948,153.93	4,946,243.96	4,852,023.79	4,827,651.33	0.00	0.00		50,029,722.92		
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	33,426,484.52	33,895,682.19	33,999,899.45	34,002,984.93	0.00	0.00		334,568,369.33		
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	20,537,669.50	20,900,038.31	21,025,052.59	21,044,108.64	0.00	0.00		204,927,965.82		
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	41,363,340.91	41,927,245.78	41,925,737.90	41,820,931.39	0.00	0.00		413,732,177.94		
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	24,949.47	14,570.83	24,078.03	25,853.97	0.00	0.00		240,392.74		
371D	ADULT <40% EXP MAL E	527,076.34	241,808.81	265,078.05	222,838.34	176,484.70	183,566.85	220,453.86	166,115.23	282,375.40	186,934.46	0.00	0.00		2,472,732.04		
371E	ADULT <40% EXP FEM AL	415,699.52	230,089.36	214,764.40	182,776.31	141,258.86	154,392.19	196,493.33	163,663.69	218,525.06	183,327.96	0.00	0.00		2,100,990.68		
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	2,497,616.45	1,941,038.91	2,392,766.34	1,740,168.11	0.00	0.00		22,693,460.92		
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	1,327,172.13	1,018,249.48	1,424,200.60	922,208.60	0.00	0.00		12,510,679.16		
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	2,250,577.95	1,690,009.24	2,129,684.82	1,549,668.47	0.00	0.00		20,338,893.09		
371J	ADULT <40% EXP M&F 6	0.00	1,906.05	554.43	0.00	0.00	5,406.48	0.00	2,699.58	0.00	674.59	0.00	0.00		11,241.13		
3724	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	294.84	458.64	0.00	0.00	0.00		753.48		
3726	ADULT <40% EXP MAL E	3,446.36	2,080.08	5,035.25	4,333.86	5,684.84	6,290.68	5,582.76	3,849.68	3,146.06	3,948.37	0.00	0.00		43,397.94		
3727	ADULT <40% EXP FEM AL	1,623.77	1,311.51	497.15	0.00	90.00	3,186.06	3,362.18	1,598.54	528.94	712.39	0.00	0.00		12,910.54		
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	4,274.28	7,482.61	3,240.55	4,259.04	0.00	0.00		55,552.10		
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		
372D	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	252.33	0.00	0.00	0.00	0.00		252.33		
372F	ADULT <40% EXP MAL E	1,504.22	452.54	22.53	1,613.88	2,418.90	4,535.06	713.49	3,823.30	928.72	1,622.53	0.00	0.00		17,635.17		
372G	ADULT <40% EXP FEM AL	675.81	218.00	0.00	0.00	494.70	2,765.25	500.50	891.42	715.54	418.99	0.00	0.00		6,680.21		
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	4,453.07	289.11	2,082.86	1,899.13	0.00	0.00		20,678.83		
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	160,407,635.27	160,156,250.10	162,038,408.06	159,302,020.71	0.00	0.00		1,587,172,942.33		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9935	BIRTH SUPP PAYMENT A	287,840.28	262,331.58	201,591.00	278,823.61	241,562.08	333,303.14	273,796.19	261,906.19	308,945.20	208,492.77	0.00	0.00	2,658,592.04	
9937	BIRTH SUPP PAYMENT A	598,513.41	678,326.85	685,208.54	529,944.88	539,404.91	558,552.39	481,403.56	517,072.33	546,875.43	408,924.98	0.00	0.00	5,544,227.28	
SUBTOTAL	:	886,353.69	940,658.43	886,799.54	808,768.49	780,966.99	891,855.53	755,199.75	778,978.52	855,820.63	617,417.75	0.00	0.00	8,202,819.32	

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	
3906	NEWLY ELIGIBLE MALE	4,896.46	3,633.24	2,121.67	3,220.46	569.79	2,399.56	1,661.30	1,770.86	610.04	852.80	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	2,726.25	3,437.55	1,624.70	1,969.81	1,586.87	2,479.22	1,403.57	1,250.32	1,554.28	2,886.76	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	37,160.26	34,294.07	28,140.59	27,537.99	23,080.17	32,646.74	23,773.84	24,137.03	21,332.10	25,818.97	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	2,216.27	2,338.07	4,878.84	3,839.81	4,250.06	6,298.52	2,889.93	2,340.62	2,298.87	2,940.19	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	-236.15	149.13	1,045.25	0.00	798.46	256.94	170.87	191.53	334.58	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1,662.50	511.99	535.13	0.00	0.00	102.15	449.66	250.51	308.66	239.21	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	4,162.37	385.56	3,911.38	2,087.92	273.38	618.88	1,578.52	851.27	1,948.26	10,678.69	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	11.02	1,310.04	182.13	0.00	0.00	0.00	6,119.08	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	993,353.20	1,010,781.92	1,036,935.63	1,098,477.54	1,098,114.35	1,301,276.48	1,181,640.12	1,215,823.59	1,237,999.49	1,275,349.55	0.00	0.00	
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	1,348,376.36	1,360,941.36	1,384,043.67	1,455,929.83	0.00	0.00	
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	7,745,163.79	7,785,800.46	7,784,991.30	7,955,081.32	0.00	0.00	
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	10,692,049.53	10,687,900.82	10,648,844.67	10,851,837.68	0.00	0.00	
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	11,518,550.48	11,543,772.03	11,571,192.87	11,867,174.74	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	5,613.74	6,337.38	4,809.99	6,649.62	5,089.92	9,131.94	8,278.22	7,101.76	6,646.31	7,780.66	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	53,561.17	31,001.51	35,796.42	26,630.20	17,981.79	22,666.66	22,283.26	27,239.65	41,317.68	27,780.27	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	73,185.98	37,874.44	31,818.36	32,250.20	35,979.77	32,467.58	33,161.43	33,115.44	49,206.39	25,283.71	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	544,427.88	264,421.24	269,746.28	231,138.23	173,322.60	264,546.70	304,965.00	244,663.72	341,757.75	226,550.90	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	645,279.14	319,627.95	351,282.99	302,318.16	244,905.13	293,343.48	364,603.76	295,043.58	396,226.63	287,545.33	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	535,632.09	262,888.10	263,717.14	275,715.62	210,221.06	318,108.73	388,870.87	298,140.44	380,905.91	252,222.88	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	3,073.64	1,366.00	341.50	0.00	0.00	341.73	0.00	0.00	0.00	0.00	0.00	
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	
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	665.04	0.00	0.00	253.40	0.00	0.00	219.20	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	1,094.45	1,114.10	2,616.76	337.60	0.00	682.52	412.85	0.00	717.08	526.95	0.00	0.00	
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	
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	
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	87.11	0.00	0.00	0.00	0.00	0.00	154.33	0.00	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.00	384.57	813.42	1,140.83	0.00	0.00	330.71	0.00	0.00	150.04	0.00	0.00	
SUBTOTAL:	32,061,907.41	31,054,674.03	31,281,763.8	32,889,729.90	32,790,707.97	39,107,431.56	33,647,160.95	33,530,314.33	33,872,467.02	34,276,965.06	0.00	0.00	

 
129.91	
21,736.18	
20,919.33	
277,921.76	
34,291.18	
2,710.61	
4,059.81	
26,496.23	
7,622.27	
11,449,751.87	
13,254,482.25	
77,149,490.66	
107,414,342.98	
114,519,884.50	
67,439.54	
306,258.61	
384,343.30	
2,865,540.30	
3,500,176.15	
3,186,422.84	
5,122.87	
1,060.58	
1,137.64	
7,502.31	
254.57	
962.77	
241.44	
2,819.57	
334,513,122.03	

9939	BIRTH SUPP PAYMENT N	465,794.15	642,903.37	516,533.17	500,463.01	487,279.13	377,113.93	480,181.19	424,392.94	457,270.13	379,683.41	0.00	0.00	
SUBTOTAL:	465,794.15	642,903.37	516,533.17	500,463.01	487,279.13	377,113.93	480,181.19	424,392.94	457,270.13	379,683.41	0.00	0.00	

 
4,731,614.43	
4,731,614.43	

4403	SOBRA 100-133% M&F
6

0.00	0.00	0.00	310.51	331.92	117.78	116.29	231.88	130.60	208.77	0.00	0.00	1,447.75

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4404	SOBRA 100-133% MALE	0.00	146.73	290.72	291.71	291.71	361.75	625.18	459.07	459.07	395.03	0.00	0.00	3,320.97	
4405	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	532.32	266.32	0.00	0.00	798.64	
440C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	138.17	0.00	0.00	0.00	0.00	103.11	33.07	0.00	0.00	274.35	
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	837.88	
440E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165.79	0.00	0.00	0.00	165.79	
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	141.29	
4412	SOBRA 100-133% M&F
1	1,928.16	1,449.26	1,448.90	912.82	1,202.09	1,334.87	1,019.62	710.22	663.92	565.56	0.00	0.00	11,235.42	
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	5,917,103.46	5,910,195.77	5,945,209.99	5,951,723.76	0.00	0.00	60,237,689.91	
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	2,041,864.42	2,074,130.25	2,083,746.36	2,096,781.42	0.00	0.00	20,809,366.99	
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	3,156,491.68	3,182,243.59	3,223,156.76	3,211,156.85	0.00	0.00	31,948,196.30	
441B	SOBRA 100-133% M&F
1	445.44	0.00	0.00	112.55	14.70	0.00	165.33	35.43	3.56	0.00	0.00	0.00	777.01	
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	60,750.23	55,510.48	77,041.71	61,395.54	0.00	0.00	743,993.66	
441D	SOBRA 100-133% MALE	86,665.55	50,248.54	57,787.59	46,488.16	35,388.26	46,682.47	41,975.22	45,744.68	63,713.87	44,453.82	0.00	0.00	519,148.16	
441E	SOBRA 100-133% FEM AL	139,238.73	65,193.24	72,773.77	65,282.53	38,391.66	50,108.66	59,128.88	59,963.80	73,033.28	56,589.65	0.00	0.00	679,704.20	
4423	SOBRA 100-133% M&F
6	0.00	0.00	0.00	66.90	0.00	0.00	115.59	0.00	0.00	0.00	0.00	0.00	182.49	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	165.11	222.71	133.96	166.11	0.00	0.00	0.00	0.00	687.89	
SUBTOTAL	:	11,272,874.22	10,997,151.60	11,138,027.33	11,207,865.93	11,154,030.86	13,687,607.49	11,279,489.86	11,329,391.28	11,467,960.34	11,423,569.79	0.00	0.00	114,957,968.70	

4517	BC PATIENT FEMALE 2 1	5,396.74	5,104.69	4,725.99	4,457.14	4,429.66	5,368.23	4,299.69	4,482.79	4,442.26	4,668.56	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	53,857.71	49,046.24	47,557.74	47,301.77	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	660.83	355.54	2,175.25	5,612.45	6,525.31	355.54	355.54	355.54	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	163.19	0.00	1,094.76	0.00	182.97	559.32	114.45	333.45	0.00	555.45	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	1,953.05	3,095.87	0.00	5,454.62	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	1,991.61	1,759.02	2,487.26	3,919.84	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	2,784.34	3,268.28	3,268.28	3,268.28	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	1,529.29	339.55	0.00	0.00	
SUBTOTAL:	91,387.00	82,103.07	80,487.07	71,854.25	77,355.25	94,061.29	71,526.16	62,341.19	59,640.37	65,863.61	0.00	0.00	

47,375.75	
602,401.52	
16,396.00	
3,003.59	
20,135.54	
31,878.52	
33,265.60	
2,162.74	
756,619.26	

8600	SSI BLIND FREEDOM/W O	1,497.85	1,497.85	1,497.85	1,708.04	1,708.04	1,708.04	1,708.04	1,773.40	2,938.58	4,134.40	0.00	0.00	
860Z	SSI BLIND FREEDOM/W O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,349.88	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	1,596,854.77	1,613,841.65	1,636,197.19	1,674,616.81	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	44,273.83	29,860.36	37,938.77	37,599.68	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	338,771.80	336,928.69	324,538.97	345,550.72	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	24,041.77	22,722.94	22,865.92	8,636.84	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	169,626.23	162,427.67	169,072.41	175,456.44	0.00	0.00	

20,172.09	
3,349.88	
16,102,124.12	
229,712.87	
3,232,966.61	
152,651.16	
1,632,052.42	

9944	BIRTH SUPP PAYMENT S	35,856.55	55,987.51	36,542.55	61,327.79	50,782.96	12,517.40	42,890.31	5,770.44	42,807.72	31,929.76	0.00	0.00	
SUBTOTAL:	35,856.55	55,987.51	36,542.55	61,327.79	50,782.96	12,517.40	42,890.31	5,770.44	42,807.72	31,929.76	0.00	0.00	

 
376,412.99	
376,412.99	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
872Z	SSI DISABLED FREEDO M	208.68	121.10	148.84	1,472.74	159.84	2,019.87	770.78	159.71	1,768.30	1,133.97	0.00	0.00	7,963.83	
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	2,176,047.22	2,167,714.42	2,198,670.02	2,247,128.86	0.00	0.00	21,380,992.98	

524,137,104.09	513,951,069.46	518,150,668.23	533,228,708.32	531,374,153.28	619,287,094.79	540,141,462.71	537,145,498.88	542,979,018.22	536,702,753.93	0.00	0.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017	
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	2.00	3.25	3.32	2.68	0.00	0.00		14.90		
1002	TANF 01-05 M & F WIT	0.00	0.00	0.26	1.00	0.00	0.00	2.00	2.00	3.93	4.00	0.00	0.00		13.19		
1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	1.00	0.00	0.00	1.70	2.00	5.00	5.00	0.00	0.00		14.70		
1004	TANF 14-20 MALE WITH	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.90	1.00	0.00	0.00		18.90		
1005	TANF 14-20 FEMALE WI	4.99	3.00	3.00	2.00	2.00	2.00	1.42	3.00	3.00	1.23	0.00	0.00		25.64		
1006	TANF 21-44 MALE WITH	105.64	116.50	122.90	121.77	112.58	103.11	93.18	80.83	82.36	83.52	0.00	0.00		1,022.39		
1007	TANF 21-44 FEMALE WI	181.79	195.90	194.31	186.27	171.61	156.02	153.62	150.94	147.42	144.91	0.00	0.00		1,682.79		
1008	TANF 45-64 M & F WIT	268.21	287.79	294.87	260.17	251.14	238.36	210.83	201.88	192.38	177.68	0.00	0.00		2,383.31		
1009	TANF 65+ M & F WITH	116.75	130.64	133.33	127.13	117.54	110.88	107.89	112.45	97.00	86.63	0.00	0.00		1,140.24		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	7.23	1.60	1.16	0.00	9.00	-9.00	0.00	0.00		9.99		
100B	TANF 01-05 M & F WIT	0.00	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.06	0.00	0.00	0.00		0.79		
100C	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.29	0.00	0.00	0.00	0.00	0.00		0.29		
100F	TANF 21-44 MALE WITH	12.95	6.38	1.64	2.50	1.09	5.24	5.39	1.32	6.58	2.46	0.00	0.00		45.55		
100G	TANF 21-44 FEMALE WI	5.05	4.32	5.17	3.84	11.40	5.00	8.52	10.68	4.61	1.19	0.00	0.00		59.78		
100H	TANF 44-64 M & F WIT	9.51	7.35	5.34	4.24	0.81	9.97	9.85	4.82	7.01	6.29	0.00	0.00		65.19		
100J	TANF 65+ M & F WITH	4.22	1.12	1.66	7.58	1.68	12.77	5.08	1.10	3.00	3.36	0.00	0.00		41.57		
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	11,717.13	12,156.23	12,562.45	12,601.62	0.00	0.00		118,630.58		
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	19,612.18	19,532.86	19,839.69	20,180.32	0.00	0.00		185,501.77		
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	30,480.46	31,079.59	31,190.84	31,484.37	0.00	0.00		293,482.30		
1014	TANF 14-20 MALE NON-	7,849.50	8,080.91	8,195.85	8,273.67	8,323.39	8,492.84	8,659.07	8,865.14	8,588.19	8,524.35	0.00	0.00		83,852.91		
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	11,440.59	11,524.14	11,243.09	11,260.74	0.00	0.00		112,211.20		
1016	TANF 21-44 MALE NON-	25,794.90	26,636.23	27,208.92	27,085.56	27,212.69	27,492.79	27,446.49	27,713.22	27,773.61	27,437.81	0.00	0.00		271,802.22		
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	81,865.10	82,467.51	82,828.32	82,402.29	0.00	0.00		815,549.39		
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	21,291.16	21,545.04	21,643.38	21,421.83	0.00	0.00		210,541.10		
1019	TANF 65+ M & F NON-M	82.44	87.95	83.71	84.16	87.04	88.37	79.05	80.58	84.70	81.30	0.00	0.00		839.30		
101A	TANF < 1 M & F NON-M	1,368.89	819.40	613.87	559.26	852.99	1,643.54	1,946.97	1,213.88	1,477.52	1,313.40	0.00	0.00		11,809.72		
101B	TANF 01-05 M & F NON	682.65	652.33	333.31	396.33	345.82	490.50	317.35	358.48	512.69	320.27	0.00	0.00		4,409.73		
101C	TANF 06-13 M & F NON	588.07	716.90	269.48	309.22	272.45	188.98	286.48	214.78	355.21	310.33	0.00	0.00		3,511.90		
101D	TANF 14-20 MALE NON-	275.74	179.54	166.65	110.82	101.75	109.00	114.27	53.46	112.10	129.40	0.00	0.00		1,352.73		
101E	TANF 14-20 FEMALE N O	392.46	264.03	203.17	162.04	121.91	123.04	159.75	138.07	242.66	154.54	0.00	0.00		1,961.67		
101F	TANF 21-44 MALE NON-	2,233.16	1,246.55	971.70	792.03	795.69	776.19	991.87	686.80	907.63	778.79	0.00	0.00		10,180.41		
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	1,905.87	1,570.83	1,982.23	1,744.26	0.00	0.00		22,371.54		
101H	TANF 44-64 M & F NON	1,044.93	668.56	619.71	457.87	378.53	377.29	495.19	433.96	512.09	421.12	0.00	0.00		5,409.25		
101J	TANF 65+ N & F NON-M	7.16	1.47	3.58	4.06	4.24	3.32	1.85	1.60	1.29	0.70	0.00	0.00		29.27		
1026	TANF 21-44 MALE WITH	40.21	39.35	36.00	42.70	38.83	42.76	41.00	44.00	50.70	46.00	0.00	0.00		421.55		
1027	TANF 21-44 FEMALE WI	55.59	51.12	51.66	62.41	66.63	77.48	82.20	87.30	82.83	84.63	0.00	0.00		701.85		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	75.00	69.96	69.62	81.22	81.00	92.83	102.00	118.89	125.06	119.80	0.00	0.00		935.38		
1029	TANF 65+ M & F WITH	27.20	27.00	24.56	31.93	38.43	46.54	45.00	46.00	45.12	46.66	0.00	0.00		378.44		
102F	TANF 21-44 MALE WITH	3.38	0.32	0.00	0.00	0.60	0.22	0.00	0.00	0.96	0.00	0.00	0.00		5.48		
102G	TANF 21-44 FEMALE WI	0.00	2.15	1.30	0.41	0.00	0.00	0.35	1.45	1.00	0.36	0.00	0.00		7.02		
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	0.20	0.00	0.00		14.02		
102J	TANF 65+ M & F WITH	0.00	0.00	1.43	5.06	0.56	3.45	0.00	0.00	2.87	0.33	0.00	0.00		13.70		
2100	SSI AGED WITH MEDIC A	4,687.07	4,820.28	4,932.67	4,960.19	4,993.69	4,950.86	5,010.20	4,958.48	4,976.43	4,893.94	0.00	0.00		49,183.81		
210Z	SSI AGED WITH MEDIC A	401.49	304.61	422.21	299.56	324.48	244.26	286.15	324.50	308.28	233.00	0.00	0.00		3,148.54		
2110	SSI AGED NON-MEDIC AR	5,548.22	5,555.50	5,634.93	5,653.20	5,723.40	5,738.02	5,776.80	5,807.56	5,724.93	5,751.55	0.00	0.00		56,914.11		
211Z	SSI AGED NON-MEDIC AR	216.60	250.09	229.13	256.06	209.31	234.95	260.41	232.68	304.57	227.91	0.00	0.00		2,421.71		
2120	SSI AGED WITH QMB	27,168.47	27,829.76	28,631.17	29,913.89	29,919.48	30,922.62	31,829.79	32,677.91	38,475.36	38,337.83	0.00	0.00		315,706.28		
212Z	SSI AGED WITH QMB P P	67.03	76.42	130.57	54.73	35.88	46.57	54.70	32.99	42.20	28.58	0.00	0.00		569.67		
2200	SSI DISABLED WITH M E	5,051.73	5,011.37	5,017.01	4,955.26	4,862.22	4,826.30	4,853.77	4,861.98	4,755.85	4,664.07	0.00	0.00		48,859.56		
220Z	SSI DISABLED WITH M E	259.75	180.95	228.13	199.49	211.99	217.73	206.30	265.63	249.30	200.79	0.00	0.00		2,220.06		
2210	SSI DISABLED NON-ME D	56,419.86	56,072.96	55,978.26	55,811.91	55,691.20	55,489.08	55,432.43	55,481.01	55,220.50	55,057.31	0.00	0.00		556,654.52		
221Z	SSI DISABLED NON-ME D	759.89	735.30	931.82	815.33	751.41	666.76	952.98	1,038.86	975.23	893.22	0.00	0.00		8,520.80		
2220	SSI DISABLED WITH Q M	27,588.74	27,999.85	28,560.56	29,367.97	29,376.90	30,014.18	30,333.84	30,835.77	34,495.76	34,295.05	0.00	0.00		302,868.62		
222Z	SSI DISABLED WITH Q M	50.54	64.24	90.67	35.27	62.39	49.98	78.93	65.54	81.33	75.02	0.00	0.00		653.91		
2300	SSI BLIND WITH MEDIC	27.00	29.00	28.00	28.00	27.50	26.98	26.00	24.71	25.00	25.80	0.00	0.00		267.99		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	4.09	0.00	0.60	2.00	0.00	0.00	0.00		6.69		
2310	SSI BLIND NON-MEDIC A	461.02	472.94	470.49	467.32	475.67	472.18	475.60	475.46	484.69	489.27	0.00	0.00		4,744.64		
231Z	SSI BLIND NON-MEDIC A	14.08	16.02	6.45	1.92	16.88	7.60	7.41	7.03	23.04	26.18	0.00	0.00		126.61		
2320	SSI BLIND WITH QMB	208.99	210.04	210.62	210.56	206.15	210.00	212.70	213.00	215.67	218.00	0.00	0.00		2,115.73		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.12	0.00	0.00	0.00	0.00	1.32	0.00	0.00	0.00		1.44		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.60	4.99	4.66	6.38	5.00	4.00	4.00	4.00	0.00	0.00		33.63		
4302	SOBRA CHILD 01-05 M	3.00	3.00	4.76	9.00	6.20	16.40	20.91	33.00	40.36	38.38	0.00	0.00		175.01		
4303	SOBRA CHILD 06-13 M	6.70	6.12	7.42	19.66	24.26	12.70	27.77	30.28	35.99	43.65	0.00	0.00		214.55		
4304	SOBRA CHILD 14-20 MA	3.00	2.00	2.26	5.06	8.26	6.12	10.00	11.96	14.00	15.40	0.00	0.00		78.06		
4305	SOBRA CHILD 14-20 FE	6.38	8.49	8.26	10.35	7.03	6.41	8.99	7.25	-0.01	5.90	0.00	0.00		69.05		
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	2.15	0.00	1.78	1.08	0.00	0.00		1.68		
430C	SOBRA CHILD 06-13 M	0.06	0.00	2.11	6.36	1.73	-5.54	0.00	0.75	-0.12	2.41	0.00	0.00		7.76		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.73	1.77	1.73	0.00	0.00	1.03	0.00	0.60	0.00	0.00		5.86		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	0.73	0.64	0.00	0.00	0.00	0.00	0.00	1.10	0.00	0.00		2.47		
4311	SOBRA CHILD <1 M & F	39,790.63	40,146.76	40,163.90	39,523.14	39,368.27	38,933.42	38,716.96	37,686.41	37,355.61	36,712.55	0.00	0.00		388,397.65		
4312	SOBRA CHILD 01-05 M	188,466.60	189,087.15	189,910.31	189,321.12	187,168.96	187,945.84	186,612.49	187,161.28	186,587.22	184,865.61	0.00	0.00		1,877,126.58		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4313	SOBRA CHILD 06-13 M	233,049.16	235,593.66	237,736.70	237,670.85	237,504.09	237,478.64	235,492.70	234,753.18	234,105.60	232,106.42	0.00	0.00		2,355,491.00		
4314	SOBRA CHILD 14-20 MA	54,382.11	55,359.01	56,494.43	57,144.50	57,962.23	58,222.49	58,077.95	58,185.72	58,927.15	58,486.81	0.00	0.00		573,242.40		
4315	SOBRA CHILD 14-20 FE	54,106.61	55,018.18	56,134.61	56,838.63	57,549.93	57,955.59	57,885.36	57,977.72	58,630.79	58,158.70	0.00	0.00		570,256.12		
431A	SOBRA CHILD < 1 M &	1,208.09	704.71	883.39	879.48	228.79	222.46	570.16	150.82	386.86	311.92	0.00	0.00		5,546.68		
431B	SOBRA CHILD 01-05 M	9,938.87	5,510.49	5,314.91	4,820.21	3,433.09	4,103.06	5,049.97	4,082.78	4,983.30	4,104.82	0.00	0.00		51,341.50		
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	4,550.49	3,893.67	4,700.82	3,788.48	0.00	0.00		52,498.94		
431D	SOBRA CHILD 14-20 MA	3,383.27	1,549.83	1,503.76	1,251.31	1,054.40	1,059.81	1,379.85	1,060.60	1,242.60	1,058.33	0.00	0.00		14,543.76		
431E	SOBRA CHILD 14-20 FE	2,833.78	1,413.80	1,559.21	1,256.55	1,028.70	1,064.42	1,295.86	1,019.62	1,247.92	1,055.05	0.00	0.00		13,774.91		
4321	SOBRA CHILD <1 M & F	0.00	1.00	-1.00	1.00	1.00	1.00	2.00	1.00	1.00	1.00	0.00	0.00		8.00		
4322	SOBRA CHILD 01-05 M	2.00	2.00	1.23	1.00	1.00	1.00	1.00	0.96	1.00	0.00	0.00	0.00		11.19		
4323	SOBRA CHILD 06-13 M	0.00	-1.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		2.00		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.93	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		1.93		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	1.00	1.00	1.00	4.00	4.00	4.00	5.00	0.00	0.00		20.00		
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	2.00	0.00	0.58	0.00	0.00	0.00		4.90		
5007	SOBRA PREG 21-44 FE M	54.43	49.34	63.74	53.96	45.22	43.53	46.76	61.02	64.61	64.97	0.00	0.00		547.58		
5008	SOBRA PREG 45-64 FE M	5.32	4.00	4.00	5.00	5.00	4.99	4.00	4.00	4.32	5.00	0.00	0.00		45.63		
500E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	2.67	0.00	0.00	0.00	0.00	1.08	0.00	0.00	0.00		3.75		
500G	SOBRA PREG 21-44 FE M	3.19	2.70	2.17	3.02	5.05	4.53	4.06	9.41	6.34	7.97	0.00	0.00		48.44		
500H	SOBRA PREG 45-64 FE M	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.67	0.00	0.00	0.00		1.34		
5013	SOBRA PREG 09-13 FE M	6.16	8.00	9.00	8.00	8.00	7.00	10.00	6.00	9.00	13.00	0.00	0.00		84.16		
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	3,478.56	3,496.16	3,505.89	3,523.11	0.00	0.00		37,511.51		
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	18,634.68	18,641.94	18,612.11	18,879.16	0.00	0.00		194,061.11		
5018	SOBRA PREG 45-64 FE M	69.37	50.47	56.39	58.27	58.19	54.32	56.78	57.29	58.59	60.53	0.00	0.00		580.20		
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	1.00	0.00	0.00		1.61		
501E	SOBRA PREG 14-20 FE M	704.07	289.25	297.62	231.65	223.26	260.87	260.31	217.32	271.20	231.71	0.00	0.00		2,987.26		
501G	SOBRA PREG 21-44 FE M	2,575.10	1,286.76	1,250.34	1,121.90	986.61	1,133.73	1,174.21	1,018.89	1,225.15	999.61	0.00	0.00		12,772.30		
501H	SOBRA PREG 45-64 FE M	6.61	4.05	6.11	4.69	0.80	1.54	3.19	3.95	12.11	0.46	0.00	0.00		43.51		
5027	SOBRA PREG 21-44 FE M	22.12	25.35	24.93	29.18	41.23	48.92	56.19	53.78	52.00	55.20	0.00	0.00		408.90		
5028	SOBRA PREG 45-64 FE M	1.00	1.00	1.00	1.19	2.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		11.19		
502G	SOBRA PREG 21-44 FE M	0.87	1.09	0.76	1.45	0.36	0.06	0.00	0.21	0.00	0.00	0.00	0.00		4.80		
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	968,929.67	967,450.79	981,188.78	971,405.82	0.00	0.00		9,669,418.88		

9910	TANF & SOBRA CHILDR E	296.00	348.00	307.00	319.00	288.00	275.00	302.00	270.00	280.00	234.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	6.00	6.00	7.00	4.00	6.00	11.00	4.00	3.00	6.00	8.00	0.00	0.00	

 
2,919.00	
61.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9921	SSI W/O MEDICARE KI	31.00	39.00	24.00	30.00	29.00	35.00	27.00	24.00	14.00	22.00	0.00	0.00	275.00	

9950	C
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	
2,284.00	
1,844.00	
2,100.00	
1,771.00	
0.00	
0.00	
21,637.00	

SUBTOTAL:	
2,472.00	
2,821.00	
2,736.00	
2,628.00	
2,516.00	
2,526.00	
2,617.00	
2,141.00	
2,400.00	
2,035.00	
0.00	
0.00	
24,892.00	

3100	TRANSPLANT OPTION 1	3.00	3.00	3.00	3.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.00	3.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	

18.00	
18.00	

1106	TANF EXPANDED 21-44	788.67	816.15	831.69	763.69	714.36	650.05	588.67	523.66	487.78	437.09	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	1,177.63	1,052.57	936.16	856.01	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	2,337.38	2,189.43	2,054.68	1,915.27	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	923.26	858.27	820.78	768.30	0.00	0.00	
110F	TANF EXPANDED 21-44	55.35	14.50	18.23	23.85	15.67	11.80	23.67	19.84	22.09	21.39	0.00	0.00	
110G	TANF EXPANDED 21-44	45.79	45.56	59.04	39.99	24.10	44.79	34.06	36.06	22.84	31.86	0.00	0.00	
110H	TANF EXPANDED 45-64	104.82	65.06	61.85	64.53	46.32	37.01	45.86	34.82	47.26	44.11	0.00	0.00	
110J	TANF EXPANDED 65+
M&	27.91	37.48	41.73	22.46	32.67	21.52	34.34	21.94	37.28	12.38	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	16.00	15.00	15.00	11.00	0.00	0.00	
1113	TANF EXPANDED 06-13	131.04	120.00	110.00	101.48	91.92	86.00	82.95	64.00	57.00	51.00	0.00	0.00	
1114	TANF EXPANDED 14-20	576.14	573.34	572.53	565.50	561.62	542.08	528.80	507.25	486.48	474.71	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	1,942.81	1,922.30	1,896.83	1,863.88	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	31,561.52	31,350.11	31,368.20	31,065.91	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	74,299.90	74,152.42	74,196.95	73,642.74	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	27,007.48	26,878.57	26,890.05	26,629.41	0.00	0.00	
1119	TANF EXPANDED 65+
M&	83.66	90.73	84.94	80.63	75.48	73.72	76.51	76.87	83.87	81.53	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	1.03	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	13.86	11.89	15.18	26.85	0.00	0.00	
111E	TANF EXPANDED 14-20	140.45	79.30	47.46	37.05	37.74	40.86	54.30	43.50	59.06	34.50	0.00	0.00	
111F	TANF EXPANDED 21-44	2,076.01	1,098.80	1,054.29	866.48	667.86	727.15	1,042.04	869.29	1,062.79	797.63	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	1,446.10	1,433.32	1,656.98	1,339.86	0.00	0.00	
111H	TANF EXPANDED 45-64	1,397.05	614.36	610.74	521.63	393.72	564.42	664.30	570.99	640.56	535.67	0.00	0.00	
111J	TANF EXPANDED 65+
M&	27.62	12.27	0.56	8.36	0.92	2.09	2.46	3.67	3.12	3.80	0.00	0.00	
1125	TANF EXPANDED 14-20	0.00	1.00	0.00	0.00	0.00	0.00	-1.00	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	609.59	683.04	734.44	770.83	0.00	0.00	
1127	TANF EXPANDED 21-44	702.41	738.16	741.34	867.48	989.15	1,094.54	1,194.90	1,324.12	1,424.55	1,502.65	0.00	0.00	
1128	TANF EXPANDED 45-64	861.34	884.40	908.08	1,089.86	1,273.31	1,427.48	1,590.67	1,749.70	1,916.14	2,045.06	0.00	0.00	

6,601.81	
12,884.15	
24,829.69	
9,754.05	
226.39	
384.09	
551.64	
289.71	
2.22	
186.83	
895.39	
5,388.45	
19,890.66	
312,814.78	
731,748.03	
266,875.55	
807.94	
1.77	
0.16	
8.33	
231.69	
574.22	
10,262.34	
17,091.60	
6,513.44	
64.87	
0.00	
5,118.30	
10,579.30	
13,746.04	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1129	TANF EXPANDED 65+
M&	379.94	403.85	416.65	478.04	571.50	664.28	745.66	849.30	959.75	998.67	0.00	0.00		6,467.64		
112F	TANF EXPANDED 21-44	13.19	10.76	7.05	6.29	1.46	0.38	0.57	2.85	3.41	1.78	0.00	0.00		47.74		
112G	TANF EXPANDED 21-44	7.14	11.21	3.67	1.91	1.04	6.87	3.05	9.25	16.07	15.77	0.00	0.00		75.98		
112H	TANF EXPANDED 45-64	18.32	9.84	16.83	8.08	4.33	10.13	16.27	11.91	4.43	3.71	0.00	0.00		103.85		
112J	TANF EXPANDED 65+
M&	7.02	3.04	18.32	8.66	3.52	0.51	3.75	6.65	6.45	2.42	0.00	0.00		60.34		
2400	SSI AGED EXPANDED WI	426.73	443.44	472.02	440.67	421.28	416.03	420.93	413.53	438.49	394.72	0.00	0.00		4,287.84		
240Z	SSI AGED EXPANDED WI	259.45	185.24	285.34	182.17	156.25	182.04	231.36	208.25	226.85	195.91	0.00	0.00		2,112.86		
2410	SSI AGED EXPANDED NO	126.95	125.69	114.65	110.10	102.07	100.93	103.30	105.69	98.88	101.47	0.00	0.00		1,089.73		
241Z	SSI AGED EXPANDED NO	10.56	5.52	10.37	8.07	18.00	8.21	18.47	6.31	9.01	4.38	0.00	0.00		98.90		
2420	SSI AGED EXPANDED WI	17,593.09	17,259.82	16,957.44	16,174.97	15,572.31	15,222.85	15,207.75	14,817.35	9,621.56	9,992.44	0.00	0.00		148,419.58		
242Z	SSI AGED EXPANDED WI	124.19	55.44	148.30	30.91	27.11	61.83	56.01	40.20	64.42	53.50	0.00	0.00		661.91		
2500	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
2520	SSI BLIND EXPANDED W	2.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		8.00		
2600	SSI DISABLED EXPAND E	492.88	464.34	445.06	397.48	316.87	354.84	355.99	348.57	328.84	291.02	0.00	0.00		3,795.89		
260Z	SSI DISABLED EXPAND E	161.06	113.94	138.72	163.02	133.69	175.63	172.06	182.56	197.19	167.42	0.00	0.00		1,605.29		
2610	SSI DISABLED EXPAND E	1,749.60	1,549.45	1,399.14	1,339.50	1,277.70	1,221.60	1,156.70	1,138.45	1,098.58	1,144.08	0.00	0.00		13,074.80		
261Z	SSI DISABLED EXPAND E	60.98	43.92	59.01	40.76	37.50	49.05	75.77	60.42	60.48	34.27	0.00	0.00		522.16		
2620	SSI DISABLED EXPAND E	14,973.36	14,550.51	14,192.55	13,454.69	13,193.27	12,672.31	12,548.53	12,250.33	8,625.87	8,650.43	0.00	0.00		125,111.85		
262Z	SSI DISABLED EXPAND E	57.37	57.71	62.26	22.33	26.27	49.90	39.03	41.64	53.04	45.82	0.00	0.00		455.37		
SUBTOTAL:	182,154.75	178,380.59	179,678.9	2	178,359.34	178,306.08	178,297.67	178,456.29	176,886.89	168,750.39	167,062.25	0.00	0.00		1,766,333.17		

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	

9911	SB PAYMENT FOR TAN F	203.00	222.00	227.00	229.00	202.00	196.00	213.00	169.00	222.00	167.00	0.00	0.00	
9922	SB PAYMENT FOR SSI E	3.00	1.00	1.00	0.00	1.00	1.00	1.00	1.00	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	214.00	170.00	222.00	167.00	0.00	0.00	

 
2,050.00	
9.00	
1.00	
2,060.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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	0.16	0.64	3.53	1.83	0.00	0.00	
3507	ADULT 40-100% FEMAL E	1.41	1.51	4.33	7.00	2.96	2.67	2.29	2.89	0.77	2.13	0.00	0.00	
3508	ADULT 40-100% M&F 45	48.19	59.75	62.73	53.99	47.58	29.17	22.36	41.78	19.97	17.86	0.00	0.00	
3509	ADULT 40-100% M&F 65	11.70	10.93	12.00	11.41	7.00	6.00	4.00	3.00	1.35	2.00	0.00	0.00	
350F	ADULT 40-100% MALE
2	1.38	0.00	2.85	0.00	1.30	1.06	0.83	1.35	1.44	0.16	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.58	0.77	0.66	0.00	1.03	3.43	2.70	2.10	0.22	1.86	0.00	0.00	
350H	ADULT 40-100% M&F 45	10.10	5.21	0.26	0.57	6.39	1.00	7.58	1.50	6.94	5.13	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	0.64	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	5,803.48	5,880.38	5,944.93	6,021.22	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	6,265.55	6,340.56	6,354.09	6,430.48	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	20,809.84	21,163.03	20,941.27	20,954.18	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	17,336.51	17,429.42	17,352.64	17,434.49	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	41,858.59	42,069.35	41,808.80	41,511.42	0.00	0.00	
3519	ADULT 40-100% M&F 65	21.41	25.00	17.00	19.00	18.00	20.00	19.00	15.00	18.00	20.00	0.00	0.00	
351D	ADULT 40-100% MALE
1	347.75	138.36	119.42	158.86	103.73	121.24	131.40	119.15	184.36	115.33	0.00	0.00	
351E	ADULT 40-100% FEMAL E	318.47	148.34	190.06	144.66	88.26	135.84	165.93	153.71	179.57	146.02	0.00	0.00	
351F	ADULT 40-100% MALE
2	1,280.29	671.30	703.96	627.89	448.47	641.91	886.59	691.62	937.20	515.38	0.00	0.00	
351G	ADULT 40-100% FEMAL E	965.22	464.82	496.19	554.47	423.34	540.27	712.58	511.88	693.87	484.44	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	1,647.36	1,115.11	1,453.48	1,011.41	0.00	0.00	
351J	ADULT 40-100% M&F 65	22.58	3.00	9.00	4.00	1.00	-1.40	6.00	2.00	1.40	6.00	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	1.51	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	1.00	0.19	1.46	0.00	0.00	0.00	0.93	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	3.83	4.96	4.00	0.60	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.12	0.00	1.00	1.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	

 
26.89	
27.96	
403.38	
69.39	
10.37	
13.35	
44.68	
2.28	
56,721.60	
61,689.65	
204,206.84	
168,544.55	
412,530.69	
192.41	
1,539.60	
1,670.86	
7,404.61	
5,847.08	
12,807.52	
53.58	
12.12	
3.58	
43.91	
3.12	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
352F	ADULT 40-100% MALE
2	0.00	0.35	0.93	0.12	0.46	0.00	0.00	0.00	0.48	0.00	0.00	0.00		2.34		
352G	ADULT 40-100% FEMAL E	0.00	0.00	0.53	0.00	0.00	0.00	5.06	0.00	0.00	0.00	0.00	0.00		5.59		
352H	ADULT 40-100% M&F 45	0.00	0.32	0.86	0.89	0.36	0.00	9.16	1.03	0.03	0.40	0.00	0.00		13.05		
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		
3705	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		1.00		
3706	ADULT <40% EXP MAL E	15.41	17.00	16.24	24.93	27.77	14.52	13.67	18.37	18.56	12.48	0.00	0.00		178.95		
3707	ADULT <40% EXP FEM AL	9.61	12.63	3.73	7.16	7.66	2.54	2.34	5.70	5.14	3.03	0.00	0.00		59.54		
3708	ADULT <40% EXP M&F 4	79.34	86.57	80.65	72.41	83.25	56.35	36.03	42.90	36.39	35.32	0.00	0.00		609.21		
3709	ADULT <40% EXP M&F 6	3.99	8.24	0.00	4.45	5.00	1.00	4.00	0.00	0.00	2.00	0.00	0.00		28.68		
370F	ADULT <40% EXP MAL E	0.03	3.87	2.81	14.31	5.59	3.91	2.69	5.71	10.48	5.04	0.00	0.00		54.44		
370G	ADULT <40% EXP FEM AL	7.40	0.12	1.26	0.83	1.32	0.91	0.83	0.85	1.98	1.20	0.00	0.00		16.70		
370H	ADULT <40% EXP M&F 4	62.90	4.82	11.94	8.36	1.02	1.75	4.36	4.70	6.52	7.94	0.00	0.00		114.31		
3714	ADULT <40% EXP MAL E	12,053.30	11,993.59	11,889.17	11,702.80	11,433.43	11,404.82	11,314.64	11,246.95	11,057.66	10,992.78	0.00	0.00		115,089.14		
3715	ADULT <40% EXP FEM AL	10,566.05	10,578.54	10,458.81	10,259.28	10,054.16	10,056.84	10,016.60	9,970.74	9,790.73	9,697.61	0.00	0.00		101,449.36		
3716	ADULT <40% EXP MAL E	60,788.30	61,489.48	61,720.28	61,704.56	62,203.68	62,733.33	61,730.01	62,483.80	62,604.92	62,067.07	0.00	0.00		619,525.43		
3717	ADULT <40% EXP FEM AL	36,217.95	36,585.39	36,742.16	36,721.82	37,041.08	37,387.97	37,140.94	37,531.70	37,690.47	37,424.17	0.00	0.00		370,483.65		
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	77,566.57	78,250.13	78,165.22	77,414.90	0.00	0.00		775,782.49		
3719	ADULT <40% EXP M&F 6	46.67	55.00	38.00	56.38	44.03	38.16	49.00	30.94	48.00	55.00	0.00	0.00		461.18		
371D	ADULT <40% EXP MAL E	785.47	365.33	398.98	325.58	262.69	270.65	322.13	246.12	410.61	279.02	0.00	0.00		3,666.58		
371E	ADULT <40% EXP FEM AL	622.58	343.02	319.92	267.63	210.79	224.26	290.84	238.53	313.75	270.85	0.00	0.00		3,102.17		
371F	ADULT <40% EXP MAL E	7,431.73	2,823.52	3,229.94	2,724.89	2,157.68	2,538.66	3,584.24	2,767.27	3,317.27	2,436.76	0.00	0.00		33,011.96		
371G	ADULT <40% EXP FEM AL	3,715.62	1,653.65	1,678.50	1,655.36	1,276.43	1,523.11	1,899.11	1,418.26	1,975.49	1,297.44	0.00	0.00		18,092.97		
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	3,214.25	2,400.41	2,974.46	2,152.64	0.00	0.00		29,409.87		
371J	ADULT <40% EXP M&F 6	0.00	3.00	1.00	0.00	0.00	8.00	0.00	4.00	0.00	1.00	0.00	0.00		17.00		
3724	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.64	1.00	0.00	0.00	0.00		1.64		
3726	ADULT <40% EXP MAL E	3.77	2.02	5.00	6.23	6.79	5.57	6.37	4.46	4.08	2.74	0.00	0.00		47.03		
3727	ADULT <40% EXP FEM AL	1.77	1.34	1.00	0.00	0.26	2.77	3.25	3.56	1.03	1.43	0.00	0.00		16.41		
3728	ADULT <40% EXP M&F 4	10.87	10.49	6.79	5.15	7.15	8.11	4.72	9.57	6.58	6.11	0.00	0.00		75.54		
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		
372D	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.35	0.00	0.00	0.00	0.00		0.35		
372F	ADULT <40% EXP MAL E	2.22	0.63	0.03	2.51	3.29	7.75	0.61	3.53	1.21	1.22	0.00	0.00		23.00		
372G	ADULT <40% EXP FEM AL	1.00	0.32	0.00	0.00	0.73	1.22	0.74	1.32	0.96	0.56	0.00	0.00		6.85		
372H	ADULT <40% EXP M&F 4	1.64	2.75	2.22	2.57	5.47	3.39	5.23	0.42	3.20	1.65	0.00	0.00		28.54		
SUBTOTAL:	306,430.98	295,595.84	298,069.0	0	297,419.12	297,277.20	302,092.15	302,915.90	302,241.39	304,356.20	298,853.30	0.00	0.00		3,005,251.08		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9935	BIRTH SUPP PAYMENT A	47.00	43.00	33.00	45.00	39.00	54.00	45.00	42.00	50.00	33.00	0.00	0.00	431.00	
9937	BIRTH SUPP PAYMENT A	97.00	110.00	112.00	86.00	87.00	90.00	78.00	83.00	88.00	66.00	0.00	0.00	897.00	
SUBTOTAL	:	144.00	153.00	145.00	131.00	126.00	144.00	123.00	125.00	138.00	99.00	0.00	0.00	1,328.00	

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	
3906	NEWLY ELIGIBLE MALE	9.99	6.59	5.63	7.18	1.50	1.89	4.22	4.50	1.51	1.80	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	7.24	9.28	4.52	5.00	4.00	4.74	3.64	3.17	4.08	2.30	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	76.38	71.01	65.15	62.68	56.05	57.26	52.55	55.45	43.94	50.82	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	6.16	6.44	13.46	10.00	11.00	10.00	7.41	6.00	6.00	7.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	-0.58	0.36	0.64	0.00	1.09	0.76	0.50	0.48	1.20	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	4.73	1.61	1.43	0.00	0.00	0.25	1.35	0.82	0.90	0.70	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	12.91	1.12	10.87	5.92	0.79	1.71	4.55	2.31	3.02	17.09	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.03	4.70	0.53	0.00	0.00	0.00	15.12	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	2,581.12	2,636.90	2,704.30	2,731.01	2,760.99	2,874.35	2,931.67	3,010.23	3,050.00	3,100.88	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,107.33	3,144.71	3,193.71	3,228.95	3,256.44	3,327.84	3,344.56	3,383.17	3,439.51	3,546.48	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	18,434.91	18,432.63	18,507.12	18,595.42	18,621.41	18,933.68	18,822.72	18,867.96	18,881.55	18,825.48	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	26,612.98	26,254.10	26,325.85	26,195.60	26,108.59	26,484.47	26,258.95	26,221.96	26,101.65	26,024.86	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	27,106.66	27,120.36	27,282.10	27,501.42	27,719.53	28,047.40	27,932.05	28,001.06	27,913.66	27,817.39	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	15.00	17.00	13.00	17.00	13.00	14.00	21.00	18.03	17.00	17.70	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	158.25	91.82	109.98	82.70	53.83	68.82	66.00	81.79	123.98	85.41	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	222.94	115.52	94.87	97.18	111.84	96.79	99.62	99.73	142.66	75.82	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	1,637.68	787.81	817.83	674.17	504.08	759.81	875.87	710.64	978.96	655.39	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	1,958.63	963.80	1,062.42	891.79	711.85	867.99	1,039.48	860.75	1,162.30	853.53	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	1,626.88	792.26	797.78	827.88	609.56	922.35	1,141.87	879.45	1,091.39	729.40	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	9.00	4.00	1.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	1.00	0.87	0.00	0.00	0.00	0.54	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	1.76	0.00	0.00	0.00	0.00	0.00	0.54	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	3.00	2.92	2.20	0.93	0.00	1.00	1.03	0.00	2.00	1.46	0.00	0.00	
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	
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	
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.23	0.00	0.00	0.00	0.00	0.00	0.45	0.00	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.00	1.06	2.00	4.06	0.00	0.00	0.96	0.00	0.00	0.53	0.00	0.00	
SUBTOTAL:	83,583.82	80,471.05	81,021.10	80,940.53	80,544.46	82,479.43	82,626.38	82,207.52	82,965.58	81,815.24	0.00	0.00	

 
0.00	
44.81	
47.97	
591.29	
83.47	
4.45	
11.79	
60.29	
20.38	
28,381.45	
32,972.70	
186,922.88	
262,589.01	
276,441.63	
162.73	
922.58	
1,156.97	
8,402.24	
10,372.54	
9,418.82	
15.00	
2.41	
2.30	
14.54	
0.00	
3.57	
0.68	
8.61	
818,655.11	

9939	BIRTH SUPP PAYMENT N	76.00	105.00	84.00	81.00	78.00	61.00	77.00	69.00	73.00	61.00	0.00	0.00	
SUBTOTAL:	76.00	105.00	84.00	81.00	78.00	61.00	77.00	69.00	73.00	61.00	0.00	0.00	

 
765.00	
765.00	

4403	SOBRA 100-133% M&F
6

0.00	0.00	0.00	2.80	3.00	1.06	1.00	2.00	1.12	1.80	0.00	0.00	12.78

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4404	SOBRA 100-133% MALE	0.00	1.00	2.00	2.00	2.00	2.25	4.00	3.00	3.00	2.56	0.00	0.00	21.81	
4405	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.06	1.00	0.00	0.00	3.06	
440C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	3.19	0.00	0.00	0.00	0.00	1.87	0.60	0.00	0.00	5.66	
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	5.74	
440E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.93	0.00	0.00	0.00	0.93	
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	0.00	
4412	SOBRA 100-133% M&F
1	17.33	13.00	13.00	8.12	10.73	7.77	7.99	6.25	5.93	5.00	0.00	0.00	95.12	
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	47,060.31	46,953.44	47,118.39	46,980.35	0.00	0.00	470,293.12	
4414	SOBRA 100-133% MALE	11,874.13	11,798.14	11,976.67	12,103.73	12,124.08	12,300.60	12,285.78	12,395.76	12,460.57	12,519.76	0.00	0.00	121,839.22	
4415	SOBRA 100-133% FEM AL	11,579.89	11,545.15	11,686.84	11,741.62	11,839.97	11,924.67	11,849.50	11,870.01	11,998.31	11,939.27	0.00	0.00	117,975.23	
441B	SOBRA 100-133% M&F
1	7.64	0.00	0.00	1.87	0.26	0.00	3.00	0.64	0.06	0.00	0.00	0.00	13.47	
441C	SOBRA 100-133% M&F
6	3,053.61	1,390.93	1,391.31	1,278.04	838.85	1,052.35	1,131.87	1,030.96	1,420.78	1,131.79	0.00	0.00	13,720.49	
441D	SOBRA 100-133% MALE	587.39	341.97	389.46	313.10	244.45	321.17	290.62	311.38	438.48	310.80	0.00	0.00	3,548.82	
441E	SOBRA 100-133% FEM AL	714.29	336.34	375.30	334.74	195.86	257.25	300.40	308.74	371.69	287.64	0.00	0.00	3,482.25	
4423	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.58	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.58	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	1.00	1.00	0.80	1.00	0.00	0.00	0.00	0.00	3.80	
SUBTOTAL	:	74,933.28	72,063.88	72,858.10	72,890.20	72,260.24	73,194.17	72,936.27	72,883.18	73,823.19	73,180.57	0.00	0.00	731,023.08	

4517	BC PATIENT FEMALE 2 1	21.16	20.00	18.13	17.00	17.06	17.05	16.38	17.14	17.00	17.82	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	172.08	153.75	147.28	130.12	140.39	134.75	117.08	109.38	105.45	105.01	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	1.73	1.00	5.00	13.00	17.00	1.00	1.00	1.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.83	0.00	4.86	0.00	0.93	2.93	0.60	1.85	0.00	2.83	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	2.08	2.36	8.72	5.17	5.59	5.20	7.87	9.88	0.00	15.95	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	14.00	14.00	12.00	11.45	9.00	9.00	8.00	7.00	7.32	7.20	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	8.00	8.00	8.00	7.00	6.00	6.00	6.00	7.00	7.00	7.00	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	0.67	1.80	0.00	0.00	
SUBTOTAL:	218.15	198.11	200.72	173.28	183.97	187.93	172.93	153.25	138.44	158.61	0.00	0.00	

178.74	
1,315.29	
40.73	
14.83	
62.82	
98.97	
70.00	
4.01	
1,785.39	

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.51	2.00	0.00	0.00	
860Z	SSI BLIND FREEDOM/W O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.48	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	1,796.48	1,813.32	1,852.02	1,864.61	0.00	0.00	
870Z	SSI DISABLED FREEDO M	76.88	18.42	45.33	128.23	67.61	79.60	99.58	56.76	135.84	85.26	0.00	0.00	
8710	SSI DISABLED FREEDO M	276.22	268.50	283.74	286.43	291.76	289.63	296.66	293.85	283.60	303.89	0.00	0.00	
871Z	SSI DISABLED FREEDO M	35.37	9.39	8.54	31.38	10.91	31.21	40.69	34.95	36.36	14.56	0.00	0.00	
8720	SSI DISABLED FREEDO M	214.51	222.53	207.95	207.33	215.49	205.03	216.08	215.67	223.17	221.52	0.00	0.00	

11.51	
1.48	
17,900.83	
793.51	
2,874.28	
253.36	
2,149.28	

9944	BIRTH SUPP PAYMENT S	6.00	9.00	6.00	10.00	8.00	2.00	7.00	1.00	7.00	5.00	0.00	0.00	
SUBTOTAL:	6.00	9.00	6.00	10.00	8.00	2.00	7.00	1.00	7.00	5.00	0.00	0.00	

 
61.00	
61.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
872Z	SSI DISABLED FREEDO M	3.47	2.18	2.52	7.39	2.49	6.95	10.89	2.38	2.78	3.89	0.00	0.00		44.94		
SUBTOTAL:	2,360.11	2,286.27	2,298.44	2,422.62	2,348.08	2,401.87	2,461.38	2,417.93	2,536.76	2,495.73	0.00	0.00		24,029.19		

1,621,481.24

1,589,928.80

TOTAL:

1,602,417.61

1,593,302.09	1,607,374.27	1,611,537.82	1,606,747.95

1,597,338.52

16,045,619.90

1,598,892.26

1,616,599.34

0.00	0.00

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9810	RURAL HOSP PMT TAC I	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,918,750.02	0.00	0.00	1,918,750.02	
9812	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,227.60	0.00	0.00	38,227.60	
9814	RURAL HOSP PMT MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,319.99	0.00	0.00	2,319.99	
9816	RURAL HOSP PMT FMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,046,783.06	0.00	0.00	3,046,783.06	
9818	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,527.77	0.00	0.00	2,527.77	
9821	RURAL HOSP PMT SSI W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,109,143.98	0.00	0.00	2,109,143.98	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,117,752.42	0.00	0.00	7,117,752.42	

9813	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107.61	0.00	0.00	
9815	RURAL HOSP PMT MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,037.25	0.00	0.00	
9817	RURAL HOSP PMT FMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,706,244.12	0.00	0.00	
9819	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,934.97	0.00	0.00	
9823	RURAL HOSP PMT FOR S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,504.87	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,773,828.82	0.00	0.00	

 
107.61	
2,037.25	
1,706,244.12	
3,934.97	
61,504.87	
1,773,828.82	

9835	RURAL HOSPITAL PMT A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	941,715.94	0.00	0.00	
9837	RURAL HOSPITAL PMT A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,831,788.36	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,773,504.30	0.00	0.00	

 
941,715.94	
1,831,788.36	
2,773,504.30	

9845	RURAL HOSP PMT FOR B	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	656.69	0.00	0.00	
9846	RURAL HOSP PMT FOR C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	380.17	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,036.86	0.00	0.00	

 
656.69	
380.17	
1,036.86	

9887	RH PAYMENT FREEDO M T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,462.70	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,462.70	0.00	0.00	

 
10,462.70	
10,462.70	

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,676,585.10	0.00	0.00	

11,676,585.10	

TOTAL:

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9810	RURAL HOSP PMT TAC I	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9812	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9814	RURAL HOSP PMT 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	
9816	RURAL HOSP PMT FMA 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	
9818	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9821	RURAL HOSP PMT SSI W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

9835	RURAL HOSPITAL PMT 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	
9837	RURAL HOSPITAL PMT 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	
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	

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

9887	RH PAYMENT FREEDO M T	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	

9813	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9815	RURAL HOSP PMT 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	
9817	RURAL HOSP PMT FMA 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	
9819	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9823	RURAL HOSP PMT FOR S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending April 30, 2017	
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	35,370.02	32,353.93	31,809.64	28,399.18	0.00	0.00		371,698.96		
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	2,482,260.62	2,472,306.90	2,490,894.98	2,510,517.20	0.00	0.00		24,667,715.03		
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	14,241.52	14,241.52	14,241.52	14,241.52	0.00	0.00		99,519.82		
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	31,176,279.05	35,903,751.86	31,381,949.70	32,726,968.68	0.00	0.00		328,963,077.17		
210Z	SSI AGED WITH MEDIC A	542,994.93	656,811.81	649,461.51	680,788.55	579,080.36	649,230.44	606,057.82	696,432.03	878,732.62	758,890.75	0.00	0.00		6,698,480.82		
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	3,062,992.04	3,260,945.39	3,020,874.40	2,922,502.19	0.00	0.00		30,825,123.17		
211Z	SSI AGED NON-MEDIC AR	4,608.65	22,415.95	26,737.54	17,364.42	13,461.95	28,385.40	20,390.01	17,459.07	21,184.91	27,908.60	0.00	0.00		199,916.50		
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	19,632,199.04	22,433,605.60	19,543,631.00	20,349,892.59	0.00	0.00		204,797,464.83		
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	12,033.93	14,588.73	21,168.29	18,435.20	0.00	0.00		137,004.28		
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	15,269,119.77	16,706,360.63	15,409,350.56	15,737,780.75	0.00	0.00		157,007,798.79		
220Z	SSI DISABLED WITH M E	45,197.99	72,772.52	67,317.02	87,641.17	92,231.69	85,603.01	82,232.08	78,183.12	85,348.11	93,446.71	0.00	0.00		789,973.42		
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	101,552,977.07	103,493,344.77	102,586,880.62	102,891,513.75	0.00	0.00		1,010,204,457.27		
221Z	SSI DISABLED NON-ME D	23,471.98	37,264.06	50,403.94	25,347.06	33,325.75	29,238.39	27,846.12	42,089.30	17,027.19	51,123.20	0.00	0.00		337,136.99		
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	22,439,085.04	23,672,022.52	22,557,867.38	23,033,474.41	0.00	0.00		227,546,030.01		
222Z	SSI DISABLED WITH Q M	717.28	5,025.38	3,782.81	2,796.70	227.54	2,252.69	5,816.20	0.00	3,926.40	5,766.90	0.00	0.00		30,311.90		
2300	SSI BLIND WITH MEDIC	66,335.96	72,964.65	79,626.95	80,592.35	84,285.15	78,663.84	75,848.18	79,203.00	79,035.65	72,836.79	0.00	0.00		769,392.52		
2310	SSI BLIND NON-MEDIC A	486,146.90	487,621.28	485,314.45	484,339.30	492,101.69	518,525.80	504,562.06	513,504.70	499,794.59	516,915.27	0.00	0.00		4,988,826.04		
2320	SSI BLIND WITH QMB	137,707.06	142,358.29	134,795.96	136,620.70	140,028.19	137,497.66	136,820.84	153,232.97	143,345.39	148,801.28	0.00	0.00		1,411,208.34		
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	197,136,131.41	209,583,626.04	198,787,062.95	201,909,414.97	0.00	0.00		1,999,866,474.38		

8700	SSI DISABLED FREEDO M	83,704.76	94,859.85	83,565.97	89,541.14	99,604.56	89,231.29	88,762.88	89,466.64	80,005.73	85,435.86	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	5,331.26	-5,331.26	943.72	1,215.61	0.00	1,042.75	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	131,962.33	142,699.99	131,962.33	121,220.42	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	
8720	SSI DISABLED FREEDO M	17,165.70	18,421.41	17,165.70	16,989.96	18,258.18	17,279.26	20,347.37	21,672.95	20,347.37	20,777.56	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	975.18	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	242,016.30	256,030.37	232,315.43	228,476.59	0.00	0.00	

 
884,178.68	
3,202.08	
1,294,845.82	
0.00	
188,425.46	
975.18	
2,371,627.22	

190,311,535.63	204,030,120.07	191,838,793.15	196,146,010.35	209,487,257.11	202,049,311.23	197,378,147.71	209,839,656.41	199,019,378.38	202,137,891.56	0.00	0.00	

2,002,238,101.60	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending April 30, 2017	
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	10.00	9.00	9.00	8.00	0.00	0.00		105.00		
1010	TANF NON-MEDICARE	675.51	680.77	680.40	683.90	696.26	688.51	691.17	687.00	693.59	698.67	0.00	0.00		6,875.78		
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	4.00	4.00	4.00	4.00	0.00	0.00		28.00		
2100	SSI AGED WITH MEDIC A	11,265.25	11,234.08	11,290.57	11,351.42	11,348.68	11,346.72	11,221.76	11,165.89	11,290.53	11,271.18	0.00	0.00		112,786.08		
210Z	SSI AGED WITH MEDIC A	564.29	677.36	678.75	693.97	591.76	657.08	617.66	688.54	877.59	748.69	0.00	0.00		6,795.69		
2110	SSI AGED NON-MEDIC AR	596.81	592.38	586.17	582.84	573.54	568.51	566.45	566.25	561.24	536.29	0.00	0.00		5,730.48		
211Z	SSI AGED NON-MEDIC AR	5.47	24.11	27.26	18.19	14.30	30.73	20.64	19.04	22.75	29.86	0.00	0.00		212.35		
2120	SSI AGED WITH QMB	7,455.45	7,481.63	7,490.54	7,498.62	7,494.32	7,489.53	7,497.08	7,443.45	7,496.12	7,482.78	0.00	0.00		74,829.52		
212Z	SSI AGED WITH QMB P P	8.97	11.53	14.63	7.07	10.30	19.95	11.95	14.91	21.57	18.28	0.00	0.00		139.16		
2200	SSI DISABLED WITH M E	4,856.19	4,930.65	4,899.87	4,874.40	4,878.01	4,884.09	4,892.40	4,939.47	4,950.21	4,938.22	0.00	0.00		49,043.51		
220Z	SSI DISABLED WITH M E	48.42	76.93	75.24	85.66	93.51	85.23	83.10	78.83	91.22	91.50	0.00	0.00		809.64		
2210	SSI DISABLED NON-ME D	26,357.77	26,471.04	26,580.74	26,594.62	26,756.31	26,836.23	26,974.54	27,047.42	27,209.24	27,153.60	0.00	0.00		267,981.51		
221Z	SSI DISABLED NON-ME D	24.77	37.42	41.24	26.02	33.61	28.98	28.33	41.94	14.30	47.93	0.00	0.00		324.54		
2220	SSI DISABLED WITH Q M	6,861.39	6,872.57	6,919.11	6,913.09	6,938.65	6,937.12	6,947.57	6,936.21	6,975.10	7,014.00	0.00	0.00		69,314.81		
222Z	SSI DISABLED WITH Q M	0.77	4.89	4.15	2.96	0.23	2.77	6.12	0.00	3.57	5.42	0.00	0.00		30.88		
2300	SSI BLIND WITH MEDIC	20.00	21.00	24.00	24.00	24.00	23.00	22.35	22.00	23.00	21.00	0.00	0.00		224.35		
2310	SSI BLIND NON-MEDIC A	136.44	136.00	137.26	133.48	133.00	137.06	136.83	137.96	134.92	139.00	0.00	0.00		1,361.95		
2320	SSI BLIND WITH QMB	43.31	43.00	42.79	43.00	42.00	42.41	43.11	46.00	45.00	46.00	0.00	0.00		436.62		
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	59,775.06	59,847.91	60,422.95	60,254.42	0.00	0.00		597,038.23		

8700	SSI DISABLED FREEDO M	26.00	26.67	25.90	27.00	27.33	26.67	27.03	23.97	24.00	24.93	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	5.66	-5.66	0.96	1.25	0.00	1.06	0.00	0.00	
8710	SSI DISABLED FREEDO M	24.00	23.32	23.00	23.00	24.00	24.00	24.00	24.00	24.00	24.00	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	
8720	SSI DISABLED FREEDO M	6.00	6.00	6.00	6.00	6.00	6.00	7.00	7.00	7.00	7.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.00	55.99	54.90	56.00	62.99	51.01	58.99	57.22	55.00	56.99	0.00	0.00	

 
259.50	
3.27	
237.32	
0.00	
64.00	
1.00	
565.09	

TOTAL:	58,992.68	59,364.35	59,566.11	59,603.24	59,705.47	59,842.93	59,834.05	59,905.13	60,477.95	60,311.41	0.00	0.00		597,603.32		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2017	
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	169.29	258.15	344.13	408.59	0.00	0.00		1,237.06		
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.25	0.00	0.00	0.00		9.25		
1002	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.81	0.00	0.00	0.00		26.81		
1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	20.19	0.00	0.00	0.00	0.00	0.00		20.19		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	33.04	0.00	161.87	0.00	0.00	0.00		194.91		
100B	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.85	0.00	0.00	0.00		1.85		
100C	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	8.26	0.00	0.00	0.00	0.00	0.00		8.26		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	2,972,808.05	0.00	0.00	2,691,391.78	3,005,532.10	2,968,161.66	3,025,963.55	0.00	0.00		14,663,857.14		
1011	TANF <1 M & F NON-ME	0.00	0.00	4,780.98	27,888.83	0.00	4,816.59	32,674.58	27,435.16	32,528.50	21,041.58	0.00	0.00		151,166.22		
1012	TANF 01-05 M & F NON	0.00	0.00	-999.24	6,087.68	0.00	628.68	10,768.15	-8,285.24	14,453.19	6,989.13	0.00	0.00		29,642.35		
1013	TANF 06-13 M & F NON	0.00	0.00	982.48	10,237.30	0.00	541.96	10,116.69	-17,934.52	10,097.35	11,261.05	0.00	0.00		25,302.31		
1014	TANF 14-20 MALE NON-	0.00	0.00	274.85	4,661.97	0.00	76.23	2,194.14	-4,329.48	2,129.15	2,102.24	0.00	0.00		7,109.10		
1015	TANF 14-20 FEMALE N O	0.00	0.00	276.04	5,084.09	0.00	27.92	1,262.18	-4,412.31	2,327.21	1,867.40	0.00	0.00		6,432.53		
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		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	2.75	0.00	-28.66	0.00	0.00	0.00		-25.91		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	2,757.79	0.00	5,116.77	51,103.04	39,815.56	52,648.18	48,900.96	0.00	0.00		200,342.30		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	2,330.99	0.00	1,108.34	7,292.49	7,208.12	12,492.49	10,226.25	0.00	0.00		40,658.68		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	2,949.36	0.00	1,028.59	8,796.50	7,474.78	11,588.84	11,877.44	0.00	0.00		43,715.51		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	591.34	0.00	151.55	2,011.11	1,063.89	2,110.40	3,179.10	0.00	0.00		9,107.39		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	1,210.60	0.00	145.55	1,458.76	1,721.03	3,758.28	2,539.69	0.00	0.00		10,833.91		
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	55.49	172.38	57.32	29.29	0.00	0.00		425.46		
2210	SSI DISABLED NON-ME D	0.00	0.00	6,042.11	1,893,541.65	0.00	-52.10	322,823.25	344,758.27	338,840.36	340,947.75	0.00	0.00		3,246,901.29		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	736.55	0.00	542.99	4,365.42	4,710.43	4,988.83	3,464.73	0.00	0.00		18,808.95		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	977.78	0.00	0.00	375.78	321.37	350.03	349.54	0.00	0.00		2,374.50		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	2,252.75	0.00	0.00	1,522.53	1,567.02	1,588.52	1,567.53	0.00	0.00		8,498.35		
231Z	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40.38	0.00	0.00		40.38		
4300	SOBRA CHILD WITH M ED	0.00	0.00	0.00	1,998.89	0.00	0.00	2,000.87	2,603.00	3,182.73	3,472.87	0.00	0.00		13,258.36		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	168.66	0.00	56.40	12.21	0.00	0.00		237.27		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	94.54	0.00	0.00	-12.53	8.18	46.30	85.53	0.00	0.00		222.02		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.72	0.00	0.00		11.72		
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	10.10	0.00	0.00	0.00	-21.50	0.00	26.36	0.00	0.00		14.96		
430B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	85.91	0.00	51.74	31.49	0.00	0.00		169.14		
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	47.71	0.00	0.00	0.00	21.49	33.94	85.01	0.00	0.00		188.15		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.57	0.00	0.00		17.57		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	18.35	0.00	0.00	0.00	0.00	0.00	31.59	0.00	0.00		49.94		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	32,582,791.23	0.00	0.00	19,534,567.34	21,077,405.29	20,769,134.54	20,776,944.78	0.00	0.00		114,740,843.18		
4311	SOBRA CHILD <1 M & F	0.00	0.00	16,585.12	101,558.93	0.00	8,744.64	73,539.05	70,519.13	76,100.56	55,701.34	0.00	0.00		402,748.77		
4312	SOBRA CHILD 01-05 M	0.00	0.00	9,176.08	134,775.02	0.00	13,665.99	110,515.38	41,713.52	140,612.03	123,577.08	0.00	0.00		574,035.10		
4313	SOBRA CHILD 06-13 M	0.00	0.00	28,671.34	129,554.08	0.00	12,744.26	110,241.70	23,029.97	135,494.92	123,774.45	0.00	0.00		563,510.72		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	1,802.52	37,478.50	0.00	2,823.44	21,565.08	5,302.96	26,225.99	24,286.72	0.00	0.00		119,485.21		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	16,681.14	21,239.99	0.00	3,630.18	21,482.11	5,302.21	26,208.05	21,751.94	0.00	0.00		116,295.62		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	12,551.84	0.00	897.80	15,913.36	10,699.94	15,636.84	12,424.81	0.00	0.00		68,124.59		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	52,870.33	0.00	16,353.14	147,780.68	134,127.35	177,571.19	147,769.98	0.00	0.00		676,472.67		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	57,860.11	0.00	14,673.16	135,856.56	129,594.15	164,712.23	137,587.33	0.00	0.00		640,283.54		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	16,103.43	0.00	3,889.25	29,779.71	26,243.54	32,625.32	28,027.66	0.00	0.00		136,668.91		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	13,430.13	0.00	4,260.71	29,247.38	24,792.18	31,303.84	27,346.87	0.00	0.00		130,381.11		
4320	SOBRA CHILD WITH Q MB	0.00	0.00	0.00	112.39	0.00	0.00	113.80	114.64	85.98	115.69	0.00	0.00		542.50		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.02	0.00	0.00	0.00	0.00		-1.02		
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	15,827.29	18,411.71	17,926.17	18,275.51	0.00	0.00		99,767.21		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	310.77	1,029.99	0.00	233.51	801.39	923.65	1,130.63	860.81	0.00	0.00		5,290.75		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	360.58	0.00	274.66	1,166.31	1,143.43	1,664.14	1,032.10	0.00	0.00		5,641.22		
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	23,399,085.47	24,979,010.53	25,078,439.10	24,996,007.62	0.00	0.00		216,198,086.33		

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	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.79	0.00	0.00	0.00	

776.66	
14.79	

1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	6,425.42	0.00	0.00	5,357.76	4,767.45	4,302.99	3,790.65	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	87.72	0.00	0.00	27.53	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	9.21	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	-58.74	0.00	-18.49	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	-56.90	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	29.37	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	5,299.02	4,776.66	4,284.50	3,790.65	0.00	0.00	

 
24,644.27	
115.25	
9.21	
-77.23	
-56.90	
58.01	
0.00	
0.00	
24,692.61	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-96.78	0.00	0.00	-96.78	
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-3.67	0.00	0.00	-3.67	
SUBTOTAL	:	0.00	0.00	0.00	776.66	0.00	0.00	0.00	0.00	14.79	-100.45	0.00	0.00	691.00	

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	55.49	0.00	0.00	0.00	0.00	0.00	29.29	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-17.13	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	55.49	0.00	0.00	0.00	0.00	0.00	12.16	0.00	0.00	

84.78	
-17.13	
67.65	

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	83.94	0.00	0.00	140.84	143.51	143.51	174.27	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	3.70	-5.85	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-24.75	0.00	0.00	
4405	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60.82	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	53.62	17.57	0.00	0.00	
440E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.82	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	2,376,975.75	2,573,793.34	2,538,635.11	2,553,639.87	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	-51.91	7.16	26.81	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	24,768.42	3,305.91	33,847.97	27,455.76	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	1,555.12	6,025.82	0.00	674.67	5,153.21	130.23	8,006.58	6,212.42	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	1,105.03	5,327.00	0.00	639.31	4,588.26	306.82	7,733.10	5,981.38	0.00	0.00	
441B	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	85.35	18.42	1.85	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	38,764.15	36,371.99	51,504.97	41,825.89	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	2,372.99	0.00	1,117.24	7,109.85	8,440.84	12,864.38	9,605.49	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	2,691.47	0.00	878.61	8,242.45	7,799.30	11,494.33	8,408.43	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	28.45	0.00	0.00	28.45	28.66	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	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	-5.51	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	2,465,799.31	2,630,346.18	2,664,430.57	2,653,290.48	0.00	0.00	

686.07	
153.58	
-24.75	
60.82	
81.93	
53.82	
12,473,768.45	
-17.94	
131,364.32	
27,758.05	
25,680.90	
105.62	
184,284.31	
41,510.79	
39,514.59	
85.56	
-11.93	
-5.51	
12,925,048.68	

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

10.10	
18.35	
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	-86.40	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	-57.32	-62.59	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	-29.29	0.00	0.00	
SUBTOTAL:	0.00	0.00	1.85	5,146.80	0.00	0.00	0.00	-57.32	-62.59	-115.69	0.00	0.00	

75.25	
1,245.08	
2,486.20	
594.99	
511.53	
4,913.05	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	0.00	0.00	92,799.73	40,839,228.09	39,495,083.58	39,842,165.38	25,870,183.80	27,614,076.05	27,747,106.37	27,652,884.77	0.00	0.00		229,153,527.77		

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2017	
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	5.00	8.00	11.00	13.00	0.00	0.00		39.00		
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00	0.00	0.00	0.00		10.00		
1002	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.00	0.00	0.00	0.00		29.00		
1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	22.00	0.00	0.00	0.00	0.00	0.00		22.00		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	35.00	0.00	172.00	0.00	0.00	0.00		207.00		
100B	TANF 01-05 M & F WIT	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		
100C	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	9.00	0.00	0.00	0.00	0.00	0.00		9.00		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	68,480.00	0.00	0.00	71,750.00	74,704.00	73,782.00	74,809.00	0.00	0.00		363,525.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	4,081.00	26,392.00	19,606.00	24,632.00	15,691.00	0.00	0.00		90,402.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	523.00	8,613.00	-5,679.00	11,346.00	5,598.00	0.00	0.00		20,401.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	516.00	8,462.00	-12,954.00	8,255.00	7,947.00	0.00	0.00		12,226.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	68.00	1,836.00	-3,234.00	1,701.00	1,720.00	0.00	0.00		2,091.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	59.00	1,154.00	-2,868.00	1,562.00	1,305.00	0.00	0.00		1,212.00		
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	3.00	0.00	-31.00	0.00	0.00	0.00		-28.00		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	4,359.00	43,665.00	32,611.00	41,220.00	38,430.00	0.00	0.00		160,285.00		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	985.00	6,336.00	5,787.00	9,565.00	7,388.00	0.00	0.00		30,061.00		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	982.00	7,563.00	5,921.00	9,335.00	8,650.00	0.00	0.00		32,451.00		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	149.00	1,646.00	776.00	1,724.00	2,182.00	0.00	0.00		6,477.00		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	117.00	1,131.00	1,417.00	2,557.00	1,893.00	0.00	0.00		7,115.00		
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	1.00	4.00	2.00	1.00	0.00	0.00		10.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	19,129.00	0.00	-85.00	8,844.00	8,802.00	8,994.00	8,835.00	0.00	0.00		54,519.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	446.00	3,402.00	4,201.00	3,954.00	2,860.00	0.00	0.00		14,863.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	11.00	0.00	0.00	8.00	6.00	7.00	7.00	0.00	0.00		39.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	52.00	0.00	0.00	45.00	24.00	45.00	62.00	0.00	0.00		228.00		
231Z	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43.00	0.00	0.00		43.00		
4300	SOBRA CHILD WITH M ED	0.00	0.00	0.00	35.00	0.00	0.00	59.00	74.00	87.00	92.00	0.00	0.00		347.00		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	122.00	0.00	61.00	3.00	0.00	0.00		186.00		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	-7.00	11.00	40.00	80.00	0.00	0.00		124.00		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00	0.00	0.00		12.00		
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-21.00	0.00	27.00	0.00	0.00		6.00		
430B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	67.00	0.00	53.00	33.00	0.00	0.00		153.00		
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.00	26.00	74.00	0.00	0.00		121.00		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.00	0.00	0.00		18.00		
430E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.00	0.00	0.00		34.00		

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	550,197.00	0.00	0.00	529,394.00	533,704.00	525,774.00	522,219.00	0.00	0.00		2,661,288.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	7,659.00	60,013.00	50,101.00	58,649.00	42,055.00	0.00	0.00		218,477.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	11,720.00	92,473.00	28,817.00	109,125.00	93,745.00	0.00	0.00		335,880.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	11,001.00	91,081.00	15,259.00	105,704.00	94,037.00	0.00	0.00		317,082.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	2,512.00	17,983.00	3,303.00	20,456.00	18,749.00	0.00	0.00		63,003.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	2,899.00	17,433.00	4,094.00	20,461.00	16,192.00	0.00	0.00		61,079.00		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	705.00	13,376.00	8,520.00	11,637.00	9,530.00	0.00	0.00		43,768.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	14,224.00	127,486.00	106,371.00	138,955.00	116,050.00	0.00	0.00		503,086.00		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	13,249.00	117,555.00	102,628.00	131,159.00	107,977.00	0.00	0.00		472,568.00		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	3,483.00	25,825.00	20,507.00	24,978.00	22,001.00	0.00	0.00		96,794.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	3,492.00	24,633.00	19,907.00	24,359.00	21,210.00	0.00	0.00		93,601.00		
4320	SOBRA CHILD WITH Q MB	0.00	0.00	0.00	3.00	0.00	0.00	4.00	4.00	3.00	3.00	0.00	0.00		17.00		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.00	0.00	0.00	0.00	0.00		-1.00		
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	409.00	439.00	431.00	439.00	0.00	0.00		2,207.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	163.00	703.00	692.00	893.00	661.00	0.00	0.00		3,112.00		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	212.00	987.00	882.00	1,198.00	779.00	0.00	0.00		4,058.00		
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	1,310,518.00	1,024,444.00	1,372,923.00	1,243,454.00	0.00	0.00		7,070,702.00		

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	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00	0.00	0.00	0.00	

2.00	
16.00	

1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	180.00	0.00	0.00	150.00	126.00	114.00	100.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	30.00	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	9.00	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	-64.00	0.00	-20.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	-61.00	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	32.00	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	87.00	135.00	94.00	100.00	0.00	0.00	

 
670.00	
30.00	
9.00	
-84.00	
-61.00	
32.00	
0.00	
0.00	
596.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-102.00	0.00	0.00	-102.00	
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4.00	0.00	0.00	-4.00	
SUBTOTAL	:	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	16.00	-106.00	0.00	0.00	-88.00	

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-9.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	-8.00	0.00	0.00	

2.00	
-9.00	
-7.00	

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	2.00	0.00	0.00	4.00	4.00	4.00	5.00	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	4.00	-6.00	0.00	0.00	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13.00	0.00	0.00	
4405	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32.00	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	55.00	18.00	0.00	0.00	
440E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29.00	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	64,647.00	65,427.00	64,508.00	64,473.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	-29.00	7.00	29.00	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	20,392.00	2,309.00	26,139.00	20,682.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	485.00	3,928.00	20.00	5,947.00	4,700.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	535.00	3,722.00	153.00	5,995.00	4,405.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	92.00	18.00	2.00	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	32,752.00	28,593.00	40,315.00	32,367.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	868.00	5,956.00	6,255.00	9,597.00	7,289.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	730.00	6,892.00	6,129.00	8,686.00	6,416.00	0.00	0.00	
4420	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	0.00	0.00	1.00	1.00	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	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	-6.00	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	138,351.00	108,916.00	161,342.00	140,336.00	0.00	0.00	

19.00	
-2.00	
-13.00	
32.00	
73.00	
29.00	
323,605.00	
7.00	
72,809.00	
15,080.00	
14,810.00	
112.00	
138,288.00	
29,965.00	
28,853.00	
3.00	
0.00	
-6.00	
623,664.00	

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

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	-60.00	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	-56.00	-31.00	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	-30.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-56.00	-31.00	-90.00	0.00	0.00	

0.00	
-60.00	
-87.00	
0.00	
-30.00	
-177.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	0.00	0.00	0.00	703,700.00	697,116.00	793,449.00	1,448,956.00	1,133,439.00	1,534,344.00	1,383,686.00	0.00	0.00		7,694,690.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2017	
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	1,774.97	0.00	0.00		3,555.45		
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	954.94	0.00	0.00	0.00		954.94		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	1.88	0.00	212.21	2,251.59	0.00	0.00		2,465.68		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	118.39	0.00	0.00	0.00	0.00	0.00		118.39		
100F	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,503.10	0.00	0.00	0.00		3,503.10		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	36,591.46	0.00	0.00	33,577.21	56,807.33	60,193.41	77,222.81	0.00	0.00		264,392.22		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	565.66	0.00	0.00	3,334.93	9,806.77	1,089.46	0.00	0.00	0.00		14,796.82		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	295.97	0.00	0.00	2,220.16	7,963.72	5,385.27	20,126.23	0.00	0.00		35,991.35		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	2,354.77	0.00	0.00	2,259.55	3,325.38	31,434.28	8,637.46	0.00	0.00		48,011.44		
1017	TANF 21-44 FEMALE N O	0.00	0.00	1,407.35	7,975.19	0.00	387.75	18,821.01	34,593.62	40,797.46	52,616.27	0.00	0.00		156,598.65		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	2,024.76	0.00	295.97	4,682.67	9,177.08	17,812.17	17,853.62	0.00	0.00		51,846.27		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,435.99	0.00	0.00	0.00		3,435.99		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	2,470.44	0.00	0.00	1,376.80	3,993.89	0.00	0.00		7,841.13		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	1,395.02	3,164.11	0.00	1,128.32	0.00	0.00		5,687.45		
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	0.89	1,090.09	2,839.95	0.00	0.00		3,930.93		
210Z	SSI AGED WITH MEDIC A	0.00	0.00	0.00	3.23	0.00	0.00	0.00	658.78	2,677.53	709.99	0.00	0.00		4,049.53		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	611.68	0.00	0.00	0.00	0.00	0.00	887.48	0.00	0.00		1,499.16		
211Z	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,949.82	0.00	0.00	0.00	0.00		1,949.82		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	4,970.51	0.00	0.00	5,964.42	23,580.85	20,072.74	18,910.57	0.00	0.00		73,499.09		
212Z	SSI AGED WITH QMB P P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	518.00	0.00	0.00	0.00	0.00		518.00		
2200	SSI DISABLED WITH M E	0.00	0.00	4.04	11,736.62	0.00	1,395.02	13,438.87	23,828.75	28,860.55	22,513.54	0.00	0.00		101,777.39		
220Z	SSI DISABLED WITH M E	0.00	0.00	0.00	796.92	0.00	0.00	2,016.10	2,672.11	10,066.46	10,644.06	0.00	0.00		26,195.65		
2210	SSI DISABLED NON-ME D	0.00	0.00	1,099.38	217,351.29	0.00	4,311.82	249,696.73	414,841.02	477,442.18	443,289.43	0.00	0.00		1,808,031.85		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	1,815.46	0.00	0.00	8,455.55	22,592.19	14,214.14	3,343.47	0.00	0.00		50,420.81		
2220	SSI DISABLED WITH Q M	0.00	0.00	784.40	67,465.93	0.00	0.00	111,145.51	139,095.79	160,627.59	219,404.21	0.00	0.00		698,523.43		
222Z	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	-2,849.17	2,729.57	1,168.80	2,967.47	0.00	0.00		4,016.67		
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	15,039.27	0.00	0.00	0.00		15,039.27		
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	3,951.39	6,358.72	7,083.88	5,493.82	0.00	0.00		28,003.80		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	1,163.24	0.00	0.00	10,162.90	5,233.45	15,291.71	13,457.61	0.00	0.00		45,308.91		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	490.36	2,128.60	0.00	0.00	5,260.64	9,341.52	8,996.49	7,268.94	0.00	0.00		33,486.55		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	226.22	0.00	0.00	1,868.15	0.00	0.00		2,094.37		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,192.42	0.00	0.00	0.00	0.00		2,192.42		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2017	
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		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	3,015.70	0.00	0.00	1,583.50	1,644.62	1,644.62	5,620.76	0.00	0.00		13,509.20		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,151.34	477.47	0.00	0.00	0.00		5,628.81		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	632.12	597.69	0.00	0.00	774.15	2,542.36	9,064.37	9,632.23	0.00	0.00		23,242.92		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.15	0.00	0.00	0.00	0.00		411.15		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,012.96	0.00	0.00	0.00		1,012.96		
501H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,233.46	0.00	0.00	0.00	0.00		1,233.46		
5020	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	1,168.80	0.00	0.00	1,168.80	0.00	0.00	0.00	0.00	0.00		2,337.60		
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	477,406.43	791,414.82	941,025.94	954,456.84	0.00	0.00		5,408,603.89		

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	7,932.86	0.00	0.00	7,944.72	12,012.46	12,012.46	9,852.45	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	2.37	8,351.11	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,261.50	536.13	3,070.71	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	352.42	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	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	301.63	640.95	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,017.99	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	16,128.53	0.00	0.00	12,787.70	23,523.58	21,484.33	20,237.02	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	2,254.49	0.00	0.00	4,850.41	8,746.41	15,401.08	9,710.40	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	3,396.13	0.00	1,093.39	3,752.31	12,672.72	24,593.50	33,719.80	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	5.96	414.74	0.00	0.00	-1,634.64	881.05	4,848.11	9,242.92	0.00	0.00	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	318.77	2,719.36	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	876.61	0.00	0.00	0.00	1,697.43	901.89	1,774.97	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	1,235.22	0.00	0.00	1,314.14	3,688.17	3,688.17	5,852.92	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	2,449.19	3,162.99	7,860.61	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	5,379.64	352.42	20,409.52	4,405.54	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58.74	212.21	8,651.61	0.00	0.00	
112F	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	
112H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,432.41	38.96	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	8.76	4,796.18	0.00	0.00	5,022.40	9,483.29	3,956.55	9,635.02	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	980.28	0.00	0.00	1,056.16	1,175.89	1,379.36	1,920.49	0.00	0.00	
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	1,052.69	2,399.00	4,367.56	2,225.34	0.00	0.00	

 
49,754.95	
9,412.40	
6,868.34	
352.42	
6.46	
942.58	
1,017.99	
94,161.16	
40,962.79	
79,227.85	
13,758.14	
3,038.13	
5,250.90	
15,778.62	
13,472.79	
30,547.12	
8,922.56	
0.00	
1,471.37	
0.00	
0.00	
32,902.20	
6,512.18	
10,044.59	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	1,659.70	0.00	0.00	2,421.43	4,160.12	5,340.73	2,653.54	0.00	0.00	16,235.52	
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	1,287.06	0.00	0.00	0.00	0.00	0.00	1,287.06	
2620	SSI DISABLED EXPAND E	0.00	0.00	284.40	28,081.89	0.00	150.81	36,658.79	55,529.32	47,443.68	55,329.07	0.00	0.00	223,477.96	
262Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	1,220.22	2,834.85	-2,834.85	4,774.52	0.00	0.00	5,994.74	
SUBTOTAL	:	0.00	0.00	299.12	68,822.01	0.00	1,244.20	85,562.22	146,612.76	176,396.13	192,464.38	0.00	0.00	671,400.82	

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	
3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	2,340.83	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	2.27	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	36,271.85	54,005.15	55,000.82	53,947.77	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	11.10	0.00	0.00	597.69	2,856.85	795.78	8,363.45	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	1,168.91	565.55	0.00	0.00	565.55	0.00	2,476.73	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	383.92	4,915.10	26,430.84	33,832.48	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	14.60	1,916.12	0.00	0.00	11,623.68	6,364.97	36,777.90	28,121.57	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	274.74	4,796.05	0.00	188.52	8,596.80	21,591.27	47,104.07	38,316.55	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	584.40	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	3,265.47	7,989.28	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	2,339.87	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	0.00	0.21	5,316.42	5,301.76	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	611.68	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	1,774.97	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	1.44	1,703.36	0.00	530.52	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	3.23	0.00	0.00	0.00	570.90	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	293.68	3,019.97	7,580.64	0.00	0.00	
370F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	293.68	0.00	0.00	0.00	0.00	
370G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	317.02	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,298.20	8,869.73	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	177,719.03	0.00	0.00	166,208.56	240,381.17	232,126.68	269,242.99	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	1,739.25	0.00	0.00	7,642.63	14,392.92	1,060.85	17,164.24	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	2,226.07	0.00	297.89	2,981.56	3,268.72	9,702.95	3,753.32	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	60,011.61	91,524.10	206,071.77	173,874.12	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	1,291.54	16,371.03	0.00	884.87	39,163.14	74,875.60	112,319.75	130,392.71	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	65,804.00	76,509.37	195,537.01	198,016.04	0.00	0.00	
371D	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	942.58	2,813.42	0.00	2,513.77	0.00	0.00	

0.00	
2,340.83	
5.19	
2.92	
239,584.38	
12,624.87	
4,776.74	
69,697.40	
84,818.84	
120,868.00	
1,338.46	
11,267.12	
2,339.87	
10,618.39	
0.00	
611.68	
1,774.97	
2,235.32	
574.13	
10,894.29	
293.68	
317.02	
12,167.93	
1,085,678.43	
41,999.89	
22,230.51	
564,363.36	
375,298.64	
561,383.60	
6,269.77	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	716.36	0.00	0.00	1,388.63	1,115.99	0.00	6,367.92	0.00	0.00		9,588.90		
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	8,364.62	0.00	0.00	11,348.07	13,617.40	19,171.64	16,955.13	0.00	0.00		69,456.86		
371G	ADULT <40% EXP FEM AL	0.00	0.00	5.84	2,530.39	0.00	0.00	5,235.45	10,560.50	11,996.75	14,334.98	0.00	0.00		44,663.91		
371H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	1,329.05	0.00	0.00	4,529.11	10,175.75	22,248.83	16,513.05	0.00	0.00		54,795.79		
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		
3726	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	118.33	0.00	0.00		118.33		
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	1,183.31	0.00	0.00		1,183.31		
372H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295.83	0.00	0.00		295.83		
SUBTOTAL:	0.00	0.00	9,512.69	309,348.34	0.00	7,218.79	429,476.78	636,577.69	994,292.17	1,040,052.70	0.00	0.00		3,426,479.16		

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	1,432.70	0.00	0.00	456.70	176.22	0.00	1,471.72	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	2,601.52	565.55	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	4,624.33	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	0.00	527.85	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	6,174.43	176.22	0.00	1,471.72	0.00	0.00	

3,537.34	
3,167.07	
4,626.37	
527.85	
11,858.63	

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	1,934.27	19,339.69	6,540.52	14,203.99	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	8.76	452.44	0.00	0.00	0.00	490.14	2.92	7,113.95	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	150.80	0.00	0.00	312.18	234.90	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	267.10	0.00	0.00	0.00	0.00	

45,248.72	
8,068.21	
697.88	
417.90	

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	188.52	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	12,876.84	26,799.29	17,078.14	22,580.62	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	1,255.35	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	-150.81	139.87	1,975.80	0.00	709.99	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1,394.59	0.00	0.00	2,251.14	12,678.66	13,905.88	20,068.89	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	5.84	1,330.06	0.00	0.00	4,090.03	2,548.40	8,739.22	12,536.46	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	4,841.64	0.00	199.23	2,961.65	7,956.60	11,082.63	27,481.43	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,096.32	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	301.63	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	3,599.25	0.00	1,485.46	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,092.28	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	5.84	15,535.66	0.00	48.42	26,408.93	57,051.03	57,387.65	84,632.74	0.00	0.00	

 
0.00	
188.52	
87,304.26	
1,255.35	
2,674.85	
50,299.16	
29,250.01	
54,523.18	
5,096.32	
301.63	
5,084.71	
5,092.28	
241,070.27	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	292.26	3,700.79	0.00	0.00	2,246.45	20,331.83	6,543.44	21,317.94	0.00	0.00		54,432.71		

6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,870.84	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,870.84	0.00	0.00	0.00	

 
1,870.84	
1,870.84	

806,978.18

2,177,516.17

0.00

0.00

TOTAL:

0.00

0.00	14,527.56

837,526.52	1,005,331.98	1,027,275.24	1,652,164.35

2,294,396.32

9,815,716.32

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2017	
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	1.00	0.00	0.00		3.00		
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.00	0.00	0.00	0.00		18.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	18.00	0.00	4.00	29.00	0.00	0.00		51.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	6.00	0.00	0.00	0.00	0.00	0.00		6.00		
100F	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72.00	0.00	0.00	0.00		72.00		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	39.00	0.00	0.00	31.00	31.00	33.00	40.00	0.00	0.00		174.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	81.00	195.00	20.00	0.00	0.00	0.00		296.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	99.00	425.00	115.00	844.00	0.00	0.00		1,483.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	81.00	67.00	1,590.00	260.00	0.00	0.00		1,998.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	10.00	502.00	1,796.00	2,797.00	2,307.00	0.00	0.00		7,412.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	15.00	129.00	205.00	1,215.00	667.00	0.00	0.00		2,231.00		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58.00	0.00	0.00	0.00		58.00		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	61.00	0.00	0.00	25.00	85.00	0.00	0.00		171.00		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	37.00	88.00	0.00	23.00	0.00	0.00		148.00		
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	12.00	21.00	19.00	0.00	0.00		52.00		
210Z	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00	51.00	12.00	0.00	0.00		79.00		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	15.00	0.00	0.00		16.00		
211Z	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40.00	0.00	0.00	0.00	0.00		40.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	4.00	0.00	0.00	19.00	388.00	42.00	51.00	0.00	0.00		504.00		
212Z	SSI AGED WITH QMB P P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.00	0.00	0.00	0.00	0.00		13.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	12.00	0.00	37.00	278.00	454.00	618.00	545.00	0.00	0.00		1,944.00		
220Z	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	52.00	48.00	316.00	247.00	0.00	0.00		663.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	200.00	0.00	144.00	3,235.00	4,786.00	9,909.00	5,264.00	0.00	0.00		23,538.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	294.00	549.00	303.00	59.00	0.00	0.00		1,205.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	69.00	0.00	0.00	1,760.00	1,324.00	1,088.00	3,657.00	0.00	0.00		7,898.00		
222Z	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	-70.00	51.00	31.00	61.00	0.00	0.00		73.00		
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	933.00	0.00	0.00	0.00		933.00		
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	3.00	3.00	3.00	2.00	0.00	0.00		14.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	356.00	88.00	299.00	595.00	0.00	0.00		1,338.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	155.00	140.00	173.00	110.00	0.00	0.00		578.00		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	6.00	0.00	0.00	41.00	0.00	0.00		47.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.00	0.00	0.00	0.00	0.00		28.00		

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2017	
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		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	3.00	0.00	0.00	1.00	1.00	1.00	3.00	0.00	0.00		9.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	190.00	9.00	0.00	0.00	0.00		199.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	15.00	46.00	464.00	519.00	0.00	0.00		1,044.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00	0.00	0.00	0.00	0.00		7.00		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.00	0.00	0.00	0.00		26.00		
501H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.00	0.00	0.00	0.00	0.00		21.00		
5020	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	1.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00		2.00		
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	7,089.00	11,012.00	20,234.00	15,456.00	0.00	0.00		55,726.00		

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	9.00	0.00	0.00	8.00	7.00	7.00	6.00	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	22.00	143.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72.00	121.00	55.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	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	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00	17.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	16.00	0.00	0.00	12.00	13.00	11.00	10.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	120.00	180.00	1,079.00	596.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	29.00	203.00	895.00	1,290.00	1,227.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	-33.00	15.00	216.00	501.00	0.00	0.00	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00	59.00	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	40.00	17.00	30.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	1.00	0.00	0.00	1.00	2.00	2.00	3.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	61.00	131.00	283.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	218.00	6.00	630.00	96.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	4.00	182.00	0.00	0.00	
112F	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	
112H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.00	1.00	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	5.00	0.00	0.00	11.00	15.00	306.00	381.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	27.00	30.00	26.00	44.00	0.00	0.00	
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	27.00	84.00	66.00	51.00	0.00	0.00	

 
37.00	
165.00	
248.00	
6.00	
0.00	
25.00	
27.00	
62.00	
1,975.00	
3,644.00	
699.00	
67.00	
87.00	
9.00	
475.00	
950.00	
187.00	
0.00	
28.00	
0.00	
0.00	
718.00	
127.00	
228.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	19.00	29.00	125.00	627.00	0.00	0.00	800.00	
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	33.00	0.00	0.00	0.00	0.00	0.00	33.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	25.00	0.00	4.00	992.00	1,000.00	1,003.00	1,890.00	0.00	0.00	4,914.00	
262Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	31.00	59.00	-59.00	66.00	0.00	0.00	97.00	
SUBTOTAL	:	0.00	0.00	0.00	56.00	0.00	33.00	1,730.00	2,601.00	5,252.00	5,936.00	0.00	0.00	15,608.00	

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	
3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	91.00	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	31.00	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	32.00	30.00	31.00	29.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	15.00	45.00	15.00	182.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	15.00	0.00	21.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	285.00	80.00	1,586.00	1,060.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	401.00	262.00	1,756.00	1,051.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	5.00	366.00	829.00	1,951.00	1,944.00	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	15.00	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	64.00	146.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	93.00	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	0.00	2.00	128.00	95.00	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	31.00	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	1.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	15.00	32.00	0.00	10.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	28.00	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	5.00	63.00	132.00	0.00	0.00	
370F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	0.00	0.00	0.00	0.00	
370G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	16.00	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82.00	160.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	168.00	0.00	0.00	148.00	140.00	135.00	154.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	200.00	388.00	15.00	472.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	10.00	104.00	59.00	420.00	66.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	91.00	2,635.00	2,849.00	11,927.00	7,329.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	25.00	2,689.00	2,448.00	5,478.00	4,833.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	70.00	2,018.00	2,917.00	10,160.00	8,711.00	0.00	0.00	
371D	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	25.00	59.00	0.00	46.00	0.00	0.00	

0.00	
91.00	
31.00	
0.00	
160.00	
257.00	
36.00	
3,011.00	
3,470.00	
5,095.00	
15.00	
210.00	
93.00	
225.00	
0.00	
31.00	
1.00	
57.00	
28.00	
200.00	
5.00	
16.00	
242.00	
745.00	
1,075.00	
659.00	
24,831.00	
15,473.00	
23,876.00	
130.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	72.00	19.00	0.00	126.00	0.00	0.00		217.00		
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	374.00	311.00	373.00	315.00	0.00	0.00		1,373.00		
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	166.00	296.00	251.00	250.00	0.00	0.00		963.00		
371H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	116.00	190.00	498.00	300.00	0.00	0.00		1,104.00		
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		
3726	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	0.00	0.00		2.00		
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	20.00	0.00	0.00		20.00		
372H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	0.00	0.00		5.00		
SUBTOTAL:	0.00	0.00	0.00	206.00	0.00	201.00	9,937.00	11,123.00	34,936.00	27,344.00	0.00	0.00		83,747.00		

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	68.00	15.00	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	109.00	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	0.00	14.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	1.00	0.00	68.00	138.00	0.00	0.00	1.00	0.00	0.00	

2.00	
83.00	
109.00	
14.00	
208.00	

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	66.00	1,047.00	502.00	251.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.00	31.00	157.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	12.00	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	5.00	0.00	0.00	0.00	0.00	

1,868.00	
201.00	
12.00	
5.00	

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	5.00	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	10.00	14.00	10.00	13.00	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	305.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	-4.00	8.00	30.00	0.00	12.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	52.00	424.00	1,308.00	468.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	133.00	264.00	724.00	374.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	5.00	80.00	224.00	841.00	1,563.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	111.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	8.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	107.00	0.00	28.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	119.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	6.00	0.00	1.00	403.00	1,075.00	3,022.00	2,735.00	0.00	0.00	

 
0.00	
5.00	
53.00	
305.00	
46.00	
2,252.00	
1,495.00	
2,713.00	
111.00	
8.00	
135.00	
119.00	
7,242.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	2.00	0.00	0.00	78.00	1,065.00	533.00	408.00	0.00	0.00		2,086.00		

TOTAL:

0.00

0.00

0.00

603.00

1,300.00

19,375.00

26,876.00

51,880.00

164,651.00

606.00

64,011.00

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	34.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34.00	0.00	0.00	0.00	

 
34.00	
34.00	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2017	
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	467.56	439.38	598.62	550.97	0.00	0.00		3,161.55		
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	42.23	92.35	0.00	0.00	0.00	0.00		134.58		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	91.50	135.81	204.02	43.26	0.00	0.00		474.59		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	354.08	115.08	423.70	0.00	0.00		892.86		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	104.23	0.00	0.00	367.02	0.00	0.00	0.00	0.00	0.00		471.25		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	7,004,854.69	0.00	0.00	7,070,849.12	7,654,109.88	7,479,299.61	7,489,974.07	0.00	0.00		36,699,087.37		
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		
1014	TANF 14-20 MALE NON-	0.00	0.00	438.29	2,321.11	0.00	86.48	525.61	-104.06	-321.81	-2,277.80	0.00	0.00		667.82		
1015	TANF 14-20 FEMALE N O	0.00	0.00	813.01	4,947.05	0.00	535.22	3,897.27	101.29	3,401.68	-1,124.42	0.00	0.00		12,571.10		
1016	TANF 21-44 MALE NON-	0.00	0.00	7,154.15	29,902.79	0.00	4,071.65	32,051.62	-2,826.20	34,497.22	27,320.15	0.00	0.00		132,171.38		
1017	TANF 21-44 FEMALE N O	0.00	0.00	13,453.05	67,144.68	0.00	9,357.18	71,617.64	-11,536.99	86,703.19	68,336.79	0.00	0.00		305,075.54		
1018	TANF 45-64 M & F NON	0.00	0.00	3,879.61	18,566.82	0.00	2,049.22	19,160.46	-5,638.57	21,216.20	15,959.68	0.00	0.00		75,193.42		
1019	TANF 65+ M & F NON-M	0.00	0.00	150.96	119.61	0.00	51.97	-43.13	-62.60	-6.54	15.57	0.00	0.00		225.84		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	677.04	0.00	269.27	1,902.31	1,513.72	2,327.31	2,177.02	0.00	0.00		8,866.67		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	1,580.58	0.00	426.47	5,177.45	3,865.72	6,528.74	4,170.20	0.00	0.00		21,749.16		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	11,521.99	0.00	4,561.96	42,419.87	32,793.72	45,779.07	39,666.61	0.00	0.00		176,743.22		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	26,112.50	0.00	10,793.83	87,684.84	75,341.40	100,419.19	87,814.42	0.00	0.00		388,166.18		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	6,264.39	0.00	2,457.99	23,152.96	22,056.37	26,825.30	21,958.26	0.00	0.00		102,715.27		
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	118.92	0.00	48.73	93.39	81.64	65.42	36.34	0.00	0.00		444.44		
1020	TANF WITH QMB	0.00	0.00	0.00	394.08	0.00	0.00	137.87	284.67	412.71	571.70	0.00	0.00		1,801.03		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50.70	0.00	0.00	0.00	0.00		50.70		
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	37.99	0.00	0.00		37.99		
2100	SSI AGED WITH MEDIC A	0.00	0.00	-58.75	31,686.26	0.00	0.00	6,907.90	7,465.69	7,968.09	7,554.54	0.00	0.00		61,523.73		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	1,993.26	285,686.83	0.00	625.01	292,194.00	300,641.89	297,974.11	301,027.11	0.00	0.00		1,480,142.21		
211Z	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	2,554.39	0.00	1,036.30	10,641.27	11,056.37	15,018.10	10,560.82	0.00	0.00		50,867.25		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	69,158.76	0.00	0.00	31,606.58	38,080.71	43,898.05	44,745.69	0.00	0.00		227,489.79		
2200	SSI DISABLED WITH M E	0.00	0.00	59.00	261,948.03	0.00	-7.58	11,838.62	13,483.35	13,466.09	13,568.87	0.00	0.00		314,356.38		
2210	SSI DISABLED NON-ME D	0.00	0.00	2,749.04	2,519,626.74	0.00	1,146.84	1,759,367.43	1,879,026.18	1,869,105.66	1,873,222.39	0.00	0.00		9,904,244.28		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	4,633.84	0.00	2,218.07	23,287.88	25,820.69	28,616.17	27,368.10	0.00	0.00		111,944.75		
2220	SSI DISABLED WITH Q M	0.00	0.00	760.15	559,624.33	0.00	0.00	41,653.90	48,714.37	51,679.82	48,509.03	0.00	0.00		750,941.60		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	1,928.79	0.00	0.00	58.75	60.45	60.45	59.49	0.00	0.00		2,167.93		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	53.70	25,178.68	0.00	-1.63	19,640.95	20,943.51	20,699.80	21,478.33	0.00	0.00		107,993.34		
231Z	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	41.18	0.00	48.73	380.78	382.25	896.65	1,188.74	0.00	0.00		2,938.33		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	4,118.66	0.00	0.00	732.51	852.09	852.09	849.97	0.00	0.00		7,405.32		
4300	SOBRA CHILD WITH M ED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50.70	51.91	0.00	0.00		102.61		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	1,021,211.35	0.00	0.00	1,079,900.92	1,163,348.94	1,205,317.41	1,214,924.74	0.00	0.00		5,684,703.36		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	16.59	-73.40	-32.58	0.00	0.00	0.00		-89.39		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	-54.96	0.00	0.00	0.00	0.00	-26.17	0.00	0.00	0.00		-81.13		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	1,928.61	8,967.50	0.00	989.30	9,644.17	5,816.37	12,256.41	12,234.12	0.00	0.00		51,836.48		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	2,872.42	10,293.73	0.00	1,491.07	10,572.93	5,991.48	12,296.61	11,078.81	0.00	0.00		54,597.05		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-50.70	0.00	0.00	0.00	0.00		-50.70		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	3,393.32	0.00	1,518.51	14,215.39	12,724.29	17,059.09	12,113.58	0.00	0.00		61,024.18		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	3,902.74	0.00	1,808.52	15,222.48	13,461.28	18,169.04	13,744.09	0.00	0.00		66,308.15		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	58.75	0.00	0.00	0.00	0.00	0.00		58.75		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	42.23	0.00	0.00	21.11	41.65	0.00	0.00	0.00	0.00		104.99		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	1,169,673.33	0.00	0.00	1,080,904.57	1,163,322.87	1,119,153.42	1,160,193.52	0.00	0.00		5,693,247.71		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	1,377.52	5,703.57	0.00	1,503.71	8,676.50	5,099.91	11,496.03	7,600.72	0.00	0.00		41,457.96		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	8,698.21	35,078.16	0.00	8,739.41	42,644.96	17,411.12	50,215.01	38,520.83	0.00	0.00		201,307.70		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	53.70	118.58	0.00	0.00	151.52	129.57	138.07	83.64	0.00	0.00		675.08		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	3,306.29	0.00	1,450.51	10,997.25	9,719.91	12,412.24	11,085.50	0.00	0.00		48,971.70		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	18,026.07	0.00	8,826.87	57,715.43	52,520.50	63,386.78	53,631.18	0.00	0.00		254,106.83		
501H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	49.27	0.00	0.00	173.39	181.75	423.01	27.76	0.00	0.00		855.18		
5020	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	50.35	0.00	0.00	58.75	120.90	120.90	118.98	0.00	0.00		469.88		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.65	0.00	0.00	0.00		46.65		
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-51.91	0.00	0.00		-51.91		
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		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-57.84	0.00	0.00	0.00	0.00		-57.84		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-50.70	0.00	0.00	0.00		-50.70		
SUBTOTAL:	0.00	0.00	46,375.93	13,520,501.11	38,472,151.81	38,740,306.08	11,888,880.87	12,567,288.46	12,680,732.01	12,641,145.06	0.00	0.00		140,557,381.33		

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	6,241.38	0.00	0.00	5,735.47	6,198.06	5,824.35	5,803.02	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	42.23	0.00	0.00	75.41	49.66	78.36	217.78	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	93.76	0.00	0.00	116.83	97.40	60.45	241.76	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	179.85	249.59	0.00	0.00	242.81	191.43	91.27	-100.44	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	482.60	280.76	0.00	0.00	823.19	43.92	134.34	-88.74	0.00	0.00	
110H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.50	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	6,862,244.15	0.00	0.00	6,933,219.83	7,327,175.82	7,259,458.35	7,260,950.80	0.00	0.00	

29,802.28	
463.44	
610.20	
854.51	
1,676.07	
6.50	
35,643,048.95	

3010	MN/MI NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-203.66	0.00	0.00	
4110	EAC NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-59.49	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-59.49	-203.66	0.00	0.00	

 
-203.66	
-59.49	
-263.15	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1114	TANF EXPANDED 14-20	0.00	0.00	168.21	845.99	0.00	56.04	369.21	448.37	535.18	877.63	0.00	0.00		3,300.63		
1115	TANF EXPANDED 14-20	0.00	0.00	444.50	1,269.51	0.00	298.06	1,301.18	1,115.14	2,138.62	1,098.17	0.00	0.00		7,665.18		
1116	TANF EXPANDED 21-44	0.00	0.00	5,565.84	28,124.43	0.00	4,741.49	29,226.85	14,746.36	37,938.58	25,255.71	0.00	0.00		145,599.26		
1117	TANF EXPANDED 21-44	0.00	0.00	11,320.08	49,834.87	0.00	7,957.06	49,325.99	23,643.40	61,603.19	49,022.60	0.00	0.00		252,707.19		
1118	TANF EXPANDED 45-64	0.00	0.00	4,231.64	21,544.97	0.00	2,414.63	17,772.61	8,504.69	21,946.98	19,588.60	0.00	0.00		96,004.12		
1119	TANF EXPANDED 65+
M&	0.00	0.00	150.96	51.91	0.00	58.75	-17.33	299.71	52.34	-46.08	0.00	0.00		550.26		
111D	TANF EXPANDED 14-20	0.00	0.00	0.00	269.52	0.00	54.96	678.99	534.91	816.29	1,468.64	0.00	0.00		3,823.31		
111E	TANF EXPANDED 14-20	0.00	0.00	0.00	643.22	0.00	423.69	2,252.70	2,265.39	3,073.15	1,904.47	0.00	0.00		10,562.62		
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	11,460.35	0.00	5,044.39	46,681.47	41,298.49	55,100.33	41,050.77	0.00	0.00		200,635.80		
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	21,282.94	0.00	8,823.94	68,952.49	69,034.91	85,260.27	68,801.36	0.00	0.00		322,155.91		
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	8,128.89	0.00	2,899.43	30,390.92	28,823.98	32,559.27	27,023.76	0.00	0.00		129,826.25		
111J	TANF EXPANDED 65+
M&	0.00	0.00	0.00	29.74	0.00	0.00	128.59	185.81	158.29	215.78	0.00	0.00		718.21		
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	3,294.54	0.00	0.00	4,887.85	6,432.72	6,558.15	7,044.67	0.00	0.00		28,217.93		
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	12.99	-47.08	60.45	0.00	0.00	0.00		26.36		
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	54.96	50.70	-58.15	29.42	0.00	0.00		76.93		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	39.56	3.62	0.00	-86.26	0.00	0.00		-43.08		
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.39	0.00	0.00	0.00		22.39		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	943.32	0.00	0.00	1,049.19	812.50	1,290.68	1,126.40	0.00	0.00		5,222.09		
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	5,224.40	0.00	0.00	5,474.13	5,262.54	5,166.16	4,759.15	0.00	0.00		25,886.38		
241Z	SSI AGED EXPANDED NO	0.00	0.00	0.00	91.77	0.00	0.00	785.32	350.49	490.70	259.44	0.00	0.00		1,977.72		
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	15,821.03	0.00	0.00	15,138.82	17,720.87	11,326.12	10,461.39	0.00	0.00		70,468.23		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	784.67	0.00	100.70	763.59	1,096.92	623.91	407.19	0.00	0.00		3,776.98		
2610	SSI DISABLED EXPAND E	0.00	0.00	380.15	59,038.16	0.00	290.38	52,769.48	54,505.40	52,918.40	56,303.67	0.00	0.00		276,205.64		
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	582.67	0.00	341.56	2,549.59	2,482.77	3,079.08	1,726.54	0.00	0.00		10,762.21		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	10,692.84	0.00	236.09	9,584.52	10,986.63	8,421.29	7,788.81	0.00	0.00		47,710.18		
SUBTOTAL:	0.00	0.00	22,923.83	7,109,111.61	0.00	33,741.17	7,280,387.21	7,624,315.53	7,656,728.79	7,593,112.51	0.00	0.00		37,320,320.65		

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	89.91	0.00	0.00	50.35	57.84	50.70	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	82.94	39.42	49.58	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	24.36	0.00	0.00	0.00	41.65	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	4,655,476.80	5,070,013.08	4,947,597.21	5,003,041.41	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	992.40	3,954.41	0.00	755.25	3,195.34	1,032.53	5,067.50	3,217.27	0.00	0.00	

248.80	
228.80	
66.01	
24,197,481.39	
18,214.70	

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-110.19	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	-101.05	-50.70	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	-51.91	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-101.05	-50.70	-162.10	0.00	0.00	

 
-110.19	
-151.75	
-51.91	
-313.85	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3515	ADULT 40-100% FEMAL E	0.00	0.00	1,013.93	3,611.12	0.00	639.26	4,672.85	1,622.23	5,319.66	4,080.20	0.00	0.00		20,959.25		
3516	ADULT 40-100% MALE
2	0.00	0.00	5,546.63	20,673.68	0.00	2,757.30	19,777.91	-1,209.01	24,613.13	14,111.12	0.00	0.00		86,270.76		
3517	ADULT 40-100% FEMAL E	0.00	0.00	4,253.41	15,230.87	0.00	1,811.16	17,553.06	-2,089.59	17,959.18	13,907.24	0.00	0.00		68,625.33		
3518	ADULT 40-100% M&F 45	0.00	0.00	8,630.54	29,354.94	0.00	6,462.02	40,222.17	5,113.63	41,758.86	25,355.82	0.00	0.00		156,897.98		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	826.28	-45.27	-84.49	310.46	0.00	0.00		1,006.98		
351D	ADULT 40-100% MALE
1	0.00	0.00	0.00	1,819.41	0.00	869.84	6,316.38	5,913.29	9,035.00	6,275.41	0.00	0.00		30,229.33		
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1,765.77	0.00	877.05	8,186.24	7,587.36	9,006.17	6,940.01	0.00	0.00		34,362.60		
351F	ADULT 40-100% MALE
2	0.00	0.00	0.00	8,609.41	0.00	3,253.72	41,193.01	34,369.79	45,851.23	26,831.12	0.00	0.00		160,108.28		
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	7,091.78	0.00	2,330.99	34,352.89	25,432.54	35,780.87	25,283.62	0.00	0.00		130,272.69		
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	14,388.14	0.00	7,192.13	76,556.47	56,676.16	74,343.71	52,578.93	0.00	0.00		281,735.54		
351J	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	58.75	100.70	0.00	302.45	0.00	0.00		461.90		
3520	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.84	0.00	0.00	0.00	0.00		57.84		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	-24.25	126.31	0.00	0.00	0.00	0.00		102.06		
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	58.75	0.00	0.00	0.00	118.29	0.00	0.00	0.00	0.00		177.04		
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	24.36	0.00	0.00	30.05	23.67	76.30	43.26	0.00	0.00		197.64		
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	109.38	0.00	0.00	6.54	27.76	0.00	0.00		143.68		
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	44.19	0.00	0.00	77.03	88.93	255.49	162.04	0.00	0.00		627.68		
370H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.66	0.00	0.00	0.00		49.66		
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	9,810,302.35	0.00	0.00	9,772,023.43	10,693,902.12	10,358,214.48	10,430,983.19	0.00	0.00		51,065,425.57		
3714	ADULT <40% EXP MAL E	0.00	0.00	2,784.91	9,031.66	0.00	1,005.28	7,827.43	-1,445.61	14,403.89	9,459.42	0.00	0.00		43,066.98		
3715	ADULT <40% EXP FEM AL	0.00	0.00	2,062.31	6,463.28	0.00	1,055.50	8,263.50	943.48	9,844.04	9,397.79	0.00	0.00		38,029.90		
3716	ADULT <40% EXP MAL E	0.00	0.00	30,342.83	90,957.29	0.00	20,334.09	104,071.25	4,770.50	120,969.76	81,983.96	0.00	0.00		453,429.68		
3717	ADULT <40% EXP FEM AL	0.00	0.00	12,585.50	46,559.36	0.00	8,844.57	55,302.17	3,248.15	68,089.40	44,760.87	0.00	0.00		239,390.02		
3718	ADULT <40% EXP M&F 4	0.00	0.00	21,561.45	78,545.19	0.00	17,183.22	98,381.15	12,913.90	110,516.84	67,951.49	0.00	0.00		407,053.24		
3719	ADULT <40% EXP M&F 6	0.00	0.00	-50.35	-115.32	0.00	0.00	67.52	-47.08	-50.70	-278.55	0.00	0.00		-474.48		
371D	ADULT <40% EXP MAL E	0.00	0.00	0.00	4,626.58	0.00	1,285.85	14,539.37	12,257.34	20,796.57	14,285.19	0.00	0.00		67,790.90		
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	3,568.66	0.00	1,337.49	12,909.26	11,472.69	15,739.93	13,512.14	0.00	0.00		58,540.17		
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	42,355.82	0.00	16,783.10	153,766.20	126,812.59	159,736.88	120,117.01	0.00	0.00		619,571.60		
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	21,484.21	0.00	7,786.59	86,555.72	66,655.34	94,194.42	63,366.24	0.00	0.00		340,042.52		
371H	ADULT <40% EXP M&F 4	0.00	0.00	10.38	39,417.49	0.00	15,820.09	145,028.47	118,248.72	151,470.23	111,012.29	0.00	0.00		581,007.67		
371J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	151.05	0.00	50.70	0.00	0.00		201.75		
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		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43.26	0.00	0.00		43.26		
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	8.12	0.00	37.62	0.00	0.00	0.00		45.74		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	89,733.94	14,781,402.64	0.00	118,493.88	15,367,264.92	16,254,998.10	16,340,689.50	16,149,162.70	0.00	0.00		79,101,745.68		

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	229,236.70	0.00	0.00	242,907.44	259,476.93	258,260.79	262,659.97	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	235.04	2,109.94	0.00	563.09	1,492.74	-225.33	3,051.86	1,820.60	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	585.00	1,639.15	0.00	77.72	1,341.65	-25.67	2,189.31	2,367.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	643.05	0.00	620.21	3,071.57	3,146.25	3,988.75	3,485.09	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	712.30	0.00	98.81	3,321.58	3,581.82	3,508.83	2,946.15	0.00	0.00	
SUBTOTAL:	0.00	0.00	820.04	234,341.14	0.00	1,359.83	252,134.98	265,954.00	270,999.54	273,278.81	0.00	0.00	

1,252,541.83	
9,047.94	
8,174.16	
14,954.92	
14,169.49	
1,298,888.34	

4510	BC PATIENT FOR FINA N	0.00	0.00	0.00	8,193.19	0.00	0.00	6,577.04	7,020.39	6,935.91	6,548.71	0.00	0.00	
4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	81.49	8.64	0.00	43.26	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	116.49	139.77	0.00	51.97	123.18	217.15	0.00	282.53	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	634.90	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	36.01	110.56	0.00	144.66	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	67.64	0.00	48.73	464.32	531.28	0.00	792.78	0.00	0.00	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	875.16	0.00	0.00	676.15	765.00	765.00	712.27	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	11.90	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	108.04	0.00	0.00	
SUBTOTAL:	0.00	0.00	116.49	9,315.32	0.00	100.70	8,593.09	8,653.02	7,700.91	8,644.15	0.00	0.00	

35,275.24	
133.39	
931.09	
634.90	
291.23	
1,904.75	
3,793.58	
29.77	
129.73	
43,123.68	

3900	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	58.75	0.00	0.00	50.35	60.45	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	9.48	49.66	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	60.55	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	3,958,586.24	0.00	0.00	4,014,142.81	4,334,396.82	4,222,290.36	4,274,238.56	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	356.72	2,527.17	0.00	200.75	1,650.79	1,072.71	3,132.41	2,608.08	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	560.21	2,239.32	0.00	445.05	2,652.88	587.63	4,181.30	2,952.06	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	4,502.59	21,386.48	0.00	3,092.41	22,229.22	-1,531.10	30,493.15	17,708.58	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	5,869.16	29,093.80	0.00	3,965.29	29,024.40	1,040.74	39,914.47	28,951.27	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	28,500.72	5,047.68	32,689.41	23,212.72	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	-58.75	-49.27	0.00	0.00	78.84	171.19	287.05	1.72	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1,051.69	0.00	213.98	3,368.97	4,370.64	5,942.42	4,539.26	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	1,325.96	0.00	444.50	5,056.75	5,165.15	7,096.38	4,032.42	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	9,509.18	0.00	4,196.13	39,756.03	36,509.85	50,423.75	33,116.08	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	12,843.37	0.00	5,346.42	49,862.14	42,341.52	60,184.35	44,300.91	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	12,386.88	0.00	6,333.68	57,228.34	43,933.05	56,113.23	38,946.52	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	50.35	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	4,253,662.07	4,473,215.99	4,512,748.28	4,474,668.73	0.00	0.00	

 
169.55	
59.14	
60.55	
20,803,654.79	
11,548.63	
13,618.45	
97,881.33	
137,859.13	
123,636.29	
430.78	
19,486.96	
23,121.16	
173,511.02	
214,878.71	
214,941.70	
50.35	
21,834,908.54	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	1,641.69	0.00	117.50	431.85	359.12	321.09	486.71	0.00	0.00	3,357.96	
8710	SSI DISABLED FREEDO M	0.00	0.00	168.21	11,600.36	0.00	114.25	11,939.30	12,529.88	13,294.70	13,594.66	0.00	0.00	63,241.36	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	119.35	0.00	204.65	1,666.03	1,523.38	1,621.36	761.99	0.00	0.00	5,896.76	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	397.16	0.00	0.00	0.00	50.70	60.45	59.49	0.00	0.00	567.80	
SUBTOTAL	:	0.00	0.00	168.21	13,758.56	0.00	436.40	14,037.18	14,463.08	15,297.60	14,902.85	0.00	0.00	73,063.88	

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	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2017

0.00	0.00	175,456.09	39,744,034.47	38,472,151.81	38,924,391.02	39,064,960.32	41,208,787.13	41,484,786.44	41,154,549.05	0.00	0.00	

280,229,116.33	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2017	
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	9.00	8.00	11.00	10.00	0.00	0.00		53.00		
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	26.00	51.00	0.00	0.00	0.00	0.00		77.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	52.00	75.00	114.00	25.00	0.00	0.00		266.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178.00	63.00	241.00	0.00	0.00		482.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	183.00	0.00	0.00	0.00	0.00	0.00		183.00		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	135,295.00	0.00	0.00	136,631.00	140,644.00	137,430.00	136,661.00	0.00	0.00		686,661.00		
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		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	40.00	266.00	-72.00	-159.00	-1,237.00	0.00	0.00		-1,162.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	332.00	2,312.00	68.00	1,990.00	-588.00	0.00	0.00		4,114.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	2,462.00	19,093.00	-1,046.00	19,702.00	14,970.00	0.00	0.00		55,181.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	5,683.00	42,540.00	-5,651.00	49,418.00	37,524.00	0.00	0.00		129,514.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	1,216.00	11,271.00	-2,754.00	12,088.00	8,732.00	0.00	0.00		30,553.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	32.00	-28.00	-29.00	-4.00	9.00	0.00	0.00		-20.00		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	154.00	1,120.00	834.00	1,288.00	1,236.00	0.00	0.00		4,632.00		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	252.00	3,117.00	2,172.00	3,657.00	2,336.00	0.00	0.00		11,534.00		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	2,723.00	25,576.00	18,288.00	25,452.00	22,010.00	0.00	0.00		94,049.00		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	6,401.00	52,648.00	41,980.00	56,237.00	49,341.00	0.00	0.00		206,607.00		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	1,493.00	13,938.00	12,481.00	14,923.00	12,178.00	0.00	0.00		55,013.00		
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	0.00	0.00	30.00	57.00	48.00	37.00	21.00	0.00	0.00		193.00		
1020	TANF WITH QMB	0.00	0.00	0.00	4.00	0.00	0.00	3.00	5.00	7.00	10.00	0.00	0.00		29.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.00	0.00	0.00	0.00	0.00		28.00		
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	19.00	0.00	0.00		19.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	285.00	0.00	0.00	913.00	574.00	942.00	693.00	0.00	0.00		3,407.00		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	5,398.00	0.00	398.00	6,800.00	3,671.00	7,954.00	4,406.00	0.00	0.00		28,627.00		
211Z	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	662.00	6,272.00	6,254.00	8,414.00	5,851.00	0.00	0.00		27,453.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	861.00	0.00	0.00	840.00	926.00	836.00	845.00	0.00	0.00		4,308.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	2,141.00	0.00	-4.00	731.00	499.00	520.00	540.00	0.00	0.00		4,427.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	40,232.00	0.00	652.00	36,403.00	33,964.00	32,394.00	30,512.00	0.00	0.00		174,157.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	1,350.00	14,006.00	15,062.00	16,202.00	15,434.00	0.00	0.00		62,054.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	4,732.00	0.00	0.00	914.00	729.00	1,529.00	241.00	0.00	0.00		8,145.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	17.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00		21.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	422.00	0.00	-1.00	414.00	278.00	75.00	420.00	0.00	0.00		1,608.00		
231Z	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	30.00	228.00	213.00	506.00	659.00	0.00	0.00		1,636.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	41.00	0.00	0.00	15.00	15.00	15.00	15.00	0.00	0.00		101.00		
4300	SOBRA CHILD WITH M ED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		2.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	19,737.00	0.00	0.00	20,889.00	21,450.00	22,215.00	22,221.00	0.00	0.00		106,512.00		

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	13.00	-34.00	-18.00	0.00	0.00	0.00		-39.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-16.00	0.00	0.00	0.00		-16.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	594.00	5,635.00	3,140.00	6,967.00	6,719.00	0.00	0.00		23,055.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	882.00	6,260.00	3,115.00	7,012.00	6,052.00	0.00	0.00		23,321.00		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-28.00	0.00	0.00	0.00	0.00		-28.00		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	922.00	8,452.00	7,189.00	9,482.00	6,781.00	0.00	0.00		32,826.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	1,069.00	9,226.00	7,524.00	10,069.00	7,676.00	0.00	0.00		35,564.00		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00		1.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	13.00	23.00	0.00	0.00	0.00	0.00		36.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	22,659.00	0.00	0.00	20,950.00	21,486.00	20,638.00	21,160.00	0.00	0.00		106,893.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	891.00	5,162.00	2,705.00	6,482.00	4,170.00	0.00	0.00		19,410.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	5,277.00	25,240.00	9,376.00	28,660.00	21,271.00	0.00	0.00		89,824.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	87.00	64.00	80.00	46.00	0.00	0.00		277.00		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	882.00	6,691.00	5,394.00	6,865.00	6,185.00	0.00	0.00		26,017.00		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	5,391.00	34,806.00	29,475.00	35,175.00	30,033.00	0.00	0.00		134,880.00		
501H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	99.00	93.00	242.00	14.00	0.00	0.00		448.00		
5020	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	1.00	0.00	0.00	1.00	2.00	2.00	2.00	0.00	0.00		8.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.00	0.00	0.00	0.00		25.00		
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-30.00	0.00	0.00		-30.00		
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		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-28.00	0.00	0.00	0.00	0.00		-28.00		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-31.00	0.00	0.00	0.00		-31.00		
SUBTOTAL:	0.00	0.00	0.00	232,672.00	722,203.00	765,980.00	519,876.00	380,440.00	545,492.00	475,416.00	0.00	0.00		3,642,079.00		

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	125.00	0.00	0.00	114.00	109.00	102.00	102.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	52.00	23.00	39.00	118.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	76.00	59.00	31.00	132.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	134.00	95.00	52.00	-51.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	438.00	20.00	69.00	-45.00	0.00	0.00	
110H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	132,307.00	0.00	0.00	133,651.00	134,070.00	132,817.00	132,076.00	0.00	0.00	

552.00	
232.00	
298.00	
230.00	
482.00	
4.00	
664,921.00	

3010	MN/MI NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-120.00	0.00	0.00	
4110	EAC NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-30.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-30.00	-120.00	0.00	0.00	

 
-120.00	
-30.00	
-150.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	29.00	223.00	224.00	302.00	473.00	0.00	0.00		1,251.00		
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	167.00	763.00	555.00	1,231.00	618.00	0.00	0.00		3,334.00		
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	2,850.00	17,183.00	7,804.00	21,450.00	13,741.00	0.00	0.00		63,028.00		
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	4,746.00	28,974.00	12,768.00	35,176.00	26,885.00	0.00	0.00		108,549.00		
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	1,501.00	10,416.00	4,557.00	12,511.00	10,719.00	0.00	0.00		39,704.00		
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	30.00	-5.00	175.00	32.00	-29.00	0.00	0.00		203.00		
111D	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	29.00	431.00	304.00	458.00	812.00	0.00	0.00		2,034.00		
111E	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	235.00	1,336.00	1,236.00	1,723.00	1,047.00	0.00	0.00		5,577.00		
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	3,080.00	28,015.00	23,334.00	30,338.00	22,865.00	0.00	0.00		107,632.00		
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	5,382.00	41,472.00	38,820.00	47,347.00	38,512.00	0.00	0.00		171,533.00		
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	1,813.00	18,105.00	16,146.00	18,103.00	15,056.00	0.00	0.00		69,223.00		
111J	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	77.00	109.00	91.00	117.00	0.00	0.00		394.00		
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	65.00	0.00	0.00	97.00	113.00	115.00	124.00	0.00	0.00		514.00		
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	8.00	-26.00	31.00	0.00	0.00	0.00		13.00		
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	29.00	28.00	-29.00	17.00	0.00	0.00		45.00		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	31.00	2.00	0.00	-51.00	0.00	0.00		-18.00		
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00	0.00	0.00	0.00		12.00		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	11.00	0.00	0.00	425.00	185.00	592.00	318.00	0.00	0.00		1,531.00		
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	101.00	0.00	0.00	33.00	-59.00	241.00	-75.00	0.00	0.00		241.00		
241Z	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	467.00	194.00	269.00	133.00	0.00	0.00		1,063.00		
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	321.00	0.00	0.00	346.00	491.00	561.00	286.00	0.00	0.00		2,005.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	7.00	0.00	62.00	293.00	460.00	178.00	105.00	0.00	0.00		1,105.00		
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	1,134.00	0.00	188.00	1,453.00	1,226.00	1,776.00	1,479.00	0.00	0.00		7,256.00		
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	206.00	1,552.00	1,391.00	1,734.00	902.00	0.00	0.00		5,785.00		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	203.00	0.00	182.00	206.00	563.00	748.00	593.00	0.00	0.00		2,495.00		
SUBTOTAL:	0.00	0.00	0.00	134,274.00	0.00	20,500.00	286,395.00	244,976.00	308,100.00	266,983.00	0.00	0.00		1,261,228.00		

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	2.00	0.00	0.00	1.00	1.00	1.00	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	49.00	31.00	25.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.00	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	90,195.00	92,518.00	90,293.00	90,825.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	465.00	1,866.00	515.00	2,858.00	1,782.00	0.00	0.00	

5.00	
105.00	
23.00	
451,437.00	
7,486.00	

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-61.00	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	-59.00	-31.00	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	-30.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-59.00	-31.00	-91.00	0.00	0.00	

 
-61.00	
-90.00	
-30.00	
-181.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	360.00	2,742.00	922.00	2,988.00	2,243.00	0.00	0.00		9,255.00		
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	1,625.00	11,676.00	-475.00	14,018.00	7,678.00	0.00	0.00		34,522.00		
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	1,093.00	10,194.00	-996.00	10,339.00	7,725.00	0.00	0.00		28,355.00		
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	3,967.00	23,725.00	2,953.00	23,505.00	13,672.00	0.00	0.00		67,822.00		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	496.00	-25.00	-43.00	189.00	0.00	0.00		617.00		
351D	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	549.00	3,765.00	3,341.00	5,161.00	3,454.00	0.00	0.00		16,270.00		
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	498.00	4,897.00	4,304.00	4,942.00	3,825.00	0.00	0.00		18,466.00		
351F	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	1,909.00	24,717.00	19,420.00	25,414.00	14,908.00	0.00	0.00		86,368.00		
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	1,350.00	20,600.00	14,408.00	19,916.00	14,016.00	0.00	0.00		70,290.00		
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	4,446.00	46,385.00	32,034.00	41,027.00	29,197.00	0.00	0.00		153,089.00		
351J	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	31.00	62.00	0.00	185.00	0.00	0.00		278.00		
3520	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00		1.00		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	-19.00	65.00	0.00	0.00	0.00	0.00		46.00		
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	1.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00		3.00		
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	19.00	14.00	43.00	25.00	0.00	0.00		101.00		
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	62.00	0.00	0.00	4.00	14.00	0.00	0.00		80.00		
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	47.00	47.00	145.00	92.00	0.00	0.00		331.00		
370H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.00	0.00	0.00	0.00		23.00		
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	190,536.00	0.00	0.00	189,848.00	196,078.00	189,864.00	189,967.00	0.00	0.00		956,293.00		
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	599.00	4,712.00	-796.00	8,088.00	5,275.00	0.00	0.00		17,878.00		
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	616.00	4,934.00	627.00	5,582.00	5,089.00	0.00	0.00		16,848.00		
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	12,247.00	61,273.00	2,727.00	68,559.00	45,067.00	0.00	0.00		189,873.00		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	5,374.00	32,862.00	1,928.00	38,752.00	24,623.00	0.00	0.00		103,539.00		
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	10,390.00	58,593.00	7,007.00	62,610.00	37,241.00	0.00	0.00		175,841.00		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	35.00	-26.00	-26.00	-151.00	0.00	0.00		-168.00		
371D	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	764.00	8,770.00	6,765.00	11,523.00	7,975.00	0.00	0.00		35,797.00		
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	793.00	7,641.00	6,447.00	8,709.00	7,554.00	0.00	0.00		31,144.00		
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	10,078.00	92,101.00	70,783.00	88,977.00	66,958.00	0.00	0.00		328,897.00		
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	4,707.00	51,867.00	37,220.00	52,817.00	35,392.00	0.00	0.00		182,003.00		
371H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	9,538.00	88,300.00	65,731.00	84,176.00	61,700.00	0.00	0.00		309,445.00		
371J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92.00	0.00	31.00	0.00	0.00		123.00		
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		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.00	0.00	0.00		25.00		
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	5.00	0.00	23.00	0.00	0.00	0.00		28.00		

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	278,146.00	0.00	71,430.00	842,278.00	563,766.00	860,319.00	676,601.00	0.00	0.00		3,292,540.00		

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	4,438.00	0.00	0.00	4,698.00	4,795.00	4,770.00	4,811.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	325.00	857.00	-116.00	1,720.00	1,004.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	37.00	829.00	12.00	1,246.00	1,279.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	355.00	1,837.00	1,821.00	2,181.00	1,965.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	56.00	2,044.00	2,028.00	1,924.00	1,614.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	4,438.00	0.00	773.00	10,265.00	8,540.00	11,841.00	10,673.00	0.00	0.00	

23,512.00	
3,790.00	
3,403.00	
8,159.00	
7,666.00	
46,530.00	

4510	BC PATIENT FOR FINA N	0.00	0.00	0.00	159.00	0.00	0.00	129.00	125.00	124.00	117.00	0.00	0.00	
4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	43.00	4.00	0.00	25.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	32.00	65.00	116.00	0.00	151.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	488.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	19.00	55.00	0.00	87.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	30.00	244.00	301.00	0.00	451.00	0.00	0.00	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	18.00	0.00	0.00	14.00	14.00	14.00	13.00	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	6.00	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	55.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	177.00	0.00	62.00	1,002.00	615.00	138.00	905.00	0.00	0.00	

654.00	
72.00	
364.00	
488.00	
161.00	
1,026.00	
73.00	
6.00	
55.00	
2,899.00	

3900	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	1.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	5.00	23.00	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	30.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	76,644.00	0.00	0.00	77,669.00	79,359.00	77,307.00	77,769.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	126.00	1,017.00	586.00	1,775.00	1,416.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	263.00	1,542.00	335.00	2,360.00	1,617.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	1,785.00	12,972.00	-735.00	17,129.00	9,710.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	2,366.00	16,784.00	719.00	22,444.00	15,902.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	3,440.00	16,582.00	2,670.00	18,248.00	12,686.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	61.00	124.00	186.00	-3.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	121.00	2,036.00	2,439.00	3,324.00	2,502.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	263.00	3,031.00	2,911.00	3,979.00	2,278.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	2,429.00	23,872.00	20,558.00	27,840.00	18,380.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	3,186.00	29,573.00	23,810.00	33,387.00	24,676.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	3,718.00	34,319.00	24,940.00	30,698.00	21,455.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	31.00	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	219,495.00	157,740.00	238,677.00	188,418.00	0.00	0.00	

 
3.00	
28.00	
30.00	
388,748.00	
4,920.00	
6,117.00	
40,861.00	
58,215.00	
53,626.00	
368.00	
10,422.00	
12,462.00	
93,079.00	
114,632.00	
115,130.00	
31.00	
898,672.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	18.00	0.00	61.00	64.00	27.00	6.00	36.00	0.00	0.00	212.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	224.00	0.00	65.00	575.00	467.00	650.00	501.00	0.00	0.00	2,482.00	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	120.00	1,008.00	910.00	945.00	438.00	0.00	0.00	3,421.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	4.00	0.00	0.00	0.00	28.00	31.00	1.00	0.00	0.00	64.00	
SUBTOTAL	:	0.00	0.00	0.00	246.00	0.00	246.00	1,647.00	1,432.00	1,632.00	976.00	0.00	0.00	6,179.00	

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	1,880,958.00	1,357,450.00	1,966,138.00	1,619,761.00	0.00	0.00		9,149,796.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending April 30, 2017	
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	400,960.08	448,728.87	500,479.57	528,457.08	0.00	0.00		1,878,625.60		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	3,795.34	23,343.73	19,168.93	16,470.94	12,017.55	0.00	0.00		74,796.49		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	594.88	3,576.12	-3,689.93	-11,510.39	-5,994.00	0.00	0.00		-17,023.32		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	69.78	14,267.70	1,008.74	1,682.56	5,831.46	0.00	0.00		22,860.24		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	2,366.36	1,358.99	1,330.62	4,057.61	0.00	0.00		9,113.58		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	957.15	-548.47	-420.19	829.11	-1,906.82	0.00	0.00		-1,089.22		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-182.49	0.00	0.00	0.00		-182.49		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	4,140.92	20,780.50	226.22	63.55	3,243.99	0.00	0.00		28,455.18		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	-1,468.95	33.39	145.25	-676.20	0.00	0.00		-1,966.51		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	454.22	333.89	-934.90	-712.99	0.00	0.00		-859.78		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	23.26	33.39	23.37	202.11	0.00	0.00		282.13		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	348.95	46.16	23.37	0.00	0.00	0.00		418.48		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	163.22	226,405.26	224,719.23	219,289.09	223,225.41	0.00	0.00		893,802.21		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	5,365.77	303.52	1,511.76	3,216.03	0.00	0.00		10,397.08		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295.03	0.00	0.00		295.03		
4300	SOBRA CHILD WITH M ED	0.00	0.00	0.00	0.00	0.00	0.00	721.17	2,173.77	724.59	737.58	0.00	0.00		4,357.11		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	12,792,599.34	12,870,192.00	12,829,410.61	12,637,405.04	0.00	0.00		51,129,606.99		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	20,509.77	94,104.69	54,199.46	62,786.55	32,308.97	0.00	0.00		263,909.44		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	13,327.75	55,102.27	-4,522.09	-102,327.30	-77,921.85	0.00	0.00		-116,341.22		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	16,266.40	29,168.35	80,949.18	-80,121.46	-94,844.24	0.00	0.00		-48,581.77		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	2,499.16	-7,068.97	-15,696.75	-43,492.00	-22,189.38	0.00	0.00		-85,947.94		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	6,061.86	15,385.04	-11,843.82	-8,976.97	-26,477.64	0.00	0.00		-25,851.53		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	19,420.01	92,671.11	23,184.60	11,244.76	23,514.38	0.00	0.00		170,034.86		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	17,215.59	153,033.65	47,579.85	38,399.91	51,602.94	0.00	0.00		307,831.94		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	10,385.58	109,437.98	52,988.72	57,822.96	41,418.34	0.00	0.00		272,053.58		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	790.96	34,278.47	23,497.51	11,793.85	15,130.72	0.00	0.00		85,491.51		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	4,034.63	32,797.97	18,006.36	13,293.02	14,621.97	0.00	0.00		82,753.95		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	6,593.64	8,811.73	11,406.12	9,647.36	0.00	0.00		36,458.85		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	162.84	-992.52	940.58	-1,680.45	0.00	0.00		-1,569.55		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	558.33	1,135.22	677.84	0.00	0.00	0.00		2,371.39		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	120,233.00	14,105,420.41	13,841,514.43	13,532,804.47	13,374,530.00	0.00	0.00		54,974,502.31		

3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	23.26	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	2,884.68	724.59	724.59	737.58	0.00	0.00	

23.26	
5,071.44	

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	187.34	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	187.34	0.00	0.00	

 
187.34	
187.34	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	-651.38	0.00	0.00	0.00	0.00	0.00	-651.38	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	-674.64	0.00	0.00	0.00	0.00	0.00	-674.64	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	-465.27	0.00	0.00	0.00	0.00	0.00	-465.27	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	1,116.65	724.59	724.59	737.58	0.00	0.00	3,303.41	

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	49,595.40	46,727.96	45,896.09	45,268.86	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	867.42	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	1,535.40	2,462.65	7,407.68	2,329.82	427.92	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	2,096.52	-1,034.20	-958.33	633.32	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	744.43	322.39	467.45	2,453.10	491.72	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	-697.91	235.25	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,462.69	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	2,279.83	54,646.47	53,804.14	55,183.37	46,821.82	0.00	0.00	

187,488.31	
867.42	
14,163.47	
737.31	
4,479.09	
-462.66	
5,462.69	
212,735.63	

0.00	0.00	0.00	0.00	0.00	122,512.83	14,161,183.53	13,896,043.16	13,588,712.43	13,422,276.74	0.00	0.00	

55,190,728.69	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending April 30, 2017	
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	477.00	530.00	591.00	624.00	0.00	0.00		2,222.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	136.00	911.00	608.00	625.00	441.00	0.00	0.00		2,721.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	27.00	120.00	-137.00	-400.00	-233.00	0.00	0.00		-623.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	3.00	507.00	80.00	63.00	190.00	0.00	0.00		843.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	86.00	47.00	56.00	163.00	0.00	0.00		352.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	32.00	-15.00	0.00	40.00	-65.00	0.00	0.00		-8.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11.00	0.00	0.00	0.00		-11.00		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	176.00	854.00	7.00	2.00	128.00	0.00	0.00		1,167.00		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	-54.00	1.00	6.00	-28.00	0.00	0.00		-75.00		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	10.00	10.00	-31.00	-29.00	0.00	0.00		-40.00		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	8.00	0.00	0.00		11.00		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	15.00	1.00	1.00	0.00	0.00	0.00		17.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	4.00	444.00	483.00	312.00	290.00	0.00	0.00		1,533.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	157.00	9.00	40.00	103.00	0.00	0.00		309.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00	0.00	0.00		12.00		
4300	SOBRA CHILD WITH M ED	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	1.00	1.00	0.00	0.00		6.00		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	15,469.00	15,440.00	15,378.00	14,942.00	0.00	0.00		61,229.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	748.00	3,486.00	1,819.00	2,214.00	1,072.00	0.00	0.00		9,339.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	524.00	1,938.00	-236.00	-3,989.00	-3,171.00	0.00	0.00		-4,934.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	617.00	1,186.00	2,200.00	-2,904.00	-3,594.00	0.00	0.00		-2,495.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	110.00	-324.00	-558.00	-1,737.00	-779.00	0.00	0.00		-3,288.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	232.00	461.00	-414.00	-715.00	-1,005.00	0.00	0.00		-1,441.00		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	716.00	3,526.00	889.00	443.00	731.00	0.00	0.00		6,305.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	683.00	5,549.00	1,577.00	1,353.00	1,776.00	0.00	0.00		10,938.00		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	416.00	4,032.00	1,972.00	2,104.00	1,575.00	0.00	0.00		10,099.00		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	34.00	1,294.00	892.00	418.00	548.00	0.00	0.00		3,186.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	146.00	1,159.00	654.00	450.00	511.00	0.00	0.00		2,920.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	8.00	11.00	14.00	12.00	0.00	0.00		45.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	7.00	-34.00	38.00	-77.00	0.00	0.00		-66.00		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	24.00	47.00	29.00	0.00	0.00	0.00		100.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	4,604.00	41,329.00	25,902.00	14,392.00	14,146.00	0.00	0.00		100,373.00		

3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	4.00	1.00	1.00	1.00	0.00	0.00	

1.00	
7.00	

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	0.00	0.00	

 
6.00	
6.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	-28.00	0.00	0.00	0.00	0.00	0.00	-28.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	-29.00	0.00	0.00	0.00	0.00	0.00	-29.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	-20.00	0.00	0.00	0.00	0.00	0.00	-20.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	-72.00	1.00	1.00	1.00	0.00	0.00	-69.00	

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	61.00	57.00	58.00	55.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	29.00	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	66.00	89.00	273.00	93.00	-9.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	103.00	-15.00	-41.00	21.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	32.00	9.00	14.00	79.00	20.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	-30.00	10.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	129.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	98.00	261.00	339.00	318.00	87.00	0.00	0.00	

231.00	
29.00	
512.00	
68.00	
154.00	
-20.00	
129.00	
1,103.00	

TOTAL:	0.00	0.00	0.00	0.00	0.00	4,702.00	41,518.00	26,242.00	14,711.00	14,240.00	0.00	0.00		101,413.00		

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	578.71	519.51	519.51	360.84	0.00	0.00		1,978.57		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	50,467.46	77,149.04	77,698.77	79,828.95	0.00	0.00		285,144.22		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	377.29	410.39	410.39	422.92	0.00	0.00		1,620.99		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	26,165.61	29,245.30	29,499.48	30,300.21	0.00	0.00		115,210.60		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	402.84	436.48	436.48	481.12	0.00	0.00		1,756.92		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	-25.99	39,976.10	44,680.74	45,371.82	46,199.99	0.00	0.00		176,202.66		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	1,977.97	255,172.36	286,816.81	287,496.98	295,081.76	0.00	0.00		1,126,545.88		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	9,879.89	2,125,340.96	2,993,527.41	3,029,025.63	3,123,263.13	0.00	0.00		11,281,037.02		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55.40	0.00	0.00	0.00		55.40		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	522,389.70	583,053.29	587,773.31	599,342.36	0.00	0.00		2,292,558.66		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	2,036.77	2,051.95	1,859.80	1,691.68	0.00	0.00		7,640.20		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	6,627.80	7,228.64	7,479.34	7,961.13	0.00	0.00		29,296.91		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	3,386.15	4,177.15	4,177.15	4,378.56	0.00	0.00		16,119.01		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-192.15	0.00	0.00	0.00		-192.15		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	11,831.87	3,032,921.75	4,029,296.71	4,071,611.91	4,189,312.65	0.00	0.00		15,334,974.89		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	981.55	1,065.11	1,065.11	1,144.60	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	201.42	218.24	218.24	240.56	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	357.60	420.99	420.99	443.77	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	1,540.57	1,704.34	1,704.34	1,828.93	0.00	0.00	

 
4,256.37	
878.46	
1,643.35	
6,778.18	

0.00	0.00	0.00	0.00	0.00	11,831.87	3,034,462.32	4,031,001.05	4,073,316.25	4,191,141.58	0.00	0.00	

15,341,753.07	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	5.00	4.00	4.00	3.00	0.00	0.00		16.00		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	456.00	363.00	414.00	458.00	0.00	0.00		1,691.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	3.00	3.00	3.00	3.00	0.00	0.00		12.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	329.00	140.00	188.00	221.00	0.00	0.00		878.00		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	4.00	4.00	4.00	4.00	0.00	0.00		16.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	-8.00	357.00	256.00	280.00	260.00	0.00	0.00		1,145.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	407.00	2,680.00	2,508.00	2,721.00	2,606.00	0.00	0.00		10,922.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	2,047.00	26,711.00	26,317.00	28,800.00	21,354.00	0.00	0.00		105,229.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00	0.00	0.00	0.00		9.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	4,257.00	4,003.00	4,484.00	4,100.00	0.00	0.00		16,844.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	15.00	15.00	14.00	12.00	0.00	0.00		56.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	79.00	52.00	109.00	55.00	0.00	0.00		295.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	26.00	28.00	28.00	29.00	0.00	0.00		111.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-31.00	0.00	0.00	0.00		-31.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	2,446.00	34,922.00	33,693.00	37,027.00	29,105.00	0.00	0.00		137,193.00		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	9.00	9.00	9.00	9.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	2.00	2.00	2.00	2.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	3.00	3.00	3.00	3.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	14.00	14.00	14.00	14.00	0.00	0.00	

 
36.00	
8.00	
12.00	
56.00	

TOTAL:	0.00	0.00	0.00	0.00	0.00	2,446.00	34,936.00	33,707.00	37,041.00	29,119.00	0.00	0.00		137,249.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending April 30, 2017	
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	2,403.75	2,403.75	2,403.75	2,589.33	0.00	0.00		29,967.78		
1010	TANF NON-MEDICARE	191,820.80	195,596.80	195,596.80	202,266.00	205,438.80	203,852.40	207,523.75	205,921.25	209,126.25	225,771.80	0.00	0.00		2,042,914.65		
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	3,847.59	3,046.34	3,847.59	5,952.89	0.00	0.00		42,418.68		
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	7,055.24	7,055.24	5,934.02	5,363.92	0.00	0.00		65,295.52		
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	5,452.74	6,896.58	5,614.05	6,864.19	0.00	0.00		63,569.85		
1014	TANF 14-20 MALE NON-	4,174.08	3,896.00	3,617.92	2,376.55	2,376.55	2,376.55	2,887.68	2,887.68	2,406.40	2,000.36	0.00	0.00		28,999.77		
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	3,207.65	3,688.93	4,971.46	5,226.85	0.00	0.00		50,358.89		
1016	TANF 21-44 MALE NON-	0.00	0.00	477.12	0.00	0.00	0.00	0.00	0.00	0.00	500.09	0.00	0.00		977.21		
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	1,443.84	962.56	962.56	1,000.18	0.00	0.00		14,368.75		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	801.25	801.25	801.25	863.11	0.00	0.00		3,266.86		
2200	SSI DISABLED WITH M E	26,909.12	26,909.12	26,153.92	25,857.71	26,650.91	29,030.51	23,717.53	23,717.53	25,481.34	26,030.37	0.00	0.00		260,458.06		
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	4,799,395.43	4,810,131.65	4,812,371.44	5,178,913.88	0.00	0.00		47,543,727.59		
2220	SSI DISABLED WITH Q M	60,934.08	63,676.80	63,676.80	69,002.30	69,002.30	70,588.70	73,239.02	73,239.02	73,558.99	80,817.51	0.00	0.00		697,735.52		
2300	SSI BLIND WITH MEDIC	755.20	755.20	755.20	793.20	793.20	793.20	801.25	801.25	1,602.50	863.11	0.00	0.00		8,713.31		
2310	SSI BLIND NON-MEDIC A	44,041.60	44,796.80	45,552.00	46,317.39	45,842.08	47,428.48	48,720.24	49,040.21	45,033.96	51,834.79	0.00	0.00		468,607.55		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	863.11	0.00	0.00		863.11		
4311	SOBRA CHILD <1 M & F	25,957.76	26,156.80	24,646.40	21,722.09	26,320.82	23,623.33	25,174.62	26,137.18	25,814.56	23,859.75	0.00	0.00		249,413.31		
4312	SOBRA CHILD 01-05 M	201,787.20	195,069.44	196,857.92	198,822.93	192,005.07	190,100.78	190,631.59	182,460.43	176,526.41	173,278.47	0.00	0.00		1,897,540.24		
4313	SOBRA CHILD 06-13 M	231,286.72	231,605.76	228,505.92	229,397.14	231,619.32	230,350.81	236,019.97	237,627.77	242,115.30	247,043.34	0.00	0.00		2,345,572.05		
4314	SOBRA CHILD 14-20 MA	56,885.76	53,744.96	52,035.52	56,132.33	56,607.64	57,558.26	59,958.94	61,241.47	63,325.25	68,660.09	0.00	0.00		586,150.22		
4315	SOBRA CHILD 14-20 FE	54,503.04	54,025.92	52,316.48	51,046.09	52,947.33	54,215.84	53,876.86	53,556.89	53,075.61	56,398.79	0.00	0.00		535,962.85		
5015	SOBRA PREG 14-20 FE M	1,232.32	477.12	954.24	0.00	0.00	475.31	481.28	962.56	962.56	1,000.18	0.00	0.00		6,545.57		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	481.28	481.28	0.00	500.09	0.00	0.00		1,462.65		
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	5,747,121.50	5,753,060.82	5,755,935.25	6,166,196.20	0.00	0.00		56,944,889.99		

3514	ADULT 40-100% MALE
1	1,908.48	2,385.60	2,862.72	2,851.86	3,327.17	3,327.17	3,850.24	2,887.68	2,406.40	2,500.45	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,431.36	1,431.36	954.24	950.62	475.31	475.31	481.28	481.28	481.28	500.09	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	481.28	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	5,294.08	6,256.64	6,737.92	7,001.26	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	6,256.64	5,294.08	5,775.36	7,001.26	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	1,443.84	1,443.84	962.56	1,500.27	0.00	0.00	

28,307.77	
7,662.13	
481.28	
2,857.29	
73,397.57	
68,144.55	
16,777.86	

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	500.09	0.00	0.00	
1115	TANF EXPANDED 14-20	477.12	477.12	477.12	475.31	0.00	0.00	0.00	0.00	481.28	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	481.28	481.28	1,000.18	0.00	0.00	
SUBTOTAL:	477.12	477.12	477.12	475.31	0.00	0.00	0.00	481.28	962.56	1,500.27	0.00	0.00	

 
500.09	
2,387.95	
1,962.74	
4,850.78	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEM AL	477.12	1,431.36	1,431.36	1,425.93	1,425.93	1,901.24	962.56	1,443.84	1,443.84	1,500.27	0.00	0.00	13,443.45	
SUBTOTAL	:	24,333.12	23,378.88	23,378.88	22,339.57	21,864.26	21,388.95	18,288.64	18,288.64	17,807.36	20,003.60	0.00	0.00	211,071.90	

3914	NEWLY ELIGIBLE MALE	954.24	954.24	954.24	1,425.93	1,425.93	1,425.93	962.56	962.56	962.56	1,500.27	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	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	481.28	500.09	0.00	0.00	
SUBTOTAL:	1,431.36	1,431.36	1,431.36	1,901.24	1,901.24	1,425.93	962.56	962.56	1,443.84	2,000.36	0.00	0.00	

11,528.46	
2,381.98	
981.37	
14,891.81	

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	13,314.53	11,870.69	11,389.41	10,001.80	0.00	0.00	
4414	SOBRA 100-133% MALE	2,862.72	2,862.72	1,908.48	1,425.93	1,901.24	2,376.55	2,406.40	1,925.12	2,406.40	1,500.27	0.00	0.00	
4415	SOBRA 100-133% FEM AL	2,385.60	2,385.60	4,572.16	3,645.06	4,120.37	3,645.06	4,170.21	4,170.21	2,726.37	2,500.45	0.00	0.00	
SUBTOTAL:	13,836.48	15,744.96	18,686.72	18,222.25	20,598.80	19,648.18	19,891.14	17,966.02	16,522.18	14,002.52	0.00	0.00	

119,222.33	
21,575.83	
34,321.09	
175,119.25	

5,524,820.80	5,512,380.48	5,512,260.48	5,746,828.75	5,747,785.47	5,733,350.45	5,786,263.84	5,790,759.32	5,792,671.19	6,203,702.95	0.00	0.00	

57,350,823.73	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2017	
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	3.00	3.00	3.00	3.00	0.00	0.00		38.00		
1010	TANF NON-MEDICARE	254.00	259.00	259.00	255.00	259.00	257.00	259.00	257.00	261.00	262.00	0.00	0.00		2,582.00		
1011	TANF <1 M & F NON-ME	9.00	6.00	7.00	7.00	7.00	6.00	6.00	5.00	6.00	9.00	0.00	0.00		68.00		
1012	TANF 01-05 M & F NON	9.00	12.00	12.00	13.00	10.00	14.00	12.00	12.00	11.00	10.00	0.00	0.00		115.00		
1013	TANF 06-13 M & F NON	13.00	10.00	11.00	12.00	9.00	11.00	10.00	13.00	11.00	13.00	0.00	0.00		113.00		
1014	TANF 14-20 MALE NON-	7.00	7.00	7.00	5.00	5.00	5.00	6.00	6.00	5.00	4.00	0.00	0.00		57.00		
1015	TANF 14-20 FEMALE N O	12.00	12.00	10.00	11.00	10.00	8.00	6.00	7.00	9.00	9.00	0.00	0.00		94.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		2.00		
1017	TANF 21-44 FEMALE N O	3.00	3.00	4.00	3.00	4.00	4.00	3.00	2.00	2.00	2.00	0.00	0.00		30.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00		4.00		
2200	SSI DISABLED WITH M E	36.00	36.00	35.00	33.00	34.00	37.00	30.00	30.00	33.00	31.00	0.00	0.00		335.00		
2210	SSI DISABLED NON-ME D	6,198.00	6,188.00	6,187.00	6,191.00	6,185.00	6,165.00	6,162.00	6,175.00	6,175.00	6,174.00	0.00	0.00		61,800.00		
2220	SSI DISABLED WITH Q M	84.00	88.00	88.00	91.00	91.00	93.00	95.00	95.00	95.00	97.00	0.00	0.00		917.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	1.00	0.00	0.00		11.00		
2310	SSI BLIND NON-MEDIC A	62.00	63.00	64.00	62.00	61.00	63.00	64.00	64.00	59.00	63.00	0.00	0.00		625.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		1.00		
4311	SOBRA CHILD <1 M & F	41.00	42.00	40.00	35.00	42.00	39.00	43.00	45.00	43.00	39.00	0.00	0.00		409.00		
4312	SOBRA CHILD 01-05 M	339.00	329.00	331.00	324.00	313.00	311.00	309.00	300.00	289.00	271.00	0.00	0.00		3,116.00		
4313	SOBRA CHILD 06-13 M	395.00	398.00	395.00	391.00	393.00	391.00	394.00	400.00	406.00	396.00	0.00	0.00		3,959.00		
4314	SOBRA CHILD 14-20 MA	93.00	87.00	84.00	88.00	89.00	91.00	94.00	96.00	99.00	101.00	0.00	0.00		922.00		
4315	SOBRA CHILD 14-20 FE	95.00	94.00	91.00	88.00	92.00	94.00	92.00	92.00	91.00	91.00	0.00	0.00		920.00		
5015	SOBRA PREG 14-20 FE M	2.00	1.00	2.00	0.00	0.00	1.00	1.00	2.00	2.00	2.00	0.00	0.00		13.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	1.00	0.00	0.00		3.00		
SUBTOTAL:	7,657.00	7,640.00	7,633.00	7,615.00	7,610.00	7,595.00	7,592.00	7,607.00	7,603.00	7,582.00	0.00	0.00		76,134.00		

3514	ADULT 40-100% MALE
1	4.00	5.00	6.00	6.00	7.00	7.00	8.00	6.00	5.00	5.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	3.00	3.00	2.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	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	11.00	13.00	14.00	14.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	18.00	16.00	15.00	14.00	15.00	14.00	13.00	11.00	12.00	14.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	4.00	4.00	3.00	3.00	5.00	5.00	3.00	3.00	2.00	3.00	0.00	0.00	

59.00	
16.00	
1.00	
6.00	
153.00	
142.00	
35.00	

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
1115	TANF EXPANDED 14-20	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	1.00	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	1.00	1.00	2.00	0.00	0.00	
SUBTOTAL:	1.00	1.00	1.00	1.00	0.00	0.00	0.00	1.00	2.00	3.00	0.00	0.00	

 
1.00	
5.00	
4.00	
10.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEM AL	1.00	3.00	3.00	3.00	3.00	4.00	2.00	3.00	3.00	3.00	0.00	0.00	28.00	
SUBTOTAL	:	51.00	49.00	49.00	47.00	46.00	45.00	38.00	38.00	37.00	40.00	0.00	0.00	440.00	

3914	NEWLY ELIGIBLE MALE	2.00	2.00	2.00	3.00	3.00	3.00	2.00	2.00	2.00	3.00	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	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.00	4.00	4.00	3.00	2.00	2.00	3.00	4.00	0.00	0.00	

24.00	
5.00	
2.00	
31.00	

4413	SOBRA 100-133% M&F
6	18.00	22.00	25.00	27.00	30.00	28.00	27.00	24.00	23.00	20.00	0.00	0.00	
4414	SOBRA 100-133% MALE	6.00	6.00	4.00	3.00	4.00	5.00	5.00	4.00	5.00	3.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	5.00	5.00	9.00	7.00	8.00	7.00	8.00	8.00	5.00	5.00	0.00	0.00	
SUBTOTAL:	29.00	33.00	38.00	37.00	42.00	40.00	40.00	36.00	33.00	28.00	0.00	0.00	

244.00	
45.00	
67.00	
356.00	

TOTAL:	7,741.00	7,726.00	7,724.00	7,704.00	7,702.00	7,683.00	7,672.00	7,684.00	7,678.00	7,657.00	0.00	0.00		76,971.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	966.16	472.85	1,463.01	1,041.33	0.00	0.00		16,814.31		
1007	TANF 21-44 FEMALE WI	11,505.38	19,187.09	10,505.19	13,081.14	12,255.21	5,857.34	6,905.44	5,726.11	12,391.83	802.90	0.00	0.00		98,217.63		
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	5,124.58	8,610.56	8,029.89	12,723.86	0.00	0.00		93,497.10		
1009	TANF 65+ M & F WITH	2,022.37	2,905.92	1,922.18	3,376.98	5,415.68	4,221.49	1,966.18	1,851.93	3,389.30	3,519.11	0.00	0.00		30,591.14		
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	703,914.31	1,591,060.88	1,624,090.03	1,180,808.17	0.00	0.00		10,251,598.52		
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	274,262.24	469,222.97	492,392.07	338,123.27	0.00	0.00		3,570,249.49		
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	254,326.82	337,894.26	336,680.48	281,345.85	0.00	0.00		3,076,010.00		
1014	TANF 14-20 MALE NON-	88,902.93	72,599.25	62,332.53	62,617.64	90,941.50	84,475.92	69,597.44	81,146.50	106,734.11	74,266.95	0.00	0.00		793,614.77		
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	204,015.64	271,354.53	264,289.14	214,271.38	0.00	0.00		2,376,316.75		
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	1,400,411.55	1,912,486.00	2,223,615.59	1,479,251.36	0.00	0.00		16,920,573.58		
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	4,393,173.49	6,100,958.38	6,145,927.27	4,910,851.36	0.00	0.00		54,625,380.65		
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	1,788,931.53	2,210,744.16	2,847,441.08	2,048,818.07	0.00	0.00		22,282,260.32		
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	2,051.15	7,125.20	3,481.51	4,387.63	0.00	0.00		84,487.43		
1026	TANF 21-44 MALE WITH	1,000.95	2,620.04	1,137.34	2,285.50	955.88	180.71	1,435.52	1,778.95	179.72	213.29	0.00	0.00		11,787.90		
1027	TANF 21-44 FEMALE WI	3,449.27	3,490.82	1,096.67	4,139.90	2,045.11	510.96	653.32	461.41	1,353.21	1,034.29	0.00	0.00		18,234.96		
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	6,399.53	8,812.42	14,243.76	8,036.28	0.00	0.00		80,242.69		
1029	TANF 65+ M & F WITH	111.13	364.33	6.64	1,438.51	195.66	525.26	212.94	196.61	515.79	4,339.57	0.00	0.00		7,906.44		
2100	SSI AGED WITH MEDIC A	190,983.36	191,970.63	82,013.82	76,365.39	91,088.43	84,485.74	85,031.10	86,311.65	140,362.09	79,582.11	0.00	0.00		1,108,194.32		
2110	SSI AGED NON-MEDIC AR	92,974.35	100,505.44	91,252.74	187,019.51	212,617.39	73,413.33	74,007.47	147,477.35	214,910.41	129,451.14	0.00	0.00		1,323,629.13		
2120	SSI AGED WITH QMB	469,076.56	646,192.71	528,246.07	449,589.56	450,826.87	348,768.55	368,167.12	472,821.90	671,320.18	458,508.37	0.00	0.00		4,863,517.89		
2200	SSI DISABLED WITH M E	358,598.07	500,225.09	440,571.93	338,158.99	391,009.98	311,665.78	254,012.59	314,015.42	488,639.95	300,387.11	0.00	0.00		3,697,284.91		
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	7,028,841.59	8,894,230.46	10,223,999.33	8,566,360.68	0.00	0.00		85,992,839.77		
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	933,802.62	1,240,511.82	1,739,157.40	1,036,863.96	0.00	0.00		12,439,190.92		
2300	SSI BLIND WITH MEDIC	457.17	1,105.82	1,395.49	132.01	491.84	428.26	1,347.96	644.54	871.25	2,285.36	0.00	0.00		9,159.70		
2310	SSI BLIND NON-MEDIC A	86,051.54	110,836.56	112,120.18	81,513.40	82,935.27	81,079.47	64,440.68	113,023.64	108,024.21	75,246.08	0.00	0.00		915,271.03		
2320	SSI BLIND WITH QMB	17,562.15	17,561.62	12,173.61	7,949.10	17,096.45	11,085.52	9,957.17	18,261.57	20,406.77	7,878.70	0.00	0.00		139,932.66		
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	2,467,687.18	3,345,285.07	3,851,645.53	2,708,077.50	0.00	0.00		27,723,728.63		
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	3,716,744.67	5,891,193.21	5,892,103.94	3,759,349.10	0.00	0.00		43,996,965.19		
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	3,882,868.56	5,552,465.07	5,715,104.55	4,093,467.87	0.00	0.00		50,691,533.18		
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	1,193,680.77	1,337,081.30	1,455,786.21	1,105,184.43	0.00	0.00		13,531,217.49		
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	1,510,001.97	1,721,278.74	2,042,582.89	1,427,293.02	0.00	0.00		16,958,899.21		
5007	SOBRA PREG 21-44 FE M	865.69	2,004.91	939.33	151.08	459.33	261.99	273.32	1,359.11	2,333.39	2,333.76	0.00	0.00		10,981.91		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,702.26	736.00	736.00	0.00	815.73	368.00	368.00	23.00	368.00	0.00	0.00		14,817.99		
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	334,043.63	400,628.53	626,427.06	413,091.63	0.00	0.00		4,079,066.01		
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	1,810,905.50	2,268,820.70	2,870,395.90	2,262,249.46	0.00	0.00		23,368,178.87		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017

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	5,247.84	15,565.51	6,353.63	3,560.30	0.00	0.00	97,027.21	
5027	SOBRA PREG 21-44 FE M	922.96	3,146.16	1,079.37	1,402.90	3,204.61	2,735.48	1,426.13	2,297.44	3,739.19	1,535.68	0.00	0.00	21,489.92	
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	32,857,203.71	44,833,544.75	50,160,404.67	36,996,908.93	0.00	0.00	405,324,219.15	

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	10,503.33	15,216.06	19,134.10	15,224.47	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	31,272.67	25,936.58	23,228.20	36,786.81	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	54,933.89	65,549.55	85,181.54	34,974.67	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	20,787.38	36,514.60	34,061.54	21,580.82	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	736.00	662.35	437.00	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	1,472.00	456.60	46.00	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	4,416.00	3,059.96	2,370.63	2,344.89	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	31,289.74	60,481.87	38,863.31	38,795.47	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	572,830.22	669,821.85	804,332.65	700,443.27	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	1,755,061.18	2,407,882.41	2,586,743.19	2,060,384.93	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	1,301,131.59	1,749,559.28	2,022,493.32	1,431,801.57	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	7,128.21	3,326.59	4,705.60	4,970.30	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	12,722.51	14,926.67	21,266.37	17,360.32	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	22,842.67	29,552.28	40,366.61	17,124.19	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	51,878.24	78,785.60	132,995.39	102,073.15	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	11,045.13	21,749.72	32,223.31	20,121.43	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	12,186.63	17,487.33	20,099.02	19,432.22	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	5,912.64	8,103.69	11,476.60	11,605.36	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	200,478.44	266,857.67	288,481.37	261,861.65	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	17,256.83	18,193.43	29,659.15	14,619.53	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	147,920.57	130,768.31	136,729.33	184,366.94	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	186,075.38	266,096.35	324,528.33	185,644.30	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	4,459,881.25	5,890,988.75	6,659,422.56	5,181,516.29	0.00	0.00	

171,670.19	
324,484.89	
829,508.80	
340,357.74	
736.00	
8,803.31	
10,201.34	
44,846.62	
416,058.59	
6,234,319.09	
21,400,972.23	
15,189,391.60	
51,372.56	
164,777.83	
201,324.27	
585,370.98	
189,306.70	
178,998.99	
64,816.60	
2,617,054.47	
233,690.49	
1,575,688.24	
2,855,107.45	
53,688,858.98	

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	-1,176.00	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	-1,264.00	-316.00	0.00	0.00	0.00	

-294.00	
-2,239.01	
-5,920.74	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	-1,264.00	-1,492.00	0.00	0.00	0.00		-8,453.75		

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	-904.00	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	-330.00	-330.00	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	-3,868.79	-1,306.00	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	-5,102.79	-1,636.00	0.00	0.00	0.00	

 
-128.19	
-3,081.67	
-23.63	
-660.00	
-9,171.02	
-3,380.00	
-12,997.57	
-29,442.08	

3506	ADULT 40-100% MALE
2	0.00	-172.78	0.00	-25.53	0.00	0.00	0.00	0.00	79.70	564.94	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	36,199.37	280.59	621.63	2,110.63	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	410.15	4,867.01	11,551.95	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	37,421.29	58,831.53	97,445.08	57,374.90	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	82,095.99	85,203.51	114,089.90	89,354.91	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	992,022.51	980,314.76	1,023,107.43	882,666.96	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	498,822.80	631,348.88	710,806.10	502,289.24	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	2,100,590.78	2,358,755.43	2,649,204.24	1,873,819.74	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	736.00	0.00	100.32	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	1.89	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	57.38	111.32	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	57.17	0.00	2,920.58	854.28	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	197.60	635.28	1,759.27	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	5,729.48	3,479.42	12,131.33	1,916.74	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	57.96	64.80	378.04	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	232,501.13	303,401.84	332,314.25	246,318.83	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	308,436.48	364,708.59	435,560.68	260,312.10	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	5,541,068.68	6,900,652.72	7,558,827.74	6,777,770.38	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	2,810,202.84	3,453,921.75	3,790,472.03	2,849,993.81	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	8,066,390.57	9,778,920.65	11,070,305.60	8,511,862.22	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	1,505.29	4,531.31	6,597.54	2,461.04	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	93.02	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	2,219.74	1,413.68	1,461.76	201.31	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	20,716,002.01	24,926,430.37	27,811,670.38	22,073,765.63	0.00	0.00	

 
446.33	
68,651.49	
64,442.92	
527,932.16	
852,980.62	
9,042,634.91	
5,790,923.95	
22,299,064.39	
44,215.77	
217.07	
232.16	
168.70	
11,016.27	
9,282.85	
88,478.73	
7,954.38	
2,961,703.80	
3,579,675.89	
66,457,121.05	
32,644,261.63	
91,455,041.13	
39,670.44	
138.16	
31,462.45	
235,977,717.25	

3906	NEWLY ELIGIBLE MALE	600.38	328.49	29.45	209.59	411.24	590.08	0.00	327.55	86.54	0.00	0.00	0.00	2,583.32

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	-350.00	0.00	0.00	0.00		808.94		
3908	NEWLY ELIGIBLE M&F 4	9,346.79	12,574.43	4,551.68	837.13	2,803.98	3,984.00	2,900.14	964.94	8,083.50	369.66	0.00	0.00		46,416.25		
3909	NEWLY ELIGIBLE M&F 6	491.18	602.98	747.75	0.00	1,943.80	166.29	155.80	253.33	75.58	236.86	0.00	0.00		4,673.57		
3914	NEWLY ELIGIBLE MALE	22,978.31	18,527.45	13,537.31	13,309.33	31,539.02	32,825.23	16,200.85	24,950.00	20,163.27	14,892.56	0.00	0.00		208,923.33		
3915	NEWLY ELIGIBLE FEMA L	41,330.26	46,109.83	28,638.83	27,897.16	30,273.25	31,443.93	47,329.40	28,706.23	39,986.61	20,019.24	0.00	0.00		341,734.74		
3916	NEWLY ELIGIBLE MALE	331,242.92	482,310.70	341,671.18	331,691.73	336,188.43	356,055.85	307,485.16	370,921.27	472,959.23	362,794.74	0.00	0.00		3,693,321.21		
3917	NEWLY ELIGIBLE FEMA L	773,121.13	829,594.37	623,013.25	503,865.22	576,970.36	489,415.96	519,966.03	638,124.22	781,249.57	530,984.24	0.00	0.00		6,266,304.35		
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	1,068,578.68	1,445,530.24	1,476,628.55	1,206,814.72	0.00	0.00		12,214,995.11		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	736.00	368.00	736.00	0.00	368.00	0.00	0.00	1,264.04	0.00	0.00		3,472.04		
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	1,962,984.06	2,509,777.78	2,798,882.85	2,137,376.06	0.00	0.00		22,784,072.94		

4412	SOBRA 100-133% M&F
1	0.00	1,436.00	0.00	700.00	350.00	0.00	0.00	368.00	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	416,101.91	473,636.81	469,508.26	390,295.23	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	95,273.35	139,165.82	146,452.97	108,320.67	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	129,241.22	148,526.88	167,044.52	135,833.96	0.00	0.00	
SUBTOTAL:	722,194.67	942,881.73	691,984.7	5	666,487.31	863,543.05	720,122.85	640,616.48	761,697.51	783,005.75	634,449.86	0.00	0.00	

 
2,854.00	
4,559,613.20	
1,192,127.10	
1,672,389.66	
7,426,983.96	

4517	BC PATIENT FEMALE 2 1	368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	-700.00	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	736.00	1,472.00	2,392.00	5,359.00	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	736.00	1,472.00	1,692.00	5,359.00	0.00	0.00	

 
404.00	
27,994.04	
147.74	
368.00	
28,913.78	

8700	SSI DISABLED FREEDO M	11,347.92	16,496.57	21,239.51	9,895.47	12,006.69	10,563.56	4,012.02	7,835.30	9,267.16	6,649.74	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	29,471.91	496.84	1,488.70	5,106.22	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	4,549.40	2,251.99	2,860.58	1,394.92	0.00	0.00	
SUBTOTAL:	13,176.17	19,372.57	29,893.61	12,730.73	18,320.34	16,055.66	38,033.33	10,584.13	13,616.44	13,150.88	0.00	0.00	

 
109,313.94	
44,481.49	
31,138.43	
184,933.86	

66,796,397.97

73,912,984.11     67,934,757.94     60,675,456.84    78,928,128.50

67,042,526.65

60,161,831.93

88,225,566.65

0.00	0.00

725,379,642.60	

TOTAL:

76,348,717.42

85,353,274.59

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2017	
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	8.69	231.68	184.80	0.00	0.00		540.66		
1007	TANF 21-44 FEMALE WI	95.75	21.69	0.00	20.56	1,619.87	0.00	37.29	0.00	0.00	69.45	0.00	0.00		1,864.61		
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	32,855.58	39,571.41	39,866.98	61,416.92	0.00	0.00		306,557.78		
1012	TANF 01-05 M & F NON	401.51	861.55	9.55	87.48	0.00	0.00	0.00	830.56	84.79	742.92	0.00	0.00		3,018.36		
1013	TANF 06-13 M & F NON	1,152.31	-24.10	90.49	1,646.32	9,527.66	471.14	910.84	1,409.03	0.00	3,031.05	0.00	0.00		18,214.74		
1014	TANF 14-20 MALE NON-	714.39	1,253.78	2,854.79	1,212.29	1,317.94	1,063.58	5,329.62	168.51	4,290.90	2,270.19	0.00	0.00		20,475.99		
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	10,280.76	8,195.30	7,208.01	6,568.04	0.00	0.00		74,978.63		
1016	TANF 21-44 MALE NON-	22,396.21	77,167.79	17,027.50	30,769.91	19,582.98	74,267.10	64,606.54	26,171.06	28,616.71	31,845.26	0.00	0.00		392,451.06		
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	68,674.14	86,271.22	70,638.11	65,152.97	0.00	0.00		766,409.69		
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	32,720.01	23,608.47	29,891.89	12,727.76	0.00	0.00		224,438.51		
2100	SSI AGED WITH MEDIC A	15,695.91	8,647.19	17,906.90	4,577.58	24,850.76	12,624.23	8,300.15	7,004.13	15,256.08	7,403.66	0.00	0.00		122,266.59		
2110	SSI AGED NON-MEDIC AR	28,335.40	43,386.47	18,508.51	14,354.52	14,326.40	10,091.55	26,904.77	28,572.54	22,461.47	87,535.60	0.00	0.00		294,477.23		
2120	SSI AGED WITH QMB	0.00	1,048.56	0.00	0.00	0.00	388.95	18.71	0.00	176.87	271.68	0.00	0.00		1,904.77		
2200	SSI DISABLED WITH M E	2,033.62	523.52	3,191.46	2,136.22	337.95	867.18	1,096.26	236.56	1,633.62	2,705.90	0.00	0.00		14,762.29		
2210	SSI DISABLED NON-ME D	16,753.15	7,270.63	7,651.13	14,824.42	5,039.25	322.18	8,223.40	2,028.03	7,711.60	13,830.47	0.00	0.00		83,654.26		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	1.71	0.00	0.00	83.52	132.52	0.00	0.00		217.75		
4311	SOBRA CHILD <1 M & F	10,799.03	33,934.63	1,439.56	27,420.49	47,618.22	15,364.31	22,442.24	22,541.17	18,566.60	95,752.42	0.00	0.00		295,878.67		
4312	SOBRA CHILD 01-05 M	36,145.25	43,168.63	23,886.76	53,151.78	93,538.03	55,433.49	30,062.29	37,044.66	50,188.24	95,451.26	0.00	0.00		518,070.39		
4313	SOBRA CHILD 06-13 M	35,978.68	63,157.33	22,075.20	27,013.14	18,490.93	31,425.00	27,680.60	32,649.26	78,191.50	27,076.08	0.00	0.00		363,737.72		
4314	SOBRA CHILD 14-20 MA	18,930.52	12,976.10	24,307.39	12,958.69	48,135.67	14,354.58	37,742.37	9,934.46	21,501.83	35,970.11	0.00	0.00		236,811.72		
4315	SOBRA CHILD 14-20 FE	12,023.48	33,332.95	16,503.27	18,974.50	34,815.87	26,678.69	22,900.20	70,387.01	18,596.70	17,168.78	0.00	0.00		271,381.45		
5007	SOBRA PREG 21-44 FE M	214.11	0.00	0.00	0.00	0.00	0.00	67.10	31.72	0.00	4,565.81	0.00	0.00		4,878.74		
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	20,923.84	14,786.80	33,705.07	16,875.64	0.00	0.00		211,059.79		
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	78,999.72	102,773.42	106,486.62	85,462.43	0.00	0.00		859,028.78		
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	182.51	0.00	0.00		297.41		
SUBTOTAL:	385,488.23	674,902.99	344,652.4	6	418,337.10	546,678.14	481,759.95	500,776.43	514,224.01	555,388.79	674,394.23	0.00	0.00		5,096,602.33		

1106	TANF EXPANDED 21-44	0.00	16.99	0.00	0.00	64.90	0.00	173.10	353.43	139.65	601.50	0.00	0.00	
1107	TANF EXPANDED 21-44	48.90	128.09	148.39	275.17	401.97	414.56	1,374.51	265.69	1,456.29	422.93	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	320.83	1,448.83	3,797.69	1,565.31	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	49.92	230.91	0.00	129.41	51.11	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	1,190.20	93.00	0.00	0.00	0.00	10.17	415.50	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	675.61	623.32	1,657.23	302.10	0.00	0.00	

 
1,349.57	
4,936.50	
19,200.58	
461.35	
1,708.87	
9,304.49	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2017	
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	16,943.90	34,384.03	24,091.80	19,517.97	0.00	0.00		250,702.64		
1117	TANF EXPANDED 21-44	25,519.01	79,115.30	31,651.63	22,755.66	43,409.59	32,204.44	31,979.54	54,903.43	51,327.98	39,430.79	0.00	0.00		412,297.37		
1118	TANF EXPANDED 45-64	10,025.87	17,504.72	19,259.83	34,282.55	9,735.71	23,483.52	17,284.79	28,143.25	43,295.29	25,920.79	0.00	0.00		228,936.32		
1119	TANF EXPANDED 65+
M&	55.48	0.00	175.00	813.81	0.00	0.00	0.00	563.61	0.00	0.00	0.00	0.00		1,607.90		
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,275.12	0.00	0.00		1,275.12		
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	9,826.36	8,389.79	62,201.96	12,371.74	0.00	0.00		130,691.89		
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	919.29	879.87	377.14	431.56	0.00	0.00		6,088.68		
2600	SSI DISABLED EXPAND E	4,162.15	4,535.71	3,783.46	647.92	3,387.25	1,809.57	2,568.84	5,194.14	1,184.01	5,187.30	0.00	0.00		32,460.35		
2610	SSI DISABLED EXPAND E	2,877.20	578.09	517.86	37.27	692.45	3,699.97	3,718.47	1,122.52	3,850.12	2,604.59	0.00	0.00		19,698.54		
2620	SSI DISABLED EXPAND E	-21.51	114.65	0.00	418.41	0.00	90.00	143.11	114.13	508.25	142.00	0.00	0.00		1,509.04		
SUBTOTAL:	82,110.61	152,318.59	88,653.42	87,509.05	103,166.20	90,918.94	86,159.26	136,396.21	194,432.32	109,824.81	0.00	0.00		1,131,489.41		

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	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58.00	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	347.59	50.05	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	4,893.50	3,932.60	8,520.82	7,362.12	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	7,967.32	1,352.80	5,767.32	2,843.48	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	42,715.45	41,437.37	47,986.26	58,052.69	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	15,468.38	31,822.79	26,933.05	28,445.41	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	72,285.58	113,918.82	103,301.00	62,443.70	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	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	196.00	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	75.44	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	2,907.24	2,218.72	545.32	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	7,995.99	32,389.48	15,804.89	6,186.21	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	8,263.51	12,385.43	5,204.24	10,738.80	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	117,253.00	266,622.13	354,771.70	184,884.98	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	75,329.37	108,832.06	119,213.51	117,663.93	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	195,049.66	286,393.16	336,435.55	402,280.69	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	382.93	44.82	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	16.92	0.00	0.00	39.29	137.25	242.65	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	547,812.00	902,043.93	1,026,869.43	881,492.15	0.00	0.00	

 
2,994.80	
58.00	
3,081.28	
45,196.53	
42,731.72	
444,099.52	
232,429.87	
961,357.01	
369.84	
16.99	
196.00	
905.22	
12,428.83	
128,759.85	
108,122.68	
2,111,541.57	
994,441.18	
2,640,253.10	
1,733.32	
436.11	
7,731,153.42	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		489.66		
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		900.55		
3908	NEWLY ELIGIBLE M&F 4	1,522.55	2,007.21	-130.10	47.46	0.00	0.00	184.38	0.00	604.67	0.00	0.00	0.00		4,236.17		
3914	NEWLY ELIGIBLE MALE	5,721.11	5,859.40	1,492.91	2,289.17	4,340.03	5,511.27	4,802.60	8,310.04	2,571.77	1,650.53	0.00	0.00		42,548.83		
3915	NEWLY ELIGIBLE FEMA L	8,643.80	4,978.33	1,563.70	2,092.87	236.71	468.25	1,629.20	3,846.77	4,486.11	3,352.00	0.00	0.00		31,297.74		
3916	NEWLY ELIGIBLE MALE	70,300.31	68,630.75	35,919.65	13,892.41	58,542.71	28,479.75	51,656.86	21,141.39	63,057.59	44,827.45	0.00	0.00		456,448.87		
3917	NEWLY ELIGIBLE FEMA L	24,423.42	39,053.73	33,070.64	21,577.86	34,563.12	45,340.29	34,321.38	22,344.75	30,781.37	57,480.09	0.00	0.00		342,956.65		
3918	NEWLY ELIGIBLE M&F 4	91,934.27	121,532.84	100,254.80	128,043.33	153,412.32	88,359.26	63,817.22	129,431.92	193,490.56	168,145.11	0.00	0.00		1,238,421.63		
SUBTOTAL:	202,655.53	242,551.92	172,171.60	168,384.96	251,443.51	168,158.82	156,411.64	185,074.87	294,992.07	275,455.18	0.00	0.00		2,117,300.10		

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	423.93	410.34	719.55	31.01	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	12,111.39	279.42	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	26.70	0.00	9.43	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,096.24	591.33	225.58	315.32	155.36	2,063.32	423.93	419.77	12,830.94	310.43	0.00	0.00	

4,412.18	
13,983.91	
36.13	
18,432.22	

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	6,249.22	3,765.00	19,449.96	9,054.44	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	8,500.44	2,144.66	2,494.66	5,746.96	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	-756.72	2,731.69	8,611.84	7,153.48	0.00	0.00	
SUBTOTAL:	12,519.92	25,677.60	9,035.86	30,747.16	11,114.26	13,047.05	13,992.94	8,641.35	30,556.46	21,954.88	0.00	0.00	

 
98,514.08	
40,964.03	
37,809.37	
177,287.48	

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	1,305,576.20	1,746,800.14	2,115,070.01	1,963,431.68	0.00	0.00		16,272,495.95		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending April 30, 2017	
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	550.40	0.00	0.00	0.00	0.00	0.00		1,475.08		
SUBTOTAL:	0.00	576.29	0.00	348.39	0.00	0.00	550.40	0.00	0.00	0.00	0.00	0.00		1,475.08		

0.00	576.29	0.00	348.39	0.00	0.00	550.40	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	48.36	0.00	318.52	0.00	0.00	0.00	404.84	
1011	TANF <1 M & F NON-ME	3,451.27	301.65	83.70	377.87	2,556.41	204.21	4,617.23	3,593.12	475.66	4,359.90	0.00	0.00	20,021.02	
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	16,847.63	23,824.40	53,366.67	29,835.71	0.00	0.00	401,832.68	
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	56,504.49	52,230.24	54,987.25	70,925.20	0.00	0.00	624,166.95	
1014	TANF 14-20 MALE NON-	93,392.20	152,861.08	48,139.24	75,194.53	324,931.57	107,296.76	115,429.38	131,239.24	132,941.85	-20,289.96	0.00	0.00	1,161,135.89	
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	327,165.39	392,626.76	585,585.43	474,874.68	0.00	0.00	4,553,081.63	
1016	TANF 21-44 MALE NON-	126,645.84	163,695.80	98,079.03	56,898.27	58,334.35	39,877.67	32,176.30	29,490.03	30,698.85	30,764.80	0.00	0.00	666,660.94	
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	2,190,104.49	2,703,088.15	4,041,723.87	3,098,116.01	0.00	0.00	30,211,072.00	
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	172,247.53	111,596.94	185,675.36	-122,954.53	0.00	0.00	1,805,038.31	
1019	TANF 65+ M & F NON-M	4,738.82	9,707.54	11,164.74	323.40	5,875.39	2,871.88	11,980.17	668.21	2,795.71	-1,147.59	0.00	0.00	48,978.27	
2100	SSI AGED WITH MEDIC A	12,916.57	12,231.56	7,221.85	7,793.70	12,148.63	9,089.59	6,776.67	50,563.87	30,861.76	5,812.05	0.00	0.00	155,416.25	
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	918,303.10	1,372,272.24	1,385,320.63	1,574,133.88	0.00	0.00	12,262,889.01	
2120	SSI AGED WITH QMB	4,041.12	1,462.37	1,946.96	191.62	1,089.89	471.22	0.00	8,944.60	1,232.67	5,628.72	0.00	0.00	25,009.17	
2200	SSI DISABLED WITH M E	2,921.27	5,139.66	2,878.36	3,669.97	3,512.16	4,895.49	12,614.92	5,288.19	10,942.36	2,120.31	0.00	0.00	53,982.69	
2210	SSI DISABLED NON-ME D	420,657.34	364,111.90	277,016.96	249,032.75	474,676.82	288,695.61	312,530.36	315,278.40	297,237.16	83,040.65	0.00	0.00	3,082,277.95	
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	4,177,346.02	5,200,704.39	6,814,163.75	5,235,219.83	0.00	0.00	55,073,173.70	

1106	TANF EXPANDED 21-44	20.66	853.49	749.84	779.40	4,811.37	1,707.88	2,311.66	2,941.90	496.02	1,489.28	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	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165.61	97.91	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	249.26	0.00	93.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	144.99	137.60	93.02	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	130.73	-7,891.92	665.37	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	35,539.77	14,420.04	20,923.20	24,733.52	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	532,388.49	590,262.70	875,848.02	636,045.15	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	1,166,251.73	1,674,532.96	1,704,681.28	1,738,720.64	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	685,609.01	621,026.88	903,878.71	318,442.92	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	15,854.97	35,624.26	24,755.00	11,696.22	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	10,460.39	1,412.72	1,383.47	1,275.12	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	11,986.15	31,889.42	15,473.19	5,088.58	0.00	0.00	
2420	SSI AGED EXPANDED WI	62.60	24.94	383.52	319.20	354.11	0.00	2,078.06	987.87	355.36	2,908.97	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	6,359.33	8,473.08	78.07	349.25	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	2,469,181.84	2,981,868.17	3,540,171.31	2,741,415.02	0.00	0.00	

 
16,161.50	
-1,916.23	
263.52	
27.13	
350.26	
375.61	
7,850.34	
220,001.37	
6,222,098.49	
13,642,813.51	
6,623,852.64	
164,263.03	
1,877.16	
18,574.59	
228,352.71	
7,474.63	
137,038.97	
27,289,459.23	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	
3718	ADULT <40% EXP M&F 4	144.99	878.73	3,121.77	239.29	0.00	0.00	0.00	0.00	82.36	0.00	0.00	0.00	4,467.14	
SUBTOTAL	:	447.97	878.73	3,121.77	239.29	0.00	0.00	0.00	0.00	82.36	0.00	0.00	0.00	4,770.12	

3906	NEWLY ELIGIBLE MALE	3,658.03	6,533.31	3,679.09	3,982.59	6,269.15	3,584.44	4,388.46	3,374.77	11,072.20	14,853.72	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	1,212.86	365.72	-1,268.94	246.62	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	68,856.00	102,589.17	48,943.40	74,767.56	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	34,761.15	51,876.44	55,011.40	76,359.70	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	988,074.97	890,484.91	1,011,979.96	838,536.37	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	575,234.75	422,668.05	968,942.20	598,923.89	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	2,052,472.86	2,141,866.39	2,908,869.29	2,276,820.13	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	3,686.90	5,779.53	13,496.31	5,817.67	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	3,728,687.95	3,619,004.98	5,017,045.82	3,886,325.66	0.00	0.00	

 
61,395.76	
2,152.35	
24,052.41	
7,198.04	
681,542.39	
765,775.30	
8,979,316.27	
5,783,758.17	
21,861,170.26	
79,270.06	
38,245,631.01	

TOTAL:	9,886,437.64	14,111,912.66	11,414,030.97	11,171,834.62	14,288,688.22	10,328,912.85	10,375,215.81	11,801,577.54	15,371,463.24	11,862,960.51	0.00	0.00		120,613,034.06		

FEDERAL ESP CHRONIC SERVICES
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	6,982.27	0.00	0.00	0.00	0.00	0.00		6,982.27		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	6,982.27	0.00	0.00	0.00	0.00	0.00		6,982.27		

0.00	0.00	0.00	0.00	0.00	0.00	6,982.27	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending April 30, 2017

SUBTOTAL:	400,114.69	462,259.02	326,723.35	359,000.43	531,370.38	353,078.58	365,353.75	486,175.92	584,921.94	437,843.79	0.00	0.00	4,306,841.85	

TOTAL:	
400,114.69	
462,259.02	
326,723.35	
359,000.43	
531,370.38	
353,078.58	
365,353.75	
486,175.92	
584,921.94	
437,843.79	
0.00	
0.00	
4,306,841.85	

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	365,353.75	481,787.34	584,910.43	437,803.16	0.00	0.00	4,301,588.01	
8040	SLMB	4.16	0.00	0.00	0.00	4.29	7.91	0.00	3,044.20	11.51	0.00	0.00	0.00	3,072.07	
8050	QI1	7.67	86.69	626.78	0.00	75.62	0.00	0.00	1,344.38	0.00	40.63	0.00	0.00	2,181.77	

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2017	
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	334.53	1,245.22	1,641.00	2,215.08	0.00	0.00		16,616.84		
1012	TANF 01-05 M & F NON	368.00	6,424.63	12,171.54	6,859.78	9,788.83	9,203.67	7,469.36	15,300.98	21,291.33	38,770.22	0.00	0.00		127,648.34		
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	30,847.95	131,576.60	99,745.48	103,743.47	0.00	0.00		626,916.15		
1014	TANF 14-20 MALE NON-	7,533.55	31,068.97	43,660.36	19,685.20	17,281.74	15,695.59	19,487.14	59,257.84	30,625.56	32,491.07	0.00	0.00		276,787.02		
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	74,238.98	84,327.07	76,755.25	74,376.58	0.00	0.00		608,490.91		
1016	TANF 21-44 MALE NON-	50,986.98	232,739.24	158,391.39	238,145.92	268,947.55	213,560.11	203,813.52	338,745.73	608,037.96	515,266.81	0.00	0.00		2,828,635.21		
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	636,757.11	1,193,264.73	1,540,858.30	1,358,984.31	0.00	0.00		8,411,123.03		
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	132,237.00	138,909.54	212,168.35	183,872.75	0.00	0.00		1,308,338.65		
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	529.19	337.68	240.84	27.36	0.00	0.00		2,574.85		
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	8,557.70	818.88	3,501.73	11,526.43	0.00	0.00		59,005.22		
2110	SSI AGED NON-MEDIC AR	0.00	368.00	368.00	368.00	0.00	368.00	368.00	0.00	421.60	0.00	0.00	0.00		2,261.60		
2120	SSI AGED WITH QMB	2,129.89	16,890.55	8,512.82	13,797.57	24,489.11	27,241.34	29,146.35	30,365.83	34,993.93	29,677.72	0.00	0.00		217,245.11		
2200	SSI DISABLED WITH M E	4,943.64	25,786.59	15,182.25	15,394.43	21,736.34	19,832.03	15,932.70	17,574.52	26,590.42	19,793.54	0.00	0.00		182,766.46		
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	1,224,929.60	1,564,175.61	2,002,034.73	1,524,746.94	0.00	0.00		13,294,272.26		
2220	SSI DISABLED WITH Q M	57,352.69	239,617.61	215,280.59	218,399.67	280,370.96	270,585.46	243,778.12	282,666.54	351,338.92	283,339.40	0.00	0.00		2,442,729.96		
2310	SSI BLIND NON-MEDIC A	1,641.42	3,896.82	1,477.44	1,960.45	3,267.86	7,135.91	4,141.06	10,219.77	11,717.74	5,596.65	0.00	0.00		51,055.12		
2320	SSI BLIND WITH QMB	152.56	426.32	347.04	441.86	184.29	699.38	856.38	1,168.94	1,745.65	1,220.23	0.00	0.00		7,242.65		
4311	SOBRA CHILD <1 M & F	0.00	4,537.43	2,034.73	1,426.34	6,580.12	7,003.95	9,767.25	4,795.68	5,576.06	3,257.23	0.00	0.00		44,978.79		
4312	SOBRA CHILD 01-05 M	38,968.43	137,249.86	128,098.21	121,728.54	162,096.34	91,097.20	128,374.60	159,545.58	196,645.86	155,507.88	0.00	0.00		1,319,312.50		
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	2,105,463.67	3,116,522.72	3,294,860.58	2,447,888.43	0.00	0.00		24,105,996.55		
4314	SOBRA CHILD 14-20 MA	118,686.61	495,250.47	412,817.00	484,576.55	753,609.47	528,879.93	579,025.31	777,453.55	771,666.47	678,773.27	0.00	0.00		5,600,738.63		
4315	SOBRA CHILD 14-20 FE	99,195.07	477,467.78	386,605.17	499,195.74	754,614.07	576,811.53	626,249.83	768,392.47	878,584.76	821,586.85	0.00	0.00		5,888,703.27		
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	9,019.24	5,584.25	11,296.62	67,046.10	0.00	0.00		171,239.77		
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	80,948.74	129,873.61	170,313.64	187,797.66	0.00	0.00		1,152,981.40		
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	6,172,273.33	8,832,123.34	10,352,652.78	8,547,505.98	0.00	0.00		68,752,309.30		

1106	TANF EXPANDED 21-44	137.75	616.80	613.08	272.99	532.97	486.29	6,659.17	6,723.73	6,205.66	6,297.63	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	1,597.76	374.58	275.22	407.11	636.48	523.43	338.13	323.24	143.95	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	6,838.48	6,542.52	2,033.59	345.11	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	64.80	0.00	0.00	167.36	84.46	133.52	0.00	69.80	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	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	672.80	487.07	621.27	0.00	0.00	0.00	

 
28,546.07	
4,619.90	
30,483.27	
519.94	
736.00	
1,781.14	

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	137.44	4,260.77	468.71	2,643.50	912.14	1,874.36	1,867.36	3,442.88	4,029.59	1,584.74	0.00	0.00		21,221.49		
1116	TANF EXPANDED 21-44	4,744.53	38,555.84	35,932.03	37,022.29	79,859.99	37,359.82	45,658.86	120,228.74	170,311.77	139,335.71	0.00	0.00		709,009.58		
1117	TANF EXPANDED 21-44	35,688.54	179,661.54	169,883.68	176,677.23	386,454.55	193,784.64	153,239.60	314,327.96	496,550.24	350,958.94	0.00	0.00		2,457,226.92		
1118	TANF EXPANDED 45-64	12,040.84	94,798.16	87,530.61	76,865.00	142,804.48	62,357.25	34,116.49	80,367.38	103,730.60	105,840.26	0.00	0.00		800,451.07		
1126	TANF EXPANDED 21-44	24.31	48.62	0.00	0.00	0.00	0.00	0.00	56.93	0.00	0.00	0.00	0.00		129.86		
1127	TANF EXPANDED 21-44	0.00	0.00	64.80	295.12	187.16	733.08	2,144.66	423.91	5,083.70	10,238.24	0.00	0.00		19,170.67		
1128	TANF EXPANDED 45-64	0.00	389.55	143.09	11.74	75.11	909.56	757.60	1,743.36	8,194.57	6,815.50	0.00	0.00		19,040.08		
1129	TANF EXPANDED 65+
M&	0.00	87.63	0.00	0.00	0.00	98.19	245.50	0.00	287.35	2,513.43	0.00	0.00		3,232.10		
2400	SSI AGED EXPANDED WI	0.00	28.43	0.00	0.00	0.00	0.00	0.00	381.48	0.00	391.00	0.00	0.00		800.91		
2420	SSI AGED EXPANDED WI	1,847.24	7,852.62	5,140.60	3,311.71	1,221.35	958.95	1,240.54	3,077.53	3,327.89	9,762.73	0.00	0.00		37,741.16		
2600	SSI DISABLED EXPAND E	340.83	1,313.81	339.22	88.37	0.00	6,254.71	6,809.62	6,047.83	4,367.11	1,534.29	0.00	0.00		27,095.79		
2610	SSI DISABLED EXPAND E	2,514.49	16,695.75	6,889.70	9,071.56	8,556.05	4,361.11	13,551.17	2,231.00	1,298.43	13,156.30	0.00	0.00		78,325.56		
2620	SSI DISABLED EXPAND E	7,877.72	36,952.00	29,165.99	31,985.20	31,811.60	23,669.04	16,566.37	24,021.44	35,108.58	31,044.79	0.00	0.00		268,202.73		
SUBTOTAL:	66,027.96	387,092.07	340,784.8	5	341,508.33	653,955.50	335,992.46	291,025.17	570,441.89	841,543.39	679,962.62	0.00	0.00		4,508,334.24		

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	1,752.46	3,052.20	2,814.33	3,955.72	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	9,264.34	3,523.24	4,305.88	2,937.85	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	43,737.65	53,522.87	53,110.09	13,685.79	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	26,080.63	36,055.42	36,740.55	18,723.06	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	37,101.37	53,669.46	65,460.13	34,240.07	0.00	0.00	

759.29	
30,387.39	
60,592.31	
445,478.30	
306,336.13	
311,354.74	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	368.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	2,919.76	13,958.09	11,640.18	12,833.20	8,641.72	7,019.65	28,417.67	19,323.53	14,859.85	10,578.41	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	2,725.50	2,137.35	5,137.18	4,752.25	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	71,467.35	210,128.28	153,091.11	120,250.19	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	50,413.63	53,960.16	113,726.66	115,441.47	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	50,333.32	91,024.18	126,231.04	84,398.16	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	387.44	0.00	158.88	4,096.89	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	95,344.57	172,717.03	128,432.35	90,245.34	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	66,785.47	154,130.55	91,470.63	63,775.65	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	1,197,796.11	2,028,247.23	2,724,826.82	1,914,092.45	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	610,150.19	1,216,922.25	1,301,776.71	1,101,215.82	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	596,902.92	1,000,241.09	1,271,460.95	974,387.02	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	2,771,092.17	4,948,831.65	5,931,172.18	4,483,233.65	0.00	0.00	

 
368.00	
130,192.06	
45,484.93	
954,434.57	
748,098.40	
620,642.46	
14,723.65	
5,312.82	
906,509.27	
786,697.55	
14,901,659.38	
7,957,312.14	
7,282,110.14	
706.24	
34,354,251.61	

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	21,431.74	99,701.53	78,173.21	156,028.85	165,930.91	129,908.81	117,936.45	149,823.19	162,430.98	73,542.49	0.00	0.00		1,154,908.16		

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	89,268.79	132,616.73	152,960.67	115,902.82	0.00	0.00	
4414	SOBRA 100-133% MALE	4,868.73	19,328.03	13,195.48	16,884.28	44,153.42	22,515.31	22,627.58	27,695.08	28,872.99	18,143.30	0.00	0.00	
4415	SOBRA 100-133% FEM AL	9,747.31	36,201.76	28,336.16	37,423.23	47,203.48	36,724.97	32,348.52	33,252.52	52,973.36	36,320.54	0.00	0.00	
SUBTOTAL:	35,980.82	149,421.67	94,680.41	121,274.06	269,749.12	172,198.17	144,244.89	193,564.33	234,807.02	170,366.66	0.00	0.00	

 
1,017,471.10	
218,284.20	
350,531.85	
1,586,287.15	

8700	SSI DISABLED FREEDO M	0.00	128.25	0.00	263.33	92.35	68.72	80.22	47.26	69.80	52.26	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	94.52	94.52	0.00	23.63	23.63	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	1,090.92	6,229.90	7,995.85	4,555.51	0.00	0.00	
SUBTOTAL:	0.00	128.25	0.00	263.33	92.35	163.24	1,265.66	6,277.16	8,089.28	4,631.40	0.00	0.00	

 
802.19	
236.30	
19,872.18	
20,910.67	

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	

2,326,439.64	10,700,813.57	7,946,106.37	9,707,520.36	13,889,643.67	10,117,669.48	9,497,837.67	14,701,061.56	17,530,695.63	13,959,242.80	0.00	0.00	

TOTAL:

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2017

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	13,878.63	0.00	0.00	0.00	0.00	37,553.94	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	1,288.00	0.00	0.00	0.00	0.00	1,316.00	0.00	0.00	0.00	2,604.00	
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	13,878.63	1,316.00	0.00	0.00	0.00	62,925.75	

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	1,288.00	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	1,288.00	0.00	0.00	0.00	0.00	

6,531.12	
4,081.95	
8,163.90	
2,576.00	
21,352.97	

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	3,000.00	3,265.56	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	9,796.68	0.00	0.00	13,042.02	0.00	14,695.02	4,898.34	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	5,714.73	0.00	0.00	0.00	
SUBTOTAL:	0.00	28,114.53	16,327.80	45,717.84	30,186.21	1,632.78	14,695.02	4,898.34	8,714.73	3,265.56	0.00	0.00	

5,714.73	
1,632.78	
87,088.17	
42,432.06	
16,685.07	
153,552.81	

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	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,786.40	1,632.78	2,449.17	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	2,449.17	0.00	0.00	0.00	6,786.40	1,632.78	2,449.17	0.00	0.00	

2,449.17	
10,868.35	
13,317.52	

TOTAL:	11,429.46	47,616.77	38,370.34	56,802.52	36,372.55	1,632.78	14,695.02	26,851.37	11,663.51	5,714.73	0.00	0.00		251,149.05		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
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	843.38	0.00	0.00	0.00	0.00		5,085.69		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,047.07	0.00	0.00	0.00		4,047.07		
2100	SSI AGED WITH MEDIC A	62,636.18	7,321.33	10,598.16	63,394.20	68,198.13	90,939.08	300,289.60	98,803.72	26,269.97	54,035.70	0.00	0.00		782,486.07		
2110	SSI AGED NON-MEDIC AR	55,431.46	44,621.86	210,826.12	50,715.84	137,219.27	120,845.17	15,780.19	93,910.48	92,817.40	44,194.48	0.00	0.00		866,362.27		
2120	SSI AGED WITH QMB	3,240.08	492.46	0.00	0.00	0.00	4,464.46	0.00	0.00	728.78	0.00	0.00	0.00		8,925.78		
2200	SSI DISABLED WITH M E	0.00	-838.56	0.00	0.00	872.06	9,596.98	-361.64	193.90	0.00	6,843.48	0.00	0.00		16,306.22		
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	350.94	9,830.95	0.00	0.00		26,108.67		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,008.16	5,916.00	0.00	0.00		7,924.16		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	47,529.94	0.00	842.95	0.00	470.90	0.00	2,468.86	0.00	0.00		51,312.65		
5017	SOBRA PREG 21-44 FE M	3,260.38	0.00	843.73	74.15	0.00	842.95	3,311.81	5,805.61	0.00	151.30	0.00	0.00		14,289.93		
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	319,019.96	200,027.99	126,222.32	123,440.77	0.00	0.00		1,784,183.61		

3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-410.24	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-410.24	0.00	0.00	0.00	0.00	

-410.24	
-410.24	

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	382.01	0.00	3,842.47	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	359.36	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	52,437.21	50,804.97	43,341.12	14,049.31	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	1,565.40	57.37	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	842.95	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	367,560.22	91,636.75	216,857.05	279,766.15	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	28,368.89	55,879.35	15,828.20	10,029.92	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	451,336.54	439,837.31	411,797.15	402,197.05	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	60,618.59	-55,614.67	553.16	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	899,702.86	700,724.38	633,109.17	710,797.42	0.00	0.00	

61,916.82	
663.33	
416,728.07	
30,604.29	
3,259.60	
2,727,391.62	
323,404.57	
4,121,290.44	
5,349.86	
132,794.75	
7,823,403.35	

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,513.01	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	15,999.84	1,846.21	8,999.20	7,227.69	30,094.45	13,399.98	6,802.57	10,388.51	7,847.44	374.41	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	7,093.30	4,160.41	2,155.45	5,729.38	0.00	0.00	

1,513.01	
102,980.30	
8,445.95	
130,715.78	

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	

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	47,079.35	7,086.13	51,594.81	22,750.52	37,921.98	31,157.77	13,895.87	14,548.92	11,515.90	6,103.79	0.00	0.00		243,655.04		

975,409.12	1,212,578.98	1,380,044.06	934,731.27	774,483.87	820,324.45	1,232,618.69	914,891.05	770,847.39	840,341.98	0.00	0.00	

9,856,270.86	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
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	7.42	0.00	0.00	0.00		7.42		
SUBTOTAL:	3,420.00	-3,257.13	184.37	0.00	4,937.19	0.00	0.00	0.00	7.42	0.00	0.00	0.00		5,291.85		

TOTAL:	3,420.00	-3,257.13	184.37	0.00	4,937.19	0.00	0.00	0.00	7.42	0.00	0.00	0.00		5,291.85		

GRAHAM COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
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	-193.90	0.00	0.00	0.00	0.00	0.00		5,377.79		
SUBTOTAL:	5,377.79	0.00	0.00	193.90	0.00	0.00	-193.90	0.00	0.00	0.00	0.00	0.00		5,377.79		

5,377.79	0.00	0.00	193.90	0.00	0.00	-193.90	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
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	57.05	20,514.41	3,116.07	8,126.35	0.00	0.00		40,953.75		
1017	TANF 21-44 FEMALE N O	1,082.48	2,762.19	4,225.80	0.00	9,835.12	577.75	8,382.58	0.00	4,641.54	602.24	0.00	0.00		32,109.70		
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	57.05	0.00	55.74	0.00	0.00	0.00		15,180.98		
2200	SSI DISABLED WITH M E	1,309.60	80.21	289.00	7,325.67	5,634.60	15,516.38	0.00	4,977.71	251.31	0.00	0.00	0.00		35,384.48		
2210	SSI DISABLED NON-ME D	1,618.81	30,697.03	892.24	8,800.51	49,300.03	11,607.05	18,096.58	15,478.72	9,417.81	10,592.77	0.00	0.00		156,501.55		
2220	SSI DISABLED WITH Q M	4,268.62	479.48	168.42	4,913.65	175.20	1,987.39	0.00	14,338.09	0.00	841.60	0.00	0.00		27,172.45		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	402.14	31.16	82.31	17,063.27	0.00	0.00		17,578.88		
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	2,237.03	0.00	0.00	0.00		9,071.54		
5017	SOBRA PREG 21-44 FE M	0.00	470.90	2,433.80	8,561.46	15,716.18	4,977.27	3,368.43	2,848.58	6,192.83	692.50	0.00	0.00		45,261.95		
SUBTOTAL:	22,177.49	38,628.82	14,575.52	29,601.29	80,814.74	53,552.65	30,363.83	58,188.67	25,994.64	37,918.73	0.00	0.00		391,816.38		

3516	ADULT 40-100% MALE
2	337.40	9,114.07	0.00	9,805.62	160.42	152.18	4,830.12	297.72	-2,015.56	2,627.36	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	332.40	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	5,877.29	6,265.74	15,119.03	545.17	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	564.63	0.00	5,628.08	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	9,731.64	7,880.28	5,744.02	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	80,720.76	96,169.27	82,744.37	126,338.57	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	20,312.80	18,638.49	22,607.23	19,486.07	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	61,081.08	33,647.84	87,787.80	73.22	0.00	0.00	
SUBTOTAL:	78,358.45	141,664.49	83,682.16	192,212.93	134,589.29	280,159.16	182,553.69	163,463.97	212,319.29	154,698.47	0.00	0.00	

25,309.33	
8,725.86	
66,986.42	
6,192.71	
40,873.20	
10,645.90	
877,928.13	
161,309.57	
425,730.78	
1,623,701.90	

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	284.98	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	284.98	0.00	0.00	

12,907.59	
9,153.96	
22,061.55	

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,490.93	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	5,922.11	300.97	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	2,630.41	0.00	-1,275.12	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	3,164.05	-3,164.05	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	5,794.46	2,758.06	-974.15	4,490.93	0.00	0.00	

 
4,490.93	
18,246.00	
2,513.74	
31,450.14	
17,221.31	
1,754.98	
21,175.57	
96,852.67	

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	158,233.29	196,254.93	98,609.98	232,726.67	229,111.22	341,640.84	218,711.98	224,410.70	237,339.78	197,393.11	0.00	0.00		2,134,432.50		

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	167.23	0.00	2,984.24	0.00	0.00	11,473.74	
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	167.23	0.00	2,984.24	0.00	0.00	11,504.56	

3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,663.86	0.00	0.00	
3716	ADULT <40% EXP MAL E	962.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	635.43	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	3,412.32	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	8,711.61	0.00	0.00	

4,663.86	
1,597.48	
3,412.32	
102.64	
9,776.30	

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017

992.87	8,322.27	0.00	0.00	102.64	0.00	0.00	167.23	0.00	11,695.85	0.00	0.00	

21,280.86	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	11,982.91	0.00	0.00	166.20	0.00	888.52	0.00	0.00	0.00	0.00	0.00		13,037.63		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	8,879.70	0.00	304.76	0.00	0.00	0.00		9,184.46		
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		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126.14	1,275.12	0.00	0.00		1,401.26		
2210	SSI DISABLED NON-ME D	807.17	12,780.35	0.00	7,126.62	1,385.08	16,374.92	20,249.12	1,094.40	2,763.43	0.00	0.00	0.00		62,581.09		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	176.95	55.88	0.00	0.00	0.00	0.00	0.00		232.83		
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	3,817.70	3,159.52	0.00	784.52	0.00	0.00		20,232.35		
SUBTOTAL:	1,278.07	26,237.18	2,536.55	16,174.28	1,551.28	17,022.77	33,890.92	4,253.92	3,194.33	2,059.64	0.00	0.00		108,198.94		

3516	ADULT 40-100% MALE
2	0.00	8.00	0.00	773.04	3,200.23	6,747.78	17.59	1,752.04	10,045.74	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	671.85	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	4,766.94	39.48	32,145.37	6,250.32	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	7,550.50	6,438.86	2,703.89	1,540.97	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	9,341.62	6,506.01	4,301.15	18,547.51	0.00	0.00	
SUBTOTAL:	17,640.18	22,451.70	327.74	77,666.21	35,487.56	17,392.59	21,676.65	14,736.39	49,868.00	26,338.80	0.00	0.00	

22,544.42	
786.75	
78,472.03	
86,859.62	
94,923.00	
283,585.82	

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,001.06	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,001.06	0.00	0.00	0.00	

1,001.06	
1,001.06	

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	439.06	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	439.06	0.00	0.00	0.00	0.00	

 
439.06	
439.06	

TOTAL:	18,918.25	48,688.88	2,864.29	93,840.49	37,038.84	34,415.36	55,567.57	19,429.37	54,063.39	28,398.44	0.00	0.00		393,224.88		

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	-62.32	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	4,630.48	3,154.31	-3,803.40	0.00	136.25	339.32	-62.32	0.00	0.00	0.00	0.00	0.00	4,394.64	

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	1,189.81	8,329.23	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	1,189.81	8,329.23	0.00	0.00	

79,145.33	
3,902.46	
19,264.73	
102,312.52	

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.21	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.21	0.00	0.00	

10.21	
10.21	

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017

0.00

1,189.81

0.00

0.00

TOTAL:

16,871.60

46,001.93	-2,583.89

39,251.79	369.71	-62.32	0.00

8,339.44

109,378.07

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	158.97	0.00	0.00	0.00	0.00		158.97		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	935.19	0.00	2,250.83	0.00	0.00	0.00		3,186.02		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	935.19	158.97	2,250.83	0.00	0.00	0.00		3,344.99		

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	935.19	158.97	2,250.83	0.00	0.00	0.00		3,344.99		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending April 30, 2017	
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	736.00	0.00	0.00	0.00	0.00	0.00		1,472.00		
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	2,153,114.75	2,420,440.46	2,817,934.40	2,186,819.35	0.00	0.00		24,175,331.09		
2110	SSI AGED NON-MEDIC AR	149,727.64	170,783.44	154,051.47	181,595.05	188,692.42	151,634.95	170,061.39	248,958.23	221,311.74	185,417.43	0.00	0.00		1,822,233.76		
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	3,033,127.28	3,370,873.20	4,179,696.29	3,247,707.66	0.00	0.00		34,063,623.84		
2200	SSI DISABLED WITH M E	537,954.02	696,721.39	546,649.90	536,933.99	658,981.77	584,706.59	598,742.35	610,233.41	813,062.82	629,886.64	0.00	0.00		6,213,872.88		
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	2,597,341.40	3,161,441.86	3,594,379.85	2,690,197.45	0.00	0.00		29,757,872.09		
2220	SSI DISABLED WITH Q M	764,491.97	940,091.58	815,616.99	716,604.42	883,677.47	782,712.79	802,139.77	833,038.88	1,050,901.59	755,890.67	0.00	0.00		8,345,166.13		
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	18,576.84	24,378.36	54,376.90	38,851.05	0.00	0.00		247,058.62		
2320	SSI BLIND WITH QMB	7,206.96	7,708.00	7,966.16	6,133.72	8,669.95	7,946.81	6,242.23	6,443.10	9,917.50	7,552.24	0.00	0.00		75,786.67		
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	9,380,082.01	10,675,807.50	12,741,581.09	9,742,322.49	0.00	0.00		104,702,494.12		

8710	SSI DISABLED FREEDO M	653.30	6,631.23	2,774.40	2,603.04	2,728.96	2,866.56	2,795.52	3,180.60	2,896.30	3,026.00	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	1,397.76	4,289.80	3,524.40	2,189.40	0.00	0.00	
SUBTOTAL:	3,418.73	10,058.43	5,516.16	5,371.68	6,223.36	5,662.08	4,193.28	7,470.40	6,420.70	5,215.40	0.00	0.00	

 
30,155.91	
29,394.31	
59,550.22	

9,673,619.94	11,818,761.59	10,004,475.94	9,333,075.60	11,165,207.33	10,203,811.07	9,384,275.29	10,683,277.90	12,748,001.79	9,747,537.89	0.00	0.00	

104,762,044.34	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	6,319.24	20,181.09	10,420.34	11,053.75	7,720.14	5,511.39	19,712.18	29,028.28	6,810.47	49,053.78	0.00	0.00	165,810.66	
2110	SSI AGED NON-MEDIC AR	200.76	1,334.55	0.00	0.00	0.00	362.78	0.00	144.99	0.00	1,022.80	0.00	0.00	3,065.88	
2120	SSI AGED WITH QMB	3,279.02	110.41	0.00	0.00	0.00	0.00	17.33	0.00	0.00	0.00	0.00	0.00	3,406.76	
2200	SSI DISABLED WITH M E	4,355.69	5,162.72	1,056.47	2,523.82	723.87	3,810.52	529.62	1,169.01	2,395.21	4,792.84	0.00	0.00	26,519.77	
2210	SSI DISABLED NON-ME D	11,384.31	301.39	764.10	7,231.73	4,550.79	11,463.96	17.06	897.33	-436.51	11,625.55	0.00	0.00	47,799.71	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,275.12	0.00	0.00	1,275.12	
SUBTOTAL	:	25,539.02	27,090.16	12,240.91	20,809.30	12,994.80	21,148.65	20,276.19	31,239.61	8,769.17	67,770.09	0.00	0.00	247,877.90	

TOTAL:	25,539.02	27,090.16	12,240.91	20,809.30	12,994.80	21,148.65	20,276.19	31,239.61	8,769.17	67,770.09	0.00	0.00		247,877.90		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	160.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.42		
SUBTOTAL:	160.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.42		

160.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCHISE COUNTY INMATES LTC  FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166.20	0.00	0.00	0.00		166.20		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166.20	0.00	0.00	0.00		166.20		

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	
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	
57.17	

TOTAL:	0.00	57.17	0.00	0.00	0.00	0.00	0.00	0.00	166.20	0.00	0.00	0.00		223.37		

COCONINO COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	436.32	53.28	0.00	5,325.91	332.04	0.00	0.00	0.00	0.00		6,147.55		
SUBTOTAL:	0.00	0.00	0.00	436.32	53.28	0.00	5,325.91	332.04	0.00	0.00	0.00	0.00		6,147.55		

0.00	0.00	0.00	436.32	53.28	0.00	5,325.91	332.04	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	278.97	4,799.61	0.00	0.00	57.05	0.00	0.00	0.00		5,135.63		
SUBTOTAL:	0.00	0.00	0.00	0.00	278.97	4,799.61	0.00	0.00	57.05	0.00	0.00	0.00		5,135.63		

0.00

0.00

TOTAL:

0.00

278.97

4,799.61

0.00

0.00

0.00

5,135.63

0.00

57.05

0.00	0.00

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending April 30, 2017	
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	12,504.48	18,911.71	42,899.74	25,341.43	0.00	0.00		183,421.70		
1013	TANF 06-13 M & F NON	26,843.26	657.79	21,985.65	28,689.48	63,946.81	58,560.80	35,001.16	41,467.44	86,367.59	50,363.77	0.00	0.00		413,883.75		
1014	TANF 14-20 MALE NON-	2,429.50	605.12	2,905.16	3,211.46	5,545.19	6,425.15	3,678.26	5,544.55	5,934.72	5,247.92	0.00	0.00		41,527.03		
1015	TANF 14-20 FEMALE N O	2,174.10	399.72	505.33	2,371.06	2,491.16	3,929.49	1,979.29	1,722.65	7,020.27	4,127.77	0.00	0.00		26,720.84		
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	136.99	176.13	0.00	0.00		470.46		
2210	SSI DISABLED NON-ME D	136,113.36	80,007.50	116,612.03	161,945.69	300,838.41	248,858.18	147,055.11	181,504.41	385,498.13	263,249.54	0.00	0.00		2,021,682.36		
2220	SSI DISABLED WITH Q M	800.49	0.00	94.90	187.94	342.48	127.08	73.30	0.00	-35.42	0.00	0.00	0.00		1,590.77		
2310	SSI BLIND NON-MEDIC A	919.88	782.99	1,582.48	1,994.80	2,667.60	1,082.22	762.50	1,251.41	4,101.78	1,787.46	0.00	0.00		16,933.12		
4305	SOBRA CHILD 14-20 FE	35.62	0.00	0.00	14.24	0.00	28.64	0.00	0.00	100.24	0.00	0.00	0.00		178.74		
4312	SOBRA CHILD 01-05 M	28,343.38	14,276.06	26,984.59	32,321.41	49,958.69	42,807.75	18,731.13	35,647.84	57,210.24	27,102.53	0.00	0.00		333,383.62		
4313	SOBRA CHILD 06-13 M	91,660.37	21,444.81	62,944.00	102,084.96	188,317.16	174,938.30	67,459.90	103,053.75	194,583.52	94,192.77	0.00	0.00		1,100,679.54		
4314	SOBRA CHILD 14-20 MA	6,894.69	11,038.98	7,338.37	7,172.50	14,161.79	19,417.16	7,360.52	8,874.52	17,503.48	10,484.22	0.00	0.00		110,246.23		
4315	SOBRA CHILD 14-20 FE	2,364.62	747.24	2,244.39	3,102.70	6,215.23	6,428.15	2,360.19	3,461.64	8,332.26	4,277.98	0.00	0.00		39,534.40		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98.20	0.00	0.00		98.20		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.02	0.00	0.00	0.00		15.02		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.92	257.30	0.00	0.00		275.22		
SUBTOTAL:	308,762.96	134,897.03	254,770.1	1	355,503.99	660,358.08	581,613.57	296,965.84	401,439.92	809,686.48	486,707.02	0.00	0.00		4,290,705.00		

1113	TANF EXPANDED 06-13	83.28	153.89	635.96	150.67	154.27	218.23	22.53	55.76	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	108.87	0.00	0.00	0.00	
SUBTOTAL:	83.28	153.89	635.96	150.67	154.27	218.23	22.53	55.76	108.87	0.00	0.00	0.00	

 
1,474.59	
108.87	
1,583.46	

3514	ADULT 40-100% MALE
1	159.17	0.00	0.00	57.88	28.94	57.94	39.36	0.00	68.38	19.68	0.00	0.00	
3515	ADULT 40-100% FEMAL E	201.78	517.73	0.00	0.00	19.66	66.42	0.00	33.21	307.31	242.32	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	37.40	0.00	18.70	37.02	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	449.14	125.87	0.00	49.15	48.62	77.21	28.97	195.32	102.62	81.43	0.00	0.00	
3715	ADULT <40% EXP FEM AL	41.40	0.00	0.00	207.92	452.45	65.27	1,760.20	468.59	191.16	296.83	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	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	372.27	152.16	0.00	0.00	
SUBTOTAL:	851.49	643.60	0.00	328.55	549.67	304.24	1,828.53	715.82	1,078.76	792.42	0.00	0.00	

 
431.35	
1,388.43	
93.12	
1,158.33	
3,483.82	
13.60	
524.43	
7,093.08	

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	73.89	58.98	145.40	69.54	85.85	61.80	115.44	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	142.91	122.49	79.80	95.76	63.84	47.88	63.84	0.00	170.56	0.00	0.00	
SUBTOTAL:	0.00	142.91	122.49	153.69	154.74	209.24	117.42	149.69	61.80	286.00	0.00	0.00	

 
610.90	
787.08	
1,397.98	

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	129.24	282.46	583.85	154.53	0.00	0.00	137,299.25

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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	-156.42	0.00	0.00	0.00		17,875.39		
4415	SOBRA 100-133% FEM AL	706.11	141.86	158.54	772.99	1,097.52	609.98	0.00	0.00	50.68	45.06	0.00	0.00		3,582.74		
SUBTOTAL:	25,448.87	9,936.41	18,047.40	30,694.82	49,407.32	24,133.16	129.24	282.46	478.11	199.59	0.00	0.00		158,757.38		

335,146.60	145,773.84	273,575.96	386,831.72	710,624.08	606,478.44	299,063.56	402,643.65	811,414.02	487,985.03	0.00	0.00	

4,459,536.90	

TOTAL:

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	24.12	863.45	1,096.28	3,313.84	0.00	0.00	7,059.07	
1010	TANF NON-MEDICARE	22,308.73	10,498.79	17,933.34	30,369.07	43,022.68	34,536.06	22,314.87	35,955.66	54,049.39	51,779.56	0.00	0.00	322,768.15	
1020	TANF WITH QMB	0.00	0.00	0.00	25.00	37.50	0.00	25.14	25.14	0.00	50.28	0.00	0.00	163.06	
2200	SSI DISABLED WITH M E	3,546.21	2,524.32	1,902.01	1,501.13	3,846.51	3,910.34	2,230.96	3,320.17	3,170.24	2,820.75	0.00	0.00	28,772.64	
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	874,796.01	997,230.40	2,005,231.28	1,596,553.01	0.00	0.00	11,153,471.72	
2220	SSI DISABLED WITH Q M	1,060.22	728.41	4,870.69	2,137.79	7,316.49	3,833.69	4,085.00	5,104.24	4,574.28	7,087.26	0.00	0.00	40,798.07	
2310	SSI BLIND NON-MEDIC A	3,791.67	2,658.34	1,592.64	4,892.81	11,517.68	7,059.71	12,648.41	7,467.89	16,190.35	13,421.50	0.00	0.00	81,241.00	
SUBTOTAL	:	828,651.69	474,874.28	685,237.98	912,729.71	1,643,386.32	1,363,964.25	916,124.51	1,049,966.95	2,084,311.82	1,675,026.20	0.00	0.00	11,634,273.71	

TOTAL:	828,651.69	474,874.28	685,237.98	912,729.71	1,643,386.32	1,363,964.25	916,124.51	1,049,966.95	2,084,311.82	1,675,026.20	0.00	0.00		11,634,273.71		

RATE COD	E	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	-1,057.84	0.00	0.00	0.00	0.00	-957.30	
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	25,284.03	0.00	0.00	25,284.03	
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	461,158.55	299,772.17	978,086.57	770,448.79	0.00	0.00	5,058,338.47	
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	43,053.41	22,870.59	-11,902.62	47,855.82	0.00	0.00	309,075.20	
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	140,088.80	22,365.38	117,910.82	72,294.54	0.00	0.00	1,340,284.09	
1014	TANF 14-20 MALE NON-	13,740.97	54,044.10	5,286.69	14.67	26,047.98	366,701.18	-83,412.30	97,399.01	31,685.13	47,391.39	0.00	0.00	558,898.82	
1015	TANF 14-20 FEMALE N O	23,666.42	-77,738.83	1,484.26	5,630.43	0.00	3,121.92	15,407.74	6,814.94	23.20	0.00	0.00	0.00	-21,589.92	
1016	TANF 21-44 MALE NON-	217,616.39	157,215.49	54,442.48	268,465.30	45,836.45	309,861.85	-119,096.40	425,612.41	25,129.70	193,375.75	0.00	0.00	1,578,459.42	
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	119,755.75	190,726.81	158,004.75	252,800.05	0.00	0.00	2,277,603.40	
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	165,453.79	53,337.03	233,775.34	326,102.00	0.00	0.00	1,898,720.25	
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	130,312.75	5,753.85	18,113.00	82,969.27	0.00	0.00	307,463.78	
2110	SSI AGED NON-MEDIC AR	388,018.03	277,060.71	184,488.03	54,193.88	121,989.09	4,331.92	57,796.64	88,158.23	102,298.67	104,512.54	0.00	0.00	1,382,847.74	
2200	SSI DISABLED WITH M E	14,893.21	9,427.77	104,031.96	-62,585.44	18,091.83	145,523.65	78,647.94	51,331.44	101,063.52	26,096.91	0.00	0.00	486,522.79	
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	5,612,468.96	5,150,980.65	6,053,431.71	3,935,573.95	0.00	0.00	55,504,118.16	
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,941.37	0.00	0.00	32,941.37	
2310	SSI BLIND NON-MEDIC A	3,144.63	15,144.29	0.00	1,933.29	0.00	38,010.74	12,986.01	5,452.25	6,192.17	-18,156.64	0.00	0.00	64,706.74	
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	844,875.94	1,638,543.90	1,770,735.50	1,441,979.39	0.00	0.00	12,748,074.20	
4312	SOBRA CHILD 01-05 M	441,100.37	296,759.82	532,152.50	544,706.11	615,576.52	304,644.90	188,119.03	673,141.58	799,355.77	552,276.02	0.00	0.00	4,947,832.62	
4313	SOBRA CHILD 06-13 M	263,996.88	399,559.68	266,337.50	410,303.43	234,978.54	755,527.86	-325,494.59	968,334.36	351,611.26	458,761.78	0.00	0.00	3,783,916.70	
4314	SOBRA CHILD 14-20 MA	173,423.73	445,022.53	247,300.85	263,469.12	242,015.11	477,731.60	76,367.35	287,516.24	273,686.29	368,564.28	0.00	0.00	2,855,097.10	
4315	SOBRA CHILD 14-20 FE	82,494.00	220,990.49	22,217.04	183,110.77	107,887.03	159,428.33	53,145.31	265,628.28	55,299.56	-18,978.36	0.00	0.00	1,131,222.45	
5015	SOBRA PREG 14-20 FE M	79,849.94	1,849.74	2,876.71	25,606.69	256.98	684.85	222,671.74	275,494.71	7,125.28	840.96	0.00	0.00	617,257.60	
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	8,803.80	10,196.86	17,133.20	21,742.86	0.00	0.00	415,250.19	
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	7,703,110.22	10,538,372.85	11,088,758.82	8,724,676.70	0.00	0.00	97,305,514.51	

1106	TANF EXPANDED 21-44	0.00	144.38	25.63	53.22	289.54	181.94	932.72	110.80	208.61	496.34	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	5,877.19	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	163,213.49	152,882.32	18,550.39	193,279.74	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	118,624.51	-36,214.99	265,295.75	138,745.73	0.00	0.00	

2,443.18	
302.90	
22,947.57	
1,108.27	
1,976,092.63	
1,719,402.67	

3100	TRANSPLANT OPTION 1	0.00	23.10	73.47	199.01	64.18	4.61	20.46	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	23.10	73.47	199.01	64.18	4.61	20.46	0.00	0.00	0.00	0.00	0.00	

 
384.83	
384.83	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	118,336.16	109,671.05	112,654.35	146,667.89	59,392.47	60,802.30	71,293.01	147,000.75	59,864.51	69,203.21	0.00	0.00	954,885.70	
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	1,775.50	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	5.49	0.00	0.53	0.00	95,678.22	0.00	0.00	0.00	95,684.24	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	3,001.34	1,600.02	1,270.23	480.93	0.00	0.00	0.00	0.00	0.00	6,352.52	
2600	SSI DISABLED EXPAND E	850.89	1,174.76	156.90	64.92	64.94	4,087.33	-604.59	1,803.68	27.48	9.19	0.00	0.00	7,635.50	
2610	SSI DISABLED EXPAND E	22,124.40	50,423.35	87,387.60	59,323.96	153,256.28	171,187.32	78,317.38	89,425.47	61,501.21	155,131.64	0.00	0.00	928,078.61	
SUBTOTAL	:	618,269.82	492,657.97	596,733.80	647,904.64	844,945.10	665,062.74	432,257.98	355,008.03	501,126.17	562,743.04	0.00	0.00	5,716,709.29	

3508	ADULT 40-100% M&F 45	13,424.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	281.13	64.69	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	-110,116.05	16.98	114,177.09	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	-784.41	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	112,390.85	492,170.62	119,353.69	472,408.30	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	58,605.13	9,458.06	-24,093.80	156,445.27	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	570,531.16	492,385.58	142,017.75	521,600.89	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	-9,118.38	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	42,216.35	10,677.09	23,265.53	4,687.08	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	-3,789.10	12,953.98	116,327.29	53,655.10	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	13,007.21	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	900,852.27	825,533.26	721,236.07	890,369.24	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	121,341.32	420,126.26	153,890.11	427,866.27	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	846,089.81	1,675,185.74	706,931.63	1,391,587.97	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	2,551,128.95	3,929,389.19	2,072,602.08	3,918,684.81	0.00	0.00	

 
13,770.35	
87,338.70	
15,737.70	
2,381,589.24	
597,135.51	
5,006,735.26	
11,548.22	
0.00	
321,128.28	
499,823.29	
94,958.11	
7,952,897.71	
3,157,847.62	
15,923,677.76	
7,738.23	
36,071,925.98	

3914	NEWLY ELIGIBLE MALE	531.22	66,490.42	0.00	70,551.01	47,248.50	53,533.32	85,083.85	2,330.62	-0.59	18,105.67	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	41,972.61	643.92	12,518.17	10,313.00	0.00	20,804.33	10,491.34	5,180.36	13,785.32	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	19,851.15	260,311.32	162,212.97	217,204.72	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	24,192.25	11,500.21	114,633.48	66,254.81	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	193,682.97	225,605.81	205,056.68	377,146.02	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	343,614.55	510,239.30	487,082.90	692,496.54	0.00	0.00	

 
343,874.02	
115,709.05	
2,285,277.70	
422,804.45	
3,246,182.41	
6,413,847.63	

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	99,614.98	70,876.40	51,766.65	48,615.09	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	510,156.01	201,838.99	176,178.39	57,560.08	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	4,729.53	26,658.21	44,714.16	2,057.66	0.00	0.00	
SUBTOTAL:	822,402.65	454,795.05	42,792.40	499,941.88	196,844.95	32,840.73	614,500.52	299,373.60	272,659.20	108,232.83	0.00	0.00	

 
1,024,868.86	
2,123,821.50	
195,693.45	
3,344,383.81	

4518	BC PATIENT FEMALE 4
5

0.00	2,325.47	11,583.11	0.00	386.23	0.00	0.00	0.00	1,439.83	0.00	0.00	0.00	15,734.64

ACUTE REINSURANCE
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	2,325.47	11,583.11	0.00	386.23	0.00	0.00	0.00	1,439.83	0.00	0.00	0.00		15,734.64		

8710	SSI DISABLED FREEDO M	2,634.47	2,674.29	13,975.57	18,318.69	0.00	2,634.47	9,527.93	2,677.02	2,677.03	0.00	0.00	0.00	
SUBTOTAL:	2,634.47	2,674.29	13,975.57	18,318.69	0.00	2,634.47	9,527.93	2,677.02	2,677.03	0.00	0.00	0.00	

 
55,119.47	
55,119.47	

20,665,911.19

14,426,346.03

0.00

0.00

TOTAL:

15,160,643.59

15,891,943.26    13,457,040.31

12,912,053.13     15,113,628.13     11,654,160.61    15,635,059.99

14,006,833.92

148,923,620.16

LONG TERM CARE REINSURANCE
For The Period Ending April 30, 2017

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	10,143.26	0.00	1.03	21.02	0.00	0.00	49,103.77	
2100	SSI AGED WITH MEDIC A	427,508.23	354,148.90	316,332.29	325,278.88	180,913.05	-32,402.61	519,879.54	460,575.02	139,378.92	205,985.64	0.00	0.00	2,897,597.86	
2110	SSI AGED NON-MEDIC AR	109,126.94	168,130.16	206,047.45	305,444.45	145,747.56	196,635.86	111,274.98	60,904.82	42,992.04	36,048.35	0.00	0.00	1,382,352.61	
2200	SSI DISABLED WITH M E	922,846.90	607,754.06	450,973.91	607,692.94	398,167.22	439,850.36	336,552.04	297,684.03	425,160.54	325,064.87	0.00	0.00	4,811,746.87	
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	1,994,989.19	1,833,459.10	2,065,011.33	2,050,065.45	0.00	0.00	31,699,455.07	
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	-411.67	0.00	757.75	813.04	0.00	0.00	74,955.99	
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	2,972,427.34	2,652,622.97	2,673,301.61	2,617,998.37	0.00	0.00	40,915,256.26	

TOTAL:	4,967,043.47	5,508,762.62	5,025,290.43	6,016,593.34	4,491,725.55	3,989,490.56	2,972,427.34	2,652,622.97	2,673,301.61	2,617,998.37	0.00	0.00		40,915,256.26		

ACUTE SMIB
For The Period Ending April 30, 2017	
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	66,179.60	60,833.00	56,586.60	52,982.10	0.00	0.00		719,148.80		
1010	TANF NON-MEDICARE	609.00	852.60	609.00	487.20	487.20	609.00	3,776.70	1,072.00	938.00	1,072.00	0.00	0.00		10,512.70		
1020	TANF WITH QMB	24,116.40	24,603.60	21,315.00	22,167.60	27,648.60	25,578.00	35,276.80	34,167.40	38,103.40	43,000.40	0.00	0.00		295,977.20		
2100	SSI AGED WITH MEDIC A	103,567.30	146,400.10	154,520.40	148,789.20	144,933.70	147,264.80	179,337.70	158,329.70	153,574.70	160,740.50	0.00	0.00		1,497,458.10		
2110	SSI AGED NON-MEDIC AR	493,790.60	499,097.90	531,909.40	527,915.80	509,066.30	521,344.80	557,227.20	528,589.80	575,908.40	591,366.10	0.00	0.00		5,336,216.30		
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	4,373,983.80	4,419,805.40	4,526,452.10	5,318,898.90	0.00	0.00		40,157,433.50		
2200	SSI DISABLED WITH M E	270,428.30	331,956.60	309,410.80	300,387.60	292,142.60	275,734.80	319,005.80	311,898.90	303,825.10	278,464.30	0.00	0.00		2,993,254.80		
2210	SSI DISABLED NON-ME D	391,130.70	391,601.00	388,254.70	391,651.10	389,445.30	392,074.20	440,069.10	441,476.50	450,274.10	432,690.30	0.00	0.00		4,108,667.00		
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	4,426,137.20	4,427,371.40	4,474,410.80	4,992,817.40	0.00	0.00		41,034,500.40		
2300	SSI BLIND WITH MEDIC	243.60	243.60	487.20	365.40	121.80	121.80	134.00	134.00	134.00	134.00	0.00	0.00		2,119.40		
2310	SSI BLIND NON-MEDIC A	3,288.60	3,288.60	3,410.40	3,532.20	3,532.20	3,532.20	3,752.00	3,886.00	5,586.50	4,020.00	0.00	0.00		37,828.70		
2320	SSI BLIND WITH QMB	29,962.80	30,084.60	30,084.60	30,693.60	30,328.20	29,597.40	32,330.60	34,511.00	33,098.00	33,768.00	0.00	0.00		314,458.80		
4300	SOBRA CHILD WITH M ED	121.80	121.80	121.80	121.80	121.80	121.80	134.00	134.00	134.00	134.00	0.00	0.00		1,266.80		
4320	SOBRA CHILD WITH Q MB	243.60	121.80	243.60	243.60	243.60	243.60	268.00	804.00	670.00	536.00	0.00	0.00		3,617.80		
5000	SOBRA PREGNANT WO MAN	243.60	243.60	121.80	121.80	121.80	121.80	-121.80	0.00	0.00	0.00	0.00	0.00		852.60		
5020	SOBRA PREGNANT WO MAN	3,897.60	3,288.60	3,288.60	4,506.60	3,897.60	6,211.80	6,992.20	6,939.80	6,813.80	7,873.60	0.00	0.00		53,710.20		
8000	SMIB ONLY NOT ELIGIB	-487.20	0.00	0.00	0.00	-730.80	0.00	-243.60	-255.80	-804.00	-260.00	0.00	0.00		-2,781.40		
8020	QMB ONLY	732,938.50	741,291.20	748,193.20	736,917.80	737,989.80	749,169.90	814,393.30	840,660.30	846,969.90	917,988.70	0.00	0.00		7,866,512.60		
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	4,815,602.60	4,928,518.30	4,953,342.60	4,964,161.80	0.00	0.00		45,436,463.50		
8888	SMIB ONLY NOT ELIGIB	-149,049.20	-27,293.50	-35,602.90	-25,963.40	-24,461.80	-13,173.60	-24,583.30	-18,911.20	-30,606.80	-10,573.80	0.00	0.00		-360,219.50		
9999	SMIB ONLY NOT ELIGIB	60,444.40	160,788.70	220,518.30	162,374.20	129,062.70	143,733.40	174,363.40	205,407.50	234,336.90	162,631.90	0.00	0.00		1,653,661.40		
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	16,224,015.30	16,385,372.00	16,629,748.10	17,952,446.20	0.00	0.00		151,160,659.70		

3520	ADULT 40-100% FOR FI	974.40	1,096.20	730.80	974.40	243.60	487.20	901.40	268.00	1,035.40	536.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	1,339.80	852.60	609.00	487.20	365.40	243.60	402.00	1,059.80	767.40	1,023.20	0.00	0.00	
SUBTOTAL:	2,314.20	1,948.80	1,339.80	1,461.60	609.00	730.80	1,303.40	1,327.80	1,802.80	1,559.20	0.00	0.00	

7,247.40	
7,150.00	
14,397.40	

1100	TANF EXPANDED FPR FI	670,306.70	690,655.60	694,042.10	689,258.80	619,093.20	571,816.50	549,033.40	516,747.30	463,652.60	417,949.70	0.00	0.00	
1110	TANF EXPANDED FOR FI	730.80	365.40	243.60	121.80	365.40	974.40	536.00	536.00	670.00	-950.70	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	545,668.10	584,095.20	653,558.10	714,632.10	0.00	0.00	
2400	SSI AGED EXPANDED WI	-974.40	365.40	0.00	365.40	121.80	-121.80	-487.20	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	2,106,855.40	2,138,019.90	2,057,196.00	1,361,791.80	0.00	0.00	
2520	SSI BLIND EXPANDED W	121.80	365.40	121.80	121.80	121.80	121.80	134.00	134.00	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	-353.20	-121.80	134.00	402.00	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	1,721,596.30	1,728,572.60	1,681,841.70	1,199,782.60	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	4,922,982.80	4,967,983.20	4,857,052.40	3,693,607.50	0.00	0.00	

 
5,882,555.90	
3,592.70	
4,471,041.00	
-730.80	
730.80	
20,620,708.10	
1,242.40	
-669.80	
17,060,876.80	
48,039,347.10	

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	377.60	0.00	0.00	1,717.40	
SUBTOTAL	:	487.20	365.40	0.00	365.40	0.00	121.80	0.00	0.00	0.00	377.60	0.00	0.00	1,717.40	

8720	SSI DISABLED FREEDO M	26,430.60	25,699.80	25,699.80	24,238.20	24,969.00	25,821.60	29,845.00	28,132.00	28,919.60	29,723.60	0.00	0.00	
SUBTOTAL:	26,430.60	25,699.80	25,699.80	24,238.20	24,969.00	25,821.60	29,845.00	28,132.00	28,919.60	29,723.60	0.00	0.00	

269,479.20	
269,479.20	

ACUTE SMIB
For The Period Ending April 30, 2017

18,427,952.50	18,899,469.20	19,106,875.90	19,012,850.70	19,061,349.90	19,220,904.10	21,178,146.50	21,382,815.00	21,517,522.90	21,677,714.10	0.00	0.00	

199,485,600.80	

TOTAL:

ACUTE HIB
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	740.00	0.00	0.00		740.00		
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	640.00	0.00	0.00		640.00		
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	555.00	0.00	0.00		1,788.00		
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	328,370.50	343,490.70	336,019.30	354,117.90	0.00	0.00		3,128,405.60		
2220	SSI DISABLED WITH Q M	125,651.90	134,161.80	139,747.40	146,768.80	143,036.60	156,332.60	156,736.90	162,432.20	159,273.20	172,728.60	0.00	0.00		1,496,870.00		
2320	SSI BLIND WITH QMB	411.00	1,315.20	863.10	863.10	863.10	863.10	867.30	867.30	867.30	1,775.30	0.00	0.00		9,555.80		
8020	QMB ONLY	2,918.00	3,514.00	2,281.00	2,281.00	2,281.00	3,514.00	2,869.60	2,746.30	3,159.30	4,398.30	0.00	0.00		29,962.50		
9999	SMIB ONLY NOT ELIGIB	-3,144.00	-4,377.10	-5,404.80	-1,397.30	-11,861.10	-3,288.00	-471.20	-9,040.70	-6,915.60	-6,798.80	0.00	0.00		-52,698.60		
SUBTOTAL:	361,563.10	411,610.20	422,086.7	0	466,526.30	462,666.40	487,546.90	488,373.10	500,495.80	492,403.50	528,156.30	0.00	0.00		4,621,428.30		

1120	TANF EXPANDED FOR FI	1,130.00	226.00	226.00	226.00	226.00	2,137.00	867.00	867.00	1,548.00	454.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,059.00	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	4,067.90	6,541.90	6,213.90	5,327.20	0.00	0.00	
SUBTOTAL:	5,630.40	6,904.40	5,363.40	5,137.40	4,274.30	5,733.20	4,934.90	9,467.90	7,761.90	5,781.20	0.00	0.00	

 
7,907.00	
2,059.00	
51,023.00	
60,989.00	

TOTAL:	367,193.50	418,514.60	427,450.10	471,663.70	466,940.70	493,280.10	493,308.00	509,963.70	500,165.40	533,937.50	0.00	0.00		4,682,417.30		

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	177,488.50	2,283,960.60	2,493,094.30	2,481,280.70	0.00	0.00	21,241,715.10	
9999	SMIB ONLY NOT ELIGIB	-9,385.60	-5,934.40	7,613.40	-3,959.40	-6,942.60	-1,948.80	2,344,753.10	200,049.80	-267,401.80	40,685.40	0.00	0.00	2,297,529.10	

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	
2,522,241.60	
2,484,010.40	
2,225,692.50	
2,521,966.10	
0.00	
0.00	
23,539,244.20	

Q1
For The Period Ending April 30, 2017

2,222,028.70	2,257,440.60	2,298,792.60	2,278,279.20	2,348,518.80	2,380,273.70	2,522,241.60	2,484,010.40	2,225,692.50	2,521,966.10	0.00	0.00	

23,539,244.20	

TOTAL:

LTC SMIB
For The Period Ending April 30, 2017	
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	1,072.00	938.00	804.00	804.00	0.00	0.00		10,560.60		
1020	TANF WITH QMB	243.60	243.60	243.60	243.60	243.60	243.60	402.00	536.00	536.00	536.00	0.00	0.00		3,471.60		
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	1,084,656.10	1,065,135.70	1,063,232.30	1,081,181.50	0.00	0.00		10,234,118.20		
2110	SSI AGED NON-MEDIC AR	185,014.20	184,527.00	197,120.70	175,537.00	184,648.80	187,450.20	205,251.40	194,903.90	200,036.10	204,496.20	0.00	0.00		1,918,985.50		
2120	SSI AGED WITH QMB	904,419.20	906,456.00	906,658.80	901,435.80	903,262.80	906,916.80	994,522.20	995,511.10	989,921.00	993,054.60	0.00	0.00		9,402,158.30		
2200	SSI DISABLED WITH M E	379,691.30	381,460.70	384,735.90	383,791.80	382,086.60	379,894.20	422,475.60	434,182.10	426,104.80	422,416.80	0.00	0.00		3,996,839.80		
2210	SSI DISABLED NON-ME D	18,635.40	20,340.60	22,607.60	20,097.00	19,366.20	20,218.80	23,328.00	24,522.00	27,116.60	25,728.00	0.00	0.00		221,960.20		
2220	SSI DISABLED WITH Q M	835,984.20	830,397.20	830,017.70	835,586.70	838,198.70	829,932.60	927,194.70	918,755.70	922,085.90	927,759.50	0.00	0.00		8,695,912.90		
2300	SSI BLIND WITH MEDIC	852.60	852.60	1,096.20	1,096.20	974.40	1,096.20	1,072.00	1,206.00	1,072.00	1,206.00	0.00	0.00		10,524.20		
2310	SSI BLIND NON-MEDIC A	365.40	243.60	243.60	609.00	487.20	487.20	536.00	536.00	402.00	402.00	0.00	0.00		4,312.00		
2320	SSI BLIND WITH QMB	5,237.40	5,359.20	5,115.60	5,115.60	5,237.40	5,237.40	5,762.00	5,746.00	6,156.00	6,046.00	0.00	0.00		55,012.60		
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	3,666,272.00	3,641,972.50	3,637,466.70	3,663,630.60	0.00	0.00		34,553,855.90		

8720	SSI DISABLED FREEDO M	609.00	609.00	487.20	487.20	487.20	487.20	536.00	670.00	670.00	670.00	0.00	0.00	
SUBTOTAL:	609.00	609.00	487.20	487.20	487.20	487.20	536.00	670.00	670.00	670.00	0.00	0.00	

 
5,712.80	
5,712.80	

TOTAL:	3,328,913.10	3,313,964.90	3,329,893.30	3,308,976.70	3,330,339.60	3,335,593.30	3,666,808.00	3,642,642.50	3,638,136.70	3,664,300.60	0.00	0.00		34,559,568.70		

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	454.30	413.00	0.00	0.00	0.00	1,689.30	
2120	SSI AGED WITH QMB	268,654.00	271,962.40	272,059.10	272,658.80	267,768.20	266,802.20	275,152.80	266,749.50	263,965.90	263,596.20	0.00	0.00	2,689,369.10	
2200	SSI DISABLED WITH M E	0.00	411.00	0.00	0.00	0.00	822.00	227.00	-227.00	1,466.00	0.00	0.00	0.00	2,699.00	
2220	SSI DISABLED WITH Q M	14,652.00	13,608.00	12,782.00	16,892.00	13,830.00	13,419.00	14,723.00	19,489.00	18,295.00	16,375.00	0.00	0.00	154,065.00	
SUBTOTAL	:	283,717.00	285,570.40	285,293.20	289,509.70	282,009.20	281,043.20	290,102.80	286,465.80	284,139.90	279,971.20	0.00	0.00	2,847,822.40	

LTC HIB
For The Period Ending April 30, 2017

283,717.00	285,570.40	285,293.20	289,509.70	282,009.20	281,043.20	290,102.80	286,465.80	284,139.90	279,971.20	0.00	0.00	

2,847,822.40	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	282.63	471.00	514.51	252.94	0.00	0.00		5,307.92		
1007	TANF 21-44 FEMALE WI	4,715.31	2,051.12	1,453.54	1,749.80	2,271.89	356.42	325.35	860.74	1,745.10	399.41	0.00	0.00		15,928.68		
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	1,339.34	2,341.50	2,734.50	2,177.88	0.00	0.00		37,305.55		
1009	TANF 65+ M & F WITH	1,498.24	2,850.90	1,807.76	2,387.00	677.41	1,262.43	145.02	688.27	2,366.10	3,187.82	0.00	0.00		16,870.95		
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	456,439.34	739,702.97	917,895.76	709,405.34	0.00	0.00		5,763,357.99		
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	235,581.78	391,982.42	371,328.28	238,922.87	0.00	0.00		2,810,589.93		
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	219,529.46	280,000.08	293,208.57	209,927.07	0.00	0.00		2,430,265.34		
1014	TANF 14-20 MALE NON-	77,950.03	61,633.93	49,927.47	46,564.70	65,284.20	71,787.12	49,892.75	63,025.20	77,275.35	57,253.23	0.00	0.00		620,593.98		
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	139,029.28	209,252.75	211,548.65	162,800.38	0.00	0.00		1,829,879.30		
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	853,485.89	1,257,184.67	1,292,424.73	894,018.06	0.00	0.00		10,186,425.39		
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	2,876,527.81	4,302,662.53	4,195,436.26	3,249,129.64	0.00	0.00		37,453,826.13		
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	1,202,438.35	1,549,148.69	1,909,854.78	1,488,839.44	0.00	0.00		14,939,108.27		
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	1,472.00	5,980.00	3,693.39	3,924.92	0.00	0.00		63,928.83		
1026	TANF 21-44 MALE WITH	736.00	139.85	1,118.62	562.40	467.90	40.06	565.60	0.00	0.00	-30.22	0.00	0.00		3,600.21		
1027	TANF 21-44 FEMALE WI	812.39	1,382.21	750.63	132.72	488.34	112.61	0.00	160.04	520.90	830.79	0.00	0.00		5,190.63		
1028	TANF 45-64 M & F WIT	3,869.59	788.58	2,676.22	2,442.10	1,744.89	703.12	2,431.28	3,866.72	2,914.92	2,532.88	0.00	0.00		23,970.30		
1029	TANF 65+ M & F WITH	111.13	364.33	0.00	0.00	59.22	22.64	212.94	196.61	248.21	298.44	0.00	0.00		1,513.52		
2100	SSI AGED WITH MEDIC A	66,138.34	96,126.19	56,493.24	20,977.68	23,692.13	22,233.45	20,862.12	29,534.11	51,480.47	25,142.82	0.00	0.00		412,680.55		
2110	SSI AGED NON-MEDIC AR	53,486.52	61,326.51	50,453.73	46,591.19	78,692.57	47,031.71	52,951.19	86,074.93	89,631.19	78,073.34	0.00	0.00		644,312.88		
2120	SSI AGED WITH QMB	229,795.08	290,274.13	250,072.81	131,217.32	132,033.60	101,985.96	110,691.41	183,505.10	255,506.75	172,126.67	0.00	0.00		1,857,208.83		
2200	SSI DISABLED WITH M E	138,965.52	205,333.70	184,379.96	67,124.29	62,539.48	68,301.93	73,171.97	105,673.82	177,994.32	85,996.01	0.00	0.00		1,169,481.00		
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	3,206,693.92	4,671,328.56	5,313,711.83	4,340,810.94	0.00	0.00		42,815,602.25		
2220	SSI DISABLED WITH Q M	434,350.13	563,385.69	444,545.28	262,116.83	263,873.74	218,711.29	224,286.42	374,986.20	463,622.38	256,614.10	0.00	0.00		3,506,492.06		
2300	SSI BLIND WITH MEDIC	442.84	1,105.82	590.51	117.68	384.15	343.70	249.90	434.58	530.72	384.78	0.00	0.00		4,584.68		
2310	SSI BLIND NON-MEDIC A	59,992.53	44,447.01	85,286.31	35,040.08	36,650.66	45,641.81	43,758.33	35,015.65	60,658.87	41,571.63	0.00	0.00		488,062.88		
2320	SSI BLIND WITH QMB	6,629.65	6,866.41	6,731.29	3,117.89	4,640.91	2,420.45	3,879.13	8,616.37	8,413.84	2,557.35	0.00	0.00		53,873.29		
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	1,566,803.75	2,244,026.76	2,305,349.60	1,757,099.95	0.00	0.00		17,023,968.50		
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	2,888,969.36	4,258,921.74	4,430,186.85	3,040,308.58	0.00	0.00		32,427,656.73		
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	2,962,497.77	4,433,751.61	4,555,076.00	3,207,694.33	0.00	0.00		40,120,161.85		
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	739,594.98	996,439.91	1,094,696.45	864,307.69	0.00	0.00		10,176,130.70		
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	1,139,348.63	1,352,236.49	1,615,571.06	1,124,402.21	0.00	0.00		13,076,122.34		
5007	SOBRA PREG 21-44 FE M	378.25	75.05	453.66	151.08	459.33	214.55	255.01	980.05	2,189.09	27.80	0.00	0.00		5,183.87		
5013	SOBRA PREG 09-13 FE M	8,701.00	2,231.36	736.00	736.00	0.00	736.00	368.00	368.00	23.00	368.00	0.00	0.00		14,267.36		
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	252,238.40	294,428.28	403,097.18	283,007.83	0.00	0.00		2,758,655.82		
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	1,184,986.22	1,558,660.17	1,629,653.25	1,525,052.67	0.00	0.00		14,849,759.27		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017

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	2,649.71	13,914.80	4,852.09	3,267.30	0.00	0.00	45,302.23	
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	64.80	278.14	85.09	1,293.67	3,060.88	982.30	0.00	0.00	5,764.88	
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	20,514,040.13	29,457,714.99	31,749,015.83	23,833,667.19	0.00	0.00	257,663,809.03	

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	1,207.03	2,216.86	2,983.60	2,671.04	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	10,439.14	13,440.41	10,417.65	25,934.37	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	12,554.08	23,412.64	29,748.44	12,935.96	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	8,403.79	19,769.95	18,804.09	10,704.89	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	736.00	368.00	437.00	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	1,472.00	391.00	46.00	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	4,416.00	2,645.00	2,093.00	1,955.00	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	18,666.08	39,085.22	32,520.85	31,926.99	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	365,255.55	512,424.86	538,757.27	530,228.85	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	1,291,398.61	1,791,529.35	1,969,681.91	1,524,759.25	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	872,310.18	1,212,262.94	1,412,779.84	1,039,387.27	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	5,888.00	2,944.00	4,267.51	4,669.00	0.00	0.00	
1126	TANF EXPANDED 21-44	3,422.37	3,051.01	1,984.77	757.45	948.46	449.08	1,377.57	2,478.44	4,032.68	2,733.51	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	3,775.61	8,276.26	9,755.94	6,031.18	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	7,121.52	16,012.93	21,072.02	16,415.13	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	4,716.55	8,696.89	10,803.86	5,179.02	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	4,472.48	5,269.34	5,795.95	9,387.98	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	5,520.00	5,704.00	11,476.60	6,610.59	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	60,317.50	102,317.23	137,920.25	82,727.12	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	8,616.85	9,120.65	10,131.12	7,983.32	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	46,835.06	62,783.74	66,956.27	60,420.31	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	55,446.90	76,960.61	94,727.28	55,500.27	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	2,790,946.50	3,918,110.32	4,395,209.13	3,438,161.05	0.00	0.00	

35,260.76	
127,505.14	
248,632.55	
175,521.03	
736.00	
5,966.59	
9,987.00	
34,056.16	
284,808.10	
4,260,073.01	
15,766,207.78	
10,644,664.25	
40,758.59	
21,235.34	
43,180.33	
118,022.55	
66,284.60	
87,484.58	
57,919.94	
1,059,404.70	
101,879.86	
749,334.96	
882,838.31	
34,821,762.13	

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	-1,176.00	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	-1,264.00	-316.00	0.00	0.00	0.00	

-294.00	
-2,131.48	
-4,076.43	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	-1,264.00	-1,492.00	0.00	0.00	0.00		-6,501.91		

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	-904.00	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	-330.00	-330.00	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	-3,768.00	-1,306.00	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	-5,002.00	-1,636.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
-660.00	
-8,809.00	
-3,380.00	
-12,262.00	
-25,111.00	

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	1,472.00	58.29	455.15	593.62	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	368.00	0.00	286.00	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	29,663.53	39,002.53	62,770.76	42,129.10	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	56,612.44	67,459.41	93,333.11	73,719.39	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	654,154.83	603,930.61	555,797.48	516,023.20	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	308,103.10	457,640.78	525,630.72	349,505.27	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	1,104,116.05	1,542,874.12	1,657,953.44	1,264,384.69	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	736.00	0.00	46.00	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	1.89	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	1,955.00	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	197.60	0.00	69.85	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	42.24	1,188.97	4,622.98	408.41	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	57.96	64.80	378.04	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	140,944.03	205,541.58	189,156.36	141,888.23	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	224,681.99	273,372.36	313,340.36	198,736.19	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	2,638,766.18	3,941,625.08	3,974,030.62	3,016,741.18	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	1,730,466.87	2,389,179.37	2,238,947.82	1,742,352.20	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	4,510,206.72	5,839,984.82	6,435,655.87	4,968,581.70	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	1,472.00	4,431.08	2,249.52	2,346.00	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	368.00	439.79	24.36	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	11,401,439.87	15,367,280.56	16,056,449.78	12,318,167.43	0.00	0.00	

 
32.05	
17,723.38	
6,370.23	
335,753.75	
666,564.41	
5,022,236.60	
4,001,899.95	
13,907,978.38	
10,736.00	
0.00	
141.53	
0.00	
4,539.65	
6,702.27	
54,778.90	
6,667.94	
1,877,920.32	
2,709,384.43	
34,067,614.39	
21,111,188.64	
52,934,542.29	
27,883.10	
45.14	
20,629.03	
136,791,332.38	

3906	NEWLY ELIGIBLE MALE	565.60	252.69	29.45	69.53	8.54	136.64	0.00	327.55	86.54	0.00	0.00	0.00	1,476.54

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	-350.00	0.00	0.00	0.00		808.94		
3908	NEWLY ELIGIBLE M&F 4	6,391.01	9,530.25	3,280.13	877.71	1,922.94	2,626.26	494.56	714.03	1,437.80	188.24	0.00	0.00		27,462.93		
3909	NEWLY ELIGIBLE M&F 6	491.18	602.98	747.75	0.00	167.47	0.00	0.00	0.00	23.33	236.86	0.00	0.00		2,269.57		
3914	NEWLY ELIGIBLE MALE	15,249.46	14,325.93	11,406.94	10,046.14	14,291.58	17,730.71	13,010.11	21,528.00	14,727.48	10,398.75	0.00	0.00		142,715.10		
3915	NEWLY ELIGIBLE FEMA L	35,329.67	39,339.71	23,671.00	13,093.41	25,444.20	23,475.47	40,394.43	24,138.68	27,708.17	17,092.01	0.00	0.00		269,686.75		
3916	NEWLY ELIGIBLE MALE	236,860.76	307,117.41	193,505.68	173,818.34	229,297.35	213,031.74	188,782.08	253,376.57	287,850.77	238,012.16	0.00	0.00		2,321,652.86		
3917	NEWLY ELIGIBLE FEMA L	595,512.26	613,831.91	463,222.16	384,839.40	412,589.35	380,208.75	352,049.69	466,429.59	538,303.70	411,701.61	0.00	0.00		4,618,688.42		
3918	NEWLY ELIGIBLE M&F 4	774,247.15	944,868.39	770,039.27	643,515.20	818,844.64	740,490.30	622,753.40	1,021,125.81	1,015,511.82	802,833.52	0.00	0.00		8,154,229.50		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	736.00	368.00	736.00	0.00	368.00	0.00	0.00	1,173.00	0.00	0.00		3,381.00		
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	1,217,852.27	1,787,640.23	1,885,299.61	1,481,636.15	0.00	0.00		15,543,128.60		

4517	BC PATIENT FEMALE 2 1	368.00	736.00	0.00	0.00	0.00	0.00	0.00	0.00	-700.00	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	736.00	1,472.00	2,392.00	5,359.00	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	736.00	1,472.00	1,692.00	5,359.00	0.00	0.00	

404.00	
25,921.29	
147.74	
368.00	
26,841.03	

8700	SSI DISABLED FREEDO M	7,296.44	5,878.33	16,900.38	5,411.35	4,232.74	5,639.92	2,182.04	3,250.29	3,907.77	4,324.83	0.00	0.00	
8710	SSI DISABLED FREEDO M	1,104.00	0.00	368.00	0.00	1,840.00	1,104.00	11,356.00	0.00	0.00	3,082.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	340.87	4,450.07	213.15	0.00	0.00	0.00	73.51	448.41	164.63	0.00	0.00	
SUBTOTAL:	8,400.44	6,219.20	21,718.45	5,624.50	6,072.74	6,743.92	13,538.04	3,323.80	4,356.18	7,571.46	0.00	0.00	

59,024.09	
18,854.00	
5,690.64	
83,568.73	

4412	SOBRA 100-133% M&F
1	0.00	1,436.00	0.00	700.00	350.00	0.00	0.00	368.00	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	280,414.50	408,454.99	372,221.57	320,489.31	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	69,537.31	108,190.51	100,844.99	79,659.27	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	105,357.80	128,163.16	138,322.27	109,540.05	0.00	0.00	
SUBTOTAL:	598,311.07	779,846.15	590,864.41	520,580.99	637,106.64	578,358.65	455,309.61	645,176.66	611,388.83	509,688.63	0.00	0.00	

 
2,854.00	
3,657,990.40	
914,175.89	
1,351,611.35	
5,926,631.64	

TOTAL:	51,739,377.28	53,563,815.76	42,730,541.60	35,196,330.12	42,531,263.00	41,201,283.62	36,393,862.42	51,174,452.56	54,700,283.36	41,594,250.91	0.00	0.00		450,825,460.63		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2017	
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	683.53	1.85	891.64	788.39	0.00	0.00		11,269.38		
1007	TANF 21-44 FEMALE WI	6,790.07	16,402.24	8,847.17	10,787.71	9,830.33	5,500.92	6,475.01	4,808.20	10,437.77	403.49	0.00	0.00		80,282.91		
1008	TANF 45-64 M & F WIT	5,745.09	7,583.01	925.31	1,105.00	11,490.06	1,594.05	3,728.07	6,203.80	5,252.36	10,386.39	0.00	0.00		54,013.14		
1009	TANF 65+ M & F WITH	524.13	55.02	114.42	854.55	4,017.07	2,959.06	1,709.75	1,072.87	600.30	331.29	0.00	0.00		12,238.46		
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	224,732.23	818,195.52	496,598.59	438,103.11	0.00	0.00		3,845,361.29		
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	31,439.10	70,375.85	109,933.76	87,671.58	0.00	0.00		695,795.88		
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	34,224.95	54,326.25	40,017.51	67,859.04	0.00	0.00		615,919.65		
1014	TANF 14-20 MALE NON-	9,809.04	10,160.19	11,971.71	14,277.45	24,852.99	12,379.65	15,757.30	17,159.43	28,978.77	16,890.58	0.00	0.00		162,237.11		
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	58,257.73	57,354.26	51,512.84	48,494.35	0.00	0.00		491,251.12		
1016	TANF 21-44 MALE NON-	538,720.43	818,731.46	521,422.83	594,944.87	672,217.52	511,299.05	502,224.81	601,520.07	862,322.84	540,525.87	0.00	0.00		6,163,929.75		
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	1,431,614.25	1,563,437.28	1,763,234.73	1,512,314.22	0.00	0.00		15,672,187.01		
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	564,262.06	603,497.14	903,278.77	504,359.16	0.00	0.00		6,774,985.38		
1019	TANF 65+ M & F NON-M	0.00	1,421.86	0.00	6,402.16	6,756.51	2,856.98	579.15	1,145.20	-211.88	462.71	0.00	0.00		19,412.69		
1026	TANF 21-44 MALE WITH	116.86	2,480.19	18.72	1,723.10	487.98	140.65	869.92	1,778.95	179.72	243.51	0.00	0.00		8,039.60		
1027	TANF 21-44 FEMALE WI	2,636.88	2,108.61	27.92	3,528.75	1,556.77	398.35	653.32	301.37	832.31	203.50	0.00	0.00		12,247.78		
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	3,524.58	4,722.46	11,327.13	5,086.99	0.00	0.00		54,967.29		
1029	TANF 65+ M & F WITH	0.00	0.00	6.64	1,438.51	136.44	502.62	0.00	0.00	162.21	3,357.64	0.00	0.00		5,604.06		
2100	SSI AGED WITH MEDIC A	115,748.46	91,408.50	23,387.24	52,926.52	63,459.66	60,447.58	61,620.80	52,681.97	87,707.15	50,168.64	0.00	0.00		659,556.52		
2110	SSI AGED NON-MEDIC AR	31,788.57	48,642.55	31,256.79	125,559.23	108,863.17	18,844.60	15,665.96	14,118.41	53,553.80	42,486.26	0.00	0.00		490,779.34		
2120	SSI AGED WITH QMB	229,484.07	344,087.35	270,699.28	303,353.04	306,132.68	229,783.12	246,073.63	278,150.78	395,520.60	276,179.35	0.00	0.00		2,879,463.90		
2200	SSI DISABLED WITH M E	210,777.77	283,035.91	243,423.96	176,967.44	315,518.68	234,425.64	172,019.39	200,229.48	303,548.17	212,285.54	0.00	0.00		2,352,231.98		
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	3,568,672.33	3,995,193.90	4,403,220.72	3,380,418.03	0.00	0.00		39,444,230.91		
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	676,807.59	828,942.20	1,210,075.05	736,799.41	0.00	0.00		8,528,030.55		
2300	SSI BLIND WITH MEDIC	14.33	0.00	804.98	14.33	107.69	84.56	1,098.06	209.96	340.53	1,900.58	0.00	0.00		4,575.02		
2310	SSI BLIND NON-MEDIC A	25,883.10	61,596.20	26,069.05	45,729.97	39,652.49	35,017.47	19,445.72	75,381.70	43,574.25	24,788.03	0.00	0.00		397,137.98		
2320	SSI BLIND WITH QMB	9,644.50	10,606.91	5,210.39	4,646.52	12,453.83	7,366.51	5,957.87	9,111.90	9,231.94	4,986.20	0.00	0.00		79,216.57		
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	842,840.84	973,560.33	1,467,551.08	775,617.08	0.00	0.00		9,701,024.64		
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	723,445.78	1,524,221.73	1,341,066.03	498,654.64	0.00	0.00		9,615,136.41		
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	861,220.94	1,074,667.96	1,086,300.48	834,204.89	0.00	0.00		10,043,926.54		
4314	SOBRA CHILD 14-20 MA	235,587.23	343,925.37	241,039.86	292,752.49	340,091.21	338,149.49	406,307.09	321,088.01	334,472.45	230,668.58	0.00	0.00		3,084,081.78		
4315	SOBRA CHILD 14-20 FE	319,825.62	385,924.79	344,546.58	352,532.31	415,333.28	417,725.77	348,247.56	352,341.70	406,616.23	281,492.76	0.00	0.00		3,624,586.60		
5007	SOBRA PREG 21-44 FE M	459.90	1,929.86	485.67	0.00	0.00	47.44	18.31	379.06	144.30	2,305.96	0.00	0.00		5,770.50		
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	70,197.17	90,796.94	176,781.88	101,971.78	0.00	0.00		1,053,347.58		
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	563,663.92	620,935.24	1,036,815.06	652,531.06	0.00	0.00		7,286,782.38		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2017

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	2,598.13	1,650.71	1,501.54	293.00	0.00	0.00	51,608.32	
5027	SOBRA PREG 21-44 FE M	866.28	3,055.50	1,079.37	1,331.27	3,041.80	2,429.88	1,341.04	1,003.77	678.31	553.38	0.00	0.00	15,380.60	
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	11,467,977.89	14,220,566.25	16,644,048.94	11,345,786.99	0.00	0.00	133,999,585.28	

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	8,302.75	12,179.06	16,150.50	12,480.61	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	20,560.54	12,266.49	12,188.57	10,761.28	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	40,986.63	40,561.02	51,405.69	21,565.90	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	11,627.74	16,300.77	14,442.15	9,015.98	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	294.35	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	65.60	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	414.96	277.63	389.89	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	12,100.46	19,934.91	5,375.54	6,558.29	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	198,012.46	140,212.52	241,130.17	128,677.84	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	421,907.54	555,388.71	615,383.36	478,731.07	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	410,233.46	496,243.38	566,934.54	379,494.72	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	250.16	893.25	685.65	449.28	5,973.44	380.30	382.59	438.09	301.30	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	11,250.30	12,173.81	17,147.73	14,291.68	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	17,488.58	20,591.80	30,159.06	10,794.16	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	43,801.34	58,799.30	107,565.38	83,441.89	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	5,599.86	12,796.20	20,985.96	14,855.97	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	6,597.63	12,207.83	12,258.23	9,617.33	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	-504.84	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	135,682.22	157,361.39	141,064.66	172,902.92	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	7,651.69	7,069.24	12,251.88	4,466.08	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	99,661.83	65,964.83	67,027.75	121,122.71	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	124,665.52	181,107.96	219,900.42	121,870.47	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	1,576,510.85	1,821,811.88	2,152,087.31	1,601,340.09	0.00	0.00	

126,224.22	
189,801.88	
558,078.37	
155,288.42	
0.00	
2,836.72	
214.34	
10,790.46	
120,365.69	
1,711,705.73	
5,077,590.02	
4,289,404.69	
9,754.06	
140,016.50	
151,826.45	
450,067.34	
119,964.80	
77,518.25	
-1,233.55	
1,480,027.94	
115,017.17	
787,765.01	
1,886,314.94	
17,459,339.45	

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 April 30, 2017	
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	-13.47	0.00	0.00	0.00	0.00	
SUBTOTAL:	-138.35	-14.92	-825.64	-3,137.15	-107.23	0.00	0.00	-13.47	0.00	0.00	0.00	0.00	

 
-128.19	
-3,081.67	
-23.63	
0.00	
-362.02	
0.00	
-641.25	
-4,236.76	

3506	ADULT 40-100% MALE
2	0.00	-204.83	0.00	-25.53	0.00	0.00	0.00	0.00	79.70	210.49	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	34,727.37	222.30	0.00	1,325.56	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	4,867.01	11,265.95	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	7,367.72	19,481.84	30,201.66	13,915.21	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	18,907.32	16,510.26	19,175.98	15,067.25	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	318,463.90	334,195.51	393,122.37	296,965.98	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	157,419.73	160,233.37	132,083.57	123,298.49	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	787,219.51	653,847.46	886,385.83	495,271.27	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	54.32	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	57.38	111.32	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	648.18	1,093.02	337.31	689.76	0.00	57.17	0.00	965.58	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	635.28	1,689.42	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	4,345.06	2,233.44	7,369.79	357.78	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	83,844.43	83,224.40	106,314.97	100,437.37	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	72,606.45	74,546.50	116,506.01	53,924.23	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	2,696,624.04	2,762,513.27	3,314,078.07	2,327,401.44	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	975,500.14	975,774.61	1,435,536.72	901,005.57	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	3,250,381.60	3,652,709.08	4,400,740.86	3,244,367.42	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	33.29	100.23	4,348.02	115.04	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	731.86	1,007.97	659.63	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	8,408,229.59	8,736,600.24	10,853,182.75	7,586,729.79	0.00	0.00	

 
59.83	
50,420.86	
58,030.54	
174,650.99	
160,052.40	
3,431,809.08	
1,503,150.33	
6,988,318.85	
31,919.75	
217.07	
90.63	
168.70	
3,791.02	
2,580.58	
30,453.32	
1,286.44	
950,749.28	
773,329.46	
28,660,441.93	
10,333,283.10	
35,607,711.98	
11,642.08	
0.00	
5,559.65	
88,779,717.87	

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 April 30, 2017	
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	2,405.58	70.20	5,525.08	67.81	0.00	0.00		17,120.49		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	1,776.33	150.63	155.80	253.33	0.00	0.00	0.00	0.00		2,336.09		
3914	NEWLY ELIGIBLE MALE	6,895.37	4,020.80	2,130.37	3,263.19	16,838.11	14,476.85	2,703.55	3,405.98	5,358.81	4,493.81	0.00	0.00		63,586.84		
3915	NEWLY ELIGIBLE FEMA L	6,000.59	6,770.12	4,415.72	14,631.01	3,996.59	7,835.28	4,355.24	4,009.49	11,697.84	1,606.13	0.00	0.00		65,318.01		
3916	NEWLY ELIGIBLE MALE	86,585.35	154,491.69	129,941.11	92,209.11	96,904.07	82,937.24	103,818.48	94,870.29	173,723.91	110,964.57	0.00	0.00		1,126,445.82		
3917	NEWLY ELIGIBLE FEMA L	150,672.73	178,002.93	118,358.99	104,012.75	150,614.67	94,760.95	158,244.21	153,979.77	194,608.94	96,737.46	0.00	0.00		1,399,993.40		
3918	NEWLY ELIGIBLE M&F 4	302,477.81	320,499.76	328,674.25	338,201.99	340,449.66	383,639.65	414,005.02	359,454.61	416,523.76	338,876.98	0.00	0.00		3,542,803.49		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	91.04	0.00	0.00		91.04		
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	685,687.88	616,043.67	807,438.34	552,837.80	0.00	0.00		6,218,562.20		

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	81,110.62	63,302.90	86,416.14	68,154.31	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	24,363.03	29,761.20	40,455.97	22,017.54	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	23,465.68	18,349.07	26,080.18	23,681.60	0.00	0.00	
SUBTOTAL:	108,488.75	145,082.93	94,430.24	125,533.56	208,368.92	129,531.86	128,939.33	111,413.17	152,952.29	113,853.45	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	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	

8700	SSI DISABLED FREEDO M	4,051.48	9,611.52	2,832.06	4,024.33	5,669.59	2,234.13	1,294.22	4,585.01	4,173.92	931.18	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	1,664.74	4,494.92	496.84	1,488.70	2,024.22	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	4,549.40	2,178.48	2,412.17	1,230.29	0.00	0.00	
SUBTOTAL:	4,775.73	12,125.11	4,377.14	6,646.44	9,998.75	7,220.59	10,338.54	7,260.33	8,074.79	4,185.69	0.00	0.00	

TOTAL:

22,144,827.06

0.00	
784,947.50	
238,057.77	
295,589.23	
1,318,594.50	

0.00	
2,037.96	
0.00	
0.00	
2,037.96	

39,407.44	
10,169.42	
25,426.25	
75,003.11	

22,174,272.47

28,781,646.39     24,663,852.45     22,277,684.08    25,513,682.07

21,204,733.81

22,624,092.82

30,617,784.42

0.00	0.00

247,848,490.28	

27,845,914.71

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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 April 30, 2017

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 April 30, 2017	
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 April 30, 2017	
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		

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	

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	

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	56.86	0.00	0.00	0.00		56.86		
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	57.17	0.00	43.03	159.59	0.00	0.00		2,024.50		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.89	0.00	0.00	0.00	0.00		13.89		
1011	TANF <1 M & F NON-ME	1,804.59	2,706.60	180.67	3,089.60	2,238.40	888.35	2,379.65	2,786.67	66,721.13	3,083.82	0.00	0.00		85,879.48		
1012	TANF 01-05 M & F NON	3,987.61	3,263.59	24.45	74.10	74.84	51.54	186.67	2,872.04	7,904.28	501.60	0.00	0.00		18,940.72		
1013	TANF 06-13 M & F NON	3,653.62	44.01	117.52	1,337.04	470.18	44.01	131.34	1,107.86	1,413.95	747.94	0.00	0.00		9,067.47		
1014	TANF 14-20 MALE NON-	1,143.86	301.79	433.35	0.00	430.90	-33.55	314.20	33.21	216.38	123.14	0.00	0.00		2,963.28		
1015	TANF 14-20 FEMALE N O	1,333.07	0.00	0.00	272.67	55.05	775.37	986.61	187.43	396.82	74.30	0.00	0.00		4,081.32		
1016	TANF 21-44 MALE NON-	2,299.03	1,606.33	7,315.24	3,093.77	642.56	6,843.53	-84.49	5,249.74	13,581.48	3,489.94	0.00	0.00		44,037.13		
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	6,191.87	12,122.75	23,300.73	17,174.66	0.00	0.00		154,743.87		
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	822.07	1,730.54	3,396.56	16,799.29	0.00	0.00		64,219.92		
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	59.93	287.91	96.25	4,106.31	0.00	0.00		12,055.82		
2110	SSI AGED NON-MEDIC AR	5,148.07	-9,481.65	7,030.69	14,677.98	22,927.47	7,360.07	5,134.33	46,599.13	69,527.92	8,471.21	0.00	0.00		177,395.22		
2120	SSI AGED WITH QMB	242.01	-109.74	3.33	-104.35	108.19	-1,169.48	69.20	0.00	2,090.15	1,099.66	0.00	0.00		2,228.97		
2200	SSI DISABLED WITH M E	60.91	-225.64	2,470.61	-272.04	1,010.07	461.97	1,375.49	401.41	1,576.36	255.57	0.00	0.00		7,114.71		
2210	SSI DISABLED NON-ME D	27,621.59	22,101.33	16,667.85	687.91	1,579.78	2,985.98	60,585.31	-45,762.89	7,181.79	7,979.16	0.00	0.00		101,627.81		
2220	SSI DISABLED WITH Q M	2,632.34	-15.23	394.41	608.50	3,385.69	683.16	2,103.56	1,248.26	1,157.24	-272.81	0.00	0.00		11,925.12		
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	2,616.36	2,449.32	-6,434.67	1,022.33	0.00	0.00		32,747.86		
4312	SOBRA CHILD 01-05 M	65,933.12	13,197.35	21,624.82	5,408.49	6,709.04	6,772.19	4,277.46	8,096.77	43,376.47	3,370.78	0.00	0.00		178,766.49		
4313	SOBRA CHILD 06-13 M	104,379.21	2,798.52	14,577.29	2,003.75	-104.06	2,493.05	7,230.92	4,387.21	5,884.77	4,710.50	0.00	0.00		148,361.16		
4314	SOBRA CHILD 14-20 MA	11,733.15	2,913.24	6,838.28	4,514.52	6,851.42	5,692.98	1,914.53	816.97	2,657.46	370.71	0.00	0.00		44,303.26		
4315	SOBRA CHILD 14-20 FE	7,732.31	6,972.91	15,121.73	3,090.71	-857.41	1,558.35	7,971.39	90.56	5,541.40	-112.13	0.00	0.00		47,109.82		
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	2,723.13	819.42	6,657.46	6,080.65	0.00	0.00		35,901.44		
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	14,372.06	16,334.28	35,447.26	6,836.89	0.00	0.00		240,507.71		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017

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	121,418.76	61,872.48	291,791.08	86,073.11	0.00	0.00	1,426,443.88	

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	33.53	0.00	25.84	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	698.08	897.98	0.00	38.54	43.92	93.36	164.26	32.12	1,105.21	100.93	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	27.46	263.42	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	874.90	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	2,282.57	333.74	5,057.04	30,457.19	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	3,066.25	21,967.55	11,903.04	8,950.86	0.00	0.00	
1118	TANF EXPANDED 45-64	861.72	647.82	886.54	1,515.37	3,446.49	163.09	655.79	869.30	1,082.02	92.97	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	23.31	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	4.99	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	33.98	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	1,116.52	8.88	641.16	270.14	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	80.08	310.66	392.64	2,904.53	0.00	4,994.77	0.00	0.00	
2420	SSI AGED EXPANDED WI	174.44	0.00	0.00	0.00	0.00	38.59	0.00	62.21	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	799.72	652.66	4,403.90	2,083.31	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	808.13	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,647.33	17.88	0.00	53.93	21.16	189.60	66.44	79.40	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	8,611.70	27,813.59	25,053.80	47,213.59	0.00	0.00	

0.00	
989.33	
3,174.40	
290.88	
0.00	
0.00	
0.00	
0.00	
1,110.57	
54,203.53	
96,475.50	
10,221.11	
0.00	
0.00	
465.39	
13.31	
273.41	
6,524.89	
8,682.68	
275.24	
10,172.02	
14,728.62	
2,075.74	
209,676.62	

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 April 30, 2017	
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	-87.32	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-87.32	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
-87.32	
-87.32	

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	167.38	137.25	0.00	49.03	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	740.27	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	2,123.01	11,705.40	5,486.44	8,027.47	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	1,903.38	1,901.84	12,028.26	4,160.64	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	15,495.32	16,716.69	16,761.40	36,016.58	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	854.28	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	1,342.18	29.56	30.64	13.26	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	4,350.23	1,398.19	33,338.08	376.84	0.00	0.00	
3715	ADULT <40% EXP FEM AL	6,327.32	218.97	103.21	444.72	2,863.82	611.63	869.88	5,762.72	1,987.76	2,541.27	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	82,787.51	56,251.78	71,352.44	47,000.04	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	3,739.07	17,423.92	41,299.00	50,843.06	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	72,290.56	75,774.69	44,672.56	110,009.34	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	93.02	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	1,487.88	37.71	362.34	176.95	0.00	0.00	
SUBTOTAL:	125,482.91	321,139.99	143,518.2	291,072.44	165,729.12	136,605.74	186,556.40	187,139.75	228,059.19	260,161.78	0.00	0.00	

 
0.00	
12.85	
0.00	
6,507.67	
2,182.25	
134,387.27	
43,555.86	
187,302.19	
0.00	
0.00	
0.00	
0.00	
2,685.60	
0.00	
1,841.26	
0.00	
57,321.42	
21,731.30	
592,776.24	
250,138.45	
739,656.39	
0.00	
93.02	
5,273.77	
2,045,465.54	

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 April 30, 2017	
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	487.19	0.00	76.98	0.00	0.00	0.00		1,181.84		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	76.13	172.74	776.01	29.89	0.00	0.00	394.91	1,321.10	0.00	0.00		2,770.78		
3916	NEWLY ELIGIBLE MALE	2,914.09	14,106.81	6,628.24	15,285.71	5,946.75	50,306.73	4,088.70	4,180.73	3,779.04	9,229.01	0.00	0.00		116,465.81		
3917	NEWLY ELIGIBLE FEMA L	11,968.55	10,649.44	3,947.00	10,034.39	5,485.50	5,480.40	1,318.45	1,961.63	9,291.39	8,388.98	0.00	0.00		68,525.73		
3918	NEWLY ELIGIBLE M&F 4	12,324.30	13,624.14	7,696.01	-2,853.79	15,897.06	8,064.83	8,070.41	21,108.50	24,876.14	46,282.36	0.00	0.00		155,089.96		
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	13,964.75	27,250.86	38,418.46	65,221.45	0.00	0.00		344,526.85		

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	48,193.66	0.00	-147.49	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	806.14	1,033.81	4,619.86	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	901.53	974.71	144.25	19.10	0.00	0.00	324.72	356.58	896.87	103.62	0.00	0.00	
SUBTOTAL:	9,280.28	5,032.17	996.95	10,655.19	5,583.18	1,880.64	49,324.52	1,390.39	5,369.24	103.62	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	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	

8700	SSI DISABLED FREEDO M	0.00	651.68	1,507.07	438.25	175.38	182.62	81.04	0.00	908.65	1,275.12	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	2,290.95	0.00	144.49	-598.36	13,620.99	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	13,702.03	0.00	908.65	1,275.12	0.00	0.00	

TOTAL:

511,418.72

0.00	
70,981.98	
14,912.82	
3,721.38	
89,616.18	

0.00	
19.37	
0.00	
0.00	
19.37	

5,219.81	
15,458.07	
21.54	
20,699.42	

325,648.49

329,529.25

301,924.55

393,578.16

305,379.75

460,048.67

430,016.47

589,600.42

0.00	0.00

4,136,360.54	

489,216.06

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	22,229.29	34,250.96	46,500.57	30,039.54	0.00	0.00		354,945.62		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.04	0.00	0.00	0.00	0.00		10.04		
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	53,054.5	5	45,687.23	31,004.90	34,052.38	21,371.45	22,229.29	34,261.00	46,500.57	30,039.54	0.00	0.00		355,073.07		

TOTAL:

36,872.16

53,054.55

45,687.23

34,052.38

21,371.45

22,229.29

34,261.00

30,039.54

355,073.07

31,004.90

46,500.57

0.00	0.00

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending April 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	0.00	589.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589.33		
SUBTOTAL:	0.00	0.0	589.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589.33		

0.00

0.00

0.00

0.00

TOTAL:

0.00

0.00	589.33

0.00	0.00	0.00	0.00

0.00

589.33

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	342,804.13	447,135.06	537,241.64	407,763.62	0.00	0.00		3,944,687.48		
8040	SLMB	4.16	0.00	0.00	0.00	4.29	7.91	0.00	3,034.16	11.51	0.00	0.00	0.00		3,062.03		
8050	QI1	7.67	86.69	-4.34	0.00	0.00	0.00	0.00	1,344.38	0.00	40.63	0.00	0.00		1,475.03		
SUBTOTAL:	363,239.62	409,204.47	280,446.79	327,995.53	497,318.00	331,645.00	342,804.13	451,513.60	537,253.15	407,804.25	0.00	0.00		3,949,224.54		

TOTAL:

363,239.62

409,204.47

280,446.79

497,318.00

331,645.00

342,804.13

451,513.60

407,804.25

3,949,224.54

327,995.53

537,253.15

0.00	0.00

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2017	
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	105.08	57.17	208.96	0.00	0.00	0.00		1,913.04		
1008	TANF 45-64 M & F WIT	14.46	31.99	67.85	0.00	36.26	-61.91	0.00	65.26	0.00	0.00	0.00	0.00		153.91		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	135.43	721.20	0.00	111.41	76.90	422.90	0.00	0.00	0.00		1,467.84		
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	20,363.09	30,375.72	142,874.55	30,215.90	0.00	0.00		556,999.76		
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	7,054.69	3,992.66	3,225.75	11,027.22	0.00	0.00		44,922.96		
1013	TANF 06-13 M & F NON	-34.11	397.76	542.41	1,165.54	10,191.23	741.32	441.07	2,460.07	2,040.45	2,811.80	0.00	0.00		20,757.54		
1014	TANF 14-20 MALE NON-	0.00	503.34	0.00	1,775.49	373.41	342.70	3,633.19	928.66	263.61	0.00	0.00	0.00		7,820.40		
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	5,742.02	4,560.09	830.83	2,902.35	0.00	0.00		51,105.01		
1016	TANF 21-44 MALE NON-	45,482.98	57,982.31	50,834.68	63,481.02	65,002.73	53,576.70	44,785.34	48,531.52	55,286.54	41,217.49	0.00	0.00		526,181.31		
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	78,839.56	99,575.82	163,955.55	75,307.84	0.00	0.00		1,160,298.64		
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	21,409.05	56,367.79	30,910.97	38,820.18	0.00	0.00		503,946.75		
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	443.67	223.24	1.71	416.41	0.00	0.00		1,305.10		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105.37	683.49	0.00	0.00		788.86		
2100	SSI AGED WITH MEDIC A	8,499.66	938.66	2,046.26	278.19	2,787.50	1,812.69	2,488.25	3,807.66	1,078.22	164.34	0.00	0.00		23,901.43		
2110	SSI AGED NON-MEDIC AR	2,551.19	18.03	2,511.53	191.11	2,134.18	176.95	255.99	684.88	2,197.50	420.33	0.00	0.00		11,141.69		
2120	SSI AGED WITH QMB	9,555.40	11,940.97	7,470.65	15,123.55	12,552.40	18,168.95	11,332.88	11,166.02	18,202.68	9,102.69	0.00	0.00		124,616.19		
2200	SSI DISABLED WITH M E	8,793.87	12,081.12	10,297.40	5,147.30	11,941.75	4,236.24	7,445.74	7,710.71	5,521.10	1,849.99	0.00	0.00		75,025.22		
2210	SSI DISABLED NON-ME D	243,889.19	242,188.71	228,595.91	178,902.13	254,368.08	181,654.32	192,890.03	267,667.89	262,575.99	277,356.55	0.00	0.00		2,330,088.80		
2220	SSI DISABLED WITH Q M	36,584.54	51,182.69	28,824.97	28,013.13	39,195.84	34,975.82	30,605.05	35,335.16	64,302.73	43,723.26	0.00	0.00		392,743.19		
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	1,236.63	2,626.29	3,791.09	8,886.42	0.00	0.00		29,902.63		
2320	SSI BLIND WITH QMB	1,288.00	88.30	231.93	184.69	1.71	1,298.56	120.17	533.30	2,760.99	335.15	0.00	0.00		6,842.80		
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	55,426.23	125,248.66	85,179.52	72,422.14	0.00	0.00		864,071.63		
4312	SOBRA CHILD 01-05 M	31,803.55	53,396.45	28,866.55	50,706.97	65,556.76	44,433.72	100,052.07	99,952.97	77,474.59	50,731.10	0.00	0.00		602,974.73		
4313	SOBRA CHILD 06-13 M	22,465.50	28,513.24	13,984.93	40,915.69	31,610.75	35,314.85	51,918.93	39,658.29	67,843.30	46,858.15	0.00	0.00		379,083.63		
4314	SOBRA CHILD 14-20 MA	8,438.19	7,014.89	19,047.97	14,802.86	55,470.21	23,529.75	45,864.17	18,736.41	23,959.85	9,837.45	0.00	0.00		226,701.75		
4315	SOBRA CHILD 14-20 FE	21,162.92	41,843.06	21,752.40	17,573.54	18,927.56	22,412.21	14,434.39	16,609.99	14,854.20	21,510.18	0.00	0.00		211,080.45		
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	8,884.93	14,583.89	39,890.54	22,031.37	0.00	0.00		231,161.17		
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	47,883.30	72,891.01	168,480.33	77,828.84	0.00	0.00		991,129.51		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2017

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	753,766.93	964,428.03	1,238,239.82	846,460.64	0.00	0.00	9,380,987.13	

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	993.55	820.14	0.00	72.82	0.00	0.00	
1107	TANF EXPANDED 21-44	742.62	1,250.14	606.18	538.50	1,601.66	293.00	239.46	229.68	596.14	91.16	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	1,228.92	1,543.77	2,922.20	371.88	0.00	0.00	
1109	TANF EXPANDED 65+
M&	283.01	255.70	323.31	2,190.56	1,064.09	1,556.64	755.85	443.88	787.84	1,596.53	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	523.20	586.84	966.92	310.19	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	7,279.64	16,850.73	19,388.17	11,079.39	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	38,688.78	38,996.80	-10,225.12	47,943.75	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	17,932.16	40,183.66	41,696.92	12,826.61	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	859.91	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	94.64	274.42	85.96	335.13	0.00	0.00	
1127	TANF EXPANDED 21-44	958.28	260.08	80.13	62.88	842.18	658.70	1,578.48	660.91	451.61	298.85	0.00	0.00	
1128	TANF EXPANDED 45-64	474.42	1,133.94	69.10	687.88	2,356.75	1,047.81	955.38	3,968.38	4,357.99	2,216.13	0.00	0.00	
1129	TANF EXPANDED 65+
M&	345.00	291.62	178.40	72.29	397.63	27.65	694.74	256.63	433.49	86.44	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	25.19	5,703.60	30.44	12.17	138.14	0.00	1.28	1,403.68	156.77	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	4,478.72	7,116.84	9,496.46	6,231.61	0.00	0.00	
2600	SSI DISABLED EXPAND E	127.08	678.60	160.68	590.40	566.16	0.00	188.57	1,350.88	2,872.25	86.82	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	1,423.68	2,019.74	1,937.18	2,823.92	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	5,896.52	7,948.38	9,900.63	8,273.56	0.00	0.00	
SUBTOTAL:	98,257.39	216,685.29	144,224.59	98,281.03	162,916.65	84,536.79	83,812.20	123,252.96	87,072.32	94,801.56	0.00	0.00	

10,185.21	
6,188.54	
19,623.48	
9,257.41	
0.00	
0.00	
0.00	
0.00	
9,774.23	
208,336.82	
456,458.93	
245,101.55	
859.91	
3,525.99	
5,852.10	
17,267.78	
2,783.89	
7,471.27	
-552.47	
77,346.59	
6,621.44	
23,859.65	
83,878.46	
1,193,840.78	

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 April 30, 2017	
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	354.45	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	166.48	191.45	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	42.15	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	222.66	209.91	4,472.66	1,281.56	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	6,576.23	1,233.84	840.54	568.27	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	17,280.77	30,483.24	68,701.14	61,650.31	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	31,396.59	11,572.89	41,063.55	25,324.84	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	86,189.90	130,073.16	88,103.57	78,147.20	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	27.45	107.92	1,137.29	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	3,362.44	13,237.67	3,504.84	3,616.39	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	10,278.16	11,027.01	3,726.55	5,110.41	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	122,890.95	118,624.59	199,366.61	1,386,627.72	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	100,496.76	71,543.85	74,688.49	155,792.98	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	233,511.69	210,452.06	189,236.31	188,903.76	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	612,206.15	598,527.82	673,978.66	1,908,706.63	0.00	0.00	

 
354.45	
494.40	
42.15	
11,019.75	
24,181.56	
454,201.96	
242,317.81	
888,991.97	
1,560.02	
0.00	
0.00	
0.00	
0.00	
0.00	
1,405.25	
0.00	
75,712.78	
75,230.70	
2,950,690.62	
949,651.44	
2,173,130.47	
145.26	
0.00	
0.00	
7,849,130.59	

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 April 30, 2017	
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	180.71	1,120.62	113.61	0.00	0.00		1,414.94		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	15.66	0.00	0.00	52.25	0.00	0.00	0.00		67.91		
3914	NEWLY ELIGIBLE MALE	833.48	180.72	0.00	0.00	409.33	0.00	0.00	16.02	0.00	0.00	0.00	0.00		1,439.55		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	475.98	0.00	56.45	103.29	2,579.73	558.06	185.69	0.00	0.00	0.00		3,959.20		
3916	NEWLY ELIGIBLE MALE	4,882.72	6,594.79	11,596.15	50,378.57	4,040.26	9,780.14	10,795.90	18,493.68	7,605.51	4,589.00	0.00	0.00		128,756.72		
3917	NEWLY ELIGIBLE FEMA L	14,967.59	27,110.09	37,485.10	4,978.68	8,280.84	8,965.86	8,353.68	15,753.23	39,045.54	14,156.19	0.00	0.00		179,096.80		
3918	NEWLY ELIGIBLE M&F 4	19,064.87	22,092.71	22,177.93	124,588.84	43,597.89	25,220.06	23,749.85	43,841.32	19,716.83	18,821.86	0.00	0.00		362,872.16		
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	45,479.16	78,843.02	67,726.44	37,680.66	0.00	0.00		677,855.29		

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	1,139.50	2,633.39	2,020.93	8,232.96	8,660.24	2,074.60	6,383.13	1,878.92	11,018.04	1,651.61	0.00	0.00	
4414	SOBRA 100-133% MALE	476.67	8,563.64	2,311.93	151.82	93.02	5,460.36	566.87	180.30	532.15	6,643.86	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	93.02	1,658.07	1,745.20	2,508.69	0.00	0.00	
SUBTOTAL:	6,114.57	12,920.48	5,693.15	9,717.57	12,484.31	10,351.70	7,043.02	3,717.29	13,295.39	10,804.16	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	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	

8700	SSI DISABLED FREEDO M	0.00	355.04	0.00	21.54	1,928.98	2,506.89	454.72	0.00	276.82	118.61	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	454.72	0.00	276.82	118.61	0.00	0.00	

TOTAL:

1,787,758.49

0.00	
45,693.32	
24,980.62	
21,467.70	
92,141.64	

0.00	
15.42	
0.00	
0.00	
15.42	

5,662.60	
0.00	
0.00	
5,662.60	

1,487,613.41

2,262,574.47	1,567,922.32	1,502,762.18	1,768,769.12

2,898,572.26

1,676,911.52

2,080,589.45

0.00	0.00

19,199,626.45	

2,166,153.23

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2017	
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	736.00	0.00	0.00	0.00	0.00	0.00		1,472.00		
2100	SSI AGED WITH MEDIC A	219,052.35	253,349.25	121,463.64	90,376.31	64,358.63	118,343.68	53,458.15	103,560.11	154,321.72	95,205.51	0.00	0.00		1,273,489.35		
2110	SSI AGED NON-MEDIC AR	40,660.18	71,145.23	35,038.90	71,771.11	42,485.37	34,633.59	24,072.19	57,188.14	73,223.36	15,638.97	0.00	0.00		465,857.04		
2120	SSI AGED WITH QMB	182,700.41	209,792.30	159,732.00	109,007.17	110,830.05	95,397.85	80,718.25	134,543.93	176,630.39	119,855.17	0.00	0.00		1,379,207.52		
2200	SSI DISABLED WITH M E	34,869.86	45,426.05	38,471.02	26,683.93	20,108.19	15,168.82	15,737.40	30,609.33	29,491.24	24,956.19	0.00	0.00		281,522.03		
2210	SSI DISABLED NON-ME D	717,819.30	840,735.89	669,730.82	575,860.18	624,054.60	683,828.40	599,792.59	843,047.72	966,167.41	659,918.36	0.00	0.00		7,180,955.27		
2220	SSI DISABLED WITH Q M	69,871.55	87,449.75	85,703.33	53,253.94	51,148.27	45,343.15	41,626.66	72,400.49	73,085.73	45,713.50	0.00	0.00		625,596.37		
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	8,096.00	11,585.61	16,085.05	8,142.00	0.00	0.00		97,876.78		
2320	SSI BLIND WITH QMB	388.66	676.12	219.85	166.47	64.80	64.80	10.25	129.60	226.12	0.00	0.00	0.00		1,946.67		
SUBTOTAL:	1,269,815.59	1,517,614.81	1,120,248.41	934,014.11	928,855.91	1,001,478.10	824,247.49	1,253,064.93	1,489,231.02	969,429.70	0.00	0.00		11,308,000.07		

8710	SSI DISABLED FREEDO M	653.30	1,245.63	0.00	0.00	0.00	0.00	0.00	190.20	190.70	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	190.20	190.70	0.00	0.00	0.00	

 
2,279.83	
0.00	
2,279.83	

TOTAL:	1,270,468.89	1,518,860.44	1,120,248.41	934,014.11	928,855.91	1,001,478.10	824,247.49	1,253,255.13	1,489,421.72	969,429.70	0.00	0.00		11,310,279.90		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending April 30, 2017	
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	2,048,247.13	2,283,224.18	2,633,975.90	2,043,759.26	0.00	0.00		22,385,997.77		
2110	SSI AGED NON-MEDIC AR	108,527.50	93,777.18	118,373.10	98,203.67	145,392.38	113,770.05	141,253.25	173,329.67	146,983.95	167,840.45	0.00	0.00		1,307,451.20		
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	2,945,520.16	3,228,008.05	3,980,799.38	3,106,333.57	0.00	0.00		32,473,836.99		
2200	SSI DISABLED WITH M E	499,603.04	639,287.37	497,917.52	493,961.36	627,636.13	566,146.99	578,888.87	566,862.21	771,564.04	596,923.17	0.00	0.00		5,838,790.70		
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	1,950,217.56	2,211,734.59	2,498,061.16	1,955,540.54	0.00	0.00		21,442,799.32		
2220	SSI DISABLED WITH Q M	686,455.43	834,681.23	718,107.95	654,700.95	825,634.11	732,198.97	752,821.21	755,364.04	966,808.79	705,170.07	0.00	0.00		7,631,942.75		
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	10,480.84	12,792.75	38,291.85	30,709.05	0.00	0.00		148,854.89		
2320	SSI BLIND WITH QMB	6,736.52	6,974.71	7,689.14	5,785.34	8,605.15	7,858.67	6,231.98	6,313.50	9,497.23	7,552.24	0.00	0.00		73,244.48		
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	8,433,661.00	9,237,628.99	11,045,982.30	8,613,828.35	0.00	0.00		91,302,918.10		

8710	SSI DISABLED FREEDO M	0.00	5,385.60	2,774.40	2,603.04	2,728.96	2,866.56	2,795.52	2,990.40	2,705.60	3,026.00	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	1,397.76	4,289.80	3,524.40	2,189.40	0.00	0.00	
SUBTOTAL:	2,765.43	8,812.80	5,516.16	5,371.68	6,223.36	5,662.08	4,193.28	7,280.20	6,230.00	5,215.40	0.00	0.00	

 
27,876.08	
29,394.31	
57,270.39	

8,215,691.42	10,023,435.58	8,696,436.37	8,205,857.15	9,854,799.41	9,009,949.04	8,437,854.28	9,244,909.19	11,052,212.30	8,619,043.75	0.00	0.00	

91,360,188.49	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2017	
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	38,160.40	5,879.55	15,527.25	34,773.00	0.00	0.00		359,814.58		
2110	SSI AGED NON-MEDIC AR	321.97	0.00	419.90	11,620.27	326.31	2,893.78	3,384.21	16,213.48	0.00	0.00	0.00	0.00		35,179.92		
2120	SSI AGED WITH QMB	16,004.46	3,678.81	7,559.43	-86.23	16,376.35	33,532.66	0.00	-1,709.62	6,446.56	7,292.80	0.00	0.00		89,095.22		
2200	SSI DISABLED WITH M E	859.25	960.45	6,967.11	7,944.79	2,533.01	1,144.21	425.04	9,451.92	2,512.40	5,385.13	0.00	0.00		38,183.31		
2210	SSI DISABLED NON-ME D	65,859.49	70,521.46	53,975.25	80,967.85	145,314.60	45,760.55	28,774.30	67,707.69	86,103.88	41,260.06	0.00	0.00		686,245.13		
2220	SSI DISABLED WITH Q M	304.54	4,059.22	8,911.33	3,935.90	2,353.48	777.30	3,969.14	848.11	460.62	486.64	0.00	0.00		26,106.28		
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	74,713.09	98,391.13	111,050.71	89,197.63	0.00	0.00		1,234,951.39		

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:	103,457.08	145,371.04	113,863.26	128,109.14	257,900.59	112,897.72	74,713.09	98,391.13	111,050.71	89,197.63	0.00	0.00		1,234,951.39		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending April 30, 2017	
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	13,249.07	27,776.62	14,109.53	13,081.58	0.00	0.00		156,029.39		
2110	SSI AGED NON-MEDIC AR	217.99	5,861.03	219.57	0.00	488.36	337.53	1,351.74	2,226.94	1,104.43	1,938.01	0.00	0.00		13,745.60		
2120	SSI AGED WITH QMB	16,020.55	21,126.19	4,933.20	9,563.06	9,888.55	12,986.77	6,888.87	10,030.84	15,819.96	14,226.12	0.00	0.00		121,484.11		
2200	SSI DISABLED WITH M E	2,621.87	11,047.52	3,294.25	8,343.91	8,704.44	2,246.57	3,691.04	3,309.95	9,495.14	2,622.15	0.00	0.00		55,376.84		
2210	SSI DISABLED NON-ME D	46,899.42	39,426.91	48,635.30	31,702.89	93,104.37	53,068.78	18,556.95	38,951.86	44,047.40	33,478.49	0.00	0.00		447,872.37		
2220	SSI DISABLED WITH Q M	7,860.45	13,901.38	2,894.38	4,713.63	4,541.61	4,393.37	3,722.76	4,426.24	10,546.45	4,520.46	0.00	0.00		61,520.73		
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	194.15	0.00	0.00	0.00		595.52		
SUBTOTAL:	84,002.55	131,094.53	73,927.90	65,095.20	123,651.42	79,486.21	47,460.43	86,722.45	95,317.06	69,866.81	0.00	0.00		856,624.56		

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	

84,002.55	131,094.53	73,927.90	65,095.20	123,651.42	79,486.21	47,460.43	86,722.45	95,317.06	69,866.81	0.00	0.00	

856,624.56	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	479.18	-557.49	21,350.80	37,417.60	55,947.22	65,109.08	82,503.81	83,106.41	91,359.11	105,549.47	0.00	0.00	542,265.19	

6012	C
KIDS 1-5 M & F NON-M	
0.00	
-6,189.47	
77,969.11	
170,721.14	
269,206.40	
300,425.01	
408,623.64	
433,847.10	
494,147.05	
554,762.77	
0.00	
0.00	
2,703,512.75	
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	773,549.94	816,373.25	883,436.74	999,911.45	0.00	0.00	5,185,047.18	
6014	KIDS 14-19 MALE NON-	31,612.49	24,016.15	68,826.52	122,434.57	176,702.06	203,272.99	256,746.77	260,851.25	292,161.51	343,222.97	0.00	0.00	1,779,847.28	
6015	KIDS 14-19 FEMALE NO	40,507.26	29,084.45	101,226.61	190,450.61	278,101.35	320,109.20	404,738.92	430,662.03	482,001.30	552,542.29	0.00	0.00	2,829,424.02	
9960	KIDSCARE KICK PAYM EN	0.00	0.00	0.00	0.00	6,100.23	0.00	19,072.24	0.00	12,759.89	5,364.20	0.00	0.00	43,296.56	
SUBTOTAL:	105,824.56	60,026.29	453,014.31	868,375.56	1,313,240.04	1,495,618.11	1,945,235.32	2,024,840.04	2,255,865.60	2,561,353.15	0.00	0.00	13,083,392.98	

TOTAL:	105,824.56	60,026.29	453,014.31	868,375.56	1,313,240.04	1,495,618.11	1,945,235.32	2,024,840.04	2,255,865.60	2,561,353.15	0.00	0.00		13,083,392.98		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	1.00	1.00	44.12	80.57	120.31	138.90	175.61	176.56	194.41	224.66	0.00	0.00	1,157.14	
6012	KIDS 1-5 M & F NON-M	0.00	0.41	658.36	1,428.42	2,256.23	2,527.97	3,392.09	3,597.27	4,061.77	4,553.71	0.00	0.00	22,476.23	
6013	KIDS 6-13 M & F NON-	243.88	228.41	1,455.13	2,839.29	4,347.22	4,881.76	6,394.41	6,745.87	7,312.49	8,244.92	0.00	0.00	42,693.38	
6014	KIDS 14-19 MALE NON-	166.11	161.00	387.76	725.50	1,065.03	1,171.24	1,549.73	1,575.15	1,786.11	2,085.04	0.00	0.00	10,672.67	
6015	KIDS 14-19 FEMALE NO	138.19	130.41	377.56	709.71	1,046.78	1,134.25	1,518.45	1,619.21	1,819.32	2,088.50	0.00	0.00	10,582.38	
9960	KIDSCARE KICK PAYM EN	0.00	0.00	0.00	0.00	1.00	0.00	3.00	0.00	2.00	1.00	0.00	0.00	7.00	
SUBTOTAL	:	549.18	521.23	2,922.93	5,783.49	8,836.57	9,854.12	13,033.29	13,714.06	15,176.10	17,197.83	0.00	0.00	87,588.80	

549.18	521.23	2,922.93	5,783.49	8,836.57	9,854.12	13,033.29	13,714.06	15,176.10	17,197.83	0.00	0.00	

87,588.80	

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	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	6,576.09	6,980.13	7,855.78	9,167.51	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	123,708.25	139,896.58	158,570.75	183,798.89	0.00	0.00	
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	101,202.62	0.00	-57.56	235,185.98	262,676.90	288,029.82	331,387.20	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	26,413.11	0.00	0.00	60,393.99	65,161.77	75,648.76	90,396.43	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	27,299.09	0.00	0.00	60,040.92	67,440.08	76,669.64	89,328.62	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	208,752.54	0.00	-86.34	485,905.23	542,155.46	606,774.75	704,078.65	0.00	0.00	

 
33,431.68	
656,931.24	
1,218,424.96	
318,014.06	
320,778.35	
2,547,580.29	

TOTAL:	0.00	0.00	0.00	208,752.54	325,271.16	344,022.94	485,905.23	542,155.46	606,774.75	704,078.65	0.00	0.00		3,216,960.73		

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	514.00	383.00	618.00	903.00	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	5,875.00	7,586.00	10,105.00	14,800.00	0.00	0.00	
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	2,738.00	0.00	0.00	10,820.00	14,806.00	18,050.00	23,367.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	687.00	0.00	0.00	2,705.00	3,065.00	4,692.00	5,370.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	681.00	0.00	0.00	3,144.00	3,368.00	4,135.00	5,354.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	5,568.00	0.00	0.00	23,058.00	29,208.00	37,600.00	49,794.00	0.00	0.00	

 
2,497.00	
39,749.00	
69,781.00	
16,519.00	
16,682.00	
145,228.00	

0.00	0.00	0.00	5,568.00	8,679.00	9,163.00	23,058.00	29,208.00	37,600.00	49,794.00	0.00	0.00	

163,070.00	

TOTAL:

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending April 30, 2017	
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	481.28	481.28	481.28	500.09	0.00	0.00		2,894.55		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	475.31	475.31	481.28	481.28	962.56	2,000.36	0.00	0.00		4,876.10		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	475.31	475.31	481.28	0.00	0.00	0.00	0.00	0.00		1,431.90		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	481.28	481.28	0.00	0.00	0.00		962.56		
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	0.00	0.00	0.00	1,425.93	1,901.24	1,443.84	1,443.84	1,925.12	2,500.45	0.00	0.00		10,640.42		

TOTAL:	0.00	0.00	0.00	0.00	1,425.93	1,901.24	1,443.84	1,443.84	1,925.12	2,500.45	0.00	0.00		10,640.42		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2017	
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	1.00	1.00	1.00	1.00	0.00	0.00		6.00		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	2.00	4.00	0.00	0.00		10.00		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		3.00		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00		2.00		
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	3.00	3.00	4.00	5.00	0.00	0.00		22.00		

0.00

3.00

4.00

3.00

3.00

5.00

0.00

4.00

0.00	0.00

22.00	

TOTAL:

0.00

0.00

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	0.00	0.00	0.00	0.00	167.63	301.30	5,534.00	728.21	243.98	284.58	0.00	0.00	7,259.70	

6012	C
KIDS 1-5 M & F NON-M	
0.00	
0.00	
271.99	
2,214.23	
14,593.88	
18,380.56	
6,880.28	
14,591.86	
10,798.29	
13,378.77	
0.00	
0.00	
81,109.86	
6013	KIDS 6-13 M & F NON-	0.00	0.00	317.51	3,907.07	6,662.69	7,261.75	13,980.79	8,455.28	19,552.24	11,122.13	0.00	0.00	71,259.46	
6014	KIDS 14-19 MALE NON-	0.00	15.43	338.82	399.04	9,728.06	1,853.73	6,689.53	344.15	2,763.04	6,061.51	0.00	0.00	28,193.31	
6015	KIDS 14-19 FEMALE NO	0.00	214.91	133.90	3,927.77	1,118.06	11,112.33	10,757.88	5,481.22	4,267.32	7,806.87	0.00	0.00	44,820.26	

SUBTOTAL:	
0.00	
230.34	
1,062.22	
10,448.11	
32,270.32	
38,909.67	
43,842.48	
29,600.72	
37,624.87	
38,653.86	
0.00	
0.00	
232,642.59	

TOTAL:	0.00	230.34	1,062.22	10,448.11	32,270.32	38,909.67	43,842.48	29,600.72	37,624.87	38,653.86	0.00	0.00		232,642.59		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,361.98	48,522.05	0.00	0.00	65,884.03	
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	13,282.88	0.00	0.00	13,282.88	
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,125.57	21,667.42	0.00	0.00	51,792.99	
6014	KIDS 14-19 MALE NON-	82,673.79	198.95	63,655.88	150.18	-0.01	0.00	30.05	0.00	234.66	31,743.27	0.00	0.00	178,686.77	
SUBTOTAL	:	82,673.79	198.95	63,655.88	150.18	-0.01	0.00	30.05	0.00	47,722.21	115,215.62	0.00	0.00	309,646.67	

82,673.79	198.95	63,655.88	150.18	-0.01	0.00	30.05	0.00	47,722.21	115,215.62	0.00	0.00	

309,646.67	

TOTAL:

4

2

301,287.96

301,287.96

95.00

6,785.78

5.49

28.00

1,840.23

38.00

2,739.90

19,924.15

226,724.56

6.73

41,354.71

152.00

1,174.22

280.19

93.00

16.00

30.00

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending April 30, 2017

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	9.00	8.00	8.00	7.00	0.00	0.00	
1010	TANF NON-MEDICARE	666.51	671.77	670.37	675.93	687.26	679.51	682.17	678.00	684.59	689.67	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	4.00	4.00	4.00	4.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	170.32	172.75	175.00	184.05	188.99	180.18	191.73	189.22	192.00	195.99	0.00	0.00	
2110	SSI AGED NON-MEDICAR	4.00	4.00	3.00	3.00	4.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00	
2120	SSI AGED WITH QMB	271.83	271.02	270.00	270.48	268.86	268.90	275.40	276.28	281.00	286.13	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	2,006.81	2,021.26	2,031.37	2,036.45	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	22,839.93	22,933.35	23,060.39	23,020.97	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	1.38	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	4,155.09	4,150.77	4,168.77	4,181.71	0.00	0.00	
2300	SSI BLIND WITH MEDIC	13.00	14.00	16.00	16.00	16.00	16.00	16.00	16.00	16.00	13.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	118.99	121.00	122.00	116.48	114.00	117.00	116.83	116.00	113.92	118.00	0.00	0.00	
2320	SSI BLIND WITH QMB	28.19	28.00	27.00	27.00	27.00	27.00	27.00	29.00	29.00	31.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	9.00	9.00	9.00	10.00	10.00	10.00	9.00	9.00	9.00	9.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	
SUBTOTAL:	29,556.98	29,741.31	29,883.95	29,882.54	30,067.41	30,163.59	30,341.96	30,439.88	30,608.42	30,601.92	0.00	0.00	
TOTAL:	29,556.98	29,741.31	29,883.95	29,882.	5	30,067.41	30,163.59	30,341.96	30,439.88	30,608.42	30,601.9	0.00	0.00	

 
ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM
EPD/DD EXPENDITURES
For the Period Ending April 30, 2017

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	394,426.39	391,601.89	394,661.85	393,967.36	0.00	0.00	3,882,476.78	
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	88,955,090.26	101,068,970.18	89,644,164.10	92,864,215.38	0.00	0.00	927,018,969.18	
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	89,349,516.65	101,460,572.07	90,038,825.95	93,258,182.74	0.00	0.00	930,901,445.96	
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	108,028,631.06	108,379,084.34	108,980,552.43	108,879,708.82	0.00	0.00	1,071,336,655.64	
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	108,028,631.06	108,379,084.34	108,980,552.43	108,879,708.82	0.00	0.00	1,071,336,655.64	
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	197,378,147.71	209,839,656.41	199,019,378.38	202,137,891.56	0.00	0.00	2,002,238,101.60	

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	9,384,275.29
0.00	10,683,277.90
0.00	12,748,001.79
0.00	9,747,537.89
0.00	0.00
0.00	0.00
0.00	104,762,044.34
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	9,384,275.29	10,683,277.90	12,748,001.79	9,747,537.89	0.00	0.00	104,762,044.34	

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	2,362,037.54
610,389.80	1,659,616.14
993,006.83	2,055,047.90
618,253.71	2,114,855.70
503,142.67	0.00
0.00	0.00
0.00	34,604,431.58
6,310,824.68	
	513,400.18	371,137.98	818,556.37	521,755.20	1,059,285.15	301,896.79	610,389.80	993,006.83	618,253.71	503,142.67	0.00	0.00	6,310,824.68	
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	2,972,427.34	2,652,622.97	2,673,301.61	2,617,998.37	0.00	0.00	40,915,256.26	

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	3,956,910.80	3,929,108.30	3,922,276.60	3,944,271.80	0.00	0.00	37,407,391.10	

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.

Wednesday, May 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	14,545,079.33	14,541,833.57	14,531,902.27	14,742,282.20	0.00	0.00	149,805,730.93	
010145	CRS ACUTE SEMI INTEGRATED - CAP	145,463.25	142,476.36	145,562.28	109,407.35	109,309.61	169,789.77	110,973.24	110,344.14	117,823.66	110,328.38	0.00	0.00	1,271,478.04	
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	5,243,380.00	5,240,175.00	5,252,193.75	5,645,602.51	0.00	0.00	51,879,991.26	
999135	CRS ONLY PLAN - CAP	551,073.60	552,982.08	550,596.48	544,229.95	541,853.40	541,378.09	544,327.68	552,028.16	542,402.56	560,600.89	0.00	0.00	5,481,472.89	
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	20,443,760.25	20,444,380.87	20,444,322.24	21,058,813.98	0.00	0.00	208,438,673.12	

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	348,477.26	2,750,482.76	5,603,441.72	2,112,888.15	0.00	0.00	18,510,976.55	
Subtotal	2,326,263.42	446,456.85	911,431.67	1,717,829.88	1,131,339.38	1,162,365.46	348,477.26	2,750,482.76	5,603,441.72	2,112,888.15	0.00	0.00	18,510,976.55	

22,230,198.07	20,031,142.29	20,753,240.44	21,911,262.74	21,337,651.86	27,479,587.04	20,792,237.51	23,194,863.63	26,047,763.96	23,171,702.13	0.00	0.00	226,949,649.67	

GRAND TOTAL

Wednesday, May 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	16,894.34	16,883.15	16,854.57	16,716.28	0.00	0.00	169,274.06	
010145	CRS ACUTE SEMI INTEGRATED - MM	181.59	179.98	181.73	184.85	185.14	190.54	187.88	186.90	200.58	199.50	0.00	0.00	1,878.69	
999125	CRS SEMI INTEGRATED PLAN - MM	6,586.00	6,567.00	6,570.00	6,559.00	6,565.00	6,548.00	6,544.00	6,540.00	6,555.00	6,541.00	0.00	0.00	65,575.00	
999135	CRS ONLY PLAN - MM	1,155.00	1,159.00	1,154.00	1,145.00	1,137.00	1,135.00	1,128.00	1,144.00	1,123.00	1,116.00	0.00	0.00	11,396.00	
Subtotal	25,024.74	24,896.48	24,911.89	24,837.78	24,815.22	24,823.44	24,754.22	24,754.05	24,733.15	24,572.78	0.00	0.00	248,123.75	

25,024.74	24,896.48	24,911.89	24,837.78	24,815.22	24,823.44	24,754.22	24,754.05	24,733.15	24,572.78	0.00	0.00	248,123.75	

GRAND TOTAL

Wednesday, May 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	-62,707.82	-20,246.78	-15,191.89	0.00	0.00	0.00	53,116,056.79	
010715	HEALTH CHOICE INTEGRATED - CAP	0.00	0.00	0.00	0.00	0.00	28,706.14	9,754,685.55	10,180,787.31	10,235,628.04	10,102,203.85	0.00	0.00	40,302,010.89	
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	-177,847.83	-118,824.47	-5,937.67	-50,380.20	0.00	0.00	123,270,809.33	
010735	CENPATICO INTEGRATED - CAP	0.00	0.00	0.00	0.00	0.00	74,012.57	21,567,561.70	22,226,452.30	22,528,828.39	22,279,607.20	0.00	0.00	88,676,462.16	
010795	MERCY MARICOPA INTEGRATED - CAP	0.00	0.00	0.00	0.00	0.00	106,452.36	47,464,238.95	47,610,393.84	47,935,290.70	50,238,545.88	0.00	0.00	193,354,921.73	
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	-574,596.40	-190,821.96	-87,756.76	-11,096.96	0.00	0.00	273,435,657.45	
Subtotal	71,766,264.29	72,827,766.51	73,188,258.13	77,371,329.60	77,848,318.49	78,345,166.36	77,971,334.15	79,687,740.24	80,590,860.81	82,558,879.77	0.00	0.00	772,155,918.35	

71,766,264.29	72,827,766.51	73,188,258.13	77,371,329.60	77,848,318.49	78,345,166.36	77,971,334.15	79,687,740.24	80,590,860.81	82,558,879.77	0.00	0.00	772,155,918.35	

GRAND TOTAL

Wednesday, May 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	-39.53	-12.63	-9.77	0.00	0.00	0.00	33,091.68	
010715	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	0.00	0.00	0.00	16.71	5,708.41	5,740.94	5,770.05	5,719.81	0.00	0.00	22,955.92	
010725	CENPATICO INTEGRATED - MM	12,956.97	13,057.68	13,037.47	13,175.18	13,188.37	13,241.02	-114.04	-76.31	-3.72	-32.47	0.00	0.00	78,430.15	
010735	CENPATICO INTEGRATED - MM	0.00	0.00	0.00	0.00	0.00	45.48	13,309.48	13,391.64	13,571.13	13,532.30	0.00	0.00	53,850.03	
010795	MERCY MARICOPA INTEGRATED - MM	0.00	0.00	0.00	0.00	0.00	46.99	21,036.57	21,086.46	21,227.59	21,211.17	0.00	0.00	84,608.78	
078999	MERCY MARICOPA INTEGRATED - MM	19,855.38	20,248.88	20,392.35	20,636.60	20,777.74	20,835.63	-256.23	-85.17	-39.16	-4.92	0.00	0.00	122,361.10	
Subtotal	38,246.47	38,742.69	38,912.12	39,342.90	39,579.32	39,842.56	39,644.66	40,044.93	40,516.12	40,425.89	0.00	0.00	395,297.66	

38,246.47	38,742.69	38,912.12	39,342.90	39,579.32	39,842.56	39,644.66	40,044.93	40,516.12	40,425.89	0.00	0.00	395,297.66	

GRAND TOTAL