September 28, 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 2018 Appropriation Status Report for the Period Ended August 31, 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 August 31, 2017.

Status Summary – As part of the FY 2019 budget request to the Governor’s Office of Strategic Planning and Budgeting, a FY 2018 rebase was prepared. Based on that rebase, AHCCCS believes the FY 2018 appropriations will be sufficient. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

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.
CHIP Funding Reauthorization.
Final Medicare Premium rate increases.
Potential Agency audit liabilities, which are detailed in the ASR.

AHCCCS also intends to utilize surplus FY 2017 General Fund and Expenditure Authority for administrative adjustments of expenditures with dates of service prior to July 1, 2017.

Enrollment Update – August 2017 enrollment is 1,922,792 members, a 519 member increase over the prior month. Enrollment for September 2017 decreased to 1,920,369 members, a 2,425 member change.

Major September 2017 changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 1,906; Supplemental Security Income – increase of 235; Prop 204 Restoration - decrease of 922; Adult Expansion – decrease of 325; Medicare Cost Sharing – increase of 182; KidsCare – increase of 227; and Federal Emergency Services - decrease of 211.

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 September 28, 2017
Page 2

Tobacco

Funds  Revenue  Update  -  Tobacco  tax  collections  through  August  2017 are

$3.6

million more than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the
tobacco funds reven  e collections to determine any impact on the FY 2018 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
Matthew Gress, Director, Governor’s Office of Strategic Planning and Budgeting Richard Stavneak, Director, Joint Legislative Budget Committee

Appropriation Status Report (ASR)
Fiscal Year 2018
Through August 31, 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 2018…	2
Appropriated Expenditures by Funding Source…	3
Appropriated Revenue Received Detail Schedule…	5
FOOTNOTES	7
CASELOAD AND EXPENDITURES BY RATE CODE	10

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending August 31,  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	$	94,260,300		$	12,324,425		$	12,340,630		$	(16,205)		$	94,260,300		$	-		
AHCCCS Prop 204 Administration	12,908,400		1,767,289		2,923,788		(1,156,499)		12,908,400		-		
DES Eligibility	91,874,500		16,288,100		15,385,116		902,984		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		8,304,700		5,544,059		2,760,641		44,358,700		-		
Prop 206 Provider Assessment Study	200,000		5,972		-		5,972		200,000		-		
TOTAL  ADMINISTRATION	 	243,601,900 		 	38,690,485 		 	36,193,593 		 	2,496,892 		 	243,601,900 		 	-			

Traditional Medicaid Services	3,896,328,000	638,985,500	653,678,765	(14,693,265)	3,896,328,000	-	
Proposition 204 Services	2,773,331,800	449,635,900	466,345,154	(16,709,254)	2,773,331,800	-	
ACA Adult Expansion	475,591,600	83,543,900	81,536,613	2,007,287	475,591,600	-	
Children's Rehabilitative Services	270,673,900	41,568,000	45,941,441	(4,373,441)	270,673,900	-	
KidsCare Services	111,961,100	14,052,300	8,940,567	5,111,733	111,961,100	-	
ALTCS Services	1,544,082,800	253,936,600	258,947,374	(5,010,774)	1,544,082,800	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	22,650,000	-	-	-	22,650,000	-	
Voluntary Political Subdivision Programs	340,729,800	-	-	-	340,729,800	-	
Behavioral Health Traditional Medicaid Services	1,156,192,500	176,841,700	190,233,469	(13,391,769)	1,156,192,500	-	
Behavioral Health Proposition 204 Services	788,262,700	120,505,100	130,655,033	(10,149,933)	788,262,700	-	
Behavioral Health ACA Adult Expansion	86,141,400	12,517,900	13,603,012	(1,085,112)	86,141,400	-	
Behavioral Health CMDP	217,719,100	36,229,200	25,706,479	10,522,721	217,719,100	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	13,141,200	13,300,441	(159,241)	78,846,900	-	
Supported Housing	5,324,800	887,400	874,967	12,433	5,324,800	-	
Crisis Services	16,391,300	2,731,800	2,717,717	14,083	16,391,300	-	

TOTAL PROGRAMMATIC	 	11,789,314,800	 	1,844,576,500	 	1,892,481,032	 	(47,904,532)	 	11,789,314,800	 	-	

TOTAL EXPENDITURES

$	12,032,916,700

$	1,883,266,985

$	1,928,674,625

$	(45,407,640)

$   12,032,916,700	$	-

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 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	$	55,962,100	$	8,657,779	$	9,725,695	(1,067,916)	$	55,962,100	$	-	
Proposition 204 - Administrative Expenditures	21,251,600	3,762,500	2,603,115	1,159,385	21,251,600	-	

Programmatic Expenditures							
Traditional Medicaid Services	830,106,600	138,625,700	138,067,542	558,158	830,106,600	-	
Proposition 204 Services	-	-	(723,896)	723,896	-	-
Children's Rehabilitative Services	81,939,800	12,791,600	12,955,654	(164,054)	81,939,800	- KidsCare Services		-		-		(30,419)		30,419		-	-
ALTCS Services	185,064,700	30,516,500	30,874,112	(357,612)	185,064,700	-
DSH and Rural Hospitals	7,086,300	-	-	-	7,086,300	-
Behavioral Health Traditional Medicaid Services	316,050,500	49,258,100	51,787,465	(2,529,365)	316,050,500	-	
Behavioral Health Proposition 204 Services	109,562,000	17,524,800	22,872,846	(5,348,046)	109,562,000	-	
Behavioral Health ACA Adult Expansion	4,269,200	558,900	680,074	(121,174)	4,269,200	-	
Behavioral Health CMDP	65,719,400	11,112,600	7,903,131	3,209,469	65,719,400	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	13,141,200	13,300,441	(159,241)	78,846,900	-	
Supported Housing	5,324,800	887,400	874,967	12,433	5,324,800	-	
Crisis Services	 	14,141,100 	 	2,356,800 	 	2,342,683 	 	14,117 	 	14,141,100 	 	- 	
TOTAL GF EXPENDITURES	1,775,325,000	289,193,879	293,233,411	(4,039,532)	1,775,325,000	-	

FEDERAL		
Administrative Expenditures	129,511,800	19,858,700	17,997,645	1,861,055	129,511,800	-	
Proposition 204 - Administrative Expenditures	32,360,200	5,625,189	5,864,732	(239,543)	32,360,200	-	

Programmatic Expenditures	
Traditional Medicaid Services	2,412,443,400	392,160,800	360,937,520	31,223,280	2,412,443,400	-	
Proposition 204 Services	2,397,123,600	383,693,600	391,654,690	(7,961,090)	2,397,123,600	-	
ACA Adult Expansion	450,284,200	79,479,700	77,436,510	2,043,190	450,284,200	-	
Children's Rehabilitative Services	188,734,100	28,776,400	32,985,787	(4,209,387)	188,734,100	-	
KidsCare Services	111,591,100	12,481,200	8,970,986	3,510,214	111,591,100	-	
ALTCS Services and Nursing Facility Assessment	956,062,900	153,895,000	170,444,973	(16,549,973)	956,062,900	-	
DSH and Rural Hospitals
Behavioral Health Traditional Medicaid Services	20,650,800
804,576,200	- 122,040,500	- 131,164,232	- (9,123,732)	20,650,800
804,576,200	-
-	
Behavioral Health Proposition 204 Services	655,527,700	99,273,700	107,782,187	(8,508,487)	655,527,700	-	
Behavioral Health ACA Adult Expansion	81,390,900	11,838,600	12,922,937	(1,084,337)	81,390,900	-	
Behavioral Health CMDP	151,999,700	25,116,600	17,803,349	7,313,251	151,999,700	-	
Voluntary Political Subdivision Programs - See Note 5	 	237,582,300 	 	- 	 	- 	 	- 	 	237,582,300 	 	- 	
TOTAL FEDERAL EXPENDITURES	8,629,838,900	1,334,239,989	1,335,965,547	(1,725,558)	8,629,838,900	-	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,655,300	684,300	-	684,300	3,655,300	-	
Programmatic Expenditures						
Traditional Medicaid Services Acute Care	49,687,700	8,311,500	8,243,267	68,233	49,687,700	-	
ALTCS Services	 	249,980,000 	 	43,642,200 	 	50,358,275	 	(6,716,075)	 	249,980,000 	 	- 	
TOTAL COUNTY EXPENDITURES	303,323,000	52,638,000	58,601,542	(5,963,542)	303,323,000	-	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 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	6,290,500	7,663,941	(1,373,441)	37,432,400	-	
Behavioral Health Traditional Medicaid Services - Medically Needy		35,565,800	5,543,100	7,281,772	(1,738,672)	35,565,800	-	
Proposition 204 Services - Emergency Health Services		19,244,300	3,312,700	3,363,984	(51,284)	19,244,300	-	
Proposition 204 Services - Proposition 204 Protection		17,240,000	2,967,700	7,063,749	(4,096,049)	17,240,000	-	
Behavioral Health Proposition 204 Services - Proposition 204 Protection		23,173,000	3,706,600	-	3,706,600	23,173,000	-	
Proposition 204 Services - ATLSF	 	79,000,000 	 	- 	 	- 	 	- 	 	79,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	211,655,500	21,820,600	25,373,446	(3,552,846)	211,655,500	-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	

OTHER

860,900	

102,017	2,406	99,612	860,900	-	
Acute Care - Prescription Drug Rebate Program State Match	137,191,000	23,054,700	22,865,167	189,533	137,191,000	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	429,241,000	70,509,600	115,792,421	(45,282,821)	429,241,000	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	1,248,900	1,263,067	(14,167)	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	5,954,300	5,714,098	240,202	36,422,000	-	
Proposition 204 Services - Hospital Assessment	260,723,900	59,661,900	64,986,628	(5,324,728)	260,723,900	-	
ACA Adult Expansion - Hospital Assessment	25,307,400	4,064,200	4,100,104	(35,904)	25,307,400	-	
Behavioral Health ACA Adult Expansion - Hospital Assessment	481,300	120,400	-	120,400	481,300	-	
Traditional Medicaid Services - TPL	194,700	32,700	97,135	(64,435)	194,700	-	
ALTCS Services - TPL	-	-	292,849	(292,849)	-	-	
ALTCS Services - Nursing Facility Assessment	108,974,800	18,679,700	-	18,679,700	108,974,800	-	
KidsCare Services Premiums	370,000	1,571,100	-	1,571,100	370,000	-	
Freedom to Work Premiums	31,200	-	11,773	(11,773)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	375,000	375,033	(33)	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	103,147,500 	 	- 	 	- 	 	- 	 	103,147,500 	 	- 	
TOTAL OTHER EXPENDITURES	1,112,774,300	185,374,517	215,500,680	(30,126,162)	1,112,774,300	-	

TOTAL		
Administrative Expenditures	243,601,900		38,690,485		36,193,593		2,496,892		243,601,900		-	
Acute Care	10,245,232,000		1,590,639,900		1,633,533,658		(42,893,758)		10,245,232,000		-	
Long Term Care	 	1,544,082,800 		 	253,936,600 		 	258,947,374 		 	(5,010,774)		 	1,544,082,800 		 	- 	
TOTAL EXPENDITURES	  $	12,032,916,700 		  $	1,883,266,985 		  $	1,928,674,625 		  $	(45,407,639)		  $	12,032,916,700 		  $	- 	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending August 31, 2017

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	975,094,800	$	160,075,079	$	160,748,891	
Proposition 204 Services & Administrative	21,251,600	3,762,500	24,752,065	
KidsCare Services	-	-	(30,419)	
ALTCS Services	185,064,700	30,516,500	30,874,112	
Behavioral Health Traditional Medicaid Services	 	593,913,900	 	94,839,800	 	76,208,687 	
TOTAL	1,775,325,000	289,193,879	292,553,336	

FEDERAL:
Acute & Administrative	5,868,690,400		909,594,389		886,832,589	
KidsCare Services	111,591,100		12,481,200		9,421,539	
ALTCS Services	956,062,900		153,895,000		177,956,268	
Behavioral Health Traditional Medicaid Services	 	1,693,494,500 		 	258,269,400 		 	269,666,558 	
TOTAL	8,629,838,900		1,334,239,989		1,343,876,954	

COUNTY:						
Acute & Administrative	53,343,000		8,995,800		7,382,187	
ALTCS Services	 	249,980,000 		 	43,642,200 		 	44,112,200 	
TOTAL	303,323,000		52,638,000		51,494,387	

TOBACCO FUNDS:						
Traditional Medicaid Services	72,998,200		11,833,600		14,945,713	
Proposition 204 Services	 	138,657,300 		 	9,987,000 		 	10,427,733 	
TOTAL	211,655,500		21,820,600		25,373,446	

OTHER:

Administrative	860,900		102,017		2,406	
Acute Care - Prescription Drug Rebate Program	566,432,000		93,564,300		138,657,588	
Long Term Care - Prescription Drug Rebate Program	44,000,400		7,203,200		6,977,165	
Hospital Assessment	286,512,600		63,846,500		71,825,491	
ALTCS - Nursing Facility Assessment	108,974,800		18,679,700		79,051	
Acute TPL - Note 1	194,700		32,700		97,135	
LTC TPL - Note 1	-		-		292,849	
KidsCare TPL - Note 1	-		-		17	
Member Premiums - CHIP	370,000		1,571,100		911,073	
Member Premiums - Freedom to Work	31,200		-		11,773	
Behavioral Health Traditional Medicaid Services	2,250,200		375,000		254,758	
Voluntary Political Subdivision - State Match	 	103,147,500 		 	-			 	-		
TOTAL	1,112,774,300		185,374,517		219,109,305	

TOTAL REVENUE

$	12,032,916,700

$	1,883,266,985

$	1,932,407,428

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 2017	
Note 1:    Third Party Liability Collections:	August 2017		August 2016		July 1, 2017		July 1, 2016	
Gross Collections:					August 31, 2017		August 31, 2016	
Acute	$	413,294		$	535,095		$	1,111,906		$	741,962	
LTC	386,182		290,705		1,282,168		780,033	
KidsCare	-		-		85		-	
Total TPL Collections	$	799,476		$	825,800		$	2,394,159		$	1,521,995	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	40,516		$	26,905		$	97,135		$	41,679		
LTC	89,119		58,901		292,849		173,905		
KidsCare	-		-		17		(2)		
Total Expenditure Offsets	$	129,635		$	85,806		$	390,001		$	215,582		

FY 18 Total
Note 2:    Authorized Positions	1,161.0
Actual Positions as of August 31, 2017	1,079.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 2017

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2017	$	2,456,040	
	Revenues	1,383,800	
	Transfers-In	 	119,151 	
	Total Revenues	 	1,502,952 	
	Expenditures Transfers-out
Total Expenditures	1,052,087
 	-	
 	1,052,087 	
	Ending Balance August 31, 2017	  $	2,906,905 	

Of the $2,906,905 ending balance, $1.127,960 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through September 2017.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.
Schedule of Outstanding Liabilities
As of August 31, 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 August 31, 2017 Expenditures

State Match	Federal	Total

DSH Voluntary	$	-	$	-	$	-
GME Voluntary	-	-	-
Safety Net Care Pool	-	-	-

Total Voluntary Political Subdivision Program Expenditure $	-	$	-	$	-

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	285,522,617	281,333,799	0	0	0	0	0	0	0	0	0	0	566,856,416	
CAPITATION - LTC	206,776,494	226,817,304	0	0	0	0	0	0	0	0	0	0	433,593,798	
MENTAL HEALTH - CHILD	27,544,565	27,724,984	0	0	0	0	0	0	0	0	0	0	55,269,548	
MENTAL HEALTH - ADULT	943,019	720,852	0	0	0	0	0	0	0	0	0	0	1,663,871	
MENTAL HEALTH - GENERAL	12,841,280	12,960,968	0	0	0	0	0	0	0	0	0	0	25,802,248	
MENTAL HEALTH - CMDP	13,096,578	12,797,592	0	0	0	0	0	0	0	0	0	0	25,894,170	
MENTAL HEALTH - DD	4,268,444	4,283,815	0	0	0	0	0	0	0	0	0	0	8,552,259	
CHILDREN'S REHAB SERVICES	6,152,157	6,176,648	0	0	0	0	0	0	0	0	0	0	12,328,805	
FEE FOR SERVICE - ACUTE	37,517,260	57,106,521	0	0	0	0	0	0	0	0	0	0	94,623,781	
FFS - PRIOR QUARTER COVERAGE	477,647	732,384	0	0	0	0	0	0	0	0	0	0	1,210,030	
EMERGENCY SERVICES - FEDERAL	5,092,983	7,198,427	0	0	0	0	0	0	0	0	0	0	12,291,410	
FFS MEDICAID IN PUBLIC SCHOOLS	498,616	218,798	0	0	0	0	0	0	0	0	0	0	717,413	
INPATIENT INMATES FFS	223,348	131,891	0	0	0	0	0	0	0	0	0	0	355,239	
FFS TRBHA FEE FOR SERVICE	11,064,992	13,491,379	0	0	0	0	0	0	0	0	0	0	24,556,371	
STATE ONLY TRBHA FFS	6,531	0	0	0	0	0	0	0	0	0	0	0	6,531	
QMB - FEE FOR SERVICE	489,558	701,001	0	0	0	0	0	0	0	0	0	0	1,190,559	
PIMA COUNTY INMATES FFS	564	690	0	0	0	0	0	0	0	0	0	0	1,254	
MARICOPA CTY INMATES FFS	68,686	30,039	0	0	0	0	0	0	0	0	0	0	98,725	
MOHAVE COUNTY INMATES FFS	0	6,214	0	0	0	0	0	0	0	0	0	0	6,214	
FEE FOR SERVICE - LTC	11,075,900	14,779,589	0	0	0	0	0	0	0	0	0	0	25,855,489	
LFFS - PRIOR QUARTER COVERAGE	31,031	30,711	0	0	0	0	0	0	0	0	0	0	61,742	
MARICOPA CTY INMATES LTC FFS	166	0	0	0	0	0	0	0	0	0	0	0	166	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,540,502	836,850	0	0	0	0	0	0	0	0	0	0	2,377,352	
REINSURANCE - ACUTE	14,094,798	9,458,578	0	0	0	0	0	0	0	0	0	0	23,553,376	
REINSURANCE - LTC	8,708,155	6,429,637	0	0	0	0	0	0	0	0	0	0	15,137,792	
SMIB - ACUTE	14,841,421	15,030,410	0	0	0	0	0	0	0	0	0	0	29,871,831	
HIB - ACUTE	530,608	606,349	0	0	0	0	0	0	0	0	0	0	1,136,957	
Q1	2,585,545	2,637,260	0	0	0	0	0	0	0	0	0	0	5,222,805	
SMIB - LTC	3,694,581	3,701,005	0	0	0	0	0	0	0	0	0	0	7,395,586	
HIB - LTC	280,970	287,260	0	0	0	0	0	0	0	0	0	0	568,229	
SUBTOTAL	669,969,014	706,230,953	0	0	0	0	0	0	0	0	0	0	1,376,199,967	

TITLE XIX PROP 204

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

TOTAL

CAPITATION - ACUTE	216,118,852	215,843,745	0	0	0	0	0	0	0	0	0	0	431,962,597	
MENTAL HEALTH - CHILD	3,567	3,361	0	0	0	0	0	0	0	0	0	0	6,928	
MENTAL HEALTH - ADULT	1,025,896	887,584	0	0	0	0	0	0	0	0	0	0	1,913,480	
MENTAL HEALTH - GENERAL	23,612,539	23,858,290	0	0	0	0	0	0	0	0	0	0	47,470,829	
MENTAL HEALTH - CMDP	1,317	798	0	0	0	0	0	0	0	0	0	0	2,115	
CHILDREN'S REHAB SERVICES	20,262	22,004	0	0	0	0	0	0	0	0	0	0	42,266	
FEE FOR SERVICE - ACUTE	27,971,969	41,819,103	0	0	0	0	0	0	0	0	0	0	69,791,072	
FFS - PRIOR QUARTER COVERAGE	1,089,761	1,673,864	0	0	0	0	0	0	0	0	0	0	2,763,624	
FFS - PRESUMPTIVE ELIGIBILITY	607	0	0	0	0	0	0	0	0	0	0	0	607	
EMERGENCY SERVICES - FEDERAL	4,079,461	6,001,485	0	0	0	0	0	0	0	0	0	0	10,080,947	
FFS MEDICAID IN PUBLIC SCHOOLS	897	448	0	0	0	0	0	0	0	0	0	0	1,345	
STATE ONLY TRBHA FFS	3,266	14,268	0	0	0	0	0	0	0	0	0	0	17,534	
FFS TRBHA FEE FOR SERVICE	6,143,299	6,633,226	0	0	0	0	0	0	0	0	0	0	12,776,525	
INPATIENT INMATES FFS	1,021,190	712,562	0	0	0	0	0	0	0	0	0	0	1,733,752	
MOHAVE COUNTY INMATES FFS	0	4,601	0	0	0	0	0	0	0	0	0	0	4,601	
PINAL COUNTY INMATES FFS	499	0	0	0	0	0	0	0	0	0	0	0	499	
PIMA COUNTY INMATES FFS	15,143	31,906	0	0	0	0	0	0	0	0	0	0	47,049	
MARICOPA CTY INMATES FFS	265,078	189,865	0	0	0	0	0	0	0	0	0	0	454,944	
COCHISE COUNTY INMATES LTC FFS	0	1,483	0	0	0	0	0	0	0	0	0	0	1,483	
REINSURANCE - ACUTE	6,219,075	3,398,890	0	0	0	0	0	0	0	0	0	0	9,617,965	
SMIB - ACUTE	6,495,931	6,622,978	0	0	0	0	0	0	0	0	0	0	13,118,909	
HIB - ACUTE	4,563	4,976	0	0	0	0	0	0	0	0	0	0	9,539	
SUBTOTAL	294,093,172	307,725,439	0	0	0	0	0	0	0	0	0	0	601,818,611	

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

TOTAL

CAPITATION - ACUTE	33,908,701	33,182,353	0	0	0	0	0	0	0	0	0	0	67,091,054	
MENTAL HEALTH - ADULT	50,440	101,285	0	0	0	0	0	0	0	0	0	0	151,724	
MENTAL HEALTH - GENERAL	4,449,323	4,495,516	0	0	0	0	0	0	0	0	0	0	8,944,839	
CHILDREN'S REHAB SERVICES	1,500	1,500	0	0	0	0	0	0	0	0	0	0	3,001	
FEE FOR SERVICE - ACUTE	2,634,455	3,608,952	0	0	0	0	0	0	0	0	0	0	6,243,407	
FFS - PRIOR QUARTER COVERAGE	350,598	546,221	0	0	0	0	0	0	0	0	0	0	896,819	
EMERGENCY SERVICES - FEDERAL	4,555,737	7,325,871	0	0	0	0	0	0	0	0	0	0	11,881,607	
FFS MEDICAID IN PUBLIC SCHOOLS	29	0	0	0	0	0	0	0	0	0	0	0	29	
STATE ONLY TRBHA FFS	0	53,882	0	0	0	0	0	0	0	0	0	0	53,882	
INPATIENT INMATES FFS	84,703	44,767	0	0	0	0	0	0	0	0	0	0	129,471	
FFS TRBHA FEE FOR SERVICE	144,138	202,842	0	0	0	0	0	0	0	0	0	0	346,980	
PIMA COUNTY INMATES FFS	594	388	0	0	0	0	0	0	0	0	0	0	982	
REINSURANCE - ACUTE	529,482	119,226	0	0	0	0	0	0	0	0	0	0	648,708	
SMIB - ACUTE	268	512	0	0	0	0	0	0	0	0	0	0	780	
	46,709,967	49,683,315	0	0	0	0	0	0	0	0	0	0	96,393,282	
	1,010,772,153	1,063,639,707	0	0	0	0	0	0	0	0	0	0	2,074,411,860	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - CHILD	36	83	0	0	0	0	0	0	0	0	0	0	119	
MENTAL HEALTH - GENERAL	-59	0	0	0	0	0	0	0	0	0	0	0	-59	
KidsCare - CAPITATION	3,237,786	3,285,902	0	0	0	0	0	0	0	0	0	0	6,523,689	
KidsCare - FEE FOR SERVICE	55,088	85,410	0	0	0	0	0	0	0	0	0	0	140,499	
KidsCare - MENTAL HEALTH	852,332	869,444	0	0	0	0	0	0	0	0	0	0	1,721,776	
KidsCare - REINSURANCE	90,334	651,642	0	0	0	0	0	0	0	0	0	0	741,976	
KidsCare - CHILD REHAB SERVICES	3,001	4,864	0	0	0	0	0	0	0	0	0	0	7,864	

4,238,517	4,897,346	0	0	0	0	0	0	0	0	0	0	9,135,863	

TOTAL TITLE XXI

1,015,010,670	1,068,537,053	0	0	0	0	0	0	0	0	0	0	2,083,547,724	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	942.31	480.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,422.45		
1002	TANF 01-05 M & F WIT	330.04	662.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		992.39		
1003	TANF 06-13 M & F WIT	111.05	341.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		452.95		
1004	TANF 14-20 MALE WITH	-35.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-35.88		
1005	TANF 14-20 FEMALE WI	127.97	652.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		780.16		
1006	TANF 21-44 MALE WITH	34,934.55	37,443.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,378.25		
1007	TANF 21-44 FEMALE WI	68,398.48	67,286.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,684.86		
1008	TANF 45-64 M & F WIT	98,664.26	95,156.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,820.48		
1009	TANF 65+ M & F WITH	34,339.80	38,378.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,718.27		
100E	TANF 14-20 FEMALE WI	360.46	98.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		458.75		
100F	TANF 21-44 MALE WITH	191.46	384.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		575.95		
100G	TANF 21-44 FEMALE WI	741.72	2,685.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,427.07		
100H	TANF 45-64 M & F WIT	2,193.83	5,135.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,329.82		
100J	TANF 65+ M & F WITH	1,031.55	499.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,531.47		
1011	TANF <1 M & F NON-ME	5,800,515.18	5,986,609.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,787,124.72		
1012	TANF 01-05 M & F NON	2,591,577.99	2,625,129.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,216,707.54		
1013	TANF 06-13 M & F NON	4,099,165.87	4,028,576.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,127,742.40		
1014	TANF 14-20 MALE NON-	1,554,134.01	1,539,972.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,094,106.17		
1015	TANF 14-20 FEMALE N O	3,181,619.83	3,154,775.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,336,395.50		
1016	TANF 21-44 MALE NON-	4,791,560.01	4,758,662.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,550,222.96		
1017	TANF 21-44 FEMALE N O	24,021,285.07	23,810,217.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,831,502.97		
1018	TANF 45-64 M & F NON	9,727,126.16	9,884,272.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,611,398.55		
1019	TANF 65+ M & F NON-M	32,576.87	37,347.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,924.81		
101A	TANF < 1 M & F NON-M	1,023,730.67	1,103,021.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,126,751.77		
101B	TANF 01-05 M & F NON	15,605.69	22,617.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,222.99		
101C	TANF 06-13 M & F NON	12,934.97	17,575.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,510.08		
101D	TANF 14-20 MALE NON-	16,158.27	8,385.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,543.91		
101E	TANF 14-20 FEMALE N O	20,152.60	9,366.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,518.77		
101F	TANF 21-44 MALE NON-	141,843.98	8,433.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,277.37		
101G	TANF 21-44 FEMALE N O	376,743.23	-38,348.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338,394.35		
101H	TANF 44-64 M & F NON	127,847.88	-8,167.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,680.46		
101J	TANF 65+ N & F NON-M	771.11	-2,520.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,749.11		
1021	TANF <1 M & F WITH Q	-2.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2.98		
1025	TANF 14-20 FEMALE WI	7.95	231.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.63		
1026	TANF 21-44 MALE WITH	23,824.71	18,670.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,494.91		
1027	TANF 21-44 FEMALE WI	63,697.04	57,779.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,476.53		

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	68,085.21	73,049.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,134.36		
1029	TANF 65+ M & F WITH	33,210.14	34,038.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,248.40		
102F	TANF 21-44 MALE WITH	244.64	188.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433.24		
102G	TANF 21-44 FEMALE WI	0.00	682.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		682.19		
102H	TANF 44-64 M & F WIT	0.00	2,122.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,122.59		
102J	TANF 65+ M & F WITH	2,351.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,351.09		
2100	SSI AGED WITH MEDIC A	897,693.12	795,728.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,693,421.37		
210Z	SSI AGED WITH MEDIC
A	24,132.41	32,576.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,708.57		
2110	SSI AGED NON-MEDICA R	6,075,643.74	5,465,504.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,541,147.84		
211Z	SSI AGED NON-MEDICA
R	82,203.22	98,950.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,154.18		
2120	SSI AGED WITH QMB	5,637,211.81	5,279,745.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,916,956.96		
212Z	SSI AGED WITH QMB P P	9,453.31	3,922.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,375.41		
2200	SSI DISABLED WITH M
E	1,844,213.19	1,807,931.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,652,144.82		
220Z	SSI DISABLED WITH M E	82,731.69	79,013.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,744.93		
2210	SSI DISABLED NON-ME
D	62,508,046.41	60,865,684.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,373,730.71		
221Z	SSI DISABLED NON-ME D	427,254.43	530,302.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		957,556.65		
2220	SSI DISABLED WITH Q
M	16,136,563.08	15,910,270.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,046,834.00		
222Z	SSI DISABLED WITH Q M	41,384.71	50,975.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,359.94		
2300	SSI BLIND WITH MEDIC	7,950.20	7,844.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,795.17		
2310	SSI BLIND NON-MEDIC A	491,202.64	477,214.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		968,417.45		
231Z	SSI BLIND NON-MEDIC
A	11,701.90	5,145.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,847.01		
2320	SSI BLIND WITH QMB	53,206.29	52,023.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,229.71		
232Z	SSI BLIND WITH QMB P	76.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.41		
4301	SOBRA CHILD <1 M & F	2,382.74	1,824.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,207.20		
4302	SOBRA CHILD 01-05 M	5,435.95	6,701.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,137.36		
4303	SOBRA CHILD 06-13 M	3,583.56	5,282.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,866.11		
4304	SOBRA CHILD 14-20 MA	2,430.85	2,106.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,537.28		
4305	SOBRA CHILD 14-20 FE	1,788.43	1,048.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,837.16		
430A	SOBRA CHILD < 1 M &	0.00	2,075.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,075.78		
430B	SOBRA CHILD 01-05 M	48.00	318.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		366.57		
430C	SOBRA CHILD 06-13 M	0.00	301.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		301.36		
430E	SOBRA CHILD 14-20 FE	0.00	126.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126.48		
4311	SOBRA CHILD <1 M & F	16,404,979.48	17,089,141.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,494,120.56		
4312	SOBRA CHILD 01-05 M	23,645,128.51	23,124,722.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,769,850.59		
4313	SOBRA CHILD 06-13 M	30,350,567.88	29,716,938.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,067,506.48		
4314	SOBRA CHILD 14-20 MA	10,183,859.56	9,979,977.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,163,836.68		

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	15,876,216.68	15,661,206.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,537,423.62	
431A	SOBRA CHILD < 1 M &	288,304.92	422,712.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	711,017.23	
431B	SOBRA CHILD 01-05 M	221,477.28	-7,371.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	214,105.96	
431C	SOBRA CHILD 6-13 M& F	216,577.94	-113,174.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,403.19	
431D	SOBRA CHILD 14-20 MA	158,371.19	-38,159.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	120,211.90	
431E	SOBRA CHILD 14-20 FE	207,585.75	-42,810.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	164,775.66	
4321	SOBRA CHILD <1 M & F	25.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25.69	
4322	SOBRA CHILD 01-05 M	229.63	329.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	559.04	
4323	SOBRA CHILD 06-13 M	236.17	115.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	351.76	
4324	SOBRA CHILD 14-20 MA	11.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.50	
4325	SOBRA CHILD 14-20 FE	540.85	788.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,329.77	
5005	SOBRA PREG 14-20 FE M	508.73	207.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	716.60	
5007	SOBRA PREG 21-44 FE
M	27,061.65	28,571.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,632.68	
5008	SOBRA PREG 45-64 FE M	3,979.99	662.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,642.68	
500G	SOBRA PREG 21-44 FE
M	306.32	611.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		917.50	
500H	SOBRA PREG 45-64 FE M	771.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		771.11	
5013

5015	SOBRA PREG 09-13 FE
M
SOBRA PREG 14-20 FE
M	916.02

926,061.72	920.55

932,881.49	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		1,836.57

1,858,943.21	
5017

5018	SOBRA PREG 21-44 FE M
SOBRA PREG 45-64 FE
M	5,075,438.74

18,556.70	5,022,830.06

17,501.16	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		10,098,268.80

36,057.86	
501E

501G	SOBRA PREG 14-20 FE M
SOBRA PREG 21-44 FE
M	49,647.81

202,834.23	-33,791.33

-39,812.61	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		15,856.48

163,021.62	
501H	SOBRA PREG 45-64 FE M	1,185.71	329.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,515.51	
5027	SOBRA PREG 21-44 FE
M	24,727.60	30,213.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,940.84	
5028	SOBRA PREG 45-64 FE M	424.97	423.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		848.79	
502G	SOBRA PREG 21-44 FE
M	6.14	744.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	750.72	
SUBTOTAL:	256,201,977.35	250,621,222.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	506,823,200.19	

9910	TANF & SOBRA CHILDR E	1,671,858.21	1,914,618.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	41,766.35	49,883.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	124,693.16	188,260.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	13,407,782.88	14,821,850.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,246,100.60	16,974,611.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,586,476.27	
91,650.00	
312,953.35	
28,229,632.96	
32,220,712.58	

1106	TANF EXPANDED 21-44	115,280.73	114,224.09	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	375,187.64	366,538.58	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	969,358.60	933,329.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

229,504.82	
741,726.22	
1,902,688.59	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+
M&	283,247.60	271,616.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		554,864.08		
110F	TANF EXPANDED 21-44	6,434.27	833.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,267.76		
110G	TANF EXPANDED 21-44	17,187.04	20,010.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,197.61		
110H	TANF EXPANDED 45-64	24,588.37	18,477.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,066.35		
110J	TANF EXPANDED 65+
M&	10,009.21	4,963.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,972.70		
1111	TANF EXPANDED <1 M
&F	49.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.12		
1112	TANF EXPANDED 01-05	982.24	773.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,755.73		
1113	TANF EXPANDED 06-13	7,530.15	6,396.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,926.49		
1114	TANF EXPANDED 14-20	78,885.78	74,581.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,467.33		
1115	TANF EXPANDED 14-20	480,991.35	468,272.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		949,264.02		
1116	TANF EXPANDED 21-44	5,205,535.87	5,124,163.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,329,699.32		
1117	TANF EXPANDED 21-44	20,323,286.61	19,947,918.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,271,205.52		
1118	TANF EXPANDED 45-64	11,730,164.19	11,843,417.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,573,581.60		
1119	TANF EXPANDED 65+
M&	28,256.55	28,078.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,335.10		
111C	TANF EXPANDED 06-13	87.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.45		
111D	TANF EXPANDED 14-20	1,869.30	-6,003.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,134.32		
111E	TANF EXPANDED 14-20	5,280.99	-9,343.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,062.90		
111F	TANF EXPANDED 21-44	113,756.88	1,485.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,242.86		
111G	TANF EXPANDED 21-44	252,045.26	-86,740.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,304.44		
111H	TANF EXPANDED 45-64	124,191.45	-46,232.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,958.53		
111J	TANF EXPANDED 65+
M&	494.89	-2,806.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,311.65		
1125	TANF EXPANDED 14-20	270.06	270.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		540.12		
1126	TANF EXPANDED 21-44	381,006.44	383,503.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		764,510.41		
1127	TANF EXPANDED 21-44	1,014,812.39	1,051,819.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,066,632.15		
1128	TANF EXPANDED 45-64	1,418,896.68	1,476,267.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,895,164.58		
1129	TANF EXPANDED 65+
M&	495,757.35	518,707.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,014,464.61		
112F	TANF EXPANDED 21-44	1,142.03	-462.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		679.93		
112G	TANF EXPANDED 21-44	3,902.35	1,608.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,511.30		
112H	TANF EXPANDED 45-64	1,484.83	1,137.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,621.95		
112J	TANF EXPANDED 65+
M&	590.21	399.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989.95		
2400	SSI AGED EXPANDED WI	70,982.22	60,953.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,935.27		
240Z	SSI AGED EXPANDED
WI	13,292.73	18,104.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,397.17		
2410	SSI AGED EXPANDED NO	111,573.31	93,539.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205,112.61		
241Z	SSI AGED EXPANDED
NO	3,594.96	4,633.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,228.79		
2420	SSI AGED EXPANDED WI	5,048,533.15	4,858,902.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,907,435.34		
242Z	SSI AGED EXPANDED
WI	5,768.70	2,945.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,714.69		

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2500	SSI BLIND EXPANDED W	439.11	167.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		606.78		
2510	SSI BLIND EXPANDED
N	106.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.76		
2520	SSI BLIND EXPANDED W	171.43	125.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		297.32		
2600	SSI DISABLED EXPAND
E	215,717.42	190,692.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406,410.25		
260Z	SSI DISABLED EXPAND E	68,640.56	81,350.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,990.82		
2610	SSI DISABLED EXPAND
E	2,036,765.94	1,767,448.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,804,214.36		
261Z	SSI DISABLED EXPAND E	24,058.45	27,936.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,995.09		
2620	SSI DISABLED EXPAND
E	11,145,576.62	11,100,954.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,246,531.21		
262Z	SSI DISABLED EXPAND E	17,013.33	40,720.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,733.64		
SUBTOTAL:	62,234,798.57	60,755,683.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,990,481.87		

3504	ADULT 40-100% MALE 1	4.57	524.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3505	ADULT 40-100% FEMAL E	11.28	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	1,596.06	462.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	1,621.87	6,170.00	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	11,510.40	24,329.60	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	-269.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	2,884.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	1,153.34	348.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	3,127.80	5,761.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	2,852,736.53	2,959,028.68	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	3,023,174.20	3,119,177.27	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	9,879,165.10	10,570,723.64	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	8,205,716.71	8,796,499.02	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	18,927,504.84	20,154,964.40	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	7,808.53	9,609.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	72,359.73	-49,736.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	63,306.58	-18,704.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	291,967.08	8,303.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	229,537.12	-11,995.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	545,163.08	-65,763.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	11,658.82	-3,539.60	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	396.51	461.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

529.14	
11.28	
2,058.85	
7,791.87	
35,840.00	
-269.59	
2,884.85	
1,501.52	
8,889.17	
5,811,765.21	
6,142,351.47	
20,449,888.74	
17,002,215.73	
39,082,469.24	
17,418.19	
22,623.01	
44,602.31	
300,270.27	
217,541.39	
479,400.03	
8,119.22	
857.83	

9911	SB PAYMENT FOR TAN F	1,371,150.11	1,352,929.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	0.00	12,759.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,371,150.11	1,365,689.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,724,079.49	
12,759.89	
2,736,839.38	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3527	ADULT 40-100% FEMAL E	-9.13	2,368.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,359.46		
3528	ADULT 40-100% M&F 45	2,052.47	4,019.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,071.57		
3529	ADULT 40-100% M&F 65	354.63	904.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,259.34		
352H	ADULT 40-100% M&F 45	2,162.61	2,114.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,276.65		
3704	ADULT <40% EXP MALE	18.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.53		
3706	ADULT <40% EXP MALE	6,494.13	11,445.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,939.44		
3707	ADULT <40% EXP FEM AL	4,432.57	11,559.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,991.87		
3708	ADULT <40% EXP M&F
4	14,067.06	21,252.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,319.82		
3709	ADULT <40% EXP M&F 6	1,019.42	923.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,942.50		
370F	ADULT <40% EXP MALE	3,252.78	4,082.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,335.29		
370G	ADULT <40% EXP FEM AL	4,275.36	-105.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,170.00		
370H	ADULT <40% EXP M&F
4	20,886.74	12,971.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,857.98		
3714	ADULT <40% EXP MALE	5,219,470.41	5,394,579.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,614,049.43		
3715	ADULT <40% EXP FEM AL	4,642,825.69	4,808,976.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,451,802.30		
3716	ADULT <40% EXP MALE	33,047,874.79	34,761,629.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,809,504.41		
3717	ADULT <40% EXP FEM AL	20,320,142.05	21,465,807.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,785,949.44		
3718	ADULT <40% EXP M&F
4	40,004,359.73	42,354,058.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,358,418.44		
3719	ADULT <40% EXP M&F 6	15,351.84	18,714.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,066.22		
371D	ADULT <40% EXP MALE	146,006.19	-155,374.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-9,368.41		
371E	ADULT <40% EXP FEM AL	144,773.10	-80,125.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,647.45		
371F	ADULT <40% EXP MALE	1,612,184.26	-543,288.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,068,895.99		
371G	ADULT <40% EXP FEM AL	963,473.42	-72,313.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		891,160.15		
371H	ADULT <40% EXP M&F
4	1,422,746.28	-670,271.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		752,474.74		
371J	ADULT <40% EXP M&F 6	3,132.07	6,682.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,814.76		
3724	ADULT <40% EXP MALE	-6.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6.26		
3725	ADULT <40% EXP FEM AL	4.46	870.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		874.55		
3726	ADULT <40% EXP MALE	6,441.63	3,337.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,779.19		
3727	ADULT <40% EXP FEM AL	251.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251.87		
3728	ADULT <40% EXP M&F
4	5,999.63	7,782.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,782.47		
3729	ADULT <40% EXP M&F 6	448.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448.69		
372F	ADULT <40% EXP MALE	388.35	883.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,271.37		
372H	ADULT <40% EXP M&F 4	997.14	5,797.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,794.90		
SUBTOTAL:	151,748,007.92	152,885,905.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304,633,913.88		

9935	BIRTH SUPP PAYMENT A	276,810.08	265,656.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	488,085.14	570,809.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
542,466.61	
1,058,895.09	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	764,895.22	836,466.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,601,361.70		

9939	BIRTH SUPP PAYMENT N	423,614.42	322,314.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	423,614.42	322,314.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

745,929.24	
745,929.24	

4403	SOBRA 100-133% M&F
6	794.23	905.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	326.61	315.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4405	SOBRA 100-133% FEMA L	757.74	507.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,700.11	
641.84	
1,265.60	

3904	NEWLY ELIGIBLE MALE	2.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	-11.24	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	955.33	2,177.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	1,508.51	1,425.48	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	18,149.81	56,587.27	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	2,088.17	2,354.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	496.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	407.87	99.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.00	838.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	224.85	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	1,273,793.61	1,294,010.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1,443,708.45	1,452,256.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	7,793,548.62	7,828,522.86	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	10,614,962.26	10,780,139.03	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	11,600,013.20	11,586,923.15	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	5,388.09	5,528.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	24,013.79	-12,675.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	29,024.73	-17,035.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	207,852.91	-68,573.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	258,501.92	-57,783.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	202,007.44	-538.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	2,782.92	341.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	1,466.71	2,601.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	390.74	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	824.99	1,840.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	83.77	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	3,285.46	99.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	110.24	402.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	33,485,086.10	32,860,038.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.95	
-11.24	
3,132.94	
2,933.99	
74,737.08	
4,442.17	
496.06	
507.08	
838.99	
224.85	
2,567,803.97	
2,895,964.76	
15,622,071.48	
21,395,101.29	
23,186,936.35	
10,916.32	
11,338.31	
11,988.74	
139,279.16	
200,718.65	
201,469.20	
3,124.65	
4,068.13	
390.74	
2,665.91	
83.77	
3,385.29	
513.11	
66,345,124.70	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4411	SOBRA 100-133% M&F
<	6.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.06		
4412	SOBRA 100-133% M&F
1	1,485.88	793.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,279.63		
4413	SOBRA 100-133% M&F
6	6,068,565.70	5,973,077.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,041,643.66		
4414	SOBRA 100-133% MALE	2,167,517.45	2,117,655.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,285,173.21		
4415	SOBRA 100-133% FEMA L	3,278,980.37	3,244,965.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,523,945.90		
441B	SOBRA 100-133% M&F
1	121.34	-298.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-176.96		
441C	SOBRA 100-133% M&F
6	50,659.34	-27,962.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,696.48		
441D	SOBRA 100-133% MALE	31,972.74	-9,902.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,070.62		
441E	SOBRA 100-133% FEMA L	40,438.24	-26,343.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,094.72		
4424	SOBRA 100-133% MALE	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4425	SOBRA 100-133% FEMA L	2.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.61		
SUBTOTAL:	11,641,631.31	11,273,715.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,915,346.48		

4517	BC PATIENT FEMALE 2 1	5,030.43	5,596.82	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	61,540.15	46,784.42	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	-3.50	57.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.00	1,438.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	2,694.80	1,816.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	4,450.82	4,513.74	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	4,367.07	4,793.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4619	CC PATIENT FEMALE 6
5	-4.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	191.12	257.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	1,162.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	78,266.48	66,420.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10,627.25	
108,324.57	
53.55	
1,438.90	
4,511.15	
8,964.56	
9,160.94	
-4.41	
448.50	
1,162.41	
144,687.42	

8600	SSI BLIND FREEDOM/W O	3,473.55	4,134.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
860Z	SSI BLIND FREEDOM/W
O	1,122.93	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	1,677,240.71	1,702,839.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	25,793.64	29,914.96	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	417,995.55	395,949.89	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	12,807.76	17,411.37	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	190,928.86	183,129.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	902.78	7,362.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,330,265.78	2,340,741.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,607.95	
1,122.93	
3,380,080.37	
55,708.60	
813,945.44	
30,219.13	
374,058.17	
8,265.17	
4,671,007.76	

9944	BIRTH SUPP PAYMENT S	24,374.98	57,086.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	24,374.98	57,086.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
81,461.38	
81,461.38	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	535,550,168.84	530,359,897.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,065,910,066.58		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1002	TANF 01-05 M & F WIT	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1003	TANF 06-13 M & F WIT	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1004	TANF 14-20 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		
1005	TANF 14-20 FEMALE WI	0.16	2.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.64		
1006	TANF 21-44 MALE WITH	78.57	79.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.67		
1007	TANF 21-44 FEMALE WI	121.95	130.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252.38		
1008	TANF 45-64 M & F WIT	167.87	166.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334.39		
1009	TANF 65+ M & F WITH	76.75	83.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159.88		
100E	TANF 14-20 FEMALE WI	1.83	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.34		
100F	TANF 21-44 MALE WITH	1.41	2.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.97		
100G	TANF 21-44 FEMALE WI	3.92	10.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.51		
100H	TANF 45-64 M & F WIT	6.63	5.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.76		
100J	TANF 65+ M & F WITH	3.21	1.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.02		
1011	TANF <1 M & F NON-ME	12,680.31	12,878.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,558.31		
1012	TANF 01-05 M & F NON	20,425.00	21,039.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,464.07		
1013	TANF 06-13 M & F NON	31,421.44	31,527.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,949.27		
1014	TANF 14-20 MALE NON-	8,500.86	8,645.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,146.04		
1015	TANF 14-20 FEMALE N O	11,347.13	11,438.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,785.78		
1016	TANF 21-44 MALE NON-	27,141.38	27,294.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,435.54		
1017	TANF 21-44 FEMALE N O	83,553.33	83,865.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,419.22		
1018	TANF 45-64 M & F NON	21,279.36	21,168.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,447.67		
1019	TANF 65+ M & F NON-M	83.83	84.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168.27		
101A	TANF < 1 M & F NON-M	1,013.07	1,097.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,110.52		
101B	TANF 01-05 M & F NON	279.37	412.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		691.98		
101C	TANF 06-13 M & F NON	239.36	317.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557.16		
101D	TANF 14-20 MALE NON-	106.20	56.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.66		
101E	TANF 14-20 FEMALE N O	103.24	29.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132.26		
101F	TANF 21-44 MALE NON-	825.45	-28.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796.73		
101G	TANF 21-44 FEMALE N O	1,728.03	-483.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,244.58		
101H	TANF 44-64 M & F NON	375.11	-16.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		358.61		
101J	TANF 65+ N & F NON-M	2.16	-2.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.63		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1025	TANF 14-20 FEMALE WI	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1026	TANF 21-44 MALE WITH	55.44	57.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.26		
1027	TANF 21-44 FEMALE WI	92.00	97.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189.93		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	120.86	130.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250.86		
1029	TANF 65+ M & F WITH	72.70	76.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148.70		
102F	TANF 21-44 MALE WITH	1.66	1.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.94		
102G	TANF 21-44 FEMALE WI	0.00	3.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.06		
102H	TANF 44-64 M & F WIT	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
102J	TANF 65+ M & F WITH	6.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.51		
2100	SSI AGED WITH MEDIC A	4,505.33	4,499.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,004.86		
210Z	SSI AGED WITH MEDIC
A	227.54	242.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		470.48		
2110	SSI AGED NON-MEDICA R	5,793.97	5,820.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,614.26		
211Z	SSI AGED NON-MEDICA
R	140.26	171.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		312.03		
2120	SSI AGED WITH QMB	27,697.42	27,990.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,687.93		
212Z	SSI AGED WITH QMB P P	54.23	49.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.14		
2200	SSI DISABLED WITH M
E	3,558.35	3,571.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,129.70		
220Z	SSI DISABLED WITH M E	218.85	200.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		419.49		
2210	SSI DISABLED NON-ME
D	54,047.38	53,981.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,029.04		
221Z	SSI DISABLED NON-ME D	602.83	763.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,366.56		
2220	SSI DISABLED WITH Q
M	27,058.57	27,073.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,132.45		
222Z	SSI DISABLED WITH Q M	75.34	64.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.88		
2300	SSI BLIND WITH MEDIC	24.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.00		
2310	SSI BLIND NON-MEDIC A	487.19	490.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		977.40		
231Z	SSI BLIND NON-MEDIC
A	20.21	8.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.55		
2320	SSI BLIND WITH QMB	221.71	223.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445.70		
232Z	SSI BLIND WITH QMB P	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		
4301	SOBRA CHILD <1 M & F	5.00	3.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.90		
4302	SOBRA CHILD 01-05 M	42.12	46.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.67		
4303	SOBRA CHILD 06-13 M	24.00	39.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.20		
4304	SOBRA CHILD 14-20 MA	16.16	14.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.25		
4305	SOBRA CHILD 14-20 FE	7.00	4.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.38		
430A	SOBRA CHILD < 1 M &	0.00	2.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.02		
430B	SOBRA CHILD 01-05 M	0.87	5.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.64		
430C	SOBRA CHILD 06-13 M	0.00	5.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.84		
430E	SOBRA CHILD 14-20 FE	0.00	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.64		
4311	SOBRA CHILD <1 M & F	35,824.32	36,535.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,359.95		
4312	SOBRA CHILD 01-05 M	183,884.02	183,433.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		367,317.19		
4313	SOBRA CHILD 06-13 M	231,154.67	231,125.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462,279.91		
4314	SOBRA CHILD 14-20 MA	58,533.44	58,545.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117,078.47		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	58,251.71	58,249.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	116,501.14	
431A	SOBRA CHILD < 1 M &	294.85	419.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	714.83	
431B	SOBRA CHILD 01-05 M	3,855.57	-23.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,831.76	
431C	SOBRA CHILD 6-13 M& F	3,793.44	-1,590.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,202.79	
431D	SOBRA CHILD 14-20 MA	1,055.11	-176.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	878.50	
431E	SOBRA CHILD 14-20 FE	1,044.75	-215.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	829.60	
4321	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	
4322	SOBRA CHILD 01-05 M	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
4323	SOBRA CHILD 06-13 M	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	
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	
4325	SOBRA CHILD 14-20 FE	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
5005	SOBRA PREG 14-20 FE M	2.00	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.87	
5007	SOBRA PREG 21-44 FE
M	47.50	47.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.44	
5008	SOBRA PREG 45-64 FE M	3.83	5.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.50	
500G	SOBRA PREG 21-44 FE
M	1.58	3.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.70	
500H	SOBRA PREG 45-64 FE M	2.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.16	
5013

5015	SOBRA PREG 09-13 FE
M
SOBRA PREG 14-20 FE
M	8.00

3,459.15	8.00

3,491.72	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		16.00

6,950.87	
5017

5018	SOBRA PREG 21-44 FE M
SOBRA PREG 45-64 FE
M	18,483.38

47.50	18,642.58

43.38	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		37,125.96

90.88	
501E

501G	SOBRA PREG 14-20 FE M
SOBRA PREG 21-44 FE
M	254.06

1,005.81	-168.85

-233.91	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		85.21

771.90	
501H	SOBRA PREG 45-64 FE M	3.46	0.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.44	
5027	SOBRA PREG 21-44 FE
M	47.80	48.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.42	
5028	SOBRA PREG 45-64 FE M	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00	
502G	SOBRA PREG 21-44 FE
M	0.03	0.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.60	
SUBTOTAL:	947,815.60	933,686.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,881,501.99	

9910	TANF & SOBRA CHILDR E	270.00	308.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	20.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,172.00	2,397.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,469.00	2,744.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

578.00	
15.00	
51.00	
4,569.00	
5,213.00	

1106	TANF EXPANDED 21-44	335.07	330.91	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	693.13	652.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,615.00	1,566.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

665.98	
1,345.25	
3,181.75	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+
M&	624.46	600.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,224.86		
110F	TANF EXPANDED 21-44	15.51	-10.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.40		
110G	TANF EXPANDED 21-44	33.03	36.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.56		
110H	TANF EXPANDED 45-64	37.12	44.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.08		
110J	TANF EXPANDED 65+
M&	25.18	12.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.53		
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1112	TANF EXPANDED 01-05	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
1113	TANF EXPANDED 06-13	44.64	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.64		
1114	TANF EXPANDED 14-20	458.88	455.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		914.07		
1115	TANF EXPANDED 14-20	1,774.24	1,765.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,539.75		
1116	TANF EXPANDED 21-44	31,047.87	30,993.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,041.29		
1117	TANF EXPANDED 21-44	73,554.07	73,351.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,905.24		
1118	TANF EXPANDED 45-64	26,429.46	26,352.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,781.53		
1119	TANF EXPANDED 65+
M&	67.61	62.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.37		
111C	TANF EXPANDED 06-13	1.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.35		
111D	TANF EXPANDED 14-20	12.87	-37.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-25.09		
111E	TANF EXPANDED 14-20	27.19	-49.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-22.42		
111F	TANF EXPANDED 21-44	757.55	-17.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		739.77		
111G	TANF EXPANDED 21-44	1,200.28	-537.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		663.06		
111H	TANF EXPANDED 45-64	385.98	-108.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277.31		
111J	TANF EXPANDED 65+
M&	1.38	-10.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-8.70		
1125	TANF EXPANDED 14-20	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1126	TANF EXPANDED 21-44	859.34	880.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,739.66		
1127	TANF EXPANDED 21-44	1,676.07	1,728.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,404.38		
1128	TANF EXPANDED 45-64	2,310.86	2,399.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,710.66		
1129	TANF EXPANDED 65+
M&	1,094.60	1,126.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,220.69		
112F	TANF EXPANDED 21-44	8.80	-3.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.60		
112G	TANF EXPANDED 21-44	2.41	3.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.22		
112H	TANF EXPANDED 45-64	4.23	3.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.69		
112J	TANF EXPANDED 65+
M&	2.41	1.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.95		
2400	SSI AGED EXPANDED WI	308.22	313.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		621.93		
240Z	SSI AGED EXPANDED
WI	194.97	185.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		380.08		
2410	SSI AGED EXPANDED NO	97.29	98.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195.42		
241Z	SSI AGED EXPANDED
NO	6.61	7.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.39		
2420	SSI AGED EXPANDED WI	22,108.12	22,316.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,424.16		
242Z	SSI AGED EXPANDED
WI	37.37	39.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.03		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2500	SSI BLIND EXPANDED W	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2510	SSI BLIND EXPANDED
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		
2520	SSI BLIND EXPANDED W	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2600	SSI DISABLED EXPAND
E	347.79	324.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		672.40		
260Z	SSI DISABLED EXPAND E	123.78	154.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278.26		
2610	SSI DISABLED EXPAND
E	1,663.98	1,676.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,340.25		
261Z	SSI DISABLED EXPAND E	40.40	29.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.90		
2620	SSI DISABLED EXPAND
E	17,106.28	17,265.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,371.43		
262Z	SSI DISABLED EXPAND E	33.13	52.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.62		
SUBTOTAL:	187,179.53	184,108.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371,288.30		

3504	ADULT 40-100% MALE 1	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3505	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	
3506	ADULT 40-100% MALE 2	1.99	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	3.28	5.47	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	27.33	44.68	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	1.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	1.69	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	3.63	4.26	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	6,040.37	6,121.37	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	6,434.05	6,464.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	20,700.55	20,821.39	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	17,131.52	17,173.85	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	40,830.77	40,729.18	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	18.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	108.95	-81.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	95.12	-38.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	425.91	-15.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	327.74	-34.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	792.15	-118.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	17.00	-5.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
0.00	
2.99	
8.75	
72.01	
1.00	
1.99	
2.20	
7.89	
12,161.74	
12,898.53	
41,521.94	
34,305.37	
81,559.95	
38.00	
27.51	
57.08	
410.28	
293.03	
673.68	
12.00	
2.00	

9911	SB PAYMENT FOR TAN F	221.00	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	221.00	220.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
439.00	
2.00	
441.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3527	ADULT 40-100% FEMAL E	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3528	ADULT 40-100% M&F 45	4.66	5.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.64		
3529	ADULT 40-100% M&F 65	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
352H	ADULT 40-100% M&F 45	3.31	2.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.30		
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	6.74	12.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.89		
3707	ADULT <40% EXP FEM AL	4.58	6.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.36		
3708	ADULT <40% EXP M&F
4	23.17	31.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.57		
3709	ADULT <40% EXP M&F 6	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
370F	ADULT <40% EXP MALE	2.23	5.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.60		
370G	ADULT <40% EXP FEM AL	4.45	-1.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.28		
370H	ADULT <40% EXP M&F
4	16.31	12.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.45		
3714	ADULT <40% EXP MALE	10,805.54	10,877.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,683.52		
3715	ADULT <40% EXP FEM AL	9,615.96	9,669.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,285.90		
3716	ADULT <40% EXP MALE	62,436.00	63,349.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,785.72		
3717	ADULT <40% EXP FEM AL	37,546.58	37,992.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,538.68		
3718	ADULT <40% EXP M&F
4	77,487.79	78,144.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,632.41		
3719	ADULT <40% EXP M&F 6	42.15	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.15		
371D	ADULT <40% EXP MALE	220.48	-235.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14.54		
371E	ADULT <40% EXP FEM AL	211.92	-119.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.16		
371F	ADULT <40% EXP MALE	2,271.65	-992.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,279.35		
371G	ADULT <40% EXP FEM AL	1,322.71	-206.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,115.96		
371H	ADULT <40% EXP M&F
4	1,998.95	-1,114.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		884.02		
371J	ADULT <40% EXP M&F 6	5.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
3724	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3725	ADULT <40% EXP FEM AL	0.00	0.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.99		
3726	ADULT <40% EXP MALE	7.85	3.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.57		
3727	ADULT <40% EXP FEM AL	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3728	ADULT <40% EXP M&F
4	9.18	9.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.45		
3729	ADULT <40% EXP M&F 6	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
372F	ADULT <40% EXP MALE	0.53	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.26		
372H	ADULT <40% EXP M&F 4	1.63	8.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.31		
SUBTOTAL:	297,018.41	288,614.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		585,632.94		

9935	BIRTH SUPP PAYMENT A	45.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	79.00	92.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
88.00	
171.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	124.00	135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.00		

9939	BIRTH SUPP PAYMENT N	68.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	68.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

120.00	
120.00	

4403	SOBRA 100-133% M&F
6	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4405	SOBRA 100-133% FEMA L	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15.00	
4.00	
5.00	

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	
3905	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	
3906	NEWLY ELIGIBLE MALE	2.00	5.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	3.80	3.70	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	38.00	122.33	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	4.19	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	1.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1.19	0.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.00	2.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.80	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	3,170.21	3,191.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,569.35	3,612.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	18,777.73	18,863.69	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	26,090.37	26,337.35	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	27,742.64	27,884.04	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	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	71.15	-34.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	86.75	-55.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	560.99	-214.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	757.74	-209.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	581.40	-56.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	10.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.61	1.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	1.00	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	1.67	4.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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	1.38	0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.32	1.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	81,486.29	79,485.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
7.54	
7.50	
160.33	
10.19	
1.45	
1.48	
2.63	
0.80	
6,362.16	
7,182.01	
37,641.42	
52,427.72	
55,626.68	
27.00	
36.57	
31.59	
346.81	
548.43	
525.26	
11.00	
2.25	
1.00	
6.43	
0.00	
1.73	
1.54	
160,971.52	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	6.22	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.22		
4413	SOBRA 100-133% M&F
6	46,895.22	47,076.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,971.85		
4414	SOBRA 100-133% MALE	12,578.90	12,653.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,232.61		
4415	SOBRA 100-133% FEMA L	12,030.22	12,087.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,117.25		
441B	SOBRA 100-133% M&F
1	2.77	-5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2.23		
441C	SOBRA 100-133% M&F
6	939.08	-510.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		428.85		
441D	SOBRA 100-133% MALE	218.83	-61.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.20		
441E	SOBRA 100-133% FEMA L	208.03	-134.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.43		
4424	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		0.00		
4425	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	72,891.27	71,124.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,016.18		

4517	BC PATIENT FEMALE 2 1	18.00	21.53	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	116.79	104.47	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	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.00	7.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	7.95	5.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	9.00	9.64	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	10.00	10.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4619	CC 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	
461G	CC PATIENT FEMALE 2 1	1.00	1.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	3.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	162.74	164.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

39.53	
221.26	
0.12	
7.43	
13.60	
18.64	
20.74	
0.00	
2.35	
3.25	
326.92	

8600	SSI BLIND FREEDOM/W O	2.70	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
860Z	SSI BLIND FREEDOM/W
O	5.28	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	1,908.94	1,939.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	50.68	69.14	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	336.40	351.75	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	19.43	23.53	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	232.56	232.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	3.39	8.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,559.38	2,626.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.70	
5.28	
3,848.02	
119.82	
688.15	
42.96	
464.95	
11.95	
5,185.83	

9944	BIRTH SUPP PAYMENT S	4.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13.00	
13.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	1,591,999.22	1,562,970.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,154,969.68		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	32,582.20	29,740.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,323.02		
1010	TANF NON-MEDICARE	2,613,870.08	2,616,266.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,230,136.33		
1020	TANF WITH QMB	14,552.84	14,552.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,105.68		
2100	SSI AGED WITH MEDIC A	32,933,806.96	40,503,011.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,436,818.71		
210Z	SSI AGED WITH MEDIC
A	652,373.23	802,200.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,454,573.28		
2110	SSI AGED NON-MEDICA R	2,945,767.23	3,442,829.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,388,596.39		
211Z	SSI AGED NON-MEDICA
R	26,026.97	37,754.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,781.64		
2120	SSI AGED WITH QMB	20,774,403.47	25,359,009.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,133,412.88		
212Z	SSI AGED WITH QMB P P	18,726.37	17,194.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,920.79		
2200	SSI DISABLED WITH M
E	15,894,224.54	17,882,836.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,777,060.63		
220Z	SSI DISABLED WITH M E	68,599.31	115,034.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183,634.17		
2210	SSI DISABLED NON-ME
D	106,245,644.56	109,460,228.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,705,872.93		
221Z	SSI DISABLED NON-ME D	21,758.30	32,964.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,723.20		
2220	SSI DISABLED WITH Q
M	23,534,174.16	25,423,926.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,958,101.10		
222Z	SSI DISABLED WITH Q M	9,199.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,199.93		
2300	SSI BLIND WITH MEDIC	70,372.06	79,197.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,569.39		
2310	SSI BLIND NON-MEDIC A	534,836.83	549,634.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,084,471.46		
2320	SSI BLIND WITH QMB	144,734.34	166,531.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		311,265.78		
SUBTOTAL:	206,535,653.38	226,532,913.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433,068,567.31		

8700	SSI DISABLED FREEDO M	85,343.64	104,810.80	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	130,847.60	152,194.77	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	24,649.26	27,384.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	240,840.50	284,390.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
190,154.44	
283,042.37	
52,033.80	
525,230.61	

206,776,493.88	226,817,304.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	9.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1010	TANF NON-MEDICARE	713.19	711.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,425.06		
1020	TANF WITH QMB	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2100	SSI AGED WITH MEDIC A	11,369.40	11,418.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,788.05		
210Z	SSI AGED WITH MEDIC
A	627.42	774.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,401.67		
2110	SSI AGED NON-MEDICA R	541.12	550.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,092.10		
211Z	SSI AGED NON-MEDICA
R	24.80	35.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.59		
2120	SSI AGED WITH QMB	7,613.97	7,668.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,282.25		
212Z	SSI AGED WITH QMB P P	18.33	17.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.89		
2200	SSI DISABLED WITH M
E	4,922.28	4,934.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,856.39		
220Z	SSI DISABLED WITH M E	67.01	92.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159.32		
2210	SSI DISABLED NON-ME
D	27,568.14	27,678.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,246.97		
221Z	SSI DISABLED NON-ME D	19.53	32.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.08		
2220	SSI DISABLED WITH Q
M	7,082.95	7,092.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,175.00		
222Z	SSI DISABLED WITH Q M	8.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.46		
2300	SSI BLIND WITH MEDIC	20.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
2310	SSI BLIND NON-MEDIC A	139.64	141.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281.42		
2320	SSI BLIND WITH QMB	44.22	48.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.22		
SUBTOTAL:	60,793.46	61,230.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,023.47		

TOTAL:

60,850.04

61,290.01

0.00

0.00

0.00

0.00

0.00

0.00

122,140.05

0.00

0.00

0.00	0.00

8700	SSI DISABLED FREEDO M	24.58	27.00	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	24.00	25.00	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	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.58	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
51.58	
49.00	
16.00	
116.58	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	203.56	348.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		552.10		
1005	TANF 14-20 FEMALE WI	0.00	27.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.63		
100E	TANF 14-20 FEMALE WI	0.00	29.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.48		
1010	TANF NON-MEDICARE	3,026,390.29	3,050,590.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,076,981.25		
1011	TANF <1 M & F NON-ME	21,465.67	27,973.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,439.23		
1012	TANF 01-05 M & F NON	4,553.03	8,838.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,391.22		
1013	TANF 06-13 M & F NON	6,028.74	10,281.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,310.50		
1014	TANF 14-20 MALE NON-	1,035.47	1,748.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,784.04		
1015	TANF 14-20 FEMALE N O	837.07	1,900.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,737.54		
1017	TANF 21-44 FEMALE N
O	0.00	-17.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-17.01		
101A	TANF < 1 M & F NON-M	45,350.70	47,819.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,170.07		
101B	TANF 01-05 M & F NON	10,678.65	14,220.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,899.40		
101C	TANF 06-13 M & F NON	9,637.85	12,440.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,078.66		
101D	TANF 14-20 MALE NON-	2,927.22	2,190.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,117.53		
101E	TANF 14-20 FEMALE N O	1,386.26	3,030.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,417.09		
2200	SSI DISABLED WITH M
E	58.58	115.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.27		
2210	SSI DISABLED NON-ME D	339,385.86	339,565.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		678,951.18		
221Z	SSI DISABLED NON-ME
D	3,473.04	2,989.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,462.34		
2220	SSI DISABLED WITH Q M	317.52	323.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		640.71		
2310	SSI BLIND NON-MEDIC
A	1,549.96	1,579.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,129.21		
4300	SOBRA CHILD WITH ME D	3,672.02	3,706.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,378.74		
4301	SOBRA CHILD <1 M & F	0.00	26.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.46		
4302	SOBRA CHILD 01-05 M	3.78	53.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.19		
4303	SOBRA CHILD 06-13 M	-22.11	137.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.05		
4304	SOBRA CHILD 14-20 MA	-24.57	-26.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-51.03		
4305	SOBRA CHILD 14-20 FE	0.00	-17.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-17.96		
430A	SOBRA CHILD < 1 M &	0.00	59.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.46		
430B	SOBRA CHILD 01-05 M	25.51	169.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194.83		
430C	SOBRA CHILD 06-13 M	0.00	225.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.72		
430E	SOBRA CHILD 14-20 FE	0.00	18.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.90		
4310	SOBRA CHILD NON-ME DI	20,726,044.30	20,662,708.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,388,753.19		
4311	SOBRA CHILD <1 M & F	74,767.02	85,586.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,353.38		
4312	SOBRA CHILD 01-05 M	97,241.60	128,724.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225,965.96		
4313	SOBRA CHILD 06-13 M	100,730.14	146,407.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,137.73		
4314	SOBRA CHILD 14-20 MA	18,684.49	29,311.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,996.22		
4315	SOBRA CHILD 14-20 FE	22,348.49	28,238.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,586.60		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431A	SOBRA CHILD < 1 M &	13,722.48	16,441.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,163.82		
431B	SOBRA CHILD 01-05 M	144,680.47	160,579.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		305,259.59		
431C	SOBRA CHILD 6-13 M& F	141,402.90	172,682.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,085.70		
431D	SOBRA CHILD 14-20 MA	28,416.16	40,056.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,472.95		
431E	SOBRA CHILD 14-20 FE	29,144.05	35,772.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,916.38		
4320	SOBRA CHILD WITH Q MB	115.69	144.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260.67		
5000	SOBRA PREGNANT WO
MAN	57.11	57.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.22		
5005	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		
5010	SOBRA PREGNANT WO
MAN	18,588.05	18,426.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,014.89		
5015	SOBRA PREG 14-20 FE M	1,222.55	1,050.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,273.53		
501E	SOBRA PREG 14-20 FE
M	1,495.46	965.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,461.07		
SUBTOTAL:	24,897,595.06	25,057,504.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,955,099.70		

1110	TANF EXPANDED FOR FI	3,442.11	3,361.12	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	40.34	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	84.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,567.15	3,361.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,803.23	
40.34	
84.70	
6,928.27	

4400	SOBRA 100-133% FOR F	405.65	411.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR
F	2,561,241.45	2,564,232.13	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	12.90	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	24,015.75	31,189.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	4,720.28	6,358.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	4,916.84	6,421.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	158.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	37,173.67	41,624.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	7,146.53	8,538.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	7,177.96	8,702.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,646,969.46	2,667,478.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
816.71	
5,125,473.58	
12.90	
55,205.72	
11,079.16	
11,338.65	
158.43	
78,797.88	
15,685.09	
15,880.22	
5,314,448.34	

6013	KIDS 6-13 M & F NON-	0.00	82.86	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	36.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36.30	82.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
82.86	
36.30	
119.16	

27,548,167.97	27,728,427.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

55,276,595.47	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	6.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1005	TANF 14-20 FEMALE WI	0.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
100E	TANF 14-20 FEMALE WI	0.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1010	TANF NON-MEDICARE	75,114.00	75,754.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,868.00		
1011	TANF <1 M & F NON-ME	16,478.00	20,513.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,991.00		
1012	TANF 01-05 M & F NON	3,283.00	6,117.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,400.00		
1013	TANF 06-13 M & F NON	4,434.00	7,468.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,902.00		
1014	TANF 14-20 MALE NON-	805.00	1,206.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,011.00		
1015	TANF 14-20 FEMALE N O	685.00	1,374.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,059.00		
1017	TANF 21-44 FEMALE N
O	0.00	-18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-18.00		
101A	TANF < 1 M & F NON-M	36,259.00	36,657.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,916.00		
101B	TANF 01-05 M & F NON	7,810.00	10,925.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,735.00		
101C	TANF 06-13 M & F NON	7,009.00	9,542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,551.00		
101D	TANF 14-20 MALE NON-	2,190.00	1,584.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,774.00		
101E	TANF 14-20 FEMALE N O	958.00	2,007.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,965.00		
2200	SSI DISABLED WITH M
E	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2210	SSI DISABLED NON-ME D	9,234.00	9,405.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,639.00		
221Z	SSI DISABLED NON-ME
D	3,316.00	2,514.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,830.00		
2220	SSI DISABLED WITH Q M	2.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
2310	SSI BLIND NON-MEDIC
A	44.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89.00		
4300	SOBRA CHILD WITH ME D	95.00	96.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.00		
4301	SOBRA CHILD <1 M & F	0.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.00		
4302	SOBRA CHILD 01-05 M	4.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.00		
4303	SOBRA CHILD 06-13 M	-12.00	90.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.00		
4304	SOBRA CHILD 14-20 MA	-26.00	-28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-54.00		
4305	SOBRA CHILD 14-20 FE	0.00	-19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-19.00		
430A	SOBRA CHILD < 1 M &	0.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		
430B	SOBRA CHILD 01-05 M	27.00	179.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206.00		
430C	SOBRA CHILD 06-13 M	0.00	181.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.00		
430E	SOBRA CHILD 14-20 FE	0.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
4310	SOBRA CHILD NON-ME DI	520,532.00	518,762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,039,294.00		
4311	SOBRA CHILD <1 M & F	57,234.00	65,492.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,726.00		
4312	SOBRA CHILD 01-05 M	74,257.00	98,343.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172,600.00		
4313	SOBRA CHILD 06-13 M	76,745.00	110,488.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		187,233.00		
4314	SOBRA CHILD 14-20 MA	14,555.00	22,288.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,843.00		
4315	SOBRA CHILD 14-20 FE	16,435.00	21,114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,549.00		

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431A	SOBRA CHILD < 1 M &	10,534.00	12,972.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,506.00		
431B	SOBRA CHILD 01-05 M	113,003.00	126,383.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239,386.00		
431C	SOBRA CHILD 6-13 M& F	109,391.00	134,858.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,249.00		
431D	SOBRA CHILD 14-20 MA	22,938.00	31,642.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,580.00		
431E	SOBRA CHILD 14-20 FE	22,513.00	27,295.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,808.00		
4320	SOBRA CHILD WITH Q MB	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
5000	SOBRA PREGNANT WO
MAN	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5005	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		
5010	SOBRA PREGNANT WO
MAN	455.00	451.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906.00		
5015	SOBRA PREG 14-20 FE M	855.00	699.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,554.00		
501E	SOBRA PREG 14-20 FE
M	1,142.00	725.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,867.00		
SUBTOTAL:	1,208,310.00	1,357,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,565,650.00		

4400	SOBRA 100-133% FOR F	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR
F	64,742.00	64,844.00	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	7.00	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	18,476.00	23,707.00	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	3,761.00	4,701.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	3,606.00	4,868.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	28,033.00	32,314.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	5,432.00	6,420.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	5,061.00	6,755.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	129,214.00	143,620.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.00	
129,586.00	
7.00	
42,183.00	
8,462.00	
8,474.00	
85.00	
60,347.00	
11,852.00	
11,816.00	
272,834.00	

6013	KIDS 6-13 M & F NON-	0.00	62.00	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	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	18.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

62.00	
18.00	
80.00	

1110	TANF EXPANDED FOR FI	90.00	88.00	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	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111C	TANF EXPANDED 06-13	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	151.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
178.00	
20.00	
41.00	
239.00	

TOTAL:	1,337,693.00	1,501,110.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,838,803.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	67,703.26	70,281.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,984.84		
1014	TANF 14-20 MALE NON-	9,870.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,870.85		
1015	TANF 14-20 FEMALE N O	9,065.75	7,469.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,535.65		
1016	TANF 21-44 MALE NON-	11,569.46	4,589.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,158.72		
1017	TANF 21-44 FEMALE N O	39,839.71	20,361.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,201.26		
1018	TANF 45-64 M & F NON	15,115.50	16,726.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,841.61		
101F	TANF 21-44 MALE NON-	2,118.51	1,030.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,149.14		
101G	TANF 21-44 FEMALE N O	565.55	3,250.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,816.12		
101H	TANF 44-64 M & F NON	2,290.28	116.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,407.16		
2100	SSI AGED WITH MEDIC A	2,112.72	3,487.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,599.94		
210Z	SSI AGED WITH MEDIC
A	2,434.39	3,148.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,582.97		
2110	SSI AGED NON-MEDICA R	1,259.68	858.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,118.54		
2120	SSI AGED WITH QMB	16,448.33	21,497.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,945.55		
2200	SSI DISABLED WITH M E	26,832.39	8,551.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,383.76		
220Z	SSI DISABLED WITH M
E	7,897.63	4,002.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,900.59		
2210	SSI DISABLED NON-ME D	472,088.18	390,714.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		862,802.42		
221Z	SSI DISABLED NON-ME
D	5,257.87	-15,475.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-10,218.09		
2220	SSI DISABLED WITH Q M	202,597.90	137,282.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339,880.10		
222Z	SSI DISABLED WITH Q
M	2,118.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,118.27		
2310	SSI BLIND NON-MEDIC A	0.00	1,566.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,566.67		
4310	SOBRA CHILD NON-ME
DI	3,504.62	3,488.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,992.62		
4314	SOBRA CHILD 14-20 MA	8,861.93	16,995.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,857.76		
4315	SOBRA CHILD 14-20 FE	18,118.52	7,079.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,198.16		
431D	SOBRA CHILD 14-20 MA	0.00	1,259.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,259.65		
5008	SOBRA PREG 45-64 FE M	0.00	2,397.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,397.16		
5010	SOBRA PREGNANT WO
MAN	5,021.66	5,021.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,043.32		
5015	SOBRA PREG 14-20 FE M	0.00	858.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		858.86		
5017	SOBRA PREG 21-44 FE
M	2,770.42	515.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,285.74		
5027	SOBRA PREG 21-44 FE M	1,124.15	949.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,073.65		
SUBTOTAL:	936,587.53	718,025.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,654,612.99		

1100	TANF EXPANDED FPR FI	7,965.10	8,365.92	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	5,319.85	57.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,852.74	801.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	24,531.79	21,260.49	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	8,122.79	3,098.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,331.02	
5,377.11	
2,654.34	
45,792.28	
11,220.83	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	3,681.87	8,276.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,958.60		
1118	TANF EXPANDED 45-64	494.65	2,138.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,632.73		
111G	TANF EXPANDED 21-44	0.00	617.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617.17		
1120	TANF EXPANDED FOR FI	5,852.92	4,953.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,806.72		
1127	TANF EXPANDED 21-44	2,490.29	-1,201.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,288.99		
1128	TANF EXPANDED 45-64	11,921.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,921.64		
2400	SSI AGED EXPANDED WI	9,310.14	414.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,724.30		
240Z	SSI AGED EXPANDED
WI	9,156.73	1,005.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,162.55		
2420	SSI AGED EXPANDED WI	15,629.69	21,652.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,282.23		
2600	SSI DISABLED EXPAND
E	8,175.29	9,624.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,799.39		
260Z	SSI DISABLED EXPAND E	1,780.54	1,614.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,394.68		
2610	SSI DISABLED EXPAND
E	16,459.44	4,129.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,588.74		
2620	SSI DISABLED EXPAND E	95,463.82	68,058.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,522.77		
262Z	SSI DISABLED EXPAND
E	2,291.08	942.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,233.66		
SUBTOTAL:	230,500.37	155,809.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		386,309.75		

3507	ADULT 40-100% FEMAL E	0.00	1,660.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL
E	0.00	57.26	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	45,540.66	47,296.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	14,355.78	536.20	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	944.02	1,030.63	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	1,997.16	13,607.95	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	20,183.57	5,560.35	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	55,029.73	1,576.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	0.73	1,774.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	59.17	-584.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	4,570.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	57.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	3,798.07	15,907.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	343.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	2,011.63	1,583.64	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	2.92	3,149.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370F	ADULT <40% EXP MALE	118.33	114.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP M&F 4	0.00	4,752.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED
FO	269,577.60	259,367.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	8,520.05	19,861.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,660.46	
57.26	
92,836.69	
14,891.98	
1,974.65	
15,605.11	
25,743.92	
56,606.30	
1,775.70	
-525.23	
4,570.50	
57.26	
19,705.94	
343.56	
3,595.27	
3,152.06	
232.84	
4,752.34	
528,945.47	
28,381.23	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	4,333.10	8,226.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,560.00		
3716	ADULT <40% EXP MALE	126,138.11	115,879.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242,017.70		
3717	ADULT <40% EXP FEM AL	111,889.44	66,507.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178,397.03		
3718	ADULT <40% EXP M&F
4	99,355.58	107,006.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,362.54		
371F	ADULT <40% EXP MALE	7,355.98	18,855.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,211.57		
371G	ADULT <40% EXP FEM AL	6,994.39	16,512.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,507.15		
371H	ADULT <40% EXP M&F
4	16,563.47	14,714.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,277.99		
3720	AHC CARE EXPANDED FO	0.00	2,190.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,190.60		
3726	ADULT <40% EXP MALE	282.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		282.66		
SUBTOTAL:	795,395.71	731,774.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,527,170.55		

3908	NEWLY ELIGIBLE M&F 4	0.00	744.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.00	1,030.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	23,869.83	30,399.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,774.97	4,752.34	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	858.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,832.23	14,837.13	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	13,063.62	16,066.65	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	6,921.49	27,462.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	-5,096.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	801.60	2,089.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	2,175.77	3,236.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	0.00	4,904.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	50,439.51	101,284.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
744.34	
1,030.63	
54,269.09	
6,527.31	
858.86	
16,669.36	
29,130.27	
34,384.02	
-5,096.32	
2,890.93	
5,411.96	
4,904.01	
151,724.46	

4410	SOBRA 100-133% FOR F	2,195.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,195.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,195.38	
2,195.38	

8700	SSI DISABLED FREEDO M	4,236.18	2,539.98	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	286.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,236.18	2,826.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,776.16	
286.29	
7,062.45	

2,019,354.68	1,709,720.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,729,075.58	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	36.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.00		
1014	TANF 14-20 MALE NON-	172.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172.00		
1015	TANF 14-20 FEMALE N O	188.00	131.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		319.00		
1016	TANF 21-44 MALE NON-	180.00	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255.00		
1017	TANF 21-44 FEMALE N O	847.00	359.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,206.00		
1018	TANF 45-64 M & F NON	273.00	324.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		597.00		
101F	TANF 21-44 MALE NON-	37.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
101G	TANF 21-44 FEMALE N O	15.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
101H	TANF 44-64 M & F NON	40.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.00		
2100	SSI AGED WITH MEDIC A	8.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
210Z	SSI AGED WITH MEDIC
A	56.00	59.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.00		
2110	SSI AGED NON-MEDICA R	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
2120	SSI AGED WITH QMB	146.00	408.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		554.00		
2200	SSI DISABLED WITH M E	361.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		397.00		
220Z	SSI DISABLED WITH M
E	141.00	73.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214.00		
2210	SSI DISABLED NON-ME D	6,212.00	1,321.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,533.00		
221Z	SSI DISABLED NON-ME
D	91.00	-219.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-128.00		
2220	SSI DISABLED WITH Q M	2,128.00	724.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,852.00		
222Z	SSI DISABLED WITH Q
M	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.00		
2310	SSI BLIND NON-MEDIC A	0.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.00		
4310	SOBRA CHILD NON-ME
DI	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4314	SOBRA CHILD 14-20 MA	162.00	295.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457.00		
4315	SOBRA CHILD 14-20 FE	344.00	132.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		476.00		
431D	SOBRA CHILD 14-20 MA	0.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
5008	SOBRA PREG 45-64 FE M	0.00	143.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143.00		
5010	SOBRA PREGNANT WO
MAN	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
5015	SOBRA PREG 14-20 FE M	0.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
5017	SOBRA PREG 21-44 FE
M	60.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.00		
5027	SOBRA PREG 21-44 FE M	19.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
SUBTOTAL:	11,572.00	4,119.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,691.00		

1100	TANF EXPANDED FPR FI	5.00	5.00	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	85.00	1.00	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	275.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	12.00	11.00	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	112.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10.00	
86.00	
289.00	
23.00	
164.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	277.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		419.00		
1118	TANF EXPANDED 45-64	7.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
111G	TANF EXPANDED 21-44	0.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1120	TANF EXPANDED FOR FI	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1127	TANF EXPANDED 21-44	36.00	-17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
1128	TANF EXPANDED 45-64	186.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186.00		
2400	SSI AGED EXPANDED WI	194.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201.00		
240Z	SSI AGED EXPANDED
WI	148.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.00		
2420	SSI AGED EXPANDED WI	39.00	388.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.00		
2600	SSI DISABLED EXPAND
E	181.00	164.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345.00		
260Z	SSI DISABLED EXPAND E	32.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65.00		
2610	SSI DISABLED EXPAND
E	1,010.00	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,064.00		
2620	SSI DISABLED EXPAND E	2,376.00	978.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,354.00		
262Z	SSI DISABLED EXPAND
E	47.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.00		
SUBTOTAL:	5,025.00	1,924.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,949.00		

3507	ADULT 40-100% FEMAL E	0.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL
E	0.00	1.00	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	26.00	26.00	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	349.00	295.00	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	17.00	18.00	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	38.00	302.00	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	394.00	102.00	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	1,734.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	7.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	1.00	-15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	86.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	82.00	475.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	35.00	28.00	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	31.00	55.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370F	ADULT <40% EXP MALE	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP M&F 4	0.00	83.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED
FO	152.00	148.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	155.00	373.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
29.00	
1.00	
52.00	
644.00	
35.00	
340.00	
496.00	
1,762.00	
38.00	
-14.00	
86.00	
1.00	
557.00	
0.00	
63.00	
86.00	
4.00	
83.00	
300.00	
528.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	124.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264.00		
3716	ADULT <40% EXP MALE	2,391.00	2,013.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,404.00		
3717	ADULT <40% EXP FEM AL	2,801.00	1,457.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,258.00		
3718	ADULT <40% EXP M&F
4	2,753.00	2,051.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,804.00		
371F	ADULT <40% EXP MALE	145.00	387.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		532.00		
371G	ADULT <40% EXP FEM AL	155.00	298.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453.00		
371H	ADULT <40% EXP M&F
4	269.00	283.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		552.00		
3720	AHC CARE EXPANDED FO	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3726	ADULT <40% EXP MALE	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
SUBTOTAL:	11,665.00	8,698.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,363.00		

4410	SOBRA 100-133% FOR F	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
1.00	

8700	SSI DISABLED FREEDO M	51.00	4.00	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	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	51.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

55.00	
5.00	
60.00	

3908	NEWLY ELIGIBLE M&F 4	0.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	13.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	31.00	82.00	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	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	32.00	313.00	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	261.00	285.00	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	107.00	543.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	-111.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	14.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	38.00	58.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	0.00	113.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	496.00	1,391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13.00	
18.00	
29.00	
113.00	
15.00	
345.00	
546.00	
650.00	
-111.00	
60.00	
96.00	
113.00	
1,887.00	

TOTAL:	28,810.00	16,141.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,951.00		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	721.86	669.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,391.81		
1005	TANF 14-20 FEMALE WI	8.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.37		
1006	TANF 21-44 MALE WITH	43.54	49.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93.43		
1007	TANF 21-44 FEMALE WI	0.00	48.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.56		
1010	TANF NON-MEDICARE	7,528,314.05	7,511,991.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,040,305.26		
1011	TANF <1 M & F NON-ME	-266.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-266.33		
1014	TANF 14-20 MALE NON-	1,054.08	806.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,860.76		
1015	TANF 14-20 FEMALE N O	3,101.01	3,991.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,092.11		
1016	TANF 21-44 MALE NON-	21,980.86	33,636.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,617.06		
1017	TANF 21-44 FEMALE N O	56,880.49	85,190.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,071.02		
1018	TANF 45-64 M & F NON	15,596.43	20,519.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,115.65		
1019	TANF 65+ M & F NON-M	-6.35	-29.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-35.72		
101A	TANF < 1 M & F NON-M	-35.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-35.73		
101D	TANF 14-20 MALE NON-	1,729.83	2,864.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,594.28		
101E	TANF 14-20 FEMALE N O	3,759.41	4,623.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,383.40		
101F	TANF 21-44 MALE NON-	42,225.70	48,848.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,074.54		
101G	TANF 21-44 FEMALE N O	88,550.44	103,417.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,968.41		
101H	TANF 44-64 M & F NON	19,829.13	24,800.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,629.99		
101J	TANF 65+ N & F NON-M	112.19	578.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		690.51		
1020	TANF WITH QMB	350.91	395.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		746.15		
1026	TANF 21-44 MALE WITH	0.00	-57.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-57.48		
2100	SSI AGED WITH MEDIC A	6,711.47	6,454.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,165.57		
2110	SSI AGED NON-MEDICA
R	304,645.22	312,668.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617,314.00		
211Z	SSI AGED NON-MEDICA R	7,325.76	9,345.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,670.94		
2120	SSI AGED WITH QMB	33,188.84	34,747.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,935.90		
2200	SSI DISABLED WITH M E	11,894.44	11,728.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,622.75		
2210	SSI DISABLED NON-ME
D	1,826,599.90	1,829,961.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,656,561.19		
221Z	SSI DISABLED NON-ME D	19,573.57	27,156.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,729.99		
2220	SSI DISABLED WITH Q
M	43,400.80	43,879.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87,280.26		
2300	SSI BLIND WITH MEDIC	116.97	116.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233.94		
2310	SSI BLIND NON-MEDIC A	21,375.83	21,540.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,916.11		
231Z	SSI BLIND NON-MEDIC
A	985.66	432.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,418.39		
2320	SSI BLIND WITH QMB	849.97	849.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,699.94		
4300	SOBRA CHILD WITH ME D	51.91	51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.82		
4310	SOBRA CHILD NON-ME
DI	1,199,527.27	1,202,853.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,402,380.41		
4311	SOBRA CHILD <1 M & F	0.00	-12.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-12.98		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4312	SOBRA CHILD 01-05 M	-161.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-161.39		
4313	SOBRA CHILD 06-13 M	-23.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-23.44		
4314	SOBRA CHILD 14-20 MA	8,427.67	11,429.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,857.56		
4315	SOBRA CHILD 14-20 FE	8,251.14	13,109.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,360.77		
431D	SOBRA CHILD 14-20 MA	12,387.06	15,098.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,485.65		
431E	SOBRA CHILD 14-20 FE	13,313.17	15,536.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,849.66		
5000	SOBRA PREGNANT WO MAN	0.00	51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.91		
5010	SOBRA PREGNANT WO
MAN	1,134,751.73	1,131,930.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,266,681.84		
5015	SOBRA PREG 14-20 FE M	7,474.09	10,129.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,603.57		
5017	SOBRA PREG 21-44 FE
M	36,560.83	47,140.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,700.95		
5018	SOBRA PREG 45-64 FE M	81.63	113.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194.67		
501E	SOBRA PREG 14-20 FE
M	11,820.56	12,545.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,365.92		
501G	SOBRA PREG 21-44 FE M	53,792.57	59,942.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,735.00		
501H	SOBRA PREG 45-64 FE
M	193.08	257.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		450.99		
SUBTOTAL:	12,547,066.20	12,661,403.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,208,469.94		

1100	TANF EXPANDED FPR FI	4,486.72	4,102.62	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	49.89	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	58.89	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	36.84	182.35	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&	20.40	11.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	7,245,573.06	7,191,699.09	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	219.40	450.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	1,395.00	1,295.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	20,750.25	33,505.33	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	38,140.36	58,236.64	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	16,495.40	23,554.04	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&	-142.34	3.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	724.59	387.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	1,501.08	1,471.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	39,523.53	50,612.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	61,738.58	77,496.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	21,336.56	30,393.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	72.00	48.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,589.34	
49.89	
58.89	
219.19	
32.12	
14,437,272.15	
670.06	
2,690.25	
54,255.58	
96,377.00	
40,049.44	
-138.89	
1,112.34	
2,972.49	
90,135.65	
139,235.31	
51,730.02	
120.56	

4110	EAC NON-MEDICARE	-51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-51.91	
-51.91	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1120	TANF EXPANDED FOR FI	7,388.46	7,768.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,157.00		
1126	TANF EXPANDED 21-44	0.00	42.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.22		
1127	TANF EXPANDED 21-44	11.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.72		
1128	TANF EXPANDED 45-64	1.17	26.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.96		
2400	SSI AGED EXPANDED WI	579.46	611.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,190.97		
2410	SSI AGED EXPANDED
NO	4,629.90	5,308.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,937.94		
241Z	SSI AGED EXPANDED NO	372.82	419.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		792.28		
2420	SSI AGED EXPANDED
WI	23,789.79	26,119.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,909.75		
2600	SSI DISABLED EXPAND E	516.50	279.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796.18		
2610	SSI DISABLED EXPAND
E	82,947.40	83,737.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,684.67		
261Z	SSI DISABLED EXPAND E	1,639.72	1,242.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,881.96		
2620	SSI DISABLED EXPAND
E	13,715.54	13,591.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,306.61		
SUBTOTAL:	7,587,513.80	7,612,656.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,200,170.65		

3500	ADULT 40-100% FOR FI	170.89	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	38.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	98.79	59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	4,935,137.60	4,938,835.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	2,543.67	2,705.56	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	4,207.15	4,307.18	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	12,943.81	16,091.09	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	8,966.17	13,987.14	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	23,376.59	31,932.62	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	-43.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	5,379.27	7,105.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	5,124.57	6,463.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	21,965.91	29,130.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	17,043.40	20,971.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	41,803.57	52,354.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	905.92	486.29	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	43.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	100.47	103.83	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	28.78	88.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

170.89	
38.51	
158.28	
9,873,973.40	
5,249.23	
8,514.33	
29,034.90	
22,953.31	
55,309.21	
-43.54	
12,485.16	
11,587.96	
51,096.22	
38,015.23	
94,157.74	
1,392.21	
43.54	
204.30	
117.53	

3616	AHC CARE/MI MALE 21-	0.00	-51.91	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	-59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-111.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-51.91	
-59.49	
-111.40	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	91.75	35.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126.91		
3710	AHC CARE EXPANDED
FO	10,450,228.78	10,502,948.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,953,176.83		
3714	ADULT <40% EXP MALE	6,115.08	8,625.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,740.19		
3715	ADULT <40% EXP FEM AL	7,339.31	8,582.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,921.72		
3716	ADULT <40% EXP MALE	68,031.82	105,097.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173,129.40		
3717	ADULT <40% EXP FEM AL	39,795.47	54,797.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,592.76		
3718	ADULT <40% EXP M&F
4	68,319.05	90,380.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,699.85		
3719	ADULT <40% EXP M&F 6	-188.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-188.99		
371D	ADULT <40% EXP MALE	12,088.08	11,984.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,072.22		
371E	ADULT <40% EXP FEM AL	11,098.59	11,970.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,069.51		
371F	ADULT <40% EXP MALE	113,555.01	131,660.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		245,215.55		
371G	ADULT <40% EXP FEM AL	64,615.40	76,406.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,021.63		
371H	ADULT <40% EXP M&F
4	103,824.25	118,397.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,222.21		
371J	ADULT <40% EXP M&F 6	273.50	159.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		432.95		
3728	ADULT <40% EXP M&F
4	41.86	36.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.70		
SUBTOTAL:	16,025,025.52	16,245,744.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,270,769.85		

4410	SOBRA 100-133% FOR F	261,749.30	263,955.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,105.62	1,874.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,174.78	1,743.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	2,281.96	2,047.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	2,162.61	3,226.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

525,705.18	
3,980.53	
2,917.95	
4,329.16	
5,389.56	

3900	NEWLY ELIGIBLE FOR F	176.46	170.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR
F	4,279,517.52	4,290,693.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,997.23	2,282.50	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	2,567.80	3,091.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	14,421.46	23,913.07	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	24,200.12	29,808.29	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	17,738.46	22,130.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	3,621.45	3,615.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	4,410.34	5,728.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	28,767.21	34,616.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	40,309.72	45,143.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	31,477.45	34,268.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	117.50	51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,449,322.72	4,495,515.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
347.35	
8,570,211.33	
4,279.73	
5,659.51	
38,334.53	
54,008.41	
39,869.39	
7,237.06	
10,138.53	
63,384.05	
85,453.58	
65,745.83	
169.41	
8,944,838.71	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	269,474.27	272,848.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		542,322.38		

4510	BC PATIENT FOR FINA N	6,511.96	6,730.74	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	195.61	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	214.93	129.10	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	107.54	7.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	412.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4
5	446.37	320.06	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	998.12	998.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	0.00	38.38	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	38.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2
1	57.48	80.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4 5	0.00	169.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,336.40	9,120.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,242.70	
195.61	
344.03	
114.96	
412.84	
766.43	
1,996.24	
38.38	
38.51	
138.08	
169.13	
17,456.91	

8700	SSI DISABLED FREEDO M	436.01	487.92	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	14,946.87	15,896.65	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	1,012.89	1,151.78	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	59.49	59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,455.26	17,595.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
923.93	
30,843.52	
2,164.67	
118.98	
34,051.10	

6015	KIDS 14-19 FEMALE NO	-59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-59.49	
-59.49	

40,903,082.77	41,314,773.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

82,217,856.74	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	13.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
1005	TANF 14-20 FEMALE WI	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1006	TANF 21-44 MALE WITH	26.00	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.00		
1007	TANF 21-44 FEMALE WI	0.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
1010	TANF NON-MEDICARE	137,357.00	137,059.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,416.00		
1011	TANF <1 M & F NON-ME	-152.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-152.00		
1014	TANF 14-20 MALE NON-	595.00	434.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,029.00		
1015	TANF 14-20 FEMALE N O	1,792.00	2,220.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,012.00		
1016	TANF 21-44 MALE NON-	12,481.00	18,845.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,326.00		
1017	TANF 21-44 FEMALE N O	32,174.00	47,933.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,107.00		
1018	TANF 45-64 M & F NON	8,708.00	11,529.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,237.00		
1019	TANF 65+ M & F NON-M	0.00	-18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-18.00		
101A	TANF < 1 M & F NON-M	-22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-22.00		
101D	TANF 14-20 MALE NON-	987.00	1,632.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,619.00		
101E	TANF 14-20 FEMALE N O	2,136.00	2,636.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,772.00		
101F	TANF 21-44 MALE NON-	23,774.00	27,492.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,266.00		
101G	TANF 21-44 FEMALE N O	49,943.00	58,567.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,510.00		
101H	TANF 44-64 M & F NON	11,130.00	14,105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,235.00		
101J	TANF 65+ N & F NON-M	66.00	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408.00		
1020	TANF WITH QMB	6.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1026	TANF 21-44 MALE WITH	0.00	-30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-30.00		
2100	SSI AGED WITH MEDIC A	410.00	282.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		692.00		
2110	SSI AGED NON-MEDICA
R	5,620.00	8,275.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,895.00		
211Z	SSI AGED NON-MEDICA R	4,093.00	5,280.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,373.00		
2120	SSI AGED WITH QMB	495.00	503.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		998.00		
2200	SSI DISABLED WITH M E	227.00	198.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425.00		
2210	SSI DISABLED NON-ME
D	29,393.00	33,767.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,160.00		
221Z	SSI DISABLED NON-ME D	10,972.00	15,279.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,251.00		
2220	SSI DISABLED WITH Q
M	838.00	778.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,616.00		
2300	SSI BLIND WITH MEDIC	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2310	SSI BLIND NON-MEDIC A	366.00	501.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		867.00		
231Z	SSI BLIND NON-MEDIC
A	583.00	256.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		839.00		
2320	SSI BLIND WITH QMB	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
4300	SOBRA CHILD WITH ME D	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4310	SOBRA CHILD NON-ME
DI	21,939.00	21,999.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,938.00		
4311	SOBRA CHILD <1 M & F	0.00	-7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7.00		

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4312	SOBRA CHILD 01-05 M	-91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-91.00		
4313	SOBRA CHILD 06-13 M	-14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-14.00		
4314	SOBRA CHILD 14-20 MA	4,759.00	6,379.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,138.00		
4315	SOBRA CHILD 14-20 FE	4,707.00	7,347.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,054.00		
431D	SOBRA CHILD 14-20 MA	6,926.00	8,468.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,394.00		
431E	SOBRA CHILD 14-20 FE	7,545.00	8,778.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,323.00		
5000	SOBRA PREGNANT WO MAN	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
5010	SOBRA PREGNANT WO
MAN	20,787.00	20,727.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,514.00		
5015	SOBRA PREG 14-20 FE M	4,243.00	5,710.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,953.00		
5017	SOBRA PREG 21-44 FE
M	20,749.00	26,662.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,411.00		
5018	SOBRA PREG 45-64 FE M	47.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111.00		
501E	SOBRA PREG 14-20 FE
M	6,638.00	7,147.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,785.00		
501G	SOBRA PREG 21-44 FE M	30,237.00	34,105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,342.00		
501H	SOBRA PREG 45-64 FE
M	107.00	152.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.00		
SUBTOTAL:	462,613.00	535,489.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		998,102.00		

1100	TANF EXPANDED FPR FI	79.00	72.00	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	26.00	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	34.00	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	22.00	106.00	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&	11.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	131,770.00	130,790.00	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	124.00	247.00	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	786.00	717.00	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	11,628.00	18,736.00	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	21,506.00	32,936.00	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	9,281.00	13,176.00	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&	-85.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	397.00	220.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	838.00	822.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	22,036.00	28,490.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	34,486.00	43,780.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	11,817.00	17,128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	42.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

151.00	
26.00	
34.00	
128.00	
18.00	
262,560.00	
371.00	
1,503.00	
30,364.00	
54,442.00	
22,457.00	
-79.00	
617.00	
1,660.00	
50,526.00	
78,266.00	
28,945.00	
71.00	

4110	EAC NON-MEDICARE	-31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-31.00	
-31.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1120	TANF EXPANDED FOR FI	130.00	137.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267.00		
1126	TANF EXPANDED 21-44	0.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
1127	TANF EXPANDED 21-44	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1128	TANF EXPANDED 45-64	1.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
2400	SSI AGED EXPANDED WI	103.00	210.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		313.00		
2410	SSI AGED EXPANDED
NO	-180.00	295.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.00		
241Z	SSI AGED EXPANDED NO	203.00	243.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446.00		
2420	SSI AGED EXPANDED
WI	430.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		885.00		
2600	SSI DISABLED EXPAND E	134.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.00		
2610	SSI DISABLED EXPAND
E	1,585.00	1,980.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,565.00		
261Z	SSI DISABLED EXPAND E	907.00	708.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,615.00		
2620	SSI DISABLED EXPAND
E	168.00	277.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445.00		
SUBTOTAL:	248,252.00	291,676.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539,928.00		

3500	ADULT 40-100% FOR FI	3.00	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	23.00	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	59.00	31.00	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	89,601.00	89,666.00	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	1,437.00	1,513.00	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	2,392.00	2,427.00	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	7,357.00	8,997.00	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	5,026.00	7,790.00	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	13,101.00	17,607.00	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	-26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	3,004.00	4,010.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	2,873.00	3,660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	12,249.00	16,250.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	9,457.00	11,851.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	23,273.00	29,074.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	521.00	275.00	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	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	60.00	62.00	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	15.00	53.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
23.00	
90.00	
179,267.00	
2,950.00	
4,819.00	
16,354.00	
12,816.00	
30,708.00	
-26.00	
7,014.00	
6,533.00	
28,499.00	
21,308.00	
52,347.00	
796.00	
26.00	
122.00	
68.00	

3616	AHC CARE/MI MALE 21-	0.00	-31.00	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	-31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-62.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-31.00	
-31.00	
-62.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	52.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.00		
3710	AHC CARE EXPANDED
FO	190,341.00	191,306.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381,647.00		
3714	ADULT <40% EXP MALE	3,440.00	4,821.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,261.00		
3715	ADULT <40% EXP FEM AL	4,158.00	4,853.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,011.00		
3716	ADULT <40% EXP MALE	38,731.00	59,119.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,850.00		
3717	ADULT <40% EXP FEM AL	22,590.00	30,748.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,338.00		
3718	ADULT <40% EXP M&F
4	38,414.00	50,613.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,027.00		
3719	ADULT <40% EXP M&F 6	-109.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-109.00		
371D	ADULT <40% EXP MALE	6,744.00	6,772.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,516.00		
371E	ADULT <40% EXP FEM AL	6,189.00	6,821.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,010.00		
371F	ADULT <40% EXP MALE	63,908.00	74,799.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138,707.00		
371G	ADULT <40% EXP FEM AL	36,398.00	43,282.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,680.00		
371H	ADULT <40% EXP M&F
4	58,140.00	66,716.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,856.00		
371J	ADULT <40% EXP M&F 6	153.00	92.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		245.00		
3728	ADULT <40% EXP M&F
4	25.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.00		
SUBTOTAL:	639,602.00	733,274.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,372,876.00		

4410	SOBRA 100-133% FOR F	4,795.00	4,834.00	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	1,179.00	1,040.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	661.00	1,000.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	1,254.00	1,130.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	1,213.00	1,837.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,629.00	
2,219.00	
1,661.00	
2,384.00	
3,050.00	

3900	NEWLY ELIGIBLE FOR F	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR
F	77,879.00	78,078.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,125.00	1,276.00	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	1,471.00	1,743.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	8,119.00	13,443.00	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	13,654.00	16,716.00	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	10,005.00	12,378.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	2,060.00	2,011.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	2,472.00	3,195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	16,044.00	19,452.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	22,514.00	25,501.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	17,472.00	19,176.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	61.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	172,879.00	193,003.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
155,957.00	
2,401.00	
3,214.00	
21,562.00	
30,370.00	
22,383.00	
4,071.00	
5,667.00	
35,496.00	
48,015.00	
36,648.00	
92.00	
365,882.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	9,102.00	9,841.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,943.00		

8700	SSI DISABLED FREEDO M	8.00	9.00	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	586.00	521.00	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	570.00	667.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,165.00	1,198.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17.00	
1,107.00	
1,237.00	
2.00	
2,363.00	

6015	KIDS 14-19 FEMALE NO	-30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-30.00	
-30.00	

4510	BC PATIENT FOR FINA N	116.00	120.00	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	109.00	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	119.00	72.00	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	57.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	229.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4
5	243.00	175.00	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	18.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	0.00	20.00	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	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2
1	30.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4 5	0.00	100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	583.00	912.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
236.00	
109.00	
191.00	
61.00	
229.00	
418.00	
36.00	
20.00	
23.00	
72.00	
100.00	
1,495.00	

TOTAL:	1,534,135.00	1,765,331.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,299,466.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	571,662.28	611,477.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,183,140.04		
1011	TANF <1 M & F NON-ME	13,755.71	7,131.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,886.98		
1012	TANF 01-05 M & F NON	-4,548.84	-5,434.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-9,983.44		
1013	TANF 06-13 M & F NON	1,577.39	1,040.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,618.21		
1014	TANF 14-20 MALE NON-	2,671.57	4,894.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,565.77		
1015	TANF 14-20 FEMALE N O	1,000.46	5,820.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,820.87		
101A	TANF < 1 M & F NON-M	3,387.50	1,546.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,934.04		
101B	TANF 01-05 M & F NON	0.00	-23.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-23.79		
101C	TANF 06-13 M & F NON	1,296.20	876.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,172.45		
101D	TANF 14-20 MALE NON-	49.17	47.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.75		
101E	TANF 14-20 FEMALE N O	90.65	1,879.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,970.29		
2210	SSI DISABLED NON-ME
D	223,316.37	216,270.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		439,587.18		
221Z	SSI DISABLED NON-ME D	880.34	1,190.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,070.66		
4300	SOBRA CHILD WITH ME
D	737.58	737.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,475.16		
4310	SOBRA CHILD NON-ME DI	12,126,022.98	11,903,733.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,029,756.60		
4311	SOBRA CHILD <1 M & F	25,704.10	41,214.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,918.97		
4312	SOBRA CHILD 01-05 M	-26,470.35	-20,488.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-46,958.99		
4313	SOBRA CHILD 06-13 M	-10,870.61	-92,386.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-103,257.27		
4314	SOBRA CHILD 14-20 MA	-14,374.19	-22,086.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-36,460.87		
4315	SOBRA CHILD 14-20 FE	-23,537.71	-23,022.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-46,560.23		
431A	SOBRA CHILD < 1 M &	11,357.74	6,860.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,218.66		
431B	SOBRA CHILD 01-05 M	63,408.56	29,363.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,772.22		
431C	SOBRA CHILD 6-13 M& F	45,217.94	28,157.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,374.97		
431D	SOBRA CHILD 14-20 MA	15,738.23	22,636.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,374.57		
431E	SOBRA CHILD 14-20 FE	18,298.24	20,648.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,946.92		
5010	SOBRA PREGNANT WO MAN	11,719.82	13,394.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,113.90		
5015	SOBRA PREG 14-20 FE
M	-618.62	284.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-334.57		
SUBTOTAL:	13,057,472.51	12,755,763.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,813,236.05		

3510	ADULT 40-100% FOR FI	0.00	737.58	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	333.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	737.58	936.68	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	-689.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	151.08	-876.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	785.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,317.37	798.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
737.58	
333.10	
1,674.26	
-689.99	
-725.17	
785.60	
2,115.38	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending August 31, 2017

25,896,284.96	

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4410

4413	SOBRA 100-133% FOR F
SOBRA 100-133% M&F
6	40,228.46

114.34	38,845.46

-279.25	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	79,073.92

-164.91	
4414	SOBRA 100-133% MALE		-1,879.64	3,445.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,565.78	
4415	SOBRA 100-133% FEMA L		642.41	-1,070.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-428.27	
441C	SOBRA 100-133% M&F
6	0.00	844.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		844.77	
441D	SOBRA 100-133% MALE	0.00	42.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.24	
SUBTOTAL:	39,105.57	41,827.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,933.53	
															
TOTAL:	13,097,895.45	12,798,389.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	670.00	714.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,384.00		
1011	TANF <1 M & F NON-ME	489.00	245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		734.00		
1012	TANF 01-05 M & F NON	-180.00	-187.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-367.00		
1013	TANF 06-13 M & F NON	91.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128.00		
1014	TANF 14-20 MALE NON-	93.00	200.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293.00		
1015	TANF 14-20 FEMALE N O	38.00	215.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253.00		
101A	TANF < 1 M & F NON-M	116.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180.00		
101B	TANF 01-05 M & F NON	0.00	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1.00		
101C	TANF 06-13 M & F NON	48.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.00		
101D	TANF 14-20 MALE NON-	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
101E	TANF 14-20 FEMALE N O	3.00	78.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81.00		
2210	SSI DISABLED NON-ME
D	174.00	246.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		420.00		
221Z	SSI DISABLED NON-ME D	36.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86.00		
4300	SOBRA CHILD WITH ME
D	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4310	SOBRA CHILD NON-ME DI	14,304.00	14,040.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,344.00		
4311	SOBRA CHILD <1 M & F	970.00	1,589.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,559.00		
4312	SOBRA CHILD 01-05 M	-1,068.00	-574.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,642.00		
4313	SOBRA CHILD 06-13 M	-359.00	-3,158.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,517.00		
4314	SOBRA CHILD 14-20 MA	-517.00	-865.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,382.00		
4315	SOBRA CHILD 14-20 FE	-829.00	-783.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,612.00		
431A	SOBRA CHILD < 1 M &	412.00	240.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		652.00		
431B	SOBRA CHILD 01-05 M	2,202.00	1,117.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,319.00		
431C	SOBRA CHILD 6-13 M& F	1,673.00	1,000.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,673.00		
431D	SOBRA CHILD 14-20 MA	586.00	865.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,451.00		
431E	SOBRA CHILD 14-20 FE	643.00	716.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,359.00		
5010	SOBRA PREGNANT WO MAN	14.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
5015	SOBRA PREG 14-20 FE
M	-26.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-20.00		
SUBTOTAL:	19,586.00	15,902.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,488.00		

3510	ADULT 40-100% FOR FI	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	1.00	1.00	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	-29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	5.00	-29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	17.00	-27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
14.00	
2.00	
-29.00	
-24.00	
26.00	
-10.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending August 31, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4410

4413	SOBRA 100-133% FOR F
SOBRA 100-133% M&F
6	48.00

7.00	44.00

-27.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	92.00

-20.00	
4414	SOBRA 100-133% MALE	-79.00	117.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38.00	
4415	SOBRA 100-133% FEMA L	27.00	-45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-18.00	
441C	SOBRA 100-133% M&F
6	0.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00	
441D	SOBRA 100-133% MALE	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00	
SUBTOTAL:	3.00	110.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.00	

TOTAL:	19,606.00	15,985.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,591.00		

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	360.84	360.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		721.68		
1010	TANF NON-MEDICARE	81,858.34	80,550.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162,408.37		
1020	TANF WITH QMB	422.92	364.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		787.64		
2100	SSI AGED WITH MEDIC A	30,144.63	30,562.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,706.68		
2110	SSI AGED NON-MEDICA
R	663.48	663.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,326.96		
2120	SSI AGED WITH QMB	47,183.19	46,929.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,112.84		
2200	SSI DISABLED WITH M E	295,854.29	297,124.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		592,978.48		
2210	SSI DISABLED NON-ME
D	3,191,354.09	3,204,083.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,395,437.32		
2220	SSI DISABLED WITH Q M	603,871.83	605,939.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,209,811.43		
2300	SSI BLIND WITH MEDIC	1,629.60	1,629.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,259.20		
2310	SSI BLIND NON-MEDIC A	8,325.85	8,387.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,713.78		
2320	SSI BLIND WITH QMB	4,320.36	4,643.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,964.21		
SUBTOTAL:	4,265,989.42	4,281,239.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,547,228.59		

8700	SSI DISABLED FREEDO M	1,650.45	1,770.73	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	240.56	240.56	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	564.05	564.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,455.06	2,575.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,421.18	
481.12	
1,128.10	
5,030.40	

4,268,444.48	4,283,814.51

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

8,552,258.99	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1010	TANF NON-MEDICARE	434.00	398.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		832.00		
1020	TANF WITH QMB	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC A	126.00	184.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310.00		
2110	SSI AGED NON-MEDICA
R	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
2120	SSI AGED WITH QMB	325.00	235.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		560.00		
2200	SSI DISABLED WITH M E	2,299.00	2,440.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,739.00		
2210	SSI DISABLED NON-ME
D	25,380.00	25,076.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,456.00		
2220	SSI DISABLED WITH Q M	4,347.00	4,996.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,343.00		
2300	SSI BLIND WITH MEDIC	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
2310	SSI BLIND NON-MEDIC A	57.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.00		
2320	SSI BLIND WITH QMB	28.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.00		
SUBTOTAL:	33,019.00	33,438.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,457.00		

8700	SSI DISABLED FREEDO M	12.00	43.00	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	2.00	2.00	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	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	18.00	49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
55.00	
4.00	
8.00	
67.00	

TOTAL:	33,037.00	33,487.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,524.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2,589.33	2,589.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,178.66		
1010	TANF NON-MEDICARE	230,254.46	230,950.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		461,204.92		
1011	TANF <1 M & F NON-ME	10,542.58	11,542.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,085.34		
1012	TANF 01-05 M & F NON	2,859.42	5,864.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,723.43		
1013	TANF 06-13 M & F NON	6,220.78	8,864.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,085.33		
1014	TANF 14-20 MALE NON-	609.39	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,109.66		
1015	TANF 14-20 FEMALE N O	4,500.81	3,500.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,001.44		
1016	TANF 21-44 MALE NON-	500.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		500.09		
1017	TANF 21-44 FEMALE N O	1,000.18	500.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,500.27		
1020	TANF WITH QMB	863.11	863.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,726.22		
2200	SSI DISABLED WITH M E	27,756.59	30,846.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,602.60		
2210	SSI DISABLED NON-ME
D	5,182,687.05	5,193,036.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,375,723.51		
2220	SSI DISABLED WITH Q M	85,188.88	85,996.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,185.05		
2300	SSI BLIND WITH MEDIC	863.11	863.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,726.22		
2310	SSI BLIND NON-MEDIC A	50,108.57	51,834.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,943.36		
2320	SSI BLIND WITH QMB	863.11	863.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,726.22		
4311	SOBRA CHILD <1 M & F	21,284.97	19,270.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,555.03		
4312	SOBRA CHILD 01-05 M	157,167.47	154,378.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		311,546.40		
4313	SOBRA CHILD 06-13 M	235,190.96	240,864.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		476,055.46		
4314	SOBRA CHILD 14-20 MA	60,250.89	61,529.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,780.15		
4315	SOBRA CHILD 14-20 FE	54,343.85	54,624.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,968.23		
5015	SOBRA PREG 14-20 FE M	1,000.18	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,500.45		
SUBTOTAL:	6,136,645.78	6,161,782.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,298,428.04		

1114	TANF EXPANDED 14-20	500.09	500.09	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	500.09	500.09	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	500.09	500.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,000.18	
1,000.18	
1,000.18	
3,000.54	

3514	ADULT 40-100% MALE 1	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,000.18	1,000.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	7,243.27	7,501.35	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	7,001.26	7,001.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	500.09	1,000.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,516.46	2,500.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	18,761.53	20,503.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,000.54	
2,000.36	
14,744.62	
14,002.52	
1,500.27	
4,016.91	
39,265.22	

3914	NEWLY ELIGIBLE MALE	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,000.54

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,000.54		

4413	SOBRA 100-133% M&F
6	8,001.44	8,001.44	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	2,500.45	2,000.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	5,009.06	4,863.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,510.95	14,865.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,002.88	
4,500.81	
9,872.89	
30,376.58	

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

12,374,070.92	

TOTAL:

6,173,918.80

6,200,152.12

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1010	TANF NON-MEDICARE	267.20	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		535.20		
1011	TANF <1 M & F NON-ME	16.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
1012	TANF 01-05 M & F NON	6.71	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.71		
1013	TANF 06-13 M & F NON	13.54	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.54		
1014	TANF 14-20 MALE NON-	1.98	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.98		
1015	TANF 14-20 FEMALE N O	9.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1016	TANF 21-44 MALE NON-	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1017	TANF 21-44 FEMALE N O	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1020	TANF WITH QMB	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2200	SSI DISABLED WITH M E	33.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.00		
2210	SSI DISABLED NON-ME
D	6,161.82	6,182.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,343.99		
2220	SSI DISABLED WITH Q M	102.08	103.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205.08		
2300	SSI BLIND WITH MEDIC	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2310	SSI BLIND NON-MEDIC A	61.00	63.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.00		
2320	SSI BLIND WITH QMB	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4311	SOBRA CHILD <1 M & F	34.24	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.24		
4312	SOBRA CHILD 01-05 M	251.49	247.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.49		
4313	SOBRA CHILD 06-13 M	380.13	388.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		768.13		
4314	SOBRA CHILD 14-20 MA	91.71	94.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185.71		
4315	SOBRA CHILD 14-20 FE	86.52	86.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172.52		
5015	SOBRA PREG 14-20 FE M	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
SUBTOTAL:	7,527.42	7,566.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,093.59		

1114	TANF EXPANDED 14-20	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1.00	1.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
2.00	
2.00	
6.00	

3514	ADULT 40-100% MALE 1	3.00	3.00	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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	14.49	15.00	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	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1.00	2.00	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	3.04	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36.53	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
4.00	
29.49	
27.00	
3.00	
8.04	
77.53	

3914	NEWLY ELIGIBLE MALE	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		

4413	SOBRA 100-133% M&F
6	16.00	16.00	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	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	9.30	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30.30	29.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
32.00	
9.00	
18.30	
59.30	

TOTAL:	7,600.25	7,642.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,242.42		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,129.39	5,760.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,889.52		
1007	TANF 21-44 FEMALE WI	1,016.91	4,570.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,587.14		
1008	TANF 45-64 M & F WIT	4,063.28	14,411.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,474.77		
1009	TANF 65+ M & F WITH	1,829.47	5,196.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,025.81		
1011	TANF <1 M & F NON-ME	1,284,388.04	1,182,231.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,466,619.58		
1012	TANF 01-05 M & F NON	306,683.16	412,472.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		719,155.53		
1013	TANF 06-13 M & F NON	264,224.37	414,658.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		678,882.76		
1014	TANF 14-20 MALE NON-	86,310.63	160,809.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,120.19		
1015	TANF 14-20 FEMALE N O	206,804.78	321,511.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		528,316.04		
1016	TANF 21-44 MALE NON-	1,605,145.18	2,146,258.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,751,404.17		
1017	TANF 21-44 FEMALE N O	5,140,087.02	7,399,384.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,539,471.61		
1018	TANF 45-64 M & F NON	2,173,545.85	3,146,602.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,320,148.16		
1019	TANF 65+ M & F NON-M	5,538.38	6,532.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,070.57		
1026	TANF 21-44 MALE WITH	1,154.73	3,471.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,626.30		
1027	TANF 21-44 FEMALE WI	1,200.77	2,919.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,120.05		
1028	TANF 45-64 M & F WIT	6,497.01	18,889.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,386.30		
1029	TANF 65+ M & F WITH	167.87	1,843.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,010.90		
2100	SSI AGED WITH MEDIC A	86,634.05	198,717.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285,352.02		
2110	SSI AGED NON-MEDICA
R	100,992.78	173,440.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,433.23		
2120	SSI AGED WITH QMB	397,845.00	1,120,737.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,518,582.17		
2200	SSI DISABLED WITH M E	279,634.07	754,753.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,034,387.81		
2210	SSI DISABLED NON-ME
D	8,103,646.51	12,118,405.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,222,051.59		
2220	SSI DISABLED WITH Q M	1,094,219.47	2,360,048.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,454,268.19		
2300	SSI BLIND WITH MEDIC	136.94	1,989.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,126.06		
2310	SSI BLIND NON-MEDIC A	200,400.19	130,031.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		330,431.46		
2320	SSI BLIND WITH QMB	14,946.76	28,446.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,392.94		
4302	SOBRA CHILD 01-05 M	261.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		261.39		
4303	SOBRA CHILD 06-13 M	0.00	797.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		797.45		
4311	SOBRA CHILD <1 M & F	2,383,990.92	3,303,283.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,687,274.16		
4312	SOBRA CHILD 01-05 M	3,489,044.12	5,024,125.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,513,169.61		
4313	SOBRA CHILD 06-13 M	4,410,433.12	7,025,863.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,436,296.92		
4314	SOBRA CHILD 14-20 MA	1,070,687.79	2,357,534.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,428,222.46		
4315	SOBRA CHILD 14-20 FE	1,570,912.47	2,309,511.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,880,423.99		
5007	SOBRA PREG 21-44 FE M	65.28	178.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243.96		
5015	SOBRA PREG 14-20 FE
M	335,800.58	553,962.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		889,762.77		
5017	SOBRA PREG 21-44 FE M	2,194,707.90	3,296,850.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,491,558.08		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	7,521.12	19,754.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,275.83	
5027	SOBRA PREG 21-44 FE
M	1,129.67	190.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,320.56	
5028	SOBRA PREG 45-64 FE M	0.00	56.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.69	
SUBTOTAL	:	36,832,796.97	56,026,201.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92,858,998.74	

1106	TANF EXPANDED 21-44	7,297.18	14,844.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	7,705.45	27,104.24	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	39,957.51	129,068.40	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&	13,302.89	68,582.67	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	21.08	1,564.00	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	782.00	1,564.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	4,219.99	4,285.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	37,762.36	77,588.83	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	726,388.72	952,513.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,969,469.31	2,959,533.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,527,595.12	2,301,679.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	4,934.02	2,903.20	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	17,006.67	35,328.85	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	71,422.78	90,708.34	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	117,450.01	221,317.21	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&	33,990.50	79,209.66	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	7,895.47	27,114.18	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	8,589.87	18,708.33	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	303,350.37	970,181.74	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	16,597.73	35,014.92	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	174,183.69	189,984.93	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	309,290.16	654,696.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,399,212.88	8,863,496.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22,141.50	
34,809.69	
169,025.91	
81,885.56	
1,585.08	
2,346.00	
8,505.41	
115,351.19	
1,678,902.50	
4,929,003.06	
3,829,274.29	
7,837.22	
52,335.52	
162,131.12	
338,767.22	
113,200.16	
35,009.65	
27,298.20	
1,273,532.11	
51,612.65	
364,168.62	
963,986.40	
14,262,709.06	

3506	ADULT 40-100% MALE 2	7.64	-7.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	1,803.35	3,208.14	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	368.00	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	62,512.51	65,527.84	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	64,453.95	120,805.35	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	1,032,132.33	1,092,897.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	567,849.60	693,283.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	2,072,401.00	3,374,307.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
5,011.49	
368.00	
128,040.35	
185,259.30	
2,125,029.35	
1,261,133.13	
5,446,708.17	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	391.00	1,472.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,863.00		
3707	ADULT <40% EXP FEM AL	71.15	360.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		431.32		
3708	ADULT <40% EXP M&F
4	15,324.82	30,471.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,796.78		
3709	ADULT <40% EXP M&F 6	8.80	1,224.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,233.29		
3714	ADULT <40% EXP MALE	266,479.48	432,725.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		699,205.26		
3715	ADULT <40% EXP FEM AL	308,587.81	494,530.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		803,117.83		
3716	ADULT <40% EXP MALE	6,059,520.29	8,492,593.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,552,113.68		
3717	ADULT <40% EXP FEM AL	3,256,920.31	4,683,150.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,940,070.53		
3718	ADULT <40% EXP M&F
4	8,858,790.44	13,462,857.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,321,648.21		
3719	ADULT <40% EXP M&F 6	5,501.88	5,230.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,731.95		
3728	ADULT <40% EXP M&F
4	0.00	601.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		601.37		
SUBTOTAL:	22,572,756.36	32,955,606.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,528,363.01		

4413	SOBRA 100-133% M&F
6	366,240.89	618,481.49	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	143,656.47	195,066.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	151,202.79	234,581.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	661,100.15	1,048,129.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

984,722.38	
338,722.47	
385,784.42	
1,709,229.27	

4518	BC PATIENT FEMALE 4 5	2,933.81	1,173.00	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,933.81	1,955.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,106.81	
782.00	
4,888.81	

8700	SSI DISABLED FREEDO M	8,702.39	13,545.97	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	10,860.39	12,056.09	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	866.25	4,633.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,429.03	30,235.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22,248.36	
22,916.48	
5,499.33	
50,664.17	

3906	NEWLY ELIGIBLE MALE	79.82	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	1,137.73	2,524.17	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	15,833.99	35,220.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	36,934.84	78,842.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	479,977.47	691,218.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	544,750.39	849,994.66	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	1,554,958.77	1,950,001.07	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,634,455.01	3,608,952.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
447.82	
3,661.90	
782.00	
51,054.92	
115,777.41	
1,171,196.22	
1,394,745.05	
3,504,959.84	
782.00	
6,243,407.16	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	68,123,684.21	102,534,576.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,658,260.22		

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	179.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179.02		
1011	TANF <1 M & F NON-ME	20,654.34	33,591.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,246.20		
1012	TANF 01-05 M & F NON	913.03	363.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,276.78		
1013	TANF 06-13 M & F NON	1,039.71	4,256.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,296.65		
1014	TANF 14-20 MALE NON-	1,523.17	7,089.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,612.39		
1015	TANF 14-20 FEMALE N O	12,542.64	12,701.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,243.65		
1016	TANF 21-44 MALE NON-	15,535.91	27,655.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,191.70		
1017	TANF 21-44 FEMALE N O	69,653.95	123,234.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,888.90		
1018	TANF 45-64 M & F NON	39,319.42	16,665.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,984.75		
2100	SSI AGED WITH MEDIC A	5,270.03	11,195.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,465.78		
2110	SSI AGED NON-MEDICA
R	37,612.82	14,256.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,869.75		
2120	SSI AGED WITH QMB	776.24	185.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		962.14		
2200	SSI DISABLED WITH M E	520.23	3,742.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,262.74		
2210	SSI DISABLED NON-ME
D	10,576.12	5,504.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,080.35		
2220	SSI DISABLED WITH Q M	50.30	317.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		367.30		
4311	SOBRA CHILD <1 M & F	16,884.67	39,379.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,264.66		
4312	SOBRA CHILD 01-05 M	42,887.14	97,036.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139,923.98		
4313	SOBRA CHILD 06-13 M	27,666.18	65,720.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,386.37		
4314	SOBRA CHILD 14-20 MA	14,040.41	32,664.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,705.38		
4315	SOBRA CHILD 14-20 FE	31,383.37	26,150.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,533.91		
5007	SOBRA PREG 21-44 FE M	171.72	144.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316.64		
5015	SOBRA PREG 14-20 FE
M	13,787.75	23,661.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,448.86		
5017	SOBRA PREG 21-44 FE M	98,441.12	121,849.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,291.06		
5018	SOBRA PREG 45-64 FE
M	2,413.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,413.43		
SUBTOTAL:	463,842.72	667,369.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,131,212.39		

1106	TANF EXPANDED 21-44	104.15	947.17	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	542.71	32.47	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	265.37	1,939.82	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&	2,993.18	184.79	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	474.32	1,814.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	137.25	1,384.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	30,766.72	42,100.58	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	60,793.79	137,059.00	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	24,143.24	60,240.06	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	34.42	39.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,051.32	
575.18	
2,205.19	
3,177.97	
2,288.51	
1,521.40	
72,867.30	
197,852.79	
84,383.30	
73.55	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	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	
1129	TANF EXPANDED 65+	435.37	125.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	560.75	
M&
2400	SSI AGED EXPANDED
WI
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
SUBTOTAL:	
17,993.30

25.94

3,603.28

7,174.68

423.01

149,910.73	
15,628.68

2,104.32

4,730.53

629.11

1,356.66

270,684.04	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
33,621.98

2,130.26

8,333.81

7,803.79

1,779.67

420,594.77	

3506	ADULT 40-100% MALE 2	120.85	2,659.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	624.07	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	239.04	1,314.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	13,594.81	4,428.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	4,133.27	4,086.31	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	91,283.78	55,263.14	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	25,916.64	26,658.91	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	100,927.35	257,736.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	137.25	314.90	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	111.36	100.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	16,238.85	19,414.27	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	10,768.18	7,658.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	261,422.48	400,621.91	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	128,226.62	216,375.93	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	286,377.69	405,922.93	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	351.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	939,849.78	1,403,179.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,780.56	
624.07	
1,553.47	
18,023.30	
8,219.58	
146,546.92	
52,575.55	
358,663.79	
0.00	
452.15	
211.65	
35,653.12	
18,426.35	
662,044.39	
344,602.55	
692,300.62	
351.61	
2,343,029.68	

3908	NEWLY ELIGIBLE M&F 4	1,402.06	21.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	2,389.35	13,710.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,322.65	5,661.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	72,134.95	95,036.78	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	56,888.09	108,315.27	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	214,461.35	323,475.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	350,598.45	546,220.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,423.56	
16,100.07	
8,983.77	
167,171.73	
165,203.36	
537,936.69	
896,819.18	

4413	SOBRA 100-133% M&F
6	6,531.52	45,078.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,324.01	14,768.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

51,610.26	
16,092.17	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	5,359.35	2,711.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,070.85		
SUBTOTAL:	13,214.88	62,558.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,773.28		

8700	SSI DISABLED FREEDO M	250.85	2,220.64	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	338.21	234.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	589.06	2,455.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,471.49	
573.11	
3,044.60	

TOTAL:	1,918,005.62	2,952,468.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,870,473.90		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
9000	PRESUMPTIVE ELIGIBI L	607.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		607.14		
SUBTOTAL:	607.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		607.14		

607.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	630.24	620.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,250.83		
1011	TANF <1 M & F NON-ME	1,217.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,217.98		
1012	TANF 01-05 M & F NON	53,550.51	33,460.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87,011.46		
1013	TANF 06-13 M & F NON	72,651.17	167,216.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239,867.66		
1014	TANF 14-20 MALE NON-	103,021.56	260,724.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		363,745.82		
1015	TANF 14-20 FEMALE N O	361,349.27	528,169.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		889,518.44		
1016	TANF 21-44 MALE NON-	171.94	27,657.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,829.51		
1017	TANF 21-44 FEMALE N O	2,700,519.09	4,054,600.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,755,119.92		
1018	TANF 45-64 M & F NON	32,916.39	90,936.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,852.73		
2100	SSI AGED WITH MEDIC A	51,503.65	80,558.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,062.16		
2110	SSI AGED NON-MEDICA
R	1,449,964.08	1,564,496.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,014,461.03		
2120	SSI AGED WITH QMB	99.26	8,828.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,927.95		
2200	SSI DISABLED WITH M E	12,126.62	7,473.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,600.13		
2210	SSI DISABLED NON-ME
D	253,261.18	373,683.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		626,944.45		
SUBTOTAL:	5,092,982.94	7,198,427.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,291,410.07		

3906	NEWLY ELIGIBLE MALE	1,021.74	2,141.12	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	32.66	738.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	124,589.01	188,655.12	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	60,822.10	251,110.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,062,047.66	1,877,746.60	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	600,175.18	766,277.48	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	2,696,799.28	4,203,036.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,162.86	
770.76	
313,244.13	
311,933.00	
2,939,794.26	
1,366,452.66	
6,899,835.70	

1106	TANF EXPANDED 21-44	56.86	5,273.18	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	399.51	14,866.05	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&	613.54	4,701.08	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	2,565.40	320.54	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	26,635.69	37,853.47	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	826,854.00	1,421,530.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	2,135,572.36	3,034,778.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,061,403.35	1,427,245.50	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&	18,877.09	27,888.93	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	1,398.10	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	3,771.50	18,467.70	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	2,712.11	7,161.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,079,461.41	6,001,485.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,330.04	
15,265.56	
5,314.62	
2,885.94	
64,489.16	
2,248,384.19	
5,170,351.32	
2,488,648.85	
46,766.02	
1,398.10	
22,239.20	
9,873.87	
10,080,946.87	

FEDERAL EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3919	NEWLY ELIGIBLE M&F 6	10,249.05	36,165.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,414.09		
SUBTOTAL:	4,555,736.68	7,325,870.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,881,607.46		

0.00

0.00

0.00	0.00

TOTAL:

13,728,181.03

20,525,783.37

0.00

0.00

0.00

0.00

0.00

0.00

34,253,964.40

QMB - FEE FOR SERVICE
For The Period Ending August 31, 2017

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	489,557.87	701,000.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	1,190,558.58	
SUBTOTAL:	489,557.87	701,000.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	1,190,558.58	
															
TOTAL:	489,557.87	701,000.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00			

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	72.68	774.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846.99		
1011	TANF <1 M & F NON-ME	2,225.53	3,895.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,120.67		
1012	TANF 01-05 M & F NON	37,646.36	36,850.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,496.37		
1013	TANF 06-13 M & F NON	128,263.92	193,268.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321,532.07		
1014	TANF 14-20 MALE NON-	48,337.90	47,383.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,720.90		
1015	TANF 14-20 FEMALE N O	71,871.24	74,760.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,631.38		
1016	TANF 21-44 MALE NON-	526,340.17	530,196.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,056,536.55		
1017	TANF 21-44 FEMALE N O	1,657,566.19	1,783,786.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,441,352.63		
1018	TANF 45-64 M & F NON	304,329.16	286,978.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		591,307.56		
1027	TANF 21-44 FEMALE WI	0.00	118.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118.15		
2100	SSI AGED WITH MEDIC A	6,043.44	4,391.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,435.26		
2120	SSI AGED WITH QMB	12,745.09	25,137.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,882.88		
2200	SSI DISABLED WITH M E	22,244.82	32,885.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,129.85		
2210	SSI DISABLED NON-ME
D	1,848,011.72	2,445,227.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,293,238.93		
2220	SSI DISABLED WITH Q M	244,729.87	318,582.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		563,312.60		
2310	SSI BLIND NON-MEDIC
A	4,323.76	8,552.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,876.03		
2320	SSI BLIND WITH QMB	840.76	1,979.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,819.90		
4303	SOBRA CHILD 06-13 M	2,346.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,346.00		
4311	SOBRA CHILD <1 M & F	3,194.00	8,940.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,134.02		
4312	SOBRA CHILD 01-05 M	173,404.17	220,673.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394,077.31		
4313	SOBRA CHILD 06-13 M	3,398,748.51	4,311,852.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,710,601.42		
4314	SOBRA CHILD 14-20 MA	705,666.83	1,292,395.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,998,062.78		
4315	SOBRA CHILD 14-20 FE	1,409,888.39	1,269,627.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,679,515.96		
5015	SOBRA PREG 14-20 FE M	22,369.78	34,154.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,524.00		
5017	SOBRA PREG 21-44 FE
M	245,508.84	263,390.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		508,899.65		
SUBTOTAL:	10,876,719.13	13,195,800.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,072,519.86		

1106	TANF EXPANDED 21-44	251.01	237.62	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	39.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,003.97	1,158.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	2,043.45	2,836.72	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	206,693.38	290,344.07	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	582,408.48	448,662.96	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	202,226.77	145,351.59	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	331.99	2,174.75	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	1,429.72	10,646.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
488.63	
39.46	
2,162.68	
4,880.17	
497,037.45	
1,031,071.44	
347,578.36	
2,506.74	
12,076.51	

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	1,143.92	1,376.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,520.78	
1129	TANF EXPANDED 65+	109.11	69.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178.91	
M&
2400	SSI AGED EXPANDED
WI
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
SUBTOTAL:	
391.00

9,823.47

262.30

7,367.02

42,920.78

1,058,406.37	
0.00

13,042.81

227.63

10,021.65

65,547.02

991,738.44	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
391.00

22,866.28

489.93

17,388.67

108,467.80

2,050,144.81	

3508	ADULT 40-100% M&F 45	-368.00	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	13,135.27	20,731.56	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	35,764.55	66,257.20	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	246,082.11	245,977.75	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	64,497.56	70,223.15	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	84,172.14	119,930.46	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	449.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	202,765.41	143,906.96	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	83,487.39	155,990.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	2,123,297.17	2,393,602.77	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	985,282.52	1,174,938.57	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	1,246,326.78	1,249,929.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,084,892.74	5,641,487.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-368.00	
33,866.83	
102,021.75	
492,059.86	
134,720.71	
204,102.60	
449.84	
346,672.37	
239,477.77	
4,516,899.94	
2,160,221.09	
2,496,255.88	
10,726,380.64	

3914	NEWLY ELIGIBLE MALE	2,529.29	2,063.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1,679.70	3,811.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	35,276.13	73,528.89	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	39,566.89	58,110.12	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	65,086.20	65,328.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	144,138.21	202,842.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,592.79	
5,490.74	
108,805.02	
97,677.01	
130,414.66	
346,980.22	

4413	SOBRA 100-133% M&F
6	89,140.44	118,536.69	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	52,645.65	80,242.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	44,171.47	94,883.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	185,957.56	293,661.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

207,677.13	
132,887.66	
139,054.47	
479,619.26	

8700	SSI DISABLED FREEDO M	458.48	186.31	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	23.63	23.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1,832.76	1,706.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

644.79	
47.26	
3,539.65	

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,314.87	1,916.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,231.70		

TOTAL:	17,352,428.88	20,327,447.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,679,876.49		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME D	6,531.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,531.12	
SUBTOTAL	:	6,531.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,531.12	

1117	TANF EXPANDED 21-44	0.00	1,839.66	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	816.39	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	2,632.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	816.39	4,471.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,839.66	
816.39	
2,632.00	
5,288.05	

3716	ADULT <40% EXP MALE	0.00	9,796.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	2,449.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,449.17	9,796.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,796.68	
2,449.17	
12,245.85	

3916	NEWLY ELIGIBLE MALE	0.00	3,265.56	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	13,062.24	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	37,553.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	53,881.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,265.56	
13,062.24	
37,553.94	
53,881.74	

0.00

0.00

0.00

0.00

TOTAL:

9,796.68

68,150.08	0.00

0.00	0.00	0.00	0.00

0.00

77,946.76

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	15,377.05	33,561.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,938.27	
2110	SSI AGED NON-MEDICA
R	177,423.98	68,832.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	246,256.08	
2210	SSI DISABLED NON-ME D	5,645.08	13,622.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,267.86	
4315	SOBRA CHILD 14-20 FE	0.00	-15,761.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-15,761.81	
5017	SOBRA PREG 21-44 FE M	24,901.43	31,636.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,538.36	
SUBTOTAL	:	223,347.54	131,891.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	355,238.76	

3908	NEWLY ELIGIBLE M&F 4	8,152.60	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	55,900.91	7,936.85	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	20,649.50	36,830.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	84,703.01	44,767.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,152.60	
63,837.76	
57,480.14	
129,470.50	

3517	ADULT 40-100% FEMAL E	0.00	2,705.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	58,454.33	12,529.30	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	3,428.50	2,306.68	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	47,375.99	49,885.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	328.84	80.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	405,461.03	295,360.98	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	37,835.08	29,296.66	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	468,306.67	320,396.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,021,190.44	712,562.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,705.73	
70,983.63	
5,735.18	
97,261.77	
409.00	
0.00	
700,822.01	
67,131.74	
788,703.39	
1,733,752.45	

TOTAL:	1,329,240.99	889,220.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,218,461.71		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	171.60	1,342.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,513.71		
1017	TANF 21-44 FEMALE N O	6,455.31	3,931.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,386.31		
2120	SSI AGED WITH QMB	247.02	5,399.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,646.90		
2210	SSI DISABLED NON-ME D	15,929.93	31.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,961.09		
2220	SSI DISABLED WITH Q
M	12,271.60	16,645.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,917.32		
4314	SOBRA CHILD 14-20 MA	0.00	1,487.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,487.29		
4315	SOBRA CHILD 14-20 FE	22,968.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,968.07		
5015	SOBRA PREG 14-20 FE M	8,096.59	38.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,135.38		
5017	SOBRA PREG 21-44 FE
M	2,545.71	1,163.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,709.11		
SUBTOTAL:	68,685.83	30,039.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,725.18		

1117	TANF EXPANDED 21-44	4,021.80	894.58	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	2,400.29	348.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,422.09	1,242.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,916.38	
2,748.30	
7,664.68	

3516	ADULT 40-100% MALE 2	7,986.74	160.34	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	15,966.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	9,397.56	1,679.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	26,893.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	208,629.72	93,904.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,399.45	21,413.18	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	31,242.46	28,604.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	258,655.93	188,622.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,147.08	
15,966.79	
11,077.23	
26,893.55	
302,534.69	
22,812.63	
59,846.85	
447,278.82	

333,763.85	219,904.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

553,668.68	

TOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME D	0.00	3,527.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,527.93	
5017	SOBRA PREG 21-44 FE
M	0.00	2,685.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,685.93	
SUBTOTAL	:	0.00	6,213.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,213.86	

3717	ADULT <40% EXP FEM AL	0.00	2,443.92	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	2,157.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	4,601.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,443.92	
2,157.51	
4,601.43	

TOTAL:	0.00	10,815.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,815.29		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	690.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	690.05	
2210	SSI DISABLED NON-ME D	564.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	564.31	
SUBTOTAL	:	564.31	690.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,254.36	

3518	ADULT 40-100% M&F 45	0.00	252.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	5,931.58	6,252.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,058.04	7,602.61	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	6,153.29	17,799.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,142.91	31,906.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
252.30	
12,183.85	
10,660.65	
23,952.46	
47,049.26	

3916	NEWLY ELIGIBLE MALE	398.34	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	195.36	387.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	593.70	387.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
398.34	
583.16	
981.50	

16,300.92	32,984.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

49,285.12	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		0.00		
3718	ADULT <40% EXP M&F 4	498.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.60		
SUBTOTAL:	498.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.60		

TOTAL:	498.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.60		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.00		
2100	SSI AGED WITH MEDIC A	2,701,850.75	3,388,420.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,090,271.66		
2110	SSI AGED NON-MEDICA
R	234,576.01	198,055.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		432,631.37		
2120	SSI AGED WITH QMB	3,395,570.95	4,480,987.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,876,558.30		
2200	SSI DISABLED WITH M E	733,207.80	846,565.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,579,772.96		
2210	SSI DISABLED NON-ME
D	3,088,233.12	4,441,270.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,529,503.31		
2220	SSI DISABLED WITH Q M	873,654.11	1,373,064.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,246,718.34		
2310	SSI BLIND NON-MEDIC
A	37,466.58	37,722.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,189.26		
2320	SSI BLIND WITH QMB	8,806.95	8,742.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,549.00		
SUBTOTAL:	11,073,366.27	14,775,218.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,848,585.20		

8710	SSI DISABLED FREEDO M	0.00	1,326.10	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	2,533.80	3,044.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,533.80	4,370.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,326.10	
5,577.96	
6,904.06	

11,075,900.07    14,779,589.19

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	25,863.39	26,286.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,150.26		
2120	SSI AGED WITH QMB	636.37	359.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		996.26		
2200	SSI DISABLED WITH M E	2,582.24	3,739.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,321.24		
2210	SSI DISABLED NON-ME
D	1,948.84	324.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,273.77		
SUBTOTAL:	31,030.84	30,710.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,741.53		

TOTAL:	31,030.84	30,710.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,741.53		

COCHISE COUNTY INMATES LTC  FEE FOR SERVICE
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MALE	0.00	1,483.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,483.41		
SUBTOTAL:	0.00	1,483.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,483.41		

0.00	1,483.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	165.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.72		
SUBTOTAL:	165.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.72		

0.00

0.00

0.00	0.00

TOTAL:

165.72

0.00

0.00

0.00

0.00

0.00

0.00

0.00

165.72

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	20,344.58	9,944.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,289.51		
1013	TANF 06-13 M & F NON	48,993.85	20,403.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,397.84		
1014	TANF 14-20 MALE NON-	4,535.34	2,295.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,830.89		
1015	TANF 14-20 FEMALE N O	2,237.61	2,032.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,269.62		
2200	SSI DISABLED WITH M
E	42.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.96		
2210	SSI DISABLED NON-ME D	246,230.53	103,186.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		349,417.31		
2220	SSI DISABLED WITH Q
M	481.95	67.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		549.40		
2310	SSI BLIND NON-MEDIC A	3,023.33	882.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,906.05		
4303	SOBRA CHILD 06-13 M	117.42	78.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195.70		
4312	SOBRA CHILD 01-05 M	22,028.71	15,618.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,647.30		
4313	SOBRA CHILD 06-13 M	108,381.63	49,032.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,414.28		
4314	SOBRA CHILD 14-20 MA	10,627.54	4,788.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,416.24		
4315	SOBRA CHILD 14-20 FE	3,879.34	1,247.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,126.98		
5015	SOBRA PREG 14-20 FE M	143.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143.36		
SUBTOTAL:	471,068.15	209,579.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		680,647.44		

1114	TANF EXPANDED 14-20	80.72	16.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	80.72	16.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
97.61	
97.61	

3514	ADULT 40-100% MALE 1	65.76	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	65.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	198.82	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	485.53	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	431.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	815.87	431.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
65.76	
65.76	
198.82	
485.53	
431.12	
1,246.99	

3914	NEWLY ELIGIBLE MALE	10.30	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	18.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10.30	
18.96	
29.26	

4413	SOBRA 100-133% M&F
6	24,577.42	7,963.33	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	2,590.74	1,053.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	379.24	201.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	27,547.40	9,218.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
32,540.75	
3,644.44	
580.43	
36,765.62	

499,541.40	219,245.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending August 31, 2017

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,547.22	891.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,438.33	
1010	TANF NON-MEDICARE	46,160.98	19,385.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,546.57	
2200	SSI DISABLED WITH M E	2,162.91	1,390.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,553.78	
2210	SSI DISABLED NON-ME
D	1,473,846.63	806,564.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,280,411.53	
2220	SSI DISABLED WITH Q M	6,290.82	5,411.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,702.20	
2310	SSI BLIND NON-MEDIC
A	10,493.31	3,206.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,699.77	
SUBTOTAL:	1,540,501.87	836,850.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,377,352.18	

TOTAL:	1,540,501.87	836,850.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,377,352.18		

ACUTE REINSURANCE
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	76.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.49		
1011	TANF <1 M & F NON-ME	792,098.45	731,912.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,524,010.59		
1012	TANF 01-05 M & F NON	93,618.58	43,751.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,369.82		
1013	TANF 06-13 M & F NON	97,360.29	42,224.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139,584.81		
1014	TANF 14-20 MALE NON-	100,226.61	93.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,319.78		
1015	TANF 14-20 FEMALE N O	12,664.01	47,657.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,321.94		
1016	TANF 21-44 MALE NON-	78,305.08	-358.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,946.96		
1017	TANF 21-44 FEMALE N O	385,737.83	168,770.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		554,508.40		
1018	TANF 45-64 M & F NON	496,933.25	25,280.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		522,213.71		
2100	SSI AGED WITH MEDIC A	24,935.52	11,582.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,518.09		
2110	SSI AGED NON-MEDICA
R	229,962.20	84,260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,222.20		
2200	SSI DISABLED WITH M E	9,940.06	79,656.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,596.92		
2210	SSI DISABLED NON-ME
D	7,086,206.83	5,515,241.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,601,448.26		
2310	SSI BLIND NON-MEDIC A	0.00	5,180.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,180.64		
4311	SOBRA CHILD <1 M & F	1,999,947.14	1,220,733.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,220,680.80		
4312	SOBRA CHILD 01-05 M	462,002.32	404,898.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		866,900.35		
4313	SOBRA CHILD 06-13 M	676,994.95	300,678.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		977,673.60		
4314	SOBRA CHILD 14-20 MA	868,929.19	329,418.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,198,347.20		
4315	SOBRA CHILD 14-20 FE	203,212.23	283,295.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		486,507.81		
5015	SOBRA PREG 14-20 FE M	47,663.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,663.05		
5017	SOBRA PREG 21-44 FE
M	34,632.31	31,320.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,953.16		
5018	SOBRA PREG 45-64 FE M	8,570.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,570.09		
SUBTOTAL:	13,710,016.48	9,325,598.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,035,614.67		

3514	ADULT 40-100% MALE 1	8.44	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	13,969.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	267,573.16	141,658.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	11,751.92	75,057.61	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	788,762.31	418,359.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8.44	
13,969.80	
409,232.10	
86,809.53	
1,207,121.42	

1106	TANF EXPANDED 21-44	111.02	111.55	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	180,654.25	175,659.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	231,889.35	96,585.68	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	35,705.65	166,748.45	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	3,865.29	-2,181.93	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	99,989.18	-94,492.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	552,214.74	342,431.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
222.57	
356,314.11	
328,475.03	
202,454.10	
1,683.36	
5,496.60	
894,645.77	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	-2,793.83	8,981.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,187.31	
3714	ADULT <40% EXP MALE	228,452.96	-120,588.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	107,864.76	
3715	ADULT <40% EXP FEM AL	14,127.00	305.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,432.69	
3716	ADULT <40% EXP MALE	1,495,808.20	651,446.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,147,254.44	
3717	ADULT <40% EXP FEM AL	414,152.76	223,792.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	637,945.72	
3718	ADULT <40% EXP M&F
4	2,435,047.46	1,657,445.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,092,492.75	
SUBTOTAL	:	5,666,860.18	3,056,458.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,723,318.96	

3908	NEWLY ELIGIBLE M&F 4	0.00	12,015.55	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	8,952.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	193,608.25	27,647.28	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	59,730.80	-38,365.56	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	276,143.01	108,976.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	529,482.06	119,226.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,015.55	
8,952.17	
221,255.53	
21,365.24	
385,119.71	
648,708.20	

4413	SOBRA 100-133% M&F
6	88,977.54	47,399.25	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	150,883.37	13,995.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	56,178.29	56,758.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	296,039.20	118,152.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
136,376.79	
164,878.46	
112,936.70	
414,191.95	

8700	SSI DISABLED FREEDO M	0.00	317.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	88,742.04	14,509.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	88,742.04	14,826.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
317.33	
103,251.60	
103,568.93	

20,843,354.70	12,976,693.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

33,820,048.48	

TOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	502,760.84	215,750.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	718,511.19	
2110	SSI AGED NON-MEDICA
R	266,303.82	119,525.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	385,829.12	
2200	SSI DISABLED WITH M E	791,017.80	929,431.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,720,449.02	
2210	SSI DISABLED NON-ME
D	7,130,392.69	5,130,860.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,261,252.84	
2310	SSI BLIND NON-MEDIC A	17,679.65	34,070.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,749.82	
SUBTOTAL	:	8,708,154.80	6,429,637.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,137,791.99	

TOTAL:	8,708,154.80	6,429,637.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,137,791.99		

ACUTE SMIB
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	47,483.40	50,553.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,037.10		
1010	TANF NON-MEDICARE	804.00	938.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,742.00		
1020	TANF WITH QMB	41,088.00	44,170.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,258.00		
2100	SSI AGED WITH MEDIC A	91,554.30	80,144.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,698.30		
2110	SSI AGED NON-MEDICA
R	556,826.60	577,728.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,134,555.20		
2120	SSI AGED WITH QMB	3,808,373.40	3,854,498.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,662,871.50		
2200	SSI DISABLED WITH M E	127,371.30	120,530.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,901.30		
2210	SSI DISABLED NON-ME
D	422,855.00	441,700.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		864,555.40		
2220	SSI DISABLED WITH Q M	3,959,927.70	3,927,844.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,887,772.10		
2300	SSI BLIND WITH MEDIC	402.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		536.00		
2310	SSI BLIND NON-MEDIC A	3,886.00	3,618.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,504.00		
2320	SSI BLIND WITH QMB	34,170.00	35,778.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,948.00		
4300	SOBRA CHILD WITH ME D	134.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.00		
4320	SOBRA CHILD WITH Q
MB	268.00	402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		670.00		
5020	SOBRA PREGNANT WO MAN	5,494.00	6,298.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,792.00		
8000	SMIB ONLY NOT ELIGIB	0.00	-268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-268.00		
8020	QMB ONLY	987,237.40	1,001,287.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,988,524.50		
8040	SLMB	4,832,276.40	4,846,587.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,678,864.30		
8888	SMIB ONLY NOT ELIGIB	-62,604.00	-43,500.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-106,104.20		
9999	SMIB ONLY NOT ELIGIB	-44,786.20	51,555.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,769.60		
SUBTOTAL:	14,812,761.30	15,000,133.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,812,895.10		

3520	ADULT 40-100% FOR FI	134.00	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	1,072.00	804.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,206.00	1,072.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

402.00	
1,876.00	
2,278.00	

3920	NEWLY ELIGIBLE FOR F	268.00	511.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

779.60	

1100	TANF EXPANDED FPR FI	305,316.20	277,543.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR
FI	670.00	536.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	808,222.30	831,224.80	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	-804.00	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	3,072,858.80	3,099,648.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED
W	134.00	134.00	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	-536.00	-134.00	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	2,308,863.50	2,412,953.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,494,724.80	6,621,905.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
582,859.80	
1,206.00	
1,639,447.10	
-804.00	
6,172,507.00	
268.00	
-670.00	
4,721,816.80	
13,116,630.70	

ACUTE SMIB
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	268.00	511.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		779.60		

8720	SSI DISABLED FREEDO M	28,660.00	30,276.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,660.00	30,276.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
58,936.00	
58,936.00	

0.00

0.00

0.00

0.00

TOTAL:

21,337,620.10

21,653,899.30	0.00

0.00	0.00	0.00	0.00

0.00

42,991,519.40

ACUTE HIB
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1020	TANF WITH QMB	-1,239.00	-2,041.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,280.00		
2100	SSI AGED WITH MEDIC A	2,065.00	2,065.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,130.00		
2110	SSI AGED NON-MEDICA
R	0.00	6,422.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,422.00		
2120	SSI AGED WITH QMB	353,535.60	402,764.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		756,300.50		
2200	SSI DISABLED WITH M E	0.00	227.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.00		
2210	SSI DISABLED NON-ME
D	0.00	2,292.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,292.00		
2220	SSI DISABLED WITH Q M	175,048.90	190,674.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365,723.80		
2320	SSI BLIND WITH QMB	867.30	867.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,734.60		
8000	SMIB ONLY NOT ELIGIB	0.00	1,239.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,239.00		
8020	QMB ONLY	5,843.80	4,439.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,283.40		
9999	SMIB ONLY NOT ELIGIB	-5,513.40	-2,601.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-8,115.00		
SUBTOTAL:	530,608.20	606,349.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,136,957.30		

1120	TANF EXPANDED FOR FI	681.00	681.00	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	3,881.90	4,294.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,562.90	4,975.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,362.00	
8,176.80	
9,538.80	

TOTAL:	535,171.10	611,325.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,146,496.10		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,616,960.40	2,647,029.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,263,990.30	
9999	SMIB ONLY NOT ELIGIB	-31,415.00	-9,770.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-41,185.20	

SUBTOTAL:	
2,585,545.40	
2,637,259.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
5,222,805.10	

Q1
For The Period Ending August 31, 2017

2,585,545.40	2,637,259.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,222,805.10	

TOTAL:

LTC SMIB
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	804.00	1,072.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,876.00		
1020	TANF WITH QMB	536.00	402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938.00		
2100	SSI AGED WITH MEDIC A	1,098,996.50	1,086,174.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,185,170.80		
2110	SSI AGED NON-MEDICA
R	205,154.00	207,846.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		413,000.00		
2120	SSI AGED WITH QMB	1,000,128.60	1,012,229.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,012,358.00		
2200	SSI DISABLED WITH M E	418,872.80	414,703.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		833,576.60		
2210	SSI DISABLED NON-ME
D	27,872.00	30,150.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,022.00		
2220	SSI DISABLED WITH Q M	934,051.30	940,261.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,874,313.00		
2300	SSI BLIND WITH MEDIC	1,206.00	1,206.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,412.00		
2310	SSI BLIND NON-MEDIC A	268.00	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		536.00		
2320	SSI BLIND WITH QMB	5,888.00	5,888.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,776.00		
SUBTOTAL:	3,693,777.20	3,700,201.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,393,978.40		

8720	SSI DISABLED FREEDO M	804.00	804.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	804.00	804.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,608.00	
1,608.00	

TOTAL:	3,694,581.20	3,701,005.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,395,586.40		

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

2110	SSI AGED WITH MEDIC A
SSI AGED NON-MEDICA
R	413.00

0.00	413.00

1,239.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	826.00

1,239.00	
2120	SSI AGED WITH QMB	267,064.80	266,940.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	534,005.40	
2210

2220

SUBTOTAL	SSI DISABLED NON-ME D
SSI DISABLED WITH Q
M
:	0.00

13,492.00

280,969.80	413.00

18,254.00

287,259.60	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	0.00

0.00

0.00	413.00

31,746.00

568,229.40	

LTC HIB
For The Period Ending August 31, 2017

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

568,229.40	

TOTAL:

280,969.80

287,259.60

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 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	1,569.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,569.59		
1007	TANF 21-44 FEMALE WI	119.92	1,352.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,472.28		
1008	TANF 45-64 M & F WIT	799.65	7,922.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,722.16		
1009	TANF 65+ M & F WITH	1,384.02	4,601.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,985.41		
1011	TANF <1 M & F NON-ME	669,157.30	792,264.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,461,421.65		
1012	TANF 01-05 M & F NON	243,450.23	314,582.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		558,032.96		
1013	TANF 06-13 M & F NON	207,131.18	326,430.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		533,561.72		
1014	TANF 14-20 MALE NON-	68,592.28	129,798.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198,390.62		
1015	TANF 14-20 FEMALE N O	162,337.41	244,265.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406,602.67		
1016	TANF 21-44 MALE NON-	879,640.25	1,273,282.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,152,922.50		
1017	TANF 21-44 FEMALE N O	3,360,795.09	5,320,801.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,681,596.95		
1018	TANF 45-64 M & F NON	1,438,361.58	2,211,724.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,650,086.43		
1019	TANF 65+ M & F NON-M	4,301.00	5,474.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,775.00		
1026	TANF 21-44 MALE WITH	205.10	1,202.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,407.22		
1027	TANF 21-44 FEMALE WI	225.00	1,046.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,271.60		
1028	TANF 45-64 M & F WIT	3,286.56	11,252.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,538.97		
1029	TANF 65+ M & F WITH	15.72	1,008.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,023.94		
2100	SSI AGED WITH MEDIC A	31,295.11	144,458.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,753.15		
2110	SSI AGED NON-MEDICA
R	54,723.22	112,881.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,604.24		
2120	SSI AGED WITH QMB	134,473.34	821,999.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		956,472.70		
2200	SSI DISABLED WITH M E	81,771.02	418,355.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		500,126.57		
2210	SSI DISABLED NON-ME
D	4,257,729.54	6,230,255.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,487,984.64		
2220	SSI DISABLED WITH Q M	253,351.98	1,279,413.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,532,765.88		
2300	SSI BLIND WITH MEDIC	0.00	1,813.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,813.13		
2310	SSI BLIND NON-MEDIC A	58,144.64	56,537.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,682.30		
2320	SSI BLIND WITH QMB	3,118.22	16,427.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,545.97		
4302	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		
4303	SOBRA CHILD 06-13 M	0.00	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		782.00		
4311	SOBRA CHILD <1 M & F	1,660,593.03	1,978,758.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,639,351.05		
4312	SOBRA CHILD 01-05 M	2,593,837.97	3,894,121.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,487,959.06		
4313	SOBRA CHILD 06-13 M	3,472,830.09	5,542,229.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,015,059.69		
4314	SOBRA CHILD 14-20 MA	804,131.34	1,755,777.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,559,909.17		
4315	SOBRA CHILD 14-20 FE	1,152,566.55	1,806,830.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,959,396.60		
5007	SOBRA PREG 21-44 FE M	43.82	15.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.56		
5015	SOBRA PREG 14-20 FE
M	210,587.60	391,120.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		601,708.10		
5017	SOBRA PREG 21-44 FE M	1,360,375.53	2,160,266.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,520,641.89		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	1,207.05	18,210.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,417.21	
5027	SOBRA PREG 21-44 FE
M	1,074.17	153.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,228.10	
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	
SUBTOTAL	:	23,171,656.51	37,278,986.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,450,642.68	

1106	TANF EXPANDED 21-44	1,954.28	10,071.27	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	5,399.39	16,109.41	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	10,741.76	84,024.05	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&	7,083.35	57,989.57	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	1,564.00	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	782.00	1,564.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	4,133.16	4,278.00	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	22,923.43	39,526.84	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	380,303.68	569,632.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,458,286.64	2,182,855.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,042,573.24	1,615,251.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	4,278.00	2,737.00	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	2,224.93	10,854.84	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	41,966.63	62,586.16	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	21,576.93	102,299.56	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&	8,682.76	47,760.16	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	6,608.02	23,412.86	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	5,865.00	17,498.00	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	123,814.65	718,272.06	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	6,118.03	15,641.70	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	67,360.42	111,811.73	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	83,403.79	362,726.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,306,080.09	6,058,468.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,025.55	
21,508.80	
94,765.81	
65,072.92	
1,564.00	
2,346.00	
8,411.16	
62,450.27	
949,936.63	
3,641,142.54	
2,657,824.32	
7,015.00	
13,079.77	
104,552.79	
123,876.49	
56,442.92	
30,020.88	
23,363.00	
842,086.71	
21,759.73	
179,172.15	
446,130.71	
9,364,548.15	

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	-666.20	771.16	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	368.00	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	47,177.80	51,262.58	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	51,718.89	83,600.35	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	588,598.71	538,680.44	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	386,981.88	547,597.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	1,409,825.64	2,348,203.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
104.96	
368.00	
98,440.38	
135,319.24	
1,127,279.15	
934,579.53	
3,758,028.68	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	391.00	1,472.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,863.00		
3707	ADULT <40% EXP FEM AL	0.00	30.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.08		
3708	ADULT <40% EXP M&F
4	8,651.55	9,951.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,602.76		
3709	ADULT <40% EXP M&F 6	8.80	1,224.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,233.29		
3714	ADULT <40% EXP MALE	131,790.54	260,483.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		392,273.99		
3715	ADULT <40% EXP FEM AL	219,854.84	382,376.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		602,230.89		
3716	ADULT <40% EXP MALE	3,044,533.55	4,454,722.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,499,256.51		
3717	ADULT <40% EXP FEM AL	1,830,294.46	2,982,824.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,813,119.18		
3718	ADULT <40% EXP M&F
4	4,987,186.75	8,416,095.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,403,282.55		
3719	ADULT <40% EXP M&F 6	5,494.46	5,230.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,724.53		
3728	ADULT <40% EXP M&F
4	0.00	601.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		601.37		
SUBTOTAL:	12,711,842.67	20,085,495.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,797,338.09		

4413	SOBRA 100-133% M&F
6	310,311.87	528,458.09	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	113,097.49	148,640.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	116,076.61	191,884.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	539,485.97	868,983.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

838,769.96	
261,738.20	
307,961.09	
1,408,469.25	

4518	BC PATIENT FEMALE 4 5	2,714.00	1,173.00	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,714.00	1,955.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,887.00	
782.00	
4,669.00	

8700	SSI DISABLED FREEDO M	3,694.24	7,214.57	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	3,910.00	5,474.00	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	378.79	4,172.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,983.03	16,860.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10,908.81	
9,384.00	
4,551.18	
24,843.99	

3906	NEWLY ELIGIBLE MALE	79.82	368.00	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	856.33	847.03	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	12,058.51	16,416.32	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	33,141.95	52,556.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	224,823.53	369,878.69	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	402,318.88	658,995.27	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	992,370.83	1,367,232.30	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,666,431.85	2,467,076.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
447.82	
1,703.36	
782.00	
28,474.83	
85,698.59	
594,702.22	
1,061,314.15	
2,359,603.13	
782.00	
4,133,508.10	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	41,406,194.12	66,777,825.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,184,019.26		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,072.53	4,133.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,206.21		
1007	TANF 21-44 FEMALE WI	769.18	3,113.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,882.44		
1008	TANF 45-64 M & F WIT	1,699.93	6,488.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,188.91		
1009	TANF 65+ M & F WITH	726.82	579.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,306.00		
1011	TANF <1 M & F NON-ME	555,896.87	302,399.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		858,296.05		
1012	TANF 01-05 M & F NON	59,694.66	92,475.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152,169.69		
1013	TANF 06-13 M & F NON	38,035.56	82,126.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,162.38		
1014	TANF 14-20 MALE NON-	17,080.83	27,466.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,547.50		
1015	TANF 14-20 FEMALE N O	43,026.56	64,965.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,992.55		
1016	TANF 21-44 MALE NON-	674,056.38	825,020.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,499,076.62		
1017	TANF 21-44 FEMALE N O	1,618,662.59	1,904,822.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,523,485.15		
1018	TANF 45-64 M & F NON	707,361.29	856,387.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,563,748.86		
1019	TANF 65+ M & F NON-M	1,237.38	1,058.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,295.57		
1026	TANF 21-44 MALE WITH	949.63	2,269.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,219.08		
1027	TANF 21-44 FEMALE WI	826.61	1,825.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,651.67		
1028	TANF 45-64 M & F WIT	2,948.86	7,504.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,453.74		
1029	TANF 65+ M & F WITH	131.08	686.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		817.27		
2100	SSI AGED WITH MEDIC A	47,536.22	47,910.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,447.01		
2110	SSI AGED NON-MEDICA
R	31,124.19	52,905.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,029.34		
2120	SSI AGED WITH QMB	252,430.74	285,929.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		538,360.02		
2200	SSI DISABLED WITH M E	188,471.15	329,014.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		517,485.98		
2210	SSI DISABLED NON-ME
D	3,560,015.67	5,381,468.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,941,484.62		
2220	SSI DISABLED WITH Q M	805,895.33	1,037,192.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,843,087.45		
2300	SSI BLIND WITH MEDIC	136.94	175.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		312.93		
2310	SSI BLIND NON-MEDIC A	141,080.44	58,653.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,733.77		
2320	SSI BLIND WITH QMB	11,776.25	11,684.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,460.89		
4302	SOBRA CHILD 01-05 M	261.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		261.39		
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	606,521.98	1,227,639.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,834,161.86		
4312	SOBRA CHILD 01-05 M	850,944.83	931,330.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,782,275.58		
4313	SOBRA CHILD 06-13 M	902,187.02	1,402,010.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,304,197.57		
4314	SOBRA CHILD 14-20 MA	255,662.66	585,835.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		841,498.26		
4315	SOBRA CHILD 14-20 FE	392,742.97	435,763.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		828,506.08		
5007	SOBRA PREG 21-44 FE M	21.46	142.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.39		
5015	SOBRA PREG 14-20 FE
M	106,140.82	128,457.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		234,598.36		
5017	SOBRA PREG 21-44 FE M	711,030.95	951,398.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,662,428.96		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	6,314.07	1,544.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,858.62	
5027	SOBRA PREG 21-44 FE
M	55.50	36.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92.46	
5028	SOBRA PREG 45-64 FE M	0.00	56.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56.69	
SUBTOTAL	:	12,594,527.34	17,052,474.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,647,001.92	

1106	TANF EXPANDED 21-44	5,267.22	4,642.17	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	2,097.10	10,512.11	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	26,369.87	42,521.41	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&	5,801.81	10,221.56	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	86.83	7.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	10,834.96	38,061.99	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	310,874.32	341,304.71	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	462,224.08	651,418.05	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	455,775.55	648,987.83	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&	656.02	166.20	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	14,301.51	23,061.62	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	27,947.66	26,939.58	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	92,078.67	113,294.98	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&	22,852.09	30,903.05	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	1,255.12	2,635.56	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	2,724.87	1,210.33	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	167,163.34	241,087.48	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	9,321.18	16,641.74	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	104,807.20	77,155.74	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	219,922.00	281,504.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,942,361.40	2,562,277.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,909.39	
12,609.21	
68,891.28	
16,023.37	
0.00	
0.00	
94.25	
48,896.95	
652,179.03	
1,113,642.13	
1,104,763.38	
822.22	
37,363.13	
54,887.24	
205,373.65	
53,755.14	
3,890.68	
3,935.20	
408,250.82	
25,962.92	
181,962.94	
501,426.14	
4,504,639.07	

3506	ADULT 40-100% MALE 2	7.64	-7.64	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	2,469.55	2,436.98	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	13,215.14	12,485.39	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	11,963.08	23,715.95	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	396,654.33	509,637.36	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	116,409.54	130,347.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	549,945.01	899,294.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
4,906.53	
0.00	
25,700.53	
35,679.03	
906,291.69	
246,757.35	
1,449,239.78	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3707	ADULT <40% EXP FEM AL	71.15	330.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		401.24		
3708	ADULT <40% EXP M&F
4	6,279.49	2,605.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,884.79		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	131,971.66	151,697.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283,669.03		
3715	ADULT <40% EXP FEM AL	75,020.79	101,153.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,174.53		
3716	ADULT <40% EXP MALE	2,730,749.40	3,606,658.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,337,407.64		
3717	ADULT <40% EXP FEM AL	1,133,060.95	1,543,151.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,676,212.02		
3718	ADULT <40% EXP M&F
4	3,507,314.89	4,693,205.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,200,520.04		
3719	ADULT <40% EXP M&F 6	7.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.42		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	8,675,140.04	11,676,711.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,351,851.62		

4413	SOBRA 100-133% M&F
6	43,636.60	84,967.13	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	24,543.55	37,596.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	34,922.68	42,295.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	103,102.83	164,859.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

128,603.73	
62,140.18	
77,218.10	
267,962.01	

4518	BC PATIENT FEMALE 4 5	219.81	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:	219.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

219.81	
0.00	
219.81	

8700	SSI DISABLED FREEDO M	4,147.91	4,266.99	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	6,950.39	6,582.09	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	393.30	257.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,491.60	11,106.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,414.90	
13,532.48	
651.11	
22,598.49	

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	
3908	NEWLY ELIGIBLE M&F 4	281.40	1,677.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	3,775.48	18,428.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,687.39	14,808.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	226,498.59	256,828.14	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	119,886.27	155,178.52	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	481,953.69	514,219.92	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	
SUBTOTAL:	836,082.82	961,140.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
1,958.54	
0.00	
22,204.44	
18,495.54	
483,326.73	
275,064.79	
996,173.61	
0.00	
1,797,223.65	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	24,162,925.84	32,428,570.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,591,496.57		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 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-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4302	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		
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		
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 August 31, 2017

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		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		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		0.00		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		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		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		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		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		

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

0.00	
0.00	
0.00	
0.00	

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	
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	

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	

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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 August 31, 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	25.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.22		
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	17,980.69	4,043.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,023.83		
1012	TANF 01-05 M & F NON	1,121.82	365.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,486.84		
1013	TANF 06-13 M & F NON	1,153.16	369.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,522.91		
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	967.45	3,191.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,158.94		
1016	TANF 21-44 MALE NON-	3,273.11	3,331.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,604.72		
1017	TANF 21-44 FEMALE N O	13,274.38	18,656.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,930.52		
1018	TANF 45-64 M & F NON	176.95	12,819.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,996.00		
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	2,075.98	2,566.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,642.49		
2110	SSI AGED NON-MEDICA
R	14,911.75	7,451.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,363.47		
2120	SSI AGED WITH QMB	66.89	1,627.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,694.21		
2200	SSI DISABLED WITH M E	1,060.56	715.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,776.24		
2210	SSI DISABLED NON-ME
D	12,553.06	29,633.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,186.85		
2220	SSI DISABLED WITH Q M	4,921.08	1,324.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,245.24		
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		
4302	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		
4303	SOBRA CHILD 06-13 M	0.00	15.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.45		
4311	SOBRA CHILD <1 M & F	223.89	9,298.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,521.96		
4312	SOBRA CHILD 01-05 M	3,710.57	11,062.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,773.40		
4313	SOBRA CHILD 06-13 M	1,132.85	15,512.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,644.91		
4314	SOBRA CHILD 14-20 MA	865.72	-6,401.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,535.52		
4315	SOBRA CHILD 14-20 FE	9,007.12	691.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,698.58		
5007	SOBRA PREG 21-44 FE M	0.00	20.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.01		
5015	SOBRA PREG 14-20 FE
M	10,581.18	7,900.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,481.43		
5017	SOBRA PREG 21-44 FE M	17,136.09	25,400.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,537.04		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	116,219.52	149,595.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	265,814.74	

1106	TANF EXPANDED 21-44	52.14	36.83	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	201.80	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	525.24	354.10	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&	56.86	74.25	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	21.08	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	2,105.97	6,094.96	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	7,631.53	3,213.93	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	262.45	6,142.98	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	135.99	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	32.33	480.26	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	26.21	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	96.65	644.29	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	942.94	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	150.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,878.02	17,405.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

88.97	
201.80	
879.34	
131.11	
21.08	
0.00	
0.00	
0.00	
8,200.93	
10,845.46	
6,405.43	
0.00	
0.00	
0.00	
135.99	
0.00	
512.59	
0.00	
26.21	
740.94	
942.94	
150.83	
29,283.62	

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	123.52	1,469.45	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	398.32	9,993.11	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	12,549.57	15,771.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	2,510.06	8,276.62	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	25,805.10	28,273.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
1,592.97	
10,391.43	
28,321.04	
10,786.68	
54,078.76	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
3708	ADULT <40% EXP M&F
4	393.78	17,888.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,282.10		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	348.69	6,913.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,261.87		
3715	ADULT <40% EXP FEM AL	2,830.60	6,412.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,242.92		
3716	ADULT <40% EXP MALE	66,956.56	93,175.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,132.00		
3717	ADULT <40% EXP FEM AL	28,458.42	36,366.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,824.98		
3718	ADULT <40% EXP M&F
4	122,869.32	164,344.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287,213.84		
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		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		0.00		
SUBTOTAL:	263,243.94	388,884.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		652,128.59		

4413	SOBRA 100-133% M&F
6	6,524.44	214.62	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	49.03	3,537.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	149.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,722.65	3,752.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,739.06	
3,586.69	
149.18	
10,474.93	

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	
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	

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	

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	274.59	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	9,129.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	3,477.45	1,757.55	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	14,387.60	710.48	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	32,724.28	9,297.59	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	
SUBTOTAL:	50,589.33	21,169.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
274.59	
9,129.20	
5,235.00	
15,098.08	
42,021.87	
0.00	
71,758.74	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	448,653.46	580,807.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,029,460.62		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	38,229.76	113,507.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,737.32		
SUBTOTAL:	38,229.76	113,507.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,737.32		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

151,737.32

0.00

0.00

0.00	0.00

38,229.76

113,507.56

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending August 31, 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		
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	

TOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	451,294.58	587,446.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,038,741.07		
SUBTOTAL:	451,294.58	587,446.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,038,741.07		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

1,038,741.07

0.00

0.00

0.00	0.00

451,294.58

587,446.49

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	56.86	56.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.72		
1007	TANF 21-44 FEMALE WI	127.81	104.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232.42		
1008	TANF 45-64 M & F WIT	1,538.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,538.48		
1009	TANF 65+ M & F WITH	-281.37	15.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-265.60		
1011	TANF <1 M & F NON-ME	41,353.18	83,524.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,878.05		
1012	TANF 01-05 M & F NON	2,416.45	5,049.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,466.04		
1013	TANF 06-13 M & F NON	17,904.47	5,731.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,635.75		
1014	TANF 14-20 MALE NON-	637.52	3,544.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,182.07		
1015	TANF 14-20 FEMALE N O	473.36	9,088.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,561.88		
1016	TANF 21-44 MALE NON-	48,175.44	44,624.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,800.33		
1017	TANF 21-44 FEMALE N O	118,892.96	155,104.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273,996.99		
1018	TANF 45-64 M & F NON	27,646.03	65,670.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,316.87		
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	149.16	47.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196.78		
1028	TANF 45-64 M & F WIT	261.59	132.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		393.59		
1029	TANF 65+ M & F WITH	21.07	148.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169.69		
2100	SSI AGED WITH MEDIC A	5,726.74	3,782.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,509.37		
2110	SSI AGED NON-MEDICA
R	233.62	202.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		436.18		
2120	SSI AGED WITH QMB	10,874.03	11,181.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,055.24		
2200	SSI DISABLED WITH M E	8,331.34	6,667.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,999.02		
2210	SSI DISABLED NON-ME
D	269,492.24	321,140.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590,632.48		
2220	SSI DISABLED WITH Q M	30,051.08	42,118.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,169.62		
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	1,175.11	14,840.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,015.39		
2320	SSI BLIND WITH QMB	52.29	333.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		386.08		
4302	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		
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	61,479.02	87,587.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,066.29		
4312	SOBRA CHILD 01-05 M	40,550.75	187,610.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228,161.57		
4313	SOBRA CHILD 06-13 M	34,283.16	66,111.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,394.75		
4314	SOBRA CHILD 14-20 MA	10,028.07	22,322.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,350.55		
4315	SOBRA CHILD 14-20 FE	16,595.83	66,226.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,822.73		
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		
5015	SOBRA PREG 14-20 FE
M	8,490.98	26,483.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,974.88		
5017	SOBRA PREG 21-44 FE M	106,165.33	159,784.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		265,950.19		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	862,902.60	1,389,238.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,252,141.40	

1106	TANF EXPANDED 21-44	23.54	94.05	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	208.96	280.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	2,320.64	2,168.84	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&	360.87	297.29	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	4,003.97	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	33,104.75	35,481.16	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	41,327.06	122,045.87	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	28,983.88	31,297.28	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	480.23	1,412.39	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	1,508.49	1,182.60	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	3,794.41	5,586.68	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&	2,455.65	546.45	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	585.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	12,372.38	10,795.99	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	1,061.87	2,087.19	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	1,073.13	1,017.46	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	5,813.54	10,465.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	138,893.37	225,344.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

117.59	
489.88	
4,489.48	
658.16	
0.00	
0.00	
0.00	
4,003.97	
68,585.91	
163,372.93	
60,281.16	
0.00	
1,892.62	
2,691.09	
9,381.09	
3,002.10	
585.50	
0.00	
23,168.37	
3,149.06	
2,090.59	
16,278.72	
364,238.22	

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	1,996.05	310.42	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	373.66	3,495.94	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	34,329.72	28,807.75	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	61,948.12	7,061.45	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	86,825.25	98,535.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
2,306.47	
3,869.60	
63,137.47	
69,009.57	
185,360.95	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
3708	ADULT <40% EXP M&F
4	0.00	27.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.13		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	2,368.59	13,631.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,000.37		
3715	ADULT <40% EXP FEM AL	10,881.58	4,587.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,469.49		
3716	ADULT <40% EXP MALE	217,280.78	338,036.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		555,317.53		
3717	ADULT <40% EXP FEM AL	265,106.48	120,807.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		385,914.35		
3718	ADULT <40% EXP M&F
4	241,419.48	189,212.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430,631.78		
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		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		0.00		
SUBTOTAL:	922,529.71	804,515.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,727,044.71		

4413	SOBRA 100-133% M&F
6	5,767.98	4,841.65	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	5,966.40	5,291.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	54.32	401.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,788.70	10,534.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10,609.63	
11,257.40	
456.05	
22,323.08	

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	
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	

8700	SSI DISABLED FREEDO M	860.24	2,064.41	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	94.16	202.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	954.40	2,267.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,924.65	
0.00	
297.04	
3,221.69	

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	101.06	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	105.50	2,348.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	25,177.90	62,754.37	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	8,157.64	35,110.39	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	47,909.97	59,251.26	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	
SUBTOTAL:	81,351.01	159,565.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
101.06	
2,454.08	
87,932.27	
43,268.03	
107,161.23	
0.00	
240,916.67	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	2,018,419.79	2,591,465.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,609,885.77		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.00		
2100	SSI AGED WITH MEDIC A	282,362.60	593,435.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		875,798.49		
2110	SSI AGED NON-MEDICA
R	114,115.36	33,424.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,539.42		
2120	SSI AGED WITH QMB	106,974.53	642,052.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		749,027.25		
2200	SSI DISABLED WITH M E	20,587.92	133,462.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,050.51		
2210	SSI DISABLED NON-ME
D	690,412.33	1,298,812.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,989,224.73		
2220	SSI DISABLED WITH Q M	50,835.89	253,878.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304,714.69		
2310	SSI BLIND NON-MEDIC
A	8,165.00	27,468.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,633.40		
2320	SSI BLIND WITH QMB	79.82	10.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.04		
SUBTOTAL:	1,273,533.45	2,982,936.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,256,469.53		

TOTAL:

1,273,533.45	2,982,936.08

0.00

0.00

0.00

0.00

0.00

0.00

4,256,469.53

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	

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending August 31, 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	2,365,886.89	2,765,480.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,131,367.53		
2110	SSI AGED NON-MEDICA
R	114,010.42	163,832.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277,842.54		
2120	SSI AGED WITH QMB	3,278,193.16	3,816,786.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,094,979.37		
2200	SSI DISABLED WITH M E	705,967.24	704,921.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,410,888.47		
2210	SSI DISABLED NON-ME
D	2,342,483.57	3,086,839.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,429,322.97		
2220	SSI DISABLED WITH Q M	816,372.82	1,114,191.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,930,564.69		
2310	SSI BLIND NON-MEDIC
A	29,301.58	10,254.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,555.86		
2320	SSI BLIND WITH QMB	8,700.00	8,731.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,431.83		
SUBTOTAL:	9,660,915.68	11,671,037.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,331,953.26		

8710	SSI DISABLED FREEDO M	0.00	1,326.10	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	2,533.80	3,044.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,533.80	4,370.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,326.10	
5,577.96	
6,904.06	

9,663,449.48    11,675,407.84

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 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	34,978.33	15,196.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,174.86		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	597.24	3,085.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,682.39		
2200	SSI DISABLED WITH M E	1,957.19	904.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,861.40		
2210	SSI DISABLED NON-ME
D	23,421.88	43,085.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,507.85		
2220	SSI DISABLED WITH Q M	2,389.71	-3,161.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-771.48		
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		
SUBTOTAL:	63,344.35	59,110.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,455.02		

TOTAL:

63,344.35

59,110.67

0.00

0.00

0.00

0.00

0.00

0.00

122,455.02

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	

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending August 31, 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	18,622.93	14,307.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,930.78		
2110	SSI AGED NON-MEDICA
R	6,450.23	799.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,249.41		
2120	SSI AGED WITH QMB	9,806.02	19,063.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,869.29		
2200	SSI DISABLED WITH M E	4,695.45	7,277.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,972.58		
2210	SSI DISABLED NON-ME
D	31,915.34	12,532.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,447.76		
2220	SSI DISABLED WITH Q M	4,055.69	8,154.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,210.44		
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	27.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.13		
SUBTOTAL:	75,572.79	62,134.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,707.39		

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	

75,572.79

62,134.60

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

TOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	128,128.56	120,248.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248,376.93	
6012	KIDS 1-5 M & F NON-M	708,271.37	724,951.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,433,222.93	
6013	KIDS 6-13 M & F NON-	1,262,579.15	1,291,637.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,554,216.62	
6014	KIDS 14-19 MALE NON-	428,391.90	442,663.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	871,055.77	
6015	KIDS 14-19 FEMALE NO	697,874.36	706,401.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,404,275.53	
9960	KIDSCARE KICK PAYME N	12,541.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,541.03	
SUBTOTAL	:	3,237,786.37	3,285,902.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,523,688.81	

TOTAL:	3,237,786.37	3,285,902.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,523,688.81		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	271.65	255.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	526.65	
6012	KIDS 1-5 M & F NON-M	5,792.97	5,917.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,710.69	
6013	KIDS 6-13 M & F NON-	10,227.66	10,484.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,712.45	
6014	KIDS 14-19 MALE NON-	2,555.62	2,642.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,198.19	
6015	KIDS 14-19 FEMALE NO	2,628.75	2,664.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,293.50	
9960	KIDSCARE KICK PAYME N	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	
SUBTOTAL	:	21,478.65	21,964.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,443.48	

21,478.65	21,964.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

43,443.48	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	10,726.93	10,265.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,992.20	

6012	C
KIDS 1-5 M & F NON-M	
226,209.16	
230,820.68	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
457,029.84	
6013	KIDS 6-13 M & F NON-	397,354.76	406,599.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	803,953.86	
6014	KIDS 14-19 MALE NON-	107,522.67	110,080.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	217,602.94	
6015	KIDS 14-19 FEMALE NO	110,518.36	111,678.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	222,197.02	

SUBTOTAL:	
852,331.88	
869,443.98	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,721,775.86	

TOTAL:	852,331.88	869,443.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,721,775.86		

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

6012	KIDS <1M&F NON MEDI C
KIDS 1-5 M & F NON-M	534.00

11,318.00	380.00

11,772.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	914.00

23,090.00	
6013	KIDS 6-13 M & F NON-	20,771.00	20,367.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,138.00	
6014	KIDS 14-19 MALE NON-	5,346.00	4,920.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,266.00	
6015	KIDS 14-19 FEMALE NO	5,466.00	5,738.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,204.00	
SUBTOTAL:	43,435.00	43,177.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,612.00	
TOTAL:	43,435.00	43,177.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			

86,612.00	

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
6012	KIDS 1-5 M & F NON-M	1,500.27	3,363.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,863.83		
6013	KIDS 6-13 M & F NON-	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,000.54		
SUBTOTAL:	3,000.54	4,863.8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,864.37		

TOTAL:	3,000.54	4,863.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,864.37		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending August 31, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
6012	KIDS 1-5 M & F NON-M	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
6013	KIDS 6-13 M & F NON-	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	6.00	9.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		

6.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15.00	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	435.91	95.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	531.13	

6012	C
KIDS 1-5 M & F NON-M	
17,818.20	
23,910.93	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
41,729.13	
6013	KIDS 6-13 M & F NON-	21,381.26	42,458.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,840.10	
6014	KIDS 14-19 MALE NON-	4,092.52	9,111.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,204.30	
6015	KIDS 14-19 FEMALE NO	11,360.35	9,833.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,193.90	

SUBTOTAL:	
55,088.24	
85,410.32	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
140,498.56	

TOTAL:	55,088.24	85,410.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,498.56		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	55,790.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,790.04	
6013	KIDS 6-13 M & F NON-	23,428.15	0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,428.16	
6014	KIDS 14-19 MALE NON-	11,115.43	438.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,553.92	
6015	KIDS 14-19 FEMALE NO	0.00	651,203.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	651,203.92	

SUBTOTAL:	
90,333.62	
651,642.42	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
741,976.04	

90,333.62	651,642.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

741,976.04	

TOTAL:

00

00

15.00

1,405.07

8.00

391.46

10.00

582.29

4,097.06

8.00

46,815.26

8,435.69

26.00

242.52

62.00

25.00

4.00

8.00

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending August 31, 2017

RATE CODE

DESCRIPTION

JULY

AUGUST     SEPTEMBER

OCTOBER

NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

62,135.35

62,135.35

1000	TANF WITH MEDICARE	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	703.19	701.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	194.80	196.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICAR	5.00	5.00	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	291.11	291.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH ME	2,043.71	2,053.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
220Z	SSI DISABLED WITH ME	0.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-MED	23,361.25	23,454.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH QM	4,217.03	4,218.66	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	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	120.64	121.88	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	30.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	12.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:
TOTAL:	31,009.73	31,125.62	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	31,009.73	31,125.62	0.00	0.	0.0	0	0.00	0.00	0.00	0.00	0.	0.00	0.00	

 
ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM
EPD/DD EXPENDITURES
For the Period Ending August 31, 2017

EPD/DD  CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	397,035.59	401,971.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	799,006.94	
EPD	93,545,138.25	113,163,312.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206,708,450.37	
TOTAL AHCCCS LTC	93,942,173.84	113,565,283.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	207,507,457.31	
DES/DD	112,834,320.04	113,252,020.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	226,086,340.61	
TOTAL DES LTC	112,834,320.04	113,252,020.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	226,086,340.61	
TOTAL LTC - CAP	206,776,493.88	226,817,304.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	433,593,797.92	

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	
	11,075,900.07
0.00	14,779,589.19
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	25,855,489.26
0.00	
	0.00	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	11,075,900.07	14,779,589.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,855,489.26	

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	
	6,523,382.52
2,184,772.28	5,627,350.86
802,286.33	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	12,150,733.38
2,987,058.61	
	2,184,772.28	802,286.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,987,058.61	
TOTAL LTC - REIN	8,708,154.80	6,429,637.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,137,791.99	

EPD/DD  SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	3,975,551.00	3,988,264.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,963,815.80	

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.

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

010115	CRS FULLY INTEGRATED PLAN - CAP	14,662,836.04	14,607,837.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,270,673.91	
010145	CRS ACUTE SEMI INTEGRATED - CAP	107,432.99	107,327.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	214,760.27	
999125	CRS SEMI INTEGRATED PLAN - CAP	5,627,771.65	5,652,158.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,279,930.07	
999135	CRS ONLY PLAN - CAP	549,147.69	552,857.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,102,005.22	
Subtotal	20,947,188.37	20,920,181.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,867,369.47	

999155	CRS REINSURANCE ONLY	2,281,891.03	2,401,136.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,683,027.55	
Subtotal	2,281,891.03	2,401,136.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,683,027.55	

23,229,079.40	23,321,317.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,550,397.02	

GRAND TOTAL

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

010115	CRS FULLY INTEGRATED PLAN - MM	16,522.18	16,448.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,970.91	
010145	CRS ACUTE SEMI INTEGRATED - MM	195.65	195.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	391.08	
999125	CRS SEMI INTEGRATED PLAN - MM	6,511.77	6,545.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,056.92	
999135	CRS ONLY PLAN - MM	1,088.48	1,097.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,185.50	
Subtotal	24,318.08	24,286.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,604.41	

24,318.08	24,286.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,604.41	

GRAND TOTAL

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

010700	HEALTH CHOICE INTEGRATED - CAP	0.00	-11,438.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11,438.41	
010715	HEALTH CHOICE INTEGRATED - CAP	10,197,580.04	10,274,195.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,471,775.41	
010725	CENPATICO INTEGRATED - CAP	-783.94	-24,049.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-24,833.73	
010735	CENPATICO INTEGRATED - CAP	22,400,947.95	22,510,414.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,911,362.80	
010795	MERCY MARICOPA INTEGRATED - CAP	50,665,969.36	51,176,641.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	101,842,611.10	
078999	MERCY MARICOPA INTEGRATED - CAP	-20,396.68	-50,403.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-70,800.43	
Subtotal	83,243,316.73	83,875,360.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	167,118,676.74	

83,243,316.73	83,875,360.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	167,118,676.74	

GRAND TOTAL

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

010700	HEALTH CHOICE INTEGRATED - MM	0.00	-6.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-6.89	
010715	HEALTH CHOICE INTEGRATED - MM	5,773.09	5,816.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,589.88	
010725	CENPATICO INTEGRATED - MM	-0.48	-15.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-15.74	
010735	CENPATICO INTEGRATED - MM	13,605.33	13,671.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,277.08	
010795	MERCY MARICOPA INTEGRATED - MM	21,387.32	21,602.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,989.92	
078999	MERCY MARICOPA INTEGRATED - MM	-9.09	-22.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-31.58	
Subtotal	40,756.17	41,046.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,802.67	

40,756.17	41,046.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	81,802.67	

GRAND TOTAL