October 25, 2017

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

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

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

SUBJECT: FY 2018 Appropriation Status Report for the Period Ended September 30, 2017

Dear President Yarbrough and Speaker Mesnard:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended September 30, 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 – September 2017 enrollment is 1,920,369 members, a 2,425 member decrease over the prior month. Enrollment for October 2017 increased to 1,921,145 members, a 778 member change.

Major October 2017 changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 1,978; Supplemental Security Income – increase of 606; Prop

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 October 25, 2017
Page 2

204 Restoration - increase of 512; Adult Expansion – increase of 307; Medicare Cost Sharing – increase of 475; KidsCare – increase of 810; and Federal Emergency Services - decrease of 136.

Tobacco Funds Revenue Update - Tobacco tax collections through September 2017 are $2.0 million less 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 September 30, 2017

Prepared by: Division of Business and Finance

Appropriation Status Report
Table of Contents
APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 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 September 30,  2017
SUMMARY OF APPROPRIATED EXPENDITURES

	

ANNUAL APPROPRIATION		(A)      EXPENDITURE PLAN
YTD		(B)

EXPENDITURES YTD		(A) - (B)

VARIANCE YTD		
PROJECTED ANNUAL EXPENDITURES		

ANNUALIZED VARIANCE		

APPROPRIATIONS:													
ADMINISTRATION													
AHCCCS Operating Lump Sum	$	94,260,300		$	18,791,309		$	23,412,969		$	(4,621,660)		$	94,260,300		$	-		
AHCCCS Prop 204 Administration	13,936,000		2,659,882		2,655,742		4,140		13,936,000		-		
DES Eligibility	91,874,500		23,325,300		16,597,364		6,727,936		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		11,773,200		6,712,194		5,061,006		44,358,700		-		
Prop 206 Provider Assessment Study	200,000		16,936		-		16,936		200,000		-		
TOTAL  ADMINISTRATION	 	244,629,500 		 	56,566,627 		 	49,378,269 		 	7,188,358 		 	244,629,500 		 	-			

Traditional Medicaid Services	3,896,328,000	959,051,100	967,370,471	(8,319,371)	3,896,328,000	-	
Proposition 204 Services	2,773,331,800	666,527,600	685,954,147	(19,426,547)	2,773,331,800	-	
ACA Adult Expansion	475,591,600	125,410,700	120,352,232	5,058,468	475,591,600	-	
Children's Rehabilitative Services	269,646,300	62,352,000	75,437,797	(13,085,797)	269,646,300	-	
KidsCare Services	111,961,100	22,224,900	13,181,222	9,043,678	111,961,100	-	
ALTCS Services	1,544,082,800	372,042,600	379,667,403	(7,624,803)	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	265,553,800	284,899,384	(19,345,584)	1,156,192,500	-	
Behavioral Health Proposition 204 Services	788,262,700	180,969,300	196,074,060	(15,104,760)	788,262,700	-	
Behavioral Health ACA Adult Expansion	86,141,400	18,735,600	20,492,953	(1,757,353)	86,141,400	-	
Behavioral Health CMDP	217,719,100	54,343,800	38,169,759	16,174,041	217,719,100	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	19,711,800	19,489,345	222,455	78,846,900	-	
Supported Housing	5,324,800	1,331,100	1,310,819	20,281	5,324,800	-	
Crisis Services	16,391,300	4,097,700	4,076,575	21,125	16,391,300	-	

TOTAL PROGRAMMATIC	 	11,788,287,200	 	2,752,352,000	 	2,806,476,167	 	(54,124,167)	 	11,788,287,200	 	-	

TOTAL EXPENDITURES

$	12,032,916,700

$	2,808,918,627

$	2,855,854,435

$	(46,935,809)

$   12,032,916,700	$	-

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2017 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		
Administrative Expenditures	$	55,962,100	$	12,767,114	$	13,723,511	(956,398)	$	55,962,100	$	-	
Proposition 204 - Administrative Expenditures	21,765,400	5,383,500	2,309,589	3,073,911	21,765,400	-	

Programmatic Expenditures							
Traditional Medicaid Services	830,106,600	208,072,000	212,227,787	(4,155,787)	830,106,600	-	
Proposition 204 Services	-	-	(1,159,535)	1,159,535	-	-
Children's Rehabilitative Services	81,426,000	19,187,400	19,369,604	(182,204)	81,426,000	- KidsCare Services		-		-		188,708	(188,708)		-	-
ALTCS Services	185,064,700	45,837,700	46,266,175	(428,475)	185,064,700	-
DSH and Rural Hospitals	7,086,300	-	-	-	7,086,300	-
Behavioral Health Traditional Medicaid Services	316,050,500	73,970,100	79,620,243	(5,650,143)	316,050,500	-	
Behavioral Health Proposition 204 Services	109,562,000	26,318,300	30,613,316	(4,295,016)	109,562,000	-	
Behavioral Health ACA Adult Expansion	4,269,200	839,300	1,024,575	(185,275)	4,269,200	-	
Behavioral Health CMDP	65,719,400	16,668,900	11,743,660	4,925,241	65,719,400	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	19,711,800	19,489,345	222,455	78,846,900	-	
Supported Housing	5,324,800	1,331,100	1,310,819	20,281	5,324,800	-	
Crisis Services	 	14,141,100 	 	3,535,200 	 	3,514,025 	 	21,175 	 	14,141,100 	 	- 	
TOTAL GF EXPENDITURES	1,775,325,000	433,622,413	440,241,822	(6,619,408)	1,775,325,000	-	

FEDERAL		
Administrative Expenditures	129,511,800	29,203,311	26,204,020	2,999,291	129,511,800	-	
Proposition 204 - Administrative Expenditures	32,874,000	8,079,482	7,058,348	1,021,135	32,874,000	-	

Programmatic Expenditures	
Traditional Medicaid Services	2,412,443,400	588,638,200	568,794,373	19,843,827	2,412,443,400	-	
Proposition 204 Services	2,397,123,600	575,361,800	569,832,557	5,529,243	2,397,123,600	-	
ACA Adult Expansion	450,284,200	119,309,400	114,528,881	4,780,519	450,284,200	-	
Children's Rehabilitative Services	188,220,300	43,164,600	56,068,193	(12,903,593)	188,220,300	-	
KidsCare Services	99,809,800	19,795,700	11,606,215	8,189,485	99,809,800	-	
ALTCS Services and Nursing Facility Assessment	956,062,900	231,152,600	231,942,308	(789,708)	956,062,900	-	
DSH and Rural Hospitals
Behavioral Health Traditional Medicaid Services	20,650,800
804,576,200	- 183,259,700	- 196,387,692	- (13,127,992)	20,650,800
804,576,200	-
-	
Behavioral Health Proposition 204 Services	655,527,700	149,084,500	161,801,268	(12,716,768)	655,527,700	-	
Behavioral Health ACA Adult Expansion	81,390,900	17,775,900	19,468,378	(1,692,478)	81,390,900	-	
Behavioral Health CMDP	151,999,700	37,674,900	26,426,099	11,248,801	151,999,700	-	
Voluntary Political Subdivision Programs - See Note 5	 	237,582,300 	 	- 	 	- 	 	- 	 	237,582,300 	 	- 	
TOTAL FEDERAL EXPENDITURES	8,618,057,600	2,002,500,093	1,990,118,331	12,381,761	8,618,057,600	-	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,655,300	970,100	-	970,100	3,655,300	-	
Programmatic Expenditures					
Traditional Medicaid Services Acute Care	49,687,700	12,470,300	12,470,300	-	49,687,700	-	
ALTCS Services	 	249,980,000 	 	65,553,300 	 	66,000,162	 	(446,862)	 	249,980,000 	 	- 	
TOTAL COUNTY EXPENDITURES	303,323,000	78,993,700	78,470,462	523,238	303,323,000	-	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2017 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

	TOBACCO FUNDS		

Programmatic Expenditures			
Traditional Medicaid Services - Medically Needy		37,432,400	9,438,000	9,358,100	79,900	37,432,400	-	
Behavioral Health Traditional Medicaid Services - Medically Needy		35,565,800	8,324,000	8,891,450	(567,450)	35,565,800	-	
Proposition 204 Services - Emergency Health Services		19,244,300	4,972,400	4,392,306	580,094	19,244,300	-	
Proposition 204 Services - Proposition 204 Protection		17,240,000	4,454,600	5,563,749	(1,109,149)	17,240,000	-	
Behavioral Health Proposition 204 Services - Proposition 204 Protection		23,173,000	5,566,500	3,659,476	1,907,024	23,173,000	-	
Proposition 204 Services - ATLSF	 	79,000,000 	 	- 	 	- 	 	- 	 	79,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	211,655,500	32,755,500	31,865,081	890,419	211,655,500	-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	

OTHER

860,900	

163,121	82,801	80,320	860,900	-	
Acute Care - Prescription Drug Rebate Program State Match	137,191,000	34,590,200	34,297,750	292,450	137,191,000	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	429,241,000	105,793,300	129,978,147	(24,184,847)	429,241,000	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	1,875,900	2,652,440	(776,540)	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	8,943,400	11,986,681	(3,043,281)	36,422,000	-	
Proposition 204 Services - Hospital Assessment	260,723,900	81,738,800	107,325,069	(25,586,269)	260,723,900	-	
ACA Adult Expansion - Hospital Assessment	25,307,400	6,101,300	5,823,351	277,949	25,307,400	-	
Behavioral Health ACA Adult Expansion - Hospital Assessment	481,300	120,400	-	120,400	481,300	-	
Traditional Medicaid Services - TPL	194,700	49,100	226,047	(176,947)	194,700	-	
ALTCS Services - TPL	-	-	380,144	(380,144)	-	-	
ALTCS Services - Nursing Facility Assessment	108,974,800	18,679,700	20,439,493	(1,759,793)	108,974,800	-	
KidsCare Services Premiums	12,151,300	2,429,200	1,386,300	1,042,900	12,151,300	-	
Freedom to Work Premiums	31,200	-	17,967	(17,967)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	562,500	562,550	(50)	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	103,147,500 	 	- 	 	- 	 	- 	 	103,147,500 	 	- 	
TOTAL OTHER EXPENDITURES	1,124,555,600	261,046,921	315,158,739	(54,111,819)	1,124,555,600	-	

TOTAL		
Administrative Expenditures	244,629,500		56,566,627		49,378,269		7,188,358		244,629,500		-	
Acute Care	10,244,204,400		2,380,309,400		2,426,808,764		(46,499,364)		10,244,204,400		-	
Long Term Care	 	1,544,082,800 		 	372,042,600 		 	379,667,403 		 	(7,624,803)		 	1,544,082,800 		 	- 	
TOTAL EXPENDITURES	  $	12,032,916,700 		  $	2,808,918,627 		  $	2,855,854,436 		  $	(46,935,809)		  $	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 September 30, 2017

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	974,581,000	$	240,026,514	$	245,320,902	
Proposition 204 Services & Administrative	21,765,400	5,383,500	35,422,847	
KidsCare Services	-	-	188,708	
ALTCS Services	185,064,700	45,837,700	46,266,175	
Behavioral Health Traditional Medicaid Services	 	593,913,900	 	142,374,700	 	115,678,091 	
TOTAL	1,775,325,000	433,622,413	442,876,723	

FEDERAL:
Acute & Administrative	5,868,690,400		1,363,756,793		1,376,416,078	
KidsCare Services	99,809,800		19,795,700		12,993,507	
ALTCS Services	956,062,900		231,152,600		253,898,542	
Behavioral Health Traditional Medicaid Services	 	1,693,494,500 		 	387,795,000 		 	404,085,538 	
TOTAL	8,618,057,600		2,002,500,093		2,047,393,665	

COUNTY:						
Acute & Administrative	53,343,000		13,440,400		11,809,731	
ALTCS Services	 	249,980,000 		 	65,553,300 		 	66,168,300 	
TOTAL	303,323,000		78,993,700		77,978,031	

TOBACCO FUNDS:						
Traditional Medicaid Services	72,998,200		17,762,000		18,249,550	
Proposition 204 Services	 	138,657,300 		 	14,993,500 		 	9,956,055 	
TOTAL	211,655,500		32,755,500		28,205,605	

OTHER:

Administrative	860,900		163,121		82,801	
Acute Care - Prescription Drug Rebate Program	566,432,000		140,383,500		164,275,897	
Long Term Care - Prescription Drug Rebate Program	44,000,400		10,819,300		14,639,121	
Hospital Assessment	286,512,600		87,960,500		71,879,285	
ALTCS - Nursing Facility Assessment	108,974,800		18,679,700		86,945	
Acute TPL - Note 1	194,700		49,100		226,047	
LTC TPL - Note 1	-		-		380,144	
KidsCare TPL - Note 1	-		-		(4)	
Member Premiums - CHIP	12,151,300		2,429,200		1,386,300	
Member Premiums - Freedom to Work	31,200		-		17,967	
Behavioral Health Traditional Medicaid Services	2,250,200		562,500		431,514	
Voluntary Political Subdivision - State Match	 	103,147,500 		 	-			 	-		
TOTAL	1,124,555,600		261,046,921		253,406,016	

TOTAL REVENUE

$	12,032,916,700

$	2,808,918,627

$	2,849,860,040

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2017	
Note 1:	Third Party Liability Collections:	September 2017		September 2016		July 1, 2017		July 1, 2016	
	Gross Collections:					September 30, 2017		September 30, 2016	
	Acute	$	907,941		$	516,654		$	2,019,847		$	1,258,616	
	LTC	454,396		229,483		1,736,565		1,009,516	
	KidsCare	543		4,878		628		4,878	
	Total TPL Collections	$	1,362,880		$	751,015		$	3,757,040		$	2,273,010	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	128,912		$	27,813		$	226,047		$	69,492		
LTC	87,295		46,440		380,144		220,345		
KidsCare	(21)		980		(4)		978		
Total Expenditure Offsets	$	216,186		$	75,233		$	606,187		$	290,815		

FY 18 Total

Note 2:    Authorized Positions	1,161.0
Actual Positions as of September 30, 2017	1,084.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2017

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2017	$	2,456,040	
	Revenues	1,957,370	
	Transfers-In	 	169,783 	
	Total Revenues	 	2,127,153 	
	Expenditures	1,720,918	
	Transfers-out	 	1,000,000 	
	Total Expenditures	 	2,720,918 	
	Ending Balance September 30, 2017	  $	1,862,275 	

Of the $1,862,275 ending balance, $959,074 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through October 2017.

Note 4:

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

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

Type

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of September 30, 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	282,151,301	0	0	0	0	0	0	0	0	0	849,007,717	
CAPITATION - LTC	206,776,494	226,817,304	208,355,352	0	0	0	0	0	0	0	0	0	641,949,150	
MENTAL HEALTH - CHILD	27,544,565	27,724,984	27,624,408	0	0	0	0	0	0	0	0	0	82,893,956	
MENTAL HEALTH - ADULT	943,019	720,852	738,314	0	0	0	0	0	0	0	0	0	2,402,185	
MENTAL HEALTH - GENERAL	12,841,280	12,960,968	12,914,296	0	0	0	0	0	0	0	0	0	38,716,545	
MENTAL HEALTH - CMDP	13,096,578	12,797,592	12,457,164	0	0	0	0	0	0	0	0	0	38,351,334	
MENTAL HEALTH - DD	4,268,444	4,283,815	4,297,906	0	0	0	0	0	0	0	0	0	12,850,165	
CHILDREN'S REHAB SERVICES	6,152,157	6,176,648	6,177,229	0	0	0	0	0	0	0	0	0	18,506,033	
FEE FOR SERVICE - ACUTE	37,517,260	57,106,521	41,373,210	0	0	0	0	0	0	0	0	0	135,996,991	
FFS - PRIOR QUARTER COVERAGE	477,647	732,384	436,705	0	0	0	0	0	0	0	0	0	1,646,736	
EMERGENCY SERVICES - FEDERAL	5,092,983	7,198,427	2,476,370	0	0	0	0	0	0	0	0	0	14,767,780	
FFS MEDICAID IN PUBLIC SCHOOLS	498,616	218,798	74,000	0	0	0	0	0	0	0	0	0	791,414	
FFS TRBHA FEE FOR SERVICE	11,064,992	13,491,379	10,597,096	0	0	0	0	0	0	0	0	0	35,153,467	
STATE ONLY TRBHA FFS	6,531	0	2,449	0	0	0	0	0	0	0	0	0	8,980	
INPATIENT INMATES FFS	223,348	131,891	101,766	0	0	0	0	0	0	0	0	0	457,005	
QMB - FEE FOR SERVICE	489,558	701,001	415,528	0	0	0	0	0	0	0	0	0	1,606,086	
PINAL COUNTY INMATES FFS	0	0	0	0	0	0	0	0	0	0	0	0	0	
MOHAVE COUNTY INMATES FFS	0	6,214	0	0	0	0	0	0	0	0	0	0	6,214	
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	22,868	0	0	0	0	0	0	0	0	0	121,593	
YUMA COUNTY INMATES FFS	0	0	77	0	0	0	0	0	0	0	0	0	77	
FEE FOR SERVICE - LTC	11,075,900	14,779,589	11,033,723	0	0	0	0	0	0	0	0	0	36,889,213	
LFFS - PRIOR QUARTER COVERAGE	31,031	30,711	36,439	0	0	0	0	0	0	0	0	0	98,180	
PIMA COUNTY INMATES LTC FEE FOR SERVICE	0	0	1,680	0	0	0	0	0	0	0	0	0	1,680	
COCHISE COUNTY INMATES LTC FFS	0	0	-980	0	0	0	0	0	0	0	0	0	-980	
MARICOPA CTY INMATES LTC FFS	166	0	607	0	0	0	0	0	0	0	0	0	772	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,540,502	836,850	200,804	0	0	0	0	0	0	0	0	0	2,578,156	
REINSURANCE - ACUTE	14,094,798	9,458,578	10,548,999	0	0	0	0	0	0	0	0	0	34,102,375	
REINSURANCE - LTC	8,708,155	6,429,637	7,948,066	0	0	0	0	0	0	0	0	0	23,085,858	
SMIB - ACUTE	14,841,421	15,030,410	15,054,132	0	0	0	0	0	0	0	0	0	44,925,963	
HIB - ACUTE	530,608	606,349	597,687	0	0	0	0	0	0	0	0	0	1,734,644	
Q1	2,585,545	2,637,260	2,661,063	0	0	0	0	0	0	0	0	0	7,883,868	
SMIB - LTC	3,694,581	3,701,005	3,714,794	0	0	0	0	0	0	0	0	0	11,110,380	
HIB - LTC	280,970	287,260	286,598	0	0	0	0	0	0	0	0	0	854,827	
SUBTOTAL	669,969,014	706,230,953	662,299,649	0	0	0	0	0	0	0	0	0	2,038,499,616	

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	224,050,452	0	0	0	0	0	0	0	0	0	656,013,048	
MENTAL HEALTH - CHILD	3,567	3,361	3,294	0	0	0	0	0	0	0	0	0	10,222	
MENTAL HEALTH - ADULT	1,025,896	887,584	796,762	0	0	0	0	0	0	0	0	0	2,710,242	
MENTAL HEALTH - GENERAL	23,612,539	23,858,290	23,761,886	0	0	0	0	0	0	0	0	0	71,232,715	
MENTAL HEALTH - CMDP	1,317	798	467	0	0	0	0	0	0	0	0	0	2,583	
CHILDREN'S REHAB SERVICES	20,262	22,004	23,504	0	0	0	0	0	0	0	0	0	65,770	
FEE FOR SERVICE - ACUTE	27,971,969	41,819,103	29,937,928	0	0	0	0	0	0	0	0	0	99,729,001	
FFS - PRIOR QUARTER COVERAGE	1,089,761	1,673,864	1,069,973	0	0	0	0	0	0	0	0	0	3,833,597	
FFS - PRESUMPTIVE ELIGIBILITY	607	0	10,333	0	0	0	0	0	0	0	0	0	10,940	
EMERGENCY SERVICES - FEDERAL	4,079,461	6,001,485	2,473,282	0	0	0	0	0	0	0	0	0	12,554,229	
FFS MEDICAID IN PUBLIC SCHOOLS	897	448	50	0	0	0	0	0	0	0	0	0	1,394	
STATE ONLY TRBHA FFS	3,266	14,268	6,531	0	0	0	0	0	0	0	0	0	24,065	
FFS TRBHA FEE FOR SERVICE	6,143,299	6,633,226	5,645,698	0	0	0	0	0	0	0	0	0	18,422,224	
INPATIENT INMATES FFS	1,021,190	712,562	351,881	0	0	0	0	0	0	0	0	0	2,085,634	
MARICOPA CTY INMATES FFS	265,078	189,865	92,588	0	0	0	0	0	0	0	0	0	547,532	
YUMA COUNTY INMATES FFS	0	0	138	0	0	0	0	0	0	0	0	0	138	
PINAL COUNTY INMATES FFS	499	0	0	0	0	0	0	0	0	0	0	0	499	
MOHAVE COUNTY INMATES FFS	0	4,601	247	0	0	0	0	0	0	0	0	0	4,848	
PIMA COUNTY INMATES FFS	15,143	31,906	103,883	0	0	0	0	0	0	0	0	0	150,932	
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	5,476,986	0	0	0	0	0	0	0	0	0	15,094,951	
SMIB - ACUTE	6,495,931	6,622,978	6,625,043	0	0	0	0	0	0	0	0	0	19,743,951	
HIB - ACUTE	4,563	4,976	4,150	0	0	0	0	0	0	0	0	0	13,689	
SUBTOTAL	294,093,172	307,725,439	300,435,075	0	0	0	0	0	0	0	0	0	902,253,686	

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	34,239,878	0	0	0	0	0	0	0	0	0	101,330,932	
MENTAL HEALTH - ADULT	50,440	101,285	73,397	0	0	0	0	0	0	0	0	0	225,122	
MENTAL HEALTH - GENERAL	4,449,323	4,495,516	4,484,950	0	0	0	0	0	0	0	0	0	13,429,788	
CHILDREN'S REHAB SERVICES	1,500	1,500	1,500	0	0	0	0	0	0	0	0	0	4,501	
FEE FOR SERVICE - ACUTE	2,634,455	3,608,952	2,850,376	0	0	0	0	0	0	0	0	0	9,093,783	
FFS - PRIOR QUARTER COVERAGE	350,598	546,221	401,753	0	0	0	0	0	0	0	0	0	1,298,572	
EMERGENCY SERVICES - FEDERAL	4,555,737	7,325,871	2,925,880	0	0	0	0	0	0	0	0	0	14,807,488	
FFS MEDICAID IN PUBLIC SCHOOLS	29	0	0	0	0	0	0	0	0	0	0	0	29	
INPATIENT INMATES FFS	84,703	44,767	3,220	0	0	0	0	0	0	0	0	0	132,691	
STATE ONLY TRBHA FFS	0	53,882	0	0	0	0	0	0	0	0	0	0	53,882	
FFS TRBHA FEE FOR SERVICE	144,138	202,842	159,014	0	0	0	0	0	0	0	0	0	505,995	
PIMA COUNTY INMATES FFS	594	388	6,951	0	0	0	0	0	0	0	0	0	7,933	
MOHAVE COUNTY INMATES FFS	0	0	11,636	0	0	0	0	0	0	0	0	0	11,636	
REINSURANCE - ACUTE	529,482	119,226	735,846	0	0	0	0	0	0	0	0	0	1,384,554	
SMIB - ACUTE	268	512	670	0	0	0	0	0	0	0	0	0	1,450	
	46,709,967	49,683,315	45,895,072	0	0	0	0	0	0	0	0	0	142,288,354	
	1,010,772,153	1,063,639,707	1,008,629,797	0	0	0	0	0	0	0	0	0	3,083,041,657	

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	3,386,799	0	0	0	0	0	0	0	0	0	9,910,488	
KidsCare - FEE FOR SERVICE	55,088	85,410	94,811	0	0	0	0	0	0	0	0	0	235,309	
KidsCare - MENTAL HEALTH	852,332	869,444	893,782	0	0	0	0	0	0	0	0	0	2,615,558	
KidsCare - REINSURANCE	90,334	651,642	14,877	0	0	0	0	0	0	0	0	0	756,853	
KidsCare - CHILD REHAB SERVICES	3,001	4,864	4,864	0	0	0	0	0	0	0	0	0	12,728	

4,238,517	4,897,346	4,395,133	0	0	0	0	0	0	0	0	0	13,530,996	

TOTAL TITLE XXI

1,015,010,670	1,068,537,053	1,013,024,930	0	0	0	0	0	0	0	0	0	3,096,572,654	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 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	480.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,902.59		
1002	TANF 01-05 M & F WIT	330.04	662.35	719.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,711.77		
1003	TANF 06-13 M & F WIT	111.05	341.90	458.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		911.66		
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	536.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,316.54		
1006	TANF 21-44 MALE WITH	34,934.55	37,443.70	37,836.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,215.13		
1007	TANF 21-44 FEMALE WI	68,398.48	67,286.38	69,636.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205,321.27		
1008	TANF 45-64 M & F WIT	98,664.26	95,156.22	95,204.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289,025.16		
1009	TANF 65+ M & F WITH	34,339.80	38,378.47	36,415.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,133.31		
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	1,516.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,092.17		
100G	TANF 21-44 FEMALE WI	741.72	2,685.35	12,635.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,062.74		
100H	TANF 45-64 M & F WIT	2,193.83	5,135.99	2,741.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,071.08		
100J	TANF 65+ M & F WITH	1,031.55	499.92	13,829.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,361.04		
1011	TANF <1 M & F NON-ME	5,800,515.18	5,986,609.54	5,913,693.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,700,818.49		
1012	TANF 01-05 M & F NON	2,591,577.99	2,625,129.55	2,688,289.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,904,997.38		
1013	TANF 06-13 M & F NON	4,099,165.87	4,028,576.53	4,085,459.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,213,202.06		
1014	TANF 14-20 MALE NON-	1,554,134.01	1,539,972.16	1,544,371.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,638,477.67		
1015	TANF 14-20 FEMALE N O	3,181,619.83	3,154,775.67	3,179,745.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,516,141.01		
1016	TANF 21-44 MALE NON-	4,791,560.01	4,758,662.95	4,740,065.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,290,288.07		
1017	TANF 21-44 FEMALE N O	24,021,285.07	23,810,217.90	23,829,199.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,660,702.07		
1018	TANF 45-64 M & F NON	9,727,126.16	9,884,272.39	9,859,099.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,470,498.13		
1019	TANF 65+ M & F NON-M	32,576.87	37,347.94	38,137.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,062.22		
101A	TANF < 1 M & F NON-M	1,023,730.67	1,103,021.10	1,171,080.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,297,832.17		
101B	TANF 01-05 M & F NON	15,605.69	22,617.30	22,943.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,166.32		
101C	TANF 06-13 M & F NON	12,934.97	17,575.11	17,144.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,654.21		
101D	TANF 14-20 MALE NON-	16,158.27	8,385.64	21,451.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,995.85		
101E	TANF 14-20 FEMALE N O	20,152.60	9,366.17	40,491.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,009.78		
101F	TANF 21-44 MALE NON-	141,843.98	8,433.39	152,556.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302,833.74		
101G	TANF 21-44 FEMALE N O	376,743.23	-38,348.88	426,120.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		764,514.38		
101H	TANF 44-64 M & F NON	127,847.88	-8,167.42	168,806.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		288,486.94		
101J	TANF 65+ N & F NON-M	771.11	-2,520.22	490.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,259.10		
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	20,044.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,539.75		
1027	TANF 21-44 FEMALE WI	63,697.04	57,779.49	61,223.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,700.14		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	68,085.21	73,049.15	74,375.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,509.99		
1029	TANF 65+ M & F WITH	33,210.14	34,038.26	34,639.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,888.12		
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	6,354.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,037.10		
102H	TANF 44-64 M & F WIT	0.00	2,122.59	3,329.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,452.53		
102J	TANF 65+ M & F WITH	2,351.09	0.00	3,413.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,764.46		
2100	SSI AGED WITH MEDIC A	897,693.12	795,728.25	794,596.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,488,017.60		
210Z	SSI AGED WITH MEDIC A	24,132.41	32,576.16	23,103.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,812.05		
2110	SSI AGED NON-MEDIC AR	6,075,643.74	5,465,504.10	5,559,965.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,101,113.63		
211Z	SSI AGED NON-MEDIC AR	82,203.22	98,950.96	116,676.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		297,830.18		
2120	SSI AGED WITH QMB	5,637,211.81	5,279,745.15	5,295,895.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,212,852.00		
212Z	SSI AGED WITH QMB P P	9,453.31	3,922.10	8,011.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,386.96		
2200	SSI DISABLED WITH M E	1,844,213.19	1,807,931.63	1,818,830.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,470,974.86		
220Z	SSI DISABLED WITH M E	82,731.69	79,013.24	119,166.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		280,911.17		
2210	SSI DISABLED NON-ME D	62,508,046.41	60,865,684.30	60,779,762.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184,153,493.17		
221Z	SSI DISABLED NON-ME D	427,254.43	530,302.22	548,497.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,506,054.64		
2220	SSI DISABLED WITH Q M	16,136,563.08	15,910,270.92	15,862,362.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,909,196.62		
222Z	SSI DISABLED WITH Q M	41,384.71	50,975.23	57,078.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,438.86		
2300	SSI BLIND WITH MEDIC	7,950.20	7,844.97	7,916.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,712.00		
2310	SSI BLIND NON-MEDIC A	491,202.64	477,214.81	477,129.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,445,546.96		
231Z	SSI BLIND NON-MEDIC A	11,701.90	5,145.11	4,721.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,568.07		
2320	SSI BLIND WITH QMB	53,206.29	52,023.42	52,240.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,469.97		
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	2,230.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,437.90		
4302	SOBRA CHILD 01-05 M	5,435.95	6,701.41	7,311.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,449.06		
4303	SOBRA CHILD 06-13 M	3,583.56	5,282.55	5,795.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,661.75		
4304	SOBRA CHILD 14-20 MA	2,430.85	2,106.43	1,995.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,533.20		
4305	SOBRA CHILD 14-20 FE	1,788.43	1,048.73	1,486.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,323.90		
430A	SOBRA CHILD < 1 M &	0.00	2,075.78	2,590.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,666.11		
430B	SOBRA CHILD 01-05 M	48.00	318.57	337.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		704.35		
430C	SOBRA CHILD 06-13 M	0.00	301.36	123.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425.02		
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	16,931,076.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,425,196.96		
4312	SOBRA CHILD 01-05 M	23,645,128.51	23,124,722.08	22,913,119.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,682,969.62		
4313	SOBRA CHILD 06-13 M	30,350,567.88	29,716,938.60	29,496,917.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,564,424.13		
4314	SOBRA CHILD 14-20 MA	10,183,859.56	9,979,977.12	9,973,198.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,137,035.15		

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 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	15,571,770.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,109,193.71		
431A	SOBRA CHILD < 1 M &	288,304.92	422,712.31	402,750.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,113,767.62		
431B	SOBRA CHILD 01-05 M	221,477.28	-7,371.32	247,293.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		461,399.21		
431C	SOBRA CHILD 6-13 M& F	216,577.94	-113,174.75	243,940.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347,343.87		
431D	SOBRA CHILD 14-20 MA	158,371.19	-38,159.29	166,180.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,392.29		
431E	SOBRA CHILD 14-20 FE	207,585.75	-42,810.09	247,897.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		412,673.30		
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	445.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,004.04		
4323	SOBRA CHILD 06-13 M	236.17	115.59	115.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		467.35		
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	788.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,118.69		
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	34,685.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,318.64		
5008	SOBRA PREG 45-64 FE M	3,979.99	662.69	3,748.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,391.36		
500G	SOBRA PREG 21-44 FE M	306.32	611.18	1,055.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,972.79		
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	SOBRA PREG 09-13 FE M	916.02	920.55	618.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,454.63		
5015	SOBRA PREG 14-20 FE M	926,061.72	932,881.49	901,144.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,760,087.29		
5017	SOBRA PREG 21-44 FE M	5,075,438.74	5,022,830.06	4,980,208.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,078,476.87		
5018	SOBRA PREG 45-64 FE M	18,556.70	17,501.16	22,231.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,288.95		
501C	SOBRA PREG 09-13 FE M	0.00	0.00	49.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.51		
501E	SOBRA PREG 14-20 FE M	49,647.81	-33,791.33	45,666.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,523.20		
501G	SOBRA PREG 21-44 FE M	202,834.23	-39,812.61	209,670.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		372,691.93		
501H	SOBRA PREG 45-64 FE M	1,185.71	329.80	1,355.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,871.28		
5025	SOBRA PREG 14-20 FE M	0.00	0.00	870.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		870.09		
5027	SOBRA PREG 21-44 FE M	24,727.60	30,213.24	24,859.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,800.46		
5028	SOBRA PREG 45-64 FE M	424.97	423.82	423.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,272.61		
502G	SOBRA PREG 21-44 FE M	6.14	744.58	44.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		795.16		
SUBTOTAL:	256,201,977.35	250,621,222.84	252,344,489.0	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		759,167,689.23		

3100	TRANSPLANT OPTION 1	0.00	0.00	16.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.50	

9910	TANF & SOBRA CHILDR E	1,671,858.21	1,914,618.06	1,957,678.76	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	19,127.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	124,693.16	188,260.19	147,522.59	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	13,720,999.68	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	15,845,328.8	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,544,155.03	
110,777.82	
460,475.94	
41,950,632.64	
48,066,041.43	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	16.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.50		

1104	TANF EXPANDED 14-20	0.00	0.00	158.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1105	TANF EXPANDED 14-20	0.00	0.00	270.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	115,280.73	114,224.09	107,176.65	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	333,829.52	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	907,126.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	283,247.60	271,616.48	264,679.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	6,434.27	833.49	9,468.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	17,187.04	20,010.57	9,419.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	24,588.37	18,477.98	24,383.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+
M&	10,009.21	4,963.49	7,876.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1112	TANF EXPANDED 01-05	982.24	773.49	878.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	7,530.15	6,396.34	6,083.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	78,885.78	74,581.55	73,294.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	480,991.35	468,272.67	461,574.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	5,205,535.87	5,124,163.45	5,063,089.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	20,323,286.61	19,947,918.91	19,817,865.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	11,730,164.19	11,843,417.41	11,798,111.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	28,256.55	28,078.55	30,516.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111C	TANF EXPANDED 06-13	87.45	0.00	45.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	1,869.30	-6,003.62	1,915.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	5,280.99	-9,343.89	7,162.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	113,756.88	1,485.98	145,034.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	252,045.26	-86,740.82	334,574.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	124,191.45	-46,232.92	179,167.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	494.89	-2,806.54	1,682.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1125	TANF EXPANDED 14-20	270.06	270.06	270.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	381,006.44	383,503.97	375,635.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	1,014,812.39	1,051,819.76	1,052,061.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	1,418,896.68	1,476,267.90	1,509,810.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	495,757.35	518,707.26	541,252.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112F	TANF EXPANDED 21-44	1,142.03	-462.10	2,378.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112G	TANF EXPANDED 21-44	3,902.35	1,608.95	3,029.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112H	TANF EXPANDED 45-64	1,484.83	1,137.12	1,998.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
158.73	
270.06	
336,681.47	
1,075,555.74	
2,809,815.02	
819,543.30	
16,736.30	
46,616.81	
67,449.62	
22,848.77	
49.12	
2,634.36	
20,009.65	
226,762.29	
1,410,838.89	
15,392,788.41	
60,089,071.22	
35,371,692.68	
86,851.32	
133.38	
-2,218.84	
3,099.64	
260,277.75	
499,878.50	
257,125.90	
-629.47	
810.18	
1,140,145.45	
3,118,693.63	
4,404,974.70	
1,555,717.23	
3,058.92	
8,540.63	
4,620.65	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
112J	TANF EXPANDED 65+
M&	590.21	399.74	2,833.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,823.57	
2400	SSI AGED EXPANDED WI	70,982.22	60,953.05	42,379.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	174,314.29	
240Z	SSI AGED EXPANDED WI	13,292.73	18,104.44	15,345.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,742.51	
2410	SSI AGED EXPANDED NO	111,573.31	93,539.30	90,400.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	295,513.43	
241Z	SSI AGED EXPANDED NO	3,594.96	4,633.83	2,444.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,673.72	
2420	SSI AGED EXPANDED WI	5,048,533.15	4,858,902.19	4,913,101.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,820,536.88	
242Z	SSI AGED EXPANDED WI	5,768.70	2,945.99	16,003.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,717.86	
2500	SSI BLIND EXPANDED W	439.11	167.67	167.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	774.45	
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	125.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	423.21	
2600	SSI DISABLED EXPAND E	215,717.42	190,692.83	143,975.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	550,385.86	
260Z	SSI DISABLED EXPAND E	68,640.56	81,350.26	74,884.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	224,875.24	
2610	SSI DISABLED EXPAND E	2,036,765.94	1,767,448.42	1,732,155.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,536,369.48	
261Z	SSI DISABLED EXPAND E	24,058.45	27,936.64	20,953.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,948.59	
2620	SSI DISABLED EXPAND E	11,145,576.62	11,100,954.59	11,163,780.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,410,311.34	
262Z	SSI DISABLED EXPAND E	17,013.33	40,720.31	38,407.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,140.92	
SUBTOTAL	:	62,234,798.57	60,755,683.30	61,328,778.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	184,319,260.12	

9911	SB PAYMENT FOR TAN F	1,371,150.11	1,352,929.38	1,351,432.00	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	5,501.04	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	1,356,933.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,075,511.49	
18,260.93	
4,093,772.42	

3504	ADULT 40-100% MALE
1	4.57	524.57	524.57	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	4,866.99	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	21,298.00	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	394.77	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	2,912.68	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	2,950,540.46	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	3,125,850.76	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	10,548,405.86	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	8,762,939.55	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	20,141,357.27	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	9,072.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,053.71	
11.28	
2,058.85	
12,658.86	
57,138.00	
-269.59	
2,884.85	
1,896.29	
11,801.85	
8,762,305.67	
9,268,202.23	
30,998,294.60	
25,765,155.28	
59,223,826.51	
26,491.18	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351D	ADULT 40-100% MALE
1	72,359.73	-49,736.72	80,177.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,800.68		
351E	ADULT 40-100% FEMAL E	63,306.58	-18,704.27	100,820.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,422.95		
351F	ADULT 40-100% MALE
2	291,967.08	8,303.19	382,394.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		682,664.64		
351G	ADULT 40-100% FEMAL E	229,537.12	-11,995.73	276,148.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		493,690.03		
351H	ADULT 40-100% M&F 45	545,163.08	-65,763.05	672,288.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,151,688.38		
351J	ADULT 40-100% M&F 65	11,658.82	-3,539.60	6,745.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,865.12		
3525	ADULT 40-100% FEMAL E	0.00	0.00	524.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.57		
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		857.83		
3527	ADULT 40-100% FEMAL E	-9.13	2,368.59	588.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,948.41		
3528	ADULT 40-100% M&F 45	2,052.47	4,019.10	2,334.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,406.13		
3529	ADULT 40-100% M&F 65	354.63	904.71	904.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,164.05		
352G	ADULT 40-100% FEMAL E	0.00	0.00	629.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		629.62		
352H	ADULT 40-100% M&F 45	2,162.61	2,114.04	1,195.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,472.55		
3704	ADULT <40% EXP MAL E	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 MAL E	6,494.13	11,445.31	9,607.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,546.82		
3707	ADULT <40% EXP FEM AL	4,432.57	11,559.30	6,367.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,359.58		
3708	ADULT <40% EXP M&F 4	14,067.06	21,252.76	18,772.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,092.32		
3709	ADULT <40% EXP M&F 6	1,019.42	923.08	871.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,814.08		
370F	ADULT <40% EXP MAL E	3,252.78	4,082.51	7,058.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,393.38		
370G	ADULT <40% EXP FEM AL	4,275.36	-105.36	5,092.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,262.91		
370H	ADULT <40% EXP M&F 4	20,886.74	12,971.24	6,421.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,279.59		
3714	ADULT <40% EXP MAL E	5,219,470.41	5,394,579.02	5,348,920.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,962,969.99		
3715	ADULT <40% EXP FEM AL	4,642,825.69	4,808,976.61	4,806,346.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,258,149.11		
3716	ADULT <40% EXP MAL E	33,047,874.79	34,761,629.62	34,524,197.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,333,701.70		
3717	ADULT <40% EXP FEM AL	20,320,142.05	21,465,807.39	21,299,025.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,084,975.39		
3718	ADULT <40% EXP M&F 4	40,004,359.73	42,354,058.71	42,136,406.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,494,825.41		
3719	ADULT <40% EXP M&F 6	15,351.84	18,714.38	19,589.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,655.94		
371D	ADULT <40% EXP MAL E	146,006.19	-155,374.60	185,124.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,756.46		
371E	ADULT <40% EXP FEM AL	144,773.10	-80,125.65	177,307.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241,955.32		
371F	ADULT <40% EXP MAL E	1,612,184.26	-543,288.27	2,042,350.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,111,246.12		
371G	ADULT <40% EXP FEM AL	963,473.42	-72,313.27	1,067,613.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,958,773.79		
371H	ADULT <40% EXP M&F 4	1,422,746.28	-670,271.54	1,758,693.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,511,168.64		
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 MAL E	-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	870.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,744.64		
3726	ADULT <40% EXP MAL E	6,441.63	3,337.56	1,346.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,125.22		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3727	ADULT <40% EXP FEM AL	251.87	0.00	2,368.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,620.46	
3728	ADULT <40% EXP M&F 4	5,999.63	7,782.84	2,534.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,316.90	
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 MAL E	388.35	883.02	1,708.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,980.33	
372H

SUBTOTAL	ADULT <40% EXP M&F 4
:	997.14

151,748,007.92	5,797.76

152,885,905.96	1,631.10

160,523,146.47	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	8,426.00

465,157,060.35	

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	1,713.76	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	384.66	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	63,915.79	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	3,936.23	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	436.82	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	227.82	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	1,305,654.15	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	1,476,486.79	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	7,778,229.06	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	10,723,337.18	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	11,546,535.64	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	6,730.06	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	27,045.58	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	37,880.29	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	225,723.91	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	316,354.94	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	257,708.46	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	573.08	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	360.88	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	2,321.11	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	

2.95	
-11.24	
4,846.70	
3,318.65	
138,652.87	
8,378.40	
932.88	
507.08	
1,066.81	
224.85	
3,873,458.12	
4,372,451.55	
23,400,300.54	
32,118,438.47	
34,733,471.99	
17,646.38	
38,383.89	
49,869.03	
365,003.07	
517,073.59	
459,177.66	
3,697.73	
4,429.01	
390.74	
4,987.02	
83.77	

9935	BIRTH SUPP PAYMENT A	276,810.08	265,656.53	276,630.88	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	564,963.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	764,895.22	836,466.48	841,593.8	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
819,097.49	
1,623,858.09	
2,442,955.58	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	3,385.29	
392H	NEWLY ELIGIBLE M&F 4	110.24	402.87	284.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	797.89	
SUBTOTAL	:	33,485,086.10	32,860,038.60	33,775,840.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	100,120,965.69	

4403	SOBRA 100-133% M&F
6	794.23	905.88	826.73	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	315.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4405	SOBRA 100-133% FEM AL	757.74	507.86	507.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440C	SOBRA 100-133% M&F
6	0.00	0.00	146.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
4412	SOBRA 100-133% M&F
1	1,485.88	793.75	446.28	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	6,068,565.70	5,973,077.96	5,972,199.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,167,517.45	2,117,655.76	2,103,726.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	3,278,980.37	3,244,965.53	3,245,200.17	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	121.34	-298.30	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	50,659.34	-27,962.86	64,553.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	31,972.74	-9,902.12	41,944.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	40,438.24	-26,343.52	55,381.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
4425	SOBRA 100-133% FEM AL	2.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,641,631.31	11,273,715.17	11,485,248.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,526.84	
957.07	
1,773.46	
146.96	
6.06	
2,725.91	
18,013,842.91	
6,388,899.43	
9,769,146.07	
-176.96	
87,250.01	
64,014.88	
69,476.27	
3.00	
2.61	
34,400,594.52	

9944	BIRTH SUPP PAYMENT S	24,374.98	57,086.40	37,514.80	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	37,514.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

118,976.18	
118,976.18	

4517	BC PATIENT FEMALE 2 1	5,030.43	5,596.82	5,488.20	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	46,674.26	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	827.19	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	309.21	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	4,598.19	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	5,659.71	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	845.04	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	64,401.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,115.45	
154,998.83	
880.74	
1,438.90	
4,820.36	
13,562.75	
14,820.65	
-4.41	
448.50	
2,007.45	
209,089.22	

9939	BIRTH SUPP PAYMENT N	423,614.42	322,314.82	464,037.03	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	464,037.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,209,966.27	
1,209,966.27	

ACUTE CAPITATION - AMOUNTS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8600	SSI BLIND FREEDOM/W O	3,473.55	4,134.40	4,134.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,742.35		
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		1,122.93		
8700	SSI DISABLED FREEDO M	1,677,240.71	1,702,839.66	1,709,913.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,089,993.79		
870Z	SSI DISABLED FREEDO M	25,793.64	29,914.96	19,181.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,889.94		
8710	SSI DISABLED FREEDO M	417,995.55	395,949.89	407,312.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,221,258.06		
871Z	SSI DISABLED FREEDO M	12,807.76	17,411.37	31,913.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,132.46		
8720	SSI DISABLED FREEDO M	190,928.86	183,129.31	190,827.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		564,885.20		
872Z	SSI DISABLED FREEDO M	902.78	7,362.39	11,019.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,284.73		
SUBTOTAL:	2,330,265.78	2,340,741.98	2,374,301.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,045,309.46		

535,550,168.84	530,359,897.74	540,441,630.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,606,351,696.97	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1002	TANF 01-05 M & F WIT	3.00	6.00	6.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.56		
1003	TANF 06-13 M & F WIT	1.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.64		
1006	TANF 21-44 MALE WITH	78.57	79.10	84.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242.02		
1007	TANF 21-44 FEMALE WI	121.95	130.43	137.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390.12		
1008	TANF 45-64 M & F WIT	167.87	166.52	167.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		501.70		
1009	TANF 65+ M & F WITH	76.75	83.13	77.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237.11		
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	4.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.25		
100G	TANF 21-44 FEMALE WI	3.92	10.59	15.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.62		
100H	TANF 45-64 M & F WIT	6.63	5.13	8.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.39		
100J	TANF 65+ M & F WITH	3.21	1.81	14.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.26		
1011	TANF <1 M & F NON-ME	12,680.31	12,878.00	12,725.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,284.22		
1012	TANF 01-05 M & F NON	20,425.00	21,039.07	21,619.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,083.77		
1013	TANF 06-13 M & F NON	31,421.44	31,527.83	32,040.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,989.84		
1014	TANF 14-20 MALE NON-	8,500.86	8,645.18	8,760.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,906.35		
1015	TANF 14-20 FEMALE N O	11,347.13	11,438.65	11,498.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,284.24		
1016	TANF 21-44 MALE NON-	27,141.38	27,294.16	27,223.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,659.10		
1017	TANF 21-44 FEMALE N O	83,553.33	83,865.89	83,875.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,294.35		
1018	TANF 45-64 M & F NON	21,279.36	21,168.31	21,113.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,561.50		
1019	TANF 65+ M & F NON-M	83.83	84.44	86.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		254.60		
101A	TANF < 1 M & F NON-M	1,013.07	1,097.45	1,157.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,267.62		
101B	TANF 01-05 M & F NON	279.37	412.61	427.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,119.40		
101C	TANF 06-13 M & F NON	239.36	317.80	312.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		869.20		
101D	TANF 14-20 MALE NON-	106.20	56.46	130.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.75		
101E	TANF 14-20 FEMALE N O	103.24	29.02	206.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338.34		
101F	TANF 21-44 MALE NON-	825.45	-28.72	959.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,756.08		
101G	TANF 21-44 FEMALE N O	1,728.03	-483.45	1,992.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,237.36		
101H	TANF 44-64 M & F NON	375.11	-16.50	484.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		842.67		
101J	TANF 65+ N & F NON-M	2.16	-2.79	1.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.03		
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	52.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.99		
1027	TANF 21-44 FEMALE WI	92.00	97.93	105.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295.68		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	120.86	130.00	132.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		383.52		
1029	TANF 65+ M & F WITH	72.70	76.00	78.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.03		
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	3.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.29		
102H	TANF 44-64 M & F WIT	0.00	2.00	9.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.33		
102J	TANF 65+ M & F WITH	6.51	0.00	9.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.17		
2100	SSI AGED WITH MEDIC A	4,505.33	4,499.53	4,501.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,506.23		
210Z	SSI AGED WITH MEDIC A	227.54	242.94	326.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796.80		
2110	SSI AGED NON-MEDIC AR	5,793.97	5,820.29	5,921.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,536.23		
211Z	SSI AGED NON-MEDIC AR	140.26	171.77	198.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		510.69		
2120	SSI AGED WITH QMB	27,697.42	27,990.51	28,089.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,777.71		
212Z	SSI AGED WITH QMB P P	54.23	49.91	94.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.05		
2200	SSI DISABLED WITH M E	3,558.35	3,571.35	3,642.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,771.94		
220Z	SSI DISABLED WITH M E	218.85	200.64	307.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		727.35		
2210	SSI DISABLED NON-ME D	54,047.38	53,981.66	53,898.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,927.74		
221Z	SSI DISABLED NON-ME D	602.83	763.73	768.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,134.72		
2220	SSI DISABLED WITH Q M	27,058.57	27,073.88	27,036.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,169.15		
222Z	SSI DISABLED WITH Q M	75.34	64.54	82.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222.26		
2300	SSI BLIND WITH MEDIC	24.00	25.00	25.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.56		
2310	SSI BLIND NON-MEDIC A	487.19	490.21	490.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,468.14		
231Z	SSI BLIND NON-MEDIC A	20.21	8.34	7.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.47		
2320	SSI BLIND WITH QMB	221.71	223.99	225.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		671.02		
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	4.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.70		
4302	SOBRA CHILD 01-05 M	42.12	46.55	52.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140.72		
4303	SOBRA CHILD 06-13 M	24.00	39.20	43.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.85		
4304	SOBRA CHILD 14-20 MA	16.16	14.09	13.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.48		
4305	SOBRA CHILD 14-20 FE	7.00	4.38	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.38		
430A	SOBRA CHILD < 1 M &	0.00	2.02	2.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.55		
430B	SOBRA CHILD 01-05 M	0.87	5.77	6.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.89		
430C	SOBRA CHILD 06-13 M	0.00	5.84	2.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.17		
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	36,175.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,535.04		
4312	SOBRA CHILD 01-05 M	183,884.02	183,433.17	182,043.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		549,360.35		
4313	SOBRA CHILD 06-13 M	231,154.67	231,125.24	229,669.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		691,949.72		
4314	SOBRA CHILD 14-20 MA	58,533.44	58,545.03	58,367.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,446.07		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 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	57,964.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,465.84		
431A	SOBRA CHILD < 1 M &	294.85	419.98	405.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,120.59		
431B	SOBRA CHILD 01-05 M	3,855.57	-23.81	4,317.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,148.93		
431C	SOBRA CHILD 6-13 M& F	3,793.44	-1,590.65	4,383.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,586.74		
431D	SOBRA CHILD 14-20 MA	1,055.11	-176.61	1,128.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,007.05		
431E	SOBRA CHILD 14-20 FE	1,044.75	-215.15	1,262.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,091.95		
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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
4323	SOBRA CHILD 06-13 M	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
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	50.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145.58		
5008	SOBRA PREG 45-64 FE M	3.83	5.67	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.50		
500G	SOBRA PREG 21-44 FE M	1.58	3.12	5.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.99		
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	SOBRA PREG 09-13 FE M	8.00	8.00	5.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.40		
5015	SOBRA PREG 14-20 FE M	3,459.15	3,491.72	3,372.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,323.06		
5017	SOBRA PREG 21-44 FE M	18,483.38	18,642.58	18,463.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,589.06		
5018	SOBRA PREG 45-64 FE M	47.50	43.38	47.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.07		
501C	SOBRA PREG 09-13 FE M	0.00	0.00	0.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.89		
501E	SOBRA PREG 14-20 FE M	254.06	-168.85	226.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		311.91		
501G	SOBRA PREG 21-44 FE M	1,005.81	-233.91	1,046.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,818.50		
501H	SOBRA PREG 45-64 FE M	3.46	0.98	3.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.23		
5025	SOBRA PREG 14-20 FE M	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
5027	SOBRA PREG 21-44 FE M	47.80	48.62	36.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133.41		
5028	SOBRA PREG 45-64 FE M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
502G	SOBRA PREG 21-44 FE M	0.03	0.57	0.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.83		
SUBTOTAL:	947,815.60	933,686.39	950,268.6	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,831,770.59		

3100	TRANSPLANT OPTION 1	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	

9910	TANF & SOBRA CHILDR E	270.00	308.00	314.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	20.00	31.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,172.00	2,397.00	2,217.00	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	2,558.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
892.00	
18.00	
75.00	
6,786.00	
7,771.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		

1104	TANF EXPANDED 14-20	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1105	TANF EXPANDED 14-20	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	335.07	330.91	303.34	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	592.64	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	1,519.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	624.46	600.40	587.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	15.51	-10.11	40.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	33.03	36.53	37.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	37.12	44.96	59.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+
M&	25.18	12.35	23.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	44.64	43.00	40.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	458.88	455.19	450.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	1,774.24	1,765.51	1,744.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	31,047.87	30,993.42	30,685.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	73,554.07	73,351.17	72,882.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	26,429.46	26,352.07	26,220.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	67.61	62.76	67.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111C	TANF EXPANDED 06-13	1.35	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	12.87	-37.96	13.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	27.19	-49.61	35.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	757.55	-17.78	953.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	1,200.28	-537.22	1,678.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	385.98	-108.67	531.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+
M&	1.38	-10.08	5.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1125	TANF EXPANDED 14-20	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	859.34	880.32	885.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	1,676.07	1,728.31	1,737.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	2,310.86	2,399.80	2,452.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	1,094.60	1,126.09	1,175.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112F	TANF EXPANDED 21-44	8.80	-3.20	16.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112G	TANF EXPANDED 21-44	2.41	3.81	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112H	TANF EXPANDED 45-64	4.23	3.46	3.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
1.00	
969.32	
1,937.89	
4,700.97	
1,812.22	
45.44	
107.13	
141.78	
60.93	
0.00	
23.00	
127.80	
1,364.53	
5,283.85	
92,726.44	
219,787.88	
79,002.25	
197.98	
2.18	
-11.67	
13.00	
1,692.83	
2,341.60	
808.96	
-3.35	
3.00	
2,624.95	
5,141.81	
7,162.79	
3,396.42	
21.98	
22.09	
11.00	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
112J	TANF EXPANDED 65+
M&	2.41	1.54	10.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.81	
2400	SSI AGED EXPANDED WI	308.22	313.71	242.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	864.77	
240Z	SSI AGED EXPANDED WI	194.97	185.11	187.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	567.99	
2410	SSI AGED EXPANDED NO	97.29	98.13	95.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	290.93	
241Z	SSI AGED EXPANDED NO	6.61	7.78	4.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.82	
2420	SSI AGED EXPANDED WI	22,108.12	22,316.04	22,586.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,010.52	
242Z	SSI AGED EXPANDED WI	37.37	39.66	60.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	137.67	
2500	SSI BLIND EXPANDED W	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	
2600	SSI DISABLED EXPAND E	347.79	324.61	247.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	919.75	
260Z	SSI DISABLED EXPAND E	123.78	154.48	179.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	458.08	
2610	SSI DISABLED EXPAND E	1,663.98	1,676.27	1,644.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,984.58	
261Z	SSI DISABLED EXPAND E	40.40	29.50	33.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103.43	
2620	SSI DISABLED EXPAND E	17,106.28	17,265.15	17,370.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51,742.41	
262Z	SSI DISABLED EXPAND E	33.13	52.49	63.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	149.07	
SUBTOTAL	:	187,179.53	184,108.77	187,499.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	558,787.83	

9911	SB PAYMENT FOR TAN F	221.00	218.00	217.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	221.00	220.00	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

656.00	
3.00	
659.00	

3504	ADULT 40-100% MALE
1	0.00	1.00	1.00	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	2.83	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	42.71	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	0.16	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	4.12	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	6,098.03	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	6,467.08	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	20,744.66	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	17,096.43	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	40,738.43	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	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
0.00	
2.99	
11.58	
114.72	
1.00	
1.99	
2.36	
12.01	
18,259.77	
19,365.61	
62,266.60	
51,401.80	
122,298.38	
57.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351D	ADULT 40-100% MALE
1	108.95	-81.44	119.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146.53		
351E	ADULT 40-100% FEMAL E	95.12	-38.04	154.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211.96		
351F	ADULT 40-100% MALE
2	425.91	-15.63	568.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		978.71		
351G	ADULT 40-100% FEMAL E	327.74	-34.71	406.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		699.98		
351H	ADULT 40-100% M&F 45	792.15	-118.47	998.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,672.26		
351J	ADULT 40-100% M&F 65	17.00	-5.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
3525	ADULT 40-100% FEMAL E	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
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		2.00		
3527	ADULT 40-100% FEMAL E	0.00	1.00	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.06		
3528	ADULT 40-100% M&F 45	4.66	5.98	5.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.30		
3529	ADULT 40-100% M&F 65	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
352G	ADULT 40-100% FEMAL E	0.00	0.00	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.93		
352H	ADULT 40-100% M&F 45	3.31	2.99	1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.23		
3704	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MAL E	6.74	12.15	10.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.90		
3707	ADULT <40% EXP FEM AL	4.58	6.78	4.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.78		
3708	ADULT <40% EXP M&F 4	23.17	31.40	26.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81.03		
3709	ADULT <40% EXP M&F 6	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
370F	ADULT <40% EXP MAL E	2.23	5.37	7.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.80		
370G	ADULT <40% EXP FEM AL	4.45	-1.17	4.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.53		
370H	ADULT <40% EXP M&F 4	16.31	12.14	6.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.90		
3714	ADULT <40% EXP MAL E	10,805.54	10,877.98	10,805.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,488.95		
3715	ADULT <40% EXP FEM AL	9,615.96	9,669.94	9,631.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,917.43		
3716	ADULT <40% EXP MAL E	62,436.00	63,349.72	62,894.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188,680.00		
3717	ADULT <40% EXP FEM AL	37,546.58	37,992.10	37,666.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,204.95		
3718	ADULT <40% EXP M&F 4	77,487.79	78,144.62	77,680.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233,313.39		
3719	ADULT <40% EXP M&F 6	42.15	40.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.15		
371D	ADULT <40% EXP MAL E	220.48	-235.02	274.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260.34		
371E	ADULT <40% EXP FEM AL	211.92	-119.76	265.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		357.49		
371F	ADULT <40% EXP MAL E	2,271.65	-992.30	2,910.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,190.24		
371G	ADULT <40% EXP FEM AL	1,322.71	-206.75	1,497.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,613.38		
371H	ADULT <40% EXP M&F 4	1,998.95	-1,114.93	2,407.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,291.20		
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 MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3725	ADULT <40% EXP FEM AL	0.00	0.99	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.99		
3726	ADULT <40% EXP MAL E	7.85	3.72	2.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.43		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3727	ADULT <40% EXP FEM AL	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	
3728	ADULT <40% EXP M&F 4	9.18	9.27	5.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.71	
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 MAL E	0.53	0.73	2.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.79	
372H	ADULT <40% EXP M&F 4	1.63	8.68	2.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.03	
SUBTOTAL	:	297,018.41	288,614.53	299,637.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	885,270.18	

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	4.43	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	1.00	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	131.89	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	10.00	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	1.56	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	0.66	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	3,236.12	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	3,644.15	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	18,693.74	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	26,208.98	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	27,761.44	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	17.00	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	81.33	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	113.23	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	652.27	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	912.16	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	740.34	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	2.00	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	1.00	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	6.16	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	

0.00	
0.00	
11.97	
8.50	
292.22	
20.19	
3.01	
1.48	
3.29	
0.80	
9,598.28	
10,826.16	
56,335.16	
78,636.70	
83,388.12	
44.00	
117.90	
144.82	
999.08	
1,460.59	
1,265.60	
13.00	
3.25	
1.00	
12.59	
0.00	

9935	BIRTH SUPP PAYMENT A	45.00	43.00	45.00	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	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	124.00	135.00	136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
133.00	
262.00	
395.00	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	1.73	
392H	NEWLY ELIGIBLE M&F 4	0.32	1.22	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.37	
SUBTOTAL	:	81,486.29	79,485.23	82,220.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	243,191.81	

4403	SOBRA 100-133% M&F
6	7.00	8.00	7.33	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4405	SOBRA 100-133% FEM AL	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440C	SOBRA 100-133% M&F
6	0.00	0.00	2.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	6.22	7.00	4.00	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	46,895.22	47,076.63	47,018.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	12,578.90	12,653.71	12,604.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	12,030.22	12,087.03	12,092.21	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	2.77	-5.00	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	939.08	-510.23	1,192.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	218.83	-61.63	290.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	208.03	-134.60	282.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4425	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	72,891.27	71,124.91	73,499.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.33	
6.00	
7.00	
2.66	
0.00	
17.22	
140,990.32	
37,837.05	
36,209.46	
-2.23	
1,621.55	
447.81	
356.25	
0.00	
0.00	
217,515.42	

9944	BIRTH SUPP PAYMENT S	4.00	9.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	9.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

19.00	
19.00	

4517	BC PATIENT FEMALE 2 1	18.00	21.53	21.00	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	104.12	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	1.87	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	0.86	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	10.00	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	12.60	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	3.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	162.74	164.18	153.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

60.53	
325.38	
1.99	
7.43	
14.46	
28.64	
33.34	
0.00	
2.35	
6.65	
480.77	

9939	BIRTH SUPP PAYMENT N	68.00	52.00	74.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	68.00	52.00	74.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
194.00	
194.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8600	SSI BLIND FREEDOM/W O	2.70	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.70		
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		5.28		
8700	SSI DISABLED FREEDO M	1,908.94	1,939.08	1,947.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,795.10		
870Z	SSI DISABLED FREEDO M	50.68	69.14	45.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.68		
8710	SSI DISABLED FREEDO M	336.40	351.75	364.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052.25		
871Z	SSI DISABLED FREEDO M	19.43	23.53	29.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.61		
8720	SSI DISABLED FREEDO M	232.56	232.39	237.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		702.31		
872Z	SSI DISABLED FREEDO M	3.39	8.56	6.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.51		
SUBTOTAL:	2,559.38	2,626.45	2,632.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,818.44		

TOTAL:	1,591,999.22	1,562,970.46	1,598,904.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,753,874.04		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending September 30, 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	28,943.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,267.01		
1010	TANF NON-MEDICARE	2,613,870.08	2,616,266.25	2,631,920.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,862,057.25		
1020	TANF WITH QMB	14,552.84	14,552.84	14,552.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,658.52		
2100	SSI AGED WITH MEDIC A	32,933,806.96	40,503,011.75	33,281,856.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,718,675.47		
210Z	SSI AGED WITH MEDIC A	652,373.23	802,200.05	651,370.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,105,944.27		
2110	SSI AGED NON-MEDIC AR	2,945,767.23	3,442,829.16	3,086,070.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,474,666.84		
211Z	SSI AGED NON-MEDIC AR	26,026.97	37,754.67	25,487.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,269.31		
2120	SSI AGED WITH QMB	20,774,403.47	25,359,009.41	21,011,673.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,145,086.29		
212Z	SSI AGED WITH QMB P P	18,726.37	17,194.42	2,467.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,388.67		
2200	SSI DISABLED WITH M E	15,894,224.54	17,882,836.09	16,041,237.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,818,298.03		
220Z	SSI DISABLED WITH M E	68,599.31	115,034.86	62,678.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246,312.67		
2210	SSI DISABLED NON-ME D	106,245,644.56	109,460,228.37	106,868,665.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322,574,538.25		
221Z	SSI DISABLED NON-ME D	21,758.30	32,964.90	23,051.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,775.06		
2220	SSI DISABLED WITH Q M	23,534,174.16	25,423,926.94	23,587,390.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,545,491.61		
222Z	SSI DISABLED WITH Q M	9,199.93	0.00	4,348.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,548.55		
2300	SSI BLIND WITH MEDIC	70,372.06	79,197.33	80,370.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229,940.09		
2310	SSI BLIND NON-MEDIC A	534,836.83	549,634.63	542,529.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,627,001.11		
2320	SSI BLIND WITH QMB	144,734.34	166,531.44	155,294.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		466,560.65		
SUBTOTAL:	206,535,653.38	226,532,913.93	208,099,912.3	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		641,168,479.65		

8700	SSI DISABLED FREEDO M	85,343.64	104,810.80	93,916.27	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	136,874.37	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	24,649.26	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	255,439.9	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
284,070.71	
419,916.74	
76,683.06	
780,670.51	

206,776,493.88	226,817,304.04	208,355,352.24	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 September 30, 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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
1010	TANF NON-MEDICARE	713.19	711.87	718.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,143.18		
1020	TANF WITH QMB	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
2100	SSI AGED WITH MEDIC A	11,369.40	11,418.65	11,468.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,256.14		
210Z	SSI AGED WITH MEDIC A	627.42	774.25	623.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,024.80		
2110	SSI AGED NON-MEDIC AR	541.12	550.98	556.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,648.96		
211Z	SSI AGED NON-MEDIC AR	24.80	35.79	24.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.06		
2120	SSI AGED WITH QMB	7,613.97	7,668.28	7,718.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,000.68		
212Z	SSI AGED WITH QMB P P	18.33	17.56	2.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
2200	SSI DISABLED WITH M E	4,922.28	4,934.11	4,975.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,832.08		
220Z	SSI DISABLED WITH M E	67.01	92.31	59.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		219.13		
2210	SSI DISABLED NON-ME D	27,568.14	27,678.83	27,713.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,960.31		
221Z	SSI DISABLED NON-ME D	19.53	32.55	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.84		
2220	SSI DISABLED WITH Q M	7,082.95	7,092.05	7,107.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,282.29		
222Z	SSI DISABLED WITH Q M	8.46	0.00	4.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.80		
2300	SSI BLIND WITH MEDIC	20.00	21.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.00		
2310	SSI BLIND NON-MEDIC A	139.64	141.78	143.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		424.42		
2320	SSI BLIND WITH QMB	44.22	48.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.22		
SUBTOTAL:	60,793.46	61,230.01	61,220.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183,244.13		

TOTAL:

60,850.04

61,290.01

61,280.66

0.00

0.00

0.00

0.00

0.00

183,420.71

0.00

0.00

0.00	0.00

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

 
78.58	
74.00	
24.00	
176.58	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending September 30, 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	462.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,014.86		
1002	TANF 01-05 M & F WIT	0.00	0.00	-12.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-12.69		
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	3,095,074.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,172,055.81		
1011	TANF <1 M & F NON-ME	21,465.67	27,973.56	23,869.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,309.18		
1012	TANF 01-05 M & F NON	4,553.03	8,838.19	6,862.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,254.11		
1013	TANF 06-13 M & F NON	6,028.74	10,281.76	8,823.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,133.52		
1014	TANF 14-20 MALE NON-	1,035.47	1,748.57	2,121.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,905.14		
1015	TANF 14-20 FEMALE N O	837.07	1,900.47	1,596.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,333.70		
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	49,115.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,285.28		
101B	TANF 01-05 M & F NON	10,678.65	14,220.75	15,534.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,433.66		
101C	TANF 06-13 M & F NON	9,637.85	12,440.81	11,438.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,517.54		
101D	TANF 14-20 MALE NON-	2,927.22	2,190.31	2,332.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,449.63		
101E	TANF 14-20 FEMALE N O	1,386.26	3,030.83	2,757.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,174.75		
2200	SSI DISABLED WITH M E	58.58	115.69	58.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232.85		
2210	SSI DISABLED NON-ME D	339,385.86	339,565.32	335,692.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,014,644.04		
221Z	SSI DISABLED NON-ME D	3,473.04	2,989.30	4,514.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,976.80		
2220	SSI DISABLED WITH Q M	317.52	323.19	380.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,021.01		
2310	SSI BLIND NON-MEDIC A	1,549.96	1,579.25	1,618.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,748.00		
4300	SOBRA CHILD WITH M ED	3,672.02	3,706.72	4,056.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,435.47		
4301	SOBRA CHILD <1 M & F	0.00	26.46	23.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.89		
4302	SOBRA CHILD 01-05 M	3.78	53.41	40.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97.70		
4303	SOBRA CHILD 06-13 M	-22.11	137.16	74.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189.82		
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	74.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133.66		
430B	SOBRA CHILD 01-05 M	25.51	169.32	202.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		396.93		
430C	SOBRA CHILD 06-13 M	0.00	225.72	80.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306.12		
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	20,608,786.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,997,539.83		
4311	SOBRA CHILD <1 M & F	74,767.02	85,586.36	83,703.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,056.72		
4312	SOBRA CHILD 01-05 M	97,241.60	128,724.36	107,914.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		333,880.72		
4313	SOBRA CHILD 06-13 M	100,730.14	146,407.59	117,325.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364,463.56		
4314	SOBRA CHILD 14-20 MA	18,684.49	29,311.73	23,622.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,618.34		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	22,348.49	28,238.11	23,599.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,185.65		
431A	SOBRA CHILD < 1 M &	13,722.48	16,441.34	16,127.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,290.86		
431B	SOBRA CHILD 01-05 M	144,680.47	160,579.12	160,748.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		466,008.30		
431C	SOBRA CHILD 6-13 M& F	141,402.90	172,682.80	163,699.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		477,784.99		
431D	SOBRA CHILD 14-20 MA	28,416.16	40,056.79	32,927.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,399.96		
431E	SOBRA CHILD 14-20 FE	29,144.05	35,772.33	35,465.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,381.75		
4320	SOBRA CHILD WITH Q MB	115.69	144.98	231.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		492.05		
5000	SOBRA PREGNANT WO MAN	57.11	57.11	57.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.33		
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	16,778.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,793.55		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	22.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.84		
5015	SOBRA PREG 14-20 FE M	1,222.55	1,050.98	677.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,950.58		
501C	SOBRA PREG 09-13 FE M	0.00	0.00	50.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.85		
501E	SOBRA PREG 14-20 FE M	1,495.46	965.61	730.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,191.49		
SUBTOTAL:	24,897,595.06	25,057,504.64	24,959,260.4	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,914,360.16		

4400	SOBRA 100-133% FOR F	405.65	411.06	381.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4403	SOBRA 100-133% M&F
6	0.00	0.00	9.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440C	SOBRA 100-133% M&F
6	0.00	0.00	78.11	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	2,561,373.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	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	28,325.12	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	5,283.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	4,916.84	6,421.81	5,852.19	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	45,695.83	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	9,511.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	7,177.96	8,702.26	8,635.75	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	2,665,147.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,198.48	
9.76	
78.11	
7,686,847.30	
12.90	
83,530.84	
16,362.97	
17,190.84	
158.43	
124,493.71	
25,196.46	
24,515.97	
7,979,595.77	

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	

82.86	
36.30	

1110	TANF EXPANDED FOR FI	3,442.11	3,361.12	3,304.01	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	4.88	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	-39.68	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	24.41	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	3,293.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10,107.24	
45.22	
-39.68	
109.11	
10,221.89	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		119.16		

27,548,167.97	27,728,427.50	27,627,701.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

82,904,296.98	

TOTAL:

1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1002	TANF 01-05 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
1005	TANF 14-20 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
100E	TANF 14-20 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
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
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
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
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

Cu0.00rren0.00t an0.0d0	pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0      n.0.00

101E	TANF 14-20 FEMALE N
O
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH M
ED

0.00

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

4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	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
4304	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
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
430B	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
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
430E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4310	SOBRA CHILD NON-ME
DI

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

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

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
431C	SOBRA CHILD 6-13 M& 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	
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4320	SOBRA CHILD WITH Q MB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
501C	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
501E	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

M
SUBTOTAL:

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth data is

0.00

0.00

0.00

under revision.

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1110	TANF EXPANDED FOR FI												
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	
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	
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
440C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	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	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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		

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 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	71,506.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,491.50		
1014	TANF 14-20 MALE NON-	9,870.85	0.00	5,324.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,195.76		
1015	TANF 14-20 FEMALE N O	9,065.75	7,469.90	7,243.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,778.67		
1016	TANF 21-44 MALE NON-	11,569.46	4,589.26	1,547.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,705.89		
1017	TANF 21-44 FEMALE N O	39,839.71	20,361.55	13,838.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,039.68		
1018	TANF 45-64 M & F NON	15,115.50	16,726.11	16,077.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,918.85		
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	2,899.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,715.24		
101H	TANF 44-64 M & F NON	2,290.28	116.88	1,202.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,609.56		
1027	TANF 21-44 FEMALE WI	0.00	0.00	-1,727.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,727.98		
2100	SSI AGED WITH MEDIC A	2,112.72	3,487.22	1,774.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,374.91		
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-MEDIC AR	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	7,489.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,435.51		
2200	SSI DISABLED WITH M E	26,832.39	8,551.37	11,145.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,529.51		
220Z	SSI DISABLED WITH M E	7,897.63	4,002.96	2,118.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,019.10		
2210	SSI DISABLED NON-ME D	472,088.18	390,714.24	369,959.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,232,762.38		
221Z	SSI DISABLED NON-ME D	5,257.87	-15,475.96	3,957.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6,260.88		
2220	SSI DISABLED WITH Q M	202,597.90	137,282.20	163,966.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503,846.89		
222Z	SSI DISABLED WITH Q M	2,118.27	0.00	5,946.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,064.91		
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	2,535.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,528.13		
4314	SOBRA CHILD 14-20 MA	8,861.93	16,995.83	6,800.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,658.09		
4315	SOBRA CHILD 14-20 FE	18,118.52	7,079.64	6,848.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,046.37		
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		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	650.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		650.82		
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	5,021.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,064.98		
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	1,902.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,187.87		
5027	SOBRA PREG 21-44 FE M	1,124.15	949.50	1,956.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,029.94		
502G	SOBRA PREG 21-44 FE M	0.00	0.00	515.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		515.31		
SUBTOTAL:	936,587.53	718,025.46	710,501.0	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,365,114.00		

1100	TANF EXPANDED FPR FI	7,965.10	8,365.92	7,965.10	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	-216.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
24,296.12	
5,161.04	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		2,654.34		
1110	TANF EXPANDED FOR FI	24,531.79	21,260.49	22,448.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,241.25		
1116	TANF EXPANDED 21-44	8,122.79	3,098.04	14,019.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,239.84		
1117	TANF EXPANDED 21-44	3,681.87	8,276.73	1,086.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,044.80		
1118	TANF EXPANDED 45-64	494.65	2,138.08	3,379.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,011.91		
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		
111H	TANF EXPANDED 45-64	0.00	0.00	1,656.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,656.64		
1120	TANF EXPANDED FOR FI	5,852.92	4,953.80	4,381.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,187.92		
1126	TANF EXPANDED 21-44	0.00	0.00	2,848.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,848.49		
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	16,691.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,973.58		
2600	SSI DISABLED EXPAND E	8,175.29	9,624.10	3,584.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,384.36		
260Z	SSI DISABLED EXPAND E	1,780.54	1,614.14	6.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,401.00		
2610	SSI DISABLED EXPAND E	16,459.44	4,129.30	425.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,013.89		
2620	SSI DISABLED EXPAND E	95,463.82	68,058.95	48,111.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,634.15		
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	126,387.8	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		512,697.64		

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	
3508	ADULT 40-100% M&F 45	0.00	0.00	473.33	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	
350H	ADULT 40-100% M&F 45	0.00	0.00	3,076.61	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	49,172.44	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	6,389.89	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	4,491.44	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	7,132.25	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	17,843.46	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	236.66	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	3,549.94	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	2,767.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,660.46	
473.33	
57.26	
3,076.61	
142,009.13	
21,281.87	
1,974.65	
20,096.55	
32,876.17	
74,449.76	
1,775.70	
-525.23	
4,807.16	
3,607.20	
22,473.66	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		343.56		
3706	ADULT <40% EXP MAL E	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		3,595.27		
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		3,152.06		
370F	ADULT <40% EXP MAL E	118.33	114.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232.84		
370H	ADULT <40% EXP M&F 4	0.00	4,752.34	769.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,521.49		
3710	AHC CARE EXPANDED FO	269,577.60	259,367.87	254,857.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		783,802.50		
3714	ADULT <40% EXP MAL E	8,520.05	19,861.18	2,000.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,381.56		
3715	ADULT <40% EXP FEM AL	4,333.10	8,226.90	2,660.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,220.54		
3716	ADULT <40% EXP MAL E	126,138.11	115,879.59	172,653.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414,671.17		
3717	ADULT <40% EXP FEM AL	111,889.44	66,507.59	45,919.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,317.02		
3718	ADULT <40% EXP M&F 4	99,355.58	107,006.96	54,322.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260,684.76		
371D	ADULT <40% EXP MAL E	0.00	0.00	1,124.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,124.15		
371F	ADULT <40% EXP MAL E	7,355.98	18,855.59	23,121.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,333.05		
371G	ADULT <40% EXP FEM AL	6,994.39	16,512.76	3,610.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,117.73		
371H	ADULT <40% EXP M&F 4	16,563.47	14,714.52	13,690.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,968.37		
3720	AHC CARE EXPANDED FO	0.00	2,190.60	2,190.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,381.20		
3726	ADULT <40% EXP MAL E	282.66	0.00	-1,679.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,396.80		
SUBTOTAL:	795,395.71	731,774.84	670,374.2	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,197,544.75		

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	
4414	SOBRA 100-133% MALE	0.00	0.00	887.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	2,049.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	4,381.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,195.38	
887.48	
2,049.81	
4,381.20	

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	32,811.67	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	887.48	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	23,139.07	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	13,213.03	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	887.48	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	2,458.45	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	73,397.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
744.34	
1,030.63	
87,080.76	
7,414.79	
858.86	
39,808.43	
42,343.30	
35,271.50	
-5,096.32	
2,890.93	
7,870.41	
4,904.01	
225,121.64	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,195.38	0.00	7,318.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,513.87		

8700	SSI DISABLED FREEDO M	4,236.18	2,539.98	20,494.58	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	20,494.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
27,270.74	
286.29	
27,557.03	

2,019,354.68	1,709,720.90	1,608,473.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,337,548.93	

TOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

RATE CODE	DESCRIPTION 1010	TANF NON-MEDICARE
1014	TANF 14-20 MALE NON-

1015	TANF 14-20 FEMALE N
O
1016	TANF 21-44 MALE NON-

1017	TANF 21-44 FEMALE N
O
1018	TANF 45-64 M & F NON

101F	TANF 21-44 MALE NON-

101G	TANF 21-44 FEMALE N
O
101H	TANF 44-64 M & F NON

1027	TANF 21-44 FEMALE WI

2100	SSI AGED WITH MEDIC
A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDIC
AR
2120	SSI AGED WITH QMB

220Z

E
SI DISABLED WITH M

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

n.0.00

2200	SSI DISABLED WITH M

S E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI
4314	SOBRA CHILD 14-20 MA

4315	SOBRA CHILD 14-20 FE

431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

5008	SOBRA PREG 45-64 FE
M
5010	SOBRA PREGNANT WO
MAN
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5027	SOBRA PREG 21-44 FE
M
502G	SOBRA PREG 21-44 FE
M
SUBTOTAL:

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

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

0.00

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
0.00	
0.00	

0.00

0.00

0.00

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	0.00

1110	TANF EXPANDED FOR
FI

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

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

111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

111H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1120	TANF EXPANDED FOR
FI

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

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

2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
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

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

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

E
260Z

Cu0.00rren0.00t an0.0d0	pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0      n.0.00

2600	SSI DISABLED EXPAND

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

SSI DISABLED EXPAND E
2610	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E
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

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

3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
350G	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	
350H	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	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	
351D	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	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	
351H	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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

RATE CODE	DESCRIPTION
3700	ADULT <40% EXP FOR
F
3706	ADULT <40% EXP MAL
E
3708	ADULT <40% EXP M&F
4
370F	ADULT <40% EXP MAL
E
370H	ADULT <40% EXP M&F
4
3710	AHC CARE EXPANDED
FO
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
371D	ADULT <40% EXP MAL
E
371F	ADULT <40% EXP MAL
E
371G	ADULT <40% EXP FEM

371H	ADULT <40% EXP M&F
4

AL

37

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

20	AHC CARE EXPANDED

FO

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

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

0.00

0.00

n.0.00

3726	ADULT <40% EXP MAL
E
SUBTOTAL:

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	
390H	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	
3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

 
0.00	
0.00	
0.00	

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 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	664.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,056.19		
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	43.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.69		
1007	TANF 21-44 FEMALE WI	0.00	48.56	107.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155.84		
1010	TANF NON-MEDICARE	7,528,314.05	7,511,991.21	7,513,809.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,554,115.04		
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	1,450.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,311.64		
1015	TANF 14-20 FEMALE N O	3,101.01	3,991.10	4,411.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,503.57		
1016	TANF 21-44 MALE NON-	21,980.86	33,636.20	29,997.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,614.55		
1017	TANF 21-44 FEMALE N O	56,880.49	85,190.53	75,352.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217,423.42		
1018	TANF 45-64 M & F NON	15,596.43	20,519.22	17,841.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,957.17		
1019	TANF 65+ M & F NON-M	-6.35	-29.37	56.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.63		
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	3,471.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,065.45		
101E	TANF 14-20 FEMALE N O	3,759.41	4,623.99	6,934.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,317.65		
101F	TANF 21-44 MALE NON-	42,225.70	48,848.84	50,165.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,240.10		
101G	TANF 21-44 FEMALE N O	88,550.44	103,417.97	104,571.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296,539.96		
101H	TANF 44-64 M & F NON	19,829.13	24,800.86	25,508.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,138.73		
101J	TANF 65+ N & F NON-M	112.19	578.32	93.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		784.36		
1020	TANF WITH QMB	350.91	395.24	573.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,319.40		
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		
1028	TANF 45-64 M & F WIT	0.00	0.00	-32.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-32.57		
2100	SSI AGED WITH MEDIC A	6,711.47	6,454.10	7,325.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,490.77		
2110	SSI AGED NON-MEDIC AR	304,645.22	312,668.78	309,963.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		927,277.09		
211Z	SSI AGED NON-MEDIC AR	7,325.76	9,345.18	10,097.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,767.99		
2120	SSI AGED WITH QMB	33,188.84	34,747.06	35,091.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,027.43		
2200	SSI DISABLED WITH M E	11,894.44	11,728.31	11,925.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,548.14		
2210	SSI DISABLED NON-ME D	1,826,599.90	1,829,961.29	1,830,083.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,486,645.05		
221Z	SSI DISABLED NON-ME D	19,573.57	27,156.42	26,952.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,682.92		
2220	SSI DISABLED WITH Q M	43,400.80	43,879.46	43,623.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,903.98		
2300	SSI BLIND WITH MEDIC	116.97	116.97	174.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408.39		
2310	SSI BLIND NON-MEDIC A	21,375.83	21,540.28	21,715.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,631.94		
231Z	SSI BLIND NON-MEDIC A	985.66	432.73	424.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,842.68		
2320	SSI BLIND WITH QMB	849.97	849.97	849.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,549.91		
4300	SOBRA CHILD WITH M ED	51.91	51.91	51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155.73		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	-39.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.80		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4310	SOBRA CHILD NON-ME DI	1,199,527.27	1,202,853.14	1,184,904.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,587,285.08		
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		
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	9,877.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,734.85		
4315	SOBRA CHILD 14-20 FE	8,251.14	13,109.63	10,539.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,900.43		
431D	SOBRA CHILD 14-20 MA	12,387.06	15,098.59	13,989.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,475.16		
431E	SOBRA CHILD 14-20 FE	13,313.17	15,536.49	16,218.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,067.91		
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	1,128,068.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,394,750.68		
5015	SOBRA PREG 14-20 FE M	7,474.09	10,129.48	8,345.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,948.75		
5017	SOBRA PREG 21-44 FE M	36,560.83	47,140.12	41,677.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,378.82		
5018	SOBRA PREG 45-64 FE M	81.63	113.04	132.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327.49		
501E	SOBRA PREG 14-20 FE M	11,820.56	12,545.36	11,020.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,386.77		
501G	SOBRA PREG 21-44 FE M	53,792.57	59,942.43	55,928.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,663.49		
501H	SOBRA PREG 45-64 FE M	193.08	257.91	197.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		648.25		
5510	SOBRA FPS FEMALE W IT	0.00	0.00	-59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-59.49		
SUBTOTAL:	12,547,066.20	12,661,403.74	12,614,101.2	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,822,571.16		

1100	TANF EXPANDED FPR FI	4,486.72	4,102.62	3,814.76	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	29.85	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	97.48	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	91.16	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	7,157,293.31	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	580.71	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	1,557.62	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	27,359.39	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	52,618.96	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	18,019.31	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	-165.21	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	715.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,404.10	
79.74	
156.37	
310.35	
32.12	
21,594,565.46	
1,250.77	
4,247.87	
81,614.97	
148,995.96	
58,068.75	
-304.10	
1,828.27	

3010	MN/MI NON-MEDICARE	0.00	0.00	-118.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3100	TRANSPLANT OPTION 1	0.00	0.00	51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4110	EAC NON-MEDICARE	-51.91	0.00	-103.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-51.91	0.00	-170.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-118.98	
51.91	
-155.73	
-222.80	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111E	TANF EXPANDED 14-20	1,501.08	1,471.41	1,908.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,881.10		
111F	TANF EXPANDED 21-44	39,523.53	50,612.12	51,219.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,354.90		
111G	TANF EXPANDED 21-44	61,738.58	77,496.73	87,336.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		226,571.95		
111H	TANF EXPANDED 45-64	21,336.56	30,393.46	28,588.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,318.82		
111J	TANF EXPANDED 65+
M&	72.00	48.56	293.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414.05		
1120	TANF EXPANDED FOR FI	7,388.46	7,768.54	8,432.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,589.92		
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	51.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.63		
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		
1129	TANF EXPANDED 65+
M&	0.00	0.00	-11.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11.50		
2400	SSI AGED EXPANDED WI	579.46	611.51	230.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,421.91		
2410	SSI AGED EXPANDED NO	4,629.90	5,308.04	4,732.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,670.86		
241Z	SSI AGED EXPANDED NO	372.82	419.46	254.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,047.21		
2420	SSI AGED EXPANDED WI	23,789.79	26,119.96	26,149.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,059.45		
2600	SSI DISABLED EXPAND E	516.50	279.68	194.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		990.67		
2610	SSI DISABLED EXPAND E	82,947.40	83,737.27	81,966.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248,650.74		
261Z	SSI DISABLED EXPAND E	1,639.72	1,242.24	1,799.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,681.02		
2620	SSI DISABLED EXPAND E	13,715.54	13,591.07	13,632.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,939.13		
SUBTOTAL:	7,587,513.80	7,612,656.85	7,568,794.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,768,964.67		

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	-618.80	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	4,924,438.56	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	3,075.77	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	4,485.47	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	16,740.18	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	12,215.06	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	27,610.19	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	-144.74	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	6,397.57	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	8,446.52	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	30,242.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

170.89	
38.51	
-460.52	
14,798,411.96	
8,325.00	
12,999.80	
45,775.08	
35,168.37	
82,919.40	
-188.28	
18,882.73	
20,034.48	
81,338.89	

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 September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351G	ADULT 40-100% FEMAL E	17,043.40	20,971.83	21,682.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,697.50		
351H	ADULT 40-100% M&F 45	41,803.57	52,354.17	53,113.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,271.38		
351J	ADULT 40-100% M&F 65	905.92	486.29	519.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,911.31		
3528	ADULT 40-100% M&F 45	43.54	0.00	59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.03		
3706	ADULT <40% EXP MAL E	100.47	103.83	81.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285.60		
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		117.53		
3708	ADULT <40% EXP M&F 4	91.75	35.16	166.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293.82		
3710	AHC CARE EXPANDED FO	10,450,228.78	10,502,948.05	10,457,838.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,411,015.06		
3714	ADULT <40% EXP MAL E	6,115.08	8,625.11	8,794.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,534.56		
3715	ADULT <40% EXP FEM AL	7,339.31	8,582.41	8,070.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,991.96		
3716	ADULT <40% EXP MAL E	68,031.82	105,097.58	99,156.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,285.53		
3717	ADULT <40% EXP FEM AL	39,795.47	54,797.29	50,459.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,052.47		
3718	ADULT <40% EXP M&F 4	68,319.05	90,380.80	82,253.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,953.17		
3719	ADULT <40% EXP M&F 6	-188.99	0.00	-92.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-281.82		
371D	ADULT <40% EXP MAL E	12,088.08	11,984.14	14,798.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,870.93		
371E	ADULT <40% EXP FEM AL	11,098.59	11,970.92	14,368.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,437.79		
371F	ADULT <40% EXP MAL E	113,555.01	131,660.54	148,254.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		393,470.01		
371G	ADULT <40% EXP FEM AL	64,615.40	76,406.23	77,082.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,104.35		
371H	ADULT <40% EXP M&F 4	103,824.25	118,397.96	123,597.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345,819.64		
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	16,193,091.9	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,463,861.78		

3900	NEWLY ELIGIBLE FOR F	176.46	170.89	118.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	15.33	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	4,270,850.20	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	1,847.85	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	3,650.90	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	20,066.63	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	30,731.92	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	23,871.13	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	4,452.83	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	6,138.52	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	34,385.84	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	48,506.03	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	40,137.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
466.33	
15.33	
12,841,061.53	
6,127.58	
9,310.41	
58,401.16	
84,740.33	
63,740.52	
11,689.89	
16,277.05	
97,769.89	
133,959.61	
105,883.60	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
391J	NEWLY ELIGIBLE M&F 6	117.50	51.91	118.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	287.65	
3920	NEWLY ELIGIBLE FOR F	0.00	0.00	57.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.48	
SUBTOTAL	:	4,449,322.72	4,495,515.99	4,484,949.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,429,788.36	

4410	SOBRA 100-133% FOR F	261,749.30	263,955.88	263,138.58	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	1,968.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	1,174.78	1,743.17	2,329.73	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	2,452.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	2,162.61	3,226.95	3,607.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	269,474.27	272,848.11	273,497.1	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
788,843.76	
5,948.86	
5,247.68	
6,781.86	
8,997.37	
815,819.53	

4510	BC PATIENT FOR FINA N	6,511.96	6,730.74	6,988.28	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	53.71	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	44.99	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	1,161.43	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	35.69	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	202.27	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	8,486.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
20,230.98	
195.61	
397.74	
114.96	
412.84	
811.42	
3,157.67	
38.38	
74.20	
138.08	
371.40	
25,943.28	

8700	SSI DISABLED FREEDO M	436.01	487.92	714.30	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	16,465.99	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	1,142.63	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	59.49	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	18,382.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,638.23	
47,309.51	
3,307.30	
178.47	
52,433.51	

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	41,161,131.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

123,378,988.60	

TOTAL:

1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1005	TANF 14-20 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
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
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
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	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
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Cu0.00rren0.00t an0.0d0	pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0      n.0.00

101E	TANF 14-20 FEMALE N
O
101F	TANF 21-44 MALE NON-

101G	TANF 21-44 FEMALE N
O

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

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

101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1020	TANF WITH QMB	0.00	0.00	0.00	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
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

2100	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDIC
AR
211Z	SSI AGED NON-MEDIC
AR

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	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
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
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
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	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
231Z	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
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4300	SOBRA CHILD WITH M
ED

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

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

4304	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

RATE CODE	DESCRIPTION
4310	SOBRA CHILD NON-ME
DI
4311	SOBRA CHILD <1 M & F

4312	SOBRA CHILD 01-05 M

4313	SOBRA CHILD 06-13 M

4314	SOBRA CHILD 14-20 MA

4315	SOBRA CHILD 14-20 FE

431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

5000	SOBRA PREGNANT WO
MAN
5010	SOBRA PREGNANT WO
MAN
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501E	SOBRA PREG 14-20 FE
M

0.00

0.00

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

Cu0.00rren0.00t an0.0d0	pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0      n.0.00

501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT
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

3010	MN/MI 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	
3100	TRANSPLANT OPTION 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4110	EAC 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	
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	

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	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	
111D	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

111F

TANF EXPANDED 21-44

111G

TANF EXPANDED 21-44

111H

111J

1120

1126

TANF EXPANDED 45-64

TANF EXPANDED 65+
M&
TANF EXPANDED FOR
FI
TANF EXPANDED 21-44

1127

1128

TANF EXPANDED 21-44

TANF EXPANDED 45-64

1129

2400

2410

241Z

2420

2600

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

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

vision.

0.00

0.00

2610

261Z

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2620
E
SUBTOTAL:

0.00

0.00

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

RATE CODE	DESCRIPTION 111E	TANF EXPANDED 14-20

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

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	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	
3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

RATE CODE	DESCRIPTION
351G	ADULT 40-100% FEMAL

E
351H	ADULT 40-100% M&F 45

351J	ADULT 40-100% M&F 65

3528	ADULT 40-100% M&F 45

3706	ADULT <40% EXP MAL
E
3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3710	AHC CARE EXPANDED
FO
3714	ADULT <40% EXP MAL
E
3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MAL
E
3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F

371D	ADULT <40% EXP MAL
E

6

37

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

1E	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

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

n.0.00 	0.00

371F	ADULT <40% EXP MAL
E
371G	ADULT <40% EXP FEM
AL
371H	ADULT <40% EXP M&F
4
371J	ADULT <40% EXP M&F
6
3728	ADULT <40% EXP M&F
4
SUBTOTAL:

3900	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
391J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3920	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4510

4517

BC PATIENT FOR FINA N
BC PATIENT FEMALE 2
1
BC PATIENT FEMALE 4
5
BC PATIENT FEMALE 6
5
BC PATIENT FEMALE 2
1
BC PATIENT FEMALE 4
5
CC PATIENT FOR FINA
N
CC PATIENT FEMALE 2
1
CC PATIENT FEMALE 4
5
CC PATIENT FEMALE 2
1
CC PATIENT FEMALE 4

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4519

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

451G

451H

Current and

0.00

0.00

0.00

prior m

0.00

0.00

0.00

0.00

onth

0.00

0.00

dat

0.00

0.00

a is

0.00

0.00

under re

0.00

0.00

0.00

0.00

visio

0.00

0.00

0.00

0.00

0.00

4610

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

n.

0.00

0.00

0.00

4617

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

461G

461H

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5
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	

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
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	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	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	

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

0.00	
0.00	

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

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending September 30, 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	638,720.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,821,860.14		
1011	TANF <1 M & F NON-ME	13,755.71	7,131.27	6,861.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,748.83		
1012	TANF 01-05 M & F NON	-4,548.84	-5,434.60	-5,799.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-15,782.76		
1013	TANF 06-13 M & F NON	1,577.39	1,040.82	963.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,581.62		
1014	TANF 14-20 MALE NON-	2,671.57	4,894.20	4,102.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,668.70		
1015	TANF 14-20 FEMALE N O	1,000.46	5,820.41	508.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,329.78		
101A	TANF < 1 M & F NON-M	3,387.50	1,546.54	1,250.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,184.70		
101B	TANF 01-05 M & F NON	0.00	-23.79	368.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345.00		
101C	TANF 06-13 M & F NON	1,296.20	876.25	850.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,022.86		
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	209,148.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		648,736.05		
221Z	SSI DISABLED NON-ME D	880.34	1,190.32	199.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,269.84		
4300	SOBRA CHILD WITH M ED	737.58	737.58	737.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,212.74		
4310	SOBRA CHILD NON-ME DI	12,126,022.98	11,903,733.62	11,593,125.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,622,881.86		
4311	SOBRA CHILD <1 M & F	25,704.10	41,214.87	28,100.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,019.14		
4312	SOBRA CHILD 01-05 M	-26,470.35	-20,488.64	-41,805.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-88,764.40		
4313	SOBRA CHILD 06-13 M	-10,870.61	-92,386.66	-86,516.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-189,773.85		
4314	SOBRA CHILD 14-20 MA	-14,374.19	-22,086.68	-31,481.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-67,942.75		
4315	SOBRA CHILD 14-20 FE	-23,537.71	-23,022.52	-45,341.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-91,902.06		
431A	SOBRA CHILD < 1 M &	11,357.74	6,860.92	11,826.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,044.79		
431B	SOBRA CHILD 01-05 M	63,408.56	29,363.66	56,569.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,341.38		
431C	SOBRA CHILD 6-13 M& F	45,217.94	28,157.03	23,495.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,870.07		
431D	SOBRA CHILD 14-20 MA	15,738.23	22,636.34	20,368.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,743.16		
431E	SOBRA CHILD 14-20 FE	18,298.24	20,648.68	7,733.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,680.07		
5010	SOBRA PREGNANT WO MAN	11,719.82	13,394.08	16,941.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,055.60		
5015	SOBRA PREG 14-20 FE M	-618.62	284.05	-745.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,079.99		
SUBTOTAL:	13,057,472.51	12,755,763.54	12,410,181.5	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,223,417.56		

3510	ADULT 40-100% FOR FI	0.00	737.58	737.58	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	-270.45	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 MAL E	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 MAL E	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	467.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,475.16	
62.65	
1,674.26	
-689.99	
-725.17	
785.60	
2,582.51	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4410	SOBRA 100-133% FOR F	40,228.46	38,845.46	42,028.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121,102.14	
4413	SOBRA 100-133% M&F
6	114.34	-279.25	2,199.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,035.00	
4414	SOBRA 100-133% MALE	-1,879.64	3,445.42	1,421.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,987.01	
4415	SOBRA 100-133% FEM AL	642.41	-1,070.68	1,333.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	905.20	
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	46,982.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	127,916.36	

13,097,895.45	12,798,389.51	12,457,631.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

38,353,916.43	

TOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

RATE CODE	DESCRIPTION 1010	TANF NON-MEDICARE
1011	TANF <1 M & F NON-ME

1012	TANF 01-05 M & F NON

1013	TANF 06-13 M & F NON

1014	TANF 14-20 MALE NON-

1015	TANF 14-20 FEMALE N
O
101A	TANF < 1 M & F NON-M

101B	TANF 01-05 M & F NON

101C	TANF 06-13 M & F NON

101D	TANF 14-20 MALE NON-

101E	TANF 14-20 FEMALE N
O
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
4300	SOBRA CHILD WITH M
ED

4311

DI
A CHILD <1 M & F

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

n.0.00 	0.00

4310	SOBRA CHILD NON-ME

SOBR

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

4313	SOBRA CHILD 06-13 M

4314	SOBRA CHILD 14-20 MA

4315	SOBRA CHILD 14-20 FE

431A	SOBRA CHILD < 1 M &

431B	SOBRA CHILD 01-05 M

431C	SOBRA CHILD 6-13 M&
F
431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

5010	SOBRA PREGNANT WO
MAN
5015	SOBRA PREG 14-20 FE
M
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

3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		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		0.00		
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
441C	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		0.00		
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending September 30, 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	360.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,082.52		
1010	TANF NON-MEDICARE	81,858.34	80,550.03	81,939.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,347.71		
1020	TANF WITH QMB	422.92	364.72	364.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,152.36		
2100	SSI AGED WITH MEDIC A	30,144.63	30,562.05	31,743.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,450.15		
2110	SSI AGED NON-MEDIC AR	663.48	663.48	783.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,110.72		
2120	SSI AGED WITH QMB	47,183.19	46,929.65	46,572.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,685.24		
2200	SSI DISABLED WITH M E	295,854.29	297,124.19	297,611.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		890,589.99		
2210	SSI DISABLED NON-ME D	3,191,354.09	3,204,083.23	3,215,171.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,610,608.79		
2220	SSI DISABLED WITH Q M	603,871.83	605,939.60	605,939.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,815,750.82		
2300	SSI BLIND WITH MEDIC	1,629.60	1,629.60	1,811.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,071.16		
2310	SSI BLIND NON-MEDIC A	8,325.85	8,387.93	8,387.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,101.71		
2320	SSI BLIND WITH QMB	4,320.36	4,643.85	4,643.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,608.06		
SUBTOTAL:	4,265,989.42	4,281,239.17	4,295,330.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,842,559.23		

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

 
5,191.91	
721.68	
1,692.15	
7,605.74	

4,268,444.48	4,283,814.51	4,297,905.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,850,164.97	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.0	0	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

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

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00

SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

vis0i.0o0      n.
0.00

0.00

0.00

0.00	
0.00	
0.00	
0.00	

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

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending September 30, 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	2,589.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,767.99		
1010	TANF NON-MEDICARE	230,254.46	230,950.46	233,539.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		694,744.71		
1011	TANF <1 M & F NON-ME	10,542.58	11,542.76	11,179.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,265.08		
1012	TANF 01-05 M & F NON	2,859.42	5,864.01	6,364.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,087.53		
1013	TANF 06-13 M & F NON	6,220.78	8,864.55	9,364.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,449.97		
1014	TANF 14-20 MALE NON-	609.39	1,500.27	2,000.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,110.02		
1015	TANF 14-20 FEMALE N O	4,500.81	3,500.63	4,363.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,365.18		
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	500.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,000.36		
1020	TANF WITH QMB	863.11	863.11	863.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,589.33		
2200	SSI DISABLED WITH M E	27,756.59	30,846.01	31,709.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,311.72		
2210	SSI DISABLED NON-ME D	5,182,687.05	5,193,036.46	5,189,349.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,565,073.36		
2220	SSI DISABLED WITH Q M	85,188.88	85,996.17	90,311.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		261,496.77		
2300	SSI BLIND WITH MEDIC	863.11	863.11	863.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,589.33		
2310	SSI BLIND NON-MEDIC A	50,108.57	51,834.79	53,561.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,504.37		
2320	SSI BLIND WITH QMB	863.11	863.11	863.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,589.33		
4311	SOBRA CHILD <1 M & F	21,284.97	19,270.06	16,769.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,324.64		
4312	SOBRA CHILD 01-05 M	157,167.47	154,378.93	151,152.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462,698.84		
4313	SOBRA CHILD 06-13 M	235,190.96	240,864.50	239,364.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		715,419.69		
4314	SOBRA CHILD 14-20 MA	60,250.89	61,529.26	60,392.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,172.16		
4315	SOBRA CHILD 14-20 FE	54,343.85	54,624.38	54,261.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,229.59		
5015	SOBRA PREG 14-20 FE M	1,000.18	1,500.27	2,000.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,500.81		
SUBTOTAL:	6,136,645.78	6,161,782.26	6,161,362.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,459,790.87		

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

 
1,500.27	
1,500.27	
1,500.27	
4,500.81	

3514	ADULT 40-100% MALE
1	1,500.27	1,500.27	2,000.36	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	1,000.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	7,243.27	7,501.35	8,501.53	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	8,001.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	500.09	1,000.18	500.09	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	2,000.36	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	22,003.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,000.90	
3,000.54	
23,246.15	
22,003.96	
2,000.36	
6,017.27	
61,269.18	

3914	NEWLY ELIGIBLE MALE	1,500.27	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,500.81

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1,500.27	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,500.81		

4413	SOBRA 100-133% M&F
6	8,001.44	8,001.44	8,001.44	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	2,500.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	5,009.06	4,863.83	5,363.92	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	15,865.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
24,004.32	
7,001.26	
15,236.81	
46,242.39	

6,202,233.14

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

18,576,304.06	

TOTAL:

6,173,918.80

6,200,152.12

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1010	TANF NON-MEDICARE	267.20	268.00	271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		806.20		
1011	TANF <1 M & F NON-ME	16.00	18.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.00		
1012	TANF 01-05 M & F NON	6.71	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.71		
1013	TANF 06-13 M & F NON	13.54	17.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.54		
1014	TANF 14-20 MALE NON-	1.98	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.98		
1015	TANF 14-20 FEMALE N O	9.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1020	TANF WITH QMB	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2200	SSI DISABLED WITH M E	33.00	37.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108.00		
2210	SSI DISABLED NON-ME D	6,161.82	6,182.17	6,182.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,526.35		
2220	SSI DISABLED WITH Q M	102.08	103.00	108.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		313.08		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2310	SSI BLIND NON-MEDIC A	61.00	63.00	65.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4311	SOBRA CHILD <1 M & F	34.24	32.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93.24		
4312	SOBRA CHILD 01-05 M	251.49	247.00	242.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		740.49		
4313	SOBRA CHILD 06-13 M	380.13	388.00	385.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,153.13		
4314	SOBRA CHILD 14-20 MA	91.71	94.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		276.71		
4315	SOBRA CHILD 14-20 FE	86.52	86.00	86.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258.52		
5015	SOBRA PREG 14-20 FE M	2.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
SUBTOTAL:	7,527.42	7,566.17	7,566.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,659.95		

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

 
3.00	
3.00	
3.00	
9.00	

3514	ADULT 40-100% MALE
1	3.00	3.00	4.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	14.49	15.00	17.00	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	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	1.00	2.00	1.00	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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36.53	41.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10.00	
6.00	
46.49	
43.00	
4.00	
12.04	
121.53	

3914	NEWLY ELIGIBLE MALE	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		

4413	SOBRA 100-133% M&F
6	16.00	16.00	16.00	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	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	9.30	9.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30.30	29.0	0	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
48.00	
14.00	
28.30	
90.30	

TOTAL:	7,600.25	7,642.17	7,647.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,889.78		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,129.39	5,760.13	6,250.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,140.37		
1007	TANF 21-44 FEMALE WI	1,016.91	4,570.23	1,073.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,660.73		
1008	TANF 45-64 M & F WIT	4,063.28	14,411.49	6,861.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,336.47		
1009	TANF 65+ M & F WITH	1,829.47	5,196.34	1,470.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,496.14		
1011	TANF <1 M & F NON-ME	1,284,388.04	1,182,231.54	830,768.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,297,388.55		
1012	TANF 01-05 M & F NON	306,683.16	412,472.37	323,626.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,042,781.92		
1013	TANF 06-13 M & F NON	264,224.37	414,658.39	311,058.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989,941.24		
1014	TANF 14-20 MALE NON-	86,310.63	160,809.56	112,057.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		359,177.48		
1015	TANF 14-20 FEMALE N O	206,804.78	321,511.26	270,885.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		799,201.43		
1016	TANF 21-44 MALE NON-	1,605,145.18	2,146,258.99	1,566,079.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,317,484.15		
1017	TANF 21-44 FEMALE N O	5,140,087.02	7,399,384.59	5,718,878.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,258,350.37		
1018	TANF 45-64 M & F NON	2,173,545.85	3,146,602.31	2,409,273.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,729,421.30		
1019	TANF 65+ M & F NON-M	5,538.38	6,532.19	9,688.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,759.54		
1026	TANF 21-44 MALE WITH	1,154.73	3,471.57	1,065.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,691.63		
1027	TANF 21-44 FEMALE WI	1,200.77	2,919.28	1,334.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,454.06		
1028	TANF 45-64 M & F WIT	6,497.01	18,889.29	4,570.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,956.68		
1029	TANF 65+ M & F WITH	167.87	1,843.03	1,916.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,927.13		
2100	SSI AGED WITH MEDIC A	86,634.05	198,717.97	167,054.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		452,406.03		
2110	SSI AGED NON-MEDIC AR	100,992.78	173,440.45	97,227.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371,660.64		
2120	SSI AGED WITH QMB	397,845.00	1,120,737.17	544,810.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,063,392.21		
2200	SSI DISABLED WITH M E	279,634.07	754,753.74	406,685.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,441,072.81		
2210	SSI DISABLED NON-ME D	8,103,646.51	12,118,405.08	8,606,785.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,828,836.77		
2220	SSI DISABLED WITH Q M	1,094,219.47	2,360,048.72	1,266,419.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,720,687.94		
2300	SSI BLIND WITH MEDIC	136.94	1,989.12	60.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,186.96		
2310	SSI BLIND NON-MEDIC A	200,400.19	130,031.27	62,528.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		392,959.97		
2320	SSI BLIND WITH QMB	14,946.76	28,446.18	14,046.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,439.68		
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	37.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		835.17		
4311	SOBRA CHILD <1 M & F	2,383,990.92	3,303,283.24	2,449,918.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,137,192.27		
4312	SOBRA CHILD 01-05 M	3,489,044.12	5,024,125.49	3,745,519.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,258,689.44		
4313	SOBRA CHILD 06-13 M	4,410,433.12	7,025,863.80	5,467,457.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,903,754.37		
4314	SOBRA CHILD 14-20 MA	1,070,687.79	2,357,534.67	1,409,716.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,837,939.42		
4315	SOBRA CHILD 14-20 FE	1,570,912.47	2,309,511.52	2,000,484.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,880,908.22		
5007	SOBRA PREG 21-44 FE M	65.28	178.68	408.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		652.10		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368.00		
5015	SOBRA PREG 14-20 FE M	335,800.58	553,962.19	416,733.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,306,495.85		

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	2,194,707.90	3,296,850.18	2,163,190.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,654,748.40	
5018	SOBRA PREG 45-64 FE M	7,521.12	19,754.71	36,209.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	63,485.36	
5027	SOBRA PREG 21-44 FE M	1,129.67	190.89	1,726.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,046.73	
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	40,434,246.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133,293,245.61	

1106	TANF EXPANDED 21-44	7,297.18	14,844.32	7,468.63	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	11,416.70	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	58,983.63	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	32,742.97	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	391.00	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	2,020.59	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	27,334.03	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	725,300.88	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	2,254,909.75	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	1,604,070.10	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	2,737.00	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	24,342.63	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	59,181.46	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	123,419.50	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	44,196.32	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	9,931.76	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	5,932.73	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	468,595.41	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	12,908.96	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	206,243.10	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	352,952.43	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	6,035,079.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

29,610.13	
46,226.39	
228,009.54	
114,628.53	
1,585.08	
2,737.00	
10,526.00	
142,685.22	
2,404,203.38	
7,183,912.81	
5,433,344.39	
10,574.22	
76,678.15	
221,312.58	
462,186.72	
157,396.48	
44,941.41	
33,230.93	
1,742,127.52	
64,521.61	
570,411.72	
1,316,938.83	
20,297,788.64	

3314	AHC CARE MALE 14-20	0.00	0.00	-115.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	-588.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	-1,439.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-2,142.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-115.41	
-588.00	
-1,439.00	
-2,142.41	

3410	MED ELIGIBILITY NON-	0.00	0.00	-268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	-2,058.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-2,884.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-268.00	
-2,058.00	
-2,884.78	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	-5,210.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,210.78		

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	1,893.92	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	1,173.00	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	45,989.71	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	55,264.88	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	496,784.38	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	642,444.80	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	1,605,876.04	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	167.54	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	2,850,376.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

447.82	
5,555.82	
1,955.00	
97,044.63	
171,042.29	
1,667,980.60	
2,037,189.85	
5,110,835.88	
1,564.00	
167.54	
9,093,783.43	

4413	SOBRA 100-133% M&F
6	366,240.89	618,481.49	502,134.19	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	228,810.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,486,856.57	
567,532.62	

3506	ADULT 40-100% MALE
2	7.64	-7.64	391.00	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	4,659.68	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	84,029.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	64,453.95	120,805.35	122,829.84	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	1,054,822.93	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	564,355.82	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	2,308,268.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	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	
3707	ADULT <40% EXP FEM AL	71.15	360.17	402.73	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	15,324.82	30,471.96	7,351.90	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	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	
3714	ADULT <40% EXP MAL E	266,479.48	432,725.78	269,533.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	308,587.81	494,530.02	386,921.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	6,059,520.29	8,492,593.39	6,582,557.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,256,920.31	4,683,150.22	3,497,315.69	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	8,858,790.44	13,462,857.77	9,025,589.07	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	5,501.88	5,230.07	782.00	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	601.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	22,572,756.36	32,955,606.65	23,910,202.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
391.00	
9,671.17	
368.00	
212,070.07	
308,089.14	
3,179,852.28	
1,825,488.95	
7,754,977.04	
391.00	
1,863.00	
834.05	
53,148.68	
1,233.29	
968,738.38	
1,190,039.26	
21,134,670.93	
11,437,386.22	
31,347,237.28	
11,513.95	
601.37	
79,438,565.06	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4415	SOBRA 100-133% FEM AL	151,202.79	234,581.63	185,403.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	571,187.77	
SUBTOTAL	:	661,100.15	1,048,129.12	916,347.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,625,576.96	

4518	BC PATIENT FEMALE 4 5	2,933.81	1,173.00	2,007.93	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	782.00	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	2,789.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,114.74	
1,564.00	
7,678.74	

8700	SSI DISABLED FREEDO M	8,702.39	13,545.97	13,596.81	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	5,720.84	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	507.93	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	19,825.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
35,845.17	
28,637.32	
6,007.26	
70,489.75	

68,123,684.21	102,534,576.01	74,161,514.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

244,819,775.00	

TOTAL:

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	92.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92.46	
1008	TANF 45-64 M & F WIT	179.02	0.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	224.02	
1011	TANF <1 M & F NON-ME	20,654.34	33,591.86	259.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,505.81	
1012	TANF 01-05 M & F NON	913.03	363.75	157.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,434.17	
1013	TANF 06-13 M & F NON	1,039.71	4,256.94	137.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,433.90	
1014	TANF 14-20 MALE NON-	1,523.17	7,089.22	1,808.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,420.87	
1015	TANF 14-20 FEMALE N O	12,542.64	12,701.01	1,386.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,630.32	
1016	TANF 21-44 MALE NON-	15,535.91	27,655.79	28,917.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,109.68	
1017	TANF 21-44 FEMALE N O	69,653.95	123,234.95	48,848.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	241,737.13	
1018	TANF 45-64 M & F NON	39,319.42	16,665.33	19,875.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,860.23	
2100	SSI AGED WITH MEDIC A	5,270.03	11,195.75	20,215.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,680.82	
2110	SSI AGED NON-MEDIC AR	37,612.82	14,256.93	16,930.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68,800.20	
2120	SSI AGED WITH QMB	776.24	185.90	170.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,132.88	
2200	SSI DISABLED WITH M E	520.23	3,742.51	281.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,544.32	
2210	SSI DISABLED NON-ME D	10,576.12	5,504.23	13,221.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,301.82	
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	37,485.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	93,749.98	
4312	SOBRA CHILD 01-05 M	42,887.14	97,036.84	49,257.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	189,181.84	
4313	SOBRA CHILD 06-13 M	27,666.18	65,720.19	33,058.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,444.73	
4314	SOBRA CHILD 14-20 MA	14,040.41	32,664.97	18,374.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,079.89	
4315	SOBRA CHILD 14-20 FE	31,383.37	26,150.54	14,140.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71,674.00	
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	17,363.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,812.67	
5017	SOBRA PREG 21-44 FE M	98,441.12	121,849.94	90,725.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	311,016.49	
5018	SOBRA PREG 45-64 FE M	2,413.43	0.00	-303.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,109.45	
8020	QMB ONLY	0.00	0.00	-3.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-3.20	
SUBTOTAL	:	463,842.72	667,369.67	412,446.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,543,658.42	

1106	TANF EXPANDED 21-44	104.15	947.17	99.88	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	74.88	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	1,140.09	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	1.71	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	4,318.14	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	172.55	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	40,777.56	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	46,206.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,151.20	
650.06	
3,345.28	
3,179.68	
6,606.65	
1,693.95	
113,644.86	
244,059.23	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	24,143.24	60,240.06	31,368.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,751.87		
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		73.55		
1128	TANF EXPANDED 45-64	0.00	368.00	13.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381.09		
1129	TANF EXPANDED 65+
M&	435.37	125.38	989.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,550.54		
2400	SSI AGED EXPANDED WI	17,993.30	15,628.68	14,955.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,577.54		
2420	SSI AGED EXPANDED WI	25.94	2,104.32	1,601.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,732.13		
2600	SSI DISABLED EXPAND E	3,603.28	4,730.53	7,569.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,903.12		
2610	SSI DISABLED EXPAND E	7,174.68	629.11	532.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,336.45		
2620	SSI DISABLED EXPAND E	423.01	1,356.66	473.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,253.26		
SUBTOTAL:	149,910.73	270,684.04	150,295.6	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		570,890.46		

3908	NEWLY ELIGIBLE M&F 4	1,402.06	21.50	25.22	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	1,432.78	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	2,242.43	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	89,553.29	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	33,891.18	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	274,544.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	63.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,448.78	
17,532.85	
11,226.20	
256,725.02	
199,094.54	
812,481.63	
63.43	

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	88.70	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	1,888.11	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	3,095.55	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	70,389.31	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	33,198.57	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	102,691.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	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	2,057.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	16,238.85	19,414.27	12,185.44	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	3,363.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	261,422.48	400,621.91	188,657.56	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	175,768.53	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	326,291.80	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	919,676.8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,780.56	
624.07	
1,642.17	
19,911.41	
11,315.13	
216,936.23	
85,774.12	
461,355.38	
0.00	
452.15	
2,269.44	
47,838.56	
21,790.29	
850,701.95	
520,371.08	
1,018,592.42	
351.61	
3,262,706.57	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	350,598.45	546,220.73	401,753.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,298,572.45		

8700	SSI DISABLED FREEDO M	250.85	2,220.64	2,804.73	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	119.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	589.06	2,455.54	2,924.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,276.22	
692.63	
5,968.85	

4413	SOBRA 100-133% M&F
6	6,531.52	45,078.74	16,197.89	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	1,335.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	5,359.35	2,711.50	3,802.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,214.88	62,558.40	21,335.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
67,808.15	
17,427.23	
11,872.92	
97,108.30	

TOTAL:	1,918,005.62	2,952,468.28	1,908,431.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,778,905.05		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending September 30, 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	10,332.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,939.80		
SUBTOTAL:	607.14	0.00	10,332.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,939.80		

607.14	0.00	10,332.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 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	5,471.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,482.98		
1013	TANF 06-13 M & F NON	72,651.17	167,216.49	110,029.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		349,897.55		
1014	TANF 14-20 MALE NON-	103,021.56	260,724.26	94,070.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457,816.31		
1015	TANF 14-20 FEMALE N O	361,349.27	528,169.17	198,133.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,087,651.82		
1016	TANF 21-44 MALE NON-	171.94	27,657.57	4,550.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,379.67		
1017	TANF 21-44 FEMALE N O	2,700,519.09	4,054,600.83	1,094,597.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,849,717.59		
1018	TANF 45-64 M & F NON	32,916.39	90,936.34	28,223.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152,076.51		
2100	SSI AGED WITH MEDIC A	51,503.65	80,558.51	18,023.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,085.58		
2110	SSI AGED NON-MEDIC AR	1,449,964.08	1,564,496.95	776,470.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,790,931.76		
2120	SSI AGED WITH QMB	99.26	8,828.69	1,302.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,230.79		
2200	SSI DISABLED WITH M E	12,126.62	7,473.51	8,506.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,107.12		
2210	SSI DISABLED NON-ME D	253,261.18	373,683.27	136,989.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		763,933.45		
SUBTOTAL:	5,092,982.94	7,198,427.13	2,476,369.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,767,779.94		

3906	NEWLY ELIGIBLE MALE	1,021.74	2,141.12	5.29	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	92,782.95	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	92,823.30	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	708,155.76	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	337,834.36	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	1,687,224.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,168.15	
770.76	
406,027.08	
404,756.30	
3,647,950.02	
1,704,287.02	
8,587,060.65	

1106	TANF EXPANDED 21-44	56.86	5,273.18	818.79	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	14,204.13	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	177.80	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	1,122.36	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	5,936.98	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	542,697.03	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	1,296,650.79	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	581,214.51	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	11,298.22	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	14,952.88	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	4,208.94	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	2,473,282.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,148.83	
29,469.69	
5,492.42	
4,008.30	
70,426.14	
2,791,081.22	
6,467,002.11	
3,069,863.36	
58,064.24	
1,398.10	
37,192.08	
14,082.81	
12,554,229.30	

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 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	7,053.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,467.68		
SUBTOTAL:	4,555,736.68	7,325,870.78	2,925,880.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,807,487.66		

13,728,181.03

20,525,783.37

TOTAL:

7,875,532.50

0.00

0.00

0.00

0.00

0.00

42,129,496.90

0.00

0.00

0.00	0.00

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	414,951.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,605,510.36	
8050	QI1	0.00	0.00	576.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	576.06	

SUBTOTAL:	
489,557.87	
701,000.71	
415,527.84	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,606,086.42	

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

489,557.87	701,000.71	415,527.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,606,086.42	

TOTAL:

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 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	304.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,151.74		
1011	TANF <1 M & F NON-ME	2,225.53	3,895.14	1,431.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,551.69		
1012	TANF 01-05 M & F NON	37,646.36	36,850.01	33,191.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,687.93		
1013	TANF 06-13 M & F NON	128,263.92	193,268.15	96,268.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417,800.64		
1014	TANF 14-20 MALE NON-	48,337.90	47,383.00	45,995.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,716.69		
1015	TANF 14-20 FEMALE N O	71,871.24	74,760.14	97,556.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,187.74		
1016	TANF 21-44 MALE NON-	526,340.17	530,196.38	487,128.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,543,664.83		
1017	TANF 21-44 FEMALE N O	1,657,566.19	1,783,786.44	1,378,116.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,819,468.68		
1018	TANF 45-64 M & F NON	304,329.16	286,978.40	196,863.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		788,171.48		
1026	TANF 21-44 MALE WITH	0.00	0.00	750.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		750.81		
1027	TANF 21-44 FEMALE WI	0.00	118.15	139.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257.76		
2100	SSI AGED WITH MEDIC A	6,043.44	4,391.82	6,288.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,723.31		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	1,173.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,173.00		
2120	SSI AGED WITH QMB	12,745.09	25,137.79	18,028.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,911.21		
2200	SSI DISABLED WITH M E	22,244.82	32,885.03	23,408.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,538.42		
2210	SSI DISABLED NON-ME D	1,848,011.72	2,445,227.21	2,015,665.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,308,904.06		
2220	SSI DISABLED WITH Q M	244,729.87	318,582.73	260,878.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		824,190.97		
2310	SSI BLIND NON-MEDIC A	4,323.76	8,552.27	10,988.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,864.29		
2320	SSI BLIND WITH QMB	840.76	1,979.14	578.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,398.86		
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	11,440.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,574.83		
4312	SOBRA CHILD 01-05 M	173,404.17	220,673.14	162,567.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		556,645.07		
4313	SOBRA CHILD 06-13 M	3,398,748.51	4,311,852.91	3,015,010.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,725,612.24		
4314	SOBRA CHILD 14-20 MA	705,666.83	1,292,395.95	1,061,627.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,059,690.45		
4315	SOBRA CHILD 14-20 FE	1,409,888.39	1,269,627.57	978,059.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,657,575.05		
5015	SOBRA PREG 14-20 FE M	22,369.78	34,154.22	28,722.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,246.89		
5017	SOBRA PREG 21-44 FE M	245,508.84	263,390.81	257,152.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		766,051.74		
SUBTOTAL:	10,876,719.13	13,195,800.73	10,189,336.5	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,261,856.38		

1106	TANF EXPANDED 21-44	251.01	237.62	10.22	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	13.68	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	361.94	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	5,491.20	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	946.72	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	206,200.95	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	492,893.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
498.85	
53.14	
2,524.62	
5,491.20	
5,826.89	
703,238.40	
1,523,965.35	

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	202,226.77	145,351.59	153,277.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		500,856.29		
1126	TANF EXPANDED 21-44	331.99	2,174.75	1,549.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,056.29		
1127	TANF EXPANDED 21-44	1,429.72	10,646.79	9,971.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,048.29		
1128	TANF EXPANDED 45-64	1,143.92	1,376.86	1,514.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,035.27		
1129	TANF EXPANDED 65+
M&	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		
2400	SSI AGED EXPANDED WI	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.00		
2420	SSI AGED EXPANDED WI	9,823.47	13,042.81	20,736.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,602.33		
2600	SSI DISABLED EXPAND E	262.30	227.63	262.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		752.73		
2610	SSI DISABLED EXPAND E	7,367.02	10,021.65	20,057.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,446.36		
2620	SSI DISABLED EXPAND E	42,920.78	65,547.02	58,633.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,101.12		
SUBTOTAL:	1,058,406.37	991,738.44	971,922.2	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,022,067.04		

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	12.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	2,529.29	2,063.50	10,767.28	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	3,526.10	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	27,183.56	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	50,964.86	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	66,559.87	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	159,014.3	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12.63	
15,360.07	
9,016.84	
135,988.58	
148,641.87	
196,974.53	
505,994.52	

4413	SOBRA 100-133% M&F
6	89,140.44	118,536.69	53,052.50	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	239,205.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	44,171.47	94,883.00	115,271.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

260,729.63	
372,093.25	
254,325.78	

3508	ADULT 40-100% M&F 45	-368.00	0.00	391.00	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	9,803.20	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	30,322.49	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	194,553.11	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	49,018.02	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	115,822.37	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 MAL E	202,765.41	143,906.96	116,921.70	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	87,196.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	2,123,297.17	2,393,602.77	2,046,629.09	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	982,120.80	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	1,040,998.04	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	4,673,775.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
23.00	
43,670.03	
132,344.24	
686,612.97	
183,738.73	
319,924.97	
449.84	
463,594.07	
326,673.85	
6,563,529.03	
3,142,341.89	
3,537,253.92	
15,400,156.54	

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	185,957.56	293,661.70	407,529.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		887,148.66		

8700	SSI DISABLED FREEDO M	458.48	186.31	68.72	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	161.08	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	
SUBTOTAL:	2,314.87	1,916.83	229.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
713.51	
208.34	
3,539.65	
4,461.50	

TOTAL:	17,352,428.88	20,327,447.61	16,401,808.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,081,684.64		

RATE COD	E	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	2,449.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,980.29	
SUBTOTAL	:	6,531.12	0.00	2,449.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,980.29	

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 MAL E	0.00	9,796.68	6,531.12	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	6,531.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,327.80	
2,449.17	
18,776.97	

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	8,980.29

0.00	0.00	0.00	0.00

0.00

86,927.05

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	0.00	0.00	4,651.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,651.64	
2100	SSI AGED WITH MEDIC A	15,377.05	33,561.22	38,831.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,770.04	
2110	SSI AGED NON-MEDIC AR	177,423.98	68,832.10	46,369.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	292,625.08	
2210	SSI DISABLED NON-ME D	5,645.08	13,622.78	1,493.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,760.95	
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	10,420.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,958.86	
SUBTOTAL	:	223,347.54	131,891.22	101,766.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	457,004.76	

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	2,358.06	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	862.08	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	3,220.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,152.60	
66,195.82	
58,342.22	
132,690.64	

1,329,240.99

889,220.72

TOTAL:

456,867.57

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,675,329.28

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	
3518	ADULT 40-100% M&F 45	0.00	0.00	4,526.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	58,454.33	12,529.30	6,420.51	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	12,816.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	328.84	80.16	261.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	405,461.03	295,360.98	107,838.75	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	999.96	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	219,017.00	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	351,881.4	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,705.73	
4,526.68	
77,404.14	
5,735.18	
110,078.43	
670.87	
0.00	
808,660.76	
68,131.70	
1,007,720.39	
2,085,633.88	

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	10,405.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,919.44		
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		
1018	TANF 45-64 M & F NON	0.00	0.00	4,135.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,135.38		
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		
2200	SSI DISABLED WITH M E	0.00	0.00	101.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101.32		
2210	SSI DISABLED NON-ME D	15,929.93	31.16	1,849.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,810.33		
2220	SSI DISABLED WITH Q M	12,271.60	16,645.72	5,503.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,420.79		
4314	SOBRA CHILD 14-20 MA	0.00	1,487.29	545.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,033.12		
4315	SOBRA CHILD 14-20 FE	22,968.07	0.00	91.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,059.17		
5015	SOBRA PREG 14-20 FE M	8,096.59	38.79	235.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,370.83		
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	22,867.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,592.70		

1117	TANF EXPANDED 21-44	4,021.80	894.58	100.25	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	100.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,016.63	
2,748.30	
7,764.93	

3516	ADULT 40-100% MALE
2	7,986.74	160.34	696.87	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	177.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	9,397.56	1,679.67	57.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	26,893.55	3,203.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	208,629.72	93,904.97	39,790.60	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	12,565.34	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	35,997.15	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	92,487.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,843.95	
16,143.99	
11,134.28	
30,097.15	
342,325.29	
35,377.97	
95,844.00	
539,766.63	

333,763.85	219,904.83	115,455.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

669,124.26	

TOTAL:

RATE COD	E	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	

3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	11,635.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	11,635.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,635.95	
11,635.95	

3716	ADULT <40% EXP MAL E	0.00	0.00	246.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	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	246.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
246.80	
2,443.92	
2,157.51	
4,848.23	

TOTAL:	0.00	10,815.29	11,882.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,698.04		

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	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	

1116	TANF EXPANDED 21-44	0.00	0.00	12,937.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	12,937.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,937.80	
12,937.80	

3516	ADULT 40-100% MALE
2	0.00	0.00	71,944.37	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	252.30	8,199.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	5,931.58	6,252.27	4,191.52	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	2,345.59	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	4,264.15	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	90,945.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
71,944.37	
8,451.83	
16,375.37	
13,006.24	
28,216.61	
137,994.42	

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	6,951.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	593.70	387.80	6,951.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
398.34	
7,534.26	
7,932.60	

16,300.92	32,984.20	110,834.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

160,119.18	

TOTAL:

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	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	

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	
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	
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	

 
0.00	
498.60	
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		

YUMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2200	SSI DISABLED WITH M E	0.00	0.00	76.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.98		
SUBTOTAL:	0.00	0.00	76.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.98		

2610	SSI DISABLED EXPAND E	0.00	0.00	138.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	138.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
138.05	
138.05	

0.00	0.00	215.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

215.03	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending September 30, 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	2,666,400.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,756,672.49		
2110	SSI AGED NON-MEDIC AR	234,576.01	198,055.36	101,326.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		533,958.03		
2120	SSI AGED WITH QMB	3,395,570.95	4,480,987.35	3,484,574.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,361,133.01		
2200	SSI DISABLED WITH M E	733,207.80	846,565.16	666,437.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,246,210.14		
2210	SSI DISABLED NON-ME D	3,088,233.12	4,441,270.19	3,132,513.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,662,016.86		
2220	SSI DISABLED WITH Q M	873,654.11	1,373,064.23	945,797.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,192,515.64		
2310	SSI BLIND NON-MEDIC A	37,466.58	37,722.68	22,861.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,050.64		
2320	SSI BLIND WITH QMB	8,806.95	8,742.05	4,353.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,902.11		
SUBTOTAL:	11,073,366.27	14,775,218.93	11,024,264.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,872,849.92		

TOTAL:

11,075,900.07     14,779,589.19    11,033,723.36

0.00

0.00

0.00

0.00

0.00

36,889,212.62

0.00

0.00

0.00	0.00

8710	SSI DISABLED FREEDO M	0.00	1,326.10	6,033.96	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	3,424.68	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	9,458.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,360.06	
9,002.64	
16,362.70	

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 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	29,073.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,223.59		
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	5,497.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,818.70		
2210	SSI DISABLED NON-ME D	1,948.84	324.93	1,867.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,141.50		
SUBTOTAL:	31,030.84	30,710.69	36,438.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,180.05		

31,030.84	30,710.69	36,438.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

98,180.05	

TOTAL:

COCHISE COUNTY INMATES LTC  FEE FOR SERVICE
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1017	TANF 21-44 FEMALE N O	0.00	0.00	-979.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-979.88		
SUBTOTAL:	0.00	0.00	-979.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-979.88		

3716	ADULT <40% EXP MAL E	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	
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	
1,483.41	

TOTAL:	0.00	1,483.41	-979.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503.53		

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending September 30, 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	606.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		772.41		
SUBTOTAL:	165.72	0.00	606.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		772.41		

165.72	0.00	606.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PIMA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2220	SSI DISABLED WITH Q M	0.00	0.00	1,679.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,679.82		
SUBTOTAL:	0.00	0.00	1,679.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,679.82		

0.00

0.00

TOTAL:

1,679.82

0.00

0.00

0.00

0.00

0.00

1,679.82

0.00

0.00

0.00	0.00

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 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	2,806.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,095.56		
1013	TANF 06-13 M & F NON	48,993.85	20,403.99	5,549.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,947.55		
1014	TANF 14-20 MALE NON-	4,535.34	2,295.55	669.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,500.05		
1015	TANF 14-20 FEMALE N O	2,237.61	2,032.01	414.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,684.05		
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	31,635.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381,052.54		
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	608.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,514.46		
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	5,728.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,375.89		
4313	SOBRA CHILD 06-13 M	108,381.63	49,032.65	18,221.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,636.13		
4314	SOBRA CHILD 14-20 MA	10,627.54	4,788.70	2,674.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,090.68		
4315	SOBRA CHILD 14-20 FE	3,879.34	1,247.64	710.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,837.13		
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	69,018.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		749,665.46		

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

 
114.50	
114.50	

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 MAL E	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	32.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	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	32.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
65.76	
65.76	
198.82	
518.41	
431.12	
1,279.87	

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	4,305.52	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	298.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	379.24	201.19	378.71	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	4,982.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
36,846.27	
3,942.63	
959.14	
41,748.04	

499,541.40	219,245.52	74,050.21	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 September 30, 2017

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,547.22	891.11	520.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,958.94	
1010	TANF NON-MEDICARE	46,160.98	19,385.59	4,338.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,884.86	
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	195,436.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,475,848.47	
2220	SSI DISABLED WITH Q M	6,290.82	5,411.38	84.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,786.83	
2310	SSI BLIND NON-MEDIC A	10,493.31	3,206.46	423.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,122.80	
SUBTOTAL	:	1,540,501.87	836,850.31	200,803.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,578,155.68	

TOTAL:	1,540,501.87	836,850.31	200,803.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,578,155.68		

ACUTE REINSURANCE
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	61.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.56		
1008	TANF 45-64 M & F WIT	76.49	0.00	54,908.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,984.99		
1011	TANF <1 M & F NON-ME	792,098.45	731,912.14	596,578.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,120,588.96		
1012	TANF 01-05 M & F NON	93,618.58	43,751.24	42,582.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179,951.92		
1013	TANF 06-13 M & F NON	97,360.29	42,224.52	76,495.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		216,080.65		
1014	TANF 14-20 MALE NON-	100,226.61	93.17	24,182.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,502.52		
1015	TANF 14-20 FEMALE N O	12,664.01	47,657.93	16.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,338.69		
1016	TANF 21-44 MALE NON-	78,305.08	-358.12	111,189.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,136.82		
1017	TANF 21-44 FEMALE N O	385,737.83	168,770.57	373,755.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928,263.44		
1018	TANF 45-64 M & F NON	496,933.25	25,280.46	270,049.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		792,263.38		
2100	SSI AGED WITH MEDIC A	24,935.52	11,582.57	6,213.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,731.91		
2110	SSI AGED NON-MEDIC AR	229,962.20	84,260.00	237,253.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		551,475.78		
2200	SSI DISABLED WITH M E	9,940.06	79,656.86	50,495.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,092.65		
2210	SSI DISABLED NON-ME D	7,086,206.83	5,515,241.43	4,779,443.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,380,891.47		
2300	SSI BLIND WITH MEDIC	0.00	0.00	1,656.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,656.82		
2310	SSI BLIND NON-MEDIC A	0.00	5,180.64	13,323.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,504.51		
4311	SOBRA CHILD <1 M & F	1,999,947.14	1,220,733.66	1,185,900.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,406,581.73		
4312	SOBRA CHILD 01-05 M	462,002.32	404,898.03	810,857.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,677,757.35		
4313	SOBRA CHILD 06-13 M	676,994.95	300,678.65	943,155.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,920,829.24		
4314	SOBRA CHILD 14-20 MA	868,929.19	329,418.01	248,345.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,446,692.59		
4315	SOBRA CHILD 14-20 FE	203,212.23	283,295.58	299,543.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		786,051.50		
5015	SOBRA PREG 14-20 FE M	47,663.05	0.00	9,350.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,013.68		
5017	SOBRA PREG 21-44 FE M	34,632.31	31,320.85	55,833.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,786.36		
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	10,191,193.9	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,226,808.61		

3507	ADULT 40-100% FEMAL E	0.00	0.00	1,242.01	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	25,399.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,242.01	
25,399.38	

1106	TANF EXPANDED 21-44	111.02	111.55	136.89	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	226,323.63	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	161,316.76	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	184,003.28	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	2,847.67	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	2,264.03	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	65,448.58	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	642,340.8	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
359.46	
582,637.74	
489,791.79	
386,457.38	
2,847.67	
3,947.39	
70,945.18	
1,536,986.61	

ACUTE REINSURANCE
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		8.44		
3515	ADULT 40-100% FEMAL E	13,969.80	0.00	18,706.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,676.01		
3516	ADULT 40-100% MALE
2	267,573.16	141,658.94	148,273.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557,505.81		
3517	ADULT 40-100% FEMAL E	11,751.92	75,057.61	33,064.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,873.85		
3518	ADULT 40-100% M&F 45	788,762.31	418,359.11	584,915.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,792,036.55		
3708	ADULT <40% EXP M&F 4	-2,793.83	8,981.14	17,351.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,538.51		
3714	ADULT <40% EXP MAL E	228,452.96	-120,588.20	231,517.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339,382.08		
3715	ADULT <40% EXP FEM AL	14,127.00	305.69	13,029.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,462.34		
3716	ADULT <40% EXP MAL E	1,495,808.20	651,446.24	1,280,749.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,428,003.76		
3717	ADULT <40% EXP FEM AL	414,152.76	223,792.96	319,025.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		956,971.20		
3718	ADULT <40% EXP M&F 4	2,435,047.46	1,657,445.29	2,161,371.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,253,864.00		
SUBTOTAL:	5,666,860.18	3,056,458.78	4,834,644.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,557,963.94		

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	382.09	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	12,015.55	744.91	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	229,531.66	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	125,725.05	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	379,461.96	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	735,845.6	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
382.09	
12,760.46	
8,952.17	
450,787.19	
147,090.29	
764,581.67	
1,384,553.87	

4413	SOBRA 100-133% M&F
6	88,977.54	47,399.25	106,171.13	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	228,193.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEM AL	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	334,364.5	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
242,547.92	
393,071.86	
112,936.70	
748,556.48	

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	23,440.70	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	23,440.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
317.33	
126,692.30	
127,009.63	

20,843,354.70	12,976,693.78	16,761,830.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

50,581,879.14	

TOTAL:

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	2,773.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,773.68	
2100	SSI AGED WITH MEDIC A	502,760.84	215,750.35	394,825.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,113,336.49	
2110	SSI AGED NON-MEDIC AR	266,303.82	119,525.30	179,490.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	565,319.67	
2200	SSI DISABLED WITH M E	791,017.80	929,431.22	947,140.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,667,589.62	
2210	SSI DISABLED NON-ME D	7,130,392.69	5,130,860.15	6,388,967.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,650,220.80	
2310	SSI BLIND NON-MEDIC A	17,679.65	34,070.17	34,867.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	86,617.24	
SUBTOTAL	:	8,708,154.80	6,429,637.19	7,948,065.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,085,857.50	

TOTAL:	8,708,154.80	6,429,637.19	7,948,065.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,085,857.50		

ACUTE SMIB
For The Period Ending September 30, 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	46,884.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,921.10		
1010	TANF NON-MEDICARE	804.00	938.00	4,130.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,872.10		
1020	TANF WITH QMB	41,088.00	44,170.00	47,368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,626.00		
2100	SSI AGED WITH MEDIC A	91,554.30	80,144.00	71,804.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243,503.00		
2110	SSI AGED NON-MEDIC AR	556,826.60	577,728.60	545,065.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,679,620.90		
2120	SSI AGED WITH QMB	3,808,373.40	3,854,498.10	3,886,638.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,549,509.80		
2200	SSI DISABLED WITH M E	127,371.30	120,530.00	116,529.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364,430.50		
2210	SSI DISABLED NON-ME D	422,855.00	441,700.40	442,809.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,307,364.40		
2220	SSI DISABLED WITH Q M	3,959,927.70	3,927,844.40	3,958,180.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,845,952.40		
2300	SSI BLIND WITH MEDIC	402.00	134.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		670.00		
2310	SSI BLIND NON-MEDIC A	3,886.00	3,618.00	3,752.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,256.00		
2320	SSI BLIND WITH QMB	34,170.00	35,778.00	34,438.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,386.00		
4300	SOBRA CHILD WITH M ED	134.00	134.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		402.00		
4320	SOBRA CHILD WITH Q MB	268.00	402.00	402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,072.00		
5020	SOBRA PREGNANT WO MAN	5,494.00	6,298.00	5,494.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,286.00		
8000	SMIB ONLY NOT ELIGIB	0.00	-268.00	-268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-536.00		
8020	QMB ONLY	987,237.40	1,001,287.10	1,000,696.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,989,221.40		
8040	SLMB	4,832,276.40	4,846,587.90	4,845,005.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,523,869.60		
8888	SMIB ONLY NOT ELIGIB	-62,604.00	-43,500.20	-36,118.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-142,222.40		
9999	SMIB ONLY NOT ELIGIB	-44,786.20	51,555.80	49,571.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,340.60		
SUBTOTAL:	14,812,761.30	15,000,133.80	15,022,650.3	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,835,545.40		

3520	ADULT 40-100% FOR FI	134.00	268.00	2,546.00	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	2,960.00	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	5,506.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,948.00	
4,836.00	
7,784.00	

3920	NEWLY ELIGIBLE FOR F	268.00	511.60	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,449.60	

1100	TANF EXPANDED FPR FI	305,316.20	277,543.60	253,306.40	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	402.00	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	863,549.20	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	-268.00	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	3,116,388.10	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	134.00	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	134.00	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	2,385,890.90	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	6,619,536.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
836,166.20	
1,608.00	
2,502,996.30	
-1,072.00	
9,288,895.10	
402.00	
-536.00	
7,107,707.70	
19,736,167.30	

ACUTE SMIB
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	268.00	511.60	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,449.60		

8720	SSI DISABLED FREEDO M	28,660.00	30,276.00	31,482.00	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	31,482.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
90,418.00	
90,418.00	

0.00

0.00

0.00

0.00

TOTAL:

21,337,620.10

21,653,899.30    21,679,844.90

0.00	0.00	0.00	0.00

0.00

64,671,364.30

ACUTE HIB
For The Period Ending September 30, 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	1,362.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,917.10		
2100	SSI AGED WITH MEDIC A	2,065.00	2,065.00	7,557.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,687.90		
2110	SSI AGED NON-MEDIC AR	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	397,160.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,153,461.20		
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	190,265.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		555,988.80		
2320	SSI BLIND WITH QMB	867.30	867.30	867.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,601.90		
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	4,439.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,723.00		
9999	SMIB ONLY NOT ELIGIB	-5,513.40	-2,601.60	-3,966.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-12,081.70		
SUBTOTAL:	530,608.20	606,349.10	597,686.7	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,734,644.00		

1120	TANF EXPANDED FOR FI	681.00	681.00	681.00	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	3,468.90	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	4,149.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,043.00	
11,645.70	
13,688.70	

TOTAL:	535,171.10	611,325.00	601,836.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,748,332.70		

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	2,665,007.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,928,997.50	
9999	SMIB ONLY NOT ELIGIB	-31,415.00	-9,770.20	-3,944.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-45,129.40	

SUBTOTAL:	
2,585,545.40	
2,637,259.70	
2,661,063.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
7,883,868.10	

Q1
For The Period Ending September 30, 2017

2,585,545.40	2,637,259.70	2,661,063.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,883,868.10	

TOTAL:

LTC SMIB
For The Period Ending September 30, 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	804.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,680.00		
1020	TANF WITH QMB	536.00	402.00	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,608.00		
2100	SSI AGED WITH MEDIC A	1,098,996.50	1,086,174.30	1,089,530.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,274,701.30		
2110	SSI AGED NON-MEDIC AR	205,154.00	207,846.00	206,481.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		619,481.80		
2120	SSI AGED WITH QMB	1,000,128.60	1,012,229.40	1,016,303.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,028,661.80		
2200	SSI DISABLED WITH M E	418,872.80	414,703.80	419,209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,252,786.40		
2210	SSI DISABLED NON-ME D	27,872.00	30,150.00	30,552.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,574.00		
2220	SSI DISABLED WITH Q M	934,051.30	940,261.70	941,869.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,816,182.90		
2300	SSI BLIND WITH MEDIC	1,206.00	1,206.00	1,608.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,020.00		
2310	SSI BLIND NON-MEDIC A	268.00	268.00	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		804.00		
2320	SSI BLIND WITH QMB	5,888.00	5,888.00	6,424.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,200.00		
SUBTOTAL:	3,693,777.20	3,700,201.20	3,713,721.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,107,700.20		

8720	SSI DISABLED FREEDO M	804.00	804.00	1,072.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	804.00	804.00	1,072.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,680.00	
2,680.00	

TOTAL:	3,694,581.20	3,701,005.20	3,714,793.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,110,380.20		

LTC HIB
For The Period Ending September 30, 2017

2100

2110

2120

2210

2220

SUBTOTAL

854,827.30	

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	SSI AGED WITH MEDIC A	413.00	413.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	826.00	
	SSI AGED NON-MEDIC AR	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	
	SSI AGED WITH QMB	267,064.80	266,940.60	267,930.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	801,936.30	
	SSI DISABLED NON-ME D	0.00	413.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	413.00	
	SSI DISABLED WITH Q M	13,492.00	18,254.00	18,667.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	50,413.00	
	:	280,969.80	287,259.60	286,597.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	854,827.30	
		280,969.80	287,259.60	286,597.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	1,569.59	4,142.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,712.38		
1007	TANF 21-44 FEMALE WI	119.92	1,352.36	1,041.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,513.40		
1008	TANF 45-64 M & F WIT	799.65	7,922.51	4,571.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,293.19		
1009	TANF 65+ M & F WITH	1,384.02	4,601.39	1,499.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,485.33		
1011	TANF <1 M & F NON-ME	669,157.30	792,264.35	457,388.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,918,810.05		
1012	TANF 01-05 M & F NON	243,450.23	314,582.73	261,200.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		819,232.97		
1013	TANF 06-13 M & F NON	207,131.18	326,430.54	263,286.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796,847.86		
1014	TANF 14-20 MALE NON-	68,592.28	129,798.34	88,283.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,674.12		
1015	TANF 14-20 FEMALE N O	162,337.41	244,265.26	223,888.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		630,491.51		
1016	TANF 21-44 MALE NON-	879,640.25	1,273,282.25	966,650.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,119,573.15		
1017	TANF 21-44 FEMALE N O	3,360,795.09	5,320,801.86	3,832,644.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,514,241.15		
1018	TANF 45-64 M & F NON	1,438,361.58	2,211,724.85	1,587,736.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,237,822.47		
1019	TANF 65+ M & F NON-M	4,301.00	5,474.00	2,346.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,121.00		
1026	TANF 21-44 MALE WITH	205.10	1,202.12	880.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,288.11		
1027	TANF 21-44 FEMALE WI	225.00	1,046.60	1,214.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,486.41		
1028	TANF 45-64 M & F WIT	3,286.56	11,252.41	2,284.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,822.98		
1029	TANF 65+ M & F WITH	15.72	1,008.22	1,084.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,108.27		
2100	SSI AGED WITH MEDIC A	31,295.11	144,458.04	80,235.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,989.13		
2110	SSI AGED NON-MEDIC AR	54,723.22	112,881.02	47,844.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,448.74		
2120	SSI AGED WITH QMB	134,473.34	821,999.36	320,961.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,277,433.70		
2200	SSI DISABLED WITH M E	81,771.02	418,355.55	180,533.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		680,659.91		
2210	SSI DISABLED NON-ME D	4,257,729.54	6,230,255.10	4,448,727.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,936,712.17		
2220	SSI DISABLED WITH Q M	253,351.98	1,279,413.90	562,631.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,095,397.78		
2300	SSI BLIND WITH MEDIC	0.00	1,813.13	60.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,874.03		
2310	SSI BLIND NON-MEDIC A	58,144.64	56,537.66	36,611.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,294.04		
2320	SSI BLIND WITH QMB	3,118.22	16,427.75	7,367.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,913.62		
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	1,503,412.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,142,763.43		
4312	SOBRA CHILD 01-05 M	2,593,837.97	3,894,121.09	2,989,969.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,477,928.14		
4313	SOBRA CHILD 06-13 M	3,472,830.09	5,542,229.60	4,399,591.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,414,651.36		
4314	SOBRA CHILD 14-20 MA	804,131.34	1,755,777.83	1,072,149.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,632,058.74		
4315	SOBRA CHILD 14-20 FE	1,152,566.55	1,806,830.05	1,674,900.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,634,297.35		
5007	SOBRA PREG 21-44 FE M	43.82	15.74	408.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		467.70		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368.00		
5015	SOBRA PREG 14-20 FE M	210,587.60	391,120.50	349,910.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		951,618.50		

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	1,360,375.53	2,160,266.36	1,522,594.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,043,235.89	
5018	SOBRA PREG 45-64 FE M	1,207.05	18,210.16	1,870.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,288.06	
5027	SOBRA PREG 21-44 FE M	1,074.17	153.93	244.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,473.00	
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	:	23,171,656.51	37,278,986.17	26,900,536.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87,351,179.64	

1106	TANF EXPANDED 21-44	1,954.28	10,071.27	2,943.39	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	7,021.44	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	27,554.87	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	23,535.61	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	391.00	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	1,955.00	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	25,334.17	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	508,818.78	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	1,728,741.35	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	1,132,434.00	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	2,737.00	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	6,263.26	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	43,408.78	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	58,997.47	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	28,749.77	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	7,767.53	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	5,912.61	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	289,808.28	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	6,571.36	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	78,550.32	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	165,242.07	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	4,152,738.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14,968.94	
28,530.24	
122,320.68	
88,608.53	
1,564.00	
2,737.00	
10,366.16	
87,784.44	
1,458,755.41	
5,369,883.89	
3,790,258.32	
9,752.00	
19,343.03	
147,961.57	
182,873.96	
85,192.69	
37,788.41	
29,275.61	
1,131,894.99	
28,331.09	
257,722.47	
611,372.78	
13,517,286.21	

3314	AHC CARE MALE 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	-588.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	-1,439.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-2,027.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
-588.00	
-1,439.00	
-2,027.00	

3410	MED ELIGIBILITY NON-	0.00	0.00	-268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	-2,058.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-2,876.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-268.00	
-2,058.00	
-2,876.00	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	-5,202.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,202.00		

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	1,781.30	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	1,173.00	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	14,540.56	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	44,448.21	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	283,250.04	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	503,390.18	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	977,921.83	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	782.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,666,431.85	2,467,076.25	1,827,287.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

447.82	
3,484.66	
1,955.00	
43,015.39	
130,146.80	
877,952.26	
1,564,704.33	
3,337,524.96	
1,564.00	
0.00	
5,960,795.22	

4413	SOBRA 100-133% M&F
6	310,311.87	528,458.09	410,612.29	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	121,334.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,249,382.25	
383,072.21	

3506	ADULT 40-100% MALE
2	0.00	0.00	391.00	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	1,658.82	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	69,953.84	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	95,968.79	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	421,178.57	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	451,432.33	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	1,514,075.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	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	
3707	ADULT <40% EXP FEM AL	0.00	30.08	368.00	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	8,651.55	9,951.21	2,516.37	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	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	
3714	ADULT <40% EXP MAL E	131,790.54	260,483.45	182,802.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	219,854.84	382,376.05	275,570.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	3,044,533.55	4,454,722.96	3,529,656.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,830,294.46	2,982,824.72	2,268,039.56	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	4,987,186.75	8,416,095.80	5,398,793.88	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	5,494.46	5,230.07	782.00	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	601.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,711,842.67	20,085,495.42	14,213,579.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
391.00	
1,763.78	
368.00	
168,394.22	
231,288.03	
1,548,457.72	
1,386,011.86	
5,272,104.43	
391.00	
1,863.00	
398.08	
21,119.13	
1,233.29	
575,076.14	
877,801.58	
11,028,913.36	
7,081,158.74	
18,802,076.43	
11,506.53	
601.37	
47,010,917.69	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4415	SOBRA 100-133% FEM AL	116,076.61	191,884.48	142,492.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	450,453.59	
SUBTOTAL	:	539,485.97	868,983.28	674,438.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,082,908.05	

4518	BC PATIENT FEMALE 4 5	2,714.00	1,173.00	1,932.00	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	782.00	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	2,714.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,819.00	
1,564.00	
7,383.00	

8700	SSI DISABLED FREEDO M	3,694.24	7,214.57	9,729.88	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	3,519.00	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	391.00	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	13,639.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

20,638.69	
12,903.00	
4,942.18	
38,483.87	

TOTAL:	41,406,194.12	66,777,825.14	47,777,705.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,961,724.68		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,072.53	4,133.68	2,051.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,257.41		
1007	TANF 21-44 FEMALE WI	769.18	3,113.26	32.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,914.91		
1008	TANF 45-64 M & F WIT	1,699.93	6,488.98	2,266.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,454.94		
1009	TANF 65+ M & F WITH	726.82	579.18	-85.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,220.93		
1011	TANF <1 M & F NON-ME	555,896.87	302,399.18	302,105.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,160,401.72		
1012	TANF 01-05 M & F NON	59,694.66	92,475.03	57,268.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,437.79		
1013	TANF 06-13 M & F NON	38,035.56	82,126.82	46,348.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,511.30		
1014	TANF 14-20 MALE NON-	17,080.83	27,466.67	23,610.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,157.91		
1015	TANF 14-20 FEMALE N O	43,026.56	64,965.99	42,566.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,559.13		
1016	TANF 21-44 MALE NON-	674,056.38	825,020.24	541,751.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,040,828.13		
1017	TANF 21-44 FEMALE N O	1,618,662.59	1,904,822.56	1,795,733.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,319,218.24		
1018	TANF 45-64 M & F NON	707,361.29	856,387.57	748,150.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,311,899.44		
1019	TANF 65+ M & F NON-M	1,237.38	1,058.19	573.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,868.83		
1026	TANF 21-44 MALE WITH	949.63	2,269.45	184.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,403.52		
1027	TANF 21-44 FEMALE WI	826.61	1,825.06	119.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,770.87		
1028	TANF 45-64 M & F WIT	2,948.86	7,504.88	2,118.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,571.95		
1029	TANF 65+ M & F WITH	131.08	686.19	831.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,649.17		
2100	SSI AGED WITH MEDIC A	47,536.22	47,910.79	84,244.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179,691.99		
2110	SSI AGED NON-MEDIC AR	31,124.19	52,905.15	27,285.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,315.24		
2120	SSI AGED WITH QMB	252,430.74	285,929.28	215,441.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		753,801.97		
2200	SSI DISABLED WITH M E	188,471.15	329,014.83	214,323.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		731,809.03		
2210	SSI DISABLED NON-ME D	3,560,015.67	5,381,468.95	3,610,921.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,552,405.72		
2220	SSI DISABLED WITH Q M	805,895.33	1,037,192.12	679,746.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,522,834.05		
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	25,709.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225,442.79		
2320	SSI BLIND WITH QMB	11,776.25	11,684.64	5,363.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,823.98		
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	37.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.72		
4311	SOBRA CHILD <1 M & F	606,521.98	1,227,639.88	711,424.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,545,585.95		
4312	SOBRA CHILD 01-05 M	850,944.83	931,330.75	671,986.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,454,262.56		
4313	SOBRA CHILD 06-13 M	902,187.02	1,402,010.55	1,015,872.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,320,069.57		
4314	SOBRA CHILD 14-20 MA	255,662.66	585,835.60	325,093.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,166,591.97		
4315	SOBRA CHILD 14-20 FE	392,742.97	435,763.11	306,418.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,134,924.62		
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		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	106,140.82	128,457.54	40,024.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,622.62		

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	711,030.95	951,398.01	571,217.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,233,646.72	
5018	SOBRA PREG 45-64 FE M	6,314.07	1,544.55	34,338.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	42,197.30	
5027	SOBRA PREG 21-44 FE M	55.50	36.96	1,481.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,573.73	
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	12,106,557.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,753,559.12	

1106	TANF EXPANDED 21-44	5,267.22	4,642.17	4,347.95	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	3,690.50	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	30,351.35	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	8,417.64	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	65.59	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	1,567.91	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	186,446.71	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	466,940.90	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	443,217.17	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	17,736.64	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	14,675.52	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	61,730.37	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	15,467.27	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	1,754.13	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	20.12	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	167,204.95	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	4,126.94	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	124,225.52	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	184,131.22	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	1,736,118.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14,257.34	
16,299.71	
99,242.63	
24,441.01	
0.00	
0.00	
159.84	
50,464.86	
838,625.74	
1,580,583.03	
1,547,980.55	
822.22	
55,099.77	
69,562.76	
267,104.02	
69,222.41	
5,644.81	
3,955.32	
575,455.77	
30,089.86	
306,188.46	
685,557.36	
6,240,757.47	

3314	AHC CARE MALE 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-8.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
-8.78	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	-8.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-8.78		

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	112.62	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	14,842.75	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	10,500.33	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	185,789.12	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	126,873.16	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	408,493.43	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	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	167.54	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	746,778.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
2,071.16	
0.00	
37,047.19	
28,995.87	
669,115.85	
401,937.95	
1,404,667.04	
0.00	
167.54	
2,544,002.60	

4413	SOBRA 100-133% M&F
6	43,636.60	84,967.13	85,784.25	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	94,686.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

214,387.98	
156,826.49	

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	3,000.86	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	14,011.89	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	24,761.15	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	404,798.12	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	96,351.92	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	652,416.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	71.15	330.09	34.73	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	6,279.49	2,605.30	2,228.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	131,971.66	151,697.37	64,261.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	75,020.79	101,153.74	111,189.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	2,730,749.40	3,606,658.24	2,858,839.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,133,060.95	1,543,151.07	1,103,446.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	3,507,314.89	4,693,205.15	3,341,660.62	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	7.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,675,140.04	11,676,711.58	8,677,002.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
7,907.39	
0.00	
39,712.42	
60,440.18	
1,311,089.81	
343,109.27	
2,101,656.66	
0.00	
0.00	
435.97	
11,113.24	
0.00	
347,931.02	
287,363.90	
9,196,247.58	
3,779,658.62	
11,542,180.66	
7.42	
0.00	
29,028,854.14	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEM AL	34,922.68	42,295.42	42,910.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,128.95		
SUBTOTAL:	103,102.83	164,859.18	223,381.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		491,343.42		

4518	BC PATIENT FEMALE 4 5	219.81	0.00	75.93	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	75.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
295.74	
0.00	
295.74	

8700	SSI DISABLED FREEDO M	4,147.91	4,266.99	3,127.93	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	2,201.84	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	87.98	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	5,417.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,542.83	
15,734.32	
739.09	
28,016.24	

24,162,925.84	32,428,570.73	23,495,323.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

80,086,819.95	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

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

3314	AHC CARE MALE 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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	

0.00	
0.00	

3506	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE
2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		

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	

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	

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 September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	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	25,423.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,447.16		
1012	TANF 01-05 M & F NON	1,121.82	365.02	152.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,639.47		
1013	TANF 06-13 M & F NON	1,153.16	369.75	51.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,574.45		
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	224.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,383.22		
1016	TANF 21-44 MALE NON-	3,273.11	3,331.61	2,604.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,209.40		
1017	TANF 21-44 FEMALE N O	13,274.38	18,656.14	10,419.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,349.72		
1018	TANF 45-64 M & F NON	176.95	12,819.05	4,538.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,534.72		
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	1,276.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,918.69		
2110	SSI AGED NON-MEDIC AR	14,911.75	7,451.72	21,990.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,353.66		
2120	SSI AGED WITH QMB	66.89	1,627.32	65.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,760.00		
2200	SSI DISABLED WITH M E	1,060.56	715.68	3,609.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,385.93		
2210	SSI DISABLED NON-ME D	12,553.06	29,633.79	9,983.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,170.53		
2220	SSI DISABLED WITH Q M	4,921.08	1,324.16	59.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,304.82		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	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	37,890.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,412.43		
4312	SOBRA CHILD 01-05 M	3,710.57	11,062.83	9,008.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,781.78		
4313	SOBRA CHILD 06-13 M	1,132.85	15,512.06	3,580.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,225.03		
4314	SOBRA CHILD 14-20 MA	865.72	-6,401.24	558.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,976.60		
4315	SOBRA CHILD 14-20 FE	9,007.12	691.46	8,774.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,473.22		
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		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	10,581.18	7,900.25	167.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,648.97		

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	17,136.09	25,400.95	16,156.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	58,693.51	
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	156,536.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	422,350.79	

1106	TANF EXPANDED 21-44	52.14	36.83	10.43	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	879.26	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	-56.86	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	6,564.13	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	5,378.05	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	2,754.83	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	38.85	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	410.10	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	2,153.80	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	18,132.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

99.40	
201.80	
1,758.60	
74.25	
21.08	
0.00	
0.00	
0.00	
14,765.06	
16,223.51	
9,160.26	
0.00	
0.00	
0.00	
174.84	
0.00	
922.69	
0.00	
26.21	
2,894.74	
942.94	
150.83	
47,416.21	

3314	AHC CARE MALE 14-20	0.00	0.00	-115.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-115.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-115.41	
0.00	
0.00	
-115.41	

3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	83.72	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	14,542.36	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	1,641.52	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	4,631.81	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	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	50,589.33	21,169.41	20,899.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
274.59	
9,212.92	
19,777.36	
16,739.60	
46,653.68	
0.00	
0.00	
92,658.15	

4413	SOBRA 100-133% M&F
6	6,524.44	214.62	647.28	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	11,070.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,386.34	
14,656.93	

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	667.35	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	17,060.08	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	3,395.55	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	13,541.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	393.78	17,888.32	2,607.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	348.69	6,913.18	2,389.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	2,830.60	6,412.32	873.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	66,956.56	93,175.44	47,069.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	28,458.42	36,366.56	34,684.03	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	122,869.32	164,344.52	75,348.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	263,243.94	388,884.65	197,636.09	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	
11,058.78	
45,381.12	
14,182.23	
67,620.73	
0.00	
0.00	
0.00	
20,889.18	
0.00	
9,651.00	
10,116.49	
207,201.14	
99,509.01	
362,562.03	
0.00	
0.00	
849,764.68	

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4415	SOBRA 100-133% FEM AL	149.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	149.18	
SUBTOTAL	:	6,722.65	3,752.28	11,717.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,192.45	

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	668.70	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	668.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

668.70	
0.00	
0.00	
668.70	

448,653.46	580,807.16	405,474.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,434,935.57	

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	49,660.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,397.73		
8050	QI1	0.00	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:	38,229.76	113,507.5	49,660.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,397.73		

TOTAL:	38,229.76	113,507.56	49,660.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,397.73		

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	0.00	308.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308.30		
SUBTOTAL:	0.00	0.0	308.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308.30		

0.00	0.00	308.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

308.30	

TOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	365,291.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,404,032.44		
8050	QI1	0.00	0.00	267.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267.76		
SUBTOTAL:	451,294.58	587,446.4	9	365,559.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,404,300.20		

TOTAL:	451,294.58	587,446.49	365,559.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,404,300.20		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 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	56.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170.58		
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	24.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,563.12		
1009	TANF 65+ M & F WITH	-281.37	15.77	55.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-210.12		
1011	TANF <1 M & F NON-ME	41,353.18	83,524.87	45,851.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,729.62		
1012	TANF 01-05 M & F NON	2,416.45	5,049.59	5,005.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,471.69		
1013	TANF 06-13 M & F NON	17,904.47	5,731.28	1,371.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,007.63		
1014	TANF 14-20 MALE NON-	637.52	3,544.55	163.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,345.45		
1015	TANF 14-20 FEMALE N O	473.36	9,088.52	4,205.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,767.57		
1016	TANF 21-44 MALE NON-	48,175.44	44,624.89	55,073.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,873.47		
1017	TANF 21-44 FEMALE N O	118,892.96	155,104.03	80,082.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		354,079.26		
1018	TANF 45-64 M & F NON	27,646.03	65,670.84	68,847.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162,164.67		
1019	TANF 65+ M & F NON-M	0.00	0.00	6,769.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,769.71		
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	168.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		561.75		
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	1,296.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,806.22		
2110	SSI AGED NON-MEDIC AR	233.62	202.56	106.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		543.00		
2120	SSI AGED WITH QMB	10,874.03	11,181.21	8,341.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,396.54		
2200	SSI DISABLED WITH M E	8,331.34	6,667.68	8,218.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,217.94		
2210	SSI DISABLED NON-ME D	269,492.24	321,140.24	256,038.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846,671.35		
2220	SSI DISABLED WITH Q M	30,051.08	42,118.54	23,981.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,151.29		
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	207.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,223.14		
2320	SSI BLIND WITH QMB	52.29	333.79	1,316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,702.08		
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	197,191.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		346,257.46		
4312	SOBRA CHILD 01-05 M	40,550.75	187,610.82	74,555.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302,716.96		
4313	SOBRA CHILD 06-13 M	34,283.16	66,111.59	48,413.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148,808.41		
4314	SOBRA CHILD 14-20 MA	10,028.07	22,322.48	11,914.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,265.31		
4315	SOBRA CHILD 14-20 FE	16,595.83	66,226.90	10,390.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,213.03		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	8,490.98	26,483.90	26,630.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,605.76		

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

RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	106,165.33	159,784.86	53,222.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	319,172.28	
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	989,502.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,241,644.06	

1106	TANF EXPANDED 21-44	23.54	94.05	166.86	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	704.76	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	198.15	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	846.58	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	431.95	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	23,471.26	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	53,849.45	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	25,664.10	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	342.73	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	1,097.16	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	2,652.81	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	-20.72	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	11,582.18	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	56.86	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	3,467.26	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	3,579.14	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	128,090.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

284.45	
1,194.64	
4,687.63	
1,504.74	
0.00	
0.00	
0.00	
4,435.92	
92,057.17	
217,222.38	
85,945.26	
0.00	
2,235.35	
3,788.25	
12,033.90	
2,981.38	
585.50	
0.00	
34,750.55	
3,205.92	
5,557.85	
19,857.86	
492,328.75	

3314	AHC CARE MALE 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	16,606.40	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	232.62	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	13,202.86	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	10,539.94	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	91,059.97	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	
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	81,351.01	159,565.66	131,641.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
16,707.46	
2,686.70	
101,135.13	
53,807.97	
198,221.20	
0.00	
0.00	
372,558.46	

4413	SOBRA 100-133% M&F
6	5,767.98	4,841.65	5,090.37	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	1,719.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15,700.00	
12,976.99	

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	63.99	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	1,432.55	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	211,786.16	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	13,176.02	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	128,234.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	27.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MAL E	2,368.59	13,631.78	20,079.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	10,881.58	4,587.91	-712.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MAL E	217,280.78	338,036.75	146,991.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	265,106.48	120,807.87	91,145.50	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	241,419.48	189,212.30	193,413.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	922,529.71	804,515.00	805,610.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
2,370.46	
5,302.15	
274,923.63	
82,185.59	
313,595.22	
0.00	
0.00	
0.00	
27.13	
0.00	
36,080.22	
14,757.29	
702,308.85	
477,059.85	
624,045.16	
0.00	
0.00	
2,532,655.55	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEM AL	54.32	401.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		456.05		
SUBTOTAL:	11,788.70	10,534.38	6,809.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,133.04		

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	70.30	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	28.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	954.40	2,267.29	99.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,994.95	
0.00	
325.99	
3,320.94	

2,018,419.79	2,591,465.98	2,061,755.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,671,640.80	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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	190,117.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,065,915.53		
2110	SSI AGED NON-MEDIC AR	114,115.36	33,424.06	8,840.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,379.47		
2120	SSI AGED WITH QMB	106,974.53	642,052.72	246,548.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		995,575.85		
2200	SSI DISABLED WITH M E	20,587.92	133,462.59	59,877.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213,927.65		
2210	SSI DISABLED NON-ME D	690,412.33	1,298,812.40	863,430.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,852,655.53		
2220	SSI DISABLED WITH Q M	50,835.89	253,878.80	110,857.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415,572.54		
2310	SSI BLIND NON-MEDIC A	8,165.00	27,468.40	8,993.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,626.40		
2320	SSI BLIND WITH QMB	79.82	10.22	180.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270.23		
SUBTOTAL:	1,273,533.45	2,982,936.08	1,488,844.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,745,314.20		

TOTAL:

1,273,533.45	2,982,936.08	1,488,844.67

0.00

0.00

0.00

0.00

0.00

5,745,314.20

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 September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	2,365,886.89	2,765,480.64	2,423,012.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,554,379.89		
2110	SSI AGED NON-MEDIC AR	114,010.42	163,832.12	93,510.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371,352.89		
2120	SSI AGED WITH QMB	3,278,193.16	3,816,786.21	3,229,736.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,324,716.22		
2200	SSI DISABLED WITH M E	705,967.24	704,921.23	598,366.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,009,255.01		
2210	SSI DISABLED NON-ME D	2,342,483.57	3,086,839.40	2,211,571.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,640,893.97		
2220	SSI DISABLED WITH Q M	816,372.82	1,114,191.87	823,596.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,754,161.34		
2310	SSI BLIND NON-MEDIC A	29,301.58	10,254.28	13,868.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,424.24		
2320	SSI BLIND WITH QMB	8,700.00	8,731.83	4,039.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,470.90		
SUBTOTAL:	9,660,915.68	11,671,037.58	9,397,701.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,729,654.46		

8710	SSI DISABLED FREEDO M	0.00	1,326.10	6,033.96	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	3,424.68	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	9,458.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,360.06	
9,002.64	
16,362.70	

9,663,449.48	11,675,407.84	9,407,159.84	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 September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	34,978.33	15,196.53	42,569.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,744.06		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	-1,217.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,217.09		
2120	SSI AGED WITH QMB	597.24	3,085.15	1,027.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,709.39		
2200	SSI DISABLED WITH M E	1,957.19	904.21	6,282.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,143.61		
2210	SSI DISABLED NON-ME D	23,421.88	43,085.97	23,457.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,964.88		
2220	SSI DISABLED WITH Q M	2,389.71	-3,161.19	7,839.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,068.13		
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	79,957.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202,412.98		

TOTAL:

63,344.35

59,110.67

79,957.96

0.00

0.00

0.00

0.00

0.00

202,412.98

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 September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	18,622.93	14,307.85	10,702.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,633.01		
2110	SSI AGED NON-MEDIC AR	6,450.23	799.18	193.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,442.76		
2120	SSI AGED WITH QMB	9,806.02	19,063.27	7,262.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,131.55		
2200	SSI DISABLED WITH M E	4,695.45	7,277.13	1,911.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,883.87		
2210	SSI DISABLED NON-ME D	31,915.34	12,532.42	34,054.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,502.48		
2220	SSI DISABLED WITH Q M	4,055.69	8,154.75	3,503.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,713.63		
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	133.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.98		
SUBTOTAL:	75,572.79	62,134.60	57,760.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,468.28		

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	57,760.89	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	128,128.56	120,248.37	125,035.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	373,412.23	

6012	C
KIDS 1-5 M & F NON-M	
708,271.37	
724,951.56	
732,818.83	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
2,166,041.76	
6013	KIDS 6-13 M & F NON-	1,262,579.15	1,291,637.47	1,329,185.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,883,402.61	
6014	KIDS 14-19 MALE NON-	428,391.90	442,663.87	457,866.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,328,921.95	
6015	KIDS 14-19 FEMALE NO	697,874.36	706,401.17	729,116.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,133,392.06	
9960	KIDSCARE KICK PAYM EN	12,541.03	0.00	12,776.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,317.59	
SUBTOTAL:	3,237,786.37	3,285,902.44	3,386,799.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,910,488.20	

TOTAL:	3,237,786.37	3,285,902.44	3,386,799.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,910,488.20		

RATE COD	E	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	264.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	791.58	
6012	KIDS 1-5 M & F NON-M	5,792.97	5,917.72	6,012.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,723.46	
6013	KIDS 6-13 M & F NON-	10,227.66	10,484.79	10,776.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,488.65	
6014	KIDS 14-19 MALE NON-	2,555.62	2,642.57	2,724.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,922.52	
6015	KIDS 14-19 FEMALE NO	2,628.75	2,664.75	2,749.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,042.54	
9960	KIDSCARE KICK PAYM EN	2.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	
SUBTOTAL	:	21,478.65	21,964.83	22,529.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,972.75	

21,478.65	21,964.83	22,529.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

65,972.75	

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	10,828.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,820.68	

6012	C
KIDS 1-5 M & F NON-M	
226,209.16	
230,820.68	
235,254.69	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
692,284.53	
6013	KIDS 6-13 M & F NON-	397,354.76	406,599.10	418,704.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,222,658.72	
6014	KIDS 14-19 MALE NON-	107,522.67	110,080.27	113,538.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	331,141.36	
6015	KIDS 14-19 FEMALE NO	110,518.36	111,678.66	115,455.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	337,652.86	

SUBTOTAL:	
852,331.88	
869,443.98	
893,782.29	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
2,615,558.15	

TOTAL:	852,331.88	869,443.98	893,782.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,615,558.15		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	

TOTAL:

0.00

0.00

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending September 30, 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	3,363.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,227.39		
6013	KIDS 6-13 M & F NON-	1,500.27	1,500.27	1,500.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,500.81		
SUBTOTAL:	3,000.54	4,863.8	4,863.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,728.20		

TOTAL:	3,000.54	4,863.83	4,863.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,728.20		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 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	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
6013	KIDS 6-13 M & F NON-	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
SUBTOTAL:	6.00	9.0	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		

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

24.00	

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	2,623.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,154.57	

6012	C
KIDS 1-5 M & F NON-M	
17,818.20	
23,910.93	
41,066.47	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
82,795.60	
6013	KIDS 6-13 M & F NON-	21,381.26	42,458.84	32,205.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	96,045.79	
6014	KIDS 14-19 MALE NON-	4,092.52	9,111.78	7,520.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,724.60	
6015	KIDS 14-19 FEMALE NO	11,360.35	9,833.55	11,394.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,588.89	

SUBTOTAL:	
55,088.24	
85,410.32	
94,810.89	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
235,309.45	

TOTAL:	55,088.24	85,410.32	94,810.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235,309.45		

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	242.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	56,032.46	
6013	KIDS 6-13 M & F NON-	23,428.15	0.01	255.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,683.25	
6014	KIDS 14-19 MALE NON-	11,115.43	438.49	14,379.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,933.11	
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	
14,876.70	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
756,852.74	

90,333.62	651,642.42	14,876.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

756,852.74	

TOTAL:

00

00

93,341.15

93,341.15

22.00

2,113.19

12.00

596.26

16.00

870.07

6,159.27

8.00

70,314.69

12,674.15

40.00

365.52

94.00

38.00

6.00

12.00

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

RATE CODE

DESCRIPTION

JULY

AUGUST     SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

1000	TANF WITH MEDICARE	8.00	7.00	7.00	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	708.12	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	4.00	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	204.80	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	6.00	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	287.78	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	2,062.21	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	23,499.43	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	4,238.46	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	14.00	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	123.00	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	32.00	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	13.00	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	2.00	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	4.00	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	31,205.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	31,009.73	31,125.62	31,205.80	0.	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	

 
ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM
EPD/DD EXPENDITURES
For the Period Ending September 30, 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	401,439.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,200,446.55	
EPD	93,545,138.25	113,163,312.12	94,426,564.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	301,135,015.17	
TOTAL AHCCCS LTC	93,942,173.84	113,565,283.47	94,828,004.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	302,335,461.72	
DES/DD	112,834,320.04	113,252,020.57	113,539,308.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	339,625,648.74	
TOTAL DES LTC	112,834,320.04	113,252,020.57	113,539,308.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	339,625,648.74	
TOTAL LTC - CAP	206,776,493.88	226,817,304.04	208,367,312.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	641,961,110.46	

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	11,033,723.36
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	36,889,212.62
0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	11,075,900.07	14,779,589.19	11,033,723.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,889,212.62	

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	6,940,934.55
1,007,130.96	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	19,091,667.93
3,994,189.57	
	2,184,772.28	802,286.33	1,007,130.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,994,189.57	
TOTAL LTC - REIN	8,708,154.80	6,429,637.19	7,948,065.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,085,857.50	

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	4,001,391.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,965,207.50	

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

Wednesday, October 18, 2017

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	14,520,179.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43,790,853.58	
010145	CRS ACUTE SEMI INTEGRATED - CAP	107,432.99	107,327.28	109,527.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	324,287.44	
999125	CRS SEMI INTEGRATED PLAN - CAP	5,627,771.65	5,652,158.42	5,654,094.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,934,024.34	
999135	CRS ONLY PLAN - CAP	549,147.69	552,857.53	553,002.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,655,007.92	
Subtotal	20,947,188.37	20,920,181.10	20,836,803.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	62,704,173.28	

999155	CRS REINSURANCE ONLY	2,281,891.03	2,401,136.52	2,189,272.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,872,299.80	
Subtotal	2,281,891.03	2,401,136.52	2,189,272.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,872,299.80	

23,229,079.40	23,321,317.62	23,026,076.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69,576,473.08	

GRAND TOTAL

Wednesday, October 18, 2017

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	16,337.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,308.48	
010145	CRS ACUTE SEMI INTEGRATED - MM	195.65	195.43	199.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	590.61	
999125	CRS SEMI INTEGRATED PLAN - MM	6,511.77	6,545.15	6,549.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,606.65	
999135	CRS ONLY PLAN - MM	1,088.48	1,097.02	1,097.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,283.13	
Subtotal	24,318.08	24,286.33	24,184.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,788.87	

24,318.08	24,286.33	24,184.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	72,788.87	

GRAND TOTAL

Wednesday, October 18, 2017

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	10,255,273.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,727,048.63	
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	22,416,469.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,327,832.56	
010795	MERCY MARICOPA INTEGRATED - CAP	50,665,969.36	51,176,641.74	51,188,836.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	153,031,447.10	
078999	MERCY MARICOPA INTEGRATED - CAP	-20,396.68	-50,403.75	-2,242.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-73,043.09	
Subtotal	83,243,316.73	83,875,360.01	83,858,336.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	250,977,013.06	

83,243,316.73	83,875,360.01	83,858,336.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	250,977,013.06	

GRAND TOTAL

Wednesday, October 18, 2017

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	5,807.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,397.65	
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	13,615.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,892.80	
010795	MERCY MARICOPA INTEGRATED - MM	21,387.32	21,602.60	21,609.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64,599.27	
078999	MERCY MARICOPA INTEGRATED - MM	-9.09	-22.49	-0.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-32.57	
Subtotal	40,756.17	41,046.50	41,031.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,834.52	

40,756.17	41,046.50	41,031.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122,834.52	

GRAND TOTAL