December 26, 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 November 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 November 30, 2017.

Status Summary – As part of the FY 2019 budget revision submitted to the Governor’s Office of Strategic Planning and Budgeting on October 31st, a FY 2018 rebase was prepared.  AHCCCS is currently forecasting a FY 2018 Total Fund shortfall of $152.7 million. This shortfall is comprised of $134.0 million Federal Expenditure Authority and $18.7 million Hospital Assessment Fund Authority.

There are several issues this fiscal year that have the potential to affect the projected shortfall. They include:
Continued volatility in caseload growth and prior period expenditures.
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, which will impact the projected shortfall amounts.

Given these issues and options, for purposes of this report, projected annual expenditures equal the FY 2018 appropriations.

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

The Honorable Steve Yarbrough The Honorable J.D. Mesnard December 26, 2017
Page 2

Enrollment Update – November 2017 enrollment is 1,918,190 members, a 2,955 member decrease over the prior month. Enrollment for December 2017 decreased to 1,906,605 members, an 11,858 member change.

Major December 2017 changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 9,081; Supplemental Security Income – increase of 353; Prop 204 Restoration - decrease of 2,980; Adult Expansion – decrease of 853; Medicare Cost Sharing
– increase of 403; KidsCare – increase of 681; and Federal Emergency Services - decrease of 437.

Tobacco Funds Revenue Update - Tobacco tax collections through November 2017 are
$745,000 less than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue 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.

Sincerely,

Thomas J. Betlach Director

Enclosure

cc:	The Honorable Douglas A. Ducey, Governor
The Honorable, Debbie Lesko, Chairman, Senate Appropriations Committee
The Honorable David Livingston, Acting 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 November 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 November 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		$	32,806,801		$	39,257,515		$	(6,450,715)		$	94,260,300		$	-		
AHCCCS Prop 204 Administration	13,936,000		4,800,862		6,078,726		(1,277,863)		13,936,000		-		
DES Eligibility	91,874,500		37,399,700		29,552,199		7,847,501		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		18,710,200		11,624,448		7,085,752		44,358,700		-		
Prop 206 Provider Assessment Study	200,000		44,923		-		44,923		200,000		-		
TOTAL ADMINISTRATION	 	244,629,500 		 	93,762,486 		 	86,512,888 		 	7,249,598 		 	244,629,500 		 	-			

Traditional Medicaid Services	3,896,328,000	1,623,942,300	1,586,146,997	37,795,303	3,896,328,000	-	
Proposition 204 Services	2,773,331,800	1,141,007,200	1,129,627,824	11,379,376	2,773,331,800	-	
ACA Adult Expansion	475,591,600	205,752,300	197,745,867	8,006,433	475,591,600	-	
Children's Rehabilitative Services	269,646,300	109,728,100	124,397,335	(14,669,235)	269,646,300	-	
KidsCare Services	111,961,100	39,370,500	21,759,753	17,610,747	111,961,100	-	
ALTCS Services	1,544,082,800	632,097,500	639,677,641	(7,580,141)	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	39,450,100	39,450,064	36	340,729,800	-	
Behavioral Health Traditional Medicaid Services	1,156,192,500	464,402,600	487,934,664	(23,532,064)	1,156,192,500	-	
Behavioral Health Proposition 204 Services	788,262,700	312,754,500	343,119,039	(30,364,539)	788,262,700	-	
Behavioral Health ACA Adult Expansion	86,141,400	33,419,300	37,087,105	(3,667,805)	86,141,400	-	
Behavioral Health CMDP	217,719,100	94,196,400	59,975,040	34,221,360	217,719,100	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	32,853,000	32,798,551	54,449	78,846,900	-	
Supported Housing	5,324,800	2,218,500	2,184,699	33,801	5,324,800	-	
Crisis Services	16,391,300	6,829,500	6,794,292	35,208	16,391,300	-	

TOTAL PROGRAMMATIC	 	11,788,287,200	 	4,738,021,800	 	4,708,698,871	 	29,322,929	 	11,788,287,200	 	-	

TOTAL EXPENDITURES

  $	12,032,916,700 

$	4,831,784,286

$	4,795,211,759

$	36,572,527

$   12,032,916,700	$	-

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending November 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	$	21,333,529	$	22,487,144	(1,153,615)	$	55,962,100	$	-	
Proposition 204 - Administrative Expenditures	21,765,400	8,779,922	5,014,079	3,765,843	21,765,400	-	

Programmatic Expenditures							
Traditional Medicaid Services	830,106,600	346,282,800	331,159,420	15,123,380	830,106,600	-	
Proposition 204 Services	-	-	(1,159,535)	1,159,535	-	-
Children's Rehabilitative Services	81,426,000	33,374,800	32,946,624	428,176	81,426,000	- KidsCare Services		-		-		(83,916)		83,916		-	-
ALTCS Services	185,064,700	76,612,200	77,110,292	(498,092)	185,064,700	-
DSH and Rural Hospitals	7,086,300	-	-	-	7,086,300	-
Behavioral Health Traditional Medicaid Services	316,050,500	127,926,500	135,558,293	(7,631,793)	316,050,500	-	
Behavioral Health Proposition 204 Services	109,562,000	45,067,300	49,920,973	(4,853,673)	109,562,000	-	
Behavioral Health ACA Adult Expansion	4,269,200	1,495,600	1,854,834	(359,234)	4,269,200	-	
Behavioral Health CMDP	65,719,400	28,650,400	18,306,700	10,343,700	65,719,400	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	32,853,000	32,798,551	54,449	78,846,900	-	
Supported Housing	5,324,800	2,218,500	2,184,699	33,801	5,324,800	-	
Crisis Services	 	14,141,100 	 	5,892,000 	 	5,856,708 	 	35,292 	 	14,141,100 	 	- 	
TOTAL GF EXPENDITURES	1,775,325,000	730,486,551	713,954,865	16,531,685	1,775,325,000	-	

FEDERAL		
Administrative Expenditures	129,511,800	48,619,142	46,195,963	2,423,179	129,511,800	-	
Proposition 204 - Administrative Expenditures	32,874,000	13,189,440	12,689,095	500,345	32,874,000	-	

Programmatic Expenditures	
Traditional Medicaid Services	2,412,443,400	1,006,366,100	889,623,823	116,742,277	2,412,443,400	-	
Proposition 204 Services	2,397,123,600	983,856,500	971,388,500	12,468,000	2,397,123,600	-	
ACA Adult Expansion	450,284,200	195,792,600	188,322,959	7,469,641	450,284,200	-	
Children's Rehabilitative Services	188,220,300	76,353,300	91,450,711	(15,097,411)	188,220,300	-	
KidsCare Services	99,809,800	35,052,300	19,438,895	15,613,405	99,809,800	-	
ALTCS Services and Nursing Facility Assessment	956,062,900	390,316,800	392,637,148	(2,320,348)	956,062,900	-	
DSH and Rural Hospitals
Behavioral Health Traditional Medicaid Services	20,650,800
804,576,200	- 322,080,200	- 337,343,075	- (15,262,875)	20,650,800
804,576,200	-
-	
Behavioral Health Proposition 204 Services	655,527,700	258,155,200	283,890,045	(25,734,845)	655,527,700	-	
Behavioral Health ACA Adult Expansion	81,390,900	31,682,900	35,232,272	(3,549,372)	81,390,900	-	
Behavioral Health CMDP	151,999,700	65,546,000	41,668,341	23,877,659	151,999,700	-	
Voluntary Political Subdivision Programs - See Note 5	 	237,582,300 	 	27,143,600 	 	27,143,616 	 	(16)	 	237,582,300 	 	- 	
TOTAL FEDERAL EXPENDITURES	8,618,057,600	3,454,154,083	3,337,024,443	117,129,639	8,618,057,600	-	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,655,300	1,541,700	-	1,541,700	3,655,300	-	
Programmatic Expenditures					
Traditional Medicaid Services Acute Care	49,687,700	20,676,500	20,676,500	-	49,687,700	-	
ALTCS Services	 	249,980,000 	 	109,569,500 	 	110,401,431	 	(831,931)	 	249,980,000 	 	- 	
TOTAL COUNTY EXPENDITURES	303,323,000	131,787,700	131,077,931	709,769	303,323,000	-	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending November 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	15,648,700	15,822,289	(173,589)	37,432,400	-	
Behavioral Health Traditional Medicaid Services - Medically Needy	35,565,800	14,395,900	15,033,296	(637,396)	35,565,800	-	
Proposition 204 Services - Emergency Health Services	19,244,300	8,307,600	7,730,248	577,352	19,244,300	-	
Proposition 204 Services - Proposition 204 Protection	17,240,000	7,442,400	6,924,882	517,518	17,240,000	-	
Behavioral Health Proposition 204 Services - Proposition 204 Protection	23,173,000	9,532,000	9,308,021	223,979	23,173,000	-	
Proposition 204 Services - ATLSF	 	79,000,000 	 	- 	 	- 	 	- 	 	79,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	211,655,500	55,326,600	54,818,735	507,865	211,655,500	-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	

OTHER

860,900	

298,752	126,607	172,145	860,900	-	
Acute Care - Prescription Drug Rebate Program State Match	137,191,000	57,352,700	57,162,917	189,783	137,191,000	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	429,241,000	177,534,200	271,349,614	(93,815,414)	429,241,000	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	3,138,100	3,915,507	(777,407)	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	15,101,500	16,185,382	(1,083,882)	36,422,000	-	
Proposition 204 Services - Hospital Assessment	260,723,900	141,400,700	144,743,729	(3,343,029)	260,723,900	-	
ACA Adult Expansion - Hospital Assessment	25,307,400	9,959,700	9,422,908	536,792	25,307,400	-	
Behavioral Health ACA Adult Expansion - Hospital Assessment	481,300	240,800	-	240,800	481,300	-	
Traditional Medicaid Services - TPL	194,700	81,400	322,235	(240,835)	194,700	-	
ALTCS Services - TPL	-	-	495,581	(495,581)	-	-	
ALTCS Services - Nursing Facility Assessment	108,974,800	37,359,400	38,932,300	(1,572,900)	108,974,800	-	
KidsCare Services Premiums	12,151,300	4,318,200	2,404,774	1,913,426	12,151,300	-	
Freedom to Work Premiums	31,200	-	30,200	(30,200)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	937,500	937,583	(83)	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	103,147,500 	 	12,306,400 	 	12,306,447 	 	(47)	 	103,147,500 	 	- 	
TOTAL OTHER EXPENDITURES	1,124,555,600	460,029,352	558,335,784	(98,306,432)	1,124,555,600	-	

TOTAL		
Administrative Expenditures	244,629,500	93,762,486	86,512,888	7,249,598	244,629,500	-	
Acute Care	10,244,204,400	4,105,924,300	4,069,021,230	36,903,070	10,244,204,400	-	
Long Term Care	 	1,544,082,800 	 	632,097,500 	 	639,677,641 	 	(7,580,141)	 	1,544,082,800 	 	- 	
TOTAL EXPENDITURES	  $	12,032,916,700 	  $	4,831,784,286 	  $	4,795,211,759 	  $	36,572,527 	  $	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 November 30, 2017

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	974,581,000	$	400,991,129	$	386,593,187	
Proposition 204 Services & Administrative	21,765,400	8,779,922	63,083,539	
KidsCare Services	-	-	(83,916)	
ALTCS Services	185,064,700	76,612,200	77,110,292	
Behavioral Health Traditional Medicaid Services	 	593,913,900	 	244,103,300	 	194,704,951 	
TOTAL	1,775,325,000	730,486,551	721,408,052	

FEDERAL:
Acute & Administrative	5,868,690,400	2,351,320,683	2,224,821,407	
KidsCare Services	99,809,800	35,052,300	20,835,500	
ALTCS Services	956,062,900	390,316,800	433,584,747	
Behavioral Health Traditional Medicaid Services	 	1,693,494,500 	 	677,464,300 	 	698,139,136 	
TOTAL	8,618,057,600	3,454,154,083	3,377,380,790	

COUNTY:				
Acute & Administrative	53,343,000		22,218,200		20,566,833	
ALTCS Services	 	249,980,000 		 	109,569,500 		 	110,280,500 	
TOTAL	303,323,000		131,787,700		130,847,333	

TOBACCO FUNDS:						
Traditional Medicaid Services	72,998,200		30,044,600		30,855,585	
Proposition 204 Services	 	138,657,300 		 	25,282,000 		 	14,655,129 	
TOTAL	211,655,500		55,326,600		45,510,714	

OTHER:

Administrative	860,900	298,752	126,607	
Acute Care - Prescription Drug Rebate Program	566,432,000	234,886,900	328,512,531	
Long Term Care - Prescription Drug Rebate Program	44,000,400	18,239,600	20,100,888	
Hospital Assessment	286,512,600	151,601,200	142,469,769	
ALTCS - Nursing Facility Assessment	108,974,800	37,359,400	149,784	
Acute TPL - Note 1	194,700	81,400	322,235	
LTC TPL - Note 1	-	-	495,581	
KidsCare TPL - Note 1	-	-	(7)	
Member Premiums - CHIP	12,151,300	4,318,200	2,404,774	
Member Premiums - Freedom to Work	31,200	-	30,200	
Behavioral Health Traditional Medicaid Services	2,250,200	937,500	746,335	
Voluntary Political Subdivision - State Match	 	103,147,500 	 	12,306,400 	 	24,612,895 	
TOTAL	1,124,555,600	460,029,352	519,971,592	

TOTAL REVENUE

$	12,032,916,700

$	4,831,784,286

$	4,795,118,481

Appropriation	Status Report
Footnotes

--- HCCCS
Arizona Health Care Cost Containmen t System

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2017	
Note 1: Third Party Liability Collections:	November 2017		November 2016		July 1, 2017		July 1, 2016	
Gross Collections:					November 30, 2017		November 30, 2016	
Acute	$	765,770		$	470,067		$	3,141,476		$	2,393,311	
LTC	147,349		464,591		2,290,929		1,974,171	
KidsCare	-		-		697		4,878	
Total TPL Collections	  $	913,119 		$	934,658		$	5,433,102		$	4,372,360	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	63,882		$	21,014		$	322,235		$	127,440		
LTC	29,547		96,697		495,581		409,283		
KidsCare	-		-		(7)		978		
Total Expenditure Offsets	  $	93,429 		$	117,711		$	817,809		$	537,701		

FY 18 Total

Note 2:    Authorized Positions	1,161.0
Actual Positions as of November 30, 2017	1,077.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2017	$	2,456,040	
	Revenues	3,875,945	
	Transfers-In	 	266,215 	
	Total Revenues	 	4,142,161 	
	Expenditures	3,040,488	
	Transfers-out	 	1,000,000 	
	Total Expenditures	 	4,040,488 	
	Ending Balance November 30, 2017	  $	2,557,713 	

Of the $2,557,713 ending balance, $1,558,080 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through December 2017.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.
Schedule of Outstanding Liabilities
As of November 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 November 30, 2017 Expenditures

State Match	Federal	Total

DSH Voluntary	$	-	$	-	$	-
GME Voluntary	12,306,447	27,143,616	39,450,064
Safety Net Care Pool	-	-	-

Total Voluntary Political Subdivision Program Expenditure $

12,306,447	$

27,143,616 $

39,450,064

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	283,135,976	281,014,798	0	0	0	0	0	0	0	1,413,158,491	
CAPITATION - LTC	206,776,494	226,817,304	208,355,352	211,447,457	231,188,720	0	0	0	0	0	0	0	1,084,585,327	
MENTAL HEALTH - CHILD	27,544,565	27,724,984	27,624,408	29,228,363	29,116,650	0	0	0	0	0	0	0	141,238,969	
MENTAL HEALTH - ADULT	943,019	720,852	738,314	1,280,536	1,464,087	0	0	0	0	0	0	0	5,146,808	
MENTAL HEALTH - GENERAL	12,841,280	12,960,968	12,914,296	17,193,985	17,177,687	0	0	0	0	0	0	0	73,088,216	
MENTAL HEALTH - CMDP	13,096,578	12,797,592	12,457,164	11,015,383	10,946,142	0	0	0	0	0	0	0	60,312,859	
MENTAL HEALTH - DD	4,268,444	4,283,815	4,297,906	5,700,054	5,715,510	0	0	0	0	0	0	0	24,265,729	
CHILDREN'S REHAB SERVICES	6,152,157	6,176,648	6,177,229	6,585,737	6,597,777	0	0	0	0	0	0	0	31,689,547	
FEE FOR SERVICE - ACUTE	37,517,260	57,106,521	41,373,210	36,416,482	43,584,499	0	0	0	0	0	0	0	215,997,972	
FFS - PRIOR QUARTER COVERAGE	477,647	732,384	436,709	464,159	629,659	0	0	0	0	0	0	0	2,740,557	
EMERGENCY SERVICES - FEDERAL	5,092,983	7,198,427	2,476,370	3,693,643	4,752,948	0	0	0	0	0	0	0	23,214,371	
FFS MEDICAID IN PUBLIC SCHOOLS	498,616	218,798	74,000	659,257	465,409	0	0	0	0	0	0	0	1,916,080	
INPATIENT INMATES FFS	223,348	131,891	101,766	86,138	223,359	0	0	0	0	0	0	0	766,502	
STATE ONLY TRBHA FFS	6,531	0	2,449	26,941	45,018	0	0	0	0	0	0	0	80,940	
FFS TRBHA FEE FOR SERVICE	11,064,992	13,491,379	10,597,096	9,333,252	11,353,356	0	0	0	0	0	0	0	55,840,074	
QMB - FEE FOR SERVICE	489,558	701,001	415,525	457,695	623,098	0	0	0	0	0	0	0	2,686,876	
YUMA COUNTY INMATES FFS	0	0	77	1,377	0	0	0	0	0	0	0	0	1,454	
PINAL COUNTY INMATES FFS	0	0	0	0	0	0	0	0	0	0	0	0	0	
PIMA COUNTY INMATES FFS	564	690	0	1,602	2,837	0	0	0	0	0	0	0	5,693	
MOHAVE COUNTY INMATES FFS	0	6,214	0	0	1,103	0	0	0	0	0	0	0	7,317	
MARICOPA CTY INMATES FFS	68,686	30,039	22,868	6,568	37,763	0	0	0	0	0	0	0	165,924	
COCHISE COUNTY INMATES FFS	0	0	-980	0	0	0	0	0	0	0	0	0	-980	
FEE FOR SERVICE - LTC	11,075,900	14,779,589	11,033,723	10,412,298	12,734,589	0	0	0	0	0	0	0	60,036,100	
LFFS - PRIOR QUARTER COVERAGE	31,031	30,711	36,439	64,876	58,497	0	0	0	0	0	0	0	221,553	
PIMA COUNTY INMATES LTC FEE
FOR SERVICE	0	0	1,680	0	0	0	0	0	0	0	0	0	1,680	
MARICOPA CTY INMATES LTC FFS	166	0	607	0	114	0	0	0	0	0	0	0	887	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,540,502	836,850	200,804	1,208,857	1,423,390	0	0	0	0	0	0	0	5,210,403	
REINSURANCE - ACUTE	14,094,798	9,458,578	10,548,999	14,245,193	10,999,164	0	0	0	0	0	0	0	59,346,732	
REINSURANCE - LTC	8,708,155	6,429,637	7,948,066	7,110,450	5,402,902	0	0	0	0	0	0	0	35,599,210	
SMIB - ACUTE	14,841,421	15,030,410	15,054,132	15,184,273	15,231,589	0	0	0	0	0	0	0	75,341,825	
HIB - ACUTE	530,608	606,349	597,687	585,235	559,111	0	0	0	0	0	0	0	2,878,990	
Q1	2,585,545	2,637,260	2,661,063	2,632,237	2,722,955	0	0	0	0	0	0	0	13,239,060	
SMIB - LTC	3,694,581	3,701,005	3,714,794	3,722,089	3,743,706	0	0	0	0	0	0	0	18,576,175	
HIB - LTC	280,970	287,260	286,598	288,498	286,161	0	0	0	0	0	0	0	1,429,487	
SUBTOTAL	669,969,014	706,230,953	662,299,649	672,188,610	698,102,599	0	0	0	0	0	0	0	3,408,790,826	

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	228,076,092	226,708,074	0	0	0	0	0	0	0	1,110,797,214	
MENTAL HEALTH - CHILD	3,567	3,361	3,294	3,524	3,469	0	0	0	0	0	0	0	17,216	
MENTAL HEALTH - ADULT	1,025,896	887,584	796,762	1,675,620	2,164,533	0	0	0	0	0	0	0	6,550,396	
MENTAL HEALTH - GENERAL	23,612,539	23,858,290	23,761,886	31,600,038	31,462,983	0	0	0	0	0	0	0	134,295,736	
MENTAL HEALTH - CMDP	1,317	798	467	385	627	0	0	0	0	0	0	0	3,594	
CHILDREN'S REHAB SERVICES	20,262	22,004	23,504	25,762	26,334	0	0	0	0	0	0	0	117,866	
FEE FOR SERVICE - ACUTE	27,971,969	41,819,103	29,937,928	25,854,976	32,637,198	0	0	0	0	0	0	0	158,221,175	
FFS - PRIOR QUARTER COVERAGE	1,089,761	1,673,864	1,069,973	1,161,749	1,441,261	0	0	0	0	0	0	0	6,436,607	
FFS - PRESUMPTIVE ELIGIBILITY	607	0	10,333	113	0	0	0	0	0	0	0	0	11,053	
EMERGENCY SERVICES - FEDERAL	4,079,461	6,001,485	2,473,282	2,693,014	4,230,929	0	0	0	0	0	0	0	19,478,172	
FFS MEDICAID IN PUBLIC SCHOOLS	897	448	50	460	191	0	0	0	0	0	0	0	2,046	
INPATIENT INMATES FFS	1,021,190	712,562	351,881	689,957	973,610	0	0	0	0	0	0	0	3,749,201	
STATE ONLY TRBHA FFS	3,266	14,268	6,531	62,345	246,681	0	0	0	0	0	0	0	333,092	
FFS TRBHA FEE FOR SERVICE	6,143,299	6,633,226	5,645,698	5,144,485	5,802,227	0	0	0	0	0	0	0	29,368,935	
YUMA COUNTY INMATES FFS	0	0	138	1,266	1,562	0	0	0	0	0	0	0	2,966	
MARICOPA CTY INMATES FFS	265,078	189,865	92,588	121,267	117,255	0	0	0	0	0	0	0	786,053	
PINAL COUNTY INMATES FFS	499	0	0	0	0	0	0	0	0	0	0	0	499	
COCONINO COUNTY INMATES FFS	0	0	0	0	8	0	0	0	0	0	0	0	8	
COCHISE COUNTY INMATES FFS	0	1,483	0	85	0	0	0	0	0	0	0	0	1,568	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	635	0	0	0	0	0	0	0	635	
PIMA COUNTY INMATES FFS	15,143	31,906	103,883	37,867	32,472	0	0	0	0	0	0	0	221,272	
GRAHAM COUNTY INMATES FFS	0	0	0	71	4,682	0	0	0	0	0	0	0	4,753	
MOHAVE COUNTY INMATES FFS	0	4,601	247	8,307	1,663	0	0	0	0	0	0	0	14,818	
REINSURANCE - ACUTE	6,219,075	3,398,890	5,476,986	6,552,012	5,389,939	0	0	0	0	0	0	0	27,036,901	
SMIB - ACUTE	6,495,931	6,622,978	6,625,043	6,936,494	6,726,305	0	0	0	0	0	0	0	33,406,750	
HIB - ACUTE	4,563	4,976	4,150	6,215	4,976	0	0	0	0	0	0	0	24,880	
SUBTOTAL	294,093,172	307,725,439	300,435,075	310,652,106	317,977,615	0	0	0	0	0	0	0	1,530,883,408	

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	30,991,596	30,614,939	0	0	0	0	0	0	0	162,937,467	
MENTAL HEALTH - ADULT	50,440	101,285	73,397	91,032	134,916	0	0	0	0	0	0	0	451,070	
MENTAL HEALTH - GENERAL	4,449,323	4,495,516	4,484,950	6,023,406	5,985,231	0	0	0	0	0	0	0	25,438,425	
CHILDREN'S REHAB SERVICES	1,500	1,500	1,500	1,717	2,290	0	0	0	0	0	0	0	8,508	
FEE FOR SERVICE - ACUTE	2,634,455	3,608,952	2,850,376	2,121,538	2,910,570	0	0	0	0	0	0	0	14,125,892	
FFS - PRIOR QUARTER COVERAGE	350,598	546,221	401,753	202,324	237,125	0	0	0	0	0	0	0	1,738,021	
EMERGENCY SERVICES - FEDERAL	4,555,737	7,325,871	2,925,880	3,035,786	5,068,707	0	0	0	0	0	0	0	22,911,981	
FFS MEDICAID IN PUBLIC SCHOOLS	29	0	0	32	40	0	0	0	0	0	0	0	101	
STATE ONLY TRBHA FFS	0	53,882	0	0	19,134	0	0	0	0	0	0	0	73,016	
INPATIENT INMATES FFS	84,703	44,767	3,220	15,529	55,699	0	0	0	0	0	0	0	203,919	
FFS TRBHA FEE FOR SERVICE	144,138	202,842	159,014	129,200	147,386	0	0	0	0	0	0	0	782,580	
PIMA COUNTY INMATES FFS	594	388	6,951	1,766	2,837	0	0	0	0	0	0	0	12,536	
MOHAVE COUNTY INMATES FFS	0	0	11,636	0	555	0	0	0	0	0	0	0	12,190	
MARICOPA CTY INMATES FFS	0	0	0	0	217	0	0	0	0	0	0	0	217	
REINSURANCE - ACUTE	529,482	119,226	735,846	953,083	595,148	0	0	0	0	0	0	0	2,932,785	
SMIB - ACUTE	268	512	670	2,144	804	0	0	0	0	0	0	0	4,398	
	46,709,967	49,683,315	45,895,072	43,569,154	45,775,598	0	0	0	0	0	0	0	231,633,106	
	1,010,772,153	1,063,639,707	1,008,629,797	1,026,409,871	1,061,855,812	0	0	0	0	0	0	0	5,171,307,340	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - CHILD	36	83	0	0	-68	0	0	0	0	0	0	0	52	
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	3,457,322	3,496,264	0	0	0	0	0	0	0	16,864,074	
KidsCare - FEE FOR SERVICE	55,088	85,410	94,811	61,348	109,924	0	0	0	0	0	0	0	406,581	
KidsCare - MENTAL HEALTH	852,332	869,444	893,782	985,481	1,000,092	0	0	0	0	0	0	0	4,601,131	
KidsCare - REINSURANCE	90,334	651,642	14,877	123,660	12,323	0	0	0	0	0	0	0	892,835	
KidsCare - CHILD REHAB SERVICES	3,001	4,864	4,864	4,925	4,925	0	0	0	0	0	0	0	22,579	

4,238,517	4,897,346	4,395,133	4,632,736	4,623,460	0	0	0	0	0	0	0	22,787,192	

TOTAL TITLE XXI

1,015,010,670	1,068,537,053	1,013,024,930	1,031,042,606	1,066,479,272	0	0	0	0	0	0	0	5,194,094,532	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 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	399.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,302.00		
1002	TANF 01-05 M & F WIT	330.04	662.35	719.38	440.97	552.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,705.01		
1003	TANF 06-13 M & F WIT	111.05	341.90	458.71	665.05	551.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,128.46		
1004	TANF 14-20 MALE WITH	-35.88	0.00	0.00	0.00	120.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84.14		
1005	TANF 14-20 FEMALE WI	127.97	652.19	536.38	798.63	533.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,648.90		
1006	TANF 21-44 MALE WITH	34,934.55	37,443.70	37,836.88	41,518.27	40,849.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,582.87		
1007	TANF 21-44 FEMALE WI	68,398.48	67,286.38	69,636.41	63,400.28	64,442.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		333,164.09		
1008	TANF 45-64 M & F WIT	98,664.26	95,156.22	95,204.68	101,155.83	108,631.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498,812.50		
1009	TANF 65+ M & F WITH	34,339.80	38,378.47	36,415.04	33,385.65	31,379.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173,897.98		
100D	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	1,204.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,204.34		
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	423.42	341.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,856.61		
100G	TANF 21-44 FEMALE WI	741.72	2,685.35	12,635.67	646.25	1,153.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,862.38		
100H	TANF 45-64 M & F WIT	2,193.83	5,135.99	2,741.26	1,620.46	2,493.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,184.80		
100J	TANF 65+ M & F WITH	1,031.55	499.92	13,829.57	17.70	476.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,855.06		
1011	TANF <1 M & F NON-ME	5,800,515.18	5,986,609.54	5,913,693.77	5,473,554.99	5,431,815.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,606,188.69		
1012	TANF 01-05 M & F NON	2,591,577.99	2,625,129.55	2,688,289.84	2,766,794.87	2,889,067.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,560,860.01		
1013	TANF 06-13 M & F NON	4,099,165.87	4,028,576.53	4,085,459.66	4,192,166.59	4,291,191.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,696,559.68		
1014	TANF 14-20 MALE NON-	1,554,134.01	1,539,972.16	1,544,371.50	1,661,651.10	1,696,537.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,996,665.84		
1015	TANF 14-20 FEMALE N O	3,181,619.83	3,154,775.67	3,179,745.51	3,187,079.99	3,204,248.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,907,469.71		
1016	TANF 21-44 MALE NON-	4,791,560.01	4,758,662.95	4,740,065.11	4,910,321.78	4,932,396.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,133,006.66		
1017	TANF 21-44 FEMALE N O	24,021,285.07	23,810,217.90	23,829,199.10	23,345,734.83	23,482,231.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,488,668.06		
1018	TANF 45-64 M & F NON	9,727,126.16	9,884,272.39	9,859,099.58	9,930,228.97	9,929,143.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,329,870.77		
1019	TANF 65+ M & F NON-M	32,576.87	37,347.94	38,137.41	38,683.50	39,069.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,815.38		
101A	TANF < 1 M & F NON-M	1,023,730.67	1,103,021.10	1,171,080.40	1,142,821.70	995,229.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,435,883.33		
101B	TANF 01-05 M & F NON	15,605.69	22,617.30	22,943.33	23,528.67	22,574.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,269.13		
101C	TANF 06-13 M & F NON	12,934.97	17,575.11	17,144.13	15,244.10	12,879.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,778.03		
101D	TANF 14-20 MALE NON-	16,158.27	8,385.64	21,451.94	17,457.85	13,875.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,329.16		
101E	TANF 14-20 FEMALE N O	20,152.60	9,366.17	40,491.01	28,850.16	27,363.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,223.24		
101F	TANF 21-44 MALE NON-	141,843.98	8,433.39	152,556.37	140,163.58	114,659.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557,657.19		
101G	TANF 21-44 FEMALE N O	376,743.23	-38,348.88	426,120.03	412,444.58	362,596.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,539,555.19		
101H	TANF 44-64 M & F NON	127,847.88	-8,167.42	168,806.48	145,207.56	105,602.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539,297.15		
101J	TANF 65+ N & F NON-M	771.11	-2,520.22	490.01	138.29	362.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-758.63		
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		
1023	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	115.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.29		
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		

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1026	TANF 21-44 MALE WITH	23,824.71	18,670.20	20,044.84	23,179.82	21,936.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,656.14		
1027	TANF 21-44 FEMALE WI	63,697.04	57,779.49	61,223.61	70,083.25	66,701.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		319,484.65		
1028	TANF 45-64 M & F WIT	68,085.21	73,049.15	74,375.63	74,220.37	71,324.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361,054.81		
1029	TANF 65+ M & F WITH	33,210.14	34,038.26	34,639.72	40,147.57	38,423.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,459.52		
102F	TANF 21-44 MALE WITH	244.64	188.60	0.00	0.00	260.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		693.78		
102G	TANF 21-44 FEMALE WI	0.00	682.19	6,354.91	0.00	162.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,199.60		
102H	TANF 44-64 M & F WIT	0.00	2,122.59	3,329.94	57.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,509.99		
102J	TANF 65+ M & F WITH	2,351.09	0.00	3,413.37	17.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,781.82		
2100	SSI AGED WITH MEDIC A	897,693.12	795,728.25	794,596.23	725,867.13	714,889.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,928,774.55		
210Z	SSI AGED WITH MEDIC
A	24,132.41	32,576.16	23,103.48	33,479.47	57,993.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,285.35		
2110	SSI AGED NON-MEDIC AR	6,075,643.74	5,465,504.10	5,559,965.79	6,222,835.23	6,293,723.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,617,672.10		
211Z	SSI AGED NON-MEDIC
AR	82,203.22	98,950.96	116,676.00	115,811.09	95,099.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		508,740.44		
2120	SSI AGED WITH QMB	5,637,211.81	5,279,745.15	5,295,895.04	4,921,865.65	4,976,814.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,111,532.58		
212Z	SSI AGED WITH QMB P P	9,453.31	3,922.10	8,011.55	4,974.05	6,851.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,212.99		
2200	SSI DISABLED WITH M
E	1,844,213.19	1,807,931.63	1,818,830.04	1,702,732.97	1,673,028.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,846,736.50		
220Z	SSI DISABLED WITH M E	82,731.69	79,013.24	119,166.24	98,059.69	50,682.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		429,653.77		
2210	SSI DISABLED NON-ME
D	62,508,046.41	60,865,684.30	60,779,762.46	64,562,923.74	64,457,271.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		313,173,688.31		
221Z	SSI DISABLED NON-ME D	427,254.43	530,302.22	548,497.99	484,667.79	444,260.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,434,983.17		
2220	SSI DISABLED WITH Q
M	16,136,563.08	15,910,270.92	15,862,362.62	15,335,746.67	15,342,617.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,587,561.20		
222Z	SSI DISABLED WITH Q M	41,384.71	50,975.23	57,078.92	39,349.72	20,994.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,783.06		
2300	SSI BLIND WITH MEDIC	7,950.20	7,844.97	7,916.83	7,315.45	7,319.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,346.54		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	89.68	85.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.93		
2310	SSI BLIND NON-MEDIC A	491,202.64	477,214.81	477,129.51	522,157.03	520,305.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,488,009.47		
231Z	SSI BLIND NON-MEDIC
A	11,701.90	5,145.11	4,721.06	234.51	363.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,166.08		
2320	SSI BLIND WITH QMB	53,206.29	52,023.42	52,240.26	51,818.56	52,428.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		261,716.63		
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	-186.02	2,271.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,523.57		
4302	SOBRA CHILD 01-05 M	5,435.95	6,701.41	7,311.70	7,109.71	6,917.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,476.12		
4303	SOBRA CHILD 06-13 M	3,583.56	5,282.55	5,795.64	6,017.50	5,336.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,016.04		
4304	SOBRA CHILD 14-20 MA	2,430.85	2,106.43	1,995.92	1,967.31	1,800.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,300.97		
4305	SOBRA CHILD 14-20 FE	1,788.43	1,048.73	1,486.74	1,984.57	1,984.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,293.04		
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	124.34	113.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		941.81		
430C	SOBRA CHILD 06-13 M	0.00	301.36	123.66	0.00	226.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651.26		
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	15,617,620.11	15,510,532.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,553,349.28		

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4312	SOBRA CHILD 01-05 M	23,645,128.51	23,124,722.08	22,913,119.03	22,522,535.75	22,275,936.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,481,442.20		
4313	SOBRA CHILD 06-13 M	30,350,567.88	29,716,938.60	29,496,917.65	29,186,882.69	28,969,104.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,720,411.18		
4314	SOBRA CHILD 14-20 MA	10,183,859.56	9,979,977.12	9,973,198.47	10,501,457.20	10,475,482.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,113,975.02		
4315	SOBRA CHILD 14-20 FE	15,876,216.68	15,661,206.94	15,571,770.09	15,335,248.73	15,316,797.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,761,240.07		
431A	SOBRA CHILD < 1 M &	288,304.92	422,712.31	402,750.39	308,506.61	234,686.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,656,960.37		
431B	SOBRA CHILD 01-05 M	221,477.28	-7,371.32	247,293.25	228,427.78	200,109.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		889,936.29		
431C	SOBRA CHILD 6-13 M& F	216,577.94	-113,174.75	243,940.68	218,079.62	195,200.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		760,623.57		
431D	SOBRA CHILD 14-20 MA	158,371.19	-38,159.29	166,180.39	181,570.20	163,074.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		631,037.15		
431E	SOBRA CHILD 14-20 FE	207,585.75	-42,810.09	247,897.64	248,932.68	212,230.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		873,835.98		
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	329.07	430.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,763.62		
4323	SOBRA CHILD 06-13 M	236.17	115.59	115.59	222.18	222.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		911.71		
4324	SOBRA CHILD 14-20 MA	11.50	0.00	0.00	174.93	174.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361.36		
4325	SOBRA CHILD 14-20 FE	540.85	788.92	788.92	494.20	264.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,877.79		
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	29,266.35	22,327.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,912.82		
5008	SOBRA PREG 45-64 FE M	3,979.99	662.69	3,748.68	3,806.17	3,743.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,940.74		
500G	SOBRA PREG 21-44 FE
M	306.32	611.18	1,055.29	46.46	566.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,585.33		
500H	SOBRA PREG 45-64 FE M	771.11	0.00	0.00	153.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		924.51		
5013	SOBRA PREG 09-13 FE
M	916.02	920.55	618.06	487.80	450.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,392.91		
5015	SOBRA PREG 14-20 FE M	926,061.72	932,881.49	901,144.08	866,327.64	839,894.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,466,309.57		
5017	SOBRA PREG 21-44 FE
M	5,075,438.74	5,022,830.06	4,980,208.07	4,838,141.27	4,698,103.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,614,721.23		
5018	SOBRA PREG 45-64 FE M	18,556.70	17,501.16	22,231.09	22,502.28	19,185.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,976.51		
501C	SOBRA PREG 09-13 FE
M	0.00	0.00	49.51	30.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80.10		
501E	SOBRA PREG 14-20 FE M	49,647.81	-33,791.33	45,666.72	40,092.89	39,447.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,063.59		
501G	SOBRA PREG 21-44 FE
M	202,834.23	-39,812.61	209,670.31	214,579.01	194,857.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		782,128.24		
501H	SOBRA PREG 45-64 FE M	1,185.71	329.80	1,355.77	724.65	180.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,776.91		
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	27,645.25	29,965.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,411.25		
5028	SOBRA PREG 45-64 FE
M	424.97	423.82	423.82	0.00	390.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,662.99		
502G	SOBRA PREG 21-44 FE M	6.14	744.58	44.44	0.00	140.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		936.07		
SUBTOTAL:	256,201,977.35	250,621,222.84	252,344,489.0	4 253,125,482.21	252,139,377.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,264,432,548.95		

9910	TANF & SOBRA CHILDR E	1,671,858.21	1,914,618.06	1,957,678.76	1,856,617.17	1,816,976.13	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	11,906.92	17,679.52	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	133,284.96	170,395.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,217,748.33	
140,364.26	
764,156.66	

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
9950	S.O.B.R.A. KICK PAYM	13,407,782.88	14,821,850.08	13,720,999.68	13,916,802.45	12,853,666.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,721,101.64		
SUBTOTAL:	15,246,100.60	16,974,611.98	15,845,328.85	15,918,611.50	14,858,717.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,843,370.89		

1104	TANF EXPANDED 14-20	0.00	0.00	158.73	174.93	174.93	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	268.83	268.83	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	99,901.56	94,836.62	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	312,883.77	304,753.80	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	911,028.02	894,145.01	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	277,303.67	276,184.16	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	6,982.07	21,387.59	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	9,037.01	4,440.63	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	28,596.40	18,520.76	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	9,355.03	8,751.10	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	758.18	758.18	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	6,244.38	6,244.38	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	73,712.88	70,175.15	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	443,197.34	438,911.65	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	5,186,862.33	5,128,007.73	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	19,304,901.60	19,168,091.13	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	11,837,273.32	11,816,630.97	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	27,412.94	27,496.22	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	1,674.38	2,491.40	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	5,719.16	6,781.16	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	135,400.19	130,830.33	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	305,507.56	297,336.20	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	182,431.81	115,220.54	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	476.63	733.19	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	1,205.72	1,205.72	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	374,034.86	359,580.92	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	1,016,145.12	1,009,815.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

508.59	
807.72	
531,419.65	
1,693,193.31	
4,614,988.05	
1,373,031.13	
45,105.96	
60,094.45	
114,566.78	
40,954.90	
49.12	
4,150.72	
32,498.41	
370,650.32	
2,292,947.88	
25,707,658.47	
98,562,063.95	
59,025,596.97	
141,760.48	
133.38	
1,946.94	
15,599.96	
526,508.27	
1,102,722.26	
554,778.25	
580.35	
3,221.62	
1,873,761.23	
5,144,654.51	

3100	TRANSPLANT OPTION 1	0.00	0.00	16.50	16.50	16.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3200	TRANSPLANT OPTION
2	0.00	0.00	0.00	7.45	16.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
320Z	TRANSPLANT OPTION 2	0.00	0.00	0.00	9.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	16.50	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
49.50	
23.95	
9.05	
82.50	

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	1,418,896.68	1,476,267.90	1,509,810.12	1,527,375.53	1,565,257.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,497,607.61		
1129	TANF EXPANDED 65+
M&	495,757.35	518,707.26	541,252.62	561,486.54	569,516.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,686,720.36		
112F	TANF EXPANDED 21-44	1,142.03	-462.10	2,378.99	359.92	170.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,589.45		
112G	TANF EXPANDED 21-44	3,902.35	1,608.95	3,029.33	2,326.19	5,528.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,395.52		
112H	TANF EXPANDED 45-64	1,484.83	1,137.12	1,998.70	1,851.38	7,024.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,496.37		
112J	TANF EXPANDED 65+
M&	590.21	399.74	2,833.62	1,576.59	757.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,158.05		
2400	SSI AGED EXPANDED WI	70,982.22	60,953.05	42,379.02	46,696.54	52,616.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273,627.56		
240Z	SSI AGED EXPANDED
WI	13,292.73	18,104.44	15,345.34	24,325.63	24,885.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,953.47		
2410	SSI AGED EXPANDED NO	111,573.31	93,539.30	90,400.82	98,575.69	95,320.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		489,410.09		
241Z	SSI AGED EXPANDED
NO	3,594.96	4,633.83	2,444.93	4,077.94	1,328.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,079.85		
2420	SSI AGED EXPANDED WI	5,048,533.15	4,858,902.19	4,913,101.54	4,612,001.82	4,659,629.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,092,168.17		
242Z	SSI AGED EXPANDED
WI	5,768.70	2,945.99	16,003.17	14,030.03	8,080.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,828.06		
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	117.27	117.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		657.75		
2600	SSI DISABLED EXPAND
E	215,717.42	190,692.83	143,975.61	144,233.09	141,522.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		836,141.76		
260Z	SSI DISABLED EXPAND E	68,640.56	81,350.26	74,884.42	54,167.30	48,216.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327,258.81		
2610	SSI DISABLED EXPAND
E	2,036,765.94	1,767,448.42	1,732,155.12	1,816,796.57	1,812,515.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,165,681.60		
261Z	SSI DISABLED EXPAND E	24,058.45	27,936.64	20,953.50	19,905.37	28,503.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,357.27		
2620	SSI DISABLED EXPAND
E	11,145,576.62	11,100,954.59	11,163,780.13	10,873,351.37	10,884,391.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,168,054.52		
262Z	SSI DISABLED EXPAND E	17,013.33	40,720.31	38,407.28	26,846.32	18,577.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,565.01		
SUBTOTAL:	62,234,798.57	60,755,683.30	61,328,778.2	5 60,388,590.78	60,127,735.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304,835,586.12		

3504	ADULT 40-100% MALE
1	4.57	524.57	524.57	553.98	553.98	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	720.24	3,144.33	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	9,254.66	2,618.55	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	26,618.79	10,515.35	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	1,472.99	919.01	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	2,861.69	1,060.06	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	1,198.32	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	2,885.39	3,165.90	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	3,095,879.33	3,065,833.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,161.67	
11.28	
5,923.42	
24,532.07	
94,272.14	
2,122.41	
6,806.60	
3,094.61	
17,853.14	
14,924,018.38	

9911	SB PAYMENT FOR TAN F	1,371,150.11	1,352,929.38	1,351,432.00	1,406,467.25	1,125,625.58	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	6,279.40	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	1,406,467.25	1,131,904.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,607,604.32	
24,540.33	
6,632,144.65	

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3515	ADULT 40-100% FEMAL E	3,023,174.20	3,119,177.27	3,125,850.76	3,253,116.96	3,196,979.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,718,298.95		
3516	ADULT 40-100% MALE
2	9,879,165.10	10,570,723.64	10,548,405.86	10,927,959.59	10,879,443.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,805,697.99		
3517	ADULT 40-100% FEMAL E	8,205,716.71	8,796,499.02	8,762,939.55	9,073,866.24	9,042,421.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,881,443.24		
3518	ADULT 40-100% M&F 45	18,927,504.84	20,154,964.40	20,141,357.27	20,772,060.93	20,745,845.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,741,733.04		
3519	ADULT 40-100% M&F 65	7,808.53	9,609.66	9,072.99	8,219.85	7,722.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,433.46		
351D	ADULT 40-100% MALE
1	72,359.73	-49,736.72	80,177.67	90,718.82	69,596.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		263,116.17		
351E	ADULT 40-100% FEMAL E	63,306.58	-18,704.27	100,820.64	106,094.12	69,621.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321,138.70		
351F	ADULT 40-100% MALE
2	291,967.08	8,303.19	382,394.37	506,730.64	327,034.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,516,429.54		
351G	ADULT 40-100% FEMAL E	229,537.12	-11,995.73	276,148.64	401,727.43	296,332.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,191,750.32		
351H	ADULT 40-100% M&F 45	545,163.08	-65,763.05	672,288.35	733,547.24	525,500.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,410,735.71		
351J	ADULT 40-100% M&F 65	11,658.82	-3,539.60	6,745.90	2,698.36	6,384.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,948.06		
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	1,567.86	1,306.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,731.97		
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	3,376.73	1,932.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,714.98		
3529	ADULT 40-100% M&F 65	354.63	904.71	904.71	920.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,084.40		
352F	ADULT 40-100% MALE
2	0.00	0.00	0.00	1,787.76	356.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,144.43		
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	800.70	1,238.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,512.07		
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	12,433.27	14,334.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,314.17		
3707	ADULT <40% EXP FEM AL	4,432.57	11,559.30	6,367.71	7,094.37	6,611.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,065.04		
3708	ADULT <40% EXP M&F
4	14,067.06	21,252.76	18,772.50	14,330.47	14,901.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,324.62		
3709	ADULT <40% EXP M&F 6	1,019.42	923.08	871.58	982.73	523.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,320.48		
370F	ADULT <40% EXP MAL
E	3,252.78	4,082.51	7,058.09	6,313.54	4,809.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,516.21		
370G	ADULT <40% EXP FEM AL	4,275.36	-105.36	5,092.91	9,867.05	2,600.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,730.06		
370H	ADULT <40% EXP M&F
4	20,886.74	12,971.24	6,421.61	8,779.28	6,914.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,973.61		
3714	ADULT <40% EXP MAL E	5,219,470.41	5,394,579.02	5,348,920.56	5,535,933.27	5,421,204.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,920,107.95		
3715	ADULT <40% EXP FEM
AL	4,642,825.69	4,808,976.61	4,806,346.81	4,987,249.65	4,911,617.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,157,015.87		
3716	ADULT <40% EXP MAL E	33,047,874.79	34,761,629.62	34,524,197.29	35,574,569.16	35,828,713.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173,736,983.95		
3717	ADULT <40% EXP FEM
AL	20,320,142.05	21,465,807.39	21,299,025.95	21,846,235.51	21,900,625.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,831,836.19		
3718	ADULT <40% EXP M&F 4	40,004,359.73	42,354,058.71	42,136,406.97	43,399,233.07	43,720,390.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,614,448.62		
3719	ADULT <40% EXP M&F
6	15,351.84	18,714.38	19,589.72	18,168.12	17,490.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,314.07		
371D	ADULT <40% EXP MAL E	146,006.19	-155,374.60	185,124.87	197,311.49	151,292.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524,359.95		
371E	ADULT <40% EXP FEM
AL	144,773.10	-80,125.65	177,307.87	167,619.03	163,572.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		573,146.98		
371F	ADULT <40% EXP MAL E	1,612,184.26	-543,288.27	2,042,350.13	2,001,974.69	1,718,610.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,831,830.81		

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEM AL	963,473.42	-72,313.27	1,067,613.64	1,040,834.98	929,321.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,928,929.86		
371H	ADULT <40% EXP M&F
4	1,422,746.28	-670,271.54	1,758,693.90	1,680,863.69	1,634,044.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,826,076.81		
371J	ADULT <40% EXP M&F 6	3,132.07	6,682.69	0.00	0.00	9,267.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,081.77		
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	1,105.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,231.11		
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	3,653.75	5,699.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,669.78		
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	404.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,385.25		
372H	ADULT <40% EXP M&F 4	997.14	5,797.76	1,631.10	995.10	335.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,757.02		
SUBTOTAL:	151,748,007.92	152,885,905.96	160,523,146.4	7 165,542,592.00	164,722,405.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		795,422,057.59		

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	6,849.46	2,939.65	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	2,767.98	1,056.41	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	52,735.29	11,932.39	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	3,496.07	3,280.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	496.06	436.82	902.36	244.86	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	1,261.76	406.86	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	2,481.75	4,716.15	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	36.91	1,268.34	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	1,187,391.63	1,174,877.45	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	1,344,916.08	1,349,125.17	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	6,951,268.30	6,925,353.16	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	9,605,049.04	9,563,974.69	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	10,318,104.53	10,292,476.93	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	5,862.78	5,550.95	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	33,208.81	28,649.56	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	40,869.16	34,878.59	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	265,705.36	221,316.35	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	368,105.10	304,916.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.95	
-11.24	
14,635.81	
7,143.04	
203,320.55	
15,154.77	
2,080.10	
2,175.70	
8,264.71	
1,530.10	
6,235,727.20	
7,066,492.80	
37,276,922.00	
51,287,462.20	
55,344,053.45	
29,060.11	
100,242.26	
125,616.78	
852,024.78	
1,190,095.01	

9935	BIRTH SUPP PAYMENT A	276,810.08	265,656.53	276,630.88	193,528.66	269,037.61	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	544,913.16	456,990.89	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	738,441.82	726,028.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,281,663.76	
2,625,762.14	
3,907,425.90	

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
391H	NEWLY ELIGIBLE M&F 4	202,007.44	-538.24	257,708.46	347,676.97	265,036.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,071,890.73		
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		3,697.73		
3926	NEWLY ELIGIBLE MALE	1,466.71	2,601.42	360.88	307.45	691.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,427.67		
3927	NEWLY ELIGIBLE FEMA L	390.74	0.00	0.00	2,363.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,754.48		
3928	NEWLY ELIGIBLE M&F
4	824.99	1,840.92	2,321.11	2,412.22	340.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,739.69		
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		83.77		
392F	NEWLY ELIGIBLE MALE	3,285.46	99.83	0.00	0.00	580.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,966.00		
392H	NEWLY ELIGIBLE M&F 4	110.24	402.87	284.78	24.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		822.50		
SUBTOTAL:	33,485,086.10	32,860,038.60	33,775,840.9	9 30,543,797.36	30,193,612.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,858,375.65		

4403	SOBRA 100-133% M&F
6	794.23	905.88	826.73	816.49	328.51	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	325.15	325.15	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	514.33	763.76	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	429.02	642.60	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	5,958,875.35	5,978,572.40	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	2,233,833.59	2,252,072.20	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	3,230,199.90	3,201,911.75	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	73,751.95	53,308.94	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	42,667.34	41,537.71	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	77,184.81	50,430.21	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	11,618,597.93	11,579,893.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,671.84	
1,607.37	
3,051.55	
146.96	
6.06	
3,797.53	
29,951,290.66	
10,874,805.22	
16,201,257.72	
-176.96	
214,310.90	
148,219.93	
197,091.29	
3.00	
2.61	
57,599,085.68	

9944	BIRTH SUPP PAYMENT S	24,374.98	57,086.40	37,514.80	48,643.26	36,244.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	24,374.98	57,086.40	37,514.80	48,643.26	36,244.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

203,864.35

203,864.35

9939	BIRTH SUPP PAYMENT N	423,614.42	322,314.82	464,037.03	447,798.82	421,326.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	423,614.42	322,314.82	464,037.03	447,798.82	421,326.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,079,091.21

2,079,091.21

4517	BC PATIENT FEMALE 2 1	5,030.43	5,596.82	5,488.20	5,314.21	3,758.33	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	46,394.64	43,577.16	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	905.65	401.99	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	1,695.88	602.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,187.99	
244,970.63	
2,188.38	
1,438.90	
7,118.49	

ACUTE CAPITATION - AMOUNTS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4617	CC PATIENT FEMALE 2 1	4,450.82	4,513.74	4,598.19	4,456.14	4,126.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,145.27		
4618	CC PATIENT FEMALE 4
5	4,367.07	4,793.87	5,659.71	5,686.46	5,686.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,193.57		
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		-4.41		
461G	CC PATIENT FEMALE 2
1	191.12	257.38	0.00	0.00	267.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		715.96		
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		2,007.45		
SUBTOTAL:	78,266.48	66,420.94	64,401.80	64,452.98	58,420.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		331,962.23		

8600	SSI BLIND FREEDOM/W O	3,473.55	4,134.40	4,134.40	3,796.95	3,796.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
860Z	SSI BLIND FREEDOM/W
O	1,122.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,677,240.71	1,702,839.66	1,709,913.42	1,672,002.27	1,675,919.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	25,793.64	29,914.96	19,181.34	41,662.65	28,327.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	417,995.55	395,949.89	407,312.62	448,216.92	447,824.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	12,807.76	17,411.37	31,913.33	6,060.34	4,876.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	190,928.86	183,129.31	190,827.03	186,755.69	181,297.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	902.78	7,362.39	11,019.56	1,660.78	67.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,330,265.78	2,340,741.98	2,374,301.70	2,360,155.60	2,342,111.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,336.25	
1,122.93	
8,437,915.86	
144,880.28	
2,117,299.81	
73,069.59	
932,938.67	
21,013.40	
11,747,576.79	

2,686,893,172.51

540,441,630.39	542,203,664.51	538,337,811.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:	535,550,168.84 530,359,897.74

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1002	TANF 01-05 M & F WIT	3.00	6.00	6.56	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.56		
1003	TANF 06-13 M & F WIT	1.00	3.00	4.00	6.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.80		
1005	TANF 14-20 FEMALE WI	0.16	2.48	2.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.64		
1006	TANF 21-44 MALE WITH	78.57	79.10	84.35	91.12	94.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.80		
1007	TANF 21-44 FEMALE WI	121.95	130.43	137.74	138.73	142.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		671.65		
1008	TANF 45-64 M & F WIT	167.87	166.52	167.31	178.73	185.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		865.97		
1009	TANF 65+ M & F WITH	76.75	83.13	77.23	75.90	71.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.34		
100D	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	8.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.20		
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	2.85	2.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.17		
100G	TANF 21-44 FEMALE WI	3.92	10.59	15.11	3.20	5.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.52		
100H	TANF 45-64 M & F WIT	6.63	5.13	8.63	5.48	8.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.08		
100J	TANF 65+ M & F WITH	3.21	1.81	14.24	0.09	1.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.01		
1011	TANF <1 M & F NON-ME	12,680.31	12,878.00	12,725.91	12,742.75	12,650.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,677.42		
1012	TANF 01-05 M & F NON	20,425.00	21,039.07	21,619.70	22,402.81	23,366.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,853.25		
1013	TANF 06-13 M & F NON	31,421.44	31,527.83	32,040.57	32,865.69	33,545.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,400.65		
1014	TANF 14-20 MALE NON-	8,500.86	8,645.18	8,760.31	8,890.81	9,089.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,886.94		
1015	TANF 14-20 FEMALE N O	11,347.13	11,438.65	11,498.46	11,704.90	11,862.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,851.74		
1016	TANF 21-44 MALE NON-	27,141.38	27,294.16	27,223.56	27,009.63	27,108.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,777.48		
1017	TANF 21-44 FEMALE N O	83,553.33	83,865.89	83,875.13	84,062.27	84,501.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		419,858.46		
1018	TANF 45-64 M & F NON	21,279.36	21,168.31	21,113.83	21,152.67	21,200.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,914.39		
1019	TANF 65+ M & F NON-M	83.83	84.44	86.33	86.51	86.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		428.07		
101A	TANF < 1 M & F NON-M	1,013.07	1,097.45	1,157.10	1,267.13	1,309.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,844.50		
101B	TANF 01-05 M & F NON	279.37	412.61	427.42	438.47	443.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,001.20		
101C	TANF 06-13 M & F NON	239.36	317.80	312.04	289.23	246.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,405.17		
101D	TANF 14-20 MALE NON-	106.20	56.46	130.09	103.72	92.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		488.87		
101E	TANF 14-20 FEMALE N O	103.24	29.02	206.08	147.02	139.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		624.52		
101F	TANF 21-44 MALE NON-	825.45	-28.72	959.35	807.21	704.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,267.30		
101G	TANF 21-44 FEMALE N O	1,728.03	-483.45	1,992.78	1,842.28	1,650.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,730.24		
101H	TANF 44-64 M & F NON	375.11	-16.50	484.06	477.38	365.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,685.24		
101J	TANF 65+ N & F NON-M	2.16	-2.79	1.66	0.47	1.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.53		
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		
1023	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
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		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1026	TANF 21-44 MALE WITH	55.44	57.82	52.73	63.58	62.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		291.82		
1027	TANF 21-44 FEMALE WI	92.00	97.93	105.75	113.98	115.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.82		
1028	TANF 45-64 M & F WIT	120.86	130.00	132.66	134.70	127.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		646.18		
1029	TANF 65+ M & F WITH	72.70	76.00	78.33	84.90	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		392.93		
102F	TANF 21-44 MALE WITH	1.66	1.28	0.00	0.00	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.67		
102G	TANF 21-44 FEMALE WI	0.00	3.06	3.23	0.00	1.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.59		
102H	TANF 44-64 M & F WIT	0.00	2.00	9.33	0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.68		
102J	TANF 65+ M & F WITH	6.51	0.00	9.66	0.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.26		
2100	SSI AGED WITH MEDIC A	4,505.33	4,499.53	4,501.37	4,389.40	4,336.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,232.06		
210Z	SSI AGED WITH MEDIC
A	227.54	242.94	326.32	256.44	237.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,290.78		
2110	SSI AGED NON-MEDIC AR	5,793.97	5,820.29	5,921.97	5,942.27	6,004.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,482.69		
211Z	SSI AGED NON-MEDIC
AR	140.26	171.77	198.66	200.88	175.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		887.08		
2120	SSI AGED WITH QMB	27,697.42	27,990.51	28,089.78	28,379.49	28,657.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,815.07		
212Z	SSI AGED WITH QMB P P	54.23	49.91	94.91	36.84	53.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289.30		
2200	SSI DISABLED WITH M
E	3,558.35	3,571.35	3,642.24	3,542.97	3,560.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,875.86		
220Z	SSI DISABLED WITH M E	218.85	200.64	307.86	215.37	222.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,165.29		
2210	SSI DISABLED NON-ME
D	54,047.38	53,981.66	53,898.70	53,823.97	53,732.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269,484.40		
221Z	SSI DISABLED NON-ME D	602.83	763.73	768.16	752.07	664.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,551.16		
2220	SSI DISABLED WITH Q
M	27,058.57	27,073.88	27,036.70	27,229.60	27,209.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,608.72		
222Z	SSI DISABLED WITH Q M	75.34	64.54	82.38	64.13	56.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343.10		
2300	SSI BLIND WITH MEDIC	24.00	25.00	25.56	24.19	24.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122.98		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.80	0.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.56		
2310	SSI BLIND NON-MEDIC A	487.19	490.21	490.74	489.81	487.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,445.35		
231Z	SSI BLIND NON-MEDIC
A	20.21	8.34	7.92	0.44	0.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.61		
2320	SSI BLIND WITH QMB	221.71	223.99	225.32	223.67	227.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,122.68		
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	-1.01	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.69		
4302	SOBRA CHILD 01-05 M	42.12	46.55	52.05	49.61	47.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238.22		
4303	SOBRA CHILD 06-13 M	24.00	39.20	43.65	45.77	40.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193.27		
4304	SOBRA CHILD 14-20 MA	16.16	14.09	13.23	12.03	11.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.57		
4305	SOBRA CHILD 14-20 FE	7.00	4.38	6.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.38		
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	2.37	2.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.52		
430C	SOBRA CHILD 06-13 M	0.00	5.84	2.33	0.00	4.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.70		
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	36,039.97	35,788.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,363.70		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4312	SOBRA CHILD 01-05 M	183,884.02	183,433.17	182,043.16	180,038.68	178,006.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		907,405.17		
4313	SOBRA CHILD 06-13 M	231,154.67	231,125.24	229,669.81	228,283.23	226,770.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,147,003.04		
4314	SOBRA CHILD 14-20 MA	58,533.44	58,545.03	58,367.60	58,272.71	58,137.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		291,856.51		
4315	SOBRA CHILD 14-20 FE	58,251.71	58,249.43	57,964.70	57,836.65	57,806.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		290,109.42		
431A	SOBRA CHILD < 1 M &	294.85	419.98	405.76	413.33	414.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,948.75		
431B	SOBRA CHILD 01-05 M	3,855.57	-23.81	4,317.17	4,295.31	3,855.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,299.45		
431C	SOBRA CHILD 6-13 M& F	3,793.44	-1,590.65	4,383.95	4,049.20	3,709.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,345.76		
431D	SOBRA CHILD 14-20 MA	1,055.11	-176.61	1,128.55	1,176.24	1,027.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,210.55		
431E	SOBRA CHILD 14-20 FE	1,044.75	-215.15	1,262.35	1,260.17	1,078.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,430.12		
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	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
4323	SOBRA CHILD 06-13 M	2.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4325	SOBRA CHILD 14-20 FE	2.00	3.00	3.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
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	44.77	40.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230.44		
5008	SOBRA PREG 45-64 FE M	3.83	5.67	4.00	4.16	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.66		
500G	SOBRA PREG 21-44 FE
M	1.58	3.12	5.29	0.22	2.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.10		
500H	SOBRA PREG 45-64 FE M	2.16	0.00	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.99		
5013	SOBRA PREG 09-13 FE
M	8.00	8.00	5.40	4.38	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.78		
5015	SOBRA PREG 14-20 FE M	3,459.15	3,491.72	3,372.19	3,296.49	3,211.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,831.34		
5017	SOBRA PREG 21-44 FE
M	18,483.38	18,642.58	18,463.10	18,388.00	17,770.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,747.81		
5018	SOBRA PREG 45-64 FE M	47.50	43.38	47.19	47.47	42.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228.47		
501C	SOBRA PREG 09-13 FE
M	0.00	0.00	0.89	0.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.50		
501E	SOBRA PREG 14-20 FE M	254.06	-168.85	226.70	204.56	199.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		715.81		
501G	SOBRA PREG 21-44 FE
M	1,005.81	-233.91	1,046.60	1,042.53	975.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,836.90		
501H	SOBRA PREG 45-64 FE M	3.46	0.98	3.79	2.51	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.80		
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	40.82	46.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220.35		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
502G	SOBRA PREG 21-44 FE M	0.03	0.57	0.23	0.00	0.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.52		
SUBTOTAL:	947,815.60	933,686.39	950,268.6	0	947,638.60	943,962.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,723,372.07		

1,497.00

23.00

9910	TANF & SOBRA CHILDR E	270.00	308.00	314.00	305.00	300.00	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	2.00	3.00	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	22.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

125.00

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
9950	S.O.B.R.A. KICK PAYM	2,172.00	2,397.00	2,217.00	2,304.00	2,128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,218.00		
SUBTOTAL:	2,469.00	2,744.00	2,558.00	2,633.00	2,459.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,863.00		

1104	TANF EXPANDED 14-20	0.00	0.00	1.00	1.00	1.00	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	1.00	1.00	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	291.99	283.24	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	572.52	558.28	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	1,515.60	1,506.47	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	598.92	598.25	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	25.80	19.92	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	29.47	17.14	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	55.30	46.08	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	32.30	37.09	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	7.00	7.00	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	41.00	41.00	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	434.20	415.82	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	1,714.09	1,694.43	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	30,380.07	30,084.69	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	72,716.50	72,384.92	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	26,190.54	26,094.59	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	60.58	60.88	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	11.37	16.06	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	29.20	34.82	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	892.69	810.89	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	1,484.62	1,432.89	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	598.94	427.07	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	1.41	3.09	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	2.00	2.00	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	902.45	893.87	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	1,738.19	1,714.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
3.00	
1,544.55	
3,068.69	
7,723.04	
3,009.39	
91.16	
153.74	
243.16	
130.32	
0.00	
37.00	
209.80	
2,214.55	
8,692.37	
153,191.20	
364,889.30	
131,287.38	
319.44	
2.18	
15.76	
77.02	
3,396.41	
5,259.11	
1,834.97	
1.15	
7.00	
4,421.27	
8,594.01	

3100	TRANSPLANT OPTION 1	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3200	TRANSPLANT OPTION
2	0.00	0.00	0.00	0.45	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
320Z	TRANSPLANT OPTION 2	0.00	0.00	0.00	0.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	1.00	1.99	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
1.45	
0.54	
4.99	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	2,310.86	2,399.80	2,452.13	2,488.02	2,528.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,179.37		
1129	TANF EXPANDED 65+
M&	1,094.60	1,126.09	1,175.73	1,209.11	1,227.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,832.98		
112F	TANF EXPANDED 21-44	8.80	-3.20	16.38	2.33	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.31		
112G	TANF EXPANDED 21-44	2.41	3.81	15.87	1.41	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.08		
112H	TANF EXPANDED 45-64	4.23	3.46	3.31	7.10	6.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.52		
112J	TANF EXPANDED 65+
M&	2.41	1.54	10.86	6.92	3.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
2400	SSI AGED EXPANDED WI	308.22	313.71	242.84	291.30	317.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,473.70		
240Z	SSI AGED EXPANDED
WI	194.97	185.11	187.91	210.01	220.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		998.90		
2410	SSI AGED EXPANDED NO	97.29	98.13	95.51	94.85	91.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		477.15		
241Z	SSI AGED EXPANDED
NO	6.61	7.78	4.43	8.06	2.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.62		
2420	SSI AGED EXPANDED WI	22,108.12	22,316.04	22,586.36	22,699.51	22,883.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,593.42		
242Z	SSI AGED EXPANDED
WI	37.37	39.66	60.64	54.39	53.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		245.13		
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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2600	SSI DISABLED EXPAND
E	347.79	324.61	247.35	237.08	248.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,405.11		
260Z	SSI DISABLED EXPAND E	123.78	154.48	179.82	153.27	147.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		759.21		
2610	SSI DISABLED EXPAND
E	1,663.98	1,676.27	1,644.33	1,603.46	1,601.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,189.07		
261Z	SSI DISABLED EXPAND E	40.40	29.50	33.53	37.34	40.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.70		
2620	SSI DISABLED EXPAND
E	17,106.28	17,265.15	17,370.98	17,566.07	17,647.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,956.12		
262Z	SSI DISABLED EXPAND E	33.13	52.49	63.45	30.35	39.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		219.18		
SUBTOTAL:	187,179.53	184,108.77	187,499.5	3	187,030.33	186,260.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		932,078.54		

1,073.00

4.00

9911	SB PAYMENT FOR TAN F	221.00	218.00	217.00	232.00	185.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	221.00	220.00	218.00	232.00	186.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,077.00

3504	ADULT 40-100% MALE
1	0.00	1.00	1.00	1.00	1.00	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	1.35	2.56	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	8.86	3.00	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	45.83	17.33	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	3.00	2.00	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	1.64	1.43	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	1.64	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	2.31	5.24	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	6,130.60	6,066.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
0.00	
6.90	
23.44	
177.88	
6.00	
5.06	
4.00	
19.56	
30,456.79	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3515	ADULT 40-100% FEMAL E	6,434.05	6,464.48	6,467.08	6,433.29	6,319.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,118.70		
3516	ADULT 40-100% MALE
2	20,700.55	20,821.39	20,744.66	20,862.61	20,750.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,879.32		
3517	ADULT 40-100% FEMAL E	17,131.52	17,173.85	17,096.43	17,166.84	17,107.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,676.33		
3518	ADULT 40-100% M&F 45	40,830.77	40,729.18	40,738.43	40,793.10	40,639.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,730.84		
3519	ADULT 40-100% M&F 65	18.00	20.00	19.00	16.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.00		
351D	ADULT 40-100% MALE
1	108.95	-81.44	119.02	135.37	104.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		386.59		
351E	ADULT 40-100% FEMAL E	95.12	-38.04	154.88	161.03	103.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		476.34		
351F	ADULT 40-100% MALE
2	425.91	-15.63	568.43	732.70	478.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,190.37		
351G	ADULT 40-100% FEMAL E	327.74	-34.71	406.95	575.84	419.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,695.56		
351H	ADULT 40-100% M&F 45	792.15	-118.47	998.58	1,054.70	759.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,485.98		
351J	ADULT 40-100% M&F 65	17.00	-5.00	10.00	4.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.00		
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	1.22	2.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.75		
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	6.67	4.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.06		
3529	ADULT 40-100% M&F 65	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
352F	ADULT 40-100% MALE
2	0.00	0.00	0.00	1.76	0.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.22		
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	1.32	1.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.44		
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	11.35	10.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.47		
3707	ADULT <40% EXP FEM AL	4.58	6.78	4.42	6.50	7.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.87		
3708	ADULT <40% EXP M&F
4	23.17	31.40	26.46	21.74	17.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120.72		
3709	ADULT <40% EXP M&F 6	2.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
370F	ADULT <40% EXP MAL
E	2.23	5.37	7.20	3.20	2.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.94		
370G	ADULT <40% EXP FEM AL	4.45	-1.17	4.25	6.67	4.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.39		
370H	ADULT <40% EXP M&F
4	16.31	12.14	6.45	12.32	9.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.03		
3714	ADULT <40% EXP MAL E	10,805.54	10,877.98	10,805.43	10,750.68	10,516.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,755.82		
3715	ADULT <40% EXP FEM
AL	9,615.96	9,669.94	9,631.53	9,577.93	9,422.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,918.34		
3716	ADULT <40% EXP MAL E	62,436.00	63,349.72	62,894.28	62,968.89	63,394.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315,043.28		
3717	ADULT <40% EXP FEM
AL	37,546.58	37,992.10	37,666.27	37,631.23	37,653.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188,489.59		
3718	ADULT <40% EXP M&F 4	77,487.79	78,144.62	77,680.98	77,904.50	78,438.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		389,656.69		
3719	ADULT <40% EXP M&F
6	42.15	40.00	42.00	37.83	36.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198.44		
371D	ADULT <40% EXP MAL E	220.48	-235.02	274.88	287.45	223.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		771.38		
371E	ADULT <40% EXP FEM
AL	211.92	-119.76	265.33	242.81	232.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		832.89		
371F	ADULT <40% EXP MAL E	2,271.65	-992.30	2,910.89	2,744.62	2,380.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,315.63		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2017	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEM AL	1,322.71	-206.75	1,497.42	1,435.71	1,253.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,302.15		
371H	ADULT <40% EXP M&F
4	1,998.95	-1,114.93	2,407.18	2,351.22	2,247.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,889.75		
371J	ADULT <40% EXP M&F 6	5.00	10.00	0.00	0.00	13.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.53