May 29, 2018

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 April 30, 2018

Dear President Yarbrough and Speaker Mesnard:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended April 30, 2018.

Status Summary – Laws 2018, Chapter 276, Section 101 included $36,973,200 in expenditure authority for AHCCCS.

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

There are several issues this fiscal year that have the potential to affect the final expenditures.
Continued volatility in caseload growth and prior period expenditures.
CHIP Funding Availability.
Potential Agency audit liabilities, which are detailed in the ASR.

In December, AHCCCS administratively adjusted $214.5 million Total Fund of Fiscal Year 2018 date of service expenditures back to the Fiscal Year 2017 appropriation. The line item detail for these transactions is included in Note 6 of this report.

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

Enrollment Update – April 2018 enrollment is 1,849,500 members, a 4,022 member increase over the prior month. Enrollment for May 2018 increased to 1,850,066 members, a 566 member change.

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

The Honorable Steve Yarbrough The Honorable J.D. Mesnard May 29, 2018
Page 2

Major May 2018 changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 153; Supplemental Security Income – increase of 25; Prop 204 Restoration - increase of 214; Adult Expansion – decrease of 340; Medicare Cost Sharing – increase of 355; KidsCare – increase of 898; and Federal Emergency Services - decrease of 950.

Tobacco Funds Revenue Update - Tobacco tax collections through April 2018 are $6.0 million less than the AHCCCS monthly projected flows. In April, AHCCCS received approximately
$101.8 million in Tobacco Litigation Settlement funding which is about $21.8 million more than the FY18 appropriation of $79.0 million. The loss of the Strategic Contribution Fund component of the Master Settlement Agreement (MSA) was not as great as anticipated and the adjusted distribution for non-participating providers was greater than anticipated. This increase will result in Hospital Assessment savings within the Proposition 204 appropriation. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2018 appropriations.

Pursuant to A.R.S. § 36-3405(D), AHCCCS is now publishing monthly behavioral health enrolled and served reports. A link to the April 2018 report is provided below. Additionally, the final page of the attached program detail sheets now provides expenditures by Regional Behavioral Health Authority. https://www.azahcccs.gov/shared/Downloads/MonthlyReports/BehavioralHealthEnrolledAndSer vicedReports/FY2018/Apr252018.pdf

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, John Kavanagh, Chairman, Senate Appropriations Committee The Honorable David Livingston, 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 April 30, 2018

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	11

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2018
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		$	74,567,622		$	76,334,886		$	(1,767,264)		$	94,260,300		$	-		
AHCCCS Prop 204 Administration	13,936,000		10,913,623		10,124,722		788,901		13,936,000		-		
DES Eligibility	91,874,500		74,799,400		57,926,988		16,872,412		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		37,420,400		23,206,629		14,213,771		44,358,700		-		
Prop 206 Provider Assessment Study	200,000		139,907		61,711		78,196		200,000		-		
TOTAL ADMINISTRATION	 	244,629,500		 	197,840,951		 	167,654,936		 	30,186,016		 	244,629,500		 	-			

Traditional Medicaid Services	3,896,328,000	3,200,602,100	3,032,865,726	167,736,374	3,896,328,000	-	
Proposition 204 Services	2,773,331,800	2,300,520,900	2,238,930,818	61,590,082	2,773,331,800	-	
ACA Adult Expansion	475,591,600	396,597,600	371,225,393	25,372,207	475,591,600	-	
Children's Rehabilitative Services	269,646,300	223,159,500	248,506,189	(25,346,689)	269,646,300	-	
KidsCare Services	111,961,100	89,647,500	45,697,674	43,949,826	111,961,100	-	
ALTCS Services	1,544,082,800	1,259,112,900	1,264,014,935	(4,902,035)	1,544,082,800	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	22,650,000	5,244,300	10,491,900	(5,247,600)	22,650,000	-	
Voluntary Political Subdivision Programs	383,027,300	331,039,000	331,039,042	(42)	383,027,300	-	
Behavioral Health Traditional Medicaid Services	1,156,192,500	957,331,200	990,512,970	(33,181,770)	1,156,192,500	-	
Behavioral Health Proposition 204 Services	788,262,700	651,640,400	705,386,441	(53,746,041)	788,262,700	-	
Behavioral Health ACA Adult Expansion	86,141,400	70,956,100	77,145,503	(6,189,403)	86,141,400	-	
Behavioral Health CMDP	217,719,100	182,426,400	113,651,842	68,774,558	217,719,100	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	65,706,000	64,882,441	823,559	78,846,900	-	
Supported Housing	5,324,800	4,437,000	4,369,398	67,602	5,324,800	-	
Crisis Services	16,391,300	13,659,000	13,588,583	70,417	16,391,300	-	

TOTAL PROGRAMMATIC	 	11,830,584,700	 	9,752,079,900	 	9,512,308,856	 	239,771,044	 	11,830,584,700	 	-	

TOTAL EXPENDITURES

  $	12,075,214,200

$	9,949,920,851

$	9,679,963,792

$	269,957,060

$   12,075,214,200	$	-

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2018 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	$	45,551,271	$	41,226,169	4,325,102	$	55,962,100	$	-	
Proposition 204 - Administrative Expenditures	21,765,400	18,021,768	9,131,036	8,890,733	21,765,400	-	

Programmatic Expenditures							
Traditional Medicaid Services	830,106,600	682,822,600	632,817,486	50,005,114	830,106,600	-	
Proposition 204 Services	-	-	(1,159,535)	1,159,535	-	-
Children's Rehabilitative Services	81,426,000	67,458,000	62,795,472	4,662,528	81,426,000	- KidsCare Services		-		-		(62,623)		62,623		-	-
ALTCS Services	185,064,700	152,962,500	154,220,583	(1,258,083)	185,064,700	-	
DSH and Rural Hospitals	7,086,300	1,613,100	3,159,111	(1,546,011)	7,086,300	-	
Behavioral Health Traditional Medicaid Services	316,050,500	261,963,700	277,084,608	(15,120,908)	316,050,500	-	
Behavioral Health Proposition 204 Services	109,562,000	91,183,600	98,166,085	(6,982,485)	109,562,000	-	
Behavioral Health ACA Adult Expansion	4,269,200	3,453,600	3,697,456	(243,856)	4,269,200	-	
Behavioral Health CMDP	65,719,400	55,127,900	34,469,135	20,658,765	65,719,400	-	
Non Medicaid Seriously Mentally Ill Services	78,846,900	65,706,000	64,882,441	823,559	78,846,900	-	
Supported Housing	5,324,800	4,437,000	4,369,398	67,602	5,324,800	-	
Crisis Services	 	14,141,100	 	11,784,000	 	11,713,417	 	70,583	 	14,141,100	 	- 	
TOTAL GF EXPENDITURES	1,775,325,000	1,462,085,039	1,396,510,240	65,574,800	1,775,325,000	-	

FEDERAL		
Administrative Expenditures	129,511,800	103,243,973	92,771,415	10,472,559	129,511,800	-	
Proposition 204 - Administrative Expenditures	32,874,000	27,228,854	22,372,665	4,856,189	32,874,000	-	

Programmatic Expenditures	
Traditional Medicaid Services	2,412,443,400	1,974,141,000	1,785,605,615	188,535,385	2,412,443,400	-	
Proposition 204 Services	2,397,123,600	1,978,808,400	1,961,747,115	17,061,285	2,397,123,600	-	
ACA Adult Expansion	450,284,200	375,880,900	352,076,407	23,804,493	450,284,200	-	
Children's Rehabilitative Services	188,220,300	155,701,500	185,710,717	(30,009,217)	188,220,300	-	
KidsCare Services	99,809,800	79,866,000	40,453,224	39,412,776	99,809,800	-	
ALTCS Services and Nursing Facility Assessment	956,062,900	777,865,200	774,789,565	3,075,635	956,062,900	-	
DSH and Rural Hospitals	20,650,800	3,631,200	7,332,789	(3,701,589)	20,650,800	-	
Behavioral Health Traditional Medicaid Services	804,576,200	665,888,200	685,966,444	(20,078,244)	804,576,200	-	
Behavioral Health Proposition 204 Services	655,527,700	541,170,900	588,117,266	(46,946,366)	655,527,700	-	
Behavioral Health ACA Adult Expansion	81,390,900	67,141,300	72,966,746	(5,825,446)	81,390,900	-	
Behavioral Health CMDP	151,999,700	127,298,500	79,182,706	48,115,794	151,999,700	-	
Voluntary Political Subdivision Programs - See Note 5	 	265,093,100	 	228,898,700	 	228,898,685	 	15	 	265,093,100	 	- 	
TOTAL FEDERAL EXPENDITURES	8,645,568,400	7,106,764,628	6,877,991,359	228,773,268	8,645,568,400	-	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,655,300	3,083,400	1,827,650	1,255,750	3,655,300	-	
Programmatic Expenditures							
Traditional Medicaid Services Acute Care	49,687,700	41,187,600	41,187,600	-	49,687,700	-	
ALTCS Services	 	249,980,000	 	218,761,300	 	214,642,941	 	4,118,359	 	249,980,000	 	- 	
TOTAL COUNTY EXPENDITURES	303,323,000	263,032,300	257,658,191	5,374,109	303,323,000	-	

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

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

	TOBACCO FUNDS						

Programmatic Expenditures							
Traditional Medicaid Services - Medically Needy	37,432,400	31,172,000	28,903,202	2,268,798	37,432,400	-	
Behavioral Health Traditional Medicaid Services - Medically Needy	35,565,800	29,479,300	27,461,918	2,017,382	35,565,800	-	
Proposition 204 Services - Emergency Health Services	19,244,300	16,146,800	14,727,796	1,419,004	19,244,300	-	
Proposition 204 Services - Proposition 204 Protection	17,240,000	14,465,100	11,824,664	2,640,436	17,240,000	-	
Behavioral Health Proposition 204 Services - Proposition 204 Protection	23,173,000	19,285,900	19,103,091	182,809	23,173,000	-	
Proposition 204 Services - ATLSF	 	79,000,000	 	79,000,000	 	79,000,000	 	- 	 	79,000,000	 	- 	
TOTAL TOBACCO EXPENDITURES	211,655,500	189,549,100	181,020,671	8,528,429	211,655,500	-	

Administrative Expenditures Prescription Drug Rebate Program
Programmatic Expenditures	

OTHER

860,900	

711,684	326,001	385,683	860,900	-	
Acute Care - Prescription Drug Rebate Program State Match	137,191,000	114,246,700	114,325,833	(79,133)	137,191,000	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	429,241,000	356,869,700	429,241,000	(72,371,300)	429,241,000	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	6,260,900	7,073,173	(812,273)	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	30,095,900	29,088,229	1,007,671	36,422,000	-	
Proposition 204 Services - Hospital Assessment	260,723,900	212,100,600	172,790,778	39,309,822	260,723,900	-	
ACA Adult Expansion - Hospital Assessment	25,307,400	20,716,700	19,148,986	1,567,714	25,307,400	-	
Behavioral Health ACA Adult Expansion - Hospital Assessment	481,300	361,200	481,300	(120,100)	481,300	-	
Traditional Medicaid Services - TPL	194,700	162,400	722,528	(560,128)	194,700	-	
ALTCS Services - TPL	-	-	881,198	(881,198)	-	-	
ALTCS Services - Nursing Facility Assessment	108,974,800	73,167,100	83,319,246	(10,152,146)	108,974,800	-	
KidsCare Services Premiums	12,151,300	9,781,500	5,307,073	4,474,427	12,151,300	-	
Freedom to Work Premiums	31,200	-	62,462	(62,462)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	1,875,000	1,875,167	(167)	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	117,934,200	 	102,140,400	 	102,140,357	 	43	 	117,934,200	 	- 	
TOTAL OTHER EXPENDITURES	1,139,342,300	928,489,784	966,783,331	(38,293,547)	1,139,342,300	-	

TOTAL		
Administrative Expenditures	244,629,500	197,840,951	167,654,936	30,186,016	244,629,500	-	
Acute Care	10,286,501,900	8,492,967,000	8,248,293,921	244,673,079	10,286,501,900	-	
Long Term Care	 	1,544,082,800	 	1,259,112,900	 	1,264,014,935	 	(4,902,035)	 	1,544,082,800	 	- 	
TOTAL EXPENDITURES	  $	12,075,214,200	  $	9,949,920,851	  $	9,679,963,792	  $	269,957,059	  $	12,075,214,200	  $	- 	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending April 30, 2018

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	974,581,000	$	797,444,971	$	739,998,238	
Proposition 204 Services & Administrative	21,765,400	18,021,768	106,137,586	
KidsCare Services	-	-	(62,623)	
ALTCS Services	185,064,700	152,962,500	154,220,583	
Behavioral Health Traditional Medicaid Services	 	593,913,900	 	493,655,800	 	392,519,000	
TOTAL	1,775,325,000	1,462,085,039	1,392,812,783	

FEDERAL:
Acute & Administrative	5,896,201,200	4,847,534,528	4,634,233,654	
KidsCare Services	99,809,800	79,866,000	43,449,470	
ALTCS Services	956,062,900	777,865,200	856,106,726	
Behavioral Health Traditional Medicaid Services	 	1,693,494,500	 	1,401,498,900	 	1,426,367,685	
TOTAL	8,645,568,400	7,106,764,628	6,960,157,535	

COUNTY:				
Acute & Administrative	53,343,000		44,271,000		42,750,652	
ALTCS Services	 	249,980,000		 	218,761,300		 	220,561,000	
TOTAL	303,323,000		263,032,300		263,311,652	

TOBACCO FUNDS:						
Traditional Medicaid Services	72,998,200		60,651,300		56,365,120	
Proposition 204 Services	 	138,657,300		 	128,897,800		 	124,655,551	
TOTAL	211,655,500		189,549,100		181,020,671	

OTHER:

Administrative	860,900	711,684	264,290	
Acute Care - Prescription Drug Rebate Program	566,432,000	471,116,400	543,566,833	
Long Term Care - Prescription Drug Rebate Program	44,000,400	36,356,800	36,161,403	
Hospital Assessment	286,512,600	233,178,500	215,662,703	
ALTCS - Nursing Facility Assessment	108,974,800	73,167,100	245,466	
Acute TPL - Note 1	194,700	162,400	722,528	
LTC TPL - Note 1	-	-	881,198	
KidsCare TPL - Note 1	-	-	1,156	
Member Premiums - CHIP	12,151,300	9,781,500	5,307,073	
Member Premiums - Freedom to Work	31,200	-	62,462	
Behavioral Health Traditional Medicaid Services	2,250,200	1,875,000	1,575,421	
Voluntary Political Subdivision - State Match	 	117,934,200	 	102,140,400	 	187,612,540	
TOTAL	1,139,342,300	928,489,784	992,063,074	

TOTAL REVENUE

$	12,075,214,200

$	9,949,920,851

$	9,789,365,715

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2018 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2018	
Note 1:	Third Party Liability Collections:	April 2018		April 2017		July 1, 2017		July 1, 2016	
	Gross Collections:					April 30, 2018		April 30, 2017	
	Acute	$	555,593		$	284,711		$	7,324,147		$	4,438,254	
	LTC	319,118		735,377		4,059,480		4,508,151	
	KidsCare	6,226		-		7,815		4,878	
	Total TPL Collections	  $	880,937		$	1,020,088		$	11,391,442		$	8,951,283	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	69,159		$	80,535		$	722,528		$	404,817		
LTC	69,470		202,169		881,198		1,026,241		
KidsCare	1,187		-		1,156		976		
Total Expenditure Offsets	  $	139,816		$	282,704		$	1,604,882		$	1,432,034		

FY 18 Total		
Note 2:	Authorized Positions	1,161.0		
	Actual Positions as of April 30, 2018	1,088.0		

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2017	$	2,456,040	
	Revenues	6,938,033	
	Transfers-In	 	515,485	
	Total Revenues	 	7,453,518	
	Expenditures	5,739,747	
	Transfers-out	 	1,600,000	
	Total Expenditures	 	7,339,747	
	Ending Balance April 30, 2018	  $	2,569,812	

Of the $2,569,812 ending balance, $1,773,658 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through May 2018.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.
Schedule of Outstanding Liabilities
As of April 30, 2018
Description	Amount

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

Type

Note 5:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of April 30, 2018 Expenditures

State Match	Federal	Total

DSH Voluntary	$	1,276,234	$	2,830,054	$	4,106,288	
GME Voluntary	84,195,949	188,073,527	272,269,476	
Safety Net Care Pool	16,668,174	37,995,104	54,663,278	

Total Voluntary Political Subdivision Program Expenditure $

102,140,357	$

228,898,685 $

331,039,042

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

Note 6:

The following is a summary of $214,547,858 Total Fund ($50,508,036 General Fund/ALTCS Fund state match and $8,924,973 Hospital Assessment Fund) administrative adjustment transactions for medical service claims processed through December 2017 that either pay for or transfer expenditures with dates of service prior to June 30, 2017.

FY 2017 YTD April 30, 2018	
State Match	Expenditure	ALTCS	Total	
Funds	Authority Funds	Fund	Fund	

Traditional Medicaid Services	
$	31,529,845	$	123,894,942	$	-	$	155,424,786	
Proposition 204 Services	8,924,973	25,841,234	-	34,766,207	
ACA Adult Expansion	-	4,347,296	-	4,347,296	
KidsCare - Children Services	-	1,031,378	-	1,031,378	
Children's Rehabilitative Services	3,911,565	-	-	3,911,565	
Long Term Care	-	-	15,066,626	15,066,626	

Total

$	44,366,383	$

155,114,849	$

15,066,626	$

214,547,858

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending April 30, 2018

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	279,819,826	285,541,325	280,085,310	278,167,481	276,545,927	0	0	2,813,318,360	
CAPITATION - AIMHS	0	0	0	0	0	0	0	16	16	0	0	0	32	
CAPITATION - LTC	206,776,494	226,817,304	208,355,352	211,447,457	231,188,720	214,411,421	234,039,203	217,515,187	217,741,738	219,030,308	0	0	2,187,323,185	
MENTAL HEALTH - CHILD	27,544,565	27,724,984	27,624,408	29,228,363	29,116,650	28,834,615	28,675,134	28,249,020	28,213,106	28,013,913	0	0	283,224,757	
MENTAL HEALTH - ADULT	943,019	720,852	738,314	1,280,536	1,464,087	999,780	990,675	834,274	585,999	694,483	0	0	9,252,019	
MENTAL HEALTH - GENERAL	12,841,280	12,960,968	12,914,296	17,193,985	17,177,687	17,000,657	17,005,776	16,851,644	16,877,040	16,823,530	0	0	157,646,864	
MENTAL HEALTH - CMDP	13,096,578	12,797,592	12,457,164	11,015,383	10,946,142	10,719,913	10,728,676	10,754,953	10,792,310	10,770,266	0	0	114,078,976	
MENTAL HEALTH - DD	4,268,444	4,283,815	4,297,906	5,700,054	5,715,510	5,740,033	5,767,528	5,795,376	5,833,316	5,858,546	0	0	53,260,528	
CHILDREN'S REHAB SERVICES	6,152,157	6,176,648	6,177,229	6,585,737	6,597,777	6,604,555	6,937,784	7,689,099	6,933,524	6,918,975	0	0	66,773,485	
FEE FOR SERVICE - ACUTE	37,517,260	57,106,521	41,373,210	36,416,482	43,584,499	42,602,603	49,793,824	47,208,245	46,962,103	42,290,664	0	0	444,855,410	
FFS - PRIOR QUARTER COVERAGE	477,647	732,384	436,709	464,159	629,659	481,048	594,236	585,020	643,091	789,162	0	0	5,833,115	
EMERGENCY SERVICES - FEDERAL	5,092,983	7,198,427	2,476,370	3,693,643	4,752,948	4,484,995	4,367,779	3,865,059	3,755,528	4,101,932	0	0	43,789,664	
FFS MEDICAID IN PUBLIC SCHOOLS	498,616	218,798	74,000	659,257	465,409	547,774	668,656	843,167	1,046,320	1,167,175	0	0	6,189,171	
INPATIENT INMATES FFS	223,348	131,891	101,766	86,138	223,359	179,895	125,985	169,203	154,242	132,303	0	0	1,528,130	
STATE ONLY TRBHA FFS	6,531	0	2,449	26,941	45,018	84,358	71,825	25,857	33,720	64,348	0	0	361,047	
FFS TRBHA FEE FOR SERVICE	11,064,992	13,491,379	10,597,096	9,333,252	11,353,356	9,238,362	11,301,008	10,453,993	10,739,445	10,649,469	0	0	108,222,351	
QMB - FEE FOR SERVICE	489,558	701,001	415,525	457,695	623,098	570,009	672,948	637,828	613,810	557,339	0	0	5,738,811	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	0	0	3,084	0	0	0	0	0	3,084	
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	14,240	12,736	26,201	8,175	14,688	0	0	81,733	
MOHAVE COUNTY INMATES FFS	0	6,214	0	0	1,103	380	0	0	0	0	0	0	7,697	
MARICOPA CTY INMATES FFS	68,686	30,039	22,868	6,568	37,763	5,839	27,359	14,060	7,502	4,631	0	0	225,314	
COCHISE COUNTY INMATES FFS	0	0	-980	0	0	0	0	0	0	0	0	0	-980	
YUMA COUNTY INMATES FFS	0	0	77	1,377	0	11,786	4,858	145	627	-230	0	0	18,640	
FEE FOR SERVICE - LTC	11,075,900	14,779,589	11,033,723	10,412,298	12,734,589	11,775,496	13,299,108	10,811,041	12,120,927	11,349,852	0	0	119,392,523	
LFFS - PRIOR QUARTER COVERAGE	31,031	30,711	36,439	64,876	58,497	27,138	119,744	29,653	20,602	40,422	0	0	459,113	
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	1,751,892	2,097,939	1,313,715	1,498,710	2,120,055	0	0	13,992,714	
REINSURANCE - ACUTE	14,094,798	9,458,578	10,548,999	14,245,193	10,999,164	13,467,170	10,887,994	8,081,973	10,633,310	14,001,225	0	0	116,418,404	
REINSURANCE - LTC	8,708,155	6,429,637	7,948,066	7,110,450	5,402,902	5,592,561	3,894,983	3,197,644	3,390,712	4,781,490	0	0	56,456,600	
SMIB - ACUTE	14,841,421	15,030,410	15,054,132	15,184,273	15,231,589	15,392,162	15,425,933	15,608,215	15,705,379	15,812,061	0	0	153,285,574	
HIB - ACUTE	530,608	606,349	597,687	585,235	559,111	601,083	627,212	626,375	609,251	611,142	0	0	5,954,052	
Q1	2,585,545	2,637,260	2,661,063	2,632,237	2,722,955	2,755,500	2,539,719	2,587,980	1,905,883	2,399,576	0	0	25,427,718	
SMIB - LTC	3,694,581	3,701,005	3,714,794	3,722,089	3,743,706	3,720,120	3,769,726	3,746,327	3,723,229	3,746,785	0	0	37,282,361	
HIB - LTC	280,970	287,260	286,598	288,498	286,161	288,249	292,888	292,293	294,639	288,246	0	0	2,885,802	
SUBTOTAL	669,969,014	706,230,953	662,299,649	672,188,610	698,102,599	677,723,459	710,285,645	677,898,872	679,011,738	679,578,282	0	0	6,833,288,821	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending April 30, 2018

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	224,671,447	228,721,651	222,962,799	224,343,725	220,669,165	0	0	2,232,166,001	
MENTAL HEALTH - CHILD	3,567	3,361	3,294	3,524	3,469	3,529	2,413	2,645	2,614	2,487	0	0	30,905	
MENTAL HEALTH - ADULT	1,025,896	887,584	796,762	1,675,620	2,164,533	1,474,722	1,700,095	1,147,991	1,126,390	925,434	0	0	12,925,028	
MENTAL HEALTH - GENERAL	23,612,539	23,858,290	23,761,886	31,600,038	31,462,983	31,087,926	30,974,732	30,437,783	30,451,417	30,017,496	0	0	287,265,090	
MENTAL HEALTH - CMDP	1,317	798	467	385	627	1,163	119	0	1,255	18,266	0	0	24,397	
MENTAL HEALTH - DD	0	0	0	0	0	0	0	-77	0	0	0	0	-77	
CHILDREN'S REHAB SERVICES	20,262	22,004	23,504	25,762	26,334	28,052	28,113	30,590	26,916	26,318	0	0	257,854	
FEE FOR SERVICE - ACUTE	27,971,969	41,819,103	29,937,928	25,854,976	32,637,198	29,550,228	34,952,414	31,007,794	31,287,099	32,169,705	0	0	317,188,415	
FFS - PRIOR QUARTER COVERAGE	1,089,761	1,673,864	1,069,973	1,161,749	1,441,261	975,755	1,190,284	897,597	1,171,746	1,212,923	0	0	11,884,911	
FFS - PRESUMPTIVE ELIGIBILITY	607	0	10,333	113	0	0	2,823	0	53	0	0	0	13,929	
EMERGENCY SERVICES - FEDERAL	4,079,461	6,001,485	2,473,282	2,693,014	4,230,929	3,533,638	3,171,056	3,301,583	3,520,883	2,978,209	0	0	35,983,542	
FFS MEDICAID IN PUBLIC SCHOOLS	897	448	50	460	191	106	490	966	487	619	0	0	4,714	
INPATIENT INMATES FFS	1,021,190	712,562	351,881	689,957	973,610	641,468	999,615	625,123	974,005	809,362	0	0	7,798,775	
STATE ONLY TRBHA FFS	3,266	14,268	6,531	62,345	246,681	149,926	155,165	116,576	118,637	157,839	0	0	1,031,234	
FFS TRBHA FEE FOR SERVICE	6,143,299	6,633,226	5,645,698	5,144,485	5,802,227	4,853,037	6,023,963	6,134,105	6,312,191	5,575,540	0	0	58,267,772	
PINAL COUNTY INMATES FFS	499	0	0	0	0	12,815	0	132	1,455	114	0	0	15,015	
PIMA COUNTY INMATES FFS	15,143	31,906	103,883	37,867	32,472	12,539	41,561	18,869	30,372	17,850	0	0	342,461	
COCONINO COUNTY INMATES FFS	0	0	0	0	8	637	414	0	12,482	6,691	0	0	20,233	
COCHISE COUNTY INMATES FFS	0	1,483	0	85	0	0	2,849	1,344	0	0	0	0	5,762	
GRAHAM COUNTY INMATES FFS	0	0	0	71	4,682	0	160	0	0	0	0	0	4,914	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	635	0	268	0	9,252	1,344	0	0	11,498	
MARICOPA CTY INMATES FFS	265,078	189,865	92,588	121,267	117,255	134,821	235,932	143,946	169,236	92,994	0	0	1,562,983	
YUMA COUNTY INMATES FFS	0	0	138	1,266	1,562	25,349	686	140	0	0	0	0	29,141	
MOHAVE COUNTY INMATES FFS	0	4,601	247	8,307	1,663	9,419	1,269	0	22,383	0	0	0	47,888	
REINSURANCE - ACUTE	6,219,075	3,398,890	5,476,986	6,552,012	5,389,939	5,577,441	3,199,803	3,785,869	5,270,372	6,272,200	0	0	51,142,586	
SMIB - ACUTE	6,495,931	6,622,978	6,625,043	6,936,494	6,726,305	6,721,390	6,812,312	6,784,640	6,747,111	6,784,563	0	0	67,256,766	
HIB - ACUTE	4,563	4,976	4,150	6,215	4,976	4,976	4,853	5,544	5,042	4,578	0	0	49,872	
SUBTOTAL	294,093,172	307,725,439	300,435,075	310,652,106	317,977,615	309,470,383	318,223,042	307,405,958	311,605,123	307,743,697	0	0	3,085,331,611	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending April 30, 2018

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	30,129,373	30,617,776	29,547,783	29,397,715	28,823,189	0	0	311,453,303	
MENTAL HEALTH - ADULT	50,440	101,285	73,397	91,032	134,916	70,038	60,802	56,666	52,677	48,700	0	0	739,953	
MENTAL HEALTH - GENERAL	4,449,323	4,495,516	4,484,950	6,023,406	5,985,231	5,883,220	5,875,503	5,745,158	5,738,147	5,630,354	0	0	54,310,807	
CHILDREN'S REHAB SERVICES	1,500	1,500	1,500	1,717	2,290	1,717	1,794	1,343	1,196	1,794	0	0	16,354	
FEE FOR SERVICE - ACUTE	2,634,455	3,608,952	2,850,376	2,121,538	2,910,570	2,580,978	2,725,965	2,591,925	2,827,238	2,557,559	0	0	27,409,557	
FFS - PRIOR QUARTER COVERAGE	350,598	546,221	401,753	202,324	237,125	262,112	362,635	262,514	279,542	336,761	0	0	3,241,585	
EMERGENCY SERVICES - FEDERAL	4,555,737	7,325,871	2,925,880	3,035,786	5,068,707	4,645,867	4,774,801	3,492,010	3,807,104	4,139,731	0	0	43,771,494	
FFS MEDICAID IN PUBLIC SCHOOLS	29	0	0	32	40	168	375	85	167	70	0	0	966	
STATE ONLY TRBHA FFS	0	53,882	0	0	19,134	30,206	-3,266	0	7,348	9,025	0	0	116,330	
INPATIENT INMATES FFS	84,703	44,767	3,220	15,529	55,699	22,994	35,264	29,579	33,639	13,853	0	0	339,247	
FFS TRBHA FEE FOR SERVICE	144,138	202,842	159,014	129,200	147,386	119,792	107,399	188,844	221,657	129,395	0	0	1,549,668	
MOHAVE COUNTY INMATES FFS	0	0	11,636	0	555	0	0	0	0	0	0	0	12,190	
PIMA COUNTY INMATES FFS	594	388	6,951	1,766	2,837	3,874	9,259	0	0	4,343	0	0	30,013	
MARICOPA CTY INMATES FFS	0	0	0	0	217	4,696	4,126	0	15,224	3,450	0	0	27,713	
REINSURANCE - ACUTE	529,482	119,226	735,846	953,083	595,148	1,437,171	290,859	749,039	875,342	603,390	0	0	6,888,586	
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	45,192,207	44,863,293	42,664,949	43,256,994	42,301,613	0	0	449,912,164	
	1,010,772,153	1,063,639,707	1,008,629,797	1,026,409,871	1,061,855,812	1,032,386,049	1,073,371,980	1,027,969,778	1,033,873,855	1,029,623,593	0	0	10,368,532,595	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - CHILD	36	83	0	0	-68	-156	0	-34	-55	0	0	0	-194	
MENTAL HEALTH - GENERAL	-59	0	0	0	0	-141	0	0	0	0	0	0	-201	
KidsCare - CAPITATION	3,237,786	3,285,902	3,386,799	3,457,322	3,496,264	3,612,882	3,778,808	3,792,282	3,928,251	4,158,067	0	0	36,134,365	
KidsCare - FEE FOR SERVICE	55,088	85,410	94,811	61,348	109,924	133,807	122,271	174,896	154,322	100,654	0	0	1,092,531	
KidsCare - MENTAL HEALTH	852,332	869,444	893,782	985,481	1,000,092	1,036,489	1,034,821	1,053,651	1,092,605	1,163,983	0	0	9,982,680	
KidsCare - REINSURANCE	90,334	651,642	14,877	123,660	12,323	41,624	94,270	108,454	140,138	189,161	0	0	1,466,482	
KidsCare - CHILD REHAB SERVICES	3,001	4,864	4,864	4,925	4,925	4,925	4,187	4,646	5,383	7,178	0	0	48,898	

4,238,517	4,897,346	4,395,133	4,632,736	4,623,460	4,829,430	5,034,357	5,133,896	5,320,645	5,619,042	0	0	48,724,562	

TOTAL TITLE XXI

1,015,010,670	1,068,537,053	1,013,024,930	1,031,042,606	1,066,479,272	1,037,215,479	1,078,406,337	1,033,103,674	1,039,194,501	1,035,242,635	0	0	10,417,257,157	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
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	17.54	0.00	226.30	0.00	0.00	0.00		2,545.84		
1002	TANF 01-05 M & F WIT	330.04	662.35	719.38	440.97	552.27	662.86	584.50	333.62	224.94	110.08	0.00	0.00		4,621.01		
1003	TANF 06-13 M & F WIT	111.05	341.90	458.71	665.05	551.75	652.86	455.87	0.00	0.00	0.00	0.00	0.00		3,237.19		
1004	TANF 14-20 MALE WITH	-35.88	0.00	0.00	0.00	120.02	150.02	152.57	0.00	0.00	0.00	0.00	0.00		386.73		
1005	TANF 14-20 FEMALE WI	127.97	652.19	536.38	798.63	533.73	766.36	790.11	539.90	539.90	267.97	0.00	0.00		5,553.14		
1006	TANF 21-44 MALE WITH	34,934.55	37,443.70	37,836.88	41,518.27	40,849.47	41,180.43	45,427.46	52,322.59	51,487.88	50,158.89	0.00	0.00		433,160.12		
1007	TANF 21-44 FEMALE WI	68,398.48	67,286.38	69,636.41	63,400.28	64,442.54	69,156.30	68,183.89	64,060.30	62,613.81	56,973.81	0.00	0.00		654,152.20		
1008	TANF 45-64 M & F WIT	98,664.26	95,156.22	95,204.68	101,155.83	108,631.51	115,226.46	117,723.78	117,562.39	119,122.58	123,932.73	0.00	0.00		1,092,380.44		
1009	TANF 65+ M & F WITH	34,339.80	38,378.47	36,415.04	33,385.65	31,379.02	33,348.79	40,132.19	40,025.55	40,392.71	40,962.70	0.00	0.00		368,759.92		
100B	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.54	0.00	0.00	0.00	0.00		53.54		
100C	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.54	0.00	0.00	0.00	0.00		53.54		
100D	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	1,204.34	0.00	1.96	0.00	0.00	0.00	0.00	0.00		1,206.30		
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	1,201.69	5,972.04	184.62	51.00	9,878.52	0.00	0.00		20,144.48		
100G	TANF 21-44 FEMALE WI	741.72	2,685.35	12,635.67	646.25	1,153.39	5,280.93	2,838.68	1,331.93	1,739.92	598.04	0.00	0.00		29,651.88		
100H	TANF 45-64 M & F WIT	2,193.83	5,135.99	2,741.26	1,620.46	2,493.26	3,083.83	6,359.08	486.11	3,115.94	1,911.23	0.00	0.00		29,140.99		
100J	TANF 65+ M & F WITH	1,031.55	499.92	13,829.57	17.70	476.32	202.82	699.35	227.54	584.45	1,026.39	0.00	0.00		18,595.61		
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	5,304,792.91	5,573,755.00	5,079,673.51	5,068,590.03	4,983,903.13	0.00	0.00		54,616,903.27		
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	2,969,539.44	3,186,215.68	3,142,126.16	2,580,581.54	2,555,924.90	0.00	0.00		27,995,247.73		
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	4,321,867.45	4,561,258.40	4,508,800.56	4,355,577.23	4,380,506.87	0.00	0.00		42,824,570.19		
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	1,736,862.23	1,804,766.10	1,785,069.10	1,727,313.11	1,704,828.02	0.00	0.00		16,755,504.40		
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	3,200,804.25	3,357,521.33	3,257,433.82	3,197,716.87	3,218,064.12	0.00	0.00		32,139,010.10		
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	4,835,755.18	4,949,654.90	4,818,397.71	4,797,563.99	4,779,940.13	0.00	0.00		48,314,318.57		
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	23,276,411.92	24,160,747.62	23,411,589.74	23,291,762.26	23,329,516.53	0.00	0.00		235,958,696.13		
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	9,833,592.31	10,022,879.03	9,902,301.87	9,779,580.06	9,770,601.16	0.00	0.00		98,638,825.20		
1019	TANF 65+ M & F NON-M	32,576.87	37,347.94	38,137.41	38,683.50	39,069.66	36,307.74	36,385.57	40,652.27	39,761.04	41,284.12	0.00	0.00		380,206.12		
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	762,151.87	711,849.73	602,943.57	658,972.83	483,123.10	0.00	0.00		8,654,924.43		
101B	TANF 01-05 M & F NON	15,605.69	22,617.30	22,943.33	23,528.67	22,574.14	12,622.06	15,869.39	19,615.95	17,818.72	19,562.77	0.00	0.00		192,758.02		
101C	TANF 06-13 M & F NON	12,934.97	17,575.11	17,144.13	15,244.10	12,879.72	10,466.30	14,185.21	11,020.80	9,709.17	13,874.78	0.00	0.00		135,034.29		
101D	TANF 14-20 MALE NON-	16,158.27	8,385.64	21,451.94	17,457.85	13,875.46	10,219.71	12,437.57	14,714.56	20,097.04	9,737.84	0.00	0.00		144,535.88		
101E	TANF 14-20 FEMALE N O	20,152.60	9,366.17	40,491.01	28,850.16	27,363.30	29,338.95	28,617.54	37,181.56	29,191.91	29,656.89	0.00	0.00		280,210.09		
101F	TANF 21-44 MALE NON-	141,843.98	8,433.39	152,556.37	140,163.58	114,659.87	130,656.22	147,871.15	157,818.00	165,345.81	143,437.83	0.00	0.00		1,302,786.20		
101G	TANF 21-44 FEMALE N O	376,743.23	-38,348.88	426,120.03	412,444.58	362,596.23	363,087.76	450,199.22	437,487.67	535,593.74	432,260.89	0.00	0.00		3,758,184.47		
101H	TANF 44-64 M & F NON	127,847.88	-8,167.42	168,806.48	145,207.56	105,602.65	99,802.05	168,928.35	131,699.47	164,395.42	121,190.30	0.00	0.00		1,225,312.74		
101J	TANF 65+ N & F NON-M	771.11	-2,520.22	490.01	138.29	362.18	634.54	392.28	6,145.26	2,963.26	106.19	0.00	0.00		9,482.90		
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		

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1023	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	115.29	115.29	119.42	116.88	116.88	116.88	0.00	0.00		700.64		
1024	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	176.20	176.20	176.20	0.00	0.00	0.00		528.60		
1025	TANF 14-20 FEMALE WI	7.95	231.68	0.00	0.00	0.00	0.00	267.97	267.97	267.97	267.97	0.00	0.00		1,311.51		
1026	TANF 21-44 MALE WITH	23,824.71	18,670.20	20,044.84	23,179.82	21,936.57	20,147.09	27,803.87	27,548.77	25,363.36	26,466.54	0.00	0.00		234,985.77		
1027	TANF 21-44 FEMALE WI	63,697.04	57,779.49	61,223.61	70,083.25	66,701.26	61,058.93	65,313.97	57,650.78	56,729.46	66,109.57	0.00	0.00		626,347.36		
1028	TANF 45-64 M & F WIT	68,085.21	73,049.15	74,375.63	74,220.37	71,324.45	74,897.35	83,270.45	81,450.47	77,781.69	77,949.47	0.00	0.00		756,404.24		
1029	TANF 65+ M & F WITH	33,210.14	34,038.26	34,639.72	40,147.57	38,423.83	39,032.23	41,192.06	38,605.43	34,662.03	33,924.37	0.00	0.00		367,875.64		
102F	TANF 21-44 MALE WITH	244.64	188.60	0.00	0.00	260.54	142.92	196.07	651.07	700.40	270.57	0.00	0.00		2,654.81		
102G	TANF 21-44 FEMALE WI	0.00	682.19	6,354.91	0.00	162.50	0.00	6,216.64	156.99	0.00	501.30	0.00	0.00		14,074.53		
102H	TANF 44-64 M & F WIT	0.00	2,122.59	3,329.94	57.46	0.00	969.66	2,659.41	169.81	63.37	0.00	0.00	0.00		9,372.24		
102J	TANF 65+ M & F WITH	2,351.09	0.00	3,413.37	17.36	0.00	350.32	705.77	0.00	0.00	144.80	0.00	0.00		6,982.71		
2100	SSI AGED WITH MEDIC A	897,693.12	795,728.25	794,596.23	725,867.13	714,889.82	707,981.27	709,863.95	707,879.78	717,887.08	716,098.60	0.00	0.00		7,488,485.23		
210Z	SSI AGED WITH MEDIC
A	24,132.41	32,576.16	23,103.48	33,479.47	57,993.83	33,557.08	29,638.93	41,193.95	54,848.42	51,550.59	0.00	0.00		382,074.32		
2110	SSI AGED NON-MEDICA R	6,075,643.74	5,465,504.10	5,559,965.79	6,222,835.23	6,293,723.24	6,347,151.41	6,481,337.71	6,463,273.83	6,536,810.80	6,600,422.21	0.00	0.00		62,046,668.06		
211Z	SSI AGED NON-MEDICA
R	82,203.22	98,950.96	116,676.00	115,811.09	95,099.17	78,150.27	100,670.26	103,544.31	144,541.48	125,310.06	0.00	0.00		1,060,956.82		
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	5,003,504.79	5,052,586.88	5,097,180.61	5,137,111.27	5,140,699.15	0.00	0.00		51,542,615.28		
212Z	SSI AGED WITH QMB P P	9,453.31	3,922.10	8,011.55	4,974.05	6,851.98	15,819.27	2,982.89	6,298.78	5,171.93	11,882.41	0.00	0.00		75,368.27		
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	1,666,521.65	1,654,415.04	1,669,485.68	1,658,591.18	1,676,554.79	0.00	0.00		17,172,304.84		
220Z	SSI DISABLED WITH M E	82,731.69	79,013.24	119,166.24	98,059.69	50,682.91	78,229.47	97,328.23	114,406.63	117,560.84	104,567.78	0.00	0.00		941,746.72		
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	64,264,909.44	65,329,014.68	64,827,333.88	64,209,274.69	63,959,966.69	0.00	0.00		635,764,187.69		
221Z	SSI DISABLED NON-ME D	427,254.43	530,302.22	548,497.99	484,667.79	444,260.74	447,032.49	595,183.83	419,347.29	659,916.45	488,321.81	0.00	0.00		5,044,785.04		
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	15,309,405.79	15,398,185.61	15,531,527.15	15,461,310.49	15,408,781.96	0.00	0.00		155,696,772.20		
222Z	SSI DISABLED WITH Q M	41,384.71	50,975.23	57,078.92	39,349.72	20,994.48	97,629.93	38,021.08	23,638.95	37,652.03	38,480.85	0.00	0.00		445,205.90		
2300	SSI BLIND WITH MEDIC	7,950.20	7,844.97	7,916.83	7,315.45	7,319.09	8,221.47	8,558.41	8,146.93	10,218.35	7,841.43	0.00	0.00		81,333.13		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	89.68	85.25	0.00	207.90	0.00	76.25	0.00	0.00	0.00		459.08		
2310	SSI BLIND NON-MEDIC A	491,202.64	477,214.81	477,129.51	522,157.03	520,305.48	528,296.77	545,675.84	543,110.12	545,900.49	545,337.61	0.00	0.00		5,196,330.30		
231Z	SSI BLIND NON-MEDIC
A	11,701.90	5,145.11	4,721.06	234.51	363.50	8,278.51	16,729.08	12,677.58	3,118.09	1,902.48	0.00	0.00		64,871.82		
2320	SSI BLIND WITH QMB	53,206.29	52,023.42	52,240.26	51,818.56	52,428.10	52,535.19	52,872.03	52,540.33	50,751.75	51,134.60	0.00	0.00		521,550.53		
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	2,214.06	1,401.79	984.76	875.02	875.02	0.00	0.00		14,874.22		
4302	SOBRA CHILD 01-05 M	5,435.95	6,701.41	7,311.70	7,109.71	6,917.35	6,105.95	6,847.16	6,558.40	6,511.38	5,968.15	0.00	0.00		65,467.16		
4303	SOBRA CHILD 06-13 M	3,583.56	5,282.55	5,795.64	6,017.50	5,336.79	5,161.15	5,154.94	4,886.30	4,781.80	3,333.00	0.00	0.00		49,333.23		
4304	SOBRA CHILD 14-20 MA	2,430.85	2,106.43	1,995.92	1,967.31	1,800.46	1,450.10	1,162.11	1,101.33	1,101.33	1,101.33	0.00	0.00		16,217.17		
4305	SOBRA CHILD 14-20 FE	1,788.43	1,048.73	1,486.74	1,984.57	1,984.57	1,984.57	1,859.23	2,306.84	2,092.74	1,514.64	0.00	0.00		18,051.06		
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	4.54	79.50	0.00	0.00	0.00	0.00		1,025.85		

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
430C	SOBRA CHILD 06-13 M	0.00	301.36	123.66	0.00	226.24	0.00	5.64	42.07	0.00	0.00	0.00	0.00		698.97		
430E	SOBRA CHILD 14-20 FE	0.00	126.48	0.00	0.00	0.00	0.00	0.00	0.00	129.37	0.00	0.00	0.00		255.85		
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	15,492,869.32	16,948,070.97	15,917,626.50	16,008,298.28	16,041,361.68	0.00	0.00		161,961,576.03		
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	21,919,515.11	22,555,580.90	21,569,418.02	21,867,285.94	21,848,853.93	0.00	0.00		224,242,096.10		
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	28,751,338.40	29,543,688.42	28,808,997.65	28,148,275.27	28,102,635.01	0.00	0.00		291,075,345.93		
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	10,408,926.09	10,520,375.51	10,541,452.38	10,196,408.76	10,156,733.06	0.00	0.00		102,937,870.82		
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	15,232,650.95	15,608,000.07	15,439,465.95	14,885,520.90	14,872,247.71	0.00	0.00		153,799,125.65		
431A	SOBRA CHILD < 1 M &	288,304.92	422,712.31	402,750.39	308,506.61	234,686.14	144,493.20	188,207.82	165,893.31	203,128.99	143,971.67	0.00	0.00		2,502,655.36		
431B	SOBRA CHILD 01-05 M	221,477.28	-7,371.32	247,293.25	228,427.78	200,109.30	190,072.18	250,472.87	250,117.63	305,797.03	266,550.09	0.00	0.00		2,152,946.09		
431C	SOBRA CHILD 6-13 M&F	216,577.94	-113,174.75	243,940.68	218,079.62	195,200.08	175,768.17	232,739.82	258,048.73	349,270.54	264,544.35	0.00	0.00		2,040,995.18		
431D	SOBRA CHILD 14-20 MA	158,371.19	-38,159.29	166,180.39	181,570.20	163,074.66	144,515.40	185,006.84	213,713.49	274,246.76	217,446.28	0.00	0.00		1,665,965.92		
431E	SOBRA CHILD 14-20 FE	207,585.75	-42,810.09	247,897.64	248,932.68	212,230.00	188,969.24	262,261.08	271,219.99	362,341.00	274,483.45	0.00	0.00		2,233,110.74		
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	329.07	345.36	450.44	450.44	340.08	0.00	0.00		3,679.01		
4323	SOBRA CHILD 06-13 M	236.17	115.59	115.59	222.18	222.18	222.18	232.54	225.22	116.88	116.88	0.00	0.00		1,825.41		
4324	SOBRA CHILD 14-20 MA	11.50	0.00	0.00	174.93	174.93	174.93	179.11	176.20	176.20	176.20	0.00	0.00		1,244.00		
4325	SOBRA CHILD 14-20 FE	540.85	788.92	788.92	494.20	264.90	264.90	280.18	267.97	498.32	728.67	0.00	0.00		4,917.83		
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	17,757.32	21,581.82	23,674.15	23,513.33	22,864.95	0.00	0.00		251,304.39		
5008	SOBRA PREG 45-64 FE M	3,979.99	662.69	3,748.68	3,806.17	3,743.21	923.72	934.28	924.76	924.76	924.76	0.00	0.00		20,573.02		
500G	SOBRA PREG 21-44 FE
M	306.32	611.18	1,055.29	46.46	566.08	1,713.94	3,009.50	417.25	1,199.59	1,451.22	0.00	0.00		10,376.83		
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	615.05	1,167.93	633.69	463.48	542.40	0.00	0.00		6,815.46		
5015	SOBRA PREG 14-20 FE M	926,061.72	932,881.49	901,144.08	866,327.64	839,894.64	807,339.48	832,018.23	789,868.54	837,609.18	863,678.03	0.00	0.00		8,596,823.03		
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	4,541,050.84	4,634,662.98	4,511,055.54	4,552,911.33	4,623,995.98	0.00	0.00		47,478,397.90		
5018	SOBRA PREG 45-64 FE M	18,556.70	17,501.16	22,231.09	22,502.28	19,185.28	22,570.34	22,557.92	22,363.46	22,043.14	20,937.40	0.00	0.00		210,448.77		
501C	SOBRA PREG 09-13 FE
M	0.00	0.00	49.51	30.59	0.00	77.28	2.68	80.47	0.00	59.46	0.00	0.00		299.99		
501E	SOBRA PREG 14-20 FE M	49,647.81	-33,791.33	45,666.72	40,092.89	39,447.50	41,739.32	43,211.70	55,245.36	71,393.83	60,340.35	0.00	0.00		412,994.15		
501G	SOBRA PREG 21-44 FE
M	202,834.23	-39,812.61	209,670.31	214,579.01	194,857.30	178,766.48	216,554.89	232,083.59	276,120.57	252,208.58	0.00	0.00		1,937,862.35		
501H	SOBRA PREG 45-64 FE M	1,185.71	329.80	1,355.77	724.65	180.98	1,764.34	844.92	506.80	255.98	6,032.53	0.00	0.00		13,181.48		
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	31,131.66	32,123.71	30,769.14	24,443.19	26,041.25	0.00	0.00		281,920.20		
5028	SOBRA PREG 45-64 FE
M	424.97	423.82	423.82	0.00	390.38	390.38	391.49	1,245.74	1,245.74	3,609.48	0.00	0.00		8,545.82		
502G	SOBRA PREG 21-44 FE M	6.14	744.58	44.44	0.00	140.91	0.00	312.96	306.50	368.70	0.00	0.00	0.00		1,924.23		
SUBTOTAL:	256,201,977.3	5 250,621,222.84	252,344,489.0	4 253,125,482.21	252,139,377.51	250,362,629.95	257,955,319.18	252,592,441.05	250,699,036.18	249,523,612.01	0.00	0.00		2,525,565,587.32		

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	2,014,466.81	1,719,147.18	1,540,416.71	1,694,758.85	1,609,545.28	0.00	0.00		17,796,083.16		
9920	SSI W/MEDICARE KICK	41,766.35	49,883.65	19,127.82	11,906.92	17,679.52	41,894.17	24,485.64	36,926.57	40,376.10	24,108.82	0.00	0.00		308,155.56		
9921	SSI W/O MEDICARE KIC	124,693.16	188,260.19	147,522.59	133,284.96	170,395.76	189,930.36	132,851.92	162,007.05	147,726.04	140,432.64	0.00	0.00		1,537,104.67		
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	13,367,365.40	11,475,110.36	11,784,238.66	11,866,763.36	11,611,221.10	0.00	0.00		128,825,800.52		
SUBTOTAL:	15,246,100.6	0 16,974,611.98	15,845,328.8	5 15,918,611.50	14,858,717.96	15,613,656.74	13,351,595.10	13,523,588.99	13,749,624.35	13,385,307.84	0.00	0.00		148,467,143.91		

1104	TANF EXPANDED 14-20	0.00	0.00	158.73	174.93	174.93	174.93	2.91	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	268.83	277.66	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	95,490.45	101,679.68	90,618.59	90,227.84	84,822.62	0.00	0.00	
1107	TANF EXPANDED 21-44	375,187.64	366,538.58	333,829.52	312,883.77	304,753.80	304,464.79	298,179.03	283,304.95	284,872.62	276,478.69	0.00	0.00	
1108	TANF EXPANDED 45-64	969,358.60	933,329.99	907,126.43	911,028.02	894,145.01	882,999.71	868,838.06	854,229.40	848,613.33	791,291.07	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	283,247.60	271,616.48	264,679.22	277,303.67	276,184.16	270,258.28	285,619.59	279,083.24	276,412.50	275,989.54	0.00	0.00	
110F	TANF EXPANDED 21-44	6,434.27	833.49	9,468.54	6,982.07	21,387.59	3,473.18	3,874.53	4,308.93	6,365.35	5,785.21	0.00	0.00	
110G	TANF EXPANDED 21-44	17,187.04	20,010.57	9,419.20	9,037.01	4,440.63	14,279.20	9,517.67	16,332.85	13,469.10	5,799.38	0.00	0.00	
110H	TANF EXPANDED 45-64	24,588.37	18,477.98	24,383.27	28,596.40	18,520.76	16,110.77	24,765.87	14,736.63	28,876.10	32,115.98	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	10,009.21	4,963.49	7,876.07	9,355.03	8,751.10	8,768.06	9,020.45	7,853.03	5,599.65	12,768.07	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	843.79	799.54	457.85	321.62	321.62	0.00	0.00	
1113	TANF EXPANDED 06-13	7,530.15	6,396.34	6,083.16	6,244.38	6,244.38	6,129.09	6,203.83	5,483.92	5,376.90	4,060.06	0.00	0.00	
1114	TANF EXPANDED 14-20	78,885.78	74,581.55	73,294.96	73,712.88	70,175.15	68,643.65	70,828.33	62,473.08	66,445.45	65,284.54	0.00	0.00	
1115	TANF EXPANDED 14-20	480,991.35	468,272.67	461,574.87	443,197.34	438,911.65	424,550.74	428,260.38	379,481.54	399,240.30	389,093.16	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	5,007,050.24	5,046,054.54	4,751,547.24	4,695,277.92	4,676,240.23	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	18,896,160.96	19,381,073.06	18,391,654.79	18,250,775.42	18,172,444.18	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	11,764,367.48	11,732,000.48	11,383,658.00	11,133,559.45	11,048,050.42	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	28,256.55	28,078.55	30,516.22	27,412.94	27,496.22	26,981.65	25,619.84	29,715.23	29,069.53	29,446.51	0.00	0.00	
111B	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	66.74	0.39	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	2,149.07	2,182.83	2,174.21	4,967.05	1,990.20	0.00	0.00	
111E	TANF EXPANDED 14-20	5,280.99	-9,343.89	7,162.54	5,719.16	6,781.16	5,663.42	6,752.74	13,836.88	9,302.43	8,974.11	0.00	0.00	
111F	TANF EXPANDED 21-44	113,756.88	1,485.98	145,034.89	135,400.19	130,830.33	109,342.10	130,412.35	142,766.43	194,304.57	161,250.64	0.00	0.00	
111G	TANF EXPANDED 21-44	252,045.26	-86,740.82	334,574.06	305,507.56	297,336.20	240,410.52	341,484.01	360,647.33	469,988.68	363,424.39	0.00	0.00	
111H	TANF EXPANDED 45-64	124,191.45	-46,232.92	179,167.37	182,431.81	115,220.54	106,405.25	134,459.98	204,073.92	184,834.58	132,435.71	0.00	0.00	

686.43	
1,354.21	
994,258.83	
3,140,493.39	
8,860,959.62	
2,760,394.28	
68,913.16	
119,492.65	
231,172.13	
84,964.16	
49.12	
6,895.14	
59,752.21	
704,325.37	
4,313,574.00	
49,883,828.64	
191,654,172.36	
116,087,232.80	
282,593.24	
67.13	
133.38	
15,410.30	
60,129.54	
1,264,584.36	
2,878,677.19	
1,316,987.69	

3100	TRANSPLANT OPTION 1	0.00	0.00	16.50	16.50	16.50	16.50	16.50	16.50	16.50	-18.27	0.00	0.00	
3200	TRANSPLANT OPTION
2	0.00	0.00	0.00	7.45	16.50	16.50	16.50	16.50	16.50	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	16.5	0	33.00	33.00	33.00	33.00	33.00	33.00	-18.27	0.00	0.00	

 
97.23	
89.95	
9.05	
196.23	

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111J	TANF EXPANDED 65+ M
&	494.89	-2,806.54	1,682.18	476.63	733.19	377.30	12.06	125.82	18.68	550.89	0.00	0.00		1,665.10		
1125	TANF EXPANDED 14-20	270.06	270.06	270.06	1,205.72	1,205.72	1,205.72	1,262.15	1,095.43	0.00	249.14	0.00	0.00		7,034.06		
1126	TANF EXPANDED 21-44	381,006.44	383,503.97	375,635.04	374,034.86	359,580.92	378,248.90	359,816.92	348,186.39	340,770.07	339,940.74	0.00	0.00		3,640,724.25		
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	1,007,982.71	1,024,530.05	993,721.37	989,092.64	958,705.30	0.00	0.00		10,118,686.58		
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	1,557,086.06	1,576,775.95	1,545,817.36	1,542,918.39	1,547,568.93	0.00	0.00		15,267,774.30		
1129	TANF EXPANDED 65+ M
&	495,757.35	518,707.26	541,252.62	561,486.54	569,516.59	572,669.58	584,478.68	590,695.39	593,910.82	597,970.12	0.00	0.00		5,626,444.95		
112F	TANF EXPANDED 21-44	1,142.03	-462.10	2,378.99	359.92	170.61	0.00	318.96	1,430.00	1,145.50	3,763.68	0.00	0.00		10,247.59		
112G	TANF EXPANDED 21-44	3,902.35	1,608.95	3,029.33	2,326.19	5,528.70	860.74	2,264.40	2,160.95	3,012.52	2,245.49	0.00	0.00		26,939.62		
112H	TANF EXPANDED 45-64	1,484.83	1,137.12	1,998.70	1,851.38	7,024.34	6,414.14	4,683.69	1,053.72	3,755.83	5,914.68	0.00	0.00		35,318.43		
112J	TANF EXPANDED 65+ M
&	590.21	399.74	2,833.62	1,576.59	757.89	576.58	4,272.51	1,998.10	3,100.24	6,278.02	0.00	0.00		22,383.50		
2400	SSI AGED EXPANDED WI	70,982.22	60,953.05	42,379.02	46,696.54	52,616.73	46,349.14	40,781.16	45,644.96	45,639.25	45,264.55	0.00	0.00		497,306.62		
240Z	SSI AGED EXPANDED
WI	13,292.73	18,104.44	15,345.34	24,325.63	24,885.33	26,830.23	22,730.10	23,848.91	39,553.98	28,151.00	0.00	0.00		237,067.69		
2410	SSI AGED EXPANDED N O	111,573.31	93,539.30	90,400.82	98,575.69	95,320.97	97,454.98	109,405.38	101,585.58	106,827.37	104,879.56	0.00	0.00		1,009,562.96		
241Z	SSI AGED EXPANDED N
O	3,594.96	4,633.83	2,444.93	4,077.94	1,328.19	1,602.69	2,255.59	1,793.83	19,801.84	-2,615.39	0.00	0.00		38,918.41		
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	4,707,765.35	4,748,650.27	4,763,667.41	4,907,270.68	4,938,855.03	0.00	0.00		48,158,376.91		
242Z	SSI AGED EXPANDED
WI	5,768.70	2,945.99	16,003.17	14,030.03	8,080.17	9,960.34	15,492.37	5,778.20	19,013.78	8,123.86	0.00	0.00		105,196.61		
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	117.27	117.74	117.74	117.74	0.00	0.00	0.00		1,128.24		
2600	SSI DISABLED EXPAND
E	215,717.42	190,692.83	143,975.61	144,233.09	141,522.81	143,622.26	147,683.03	149,739.83	161,612.70	170,873.30	0.00	0.00		1,609,672.88		
260Z	SSI DISABLED EXPAND E	68,640.56	81,350.26	74,884.42	54,167.30	48,216.27	61,181.97	56,770.38	51,914.01	69,031.69	88,682.03	0.00	0.00		654,838.89		
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	1,756,435.92	1,771,926.70	1,738,996.67	1,772,014.82	1,751,690.54	0.00	0.00		17,956,746.25		
261Z	SSI DISABLED EXPAND E	24,058.45	27,936.64	20,953.50	19,905.37	28,503.31	18,935.25	13,337.04	20,872.29	30,788.34	28,918.30	0.00	0.00		234,208.49		
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	10,936,683.50	10,911,026.67	10,860,385.57	10,935,606.86	10,788,346.29	0.00	0.00		109,600,103.41		
262Z	SSI DISABLED EXPAND E	17,013.33	40,720.31	38,407.28	26,846.32	18,577.77	19,037.71	22,648.34	11,190.26	22,619.16	14,014.54	0.00	0.00		231,075.02		
SUBTOTAL:	62,234,798.5	7 60,755,683.30	61,328,778.2	5 60,388,590.78	60,127,735.22	59,606,451.24	60,329,147.89	58,540,257.83	58,605,523.29	57,966,436.93	0.00	0.00		599,883,403.30		

3504	ADULT 40-100% MALE 1	4.57	524.57	524.57	553.98	553.98	553.98	561.75	554.70	554.70	554.70	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	1,053.17	2,826.00	3,404.68	517.26	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	690.61	400.50	0.00	607.56	946.31	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	7,500.65	11,491.10	13,977.76	9,167.64	12,752.54	0.00	0.00	

4,941.50	
11.28	
13,724.53	
27,177.05	
149,161.83	

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	1,094,690.57	854,030.92	1,127,531.53	1,197,972.20	978,356.23	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	18,405.79	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	0.00	0.00	0.00	0.00	5,607.72	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,371,150.11	1,365,689.27	1,356,933.0	4	1,406,467.25	1,131,904.98	1,094,690.57	859,638.64	1,127,531.53	1,197,972.20	996,762.02	0.00	0.00	

 
11,860,185.77	
42,946.12	
5,607.72	
11,908,739.61	

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3509	ADULT 40-100% M&F 65	-269.59	0.00	0.00	1,472.99	919.01	1,077.65	1,433.85	2,476.42	1,534.96	1,387.04	0.00	0.00		10,032.33		
350F	ADULT 40-100% MALE 2	2,884.85	0.00	0.00	2,861.69	1,060.06	0.00	744.36	1,325.34	8,580.82	0.00	0.00	0.00		17,457.12		
350G	ADULT 40-100% FEMAL E	1,153.34	348.18	394.77	1,198.32	0.00	320.51	4.32	0.00	963.53	571.25	0.00	0.00		4,954.22		
350H	ADULT 40-100% M&F 45	3,127.80	5,761.37	2,912.68	2,885.39	3,165.90	1,764.44	7,681.27	1,618.64	846.84	6,854.84	0.00	0.00		36,619.17		
350J	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	10,386.86	0.00	0.00	0.00	0.00	0.00		10,386.86		
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	2,952,257.40	2,990,330.40	2,819,185.76	2,888,214.48	2,853,922.84	0.00	0.00		29,427,929.26		
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	3,163,329.21	3,183,588.16	3,027,624.61	3,083,140.57	3,063,676.62	0.00	0.00		31,239,658.12		
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	10,647,996.91	10,759,686.82	10,333,203.99	10,182,889.17	10,038,061.63	0.00	0.00		104,767,536.51		
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	8,841,725.27	9,017,760.01	8,681,247.77	8,566,983.75	8,486,538.55	0.00	0.00		87,475,698.59		
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	20,576,686.37	20,834,501.90	20,279,671.20	20,128,589.32	20,071,719.72	0.00	0.00		202,632,901.55		
3519	ADULT 40-100% M&F 65	7,808.53	9,609.66	9,072.99	8,219.85	7,722.43	8,131.57	6,301.50	4,126.42	3,522.62	3,522.62	0.00	0.00		68,038.19		
351D	ADULT 40-100% MALE 1	72,359.73	-49,736.72	80,177.67	90,718.82	69,596.67	51,845.81	109,260.10	74,837.84	129,711.82	78,529.42	0.00	0.00		707,301.16		
351E	ADULT 40-100% FEMAL E	63,306.58	-18,704.27	100,820.64	106,094.12	69,621.63	93,236.57	115,048.64	126,988.66	124,863.82	116,641.92	0.00	0.00		897,918.31		
351F	ADULT 40-100% MALE 2	291,967.08	8,303.19	382,394.37	506,730.64	327,034.26	323,811.46	507,544.45	410,575.87	547,641.24	371,323.31	0.00	0.00		3,677,325.87		
351G	ADULT 40-100% FEMAL E	229,537.12	-11,995.73	276,148.64	401,727.43	296,332.86	274,209.64	448,566.38	373,343.91	501,044.52	358,241.10	0.00	0.00		3,147,155.87		
351H	ADULT 40-100% M&F 45	545,163.08	-65,763.05	672,288.35	733,547.24	525,500.09	664,863.61	834,359.47	759,288.36	950,616.73	698,064.40	0.00	0.00		6,317,928.28		
351J	ADULT 40-100% M&F 65	11,658.82	-3,539.60	6,745.90	2,698.36	6,384.58	1,438.89	5,204.84	2,316.99	2,397.45	18,478.56	0.00	0.00		53,784.79		
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	7.07	0.00	0.00	0.00	0.00	0.00		3,739.04		
3527	ADULT 40-100% FEMAL E	-9.13	2,368.59	588.95	0.00	0.00	0.00	2.35	0.00	0.00	2,787.69	0.00	0.00		5,738.45		
3528	ADULT 40-100% M&F 45	2,052.47	4,019.10	2,334.56	3,376.73	1,932.12	2,887.41	712.07	1,403.05	0.00	462.25	0.00	0.00		19,179.76		
3529	ADULT 40-100% M&F 65	354.63	904.71	904.71	920.35	0.00	0.00	8.20	0.00	0.00	409.63	0.00	0.00		3,502.23		
352F	ADULT 40-100% MALE 2	0.00	0.00	0.00	1,787.76	356.67	0.00	10.29	0.00	0.00	0.00	0.00	0.00		2,154.72		
352G	ADULT 40-100% FEMAL E	0.00	0.00	629.62	0.00	0.00	0.00	0.00	0.00	0.00	1,194.72	0.00	0.00		1,824.34		
352H	ADULT 40-100% M&F 45	2,162.61	2,114.04	1,195.90	800.70	1,238.82	0.00	951.77	167.45	0.00	130.24	0.00	0.00		8,761.53		
3704	ADULT <40% EXP MALE	18.53	0.00	0.00	0.00	0.00	303.25	0.76	0.00	832.19	0.00	0.00	0.00		1,154.73		
3705	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	498.02	498.02	0.00	0.00		996.04		
3706	ADULT <40% EXP MALE	6,494.13	11,445.31	9,607.38	12,433.27	14,334.08	3,673.58	7,019.36	6,419.92	7,029.82	9,525.00	0.00	0.00		87,981.85		
3707	ADULT <40% EXP FEMA L	4,432.57	11,559.30	6,367.71	7,094.37	6,611.09	4,524.04	3,294.83	4,763.61	11,589.61	3,487.61	0.00	0.00		63,724.74		
3708	ADULT <40% EXP M&F
4	14,067.06	21,252.76	18,772.50	14,330.47	14,901.83	23,504.71	16,367.30	12,803.69	13,962.94	10,090.31	0.00	0.00		160,053.57		
3709	ADULT <40% EXP M&F 6	1,019.42	923.08	871.58	982.73	523.67	409.48	1,090.39	958.76	988.53	554.70	0.00	0.00		8,322.34		
370D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	245.88	2.69	0.00	601.02	0.00	0.00	0.00		849.59		
370E	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	2,023.77	0.00	0.00	0.00	0.00	0.00		2,023.77		
370F	ADULT <40% EXP MALE	3,252.78	4,082.51	7,058.09	6,313.54	4,809.29	762.40	1,933.69	6,254.42	6,020.69	2,684.96	0.00	0.00		43,172.37		
370G	ADULT <40% EXP FEMA L	4,275.36	-105.36	5,092.91	9,867.05	2,600.10	1,547.36	355.43	1,493.12	12,748.21	1,120.02	0.00	0.00		38,994.20		
370H	ADULT <40% EXP M&F
4	20,886.74	12,971.24	6,421.61	8,779.28	6,914.74	7,879.45	3,103.57	13,697.86	7,859.82	7,709.18	0.00	0.00		96,223.49		

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126.03	0.00	0.00	0.00		126.03		
3714	ADULT <40% EXP MALE	5,219,470.41	5,394,579.02	5,348,920.56	5,535,933.27	5,421,204.69	5,347,090.09	5,363,122.86	5,157,779.21	5,183,462.94	5,182,490.66	0.00	0.00		53,154,053.71		
3715	ADULT <40% EXP FEMA L	4,642,825.69	4,808,976.61	4,806,346.81	4,987,249.65	4,911,617.11	4,823,356.39	4,821,656.32	4,613,009.69	4,649,880.79	4,649,239.21	0.00	0.00		47,714,158.27		
3716	ADULT <40% EXP MALE	33,047,874.79	34,761,629.62	34,524,197.29	35,574,569.16	35,828,713.09	35,599,272.99	36,124,650.15	35,530,260.00	35,506,752.86	35,372,151.34	0.00	0.00		351,870,071.29		
3717	ADULT <40% EXP FEMA L	20,320,142.05	21,465,807.39	21,299,025.95	21,846,235.51	21,900,625.29	21,758,626.85	22,068,496.92	21,596,068.02	21,501,983.09	21,456,000.66	0.00	0.00		215,213,011.73		
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	43,454,398.29	43,821,791.48	43,128,946.21	43,055,667.78	42,837,663.15	0.00	0.00		427,912,915.53		
3719	ADULT <40% EXP M&F 6	15,351.84	18,714.38	19,589.72	18,168.12	17,490.01	17,357.32	15,951.60	14,143.62	11,711.60	11,655.17	0.00	0.00		160,133.38		
371D	ADULT <40% EXP MALE	146,006.19	-155,374.60	185,124.87	197,311.49	151,292.00	169,004.76	199,472.86	218,031.66	324,437.55	217,017.98	0.00	0.00		1,652,324.76		
371E	ADULT <40% EXP FEMA L	144,773.10	-80,125.65	177,307.87	167,619.03	163,572.63	124,867.29	166,542.70	237,638.98	242,049.50	231,263.00	0.00	0.00		1,575,508.45		
371F	ADULT <40% EXP MALE	1,612,184.26	-543,288.27	2,042,350.13	2,001,974.69	1,718,610.00	1,727,355.24	2,161,737.25	2,171,618.56	2,347,604.02	1,975,433.86	0.00	0.00		17,215,579.74		
371G	ADULT <40% EXP FEMA L	963,473.42	-72,313.27	1,067,613.64	1,040,834.98	929,321.09	967,122.47	1,105,302.17	1,167,054.01	1,478,706.35	1,152,086.58	0.00	0.00		9,799,201.44		
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	1,432,582.77	2,060,688.22	1,795,694.09	2,197,940.09	1,694,049.80	0.00	0.00		15,007,031.78		
371J	ADULT <40% EXP M&F 6	3,132.07	6,682.69	0.00	0.00	9,267.01	0.00	8,587.02	0.00	8,674.39	2,344.23	0.00	0.00		38,687.41		
3724	ADULT <40% EXP MALE	-6.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6.26		
3725	ADULT <40% EXP FEMA L	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 MALE	6,441.63	3,337.56	1,346.03	1,105.89	0.00	0.00	6.74	2,799.58	6,001.47	2,690.02	0.00	0.00		23,728.92		
3727	ADULT <40% EXP FEMA L	251.87	0.00	2,368.59	0.00	0.00	523.67	2,365.96	812.24	1,618.67	1,975.97	0.00	0.00		9,916.97		
3728	ADULT <40% EXP M&F
4	5,999.63	7,782.84	2,534.43	3,653.75	5,699.13	3,214.36	1,047.05	2,532.58	981.36	1,763.95	0.00	0.00		35,209.08		
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	476.62	0.00	0.00		925.31		
372F	ADULT <40% EXP MALE	388.35	883.02	1,708.96	404.92	0.00	0.00	2.39	1,721.19	2,112.40	2,450.77	0.00	0.00		9,672.00		
372G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	418.61	0.00	1,724.95	0.00	0.00		2,143.56		
372H	ADULT <40% EXP M&F
4	997.14	5,797.76	1,631.10	995.10	335.92	4,116.04	6.42	4,328.56	1,189.78	1,402.85	0.00	0.00		20,800.67		
372J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,023.77	0.00	3,878.25	0.00	0.00		5,902.02		
SUBTOTAL:	151,748,007.9	2 152,885,905.96	160,523,146.4	7 165,542,592.00	164,722,405.24	163,086,066.64	166,804,221.50	162,608,032.70	163,718,307.74	161,020,717.98	0.00	0.00		1,612,659,404.15		

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	1,325.22	990.44	1,492.04	1,256.56	313.83	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	1,508.51	1,425.48	384.66	2,767.98	1,056.41	896.18	1,033.66	1,707.52	1,020.91	667.17	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	13,480.45	18,321.20	16,025.63	15,126.84	13,160.37	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	1,711.46	1,419.49	3,816.86	3,391.89	3,122.31	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	496.06	436.82	902.36	244.86	467.56	484.36	290.99	3,812.48	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	407.87	99.21	0.00	1,261.76	406.86	0.00	302.50	803.70	2,568.39	400.93	0.00	0.00	

2.95	
-11.24	
20,013.90	
12,468.48	
279,435.04	
28,616.78	
7,135.49	
6,251.22	

9935	BIRTH SUPP PAYMENT A	276,810.08	265,656.53	276,630.88	193,528.66	269,037.61	387,591.06	164,109.59	205,196.99	227,190.31	225,647.89	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	488,085.14	570,809.95	564,963.00	544,913.16	456,990.89	496,647.91	564,533.29	481,779.63	594,731.30	459,599.98	0.00	0.00	
SUBTOTAL:	764,895.2	2	836,466.48	841,593.8	8	738,441.82	726,028.50	884,238.97	728,642.88	686,976.62	821,921.61	685,247.87	0.00	0.00	

 
2,491,399.60	
5,223,054.25	
7,714,453.85	

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390H	NEWLY ELIGIBLE M&F 4	0.00	838.99	227.82	2,481.75	4,716.15	955.08	1,616.74	463.01	2,938.74	6,598.28	0.00	0.00		20,836.56		
390J	NEWLY ELIGIBLE M&F
6	224.85	0.00	0.00	36.91	1,268.34	0.00	0.35	0.00	0.00	0.00	0.00	0.00		1,530.45		
3914	NEWLY ELIGIBLE MALE	1,273,793.61	1,294,010.36	1,305,654.15	1,187,391.63	1,174,877.45	1,153,911.73	1,161,184.00	1,077,694.95	1,093,903.00	1,093,376.03	0.00	0.00		11,815,796.91		
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	1,309,177.12	1,305,331.40	1,225,198.89	1,235,488.12	1,237,761.43	0.00	0.00		13,379,449.76		
3916	NEWLY ELIGIBLE MALE	7,793,548.62	7,828,522.86	7,778,229.06	6,951,268.30	6,925,353.16	6,774,362.75	6,840,890.68	6,569,872.47	6,424,293.23	6,304,216.07	0.00	0.00		70,190,557.20		
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	9,443,015.23	9,533,638.75	9,239,647.12	9,095,018.76	9,003,967.20	0.00	0.00		97,602,749.26		
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	10,248,584.23	10,276,442.89	9,985,200.75	9,885,501.32	9,779,696.10	0.00	0.00		105,519,478.74		
3919	NEWLY ELIGIBLE M&F 6	5,388.09	5,528.23	6,730.06	5,862.78	5,550.95	4,844.03	4,190.66	4,844.99	5,193.86	4,839.84	0.00	0.00		52,973.49		
391D	NEWLY ELIGIBLE MALE	24,013.79	-12,675.48	27,045.58	33,208.81	28,649.56	15,938.34	37,553.75	28,656.10	34,693.92	34,847.58	0.00	0.00		251,931.95		
391E	NEWLY ELIGIBLE FEMA L	29,024.73	-17,035.99	37,880.29	40,869.16	34,878.59	25,192.96	38,263.52	33,149.91	52,409.69	42,535.15	0.00	0.00		317,168.01		
391F	NEWLY ELIGIBLE MALE	207,852.91	-68,573.75	225,723.91	265,705.36	221,316.35	181,055.99	269,396.60	247,436.70	347,562.60	271,547.12	0.00	0.00		2,169,023.79		
391G	NEWLY ELIGIBLE FEMA L	258,501.92	-57,783.27	316,354.94	368,105.10	304,916.32	268,382.70	378,867.27	380,448.30	444,207.57	404,522.36	0.00	0.00		3,066,523.21		
391H	NEWLY ELIGIBLE M&F
4	202,007.44	-538.24	257,708.46	347,676.97	265,036.10	241,549.08	362,348.40	309,113.26	367,247.40	278,926.82	0.00	0.00		2,631,075.69		
391J	NEWLY ELIGIBLE M&F 6	2,782.92	341.73	573.08	0.00	0.00	0.00	0.00	689.77	0.00	0.00	0.00	0.00		4,387.50		
3926	NEWLY ELIGIBLE MALE	1,466.71	2,601.42	360.88	307.45	691.21	353.63	11.47	0.00	248.91	0.00	0.00	0.00		6,041.68		
3927	NEWLY ELIGIBLE FEMA L	390.74	0.00	0.00	2,363.74	0.00	45.01	0.17	169.71	0.00	0.00	0.00	0.00		2,969.37		
3928	NEWLY ELIGIBLE M&F
4	824.99	1,840.92	2,321.11	2,412.22	340.45	1,155.30	972.96	351.35	126.78	692.34	0.00	0.00		11,038.42		
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	9.19	0.00	408.29	0.00	0.00	0.00		4,383.48		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	332.21	3.17	207.85	0.00	0.00	0.00	0.00		543.23		
392H	NEWLY ELIGIBLE M&F
4	110.24	402.87	284.78	24.61	0.00	74.77	442.76	406.68	-146.73	24.82	0.00	0.00		1,624.80		
SUBTOTAL:	33,485,086.1	0 32,860,038.60	33,775,840.9	9 30,543,797.36	30,193,612.60	29,686,811.03	30,233,716.38	29,127,688.55	29,016,272.53	28,481,215.75	0.00	0.00		307,404,079.89		

4,049,223.30

4403	SOBRA 100-133% M&F
6	794.23	905.88	826.73	816.49	328.51	335.21	353.37	339.02	339.02	226.96	0.00	0.00	
4404	SOBRA 100-133% MALE	326.61	315.23	315.23	325.15	325.15	325.15	332.21	327.53	327.53	327.53	0.00	0.00	
4405	SOBRA 100-133% FEMA L	757.74	507.86	507.86	514.33	763.76	763.76	787.14	504.60	504.60	504.60	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	527.31	552.00	102.22	102.22	102.22	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	5,873,501.63	6,092,692.86	5,872,540.87	5,735,123.80	5,706,611.04	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	2,230,093.17	2,255,589.68	2,238,940.42	2,160,059.11	2,130,272.26	0.00	0.00	
4415	SOBRA 100-133% FEMA L	3,278,980.37	3,244,965.53	3,245,200.17	3,230,199.90	3,201,911.75	3,158,028.20	3,238,924.61	3,150,648.07	3,076,279.30	3,072,355.12	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	44,309.50	60,982.70	74,720.27	94,145.02	74,634.71	0.00	0.00	

5,265.42	
3,247.32	
6,116.25	
146.96	
6.06	
5,183.50	
59,231,760.86	
21,889,759.86	
31,897,493.02	
-176.96	
563,103.10	

9939	BIRTH SUPP PAYMENT N	423,614.42	322,314.82	464,037.03	447,798.82	421,326.12	442,562.41	384,059.89	420,094.86	381,442.06	341,972.87	0.00	0.00	
SUBTOTAL:	423,614.42	322,314.82	464,037.03	447,798.82	421,326.12	442,562.41	384,059.89	420,094.86	381,442.06	341,972.87	0.00	0.00	

 
4,049,223.30

ACUTE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
441D	SOBRA 100-133% MALE	31,972.74	-9,902.12	41,944.26	42,667.34	41,537.71	37,307.03	45,878.53	56,966.66	68,266.57	66,974.75	0.00	0.00		423,613.47		
441E	SOBRA 100-133% FEMA L	40,438.24	-26,343.52	55,381.55	77,184.81	50,430.21	42,522.12	66,760.23	79,012.79	101,882.38	80,318.50	0.00	0.00		567,587.31		
4424	SOBRA 100-133% MALE	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4425	SOBRA 100-133% FEMA L	2.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.61		
SUBTOTAL:	11,641,631.3	1 11,273,715.17	11,485,248.0	4 11,618,597.93	11,579,893.23	11,387,713.08	11,762,853.33	11,474,102.45	11,237,029.55	11,132,327.69	0.00	0.00		114,593,111.78		

351,177.51

9944	BIRTH SUPP PAYMENT S	24,374.98	57,086.40	37,514.80	48,643.26	36,244.91	37,045.71	42,649.67	42,391.69	6,323.05	18,903.04	0.00	0.00	
SUBTOTAL:	24,374.98	57,086.40	37,514.80	48,643.26	36,244.91	37,045.71	42,649.67	42,391.69	6,323.05	18,903.04	0.00	0.00	

 
351,177.51

4517	BC PATIENT FEMALE 2 1	5,030.43	5,596.82	5,488.20	5,314.21	3,758.33	4,014.68	4,451.38	4,590.81	4,755.05	5,130.71	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	43,337.95	45,715.55	45,746.81	46,690.80	45,922.21	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	-3.50	57.05	827.19	905.65	401.99	1,136.20	13.25	0.00	1,500.58	69.76	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	209.32	290.35	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	2,581.22	1,034.17	1,682.62	1,176.98	12,885.21	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	4,450.82	4,513.74	4,598.19	4,456.14	4,126.38	4,025.89	4,277.85	4,220.87	4,220.87	4,279.74	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	4,367.07	4,793.87	5,659.71	5,686.46	5,686.46	5,686.46	5,789.81	5,064.83	5,265.49	4,976.08	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	267.46	880.39	20.63	0.00	0.00	3,764.05	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	3,565.94	0.00	0.00	
SUBTOTAL:	78,266.48	66,420.94	64,401.8	0	64,452.98	58,420.03	61,662.79	61,302.64	61,515.26	63,900.12	80,593.70	0.00	0.00	

 
48,130.62	
472,383.95	
4,908.17	
1,938.57	
26,478.69	
43,170.49	
52,976.24	
-4.41	
5,381.03	
5,573.39	
660,936.74	

8600	SSI BLIND FREEDOM/W O	3,473.55	4,134.40	4,134.40	3,796.95	3,796.95	3,796.95	3,796.95	3,796.95	3,796.95	3,796.95	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	1,675,549.51	1,681,649.46	1,689,740.92	1,701,125.72	1,718,912.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	25,793.64	29,914.96	19,181.34	41,662.65	28,327.69	27,738.83	35,453.41	43,332.86	54,532.03	21,538.47	0.00	0.00	
8710	SSI DISABLED FREEDO M	417,995.55	395,949.89	407,312.62	448,216.92	447,824.83	439,022.48	455,929.33	452,250.48	441,857.68	456,726.70	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	12,807.76	17,411.37	31,913.33	6,060.34	4,876.79	14,701.66	8,134.15	15,587.30	24,369.25	16,744.96	0.00	0.00	
8720	SSI DISABLED FREEDO M	190,928.86	183,129.31	190,827.03	186,755.69	181,297.78	186,617.12	182,195.83	186,223.82	182,908.91	184,008.22	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	902.78	7,362.39	11,019.56	1,660.78	67.89	9,657.86	412.76	305.46	2,944.27	3,474.00	0.00	0.00	
SUBTOTAL:	2,330,265.78	2,340,741.98	2,374,301.7	0	2,360,155.60	2,342,111.73	2,357,084.41	2,367,571.89	2,391,237.79	2,411,534.81	2,405,201.30	0.00	0.00	

 
38,321.00	
1,122.93	
16,904,893.47	
327,475.88	
4,363,086.48	
152,606.91	
1,854,892.57	
37,807.75	
23,680,206.99	

5,356,937,664.58

535,550,168.84	530,359,897.74	540,441,630.39	542,203,664.51	538,337,811.03	534,620,646.54	544,880,751.99	532,595,892.32	531,908,920.49	526,038,280.73	0.00	0.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
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	1.00	0.00	0.00	0.00		6.00		
1002	TANF 01-05 M & F WIT	3.00	6.00	6.56	4.00	5.00	6.00	5.00	3.00	2.00	1.00	0.00	0.00		41.56		
1003	TANF 06-13 M & F WIT	1.00	3.00	4.00	6.00	5.00	6.00	4.00	0.00	0.00	0.00	0.00	0.00		29.00		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.80	1.00	1.00	0.00	0.00	0.00	0.00	0.00		2.80		
1005	TANF 14-20 FEMALE WI	0.16	2.48	2.00	3.00	2.00	3.00	3.00	2.00	2.00	1.00	0.00	0.00		20.64		
1006	TANF 21-44 MALE WITH	78.57	79.10	84.35	91.12	94.66	99.82	98.32	101.83	96.61	98.08	0.00	0.00		922.46		
1007	TANF 21-44 FEMALE WI	121.95	130.43	137.74	138.73	142.80	136.72	133.67	122.51	121.45	116.84	0.00	0.00		1,302.84		
1008	TANF 45-64 M & F WIT	167.87	166.52	167.31	178.73	185.54	195.59	201.10	202.14	203.25	219.16	0.00	0.00		1,887.21		
1009	TANF 65+ M & F WITH	76.75	83.13	77.23	75.90	71.33	76.29	90.04	91.91	92.50	93.42	0.00	0.00		828.50		
100B	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00		1.00		
100C	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00		1.00		
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	3.87	10.91	1.13	0.38	11.38	0.00	0.00		40.84		
100G	TANF 21-44 FEMALE WI	3.92	10.59	15.11	3.20	5.70	4.04	12.40	4.15	6.47	2.86	0.00	0.00		68.44		
100H	TANF 45-64 M & F WIT	6.63	5.13	8.63	5.48	8.21	10.96	19.25	1.67	12.46	6.83	0.00	0.00		85.25		
100J	TANF 65+ M & F WITH	3.21	1.81	14.24	0.09	1.66	0.70	3.91	0.78	3.48	3.55	0.00	0.00		33.43		
1011	TANF <1 M & F NON-ME	12,680.31	12,878.00	12,725.91	12,742.75	12,650.45	12,380.76	11,896.01	11,501.52	11,519.06	11,340.40	0.00	0.00		122,315.17		
1012	TANF 01-05 M & F NON	20,425.00	21,039.07	21,619.70	22,402.81	23,366.67	23,966.22	24,662.02	24,509.36	20,166.39	19,895.02	0.00	0.00		222,052.26		
1013	TANF 06-13 M & F NON	31,421.44	31,527.83	32,040.57	32,865.69	33,545.12	33,857.91	34,067.67	33,978.93	33,414.05	33,563.37	0.00	0.00		330,282.58		
1014	TANF 14-20 MALE NON-	8,500.86	8,645.18	8,760.31	8,890.81	9,089.78	9,224.50	9,253.33	9,159.04	8,927.86	8,883.04	0.00	0.00		89,334.71		
1015	TANF 14-20 FEMALE N O	11,347.13	11,438.65	11,498.46	11,704.90	11,862.60	11,839.55	11,833.27	11,720.80	11,631.51	11,695.21	0.00	0.00		116,572.08		
1016	TANF 21-44 MALE NON-	27,141.38	27,294.16	27,223.56	27,009.63	27,108.75	26,591.30	26,574.26	26,264.11	26,083.97	26,028.39	0.00	0.00		267,319.51		
1017	TANF 21-44 FEMALE N O	83,553.33	83,865.89	83,875.13	84,062.27	84,501.84	83,714.97	83,604.40	82,928.23	82,504.10	82,599.75	0.00	0.00		835,209.91		
1018	TANF 45-64 M & F NON	21,279.36	21,168.31	21,113.83	21,152.67	21,200.22	20,987.08	21,082.35	21,094.91	20,819.00	20,793.88	0.00	0.00		210,691.61		
1019	TANF 65+ M & F NON-M	83.83	84.44	86.33	86.51	86.96	81.44	81.04	88.12	84.51	87.30	0.00	0.00		850.48		
101A	TANF < 1 M & F NON-M	1,013.07	1,097.45	1,157.10	1,267.13	1,309.75	1,170.58	1,165.99	1,145.87	1,299.98	1,017.08	0.00	0.00		11,644.00		
101B	TANF 01-05 M & F NON	279.37	412.61	427.42	438.47	443.33	246.90	290.50	373.65	328.23	292.87	0.00	0.00		3,533.35		
101C	TANF 06-13 M & F NON	239.36	317.80	312.04	289.23	246.74	211.47	255.93	210.01	183.31	257.67	0.00	0.00		2,523.56		
101D	TANF 14-20 MALE NON-	106.20	56.46	130.09	103.72	92.40	63.66	75.44	92.22	96.41	59.44	0.00	0.00		876.04		
101E	TANF 14-20 FEMALE N O	103.24	29.02	206.08	147.02	139.16	136.00	141.65	165.87	144.28	143.13	0.00	0.00		1,355.45		
101F	TANF 21-44 MALE NON-	825.45	-28.72	959.35	807.21	704.01	791.72	874.78	822.65	894.97	824.47	0.00	0.00		7,475.89		
101G	TANF 21-44 FEMALE N O	1,728.03	-483.45	1,992.78	1,842.28	1,650.60	1,722.18	2,007.56	1,937.52	2,327.94	1,984.01	0.00	0.00		16,709.45		
101H	TANF 44-64 M & F NON	375.11	-16.50	484.06	477.38	365.19	379.77	586.88	495.45	580.63	426.60	0.00	0.00		4,154.57		
101J	TANF 65+ N & F NON-M	2.16	-2.79	1.66	0.47	1.03	2.68	2.05	4.47	9.46	0.36	0.00	0.00		21.55		
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		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1023	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		6.00		
1024	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00		3.00		
1025	TANF 14-20 FEMALE WI	0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00		5.00		
1026	TANF 21-44 MALE WITH	55.44	57.82	52.73	63.58	62.25	58.74	63.70	67.76	67.85	69.62	0.00	0.00		619.49		
1027	TANF 21-44 FEMALE WI	92.00	97.93	105.75	113.98	115.16	107.40	105.16	104.45	105.21	109.09	0.00	0.00		1,056.13		
1028	TANF 45-64 M & F WIT	120.86	130.00	132.66	134.70	127.96	127.77	144.24	142.92	136.91	135.20	0.00	0.00		1,333.22		
1029	TANF 65+ M & F WITH	72.70	76.00	78.33	84.90	81.00	82.77	86.40	84.00	78.00	76.50	0.00	0.00		800.60		
102F	TANF 21-44 MALE WITH	1.66	1.28	0.00	0.00	1.73	1.24	0.93	3.82	4.11	2.02	0.00	0.00		16.79		
102G	TANF 21-44 FEMALE WI	0.00	3.06	3.23	0.00	1.30	0.00	3.83	0.74	0.00	2.49	0.00	0.00		14.65		
102H	TANF 44-64 M & F WIT	0.00	2.00	9.33	0.35	0.00	3.22	2.74	0.70	0.44	0.00	0.00	0.00		18.78		
102J	TANF 65+ M & F WITH	6.51	0.00	9.66	0.09	0.00	1.22	2.47	0.00	0.00	0.50	0.00	0.00		20.45		
2100	SSI AGED WITH MEDIC A	4,505.33	4,499.53	4,501.37	4,389.40	4,336.43	4,340.58	4,308.12	4,273.95	4,283.11	4,211.06	0.00	0.00		43,648.88		
210Z	SSI AGED WITH MEDIC
A	227.54	242.94	326.32	256.44	237.54	309.78	275.98	339.69	404.86	402.43	0.00	0.00		3,023.52		
2110	SSI AGED NON-MEDICA R	5,793.97	5,820.29	5,921.97	5,942.27	6,004.19	6,060.59	6,061.69	6,151.05	6,220.79	6,283.50	0.00	0.00		60,260.31		
211Z	SSI AGED NON-MEDICA
R	140.26	171.77	198.66	200.88	175.51	141.84	174.51	182.67	263.24	220.47	0.00	0.00		1,869.81		
2120	SSI AGED WITH QMB	27,697.42	27,990.51	28,089.78	28,379.49	28,657.87	28,791.35	29,036.54	29,263.43	29,442.47	29,549.64	0.00	0.00		286,898.50		
212Z	SSI AGED WITH QMB P P	54.23	49.91	94.91	36.84	53.41	58.01	30.26	62.55	50.35	118.99	0.00	0.00		609.46		
2200	SSI DISABLED WITH M
E	3,558.35	3,571.35	3,642.24	3,542.97	3,560.95	3,500.67	3,487.57	3,498.23	3,515.43	3,535.27	0.00	0.00		35,413.03		
220Z	SSI DISABLED WITH M E	218.85	200.64	307.86	215.37	222.57	156.24	235.58	245.16	252.16	297.71	0.00	0.00		2,352.14		
2210	SSI DISABLED NON-ME
D	54,047.38	53,981.66	53,898.70	53,823.97	53,732.69	53,524.00	53,556.67	53,391.18	53,175.28	52,978.39	0.00	0.00		536,109.92		
221Z	SSI DISABLED NON-ME D	602.83	763.73	768.16	752.07	664.37	702.30	818.60	701.74	977.73	743.45	0.00	0.00		7,494.98		
2220	SSI DISABLED WITH Q
M	27,058.57	27,073.88	27,036.70	27,229.60	27,209.97	27,204.28	27,246.73	27,358.89	27,219.58	27,173.60	0.00	0.00		271,811.80		
222Z	SSI DISABLED WITH Q M	75.34	64.54	82.38	64.13	56.71	95.69	68.32	53.31	61.02	78.49	0.00	0.00		699.93		
2300	SSI BLIND WITH MEDIC	24.00	25.00	25.56	24.19	24.23	25.00	26.99	24.00	23.83	22.00	0.00	0.00		244.80		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.80	0.76	0.00	1.99	0.00	0.03	0.00	0.00	0.00		3.58		
2310	SSI BLIND NON-MEDIC A	487.19	490.21	490.74	489.81	487.40	495.03	499.31	498.46	505.24	505.20	0.00	0.00		4,948.59		
231Z	SSI BLIND NON-MEDIC
A	20.21	8.34	7.92	0.44	0.70	17.21	32.32	16.38	5.96	3.83	0.00	0.00		113.31		
2320	SSI BLIND WITH QMB	221.71	223.99	225.32	223.67	227.99	228.69	230.00	231.67	230.00	231.59	0.00	0.00		2,274.63		
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	4.00	3.00	2.00	2.00	2.00	0.00	0.00		29.69		
4302	SOBRA CHILD 01-05 M	42.12	46.55	52.05	49.61	47.89	45.34	44.25	41.51	42.83	38.00	0.00	0.00		450.15		
4303	SOBRA CHILD 06-13 M	24.00	39.20	43.65	45.77	40.65	37.98	37.00	33.91	34.00	29.00	0.00	0.00		365.16		
4304	SOBRA CHILD 14-20 MA	16.16	14.09	13.23	12.03	11.06	8.92	7.00	7.00	7.00	7.00	0.00	0.00		103.49		
4305	SOBRA CHILD 14-20 FE	7.00	4.38	6.00	8.00	8.00	8.00	7.00	9.00	8.18	6.00	0.00	0.00		71.56		
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	1.49	0.00	0.00	0.00	0.00		19.01		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
430C	SOBRA CHILD 06-13 M	0.00	5.84	2.33	0.00	4.53	0.00	0.00	0.78	0.00	0.00	0.00	0.00		13.48		
430E	SOBRA CHILD 14-20 FE	0.00	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.63	0.00	0.00	0.00		1.27		
4311	SOBRA CHILD <1 M & F	35,824.32	36,535.63	36,175.09	36,039.97	35,788.69	35,714.39	35,742.23	35,428.62	35,698.57	35,773.76	0.00	0.00		358,721.27		
4312	SOBRA CHILD 01-05 M	183,884.02	183,433.17	182,043.16	180,038.68	178,006.14	175,686.54	173,023.31	167,987.71	172,834.89	172,737.05	0.00	0.00		1,769,674.67		
4313	SOBRA CHILD 06-13 M	231,154.67	231,125.24	229,669.81	228,283.23	226,770.09	224,725.47	220,760.11	217,683.01	215,695.17	215,399.77	0.00	0.00		2,241,266.57		
4314	SOBRA CHILD 14-20 MA	58,533.44	58,545.03	58,367.60	58,272.71	58,137.73	57,770.93	56,702.21	57,024.11	55,706.50	55,538.91	0.00	0.00		574,599.17		
4315	SOBRA CHILD 14-20 FE	58,251.71	58,249.43	57,964.70	57,836.65	57,806.93	57,501.90	56,499.18	56,781.22	55,182.11	55,170.33	0.00	0.00		571,244.16		
431A	SOBRA CHILD < 1 M &	294.85	419.98	405.76	413.33	414.83	338.90	413.93	373.51	466.67	336.46	0.00	0.00		3,878.22		
431B	SOBRA CHILD 01-05 M	3,855.57	-23.81	4,317.17	4,295.31	3,855.21	3,576.00	4,333.75	4,652.62	5,566.45	4,808.32	0.00	0.00		39,236.59		
431C	SOBRA CHILD 6-13 M&F	3,793.44	-1,590.65	4,383.95	4,049.20	3,709.82	3,321.62	4,072.37	4,768.00	6,330.03	4,903.28	0.00	0.00		37,741.06		
431D	SOBRA CHILD 14-20 MA	1,055.11	-176.61	1,128.55	1,176.24	1,027.26	913.49	1,127.10	1,322.90	1,687.80	1,367.25	0.00	0.00		10,629.09		
431E	SOBRA CHILD 14-20 FE	1,044.75	-215.15	1,262.35	1,260.17	1,078.00	953.18	1,279.74	1,345.05	1,797.13	1,360.18	0.00	0.00		11,165.40		
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	3.00	3.00	4.00	4.00	3.00	0.00	0.00		33.00		
4323	SOBRA CHILD 06-13 M	2.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	0.00	0.00		16.00		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		7.00		
4325	SOBRA CHILD 14-20 FE	2.00	3.00	3.00	2.00	1.00	1.00	1.00	1.00	2.00	3.00	0.00	0.00		19.00		
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	34.79	37.92	37.88	36.60	38.94	0.00	0.00		416.57		
5008	SOBRA PREG 45-64 FE M	3.83	5.67	4.00	4.16	4.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00		31.66		
500G	SOBRA PREG 21-44 FE
M	1.58	3.12	5.29	0.22	2.89	2.31	4.04	2.09	5.73	3.51	0.00	0.00		30.78		
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	5.44	10.00	5.46	4.00	4.86	0.00	0.00		59.54		
5015	SOBRA PREG 14-20 FE M	3,459.15	3,491.72	3,372.19	3,296.49	3,211.79	3,073.62	3,027.81	2,934.29	3,091.66	3,191.55	0.00	0.00		32,150.27		
5017	SOBRA PREG 21-44 FE
M	18,483.38	18,642.58	18,463.10	18,388.00	17,770.75	17,103.96	16,761.70	16,748.33	16,872.71	17,176.82	0.00	0.00		176,411.33		
5018	SOBRA PREG 45-64 FE M	47.50	43.38	47.19	47.47	42.93	50.11	49.03	49.25	48.89	45.41	0.00	0.00		471.16		
501C	SOBRA PREG 09-13 FE
M	0.00	0.00	0.89	0.61	0.00	1.54	0.00	1.53	0.00	1.12	0.00	0.00		5.69		
501E	SOBRA PREG 14-20 FE M	254.06	-168.85	226.70	204.56	199.34	212.61	212.71	274.98	324.85	280.19	0.00	0.00		2,021.15		
501G	SOBRA PREG 21-44 FE
M	1,005.81	-233.91	1,046.60	1,042.53	975.87	884.78	1,022.68	1,109.63	1,328.16	1,165.58	0.00	0.00		9,347.73		
501H	SOBRA PREG 45-64 FE M	3.46	0.98	3.79	2.51	1.06	7.73	2.95	1.75	1.09	19.56	0.00	0.00		44.88		
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	42.00	41.51	42.53	39.15	40.00	0.00	0.00		425.54		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	0.00	1.00	1.00	1.00	3.00	3.00	4.00	0.00	0.00		16.00		
502G	SOBRA PREG 21-44 FE M	0.03	0.57	0.23	0.00	0.69	0.00	1.47	1.46	1.83	0.00	0.00	0.00		6.28		
SUBTOTAL:	947,815.6	0	933,686.39	950,268.6	0	947,638.60	943,962.88	935,982.85	930,775.38	922,410.22	921,411.49	916,658.00	0.00	0.00		9,350,610.01		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9910	TANF & SOBRA CHILDR E	270.00	308.00	314.00	305.00	300.00	333.00	282.00	254.00	279.00	265.00	0.00	0.00		2,910.00		
9920	SSI W/MEDICARE KICK	7.00	8.00	3.00	2.00	3.00	7.00	4.00	6.00	7.00	4.00	0.00	0.00		51.00		
9921	SSI W/O MEDICARE KIC	20.00	31.00	24.00	22.00	28.00	31.00	22.00	27.00	25.00	23.00	0.00	0.00		253.00		
9950	S.O.B.R.A. KICK PAYM	2,172.00	2,397.00	2,217.00	2,304.00	2,128.00	2,213.00	1,902.00	1,950.00	1,963.00	1,921.00	0.00	0.00		21,167.00		
SUBTOTAL:	2,469.00	2,744.00	2,558.0	0	2,633.00	2,459.00	2,584.00	2,210.00	2,237.00	2,274.00	2,213.00	0.00	0.00		24,381.00		

1104	TANF EXPANDED 14-20	0.00	0.00	1.00	1.00	1.00	1.00	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	1.00	1.00	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	284.95	289.34	270.63	272.01	256.44	0.00	0.00	
1107	TANF EXPANDED 21-44	693.13	652.12	592.64	572.52	558.28	560.71	555.23	548.52	553.13	532.39	0.00	0.00	
1108	TANF EXPANDED 45-64	1,615.00	1,566.75	1,519.22	1,515.60	1,506.47	1,472.02	1,436.02	1,431.98	1,406.74	1,371.06	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	624.46	600.40	587.36	598.92	598.25	580.20	613.31	605.85	600.29	599.03	0.00	0.00	
110F	TANF EXPANDED 21-44	15.51	-10.11	40.04	25.80	19.92	11.90	24.12	14.16	26.93	23.88	0.00	0.00	
110G	TANF EXPANDED 21-44	33.03	36.53	37.57	29.47	17.14	35.38	28.02	45.80	45.46	29.11	0.00	0.00	
110H	TANF EXPANDED 45-64	37.12	44.96	59.70	55.30	46.08	28.96	62.30	50.41	53.48	57.45	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	25.18	12.35	23.40	32.30	37.09	32.16	36.90	31.85	25.05	45.30	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	7.87	7.00	4.17	3.00	3.00	0.00	0.00	
1113	TANF EXPANDED 06-13	44.64	43.00	40.16	41.00	41.00	40.00	38.00	31.00	32.00	28.00	0.00	0.00	
1114	TANF EXPANDED 14-20	458.88	455.19	450.46	434.20	415.82	400.45	390.70	357.75	381.04	372.95	0.00	0.00	
1115	TANF EXPANDED 14-20	1,774.24	1,765.51	1,744.10	1,714.09	1,694.43	1,644.39	1,592.88	1,431.57	1,491.94	1,455.11	0.00	0.00	
1116	TANF EXPANDED 21-44	31,047.87	30,993.42	30,685.15	30,380.07	30,084.69	29,369.47	28,713.17	27,544.95	27,212.54	27,021.82	0.00	0.00	
1117	TANF EXPANDED 21-44	73,554.07	73,351.17	72,882.64	72,716.50	72,384.92	71,333.75	70,186.32	68,295.56	67,693.30	67,294.90	0.00	0.00	
1118	TANF EXPANDED 45-64	26,429.46	26,352.07	26,220.72	26,190.54	26,094.59	25,959.93	25,434.76	25,004.71	24,448.32	24,264.84	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	67.61	62.76	67.61	60.58	60.88	60.12	55.54	66.00	64.54	65.46	0.00	0.00	
111B	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	1.12	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	13.31	13.35	13.94	31.72	12.33	0.00	0.00	
111E	TANF EXPANDED 14-20	27.19	-49.61	35.42	29.20	34.82	28.54	32.94	53.94	46.50	44.43	0.00	0.00	
111F	TANF EXPANDED 21-44	757.55	-17.78	953.06	892.69	810.89	684.91	737.89	880.43	1,168.46	926.17	0.00	0.00	
111G	TANF EXPANDED 21-44	1,200.28	-537.22	1,678.54	1,484.62	1,432.89	1,196.70	1,517.36	1,657.65	2,167.13	1,730.70	0.00	0.00	
111H	TANF EXPANDED 45-64	385.98	-108.67	531.65	598.94	427.07	408.10	494.04	772.48	704.50	518.62	0.00	0.00	

4.00	
5.00	
2,917.92	
5,818.67	
14,840.86	
6,008.07	
192.15	
337.51	
495.76	
301.58	
0.00	
62.04	
378.80	
4,117.44	
16,308.26	
293,053.15	
709,693.13	
256,399.94	
631.10	
1.12	
2.18	
100.41	
283.37	
7,794.27	
13,528.65	
4,732.71	

3100	TRANSPLANT OPTION 1	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	-1.11	0.00	0.00	
3200	TRANSPLANT OPTION
2	0.00	0.00	0.00	0.45	1.00	1.00	1.00	1.00	1.00	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	1.0	0	1.99	2.00	2.00	2.00	2.00	2.00	-1.11	0.00	0.00	

 
5.89	
5.45	
0.54	
11.88	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111J	TANF EXPANDED 65+ M
&	1.38	-10.08	5.35	1.41	3.09	1.86	0.00	0.75	0.06	2.53	0.00	0.00		6.35		
1125	TANF EXPANDED 14-20	1.00	1.00	1.00	2.00	2.00	2.00	2.00	1.00	0.00	1.00	0.00	0.00		13.00		
1126	TANF EXPANDED 21-44	859.34	880.32	885.29	902.45	893.87	914.01	873.92	862.10	834.09	837.43	0.00	0.00		8,742.82		
1127	TANF EXPANDED 21-44	1,676.07	1,728.31	1,737.43	1,738.19	1,714.01	1,716.08	1,699.41	1,665.34	1,687.09	1,691.00	0.00	0.00		17,052.93		
1128	TANF EXPANDED 45-64	2,310.86	2,399.80	2,452.13	2,488.02	2,528.56	2,548.26	2,544.55	2,516.76	2,517.22	2,497.59	0.00	0.00		24,803.75		
1129	TANF EXPANDED 65+ M
&	1,094.60	1,126.09	1,175.73	1,209.11	1,227.45	1,238.76	1,255.39	1,273.23	1,285.15	1,300.71	0.00	0.00		12,186.22		
112F	TANF EXPANDED 21-44	8.80	-3.20	16.38	2.33	1.00	0.00	1.64	4.47	6.69	10.11	0.00	0.00		48.22		
112G	TANF EXPANDED 21-44	2.41	3.81	15.87	1.41	11.58	2.87	8.14	4.67	10.57	9.65	0.00	0.00		70.98		
112H	TANF EXPANDED 45-64	4.23	3.46	3.31	7.10	6.42	9.22	16.66	4.28	8.65	15.69	0.00	0.00		79.02		
112J	TANF EXPANDED 65+ M
&	2.41	1.54	10.86	6.92	3.27	3.30	14.35	7.79	11.99	24.80	0.00	0.00		87.23		
2400	SSI AGED EXPANDED WI	308.22	313.71	242.84	291.30	317.63	254.94	243.55	273.46	299.67	282.96	0.00	0.00		2,828.28		
240Z	SSI AGED EXPANDED
WI	194.97	185.11	187.91	210.01	220.90	191.99	184.19	208.50	330.30	212.01	0.00	0.00		2,125.89		
2410	SSI AGED EXPANDED N O	97.29	98.13	95.51	94.85	91.37	91.14	102.02	96.66	101.01	98.17	0.00	0.00		966.15		
241Z	SSI AGED EXPANDED N
O	6.61	7.78	4.43	8.06	2.74	3.13	3.58	3.33	27.80	-4.42	0.00	0.00		63.04		
2420	SSI AGED EXPANDED WI	22,108.12	22,316.04	22,586.36	22,699.51	22,883.39	23,203.51	23,328.59	23,273.23	23,666.30	23,729.55	0.00	0.00		229,794.60		
242Z	SSI AGED EXPANDED
WI	37.37	39.66	60.64	54.39	53.07	60.25	48.99	37.79	67.00	67.22	0.00	0.00		526.38		
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	1.00	1.00	1.00	1.00	0.00	0.00	0.00		9.00		
2600	SSI DISABLED EXPAND
E	347.79	324.61	247.35	237.08	248.28	239.75	235.11	233.99	251.98	254.50	0.00	0.00		2,620.44		
260Z	SSI DISABLED EXPAND E	123.78	154.48	179.82	153.27	147.86	116.59	174.13	132.74	190.86	172.67	0.00	0.00		1,546.20		
2610	SSI DISABLED EXPAND
E	1,663.98	1,676.27	1,644.33	1,603.46	1,601.03	1,553.99	1,526.79	1,521.48	1,551.93	1,535.86	0.00	0.00		15,879.12		
261Z	SSI DISABLED EXPAND E	40.40	29.50	33.53	37.34	40.93	26.12	21.32	35.24	41.34	43.48	0.00	0.00		349.20		
2620	SSI DISABLED EXPAND
E	17,106.28	17,265.15	17,370.98	17,566.07	17,647.64	17,707.62	17,597.20	17,447.86	17,459.52	17,247.37	0.00	0.00		174,415.69		
262Z	SSI DISABLED EXPAND E	33.13	52.49	63.45	30.35	39.76	44.29	27.68	16.98	41.69	37.28	0.00	0.00		387.10		
SUBTOTAL:	187,179.5	3	184,108.77	187,499.5	3	187,030.33	186,260.38	184,087.62	182,170.40	178,736.00	178,819.99	176,720.15	0.00	0.00		1,832,612.70		

3504	ADULT 40-100% MALE 1	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	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	2.06	4.52	3.15	1.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	3.28	5.47	2.83	8.86	3.00	1.58	1.00	0.00	1.12	2.16	0.00	0.00	
3508	ADULT 40-100% M&F 45	27.33	44.68	42.71	45.83	17.33	13.53	20.91	21.92	18.89	20.09	0.00	0.00	

9.00	
0.00	
17.63	
29.30	
273.22	

9911	SB PAYMENT FOR TAN F	221.00	218.00	217.00	232.00	185.00	181.00	140.00	186.00	198.00	162.00	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	3.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	221.00	220.00	218.0	0	232.00	186.00	181.00	141.00	186.00	198.00	165.00	0.00	0.00	

 
1,940.00	
7.00	
1.00	
1,948.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3509	ADULT 40-100% M&F 65	1.00	0.00	0.00	3.00	2.00	2.00	3.00	5.00	3.00	2.73	0.00	0.00		21.73		
350F	ADULT 40-100% MALE 2	1.99	0.00	0.00	1.64	1.43	0.00	0.93	1.46	13.83	0.00	0.00	0.00		21.28		
350G	ADULT 40-100% FEMAL E	1.69	0.51	0.16	1.64	0.00	0.41	0.00	0.00	1.87	0.83	0.00	0.00		7.11		
350H	ADULT 40-100% M&F 45	3.63	4.26	4.12	2.31	5.24	1.75	5.04	2.06	1.09	2.89	0.00	0.00		32.39		
350J	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	13.00	0.00	0.00	0.00	0.00	0.00		13.00		
3514	ADULT 40-100% MALE 1	6,040.37	6,121.37	6,098.03	6,130.60	6,066.42	5,851.23	5,802.44	5,516.46	5,683.06	5,630.16	0.00	0.00		58,940.14		
3515	ADULT 40-100% FEMAL E	6,434.05	6,464.48	6,467.08	6,433.29	6,319.80	6,245.74	6,195.70	5,902.48	6,037.42	6,009.21	0.00	0.00		62,509.25		
3516	ADULT 40-100% MALE 2	20,700.55	20,821.39	20,744.66	20,862.61	20,750.11	20,317.14	20,101.22	19,601.51	19,223.85	18,981.83	0.00	0.00		202,104.87		
3517	ADULT 40-100% FEMAL E	17,131.52	17,173.85	17,096.43	17,166.84	17,107.69	16,765.59	16,751.42	16,383.44	16,078.38	15,920.10	0.00	0.00		167,575.26		
3518	ADULT 40-100% M&F 45	40,830.77	40,729.18	40,738.43	40,793.10	40,639.36	40,310.88	40,056.25	39,537.52	39,288.60	39,100.23	0.00	0.00		402,024.32		
3519	ADULT 40-100% M&F 65	18.00	20.00	19.00	16.00	15.00	16.00	12.00	8.25	7.00	7.00	0.00	0.00		138.25		
351D	ADULT 40-100% MALE 1	108.95	-81.44	119.02	135.37	104.69	76.52	152.40	106.20	183.51	111.34	0.00	0.00		1,016.56		
351E	ADULT 40-100% FEMAL E	95.12	-38.04	154.88	161.03	103.35	137.75	160.26	173.70	178.11	162.53	0.00	0.00		1,288.69		
351F	ADULT 40-100% MALE 2	425.91	-15.63	568.43	732.70	478.96	456.52	704.76	578.38	753.05	538.16	0.00	0.00		5,221.24		
351G	ADULT 40-100% FEMAL E	327.74	-34.71	406.95	575.84	419.74	393.90	622.48	516.12	694.12	498.31	0.00	0.00		4,420.49		
351H	ADULT 40-100% M&F 45	792.15	-118.47	998.58	1,054.70	759.02	960.66	1,168.28	1,075.92	1,285.69	979.68	0.00	0.00		8,956.21		
351J	ADULT 40-100% M&F 65	17.00	-5.00	10.00	4.00	10.00	2.00	7.00	3.00	3.75	27.00	0.00	0.00		78.75		
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	1.40	0.00	0.00		3.46		
3528	ADULT 40-100% M&F 45	4.66	5.98	5.66	6.67	4.09	2.00	1.48	2.78	0.00	0.83	0.00	0.00		34.15		
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	1.00	0.00	0.00		8.00		
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	0.60	0.00	0.00		1.53		
352H	ADULT 40-100% M&F 45	3.31	2.99	1.93	1.32	1.89	0.00	1.50	0.21	0.00	0.16	0.00	0.00		13.31		
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.61	0.00	0.00	0.58	0.00	0.00	0.00		1.19		
3705	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		2.00		
3706	ADULT <40% EXP MALE	6.74	12.15	10.01	11.35	10.22	4.65	7.32	4.53	5.74	6.18	0.00	0.00		78.89		
3707	ADULT <40% EXP FEMA L	4.58	6.78	4.42	6.50	7.59	3.67	4.02	5.98	7.35	2.22	0.00	0.00		53.11		
3708	ADULT <40% EXP M&F
4	23.17	31.40	26.46	21.74	17.95	21.95	16.52	21.74	20.85	13.58	0.00	0.00		215.36		
3709	ADULT <40% EXP M&F 6	2.00	2.00	2.00	2.00	1.00	1.00	2.00	2.00	1.83	1.00	0.00	0.00		16.83		
370D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.38	0.00	0.00	0.41	0.00	0.00	0.00		0.79		
370E	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	3.00	0.00	0.00	0.00	0.00	0.00		3.00		
370F	ADULT <40% EXP MALE	2.23	5.37	7.20	3.20	2.94	0.83	2.82	4.18	3.48	1.27	0.00	0.00		33.52		
370G	ADULT <40% EXP FEMA L	4.45	-1.17	4.25	6.67	4.19	0.72	0.38	1.80	7.31	1.43	0.00	0.00		30.03		
370H	ADULT <40% EXP M&F
4	16.31	12.14	6.45	12.32	9.81	10.10	3.73	16.13	9.32	8.07	0.00	0.00		104.38		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.16	0.00	0.00	0.00		0.16		
3714	ADULT <40% EXP MALE	10,805.54	10,877.98	10,805.43	10,750.68	10,516.19	10,344.46	10,203.56	9,881.79	9,971.14	9,925.78	0.00	0.00		104,082.55		
3715	ADULT <40% EXP FEMA L	9,615.96	9,669.94	9,631.53	9,577.93	9,422.98	9,238.77	9,072.20	8,741.95	8,866.65	8,804.19	0.00	0.00		92,642.10		
3716	ADULT <40% EXP MALE	62,436.00	63,349.72	62,894.28	62,968.89	63,394.39	62,912.66	62,733.32	62,340.45	62,338.82	61,861.01	0.00	0.00		627,229.54		
3717	ADULT <40% EXP FEMA L	37,546.58	37,992.10	37,666.27	37,631.23	37,653.41	37,338.91	37,143.38	36,782.15	36,613.51	36,423.34	0.00	0.00		372,790.88		
3718	ADULT <40% EXP M&F
4	77,487.79	78,144.62	77,680.98	77,904.50	78,438.80	77,864.95	77,334.63	76,887.15	76,607.19	76,124.70	0.00	0.00		774,475.31		
3719	ADULT <40% EXP M&F 6	42.15	40.00	42.00	37.83	36.46	36.00	32.19	29.21	24.00	24.00	0.00	0.00		343.84		
371D	ADULT <40% EXP MALE	220.48	-235.02	274.88	287.45	223.59	234.61	277.17	293.51	433.59	296.04	0.00	0.00		2,306.30		
371E	ADULT <40% EXP FEMA L	211.92	-119.76	265.33	242.81	232.59	179.93	229.64	338.50	331.87	331.03	0.00	0.00		2,243.86		
371F	ADULT <40% EXP MALE	2,271.65	-992.30	2,910.89	2,744.62	2,380.77	2,375.86	2,886.77	2,920.11	3,192.39	2,623.19	0.00	0.00		23,313.95		
371G	ADULT <40% EXP FEMA L	1,322.71	-206.75	1,497.42	1,435.71	1,253.06	1,303.27	1,451.08	1,568.19	1,969.72	1,510.43	0.00	0.00		13,104.84		
371H	ADULT <40% EXP M&F
4	1,998.95	-1,114.93	2,407.18	2,351.22	2,247.33	1,999.02	2,720.88	2,428.09	2,927.80	2,280.90	0.00	0.00		20,246.44		
371J	ADULT <40% EXP M&F 6	5.00	10.00	0.00	0.00	13.53	0.00	15.80	0.00	16.00	3.00	0.00	0.00		63.33		
3724	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3725	ADULT <40% EXP FEMA L	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 MALE	7.85	3.72	2.86	2.41	0.00	0.00	0.00	1.78	3.63	1.83	0.00	0.00		24.08		
3727	ADULT <40% EXP FEMA L	1.00	0.00	1.00	0.00	0.00	1.00	1.00	1.46	1.00	1.40	0.00	0.00		7.86		
3728	ADULT <40% EXP M&F
4	9.18	9.27	5.26	5.51	4.55	4.78	2.00	1.07	2.08	3.13	0.00	0.00		46.83		
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	0.96	0.00	0.00		1.96		
372F	ADULT <40% EXP MALE	0.53	0.73	2.53	0.60	0.00	0.00	0.00	2.21	1.31	1.16	0.00	0.00		9.07		
372G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.53	0.00	1.60	0.00	0.00		2.13		
372H	ADULT <40% EXP M&F
4	1.63	8.68	2.72	1.41	0.29	2.19	0.00	2.92	1.89	0.86	0.00	0.00		22.59		
372J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	0.00	6.03	0.00	0.00		9.03		
SUBTOTAL:	297,018.4	1	288,614.53	299,637.2	4	300,151.26	298,687.31	295,436.52	295,927.54	291,722.36	292,821.11	288,259.57	0.00	0.00		2,948,275.85		

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	10.63	5.30	3.76	2.77	4.25	1.38	1.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	3.80	3.70	1.00	4.14	2.93	2.54	3.06	4.91	3.00	1.96	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	38.00	122.33	131.89	135.87	31.54	30.40	36.88	40.67	36.33	32.28	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	4.19	6.00	10.00	9.90	9.70	5.00	4.00	11.00	10.00	9.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	1.45	1.56	2.35	0.70	1.22	1.22	0.75	1.61	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1.19	0.29	0.00	3.50	1.06	0.00	0.92	2.06	7.00	1.03	0.00	0.00	

0.00	
0.00	
41.06	
31.04	
636.19	
78.79	
10.86	
17.05	

9935	BIRTH SUPP PAYMENT A	45.00	43.00	45.00	32.00	44.00	63.00	28.00	34.00	38.00	37.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	79.00	92.00	91.00	90.00	76.00	82.00	93.00	80.00	98.00	77.00	0.00	0.00	
SUBTOTAL:	124.00	135.00	136.0	0	122.00	120.00	145.00	121.00	114.00	136.00	114.00	0.00	0.00	

 
409.00	
858.00	
1,267.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390H	NEWLY ELIGIBLE M&F 4	0.00	2.63	0.66	4.68	4.41	2.41	4.01	1.32	3.91	18.43	0.00	0.00		42.46		
390J	NEWLY ELIGIBLE M&F
6	0.80	0.00	0.00	0.09	3.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.19		
3914	NEWLY ELIGIBLE MALE	3,170.21	3,191.95	3,236.12	3,310.66	3,267.85	3,212.63	3,154.38	2,969.36	3,031.13	3,006.12	0.00	0.00		31,550.41		
3915	NEWLY ELIGIBLE FEMA L	3,569.35	3,612.66	3,644.15	3,692.16	3,717.52	3,594.99	3,522.08	3,340.88	3,401.37	3,408.11	0.00	0.00		35,503.27		
3916	NEWLY ELIGIBLE MALE	18,777.73	18,863.69	18,693.74	18,775.28	18,736.32	18,346.51	18,161.83	17,711.38	17,359.82	17,060.12	0.00	0.00		182,486.42		
3917	NEWLY ELIGIBLE FEMA L	26,090.37	26,337.35	26,208.98	26,333.06	26,253.04	25,908.75	25,678.08	25,220.13	24,843.63	24,559.72	0.00	0.00		257,433.11		
3918	NEWLY ELIGIBLE M&F
4	27,742.64	27,884.04	27,761.44	27,812.37	27,770.91	27,595.70	27,200.98	26,795.80	26,570.42	26,247.36	0.00	0.00		273,381.66		
3919	NEWLY ELIGIBLE M&F 6	13.00	14.00	17.00	17.00	16.00	14.00	12.00	14.00	15.00	14.00	0.00	0.00		146.00		
391D	NEWLY ELIGIBLE MALE	71.15	-34.58	81.33	94.48	74.74	44.03	100.31	77.48	92.64	94.90	0.00	0.00		696.48		
391E	NEWLY ELIGIBLE FEMA L	86.75	-55.16	113.23	112.08	96.72	67.85	101.82	90.58	140.54	113.65	0.00	0.00		868.06		
391F	NEWLY ELIGIBLE MALE	560.99	-214.18	652.27	751.60	602.74	491.21	704.50	654.32	894.59	693.57	0.00	0.00		5,791.61		
391G	NEWLY ELIGIBLE FEMA L	757.74	-209.31	912.16	1,036.98	822.44	701.52	983.85	957.07	1,176.92	1,028.80	0.00	0.00		8,168.17		
391H	NEWLY ELIGIBLE M&F
4	581.40	-56.14	740.34	964.06	714.02	631.04	896.90	787.75	968.66	732.24	0.00	0.00		6,960.27		
391J	NEWLY ELIGIBLE M&F 6	10.00	1.00	2.00	0.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00		15.00		
3926	NEWLY ELIGIBLE MALE	0.61	1.64	1.00	1.00	1.96	1.00	0.00	0.00	0.70	0.00	0.00	0.00		7.91		
3927	NEWLY ELIGIBLE FEMA L	1.00	0.00	0.00	1.00	0.00	0.12	0.00	0.46	0.00	0.00	0.00	0.00		2.58		
3928	NEWLY ELIGIBLE M&F
4	1.67	4.76	6.16	6.93	1.00	3.35	2.93	1.03	0.29	1.93	0.00	0.00		30.05		
3929	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
392F	NEWLY ELIGIBLE MALE	1.38	0.35	0.00	0.00	2.03	0.00	0.00	0.00	1.11	0.00	0.00	0.00		4.87		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.87	0.00	0.53	0.00	0.00	0.00	0.00		1.40		
392H	NEWLY ELIGIBLE M&F
4	0.32	1.22	0.83	0.06	0.00	0.25	1.05	0.96	-0.29	0.06	0.00	0.00		4.46		
SUBTOTAL:	81,486.29	79,485.23	82,220.2	9	83,079.88	82,136.23	80,659.15	80,573.57	78,688.69	78,559.76	77,024.28	0.00	0.00		803,913.37		

664.00

4403	SOBRA 100-133% M&F
6	7.00	8.00	7.33	7.35	3.00	3.00	3.00	3.00	3.00	2.00	0.00	0.00	
4404	SOBRA 100-133% MALE	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	
4405	SOBRA 100-133% FEMA L	3.00	2.00	2.00	2.00	3.00	3.00	3.00	2.00	2.00	2.00	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	4.00	6.00	5.00	5.00	1.00	1.00	1.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	46,895.22	47,076.63	47,018.47	47,135.82	47,228.24	46,385.05	45,753.38	44,605.26	44,364.06	44,187.38	0.00	0.00	
4414	SOBRA 100-133% MALE	12,578.90	12,653.71	12,604.44	12,624.58	12,674.44	12,474.61	12,277.11	12,244.50	11,915.35	11,811.28	0.00	0.00	
4415	SOBRA 100-133% FEMA L	12,030.22	12,087.03	12,092.21	12,250.24	12,190.13	12,009.50	11,787.54	11,682.56	11,500.19	11,484.88	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	1,402.27	1,058.10	876.08	1,114.02	1,423.45	1,793.91	1,414.95	0.00	0.00	

46.68	
20.00	
24.00	
2.66	
0.00	
40.22	
460,649.51	
123,858.92	
119,114.50	
-2.23	
10,704.33	

9939	BIRTH SUPP PAYMENT N	68.00	52.00	74.00	73.00	70.00	73.00	64.00	70.00	63.00	57.00	0.00	0.00	
SUBTOTAL:	68.00	52.00	74.00	73.00	70.00	73.00	64.00	70.00	63.00	57.00	0.00	0.00	

 
664.00

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
441D	SOBRA 100-133% MALE	218.83	-61.63	290.61	285.80	271.10	243.38	281.65	361.24	424.80	419.48	0.00	0.00		2,735.26		
441E	SOBRA 100-133% FEMA L	208.03	-134.60	282.82	393.55	258.85	215.00	329.79	398.84	505.51	399.06	0.00	0.00		2,856.85		
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4425	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	72,891.27	71,124.91	73,499.2	4	74,107.61	73,694.86	72,216.62	71,556.49	70,723.85	70,511.82	69,724.03	0.00	0.00		720,050.70		

57.00

4517	BC PATIENT FEMALE 2 1	18.00	21.53	21.00	21.00	15.03	16.00	17.00	18.00	18.61	20.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	116.79	104.47	104.12	102.92	96.43	95.66	99.07	100.36	102.66	102.64	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.12	1.87	2.00	0.99	3.00	0.00	0.00	3.83	0.17	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.00	7.43	0.00	0.00	0.00	0.00	0.00	1.00	1.38	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	7.95	5.65	0.86	6.03	2.56	9.31	3.90	5.95	4.56	42.31	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	9.00	9.64	10.00	10.00	8.70	8.35	9.00	9.00	9.00	9.23	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	10.00	10.74	12.60	13.00	13.00	13.00	13.00	11.54	12.00	11.23	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	1.30	4.64	0.00	0.00	0.00	18.76	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	18.76	0.00	0.00	
SUBTOTAL:	162.74	164.18	153.8	5	154.95	138.01	149.96	141.97	145.85	152.04	223.10	0.00	0.00	

186.17	
1,025.12	
11.98	
9.81	
89.08	
91.92	
120.11	
0.00	
27.05	
25.41	
1,586.65	

8600	SSI BLIND FREEDOM/W O	2.70	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	
860Z	SSI BLIND FREEDOM/W
O	5.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,908.94	1,939.08	1,947.08	1,959.74	1,979.43	1,989.70	1,999.05	2,026.29	2,079.10	2,117.17	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	50.68	69.14	45.86	67.87	35.08	48.78	52.77	69.28	119.73	64.28	0.00	0.00	
8710	SSI DISABLED FREEDO M	336.40	351.75	364.10	370.54	374.08	375.35	378.52	379.42	370.37	382.91	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	19.43	23.53	29.65	10.62	8.87	27.01	14.17	21.88	25.39	28.78	0.00	0.00	
8720	SSI DISABLED FREEDO M	232.56	232.39	237.36	233.15	226.06	232.24	231.28	235.31	238.43	250.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	3.39	8.56	6.56	3.52	0.93	11.20	3.70	3.67	7.46	10.94	0.00	0.00	
SUBTOTAL:	2,559.38	2,626.45	2,632.6	1	2,647.44	2,626.45	2,686.28	2,681.49	2,737.85	2,842.48	2,856.08	0.00	0.00	

20.70	
5.28	
19,945.58	
623.47	
3,683.44	
209.33	
2,348.78	
59.93	
26,896.51	

9944	BIRTH SUPP PAYMENT S	4.00	9.00	6.00	8.00	6.00	6.00	7.00	7.00	1.00	3.00	0.00	0.00	
SUBTOTAL:	4.00	9.00	6.00	8.00	6.00	6.00	7.00	7.00	1.00	3.00	0.00	0.00	

 
57.00

TOTAL:	1,591,999.22	1,562,970.46	1,598,904.36	1,597,880.06	1,590,349.12	1,574,210.00	1,566,371.84	1,547,780.82	1,547,792.69	1,534,016.10	0.00	0.00		15,712,274.67		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.96	15.96	0.00	0.00	0.00		31.92		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.96	15.96	0.00	0.00	0.00		31.92		

31.92

0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.96	15.96	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00		2.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00		2.00		

TOTAL:

0.00

0.00

0.00

0.00

1.00

0.00

2.00

0.00

0.00

0.00	0.00

1.00

0.00

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending April 30, 2018	
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	29,111.92	33,600.08	32,892.74	37,910.33	37,548.23	33,743.33	33,743.33	0.00	0.00		329,816.97		
1010	TANF NON-MEDICARE	2,613,870.08	2,616,266.25	2,631,920.92	2,670,172.21	2,698,796.85	2,703,999.56	3,197,632.06	2,823,368.29	2,771,178.85	2,815,166.21	0.00	0.00		27,542,371.28		
101Z	TANF ALTCS 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		
1020	TANF WITH QMB	14,552.84	14,552.84	14,552.84	14,765.32	14,765.32	14,765.32	13,646.94	15,219.60	19,024.50	19,024.50	0.00	0.00		154,870.02		
2100	SSI AGED WITH MEDIC A	32,933,806.96	40,503,011.75	33,281,856.76	32,613,518.75	40,123,652.30	33,400,168.54	32,643,008.10	32,611,389.31	32,453,766.53	32,459,906.74	0.00	0.00		343,024,085.74		
210Z	SSI AGED WITH MEDIC
A	652,373.23	802,200.05	651,370.99	756,913.70	735,995.24	590,263.21	574,345.41	571,294.76	687,370.87	599,122.85	0.00	0.00		6,621,250.31		
2110	SSI AGED NON-MEDICA R	2,945,767.23	3,442,829.16	3,086,070.45	3,264,761.17	3,691,710.25	3,295,217.26	3,302,804.30	3,272,129.76	3,271,108.11	3,039,178.27	0.00	0.00		32,611,575.96		
211Z	SSI AGED NON-MEDICA
R	26,026.97	37,754.67	25,487.67	29,091.14	16,381.91	19,369.57	11,070.16	17,670.32	23,992.60	13,937.16	0.00	0.00		220,782.17		
2120	SSI AGED WITH QMB	20,774,403.47	25,359,009.41	21,011,673.41	20,635,489.16	25,324,469.31	21,223,510.09	20,980,683.70	20,946,546.04	20,780,382.47	21,020,084.42	0.00	0.00		218,056,251.48		
212Z	SSI AGED WITH QMB P P	18,726.37	17,194.42	2,467.88	21,466.46	5,586.23	14,951.08	11,711.31	19,670.22	28,156.10	-2,899.13	0.00	0.00		137,030.94		
2200	SSI DISABLED WITH M
E	15,894,224.54	17,882,836.09	16,041,237.40	15,810,280.52	17,828,377.65	16,119,091.86	17,497,507.79	16,504,177.70	16,428,025.17	16,684,911.70	0.00	0.00		166,690,670.42		
220Z	SSI DISABLED WITH M E	68,599.31	115,034.86	62,678.50	76,377.41	83,041.79	81,453.81	74,086.30	57,217.66	85,304.82	96,282.16	0.00	0.00		800,076.62		
2210	SSI DISABLED NON-ME
D	106,245,644.56	109,460,228.37	106,868,665.32	110,631,305.99	113,774,689.82	111,823,732.77	127,702,297.62	115,064,815.55	115,578,542.59	116,564,696.90	0.00	0.00		1,133,714,619.49		
221Z	SSI DISABLED NON-ME D	21,758.30	32,964.90	23,051.86	25,659.65	26,751.95	20,565.63	31,114.51	81,686.59	27,840.59	31,410.76	0.00	0.00		322,804.74		
2220	SSI DISABLED WITH Q
M	23,534,174.16	25,423,926.94	23,587,390.51	23,810,590.89	25,714,985.79	24,013,583.63	26,773,399.31	24,416,845.95	24,476,165.58	24,617,505.21	0.00	0.00		246,368,567.97		
222Z	SSI DISABLED WITH Q M	9,199.93	0.00	4,348.62	8,309.77	29.95	532.72	4,456.75	2,788.34	386.98	5,114.11	0.00	0.00		35,167.17		
2300	SSI BLIND WITH MEDIC	70,372.06	79,197.33	80,370.70	80,204.64	85,677.54	80,629.33	93,197.57	82,458.52	77,817.81	82,833.32	0.00	0.00		812,758.82		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	3,969.19	0.00	0.00	0.00	0.00	121.04	0.00	0.00		4,090.23		
2310	SSI BLIND NON-MEDIC A	534,836.83	549,634.63	542,529.65	563,116.31	574,194.86	569,948.71	652,102.73	574,874.95	576,102.53	541,522.60	0.00	0.00		5,678,863.80		
231Z	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	234.28	0.00	0.00	0.00	0.00	0.00		234.28		
2320	SSI BLIND WITH QMB	144,734.34	166,531.44	155,294.87	151,242.92	164,128.78	161,567.26	171,898.63	156,433.42	161,074.13	139,717.65	0.00	0.00		1,572,623.44		
SUBTOTAL:	206,535,653.3	8 226,532,913.93	208,099,912.3	4 211,192,377.93	230,900,804.81	214,166,243.09	233,773,107.80	217,256,135.21	217,479,983.56	218,761,379.80	0.00	0.00		2,184,698,511.85		

8700	SSI DISABLED FREEDO M	85,343.64	104,810.80	93,916.27	92,138.48	99,269.28	90,048.07	97,879.63	87,432.18	90,134.80	97,211.94	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	121.04	0.00	0.00	
8710	SSI DISABLED FREEDO M	130,847.60	152,194.77	136,874.37	138,845.55	161,815.58	130,796.11	141,347.14	146,983.32	146,983.32	146,959.30	0.00	0.00	
8720	SSI DISABLED FREEDO
M	24,649.26	27,384.54	24,649.26	24,095.01	26,830.29	24,334.11	26,868.60	24,636.36	24,636.36	24,636.36	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	240,840.5	0	284,390.11	255,439.9	0	255,079.04	287,915.15	245,178.29	266,095.37	259,051.86	261,754.48	268,928.64	0.00	0.00	

 
938,185.09	
121.04	
1,433,647.06	
252,720.15	
0.00	
2,624,673.34	

2,187,323,185.19

206,776,493.88	226,817,304.04	208,355,352.24	211,447,456.97	231,188,719.96	214,411,421.38	234,039,203.17	217,515,187.07	217,741,738.04	219,030,308.44	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending April 30, 2018	
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	8.00	9.00	9.00	9.00	10.00	9.00	9.00	0.00	0.00		88.00		
1010	TANF NON-MEDICARE	713.19	711.87	718.12	716.67	722.52	725.60	729.87	735.15	723.10	734.65	0.00	0.00		7,230.74		
101Z	TANF ALTCS 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		
1020	TANF WITH QMB	4.00	4.00	4.00	4.00	4.00	4.00	3.00	4.00	5.00	5.00	0.00	0.00		41.00		
2100	SSI AGED WITH MEDIC A	11,369.40	11,418.65	11,468.09	11,499.15	11,530.37	11,502.95	11,377.79	11,402.93	11,345.92	11,342.04	0.00	0.00		114,257.29		
210Z	SSI AGED WITH MEDIC
A	627.42	774.25	623.13	743.99	754.18	624.50	615.35	612.76	731.64	640.11	0.00	0.00		6,747.33		
2110	SSI AGED NON-MEDICA R	541.12	550.98	556.86	543.59	554.20	543.96	546.71	543.27	541.40	507.22	0.00	0.00		5,429.31		
211Z	SSI AGED NON-MEDICA
R	24.80	35.79	24.47	28.39	17.04	19.96	11.98	18.64	25.67	14.23	0.00	0.00		220.97		
2120	SSI AGED WITH QMB	7,613.97	7,668.28	7,718.43	7,762.28	7,803.40	7,777.59	7,731.85	7,786.53	7,713.31	7,782.13	0.00	0.00		77,357.77		
212Z	SSI AGED WITH QMB P P	18.33	17.56	2.33	21.96	5.94	16.28	12.37	20.39	29.85	-2.67	0.00	0.00		142.34		
2200	SSI DISABLED WITH M
E	4,922.28	4,934.11	4,975.69	4,948.71	4,969.19	4,966.54	5,008.44	5,058.26	5,049.86	5,124.11	0.00	0.00		49,957.19		
220Z	SSI DISABLED WITH M E	67.01	92.31	59.81	75.85	84.84	86.23	78.04	62.39	92.94	103.34	0.00	0.00		802.76		
2210	SSI DISABLED NON-ME
D	27,568.14	27,678.83	27,713.34	27,858.50	27,994.89	28,080.41	28,139.45	28,256.46	28,385.54	28,589.93	0.00	0.00		280,265.49		
221Z	SSI DISABLED NON-ME D	19.53	32.55	23.76	25.12	28.41	21.26	32.52	56.89	29.97	33.34	0.00	0.00		303.35		
2220	SSI DISABLED WITH Q
M	7,082.95	7,092.05	7,107.29	7,151.53	7,165.87	7,175.52	7,183.31	7,184.22	7,210.36	7,245.40	0.00	0.00		71,598.50		
222Z	SSI DISABLED WITH Q M	8.46	0.00	4.34	8.42	0.03	0.57	4.89	3.06	0.42	5.60	0.00	0.00		35.79		
2300	SSI BLIND WITH MEDIC	20.00	21.00	23.00	23.00	22.96	23.00	24.00	24.00	23.00	24.70	0.00	0.00		228.66		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	4.03	0.00	0.00	0.00	0.00	0.13	0.00	0.00		4.16		
2310	SSI BLIND NON-MEDIC A	139.64	141.78	143.00	144.00	144.00	145.80	145.76	143.12	142.32	134.93	0.00	0.00		1,424.35		
231Z	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.25	0.00	0.00	0.00	0.00	0.00		0.25		
2320	SSI BLIND WITH QMB	44.22	48.00	47.00	46.00	46.99	49.54	47.00	47.00	48.00	41.32	0.00	0.00		465.07		
SUBTOTAL:	60,793.46	61,230.01	61,220.6	6	61,609.16	61,861.86	61,772.71	61,701.58	61,969.07	62,107.30	62,334.51	0.00	0.00		616,600.32		

8700	SSI DISABLED FREEDO M	24.58	27.00	27.00	27.00	26.00	26.00	26.00	25.00	26.00	28.03	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.13	0.00	0.00	
8710	SSI DISABLED FREEDO M	24.00	25.00	25.00	24.00	25.00	23.15	24.00	25.00	25.00	24.79	0.00	0.00	
8720	SSI DISABLED FREEDO
M	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	7.99	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.58	60.00	60.0	0	59.00	59.00	57.15	58.00	58.00	59.00	60.94	0.00	0.00	

 
262.61	
0.13	
244.94	
79.99	
0.00	
587.67	

TOTAL:	60,850.04	61,290.01	61,280.66	61,668.16	61,920.86	61,829.86	61,759.58	62,027.07	62,166.30	62,395.45	0.00	0.00		617,187.99		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2018	
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	456.77	422.94	503.27	401.78	122.65	67.66	33.83	0.00	0.00		3,023.76		
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		
100B	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.99	0.00	0.00	0.00	0.00		54.99		
100C	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54.99	0.00	0.00	0.00	0.00		54.99		
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	3,352,046.95	3,423,781.13	3,457,919.07	3,484,027.84	3,451,655.17	3,230,094.95	3,229,525.31	0.00	0.00		32,801,106.23		
1011	TANF <1 M & F NON-ME	21,465.67	27,973.56	23,869.95	26,597.19	26,487.95	23,618.75	23,641.92	22,189.04	24,847.23	22,691.40	0.00	0.00		243,382.66		
1012	TANF 01-05 M & F NON	4,553.03	8,838.19	6,862.89	7,356.04	6,714.51	7,565.51	5,128.44	6,314.50	8,396.53	4,780.44	0.00	0.00		66,510.08		
1013	TANF 06-13 M & F NON	6,028.74	10,281.76	8,823.02	9,299.17	9,583.91	7,909.89	8,394.30	12,617.85	8,024.40	5,686.06	0.00	0.00		86,649.10		
1014	TANF 14-20 MALE NON-	1,035.47	1,748.57	2,121.10	2,070.95	1,892.86	1,457.98	1,800.22	2,712.09	2,288.99	1,588.30	0.00	0.00		18,716.53		
1015	TANF 14-20 FEMALE N O	837.07	1,900.47	1,596.16	1,954.39	1,143.14	1,611.90	1,743.19	2,820.95	2,200.38	1,097.45	0.00	0.00		16,905.10		
1017	TANF 21-44 FEMALE N
O	0.00	-17.01	0.00	0.00	-54.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-72.00		
101A	TANF < 1 M & F NON-M	45,350.70	47,819.37	49,115.21	56,284.92	57,665.00	49,239.60	49,703.01	50,836.69	56,398.96	46,006.23	0.00	0.00		508,419.69		
101B	TANF 01-05 M & F NON	10,678.65	14,220.75	15,534.26	17,482.83	17,245.66	10,351.53	11,082.56	14,895.79	14,418.44	11,071.98	0.00	0.00		136,982.45		
101C	TANF 06-13 M & F NON	9,637.85	12,440.81	11,438.88	12,124.94	10,174.64	8,315.77	9,879.44	8,829.49	7,954.10	11,476.69	0.00	0.00		102,272.61		
101D	TANF 14-20 MALE NON-	2,927.22	2,190.31	2,332.10	2,356.58	1,685.48	1,444.38	1,560.52	2,408.91	2,034.22	1,427.99	0.00	0.00		20,367.71		
101E	TANF 14-20 FEMALE N O	1,386.26	3,030.83	2,757.66	2,171.48	2,327.36	2,460.24	2,422.43	2,358.05	2,088.71	2,369.93	0.00	0.00		23,372.95		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	33.83	33.83	33.83	33.83	33.83	33.83	0.00	0.00		202.98		
2200	SSI DISABLED WITH M E	58.58	115.69	58.58	67.66	67.66	67.66	67.66	67.66	67.66	33.83	0.00	0.00		672.64		
2210	SSI DISABLED NON-ME
D	339,385.86	339,565.32	335,692.86	355,587.48	353,799.63	352,894.78	352,197.89	349,606.61	349,011.79	347,032.93	0.00	0.00		3,474,775.15		
221Z	SSI DISABLED NON-ME D	3,473.04	2,989.30	4,514.46	4,614.89	3,218.09	4,943.55	3,911.87	4,620.77	8,561.11	4,488.13	0.00	0.00		45,335.21		
2220	SSI DISABLED WITH Q
M	317.52	323.19	380.30	308.98	253.99	287.82	287.82	253.99	257.40	271.09	0.00	0.00		2,942.10		
2310	SSI BLIND NON-MEDIC A	1,549.96	1,579.25	1,618.79	1,751.33	1,870.00	1,802.34	1,768.51	1,775.76	1,858.00	1,892.29	0.00	0.00		17,466.23		
231Z	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	4.37	0.00	0.00	0.00	249.77	79.66	0.00	0.00	0.00		333.80		
4300	SOBRA CHILD WITH ME D	3,672.02	3,706.72	4,056.73	4,577.52	4,184.43	3,976.94	3,913.59	3,714.59	3,727.26	3,236.66	0.00	0.00		38,766.46		
4301	SOBRA CHILD <1 M & F	0.00	26.46	23.43	-32.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.15		
4302	SOBRA CHILD 01-05 M	3.78	53.41	40.51	20.73	30.45	5.46	0.00	23.42	-5.58	0.00	0.00	0.00		172.18		
4303	SOBRA CHILD 06-13 M	-22.11	137.16	74.77	-41.47	-65.58	-25.09	0.00	-58.92	0.00	109.98	0.00	0.00		108.74		
4304	SOBRA CHILD 14-20 MA	-24.57	-26.46	0.00	0.00	0.00	-36.01	0.00	0.00	0.00	0.00	0.00	0.00		-87.04		
4305	SOBRA CHILD 14-20 FE	0.00	-17.96	0.00	0.00	0.00	0.00	0.00	0.00	6.42	0.00	0.00	0.00		-11.54		
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	76.22	76.68	0.00	0.00	67.37	0.00	0.00	0.00	0.00		617.20		
430C	SOBRA CHILD 06-13 M	0.00	225.72	80.40	0.00	153.36	0.00	0.00	43.21	0.00	0.00	0.00	0.00		502.69		
430E	SOBRA CHILD 14-20 FE	0.00	18.90	0.00	0.00	0.00	0.00	0.00	0.00	21.29	0.00	0.00	0.00		40.19		
4310	SOBRA CHILD NON-ME DI	20,726,044.30	20,662,708.89	20,608,786.64	21,715,930.72	21,567,669.05	21,407,075.58	21,127,929.29	20,660,653.09	20,643,154.50	20,695,718.82	0.00	0.00		209,815,670.88		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4311	SOBRA CHILD <1 M & F	74,767.02	85,586.36	83,703.34	87,671.38	82,937.76	73,870.01	76,156.38	68,243.18	73,608.57	65,425.88	0.00	0.00		771,969.88		
4312	SOBRA CHILD 01-05 M	97,241.60	128,724.36	107,914.76	119,461.60	125,261.10	112,237.04	116,772.26	134,496.08	162,366.43	140,525.96	0.00	0.00		1,245,001.19		
4313	SOBRA CHILD 06-13 M	100,730.14	146,407.59	117,325.83	114,721.05	123,729.09	110,865.55	122,166.42	155,787.36	191,104.90	146,437.16	0.00	0.00		1,329,275.09		
4314	SOBRA CHILD 14-20 MA	18,684.49	29,311.73	23,622.12	23,817.57	26,660.81	23,947.05	25,243.27	34,017.47	41,244.97	30,042.76	0.00	0.00		276,592.24		
4315	SOBRA CHILD 14-20 FE	22,348.49	28,238.11	23,599.05	23,971.32	25,657.08	24,195.31	26,456.67	34,021.00	38,754.23	31,574.23	0.00	0.00		278,815.49		
431A	SOBRA CHILD < 1 M &	13,722.48	16,441.34	16,127.04	15,592.14	15,849.63	13,728.07	16,458.16	15,169.81	18,625.71	13,932.18	0.00	0.00		155,646.56		
431B	SOBRA CHILD 01-05 M	144,680.47	160,579.12	160,748.71	171,846.05	156,111.66	143,007.47	175,767.62	189,770.23	220,678.06	190,756.77	0.00	0.00		1,713,946.16		
431C	SOBRA CHILD 6-13 M&F	141,402.90	172,682.80	163,699.29	158,613.27	147,517.13	131,192.30	163,741.43	189,097.77	248,231.90	196,910.62	0.00	0.00		1,713,089.41		
431D	SOBRA CHILD 14-20 MA	28,416.16	40,056.79	32,927.01	35,444.54	32,354.81	28,237.07	35,990.36	41,487.99	51,543.89	43,399.36	0.00	0.00		369,857.98		
431E	SOBRA CHILD 14-20 FE	29,144.05	35,772.33	35,465.37	35,918.90	32,358.84	29,734.83	38,804.46	38,910.39	53,950.02	43,206.75	0.00	0.00		373,265.94		
4320	SOBRA CHILD WITH Q MB	115.69	144.98	231.38	279.13	279.13	224.14	224.14	257.97	279.13	279.13	0.00	0.00		2,314.82		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.83	0.00	0.00	0.00		33.83		
5000	SOBRA PREGNANT WO MAN	57.11	57.11	57.11	54.99	54.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281.31		
5005	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	-40.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-40.33		
5010	SOBRA PREGNANT WO MAN	18,588.05	18,426.84	16,778.66	17,269.71	16,947.13	15,986.49	16,417.59	15,871.80	16,046.39	17,548.77	0.00	0.00		169,881.43		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	22.84	13.10	0.00	15.28	0.00	15.71	0.00	82.89	0.00	0.00		149.82		
5015	SOBRA PREG 14-20 FE M	1,222.55	1,050.98	677.05	985.08	740.36	760.10	971.66	994.18	1,416.37	917.76	0.00	0.00		9,736.09		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.83	0.00	0.00	0.00		21.83		
501C	SOBRA PREG 09-13 FE M	0.00	0.00	50.85	20.73	0.00	52.38	0.00	51.95	0.00	39.76	0.00	0.00		215.67		
501E	SOBRA PREG 14-20 FE
M	1,495.46	965.61	730.42	1,039.13	633.18	957.96	1,204.33	1,165.40	1,861.89	1,186.89	0.00	0.00		11,240.27		
SUBTOTAL:	24,897,595.0	6 25,057,504.64	24,959,260.4	6 26,379,787.59	26,277,413.55	26,052,435.80	25,906,270.86	25,518,280.60	25,485,356.03	25,312,840.04	0.00	0.00		255,846,744.63		

1110	TANF EXPANDED FOR FI	3,442.11	3,361.12	3,304.01	3,524.35	3,469.36	3,401.70	3,312.88	2,661.09	2,606.10	2,453.60	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	55.46	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	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-33.83	8.19	15.79	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	-39.68	0.00	0.00	0.00	-899.64	0.00	0.00	0.00	0.00	0.00	
111B	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	71.90	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	
111E	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.04	0.00	0.00	
SUBTOTAL:	3,567.15	3,361.12	3,293.6	2	3,524.35	3,469.36	3,529.06	2,413.24	2,627.26	2,614.29	2,487.43	0.00	0.00	

 
31,536.32	
55.46	
45.22	
-9.85	
-939.32	
71.90	
109.11	
18.04	
30,886.88	

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.12	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.12	0.00	0.00	0.00	0.00	

 
18.12

18.12

2,582.79

-25.72

4400	SOBRA 100-133% FOR F	405.65	411.06	381.77	355.48	199.00	199.00	199.00	165.17	165.17	101.49	0.00	0.00	
4403	SOBRA 100-133% M&F
6	0.00	0.00	9.76	-35.48	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	

78.11

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4410	SOBRA 100-133% FOR F	2,561,241.45	2,564,232.13	2,561,373.72	2,729,022.17	2,735,819.71	2,692,482.06	2,661,717.58	2,586,278.08	2,554,170.54	2,563,890.54	0.00	0.00		26,210,227.98		
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		12.90		
4413	SOBRA 100-133% M&F
6	24,015.75	31,189.97	28,325.12	30,671.94	30,906.30	28,060.14	29,036.41	41,610.75	48,061.76	35,882.60	0.00	0.00		327,760.74		
4414	SOBRA 100-133% MALE	4,720.28	6,358.88	5,283.81	5,146.14	5,521.57	5,204.75	5,767.25	8,660.22	10,610.86	8,251.85	0.00	0.00		65,525.61		
4415	SOBRA 100-133% FEMA L	4,916.84	6,421.81	5,852.19	6,121.92	6,660.83	5,442.42	5,651.41	8,379.83	10,314.85	7,559.41	0.00	0.00		67,321.51		
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		158.43		
441C	SOBRA 100-133% M&F
6	37,173.67	41,624.21	45,695.83	56,187.63	43,407.86	35,973.87	47,698.61	57,754.39	72,854.40	58,763.56	0.00	0.00		497,134.03		
441D	SOBRA 100-133% MALE	7,146.53	8,538.56	9,511.37	8,203.90	8,418.61	7,715.25	9,285.72	13,223.56	14,939.61	12,600.03	0.00	0.00		99,583.14		
441E	SOBRA 100-133% FEMA L	7,177.96	8,702.26	8,635.75	12,901.61	8,302.26	7,101.54	9,507.12	14,667.09	16,633.17	14,023.73	0.00	0.00		107,652.49		
SUBTOTAL:	2,646,969.46	2,667,478.88	2,665,147.4	3	2,848,575.31	2,839,236.14	2,782,179.03	2,768,863.10	2,730,739.09	2,727,750.36	2,701,073.21	0.00	0.00		27,378,012.01		

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-54.99	0.00	0.00	0.00	
6013	KIDS 6-13 M & F NON-	0.00	82.86	0.00	0.00	-67.66	-88.82	0.00	-33.83	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	-33.83	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	-33.83	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36.30	82.86	0.0	0	0.00	-67.66	-156.48	0.00	-33.83	-54.99	0.00	0.00	0.00	

 
-54.99	
-107.45	
-33.83	
2.47	
-193.80	

283,255,467.84

27,627,701.51	29,231,887.25	29,120,051.39	28,837,987.41	28,677,547.20	28,251,631.24	28,215,665.69	28,016,400.68	0.00	0.00	

TOTAL:

27,548,167.97

27,728,427.50

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2018

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	
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	
100B	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	
100C	TANF 06-13 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	
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	0.00	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	
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

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	
101E	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	
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	
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

221Z	SSI DISABLED NON-ME
D
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

0.00	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

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

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	
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	

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	
4300	SOBRA CHILD WITH 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	
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	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2018

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	
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

4322	SOBRA CHILD WITH Q MB
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

0.00	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

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

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	0.00
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	
5017	SOBRA PREG 21-44 FE	0.00
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	
501C	SOBRA PREG 09-13 FE	0.00
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	
501E	SOBRA PREG 14-20 FE	0.00
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	

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	
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	
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	
111B	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	
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	
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	
SUBTOTAL:	0.00	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	
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	
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

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	

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2018	
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		
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		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% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		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		
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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

SUBTOTAL:

Cu0.0r0   ren0.0t0      an0.d00

0.00	0.00	0.00

pr0i.0o0	r m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0	n.0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
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 - ADULT
For The Period Ending April 30, 2018	
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	454.75	0.00	0.00	0.00	0.00	0.00	0.00		454.75		
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	1,281.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,281.82		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	175.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	11.10	845.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		856.90		
100F	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	189.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189.90		
1010	TANF NON-MEDICARE	67,703.26	70,281.58	71,506.66	76,206.34	64,094.65	64,970.15	58,653.45	56,217.39	51,934.97	47,724.25	0.00	0.00		629,292.70		
1014	TANF 14-20 MALE NON-	9,870.85	0.00	5,324.91	0.00	0.00	4,432.25	1,909.87	0.00	3,628.57	0.00	0.00	0.00		25,166.45		
1015	TANF 14-20 FEMALE N O	9,065.75	7,469.90	7,243.02	1,273.25	1,830.26	1,710.75	22,261.21	0.00	0.00	835.61	0.00	0.00		51,689.75		
1016	TANF 21-44 MALE NON-	11,569.46	4,589.26	1,547.17	10,005.38	48,809.54	13,931.70	4,906.54	11,790.51	24,462.64	10,161.18	0.00	0.00		141,773.38		
1017	TANF 21-44 FEMALE N O	39,839.71	20,361.55	13,838.42	74,795.80	136,485.06	83,084.48	46,957.31	12,553.34	-969.22	22,781.08	0.00	0.00		449,727.53		
1018	TANF 45-64 M & F NON	15,115.50	16,726.11	16,077.24	5,706.01	26,333.04	6,911.91	-131.25	2,241.83	3,055.99	3,401.38	0.00	0.00		95,437.76		
101F	TANF 21-44 MALE NON-	2,118.51	1,030.63	0.00	712.12	6,261.64	219.06	42.62	0.00	545.68	0.00	0.00	0.00		10,930.26		
101G	TANF 21-44 FEMALE N O	565.55	3,250.57	2,899.12	0.00	3,772.78	1,409.66	874.99	302.07	0.00	0.00	0.00	0.00		13,074.74		
101H	TANF 44-64 M & F NON	2,290.28	116.88	1,202.40	0.00	1,079.26	0.00	1,181.24	5,274.88	0.00	1,300.53	0.00	0.00		12,445.47		
1020	TANF WITH QMB	0.00	0.00	0.00	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,819.33		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	7,514.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,514.37		
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	2,819.33	2,991.10	2,819.33	10,633.26	1,308.97	980.16	2,067.51	0.00	0.00		30,994.57		
210Z	SSI AGED WITH MEDIC
A	2,434.39	3,148.58	0.00	0.00	1,603.20	0.00	3,546.51	0.00	340.93	751.82	0.00	0.00		11,825.43		
2110	SSI AGED NON-MEDICA R	1,259.68	858.86	0.00	2,910.28	0.00	0.00	4,228.99	100.69	1,572.60	469.89	0.00	0.00		11,400.99		
211Z	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	2,637.44	0.00	0.00	93.98	0.00	1,091.35	0.00	0.00	0.00		3,822.77		
2120	SSI AGED WITH QMB	16,448.33	21,497.22	7,489.96	13,674.38	44,119.74	8,173.99	33,209.50	9,637.08	8,280.84	277.58	0.00	0.00		162,808.62		
212Z	SSI AGED WITH QMB P P	0.00	0.00	0.00	0.00	826.41	2,623.76	0.00	0.00	0.00	0.00	0.00	0.00		3,450.17		
2200	SSI DISABLED WITH M
E	26,832.39	8,551.37	11,145.75	20,999.29	20,253.28	20,944.96	14,071.72	22,275.80	17,984.53	18,844.00	0.00	0.00		181,903.09		
220Z	SSI DISABLED WITH M E	7,897.63	4,002.96	2,118.51	10,558.83	10,124.90	18,401.76	3,364.72	11,882.70	14,895.06	18,091.50	0.00	0.00		101,338.57		
2210	SSI DISABLED NON-ME
D	472,088.18	390,714.24	369,959.96	607,706.91	704,089.77	475,314.98	492,640.76	366,289.97	315,987.82	385,126.82	0.00	0.00		4,579,919.41		
221Z	SSI DISABLED NON-ME D	5,257.87	-15,475.96	3,957.21	6,759.34	11,353.83	16,519.60	17,256.37	39,795.73	170.46	5,097.56	0.00	0.00		90,692.01		
2220	SSI DISABLED WITH Q
M	202,597.90	137,282.20	163,966.79	319,225.95	264,593.34	181,732.24	216,363.07	225,806.15	89,505.66	143,328.05	0.00	0.00		1,944,401.35		
222Z	SSI DISABLED WITH Q M	2,118.27	0.00	5,946.64	437.50	2,747.41	0.00	1,960.24	5,542.00	0.00	3,637.85	0.00	0.00		22,389.91		
2310	SSI BLIND NON-MEDIC
A	0.00	1,566.67	0.00	19,662.08	1,356.24	1,968.74	1,356.24	1,356.24	1,356.24	1,356.24	0.00	0.00		29,978.69		
4310	SOBRA CHILD NON-ME DI	3,504.62	3,488.00	2,535.51	5,089.63	3,873.55	2,819.33	949.80	1,321.09	1,321.09	2,677.33	0.00	0.00		27,579.95		
4314	SOBRA CHILD 14-20 MA	8,861.93	16,995.83	6,800.33	4,463.43	7,239.23	2,251.93	5,593.21	12,009.35	980.16	1,014.99	0.00	0.00		66,210.39		
4315	SOBRA CHILD 14-20 FE	18,118.52	7,079.64	6,848.21	8,976.42	14,823.73	28,044.31	15,910.09	0.00	13,049.62	11,172.64	0.00	0.00		124,023.18		
431D	SOBRA CHILD 14-20 MA	0.00	1,259.65	0.00	0.00	1,471.72	0.00	1,727.97	2,013.81	85.23	316.46	0.00	0.00		6,874.84		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	650.82	0.00	2,183.84	350.00	0.00	0.00	0.00	8,586.92	0.00	0.00		11,771.58		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	996.97	0.00	0.00	0.00	0.00	43.75	0.00	0.00	0.00		1,040.72		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5008	SOBRA PREG 45-64 FE M	0.00	2,397.16	0.00	0.00	0.00	10,677.28	0.00	0.00	0.00	0.00	0.00	0.00		13,074.44		
500G	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	474.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		474.75		
500H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	2,462.06	0.00	0.00	0.00	0.00	0.00	0.00		2,462.06		
5010	SOBRA PREGNANT WO
MAN	5,021.66	5,021.66	5,021.66	9,672.23	2,677.33	5,496.66	4,089.37	3,998.42	3,998.42	2,642.18	0.00	0.00		47,639.59		
5015	SOBRA PREG 14-20 FE M	0.00	858.86	0.00	0.00	-1,727.98	1,209.12	0.00	0.00	0.00	0.00	0.00	0.00		340.00		
5017	SOBRA PREG 21-44 FE
M	2,770.42	515.32	1,902.13	17,830.90	28,026.09	1,778.92	13,699.73	2,202.57	0.00	0.00	0.00	0.00		68,726.08		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	1,766.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,766.61		
5027	SOBRA PREG 21-44 FE
M	1,124.15	949.50	1,956.29	6,411.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,441.82		
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:	936,587.5	3	718,025.46	710,501.0	1	1,233,011.87	1,422,891.46	960,713.68	977,351.51	793,920.59	554,302.55	691,663.37	0.00	0.00		8,998,969.03		

1100	TANF EXPANDED FPR FI	7,965.10	8,365.92	7,965.10	9,707.38	9,707.38	8,351.14	5,531.81	2,819.33	5,496.66	6,994.90	0.00	0.00	
1106	TANF EXPANDED 21-44	5,319.85	57.26	-216.07	0.00	513.02	-909.77	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.30	245.29	0.00	28,743.01	28,465.03	1,406.32	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,852.74	801.60	0.00	32,810.29	0.00	0.00	2,490.52	1,356.24	636.62	2,414.05	0.00	0.00	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	818.52	2,320.65	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	0.00	0.00	0.00	1,605.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	24,531.79	21,260.49	22,448.97	26,739.37	27,063.02	30,128.47	28,471.27	32,049.72	34,727.05	36,118.44	0.00	0.00	
1116	TANF EXPANDED 21-44	8,122.79	3,098.04	14,019.01	17,412.10	14,370.33	23,384.42	404.37	0.00	0.00	21,146.22	0.00	0.00	
1117	TANF EXPANDED 21-44	3,681.87	8,276.73	1,086.20	37,089.40	82,992.44	21,334.14	57,957.93	15,220.33	2,447.60	15,544.23	0.00	0.00	
1118	TANF EXPANDED 45-64	494.65	2,138.08	3,379.18	15,075.23	5,178.22	33,518.24	7,473.19	0.00	2,537.40	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	939.78	0.00	0.00	
111G	TANF EXPANDED 21-44	0.00	617.17	0.00	686.80	5,158.17	131.25	3,007.29	604.14	272.84	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	0.00	0.00	1,656.64	627.25	0.00	949.37	1,789.86	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	5,852.92	4,953.80	4,381.20	2,685.93	3,046.73	5,461.51	2,642.18	2,642.18	5,461.51	2,642.18	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	2,848.49	0.00	38,863.38	-2,297.63	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	2,490.29	-1,201.30	0.00	17,884.03	1,989.15	0.00	0.00	-2,819.33	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	11,921.64	0.00	0.00	308.47	0.00	18,264.23	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	9,310.14	414.16	0.00	1,373.75	480.07	1,467.13	0.00	0.00	3,158.95	2,278.36	0.00	0.00	
240Z	SSI AGED EXPANDED
WI	9,156.73	1,005.82	0.00	743.74	493.29	2,044.56	0.00	503.45	2,063.65	1,152.17	0.00	0.00	
2420	SSI AGED EXPANDED WI	15,629.69	21,652.54	16,691.35	34,282.41	35,117.67	13,558.97	36,644.75	31,572.99	81,834.25	12,073.64	0.00	0.00	
242Z	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	90.95	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	8,175.29	9,624.10	3,584.97	11,355.20	5,016.55	-1,704.32	14,066.35	6,275.82	6,180.52	5,758.10	0.00	0.00	
260Z	SSI DISABLED EXPAND
E	1,780.54	1,614.14	6.32	12,038.04	2,206.45	0.00	21,834.64	6,815.98	10,044.46	6,794.32	0.00	0.00	
2610	SSI DISABLED EXPAND E	16,459.44	4,129.30	425.15	3,012.30	17,239.40	7,042.13	596.62	1,774.97	4,369.87	0.00	0.00	0.00	
261Z	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	2,943.25	340.93	0.00	0.00	0.00	0.00	0.00	0.00	

 
72,904.72	
4,764.29	
58,859.95	
42,362.06	
3,139.17	
1,605.79	
283,538.59	
101,957.28	
245,630.87	
69,794.19	
939.78	
10,477.66	
5,023.12	
39,770.14	
39,414.24	
18,342.84	
30,494.34	
18,482.56	
17,163.41	
299,058.26	
90.95	
68,332.58	
63,134.89	
55,049.18	
3,284.18	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2620	SSI DISABLED EXPAND E	95,463.82	68,058.95	48,111.38	197,720.40	130,396.09	142,611.05	103,544.74	130,139.04	172,653.71	29,589.10	0.00	0.00		1,118,288.28		
262Z	SSI DISABLED EXPAND
E	2,291.08	942.58	0.00	343.54	3,054.18	883.03	5,273.25	4,792.42	0.00	939.78	0.00	0.00		18,519.86		
SUBTOTAL:	230,500.3	7	155,809.38	126,387.8	9	423,501.72	386,074.08	304,558.85	321,290.30	264,532.96	333,382.36	144,385.27	0.00	0.00		2,690,423.18		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	678.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
350F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	678.12	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	72,508.62	54,455.10	68,025.19	69,444.49	66,989.07	65,455.68	66,989.07	0.00	0.00	
3514	ADULT 40-100% MALE 1	14,355.78	536.20	6,389.89	1,273.25	3,195.25	272.83	10,272.16	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	944.02	1,030.63	0.00	2.22	4,503.81	0.00	1,273.25	100.69	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	1,997.16	13,607.95	4,491.44	56,394.72	67,978.48	26,737.12	24,227.74	48,990.63	3,367.26	2,719.29	0.00	0.00	
3517	ADULT 40-100% FEMAL E	20,183.57	5,560.35	7,132.25	17,433.25	17,962.12	42,553.07	29,750.30	2,332.12	1,611.05	50,660.64	0.00	0.00	
3518	ADULT 40-100% M&F 45	55,029.73	1,576.57	17,843.46	12,371.84	95,051.20	36,093.26	96,143.79	12,145.44	59,620.66	39,693.35	0.00	0.00	
351D	ADULT 40-100% MALE 1	0.73	1,774.97	0.00	0.00	727.57	0.00	5,087.85	181.89	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	4,033.72	1,138.02	545.68	10,233.80	6,567.74	0.00	3,013.35	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	57.26	3,549.94	1,108.01	854.55	4,726.36	1,278.47	272.84	3,936.66	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	3,798.07	15,907.87	2,767.72	2,890.90	1,677.23	5,108.15	4,011.61	9,465.89	290.62	8,974.20	0.00	0.00	
3700	ADULT <40% EXP FOR F	343.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	2,011.63	1,583.64	0.00	0.00	0.00	0.00	3,652.45	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	2.92	3,149.14	0.00	0.00	0.00	525.00	2,819.33	0.00	3,569.97	3,020.71	0.00	0.00	
370F	ADULT <40% EXP MALE	118.33	114.51	0.00	0.00	0.00	0.00	1,963.17	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP M&F 4	0.00	4,752.34	769.15	1,303.32	0.00	831.24	0.00	3,778.10	272.84	2,617.95	0.00	0.00	
3710	AHC CARE EXPANDED
FO	269,577.60	259,367.87	254,857.03	320,926.71	290,316.38	290,255.14	285,066.58	271,967.78	275,752.50	257,904.88	0.00	0.00	
3714	ADULT <40% EXP MALE	8,520.05	19,861.18	2,000.33	10,393.91	27,244.69	25,083.07	36,085.81	37,100.15	2,202.19	1,394.51	0.00	0.00	
3715	ADULT <40% EXP FEMA L	4,333.10	8,226.90	2,660.54	3,751.78	4,031.43	12,839.05	2,623.66	273.90	1,681.80	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	126,138.11	115,879.59	172,653.47	267,809.51	458,093.48	263,102.11	263,583.40	155,216.42	177,869.81	72,958.06	0.00	0.00	
3717	ADULT <40% EXP FEMA L	111,889.44	66,507.59	45,919.99	215,056.12	277,144.71	188,734.75	221,227.40	81,606.64	85,667.53	52,796.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	99,355.58	107,006.96	54,322.22	231,581.15	396,490.73	145,638.46	214,453.47	112,541.82	58,509.54	160,988.96	0.00	0.00	
371D	ADULT <40% EXP MALE	0.00	0.00	1,124.15	0.00	2,819.33	6,015.46	7,200.67	10,191.64	5,437.28	727.57	0.00	0.00	
371E	ADULT <40% EXP FEMA L	0.00	0.00	0.00	354.99	0.00	657.84	0.00	1,692.93	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	7,355.98	18,855.59	23,121.48	19,393.63	27,197.10	23,413.23	41,583.45	36,220.73	31,563.02	16,135.95	0.00	0.00	
371G	ADULT <40% EXP FEMA L	6,994.39	16,512.76	3,610.58	6,458.30	24,840.29	7,127.75	36,044.64	9,423.53	10,560.83	18,422.64	0.00	0.00	

 
678.12	
1,660.46	
473.33	
678.12	
57.26	
3,076.61	
605,876.35	
36,295.36	
7,854.62	
250,511.79	
195,178.72	
425,569.30	
7,773.01	
-525.23	
30,339.47	
15,784.09	
54,892.26	
343.56	
7,247.72	
13,087.07	
2,196.01	
14,324.94	
2,775,992.47	
169,885.89	
40,422.16	
2,073,303.96	
1,346,550.17	
1,580,888.89	
33,516.10	
2,705.76	
244,840.16	
139,995.71	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371H	ADULT <40% EXP M&F 4	16,563.47	14,714.52	13,690.38	6,433.58	17,000.12	21,878.35	10,777.43	16,398.26	5,638.67	22,031.36	0.00	0.00		145,126.14		
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 MALE	282.66	0.00	-1,679.46	639.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-757.56		
3727	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	3,139.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,139.86		
372G	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	0.00	1,241.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,241.34		
SUBTOTAL:	795,395.7	1	731,774.84	670,374.2	0	1,252,118.77	1,778,459.03	1,170,163.11	1,378,804.92	883,458.21	793,007.91	781,048.49	0.00	0.00		10,234,605.19		

4410	SOBRA 100-133% FOR F	2,195.38	0.00	0.00	383.58	748.28	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	3,104.89	0.00	-151.62	5,129.32	12,031.66	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	2,049.81	636.62	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	2,423.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	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	
SUBTOTAL:	2,195.38	0.00	7,318.4	9	6,549.08	748.28	-151.62	5,129.32	12,031.66	0.00	0.00	0.00	0.00	

3,327.24	
21,001.73	
2,686.43	
2,423.99	
4,381.20	
33,820.59	

8700	SSI DISABLED FREEDO M	4,236.18	2,539.98	20,494.58	37,783.06	13,953.86	17,699.46	5,236.52	18,042.90	19,962.68	2,819.33	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	2,730.97	1,246.72	4,792.42	2,957.68	1,534.17	11,733.57	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	461.39	845.82	13,906.59	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	20,342.67	1,727.98	0.00	8,744.50	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	4,058.39	1,091.35	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,236.18	2,826.27	20,494.5	8	40,975.42	40,447.46	39,217.80	8,194.20	28,321.57	31,696.25	2,819.33	0.00	0.00	

142,768.55	
24,995.53	
15,213.80	
31,101.44	
5,149.74	
219,229.06	

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	218.75	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	744.34	0.00	42.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,137.49	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.00	1,030.63	0.00	681.85	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	36,627.64	33,186.92	30,742.82	24,501.23	22,270.64	23,591.73	20,914.40	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,774.97	4,752.34	887.48	1,273.25	0.00	0.00	0.00	0.00	2,465.29	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	858.86	0.00	0.00	1,315.69	0.00	0.00	0.00	181.89	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,832.23	14,837.13	23,139.07	22,056.18	7,990.26	4,341.30	1,273.25	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	13,063.62	16,066.65	13,213.03	7,782.86	44,882.76	8,615.32	6,887.65	12,861.11	1,637.03	19,974.27	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	6,921.49	27,462.53	887.48	17,568.44	41,764.07	26,267.81	14,676.74	7,633.43	15,975.95	3,101.26	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,913.12	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	1,139.40	0.00	375.91	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	2,175.77	3,236.19	2,458.45	2,897.09	3,263.65	70.66	4,207.77	7,603.76	6,366.23	3,206.40	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	0.00	4,904.01	0.00	2,102.04	1,373.61	0.00	8,879.85	4,940.93	545.68	1,503.64	0.00	0.00	
SUBTOTAL:	50,439.51	101,284.95	73,397.1	91,031.97	134,916.36	70,037.91	60,802.40	56,666.11	52,676.92	48,699.97	0.00	0.00	

 
218.75	
786.96	
1,137.49	
1,712.48	
278,916.14	
11,153.33	
2,356.44	
75,469.42	
144,984.30	
162,259.20	
1,913.12	
-5,096.32	
4,406.24	
35,485.97	
24,249.76	
739,953.28	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	2,019,354.68	1,709,720.90	1,608,473.35	3,047,188.83	3,763,536.67	2,544,539.73	2,751,572.65	2,038,931.10	1,765,065.99	1,668,616.43	0.00	0.00		22,917,000.33		

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2018

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	
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	
100F	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	
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	
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	
101F	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	
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	
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	

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	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
210Z

2110	SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	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

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

220Z	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
221Z

2220	SSI DISABLED NON-ME D
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	
222Z

2310	SSI DISABLED WITH Q M
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	

211Z

2120	SSI AGED NON-MEDICA R
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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
212Z	SSI AGED WITH QMB P P	0.00	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	

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

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
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

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5008	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		
500G	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		
500H	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		
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		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
502G	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		
SUBTOTAL:	0.00	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		

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	

0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.u00rren0.00t an0.0d0	pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00e
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1108	TANF EXPANDED 45-64	
110G		
110H	TANF EXPANDED 45-64	

0.00	0.00	0.00

TANF EXPANDED 21-44	C

r r0e.00   vis0i.0o0

n.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	
111F	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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

240Z	WI
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	
2420	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

242Z	WI
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	
260Z	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	
261Z	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	
	E													

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		0.00		
262Z	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	
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	
350F	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	
350G	ADULT 40-100% FEMAL	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	E
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	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

3517

3518

351D

351E	E
ADULT 40-100% MALE 2

ADULT 40-100% FEMAL E
ADULT 40-100% M&F 45

ADULT 40-100% MALE 1

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	0.00	0.00	0.00	0.00
Current and prior month data is
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00

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	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	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	
370F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP 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	

3710

3714

3715

3716

3717

3718	4
AHC CARE EXPANDED
FO
ADULT <40% EXP MALE

ADULT <40% EXP FEMA L
ADULT <40% EXP MALE

ADULT <40% EXP FEMA L
ADULT <40% EXP M&F
4	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00	
371D	ADULT <40% EXP 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	
371E	ADULT <40% EXP 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	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	L													

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

under revision.

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3720	AHC CARE EXPANDED
FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
372G	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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		

L
3918	NEWLY ELIGIBLE M&F
4

Current and

0.00

0.00

0.00

prior month

0.00

0.00

0.00

0.00

0.00

data is unde

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00	
0.00	
0.00	
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	
3908	NEWLY ELIGIBLE 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	

390G	4
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	
390H	NEWLY ELIGIBLE 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	

3910	4
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	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	L
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	

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	0.00
L	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	0.00
L	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	0.00
4	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	

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% 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	
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% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	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	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	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	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2018	
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	1,025.47	1,025.47	875.22	733.73	662.77	654.01	724.54	0.00	0.00		7,757.40		
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	126.01	70.53	0.00	0.00	57.94	0.00	35.27	0.00	0.00		426.44		
1007	TANF 21-44 FEMALE WI	0.00	48.56	107.28	118.30	125.56	59.15	104.65	181.36	29.58	30.56	0.00	0.00		805.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	18.00	23.92	171.51	59.51	0.00	0.00	31.89	0.00	0.00		304.83		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	66.86	0.00	0.00	25.18	0.00	0.00	0.00	0.00	0.00		92.04		
1010	TANF NON-MEDICARE	7,528,314.05	7,511,991.21	7,513,809.78	10,085,281.49	10,117,986.10	10,004,056.41	10,002,233.80	9,869,597.22	9,799,553.51	9,827,058.49	0.00	0.00		92,259,882.06		
1011	TANF <1 M & F NON-ME	-266.33	0.00	0.00	-70.53	0.00	0.00	-70.53	0.00	0.00	0.00	0.00	0.00		-407.39		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	-102.14	0.00	0.00	0.00	0.00	0.00		-102.14		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-212.88	0.00	0.00	0.00	0.00		-212.88		
1014	TANF 14-20 MALE NON-	1,054.08	806.68	1,450.88	1,124.69	1,814.24	1,821.62	1,282.38	1,891.79	2,418.11	2,128.27	0.00	0.00		15,792.74		
1015	TANF 14-20 FEMALE N O	3,101.01	3,991.10	4,411.46	4,886.52	6,214.34	3,919.87	3,352.82	6,615.26	6,363.91	5,828.06	0.00	0.00		48,684.35		
1016	TANF 21-44 MALE NON-	21,980.86	33,636.20	29,997.49	31,705.98	35,707.78	38,187.16	37,694.25	42,024.59	42,191.14	36,935.01	0.00	0.00		350,060.46		
1017	TANF 21-44 FEMALE N O	56,880.49	85,190.53	75,352.40	86,326.74	97,696.73	98,272.65	99,812.05	118,870.28	124,863.02	108,720.70	0.00	0.00		951,985.59		
1018	TANF 45-64 M & F NON	15,596.43	20,519.22	17,841.52	22,766.38	20,303.72	26,031.63	22,684.49	30,710.04	31,890.46	24,575.53	0.00	0.00		232,919.42		
1019	TANF 65+ M & F NON-M	-6.35	-29.37	56.35	47.78	-224.81	265.38	-292.10	-66.94	-26.41	-95.42	0.00	0.00		-371.89		
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	3,014.86	3,438.55	2,172.89	2,579.82	2,107.02	3,486.69	2,021.67	0.00	0.00		26,886.95		
101E	TANF 14-20 FEMALE N O	3,759.41	4,623.99	6,934.25	5,876.68	5,369.61	4,929.71	6,054.16	7,645.99	7,065.18	6,661.38	0.00	0.00		58,920.36		
101F	TANF 21-44 MALE NON-	42,225.70	48,848.84	50,165.56	50,072.48	46,730.54	54,119.41	59,732.92	56,652.69	63,031.83	58,083.69	0.00	0.00		529,663.66		
101G	TANF 21-44 FEMALE N O	88,550.44	103,417.97	104,571.55	113,820.31	110,699.69	117,829.67	135,624.37	133,679.25	161,036.22	139,145.91	0.00	0.00		1,208,375.38		
101H	TANF 44-64 M & F NON	19,829.13	24,800.86	25,508.74	29,909.58	24,624.01	26,958.78	40,495.09	35,411.24	39,372.71	29,983.25	0.00	0.00		296,893.39		
101J	TANF 65+ N & F NON-M	112.19	578.32	93.85	34.13	54.57	201.49	161.62	159.64	632.14	25.87	0.00	0.00		2,053.82		
1020	TANF WITH QMB	350.91	395.24	573.25	522.57	611.05	540.09	540.09	380.65	593.53	434.09	0.00	0.00		4,941.47		
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		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	-12.56	59.51	0.00	0.00	0.00	0.00	0.00	0.00		46.95		
1028	TANF 45-64 M & F WIT	0.00	0.00	-32.57	198.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.13		
2100	SSI AGED WITH MEDIC A	6,711.47	6,454.10	7,325.20	9,704.60	8,147.42	8,357.31	8,640.73	8,458.88	8,563.15	8,626.40	0.00	0.00		80,989.26		
2110	SSI AGED NON-MEDICA
R	304,645.22	312,668.78	309,963.09	421,949.68	425,944.44	430,645.84	431,707.96	435,503.17	442,992.19	446,411.32	0.00	0.00		3,962,431.69		
211Z	SSI AGED NON-MEDICA R	7,325.76	9,345.18	10,097.05	12,524.31	11,766.61	9,794.75	12,182.86	13,150.79	18,785.89	15,473.83	0.00	0.00		120,447.03		
2120	SSI AGED WITH QMB	33,188.84	34,747.06	35,091.53	42,563.06	42,842.83	42,350.86	42,367.03	43,351.76	46,578.99	42,808.02	0.00	0.00		405,889.98		
2200	SSI DISABLED WITH M E	11,894.44	11,728.31	11,925.39	15,583.08	15,359.11	15,679.06	15,778.04	15,402.06	15,644.13	15,803.88	0.00	0.00		144,797.50		
220Z	SSI DISABLED WITH M
E	0.00	0.00	0.00	-167.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-167.11		
2210	SSI DISABLED NON-ME D	1,826,599.90	1,829,961.29	1,830,083.86	2,428,771.96	2,426,892.37	2,424,307.60	2,423,178.38	2,417,493.61	2,411,414.58	2,404,590.45	0.00	0.00		22,423,294.00		
221Z	SSI DISABLED NON-ME
D	19,573.57	27,156.42	26,952.93	33,663.56	31,530.35	33,058.82	39,947.40	36,076.70	45,794.08	39,121.01	0.00	0.00		332,874.84		
2220	SSI DISABLED WITH Q M	43,400.80	43,879.46	43,623.72	55,539.88	56,456.62	56,818.09	56,069.48	55,637.62	54,751.44	54,277.07	0.00	0.00		520,454.18		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2300	SSI BLIND WITH MEDIC	116.97	116.97	174.45	221.64	221.64	221.64	221.64	221.64	221.64	221.64	0.00	0.00		1,959.87		
2310	SSI BLIND NON-MEDIC A	21,375.83	21,540.28	21,715.83	28,260.54	28,644.29	29,152.00	29,494.03	29,609.00	29,736.55	29,914.02	0.00	0.00		269,442.37		
231Z	SSI BLIND NON-MEDIC
A	985.66	432.73	424.29	22.75	49.37	1,109.87	2,109.03	392.72	273.70	296.40	0.00	0.00		6,096.52		
2320	SSI BLIND WITH QMB	849.97	849.97	849.97	1,060.70	1,035.52	1,035.52	1,035.52	1,035.52	1,035.52	1,035.52	0.00	0.00		9,823.73		
4300	SOBRA CHILD WITH ME D	51.91	51.91	51.91	70.53	141.06	141.06	70.53	0.00	0.00	0.00	0.00	0.00		578.91		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	-39.80	0.00	0.00	-13.65	0.00	0.00	0.00	0.00	0.00	0.00		-53.45		
4310	SOBRA CHILD NON-ME DI	1,199,527.27	1,202,853.14	1,184,904.67	1,589,360.79	1,592,116.83	1,574,756.42	1,540,285.70	1,512,572.71	1,485,426.79	1,489,237.74	0.00	0.00		14,371,042.06		
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	-37.62	-81.91	0.00	0.00	-61.43	-70.53	0.00	0.00		-412.88		
4313	SOBRA CHILD 06-13 M	-23.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.35	0.00	0.00		27.91		
4314	SOBRA CHILD 14-20 MA	8,427.67	11,429.89	9,877.29	11,093.94	12,065.70	10,745.19	13,443.85	17,005.00	19,783.45	14,366.32	0.00	0.00		128,238.30		
4315	SOBRA CHILD 14-20 FE	8,251.14	13,109.63	10,539.66	14,651.44	14,407.83	12,849.01	14,007.66	15,728.92	20,824.67	15,377.96	0.00	0.00		139,747.92		
431D	SOBRA CHILD 14-20 MA	12,387.06	15,098.59	13,989.51	17,190.81	15,490.46	15,426.73	17,028.99	19,000.86	26,546.04	19,829.96	0.00	0.00		171,989.01		
431E	SOBRA CHILD 14-20 FE	13,313.17	15,536.49	16,218.25	20,630.51	19,426.83	15,677.98	21,705.63	26,623.80	31,758.26	22,061.97	0.00	0.00		202,952.89		
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		
5007	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	211.59	0.00	0.00	0.00	0.00		211.59		
500H	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	40.19	0.00	0.00	0.00	0.00	0.00	0.00		40.19		
5010	SOBRA PREGNANT WO
MAN	1,134,751.73	1,131,930.11	1,128,068.84	1,500,125.45	1,445,188.00	1,393,071.49	1,363,342.74	1,344,156.72	1,351,921.75	1,392,575.96	0.00	0.00		13,185,132.79		
5015	SOBRA PREG 14-20 FE M	7,474.09	10,129.48	8,345.18	11,174.15	10,891.10	10,806.71	9,593.07	12,506.93	14,956.18	14,279.89	0.00	0.00		110,156.78		
5017	SOBRA PREG 21-44 FE
M	36,560.83	47,140.12	41,677.87	53,752.59	56,934.82	50,620.18	54,033.83	59,318.05	68,247.92	59,505.21	0.00	0.00		527,791.42		
5018	SOBRA PREG 45-64 FE M	81.63	113.04	132.82	114.62	65.83	307.59	72.93	17.63	143.53	258.19	0.00	0.00		1,307.81		
501E	SOBRA PREG 14-20 FE
M	11,820.56	12,545.36	11,020.85	11,680.45	13,004.53	13,306.90	13,197.39	17,336.65	20,133.63	18,217.37	0.00	0.00		142,263.69		
501G	SOBRA PREG 21-44 FE M	53,792.57	59,942.43	55,928.49	66,704.20	68,266.22	62,894.32	72,890.00	78,924.66	94,790.62	83,832.87	0.00	0.00		697,966.38		
501H	SOBRA PREG 45-64 FE
M	193.08	257.91	197.26	167.69	84.42	580.57	209.62	123.43	78.11	1,210.68	0.00	0.00		3,102.77		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	31.85	0.00	0.00	0.00	0.00	0.00	0.00		31.85		
5510	SOBRA FPS FEMALE W
IT	0.00	0.00	-59.49	0.00	0.00	0.00	-70.96	0.00	0.00	0.00	0.00	0.00		-130.45		
SUBTOTAL:	12,547,066.2	0 12,661,403.74	12,614,101.2	2 16,783,288.82	16,769,195.62	16,594,164.14	16,595,249.24	16,466,228.33	16,493,497.01	16,431,643.26	0.00	0.00		153,955,837.58		

1100	TANF EXPANDED FPR FI	4,486.72	4,102.62	3,814.76	4,840.75	4,398.76	4,610.78	4,548.58	4,310.28	4,292.76	4,311.14	0.00	0.00	
1106	TANF EXPANDED 21-44	49.89	0.00	29.85	7.35	-33.18	0.00	69.43	68.43	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	58.89	97.48	59.51	56.42	0.00	111.48	75.68	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	36.84	182.35	91.16	-22.66	126.96	57.23	59.15	193.07	70.96	103.87	0.00	0.00	

43,717.15	
191.77	
459.46	
898.93	

3010	MN/MI NON-MEDICARE	0.00	0.00	-118.98	0.00	0.00	0.00	0.00	-966.91	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	-170.8	9	0.00	0.00	0.00	0.00	-966.91	0.00	0.00	0.00	0.00	

 
-1,085.89	
51.91	
-155.73	
-1,189.71	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+ M
&	20.40	11.72	0.00	-8.08	385.32	79.72	72.01	6.54	332.61	0.00	0.00	0.00		900.24		
1110	TANF EXPANDED FOR FI	7,245,573.06	7,191,699.09	7,157,293.31	9,542,034.79	9,478,174.28	9,342,492.69	9,184,108.09	8,868,310.57	8,737,527.97	8,723,336.07	0.00	0.00		85,470,549.92		
1114	TANF EXPANDED 14-20	219.40	450.66	580.71	548.27	729.23	833.37	360.17	1,048.65	1,349.64	622.37	0.00	0.00		6,742.47		
1115	TANF EXPANDED 14-20	1,395.00	1,295.25	1,557.62	1,107.75	1,708.46	1,942.83	1,711.70	2,467.63	2,436.04	1,418.38	0.00	0.00		17,040.66		
1116	TANF EXPANDED 21-44	20,750.25	33,505.33	27,359.39	33,134.90	38,624.74	30,496.33	31,027.44	40,392.58	48,593.05	38,593.37	0.00	0.00		342,477.38		
1117	TANF EXPANDED 21-44	38,140.36	58,236.64	52,618.96	64,767.73	75,932.62	69,185.28	65,523.10	86,298.89	107,410.01	83,469.83	0.00	0.00		701,583.42		
1118	TANF EXPANDED 45-64	16,495.40	23,554.04	18,019.31	24,726.04	21,404.62	23,173.50	20,683.70	35,324.47	34,004.80	25,679.92	0.00	0.00		243,065.80		
1119	TANF EXPANDED 65+ M
&	-142.34	3.45	-165.21	-77.35	152.81	-17.51	36.48	-101.64	35.12	-17.16	0.00	0.00		-293.35		
111D	TANF EXPANDED 14-20	724.59	387.75	715.93	709.03	1,042.80	934.43	1,003.10	1,058.73	2,306.38	826.51	0.00	0.00		9,709.25		
111E	TANF EXPANDED 14-20	1,501.08	1,471.41	1,908.61	1,945.35	2,498.74	2,033.69	2,292.99	3,835.90	3,416.93	3,162.12	0.00	0.00		24,066.82		
111F	TANF EXPANDED 21-44	39,523.53	50,612.12	51,219.25	56,586.95	55,402.97	47,539.36	52,172.69	62,801.41	81,675.73	65,308.85	0.00	0.00		562,842.86		
111G	TANF EXPANDED 21-44	61,738.58	77,496.73	87,336.64	92,824.02	96,315.55	84,287.42	105,269.51	118,166.53	152,133.29	121,495.81	0.00	0.00		997,064.08		
111H	TANF EXPANDED 45-64	21,336.56	30,393.46	28,588.80	37,444.91	29,418.59	29,308.57	34,993.33	55,517.93	50,254.80	37,619.56	0.00	0.00		354,876.51		
111J	TANF EXPANDED 65+ M
&	72.00	48.56	293.49	81.49	229.98	140.56	0.00	59.79	4.55	192.46	0.00	0.00		1,122.88		
1120	TANF EXPANDED FOR FI	7,388.46	7,768.54	8,432.92	10,954.89	11,043.37	11,044.23	11,476.60	11,865.58	11,193.19	11,104.71	0.00	0.00		102,272.49		
1126	TANF EXPANDED 21-44	0.00	42.22	0.00	0.00	435.57	-26.02	68.25	42.82	0.00	25.05	0.00	0.00		587.89		
1127	TANF EXPANDED 21-44	11.72	0.00	51.91	0.00	0.00	0.00	-27.30	0.00	0.00	51.72	0.00	0.00		88.05		
1128	TANF EXPANDED 45-64	1.17	26.79	0.00	139.21	175.19	0.00	79.08	0.00	-223.63	63.91	0.00	0.00		261.72		
1129	TANF EXPANDED 65+ M
&	0.00	0.00	-11.50	0.00	0.00	0.00	59.15	-151.73	41.15	0.00	0.00	0.00		-62.93		
2400	SSI AGED EXPANDED WI	579.46	611.51	230.94	597.29	397.25	677.68	405.96	265.34	566.11	362.46	0.00	0.00		4,694.00		
240Z	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	37.78	21.08	0.00	0.00	0.00		58.86		
2410	SSI AGED EXPANDED N O	4,629.90	5,308.04	4,732.92	6,602.02	6,249.10	6,410.60	6,696.04	6,733.92	7,017.65	6,645.53	0.00	0.00		61,025.72		
241Z	SSI AGED EXPANDED N
O	372.82	419.46	254.93	551.41	204.37	228.61	260.27	236.78	1,924.97	308.93	0.00	0.00		4,762.55		
2420	SSI AGED EXPANDED WI	23,789.79	26,119.96	26,149.70	31,941.14	32,246.26	32,426.20	32,786.66	32,129.26	34,702.35	32,236.85	0.00	0.00		304,528.17		
2600	SSI DISABLED EXPAND
E	516.50	279.68	194.49	392.39	374.91	502.18	592.24	673.50	541.76	997.26	0.00	0.00		5,064.91		
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.11	0.00	0.00	0.00	0.00		15.11		
2610	SSI DISABLED EXPAND
E	82,947.40	83,737.27	81,966.07	106,781.91	106,209.13	103,371.39	101,605.24	100,993.89	102,850.49	101,868.78	0.00	0.00		972,331.57		
261Z	SSI DISABLED EXPAND E	1,639.72	1,242.24	1,799.06	2,369.44	2,229.13	1,722.10	1,558.20	2,466.37	2,720.32	3,080.21	0.00	0.00		20,826.79		
2620	SSI DISABLED EXPAND
E	13,715.54	13,591.07	13,632.52	19,133.97	18,780.37	18,761.10	18,013.22	18,179.08	18,615.39	17,987.55	0.00	0.00		170,409.81		
SUBTOTAL:	7,587,513.80	7,612,656.85	7,568,794.0	2 10,040,174.42	9,984,914.32	9,812,216.32	9,677,616.56	9,453,323.14	9,405,815.47	9,280,856.06	0.00	0.00		90,423,880.96		

-202.59

3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	-79.72	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	-51.91	0.00	0.00	0.00	-70.96	0.00	-79.72	0.00	0.00	0.00	0.00	

-79.72

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	-79.72	0.00	-70.53	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	-79.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	-79.72	0.00	-79.72	0.00	-70.53	0.00	0.00	0.00	0.00	

 

-229.97

-79.72

-150.25

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	-70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-70.53		
3618	AHC CARE/MI M&F 45-6	0.00	-59.49	0.00	0.00	0.00	0.00	0.00	-150.68	-70.53	-70.53	0.00	0.00		-351.23		
SUBTOTAL:	0.00	-111.40	0.0	0	-70.53	0.00	-150.68	0.00	-230.40	-70.53	-70.53	0.00	0.00		-704.07		

3500	ADULT 40-100% FOR FI	170.89	0.00	0.00	79.72	0.00	0.00	0.00	150.25	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	79.72	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	90.15	0.00	0.00	42.82	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	6,588,528.75	6,543,371.36	6,440,244.40	6,414,726.55	6,245,240.66	6,182,703.94	6,162,949.35	0.00	0.00	
3514	ADULT 40-100% MALE 1	2,543.67	2,705.56	3,075.77	5,455.40	5,298.41	4,100.68	4,189.75	5,247.54	7,682.19	4,096.92	0.00	0.00	
3515	ADULT 40-100% FEMAL E	4,207.15	4,307.18	4,485.47	5,597.52	6,473.72	5,933.53	6,422.59	7,457.42	8,369.11	6,743.44	0.00	0.00	
3516	ADULT 40-100% MALE 2	12,943.81	16,091.09	16,740.18	20,619.09	20,087.92	21,853.37	18,220.78	21,283.91	29,514.09	16,945.89	0.00	0.00	
3517	ADULT 40-100% FEMAL E	8,966.17	13,987.14	12,215.06	17,034.40	18,835.53	18,648.18	17,358.96	20,219.32	26,100.72	18,086.16	0.00	0.00	
3518	ADULT 40-100% M&F 45	23,376.59	31,932.62	27,610.19	37,501.55	37,281.39	46,125.00	30,801.60	47,748.02	44,728.52	40,311.14	0.00	0.00	
3519	ADULT 40-100% M&F 65	-43.54	0.00	-144.74	0.00	0.00	-43.23	-272.03	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	8,567.69	7,416.59	5,633.69	10,721.87	7,400.63	13,194.22	7,427.65	0.00	0.00	
351E	ADULT 40-100% FEMAL E	5,124.57	6,463.39	8,446.52	10,086.35	7,431.34	9,846.11	11,619.69	12,551.75	12,964.58	11,567.23	0.00	0.00	
351F	ADULT 40-100% MALE 2	21,965.91	29,130.31	30,242.67	44,866.82	32,784.74	32,631.81	49,160.77	38,892.39	53,183.35	36,961.83	0.00	0.00	
351G	ADULT 40-100% FEMAL E	17,043.40	20,971.83	21,682.27	35,421.81	28,410.61	27,590.19	43,112.92	36,689.92	48,390.36	35,043.61	0.00	0.00	
351H	ADULT 40-100% M&F 45	41,803.57	52,354.17	53,113.64	67,404.71	53,236.30	68,759.85	84,191.03	76,906.77	89,412.86	70,470.49	0.00	0.00	
351J	ADULT 40-100% M&F 65	905.92	486.29	519.10	207.64	539.42	122.44	433.08	211.59	282.87	1,825.93	0.00	0.00	
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	30.56	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	0.00	0.00	0.00	79.72	70.53	70.96	70.53	0.00	0.00	
3706	ADULT <40% EXP MALE	100.47	103.83	81.30	0.00	106.64	43.72	31.85	93.42	0.00	55.80	0.00	0.00	
3707	ADULT <40% EXP FEMA L	28.78	88.75	0.00	59.15	161.81	0.00	34.13	0.00	59.15	35.27	0.00	0.00	
3708	ADULT <40% EXP M&F
4	91.75	35.16	166.91	85.96	79.72	152.87	0.00	189.78	332.32	-70.53	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	11.38	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED
FO	10,450,228.78	10,502,948.05	10,457,838.23	13,996,481.19	13,985,392.32	13,875,727.45	13,828,030.55	13,623,979.95	13,529,346.58	13,536,470.32	0.00	0.00	
3714	ADULT <40% EXP MALE	6,115.08	8,625.11	8,794.37	10,129.15	8,759.41	11,111.21	12,092.56	12,435.69	17,086.48	13,381.60	0.00	0.00	
3715	ADULT <40% EXP FEMA L	7,339.31	8,582.41	8,070.24	10,214.25	11,309.19	10,291.07	9,603.29	11,936.19	13,910.22	11,883.43	0.00	0.00	
3716	ADULT <40% EXP MALE	68,031.82	105,097.58	99,156.13	106,708.48	112,099.41	118,936.84	102,483.71	123,638.00	140,201.62	113,174.71	0.00	0.00	
3717	ADULT <40% EXP FEMA L	39,795.47	54,797.29	50,459.71	57,594.52	61,707.36	61,426.32	52,684.82	69,410.03	80,868.71	68,360.93	0.00	0.00	
3718	ADULT <40% EXP M&F
4	68,319.05	90,380.80	82,253.32	97,639.10	114,020.98	105,769.39	89,184.22	106,679.74	137,969.29	100,204.31	0.00	0.00	
3719	ADULT <40% EXP M&F 6	-188.99	0.00	-92.83	-11.38	-151.06	-126.01	15.43	-130.96	0.00	-66.43	0.00	0.00	
371D	ADULT <40% EXP MALE	12,088.08	11,984.14	14,798.71	17,974.37	15,160.19	16,210.68	19,067.00	19,903.10	29,845.34	20,791.25	0.00	0.00	
371E	ADULT <40% EXP FEMA L	11,098.59	11,970.92	14,368.28	15,279.96	15,879.72	12,854.71	16,316.13	23,443.59	23,333.79	22,364.00	0.00	0.00	
371F	ADULT <40% EXP MALE	113,555.01	131,660.54	148,254.46	168,868.60	157,593.75	157,770.56	194,161.90	199,279.37	218,260.32	175,639.90	0.00	0.00	

 
400.86	
118.23	
-327.55	
59,376,176.97	
44,395.89	
59,997.13	
194,300.13	
171,451.64	
367,416.62	
-503.54	
79,245.07	
96,101.53	
369,820.60	
314,356.92	
657,653.39	
5,534.28	
133.59	
291.74	
617.03	
467.04	
1,063.94	
11.38	
127,786,443.42	
108,530.66	
103,139.60	
1,089,528.30	
597,105.16	
992,420.20	
-752.23	
177,822.86	
166,909.69	
1,665,044.41	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEMA L	64,615.40	76,406.23	77,082.72	88,362.67	82,220.86	85,291.08	97,533.94	106,339.30	134,034.32	102,775.07	0.00	0.00		914,661.59		
371H	ADULT <40% EXP M&F
4	103,824.25	118,397.96	123,597.43	149,256.04	151,623.87	139,033.76	184,001.41	167,139.56	202,794.51	158,968.96	0.00	0.00		1,498,637.75		
371J	ADULT <40% EXP M&F 6	273.50	159.45	0.00	0.00	722.41	0.00	1,016.29	0.00	1,031.72	211.59	0.00	0.00		3,414.96		
3720	AHC CARE EXPANDED
FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.96	0.00	0.00	0.00	0.00		70.96		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	159.44	0.00	0.00	0.00	0.00		159.44		
3727	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79.72	0.00	0.00	0.00	0.00		79.72		
3728	ADULT <40% EXP M&F
4	41.86	36.84	0.00	0.00	125.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203.73		
SUBTOTAL:	16,025,025.5	2 16,245,744.33	16,193,091.9	3 21,560,013.51	21,478,069.09	21,275,939.67	21,297,115.61	20,984,760.40	21,045,672.14	20,736,710.91	0.00	0.00		196,842,143.11		

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	150.25	150.25	150.25	150.25	150.25	150.25	150.25	0.00	0.00	
4410	SOBRA 100-133% FOR
F	261,749.30	263,955.88	263,138.58	360,786.82	361,845.81	357,170.93	356,725.11	335,421.79	328,652.60	331,364.81	0.00	0.00	
4414	SOBRA 100-133% MALE	2,105.62	1,874.91	1,968.33	2,049.17	1,932.11	2,436.66	2,244.71	2,277.25	3,218.88	3,190.57	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,174.78	1,743.17	2,329.73	2,960.89	2,344.68	2,353.59	3,421.85	2,995.39	3,881.41	2,949.95	0.00	0.00	
441D	SOBRA 100-133% MALE	2,281.96	2,047.20	2,452.70	4,681.99	3,923.70	3,707.07	4,354.58	4,020.95	4,596.42	6,591.84	0.00	0.00	
441E	SOBRA 100-133% FEMA L	2,162.61	3,226.95	3,607.81	4,512.96	3,605.39	3,377.04	7,103.02	4,797.94	6,539.12	4,829.83	0.00	0.00	
SUBTOTAL:	269,474.2	7	272,848.11	273,497.1	5	375,142.08	373,801.94	369,195.54	373,999.52	349,663.57	347,038.68	349,077.25	0.00	0.00	

1,051.75	
3,220,811.63	
23,298.21	
26,155.44	
38,658.41	
43,762.67	
3,353,738.11	

3900	NEWLY ELIGIBLE FOR F	176.46	170.89	118.98	159.44	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	59.15	50.05	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	15.33	27.30	0.00	0.00	0.00	57.94	56.88	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	47.78	81.07	59.51	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR F	4,279,517.52	4,290,693.81	4,270,850.20	5,732,004.24	5,712,085.21	5,651,440.35	5,593,435.30	5,442,615.23	5,369,141.43	5,331,917.80	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,997.23	2,282.50	1,847.85	3,920.62	2,930.86	2,385.70	2,753.20	3,744.26	3,782.18	3,734.44	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	2,567.80	3,091.71	3,650.90	4,283.03	4,804.60	3,605.65	4,285.44	4,513.74	6,201.11	5,230.80	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	14,421.46	23,913.07	20,066.63	27,014.50	29,519.52	21,076.67	19,844.48	27,905.77	31,534.96	25,746.22	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	24,200.12	29,808.29	30,731.92	40,208.95	42,655.10	35,658.77	32,530.53	45,865.06	54,024.72	45,705.35	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	17,738.46	22,130.93	23,871.13	32,621.64	33,580.77	31,109.41	25,197.09	38,159.02	39,730.62	28,925.30	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	-59.15	0.00	0.00	0.00	-58.77	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	3,621.45	3,615.61	4,452.83	5,888.19	5,150.99	3,236.07	7,027.32	5,717.04	6,657.28	6,957.71	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	4,410.34	5,728.19	6,138.52	6,814.64	6,684.51	4,930.07	7,418.18	6,580.62	10,256.49	8,337.13	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	28,767.21	34,616.84	34,385.84	46,140.76	42,191.90	34,790.29	49,862.75	46,587.88	62,635.64	49,071.24	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	40,309.72	45,143.86	48,506.03	64,217.65	56,224.09	49,654.67	68,977.58	67,082.46	83,533.97	72,394.68	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	31,477.45	34,268.38	40,137.77	60,104.57	49,403.74	45,325.47	64,073.76	56,097.97	70,532.10	52,391.76	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	117.50	51.91	118.24	0.00	0.00	0.00	0.00	150.25	0.00	0.00	0.00	0.00	
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	
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	6.83	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,449,322.72	4,495,515.99	4,484,949.6	6,023,405.53	5,985,231.29	5,883,219.95	5,875,503.46	5,745,158.31	5,738,146.89	5,630,353.66	0.00	0.00	

 
625.77	
109.20	
157.45	
188.36	
51,673,701.09	
29,378.84	
42,234.78	
241,043.28	
381,388.81	
293,064.37	
-117.92	
52,324.49	
67,298.69	
429,050.35	
596,044.71	
503,812.97	
437.90	
57.48	
6.83	
54,310,807.45	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4510	BC PATIENT FOR FINA N	6,511.96	6,730.74	6,988.28	8,895.80	8,463.43	8,180.88	8,542.72	8,684.21	8,736.36	9,000.10	0.00	0.00		80,734.48		
4517	BC PATIENT FEMALE 2
1	0.00	195.61	0.00	0.00	-138.78	0.00	0.00	70.53	43.23	0.00	0.00	0.00		170.59		
4518	BC PATIENT FEMALE 4 5	214.93	129.10	53.71	338.86	34.55	192.83	155.77	343.55	267.93	128.02	0.00	0.00		1,859.25		
4519	BC PATIENT FEMALE 6
5	107.54	7.42	0.00	147.33	2.57	218.93	121.32	30.87	8.24	0.00	0.00	0.00		644.22		
451G	BC PATIENT FEMALE 2 1	0.00	412.84	0.00	0.00	0.00	0.00	0.00	70.53	97.83	0.00	0.00	0.00		581.20		
451H	BC PATIENT FEMALE 4
5	446.37	320.06	44.99	376.60	184.38	635.53	267.60	421.00	332.13	2,559.95	0.00	0.00		5,588.61		
4610	CC PATIENT FOR FINA N	998.12	998.12	1,161.43	1,609.38	1,467.89	1,467.89	1,547.61	1,547.61	1,476.65	1,396.93	0.00	0.00		13,671.63		
4617	CC PATIENT FEMALE 2
1	0.00	38.38	0.00	0.00	49.37	28.29	0.00	0.00	0.00	16.46	0.00	0.00		132.50		
4618	CC PATIENT FEMALE 4 5	0.00	38.51	35.69	0.00	0.00	0.00	0.00	-103.01	0.00	18.60	0.00	0.00		-10.21		
461G	CC PATIENT FEMALE 2
1	57.48	80.60	0.00	0.00	91.69	329.85	0.00	0.00	0.00	1,091.51	0.00	0.00		1,651.13		
461H	CC PATIENT FEMALE 4 5	0.00	169.13	202.27	0.00	0.00	0.00	0.00	0.00	0.00	1,252.28	0.00	0.00		1,623.68		
SUBTOTAL:	8,336.40	9,120.51	8,486.3	7	11,367.97	10,155.10	11,054.20	10,635.02	11,065.29	10,962.37	15,463.85	0.00	0.00		106,647.08		

8700	SSI DISABLED FREEDO M	436.01	487.92	714.30	864.90	874.79	968.07	1,073.65	897.46	1,075.43	1,208.63	0.00	0.00	
8710	SSI DISABLED FREEDO
M	14,946.87	15,896.65	16,465.99	22,534.99	22,968.70	23,368.66	23,671.58	23,463.41	23,070.34	24,012.03	0.00	0.00	
871Z	SSI DISABLED FREEDO M	1,012.89	1,151.78	1,142.63	635.11	540.35	1,755.71	996.18	1,213.51	1,316.88	1,993.33	0.00	0.00	
8720	SSI DISABLED FREEDO
M	59.49	59.49	59.49	150.68	150.68	150.68	150.68	79.72	79.72	131.44	0.00	0.00	
SUBTOTAL:	16,455.26	17,595.84	18,382.4	1	24,185.68	24,534.52	26,243.12	25,892.09	25,654.10	25,542.37	27,345.43	0.00	0.00	

 
8,601.16	
210,399.22	
11,758.37	
1,072.07	
231,830.82	

6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	-141.06	0.00	0.00	0.00	0.00	0.00	0.00	
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	0.0	0	0.00	0.00	-141.06	0.00	0.00	0.00	0.00	0.00	0.00	

 
-141.06	
-59.49	
-200.55	

499,222,560.81

40,903,082.77	41,314,773.97	41,161,131.86	54,817,427.76	54,625,901.88	53,971,661.48	53,856,011.50	53,034,585.30	53,066,604.40	52,471,379.89	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2018

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	
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	
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	
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	0.00	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	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
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

101E	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

101F	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

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

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
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

2100	SSI AGED WITH MEDIC

2110	SSI AGED NON-MEDICA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	R															
211Z	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

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

220Z	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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

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

For The Period Ending April 30, 2018

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 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	
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	
4310

4311	SOBRA CHILD NON-ME DI
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

0.00	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	
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	

5000	SOBRA PREGNANT WO
MAN

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

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

500H	SOBRA PREG 45-64 FE	0.00
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	
5010	SOBRA PREGNANT WO	0.00
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	
5015	SOBRA PREG 14-20 FE	0.00
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	
5017	SOBRA PREG 21-44 FE	0.00
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	
5018	SOBRA PREG 45-64 FE	0.00
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	
501E	SOBRA PREG 14-20 FE	0.00
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	
501G	SOBRA PREG 21-44 FE	0.00
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	
501H	SOBRA PREG 45-64 FE	0.00
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	
5027	SOBRA PREG 21-44 FE	0.00
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	
5510	SOBRA FPS FEMALE W	0.00
IT	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	

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	0.0	0	0.00	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	

0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109

1110	TANF EXPANDED 65+ M
&
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	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

For The Period Ending April 30, 2018

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	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	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	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	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	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	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	
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	
111F	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	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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		0.00	
111J	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

1120		
FI
1126	TANF EXPANDED 21-44	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	
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		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		0.00	
1129

2400	TANF EXPANDED 65+ M
&
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	
240Z

2410	SSI AGED EXPANDED WI
SSI AGED EXPANDED 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	

TANF EXPANDED FOR

241Z	SSI AGED EXPANDED 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	
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

2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
260Z	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2610	SSI DISABLED EXPAND	0.00	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															
261Z	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2620	SSI DISABLED EXPAND	0.00	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														
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	
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		0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
SUBTOTAL:	0.00	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	
																
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		0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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		

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

351E

351F

351G	
ADULT 40-100% MALE 1

ADULT 40-100% FEMAL E
ADULT 40-100% MALE 2

ADULT 40-100% FEMAL E	
0.00	0.00	0.00
Cu0.00rren0.00t an0.0d0
0.00	0.00	0.00	
0.00	0.00
pr0i.00or m0.00
0.00	0.00	
0.00
ont0h.00
0.00	
0.00	0.00
da0.0t0 a is0.00
0.00	0.00	
0.00	0.00
und0.00er r0e.00
0.00	0.00	
0.00
vis0i.0o0
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	
351J	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	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 FEMA	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

3709

3710

3714

3715

3716

3717

3718

3719	L
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
AHC CARE EXPANDED
FO
ADULT <40% EXP MALE

ADULT <40% EXP FEMA L
ADULT <40% EXP MALE

ADULT <40% EXP FEMA L
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	
371D	ADULT <40% EXP 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	
371E	ADULT <40% EXP FEMA	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	L
ADULT <40% EXP MALE	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	0.00	
0.00	
0.00	
0.00	
0.00	

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

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3720	AHC CARE EXPANDED
FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3726	ADULT <40% EXP 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		
3727	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3900	NEWLY ELIGIBLE FOR
F

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

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

3907	NEWLY ELIGIBLE FEMA
L
3908	NEWLY ELIGIBLE M&F
4
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

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

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

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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	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	4
NEWLY ELIGIBLE M&F
6	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	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	
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	
3920	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3927	F
NEWLY ELIGIBLE FEMA	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
	L													
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	

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	
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% 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	
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% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	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 - GENERAL
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4510	BC PATIENT FOR FINA N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4517	BC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
4519	BC PATIENT FEMALE 6
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
451G	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
451H	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		0.00		
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4617	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
461G	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
461H	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		0.00		
SUBTOTAL:	0.00	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		

6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	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

8710	SSI DISABLED FREEDO	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
SSI DISABLED FREEDO	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	M	Current and prior month data is under revision.
SSI DISABLED FREEDO	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													
8720

SUBTOTAL	SSI DISABLED FREEDO	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
:	0.00	0.00	0.00	0.00	0.00	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 April 30, 2018	
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	627.43	0.00	0.00	0.00		627.43		
1010	TANF NON-MEDICARE	571,662.28	611,477.76	638,720.10	597,772.38	623,535.06	641,220.89	693,796.14	728,270.18	773,158.79	797,876.30	0.00	0.00		6,677,489.88		
1011	TANF <1 M & F NON-ME	13,755.71	7,131.27	6,861.85	11,754.63	8,312.21	13,897.69	6,040.86	18,921.38	7,165.54	7,225.24	0.00	0.00		101,066.38		
1012	TANF 01-05 M & F NON	-4,548.84	-5,434.60	-5,799.32	-3,576.27	-2,412.40	-10,519.41	-5,754.13	-620.95	-10,941.70	-4,297.74	0.00	0.00		-53,905.36		
1013	TANF 06-13 M & F NON	1,577.39	1,040.82	963.41	-1,297.14	-8,802.40	-504.11	4,302.46	226.37	9,113.01	9,261.90	0.00	0.00		15,881.71		
1014	TANF 14-20 MALE NON-	2,671.57	4,894.20	4,102.93	3,849.62	1,729.98	1,922.77	1,946.82	3,381.66	5,102.86	3,354.32	0.00	0.00		32,956.73		
1015	TANF 14-20 FEMALE N O	1,000.46	5,820.41	508.91	3,315.07	1,708.43	5,406.68	4,200.06	851.71	2,531.61	3,622.18	0.00	0.00		28,965.52		
101A	TANF < 1 M & F NON-M	3,387.50	1,546.54	1,250.66	2,919.05	1,022.38	1,712.51	3,085.39	1,379.91	0.00	490.63	0.00	0.00		16,794.57		
101B	TANF 01-05 M & F NON	0.00	-23.79	368.79	1,470.84	30.66	666.99	0.00	67.22	2,290.32	13,674.21	0.00	0.00		18,545.24		
101C	TANF 06-13 M & F NON	1,296.20	876.25	850.41	936.68	530.79	122.66	207.73	887.09	741.47	397.37	0.00	0.00		6,846.65		
101D	TANF 14-20 MALE NON-	49.17	47.58	0.00	0.00	737.58	0.00	607.19	0.00	0.00	0.00	0.00	0.00		1,441.52		
101E	TANF 14-20 FEMALE N O	90.65	1,879.64	0.00	24.59	0.00	0.00	0.00	0.00	-627.43	20.91	0.00	0.00		1,388.36		
2210	SSI DISABLED NON-ME
D	223,316.37	216,270.81	209,148.87	189,427.62	178,126.86	176,306.51	161,657.87	191,671.67	185,180.27	183,982.65	0.00	0.00		1,915,089.50		
221Z	SSI DISABLED NON-ME D	880.34	1,190.32	199.18	-2,048.24	6,631.49	721.17	424.73	77.68	950.07	3,508.06	0.00	0.00		12,534.80		
4300	SOBRA CHILD WITH ME
D	737.58	737.58	737.58	627.43	627.43	0.00	0.00	627.43	627.43	627.43	0.00	0.00		5,349.89		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	667.91	0.00	0.00	0.00	0.00	0.00	0.00		667.91		
4310	SOBRA CHILD NON-ME DI	12,126,022.98	11,903,733.62	11,593,125.26	10,124,690.53	9,927,789.05	9,764,337.74	9,716,799.66	9,589,383.72	9,639,685.42	9,596,042.10	0.00	0.00		103,981,610.08		
4311	SOBRA CHILD <1 M & F	25,704.10	41,214.87	28,100.17	43,698.19	30,021.53	45,433.06	41,400.29	41,448.67	41,775.74	39,847.73	0.00	0.00		378,644.35		
4312	SOBRA CHILD 01-05 M	-26,470.35	-20,488.64	-41,805.41	-40,907.11	-765.48	-33,208.07	7,364.86	21,175.78	-46,601.34	3,784.47	0.00	0.00		-177,921.29		
4313	SOBRA CHILD 06-13 M	-10,870.61	-92,386.66	-86,516.58	-32,848.83	46,954.78	-27,695.25	-16,292.04	24,493.92	-677.48	-7,095.56	0.00	0.00		-202,934.31		
4314	SOBRA CHILD 14-20 MA	-14,374.19	-22,086.68	-31,481.88	-13,208.57	6,637.16	-1,113.16	-37,116.40	-10,946.29	-19,920.25	-23,989.93	0.00	0.00		-167,600.19		
4315	SOBRA CHILD 14-20 FE	-23,537.71	-23,022.52	-45,341.83	-14,617.61	-4,799.17	-1,361.31	-25,379.29	4,480.20	-11,764.84	-13,511.91	0.00	0.00		-158,855.99		
431A	SOBRA CHILD < 1 M &	11,357.74	6,860.92	11,826.13	7,526.66	10,739.74	13,527.05	12,679.78	11,955.37	14,079.35	7,613.59	0.00	0.00		108,166.33		
431B	SOBRA CHILD 01-05 M	63,408.56	29,363.66	56,569.16	25,502.48	15,875.58	31,992.32	55,680.73	23,368.33	50,509.83	55,123.38	0.00	0.00		407,394.03		
431C	SOBRA CHILD 6-13 M&F	45,217.94	28,157.03	23,495.10	27,271.20	28,229.34	32,605.44	15,647.31	23,519.95	59,686.58	25,637.63	0.00	0.00		309,467.52		
431D	SOBRA CHILD 14-20 MA	15,738.23	22,636.34	20,368.59	13,247.46	15,533.88	13,473.20	22,777.17	20,951.31	29,103.84	13,697.12	0.00	0.00		187,527.14		
431E	SOBRA CHILD 14-20 FE	18,298.24	20,648.68	7,733.15	16,129.46	4,871.39	-687.09	21,222.17	19,618.14	20,520.88	15,186.13	0.00	0.00		143,541.15		
5010	SOBRA PREGNANT WO MAN	11,719.82	13,394.08	16,941.70	15,473.70	13,926.33	12,713.88	11,793.94	10,246.57	8,071.77	11,376.56	0.00	0.00		125,658.35		
5015	SOBRA PREG 14-20 FE
M	-618.62	284.05	-745.42	-769.10	-337.31	-118.70	-952.50	-1,390.51	667.91	146.40	0.00	0.00		-3,833.80		
SUBTOTAL:	13,057,472.5	1 12,755,763.54	12,410,181.5	1 10,976,364.72	10,906,454.89	10,681,521.37	10,696,140.80	10,724,046.51	10,761,057.08	10,743,601.17	0.00	0.00		113,712,604.10		

3510	ADULT 40-100% FOR FI	0.00	737.58	737.58	0.00	627.43	627.43	0.00	0.00	0.00	627.43	0.00	0.00	
3514	ADULT 40-100% MALE 1	333.10	0.00	-270.45	364.31	0.00	-384.55	0.00	0.00	101.20	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	858.61	0.00	0.00	
351D	ADULT 40-100% MALE 1	0.00	0.00	0.00	20.24	0.00	0.00	0.00	0.00	1,153.66	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	16,779.81	0.00	0.00	

 
3,357.45	
143.61	
858.61	
1,173.90	
16,779.81	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3710	AHC CARE EXPANDED FO	737.58	936.68	0.00	0.00	0.00	919.94	919.94	0.00	0.00	0.00	0.00	0.00		3,514.14		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	-801.24	0.00	0.00	0.00	0.00	0.00		-801.24		
3715	ADULT <40% EXP FEMA L	-689.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-689.99		
3716	ADULT <40% EXP MALE	151.08	-876.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-725.17		
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371F	ADULT <40% EXP MALE	785.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785.60		
SUBTOTAL:	1,317.37	798.01	467.1	3	384.55	627.43	1,162.82	118.70	0.00	1,254.86	18,265.85	0.00	0.00		24,396.72		

4410	SOBRA 100-133% FOR F	40,228.46	38,845.46	42,028.22	33,636.92	32,799.44	34,681.73	28,404.71	24,512.54	26,857.34	26,269.96	0.00	0.00	
4413	SOBRA 100-133% M&F
6	114.34	-279.25	2,199.91	3,673.17	3,219.78	2,308.86	3,361.01	3,735.22	3,044.28	-149.37	0.00	0.00	
4414	SOBRA 100-133% MALE	-1,879.64	3,445.42	1,421.23	446.32	2,789.87	845.82	182.15	717.07	-607.19	585.60	0.00	0.00	
4415	SOBRA 100-133% FEMA L	642.41	-1,070.68	1,333.47	1,261.42	585.60	525.73	-425.03	1,941.63	1,068.46	-62.74	0.00	0.00	
441C	SOBRA 100-133% M&F
6	0.00	844.77	0.00	0.00	0.00	0.00	1,011.98	0.00	445.13	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	42.24	0.00	0.00	292.80	29.68	0.00	0.00	0.00	20.91	0.00	0.00	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	445.13	0.00	0.00	0.00	
SUBTOTAL:	39,105.57	41,827.96	46,982.8	3	39,017.83	39,687.49	38,391.82	32,534.82	30,906.46	31,253.15	26,664.36	0.00	0.00	

 
328,264.78	
21,227.95	
7,946.65	
5,800.27	
2,301.88	
385.63	
445.13	
366,372.29	

114,103,373.11

12,457,631.47	11,015,767.10	10,946,769.81	10,721,076.01	10,728,794.32	10,754,952.97	10,793,565.09	10,788,531.38	0.00	0.00	

TOTAL:

13,097,895.45

12,798,389.51

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending April 30, 2018

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	
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

101A	TANF 14-20 FEMALE N O
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

0.00	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	
101E	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	
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	

221Z	SSI DISABLED NON-ME
D

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

4300	SOBRA CHILD WITH ME
D

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

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

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

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
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

5010	SOBRA PREGNANT WO
MAN
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
0.00	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

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	
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	
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	
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	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3715	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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		

441E

SOBRA 100-133% FEMA

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

L
SUBTOTAL:

Current and prior month data is 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

4410	SOBRA 100-133% FOR	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	F
SOBRA 100-133% M&F
6	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
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 - DD
For The Period Ending April 30, 2018	
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	479.91	479.91	479.91	479.91	479.91	479.91	479.91	0.00	0.00		4,441.89		
1010	TANF NON-MEDICARE	81,858.34	80,550.03	81,939.34	108,420.84	108,811.34	109,728.53	108,044.63	108,626.70	106,606.50	108,589.98	0.00	0.00		1,003,176.23		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-247.26	0.00	0.00	0.00	0.00		-247.26		
1020	TANF WITH QMB	422.92	364.72	364.72	469.58	469.58	469.58	234.79	478.09	478.09	478.09	0.00	0.00		4,230.16		
2100	SSI AGED WITH MEDIC A	30,144.63	30,562.05	31,743.47	40,382.65	40,502.34	40,019.19	40,474.69	40,153.21	39,485.41	39,764.80	0.00	0.00		373,232.44		
2110	SSI AGED NON-MEDICA
R	663.48	663.48	783.76	1,277.94	1,277.94	1,277.94	1,277.94	1,277.94	1,277.94	1,277.94	0.00	0.00		11,056.30		
2120	SSI AGED WITH QMB	47,183.19	46,929.65	46,572.40	59,355.15	59,668.65	59,632.60	60,216.87	60,389.72	60,176.86	61,774.31	0.00	0.00		561,899.40		
2200	SSI DISABLED WITH M E	295,854.29	297,124.19	297,611.51	386,000.69	386,021.56	387,589.89	394,370.31	395,008.54	395,144.68	398,302.96	0.00	0.00		3,633,028.62		
2210	SSI DISABLED NON-ME
D	3,191,354.09	3,204,083.23	3,215,171.47	4,287,011.58	4,309,641.89	4,331,330.24	4,351,974.64	4,380,103.03	4,418,400.09	4,430,412.76	0.00	0.00		40,119,483.02		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,259.86	0.00	-159.97	0.00	0.00		1,099.89		
2220	SSI DISABLED WITH Q
M	603,871.83	605,939.60	605,939.39	793,424.82	785,625.06	785,553.49	787,367.14	784,887.82	788,396.19	795,217.39	0.00	0.00		7,336,222.73		
2300	SSI BLIND WITH MEDIC	1,629.60	1,629.60	1,811.96	2,378.89	2,378.89	2,378.89	2,538.86	2,538.86	2,218.92	2,218.92	0.00	0.00		21,723.39		
2310	SSI BLIND NON-MEDIC A	8,325.85	8,387.93	8,387.93	12,170.08	11,473.40	11,548.22	11,388.25	11,014.39	11,097.28	10,879.24	0.00	0.00		104,672.57		
2320	SSI BLIND WITH QMB	4,320.36	4,643.85	4,643.85	5,569.19	5,803.98	5,963.95	5,569.19	5,569.19	5,963.95	5,484.04	0.00	0.00		53,531.55		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	245.78	0.00	0.00	0.00	0.00		245.78		
8020	QMB ONLY	0.00	0.00	0.00	-243.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-243.30		
SUBTOTAL:	4,265,989.42	4,281,239.17	4,295,330.6	4	5,696,698.02	5,712,154.54	5,735,972.43	5,763,937.22	5,791,785.78	5,829,725.82	5,854,720.37	0.00	0.00		53,227,553.41		

2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-76.64	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-76.64	0.00	0.00	0.00	0.00	

 
-76.64

-76.64

8700	SSI DISABLED FREEDO M	1,650.45	1,770.73	1,770.73	2,312.58	2,312.58	2,312.58	2,312.58	2,312.58	2,312.58	2,547.37	0.00	0.00	
8710	SSI DISABLED FREEDO
M	240.56	240.56	240.56	319.94	319.94	1,024.31	554.73	554.73	554.73	554.73	0.00	0.00	
8720	SSI DISABLED FREEDO M	564.05	564.05	564.05	723.21	723.21	723.21	723.21	723.21	723.21	723.21	0.00	0.00	
SUBTOTAL:	2,455.06	2,575.34	2,575.3	4	3,355.73	3,355.73	4,060.10	3,590.52	3,590.52	3,590.52	3,825.31	0.00	0.00	

 
21,614.76	
4,604.79	
6,754.62	
32,974.17	

53,260,450.94

4,268,444.48	4,283,814.51	4,297,905.98	5,700,053.75	5,715,510.27	5,740,032.53	5,767,527.74	5,795,299.66	5,833,316.34	5,858,545.68	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending April 30, 2018

2220

2300	SSI DISABLED WITH Q M
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

0.00	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	

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	
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	
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-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2210

221Z	SSI DISABLED NON-ME
D
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

0.00	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
QMB ONLY

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

visio

0.00

0.00

n.

0.00

8020

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

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

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	0.0	0	0.00	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		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending April 30, 2018	
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	2,754.15	3,672.20	3,672.20	3,855.28	4,186.75	3,855.28	3,855.28	0.00	0.00		33,619.13		
1010	TANF NON-MEDICARE	230,254.46	230,950.46	233,539.79	249,936.51	251,772.61	255,444.81	268,174.42	299,375.28	268,174.42	270,102.06	0.00	0.00		2,557,724.82		
1011	TANF <1 M & F NON-ME	10,542.58	11,542.76	11,179.74	11,460.01	9,397.00	9,170.09	9,969.90	11,489.20	13,326.28	12,728.14	0.00	0.00		110,805.70		
1012	TANF 01-05 M & F NON	2,859.42	5,864.01	6,364.10	7,215.33	9,051.43	10,196.39	8,507.18	8,735.44	6,480.30	7,078.44	0.00	0.00		72,352.04		
1013	TANF 06-13 M & F NON	6,220.78	8,864.55	9,364.64	10,077.73	8,360.29	9,850.82	7,775.82	5,794.76	5,383.26	5,748.94	0.00	0.00		77,441.59		
1014	TANF 14-20 MALE NON-	609.39	1,500.27	2,000.36	2,862.40	2,862.40	3,434.88	3,588.84	4,462.23	3,588.84	3,588.84	0.00	0.00		28,498.45		
1015	TANF 14-20 FEMALE N O	4,500.81	3,500.63	4,363.74	4,007.36	4,579.84	4,007.36	3,588.84	4,480.58	4,186.98	2,392.56	0.00	0.00		39,608.70		
1016	TANF 21-44 MALE NON-	500.09	0.00	0.00	0.00	0.00	0.00	0.00	598.14	0.00	0.00	0.00	0.00		1,098.23		
1017	TANF 21-44 FEMALE N O	1,000.18	500.09	500.09	572.48	572.48	572.48	598.14	1,849.47	1,794.42	1,196.28	0.00	0.00		9,156.11		
1020	TANF WITH QMB	863.11	863.11	863.11	918.05	918.05	918.05	963.82	1,074.31	963.82	963.82	0.00	0.00		9,309.25		
2200	SSI DISABLED WITH M E	27,756.59	30,846.01	31,709.12	38,439.44	36,948.91	37,866.96	42,640.54	46,261.47	43,604.36	40,712.90	0.00	0.00		376,786.30		
2210	SSI DISABLED NON-ME
D	5,182,687.05	5,193,036.46	5,189,349.85	5,510,171.54	5,525,636.55	5,526,333.64	5,807,347.71	6,453,923.74	5,829,542.27	5,817,319.99	0.00	0.00		56,035,348.80		
2220	SSI DISABLED WITH Q M	85,188.88	85,996.17	90,311.72	95,466.79	98,220.94	100,057.04	107,315.72	118,584.14	108,279.54	110,207.18	0.00	0.00		999,628.12		
2300	SSI BLIND WITH MEDIC	863.11	863.11	863.11	918.05	918.05	918.05	963.82	1,074.31	963.82	963.82	0.00	0.00		9,309.25		
2310	SSI BLIND NON-MEDIC A	50,108.57	51,834.79	53,561.01	54,500.11	55,990.64	57,826.74	60,088.54	64,623.20	57,197.08	52,012.30	0.00	0.00		557,742.98		
2320	SSI BLIND WITH QMB	863.11	863.11	863.11	918.05	918.05	918.05	0.00	110.49	0.00	0.00	0.00	0.00		5,453.97		
4311	SOBRA CHILD <1 M & F	21,284.97	19,270.06	16,769.61	20,630.10	19,830.71	19,603.80	20,073.02	23,544.61	21,368.54	22,199.14	0.00	0.00		204,574.56		
4312	SOBRA CHILD 01-05 M	157,167.47	154,378.93	151,152.44	165,731.94	154,261.52	154,834.00	165,363.88	182,679.35	161,508.60	154,662.62	0.00	0.00		1,601,740.75		
4313	SOBRA CHILD 06-13 M	235,190.96	240,864.50	239,364.23	262,683.00	263,028.57	255,921.49	267,087.06	289,225.76	255,821.64	260,241.08	0.00	0.00		2,569,428.29		
4314	SOBRA CHILD 14-20 MA	60,250.89	61,529.26	60,392.01	64,881.77	67,409.01	66,145.39	72,780.00	74,118.12	63,275.02	67,362.76	0.00	0.00		658,144.23		
4315	SOBRA CHILD 14-20 FE	54,343.85	54,624.38	54,261.36	62,927.01	64,763.11	64,190.63	66,997.08	72,670.35	66,863.86	65,301.90	0.00	0.00		626,943.53		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	110.49	0.00	0.00	0.00	0.00		110.49		
5015	SOBRA PREG 14-20 FE M	1,000.18	1,500.27	2,000.36	1,717.44	572.48	572.48	598.14	763.29	598.14	598.14	0.00	0.00		9,920.92		
SUBTOTAL:	6,136,645.78	6,161,782.26	6,161,362.8	3	6,568,789.26	6,579,684.84	6,582,455.35	6,918,277.75	7,669,735.48	6,916,776.47	6,899,236.19	0.00	0.00		66,594,746.21		

3514	ADULT 40-100% MALE 1	1,500.27	1,500.27	2,000.36	1,717.44	1,717.44	1,717.44	1,794.42	1,959.57	1,794.42	1,794.42	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,000.18	1,000.18	1,000.18	1,144.96	1,144.96	1,144.96	598.14	708.24	598.14	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL
E	0.00	0.00	0.00	0.00	572.48	572.48	598.14	598.14	598.14	598.14	0.00	0.00	
3714	ADULT <40% EXP MALE	7,243.27	7,501.35	8,501.53	10,304.64	10,877.12	12,022.08	12,560.94	12,392.26	11,364.66	10,766.52	0.00	0.00	
3715	ADULT <40% EXP FEMA L	7,001.26	7,001.26	8,001.44	8,014.72	8,014.72	8,014.72	7,775.82	9,144.66	8,373.96	8,972.10	0.00	0.00	
3716	ADULT <40% EXP MALE	500.09	1,000.18	500.09	572.48	572.48	572.48	598.14	1,849.47	598.14	598.14	0.00	0.00	

17,496.05	
8,339.94	
3,537.52	
103,534.37	
80,314.66	
7,361.69	

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	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	1,144.96	1,196.28	1,196.28	1,196.28	1,196.28	0.00	0.00	
1117	TANF EXPANDED 21-44	500.09	500.09	500.09	572.48	572.48	572.48	598.14	55.05	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	500.09	500.09	500.09	572.48	572.48	572.48	598.14	653.19	598.14	598.14	0.00	0.00	
SUBTOTAL:	1,500.27	1,500.27	1,500.2	7	1,144.96	1,144.96	2,289.92	2,392.56	1,904.52	1,794.42	1,794.42	0.00	0.00	

 
1,500.27	
5,930.08	
3,870.90	
5,665.32	
16,966.57	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3717	ADULT <40% EXP FEMA L	1,516.46	2,500.45	2,000.36	2,862.40	2,289.92	1,717.44	1,794.42	2,032.97	1,794.42	1,794.42	0.00	0.00		20,303.26		
SUBTOTAL:	18,761.53	20,503.69	22,003.96	24,616.64	25,189.12	25,761.60	25,720.02	28,685.31	25,121.88	24,523.74	0.00	0.00		240,887.49		

3914	NEWLY ELIGIBLE MALE	1,500.27	1,500.27	1,500.27	1,144.96	572.48	0.00	0.00	73.40	0.00	598.14	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	572.48	572.48	1,717.44	1,794.42	1,269.68	1,196.28	1,196.28	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	572.48	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	572.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,500.27	1,500.27	1,500.2	7	1,717.44	2,289.92	1,717.44	1,794.42	1,343.08	1,196.28	1,794.42	0.00	0.00	

 
6,889.79	
8,319.06	
572.48	
572.48	
16,353.81	

4413	SOBRA 100-133% M&F
6	8,001.44	8,001.44	8,001.44	9,159.68	10,304.64	13,739.52	10,766.52	11,665.67	10,168.38	11,962.80	0.00	0.00	
4414	SOBRA 100-133% MALE	2,500.45	2,000.36	2,500.45	2,289.92	2,862.40	3,434.88	2,990.70	2,014.62	1,794.42	2,392.56	0.00	0.00	
4415	SOBRA 100-133% FEMA L	5,009.06	4,863.83	5,363.92	5,497.89	4,925.41	4,925.41	5,748.94	5,683.34	4,785.12	5,383.26	0.00	0.00	
SUBTOTAL:	15,510.95	14,865.63	15,865.8	1	16,947.49	18,092.45	22,099.81	19,506.16	19,363.63	16,747.92	19,738.62	0.00	0.00	

 
101,771.53	
24,780.76	
52,186.18	
178,738.47	

67,047,692.55

6,173,918.80	6,200,152.12	6,202,233.14	6,613,215.79	6,626,401.29	6,634,324.12	6,967,690.91	7,721,032.02	6,961,636.97	6,947,087.39	0.00	0.00	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2018	
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	3.00	4.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00		36.00		
1010	TANF NON-MEDICARE	267.20	268.00	271.00	273.00	275.00	279.00	279.00	280.00	279.00	281.00	0.00	0.00		2,752.20		
1011	TANF <1 M & F NON-ME	16.00	18.00	18.00	17.00	14.00	13.00	13.00	14.00	18.00	17.00	0.00	0.00		158.00		
1012	TANF 01-05 M & F NON	6.71	11.00	12.00	12.00	14.00	16.00	13.00	12.00	9.00	10.00	0.00	0.00		115.71		
1013	TANF 06-13 M & F NON	13.54	17.00	18.00	17.00	14.00	16.00	13.00	8.00	9.00	9.00	0.00	0.00		134.54		
1014	TANF 14-20 MALE NON-	1.98	3.00	4.00	5.00	5.00	6.00	6.00	7.00	6.00	6.00	0.00	0.00		49.98		
1015	TANF 14-20 FEMALE N O	9.00	7.00	8.00	7.00	8.00	7.00	6.00	7.00	7.00	4.00	0.00	0.00		70.00		
1016	TANF 21-44 MALE NON-	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00		2.00		
1017	TANF 21-44 FEMALE N O	2.00	1.00	1.00	1.00	1.00	1.00	1.00	3.00	3.00	2.00	0.00	0.00		16.00		
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
2200	SSI DISABLED WITH M E	33.00	37.00	38.00	43.00	41.00	42.00	45.00	43.78	46.00	43.00	0.00	0.00		411.78		
2210	SSI DISABLED NON-ME
D	6,161.82	6,182.17	6,182.36	6,150.81	6,171.43	6,168.34	6,174.01	6,160.57	6,200.04	6,183.50	0.00	0.00		61,735.05		
2220	SSI DISABLED WITH Q M	102.08	103.00	108.00	107.00	110.00	112.00	114.00	114.00	115.00	117.00	0.00	0.00		1,102.08		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
2310	SSI BLIND NON-MEDIC A	61.00	63.00	65.00	62.00	64.00	66.00	65.00	63.00	62.00	57.00	0.00	0.00		628.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
4311	SOBRA CHILD <1 M & F	34.24	32.00	27.00	30.00	28.00	27.00	25.00	28.00	29.00	31.00	0.00	0.00		291.24		
4312	SOBRA CHILD 01-05 M	251.49	247.00	242.00	240.00	226.00	227.00	230.00	230.00	226.00	217.00	0.00	0.00		2,336.49		
4313	SOBRA CHILD 06-13 M	380.13	388.00	385.00	384.00	384.00	374.00	375.00	368.10	358.00	365.93	0.00	0.00		3,762.16		
4314	SOBRA CHILD 14-20 MA	91.71	94.00	91.00	91.00	93.00	92.00	96.00	89.00	85.00	90.00	0.00	0.00		912.71		
4315	SOBRA CHILD 14-20 FE	86.52	86.00	86.00	90.00	92.00	91.00	90.00	89.00	91.00	89.00	0.00	0.00		890.52		
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		
5015	SOBRA PREG 14-20 FE M	2.00	3.00	4.00	3.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		18.00		
SUBTOTAL:	7,527.42	7,566.17	7,566.3	6	7,538.81	7,548.43	7,545.34	7,552.01	7,524.45	7,550.04	7,529.43	0.00	0.00		75,448.46		

3514	ADULT 40-100% MALE 1	3.00	3.00	4.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL
E	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3714	ADULT <40% EXP MALE	14.49	15.00	17.00	18.00	19.00	21.00	21.00	19.00	19.00	18.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	13.00	14.00	16.00	14.00	14.00	14.00	13.00	14.00	14.00	15.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1.00	2.00	1.00	1.00	1.00	1.00	1.00	3.00	1.00	1.00	0.00	0.00	

31.00	
15.00	
6.00	
181.49	
141.00	
13.00	

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	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.0	0	2.00	2.00	4.00	4.00	3.00	3.00	3.00	0.00	0.00	

 
3.00	
10.00	
7.00	
10.00	
30.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3717	ADULT <40% EXP FEMA L	3.04	5.00	4.00	5.00	4.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00		36.04		
SUBTOTAL:	36.53	41.00	44.00	43.00	44.00	45.00	43.00	44.00	42.00	41.00	0.00	0.00		423.53		

4413	SOBRA 100-133% M&F
6	16.00	16.00	16.00	16.00	18.00	24.00	18.00	18.00	17.00	20.00	0.00	0.00	
4414	SOBRA 100-133% MALE	5.00	4.00	5.00	4.00	5.00	6.00	5.00	3.00	3.00	4.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	9.30	9.00	10.00	9.00	8.00	8.00	9.00	8.00	8.00	9.00	0.00	0.00	
SUBTOTAL:	30.30	29.00	31.0	0	29.00	31.00	38.00	32.00	29.00	28.00	33.00	0.00	0.00	

179.00	
44.00	
87.30	
310.30	

3914	NEWLY ELIGIBLE MALE	3.00	3.00	3.00	2.00	1.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	1.00	1.00	3.00	3.00	2.00	2.00	2.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.0	0	3.00	4.00	3.00	3.00	2.00	2.00	3.00	0.00	0.00	

 
13.00	
14.00	
1.00	
1.00	
29.00	

TOTAL:	7,600.25	7,642.17	7,647.36	7,615.81	7,629.43	7,635.34	7,634.01	7,602.45	7,625.04	7,609.43	0.00	0.00		76,241.29		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
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	3,169.14	2,276.56	4,106.59	4,046.18	1,531.72	2,866.72	5,774.90	0.00	0.00		36,912.18		
1007	TANF 21-44 FEMALE WI	1,016.91	4,570.23	1,073.59	1,906.70	1,580.98	1,072.42	879.70	2,272.93	5,199.49	5,114.84	0.00	0.00		24,687.79		
1008	TANF 45-64 M & F WIT	4,063.28	14,411.49	6,861.70	7,949.71	8,146.58	10,764.39	8,394.59	9,592.98	7,919.37	10,922.52	0.00	0.00		89,026.61		
1009	TANF 65+ M & F WITH	1,829.47	5,196.34	1,470.33	6,528.61	4,306.35	7,096.71	4,211.06	2,727.95	11,994.50	2,610.19	0.00	0.00		47,971.51		
1011	TANF <1 M & F NON-ME	1,284,388.04	1,182,231.54	830,768.97	922,605.76	936,094.53	907,435.51	1,280,609.13	1,113,508.69	1,381,708.58	1,388,622.69	0.00	0.00		11,227,973.44		
1012	TANF 01-05 M & F NON	306,683.16	412,472.37	323,626.39	314,052.36	445,372.15	490,979.75	633,493.13	568,770.01	383,142.86	333,380.42	0.00	0.00		4,211,972.60		
1013	TANF 06-13 M & F NON	264,224.37	414,658.39	311,058.48	275,598.57	362,861.30	343,559.87	392,508.82	395,252.67	339,346.57	297,871.36	0.00	0.00		3,396,940.40		
1014	TANF 14-20 MALE NON-	86,310.63	160,809.56	112,057.29	90,696.33	130,674.82	95,778.43	110,791.29	90,351.24	76,924.67	82,639.85	0.00	0.00		1,037,034.11		
1015	TANF 14-20 FEMALE N O	206,804.78	321,511.26	270,885.39	235,648.40	230,380.54	267,100.85	303,693.70	276,882.63	255,168.73	258,301.08	0.00	0.00		2,626,377.36		
1016	TANF 21-44 MALE NON-	1,605,145.18	2,146,258.99	1,566,079.98	1,353,156.89	1,749,136.00	1,442,212.21	1,747,350.09	1,655,013.51	1,800,247.07	1,563,493.30	0.00	0.00		16,628,093.22		
1017	TANF 21-44 FEMALE N O	5,140,087.02	7,399,384.59	5,718,878.76	4,354,640.61	5,643,436.61	5,304,617.48	6,791,215.54	6,176,634.19	6,224,000.29	5,619,822.83	0.00	0.00		58,372,717.92		
1018	TANF 45-64 M & F NON	2,173,545.85	3,146,602.31	2,409,273.14	1,891,780.48	2,261,126.74	2,232,598.15	2,725,143.83	2,409,788.47	2,664,393.82	2,271,732.68	0.00	0.00		24,185,985.47		
1019	TANF 65+ M & F NON-M	5,538.38	6,532.19	9,688.97	4,875.56	6,903.56	12,267.28	15,525.61	18,870.83	9,862.92	52,822.42	0.00	0.00		142,887.72		
1026	TANF 21-44 MALE WITH	1,154.73	3,471.57	1,065.33	1,226.58	905.01	1,784.55	577.23	1,178.61	2,230.97	2,560.34	0.00	0.00		16,154.92		
1027	TANF 21-44 FEMALE WI	1,200.77	2,919.28	1,334.01	2,199.51	2,297.44	5,257.53	1,916.52	2,477.66	4,645.16	4,409.35	0.00	0.00		28,657.23		
1028	TANF 45-64 M & F WIT	6,497.01	18,889.29	4,570.38	9,388.34	12,127.95	14,151.96	22,149.56	15,838.07	16,485.16	15,965.35	0.00	0.00		136,063.07		
1029	TANF 65+ M & F WITH	167.87	1,843.03	1,916.23	1,106.78	1,826.30	1,888.44	1,850.76	1,547.51	1,183.82	4,431.90	0.00	0.00		17,762.64		
2100	SSI AGED WITH MEDIC A	86,634.05	198,717.97	167,054.01	142,484.04	240,448.57	111,905.24	149,502.49	149,010.17	158,991.16	184,847.04	0.00	0.00		1,589,594.74		
2110	SSI AGED NON-MEDICA
R	100,992.78	173,440.45	97,227.41	98,654.54	163,062.77	87,839.04	122,009.46	256,005.80	165,509.03	136,449.71	0.00	0.00		1,401,190.99		
2120	SSI AGED WITH QMB	397,845.00	1,120,737.17	544,810.04	566,076.41	590,532.34	584,098.58	644,656.17	610,614.27	650,147.98	656,211.89	0.00	0.00		6,365,729.85		
2200	SSI DISABLED WITH M E	279,634.07	754,753.74	406,685.00	408,563.82	508,338.91	418,966.68	422,414.82	568,436.49	559,203.55	560,457.57	0.00	0.00		4,887,454.65		
2210	SSI DISABLED NON-ME
D	8,103,646.51	12,118,405.08	8,606,785.18	7,378,483.58	9,072,325.96	8,417,621.46	9,648,467.36	9,504,552.15	9,602,049.32	8,489,061.72	0.00	0.00		90,941,398.32		
2220	SSI DISABLED WITH Q M	1,094,219.47	2,360,048.72	1,266,419.75	1,311,874.56	1,506,921.73	1,411,888.73	1,613,174.80	1,376,494.80	1,618,093.84	1,583,760.00	0.00	0.00		15,142,896.40		
2300	SSI BLIND WITH MEDIC	136.94	1,989.12	60.90	1,192.44	2,697.19	1,227.26	1,130.79	3,682.93	1,358.81	5,431.93	0.00	0.00		18,908.31		
2310	SSI BLIND NON-MEDIC A	200,400.19	130,031.27	62,528.51	85,592.07	111,647.78	87,482.49	109,787.86	105,421.07	128,684.01	108,051.19	0.00	0.00		1,129,626.44		
2320	SSI BLIND WITH QMB	14,946.76	28,446.18	14,046.74	21,821.60	23,430.40	23,001.37	33,960.74	25,582.59	33,217.09	29,655.59	0.00	0.00		248,109.06		
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	2,134.79	0.00	0.00	0.00	22.29	0.00	0.00	0.00	0.00		2,992.25		
4311	SOBRA CHILD <1 M & F	2,383,990.92	3,303,283.24	2,449,918.11	2,471,807.81	2,653,216.49	4,334,545.10	3,709,273.41	3,280,449.77	3,688,081.53	2,815,502.54	0.00	0.00		31,090,068.92		
4312	SOBRA CHILD 01-05 M	3,489,044.12	5,024,125.49	3,745,519.83	3,677,467.16	4,197,147.02	4,518,165.18	5,494,516.01	5,363,812.95	4,824,755.86	4,281,030.89	0.00	0.00		44,615,584.51		
4313	SOBRA CHILD 06-13 M	4,410,433.12	7,025,863.80	5,467,457.45	5,146,948.41	5,576,924.32	5,213,093.39	5,802,411.57	5,871,032.14	5,429,295.41	4,990,585.40	0.00	0.00		54,934,045.01		
4314	SOBRA CHILD 14-20 MA	1,070,687.79	2,357,534.67	1,409,716.96	1,101,461.61	1,519,827.30	1,354,316.53	1,582,106.02	1,384,226.25	1,481,750.37	1,341,073.76	0.00	0.00		14,602,701.26		
4315	SOBRA CHILD 14-20 FE	1,570,912.47	2,309,511.52	2,000,484.23	1,428,985.48	1,785,265.09	1,630,516.64	2,017,200.30	2,029,757.33	1,797,114.00	1,902,576.77	0.00	0.00		18,472,323.83		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	852.78	1,277.36	500.03	2,218.42	2,539.14	683.14	474.54	0.00	0.00		8,545.41		
5007	SOBRA PREG 21-44 FE M	65.28	178.68	408.14	165.61	65.10	0.00	161.42	161.42	359.81	200.05	0.00	0.00		1,765.51		
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	109.40	0.00	0.00		477.40		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5015	SOBRA PREG 14-20 FE M	335,800.58	553,962.19	416,733.08	339,024.33	411,843.47	335,188.79	465,780.69	455,485.84	383,559.85	313,867.22	0.00	0.00		4,011,246.04		
5017	SOBRA PREG 21-44 FE
M	2,194,707.90	3,296,850.18	2,163,190.32	2,027,259.13	2,489,652.94	2,181,231.16	3,084,680.75	2,585,060.29	2,468,845.25	2,223,932.75	0.00	0.00		24,715,410.67		
5018	SOBRA PREG 45-64 FE M	7,521.12	19,754.71	36,209.53	3,203.04	8,864.96	9,264.80	6,722.40	949.54	0.00	151.77	0.00	0.00		92,641.87		
5027	SOBRA PREG 21-44 FE
M	1,129.67	190.89	1,726.17	737.54	851.20	1,186.92	2,343.28	493.81	0.00	161.42	0.00	0.00		8,820.90		
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:	36,832,796.9	7 56,026,201.77	40,434,246.8	7 35,691,321.08	42,663,794.32	41,864,711.51	48,956,875.50	46,316,030.71	46,179,020.71	41,544,069.17	0.00	0.00		436,509,068.61		

1106	TANF EXPANDED 21-44	7,297.18	14,844.32	7,468.63	8,253.20	14,892.91	10,079.97	8,588.19	5,649.37	8,263.81	7,609.64	0.00	0.00	
1107	TANF EXPANDED 21-44	7,705.45	27,104.24	11,416.70	13,170.76	19,255.24	13,068.73	17,384.49	11,769.84	6,180.54	6,668.05	0.00	0.00	
1108	TANF EXPANDED 45-64	39,957.51	129,068.40	58,983.63	53,285.38	37,242.30	41,285.03	48,128.82	40,912.57	60,357.38	59,570.81	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	13,302.89	68,582.67	32,742.97	33,713.99	31,387.93	22,915.36	30,121.41	29,929.55	28,173.68	35,916.64	0.00	0.00	
1112	TANF EXPANDED 01-05	21.08	1,564.00	0.00	0.00	0.00	368.00	0.00	0.00	0.00	427.00	0.00	0.00	
1113	TANF EXPANDED 06-13	782.00	1,564.00	391.00	782.00	1,564.00	4,316.54	0.00	0.00	1,287.21	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	4,219.99	4,285.42	2,020.59	3,065.33	2,209.95	1,643.80	2,961.16	3,478.19	11,875.56	2,484.77	0.00	0.00	
1115	TANF EXPANDED 14-20	37,762.36	77,588.83	27,334.03	25,017.95	20,299.56	17,982.46	24,461.54	38,589.35	39,420.62	29,245.49	0.00	0.00	
1116	TANF EXPANDED 21-44	726,388.72	952,513.78	725,300.88	534,912.44	793,954.18	729,679.38	750,803.86	628,980.23	620,878.90	733,059.49	0.00	0.00	
1117	TANF EXPANDED 21-44	1,969,469.31	2,959,533.75	2,254,909.75	1,949,529.65	2,338,218.29	2,137,051.71	2,645,918.30	2,507,724.16	2,420,265.31	2,326,982.64	0.00	0.00	
1118	TANF EXPANDED 45-64	1,527,595.12	2,301,679.17	1,604,070.10	1,583,232.31	1,710,838.13	1,700,963.37	1,872,255.86	2,058,043.23	1,665,226.25	1,637,702.55	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	4,934.02	2,903.20	2,737.00	-736.00	782.00	1,173.00	782.00	1,281.00	2,526.00	1,708.00	0.00	0.00	
1126	TANF EXPANDED 21-44	17,006.67	35,328.85	24,342.63	19,785.08	10,769.02	13,924.05	16,042.95	23,335.54	15,751.93	17,883.54	0.00	0.00	
1127	TANF EXPANDED 21-44	71,422.78	90,708.34	59,181.46	70,740.23	50,543.28	29,690.79	34,559.60	42,734.65	36,323.76	37,778.38	0.00	0.00	
1128	TANF EXPANDED 45-64	117,450.01	221,317.21	123,419.50	131,814.26	158,361.92	131,606.35	169,441.98	154,610.38	151,782.12	132,855.36	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	33,990.50	79,209.66	44,196.32	62,075.52	61,411.13	47,020.45	57,130.37	64,115.73	70,538.61	62,504.80	0.00	0.00	
2400	SSI AGED EXPANDED WI	7,895.47	27,114.18	9,931.76	9,572.02	10,340.77	10,064.91	14,847.44	17,261.75	16,142.07	17,005.73	0.00	0.00	
2410	SSI AGED EXPANDED N
O	8,589.87	18,708.33	5,932.73	7,363.52	10,318.62	12,879.07	14,229.90	18,162.54	8,904.61	13,956.62	0.00	0.00	
2420	SSI AGED EXPANDED WI	303,350.37	970,181.74	468,595.41	462,951.26	521,260.68	449,352.53	539,660.37	509,637.73	538,175.75	554,054.24	0.00	0.00	
2600	SSI DISABLED EXPAND
E	16,597.73	35,014.92	12,908.96	14,139.03	8,611.68	8,680.91	9,393.40	8,885.67	5,451.74	13,979.71	0.00	0.00	
2610	SSI DISABLED EXPAND E	174,183.69	189,984.93	206,243.10	268,797.99	368,351.85	244,127.36	196,197.44	140,760.67	217,897.86	175,957.51	0.00	0.00	
2620	SSI DISABLED EXPAND
E	309,290.16	654,696.24	352,952.43	378,345.35	437,089.96	409,325.28	519,040.32	402,074.05	453,966.41	467,288.64	0.00	0.00	
SUBTOTAL:	5,399,212.88	8,863,496.18	6,035,079.5	5,629,811.27	6,607,703.40	6,037,199.05	6,971,949.40	6,707,936.20	6,379,390.12	6,334,639.61	0.00	0.00	

 
92,947.22	
133,724.04	
568,791.83	
326,787.09	
2,380.08	
10,686.75	
38,244.76	
337,702.19	
7,196,471.86	
23,509,602.87	
17,661,606.09	
18,090.22	
194,170.26	
523,683.27	
1,492,659.09	
582,193.09	
140,176.10	
119,045.81	
5,317,220.08	
133,663.75	
2,182,502.40	
4,384,068.84	
64,966,417.69	

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	-289.00	0.00	-588.00	0.00	-294.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	-1,450.00	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	-2,342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-2,142.4	1	-4,081.00	0.00	-588.00	0.00	-294.00	0.00	0.00	0.00	0.00	

 
-115.41	
-1,759.00	
-1,450.00	
-3,781.00	
-7,105.41	

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	-268.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-55.23	0.00	0.00		-55.23		
3616	AHC CARE/MI MALE 21-	0.00	0.00	-2,058.00	-7,868.00	-330.00	0.00	0.00	35.85	0.00	-211.07	0.00	0.00		-10,431.22		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	-7,903.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,903.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-2,884.78	-14,002.00	-330.00	-572.50	0.00	0.00	0.00	0.00	0.00	0.00		-17,789.28		
SUBTOTAL:	0.00	0.00	-5,210.7	8	-29,773.00	-660.00	-572.50	0.00	35.85	0.00	-266.30	0.00	0.00		-36,446.73		

3906	NEWLY ELIGIBLE MALE	79.82	368.00	0.00	0.00	0.00	0.00	0.00	0.00	391.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	1,288.30	1,262.93	326.52	2,179.93	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	1,137.73	2,524.17	1,893.92	2,447.40	2,522.50	2,473.73	3,614.83	3,274.49	1,998.62	235.58	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	782.00	1,173.00	391.00	1,793.82	885.08	204.54	319.42	0.00	91.50	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	15,833.99	35,220.93	45,989.71	20,010.77	16,001.61	26,388.26	25,742.69	48,020.11	21,907.18	22,042.20	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	36,934.84	78,842.57	55,264.88	40,971.96	70,324.87	48,282.80	41,967.02	50,088.25	53,573.01	58,726.33	0.00	0.00	

838.82	
5,057.68	
22,122.97	
5,640.36	
277,157.45	
534,976.53	

3506	ADULT 40-100% MALE 2	7.64	-7.64	391.00	1,271.46	1,331.33	1,488.01	406.64	0.00	0.00	21.50	0.00	0.00	
3508	ADULT 40-100% M&F 45	1,803.35	3,208.14	4,659.68	7,457.81	167.17	6,987.58	6,451.96	5,458.33	28,594.79	5,372.20	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	368.00	0.00	41.76	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	53,596.02	63,695.41	43,957.74	69,554.24	75,332.66	53,971.41	57,527.63	0.00	0.00	
3515	ADULT 40-100% FEMAL E	64,453.95	120,805.35	122,829.84	84,271.89	96,509.61	123,742.25	95,658.06	97,035.48	141,982.39	105,187.94	0.00	0.00	
3516	ADULT 40-100% MALE 2	1,032,132.33	1,092,897.02	1,054,822.93	634,836.00	827,908.51	697,259.59	708,161.06	952,096.04	864,207.89	1,018,816.69	0.00	0.00	
3517	ADULT 40-100% FEMAL E	567,849.60	693,283.53	564,355.82	467,302.54	610,739.18	508,353.24	666,515.99	636,838.30	645,757.53	592,534.72	0.00	0.00	
3518	ADULT 40-100% M&F 45	2,072,401.00	3,374,307.17	2,308,268.87	1,985,532.63	2,753,357.74	2,408,219.56	2,536,758.33	2,356,070.57	2,516,802.94	2,471,525.99	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	391.00	1,984.09	544.00	967.14	1,380.68	612.76	1,988.29	1,158.84	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.00	0.00	0.00	
3706	ADULT <40% EXP MALE	391.00	1,472.00	0.00	0.00	782.00	-321.20	272.54	-25.98	1,890.88	56.79	0.00	0.00	
3707	ADULT <40% EXP FEMA L	71.15	360.17	402.73	1,677.07	4,738.43	2,666.40	3,266.30	6,201.35	2,285.47	836.14	0.00	0.00	
3708	ADULT <40% EXP M&F
4	15,324.82	30,471.96	7,351.90	3,813.39	-13,632.67	7,520.84	3,101.55	5,173.33	2,585.28	9,794.82	0.00	0.00	
3709	ADULT <40% EXP M&F 6	8.80	1,224.49	0.00	414.00	0.00	0.00	0.00	476.67	572.97	252.37	0.00	0.00	
3714	ADULT <40% EXP MALE	266,479.48	432,725.78	269,533.12	315,886.44	373,851.13	350,706.32	313,045.82	301,415.15	255,923.50	324,902.71	0.00	0.00	
3715	ADULT <40% EXP FEMA L	308,587.81	494,530.02	386,921.43	330,007.21	347,666.89	328,545.30	401,280.23	409,086.10	393,844.64	429,200.68	0.00	0.00	
3716	ADULT <40% EXP MALE	6,059,520.29	8,492,593.39	6,582,557.25	5,550,281.54	6,966,711.02	6,525,619.05	7,729,239.66	5,988,427.21	6,697,587.14	6,759,157.97	0.00	0.00	
3717	ADULT <40% EXP FEMA L	3,256,920.31	4,683,150.22	3,497,315.69	2,842,689.15	4,215,504.61	3,256,935.80	4,226,317.61	3,504,810.63	3,500,229.43	3,583,950.99	0.00	0.00	
3718	ADULT <40% EXP M&F
4	8,858,790.44	13,462,857.77	9,025,589.07	7,976,024.04	9,777,849.89	9,247,867.06	11,214,763.29	9,957,086.57	9,795,387.05	10,474,157.66	0.00	0.00	
3719	ADULT <40% EXP M&F 6	5,501.88	5,230.07	782.00	454.98	1,262.76	2,816.45	3,265.08	3,629.66	2,845.00	391.00	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	63.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEMA L	0.00	0.00	0.00	1,109.20	0.00	60.10	0.00	218.04	549.19	58.42	0.00	0.00	
3728	ADULT <40% EXP M&F
4	0.00	601.37	0.00	368.00	1,104.00	797.73	1,025.92	172.81	703.09	0.00	0.00	0.00	
SUBTOTAL:	22,572,756.3	32,955,606.65	23,910,202.0	20,259,019.22	26,030,154.51	23,514,188.96	27,980,464.96	24,300,115.68	24,907,708.88	25,835,332.06	0.00	0.00	

 
4,909.94	
70,161.01	
409.76	
629,705.18	
1,052,476.76	
8,883,138.06	
5,953,530.45	
24,783,244.80	
9,026.80	
427.00	
4,518.03	
22,505.21	
71,505.22	
2,949.30	
3,204,469.45	
3,829,670.31	
67,351,694.52	
36,567,824.44	
99,790,372.84	
26,178.88	
63.50	
1,994.95	
4,772.92	
252,265,549.33	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	479,977.47	691,218.75	496,784.38	390,045.91	409,473.24	456,402.16	524,363.45	425,419.91	435,236.06	438,521.04	0.00	0.00		4,747,442.37		
3917	NEWLY ELIGIBLE FEMA L	544,750.39	849,994.66	642,444.80	512,714.21	586,232.38	616,371.37	620,899.82	585,475.11	775,123.65	653,461.98	0.00	0.00		6,387,468.37		
3918	NEWLY ELIGIBLE M&F
4	1,554,958.77	1,950,001.07	1,605,876.04	1,155,616.03	1,824,221.51	1,428,886.53	1,507,909.56	1,478,917.75	1,532,674.02	1,383,506.36	0.00	0.00		15,422,567.64		
3919	NEWLY ELIGIBLE M&F 6	782.00	0.00	782.00	-659.00	0.00	0.00	0.00	83.75	4,148.85	973.79	0.00	0.00		6,111.39		
3927	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.56	0.00	0.00	0.00		5.56		
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		167.54		
SUBTOTAL:	2,634,455.01	3,608,952.15	2,850,376.2	7	2,121,538.28	2,910,569.93	2,580,978.23	2,725,964.84	2,591,925.31	2,827,237.88	2,557,558.78	0.00	0.00		27,409,556.68		

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	366,240.89	618,481.49	502,134.19	447,651.13	556,111.77	452,083.36	501,855.42	510,811.44	461,024.07	430,815.36	0.00	0.00	
4414	SOBRA 100-133% MALE	143,656.47	195,066.00	228,810.15	102,317.26	127,843.74	98,958.04	126,073.55	119,466.16	115,207.93	112,549.95	0.00	0.00	
4415	SOBRA 100-133% FEMA L	151,202.79	234,581.63	185,403.35	153,490.00	197,731.35	159,116.14	175,271.20	224,881.65	165,462.25	169,626.77	0.00	0.00	
SUBTOTAL:	661,100.1	5	1,048,129.12	916,347.6	9	703,458.39	881,686.86	710,525.54	803,200.17	855,159.25	741,694.25	712,992.08	0.00	0.00	

 
368.00	
4,847,209.12	
1,369,949.25	
1,816,767.13	
8,034,293.50	

4518	BC PATIENT FEMALE 4 5	2,933.81	1,173.00	2,007.93	7,483.73	12,294.22	6,263.34	10,232.75	1,557.11	17,695.45	946.56	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	0.00	782.00	782.00	391.00	782.00	391.00	427.00	0.00	0.00	1,281.00	0.00	0.00	
SUBTOTAL:	2,933.81	1,955.00	2,789.9	3	7,874.73	13,076.22	6,654.34	10,659.75	1,557.11	17,695.45	2,227.56	0.00	0.00	

 
62,587.90	
4,836.00	
67,423.90	

8700	SSI DISABLED FREEDO M	8,702.39	13,545.97	13,596.81	7,181.99	20,385.89	10,533.74	14,647.71	13,939.55	14,629.27	16,461.85	0.00	0.00	
8710	SSI DISABLED FREEDO
M	10,860.39	12,056.09	5,720.84	4,072.91	5,140.21	9,017.16	7,076.62	17,147.72	8,484.53	13,874.84	0.00	0.00	
8720	SSI DISABLED FREEDO M	866.25	4,633.08	507.93	2,572.92	415.25	1,161.09	1,364.30	4,410.18	578.36	1,038.09	0.00	0.00	
SUBTOTAL:	20,429.03	30,235.14	19,825.5	8	13,827.82	25,941.35	20,711.99	23,088.63	35,497.45	23,692.16	31,374.78	0.00	0.00	

 
133,625.17	
93,451.31	
17,547.45	
244,623.93	

789,453,381.50

68,123,684.21	102,534,576.01	74,161,514.78	64,392,996.79	79,132,266.59	74,733,809.12	87,472,203.25	80,807,963.56	81,076,439.45	77,017,927.74	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2018	
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	56.86	0.00	0.00	0.00	0.00		56.86		
1007	TANF 21-44 FEMALE WI	0.00	0.00	92.46	20.86	0.00	259.68	0.00	0.00	0.00	4,387.98	0.00	0.00		4,760.98		
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		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	137.25	0.00	34.04	0.00	0.00	0.00	0.00	0.00		171.29		
1011	TANF <1 M & F NON-ME	20,654.34	33,591.86	259.61	1,149.34	10,574.40	1,608.37	2,977.51	1,112.60	61.46	915.71	0.00	0.00		72,905.20		
1012	TANF 01-05 M & F NON	913.03	363.75	157.39	146.84	1,756.97	0.00	84.60	0.00	-192.97	0.00	0.00	0.00		3,229.61		
1013	TANF 06-13 M & F NON	1,039.71	4,256.94	137.25	0.00	3,289.17	903.86	0.00	83.14	802.17	211.98	0.00	0.00		10,724.22		
1014	TANF 14-20 MALE NON-	1,523.17	7,089.22	1,808.48	3,764.41	2,210.71	3,173.51	1,634.07	644.21	97.54	136.86	0.00	0.00		22,082.18		
1015	TANF 14-20 FEMALE N O	12,542.64	12,701.01	1,386.67	3,057.46	997.29	2,386.11	5,366.47	827.75	3,140.39	9,066.23	0.00	0.00		51,472.02		
1016	TANF 21-44 MALE NON-	15,535.91	27,655.79	28,917.98	35,899.32	57,767.66	63,626.02	25,402.11	27,526.89	22,258.20	59,798.55	0.00	0.00		364,388.43		
1017	TANF 21-44 FEMALE N O	69,653.95	123,234.95	48,848.23	42,949.44	70,647.95	74,909.46	101,793.50	46,620.45	77,528.55	98,993.67	0.00	0.00		755,180.15		
1018	TANF 45-64 M & F NON	39,319.42	16,665.33	19,875.48	41,669.85	30,938.65	14,977.35	35,360.59	51,054.12	15,948.97	24,535.35	0.00	0.00		290,345.11		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	33.74	0.00	0.00	0.00	0.00	0.00		33.74		
2100	SSI AGED WITH MEDIC A	5,270.03	11,195.75	20,215.04	7,415.96	18,283.77	18,877.07	21,549.14	20,708.05	13,830.03	17,146.36	0.00	0.00		154,491.20		
2110	SSI AGED NON-MEDICA
R	37,612.82	14,256.93	16,930.45	15,365.59	28,694.78	41,173.98	40,343.04	29,753.61	30,636.60	182,647.32	0.00	0.00		437,415.12		
2120	SSI AGED WITH QMB	776.24	185.90	170.74	825.21	1,850.50	228.89	1,327.07	0.00	1,633.35	456.64	0.00	0.00		7,454.54		
2200	SSI DISABLED WITH M E	520.23	3,742.51	281.58	612.50	558.66	932.22	2,320.48	168.59	947.77	522.27	0.00	0.00		10,606.81		
2210	SSI DISABLED NON-ME
D	10,576.12	5,504.23	13,221.47	8,519.16	15,253.00	4,013.55	5,424.25	17,341.70	3,194.74	295.64	0.00	0.00		83,343.86		
2220	SSI DISABLED WITH Q M	50.30	317.00	0.00	217.49	117.70	24.59	209.15	110.68	0.00	70.69	0.00	0.00		1,117.60		
4311	SOBRA CHILD <1 M & F	16,884.67	39,379.99	37,485.32	31,287.10	39,345.15	21,552.78	23,265.08	34,933.24	30,610.74	35,967.25	0.00	0.00		310,711.32		
4312	SOBRA CHILD 01-05 M	42,887.14	97,036.84	49,257.86	31,458.32	55,629.36	37,154.72	108,676.87	55,591.91	64,479.98	58,247.62	0.00	0.00		600,420.62		
4313	SOBRA CHILD 06-13 M	27,666.18	65,720.19	33,058.36	19,742.28	40,138.07	13,998.87	21,410.87	78,973.49	48,354.97	46,910.52	0.00	0.00		395,973.80		
4314	SOBRA CHILD 14-20 MA	14,040.41	32,664.97	18,374.51	7,305.07	48,841.16	14,276.77	21,964.33	56,567.59	55,362.54	52,527.19	0.00	0.00		321,924.54		
4315	SOBRA CHILD 14-20 FE	31,383.37	26,150.54	14,140.09	32,192.59	26,964.06	24,873.10	16,044.39	36,401.24	24,929.71	25,459.12	0.00	0.00		258,538.21		
5007	SOBRA PREG 21-44 FE M	171.72	144.92	0.00	0.00	1,570.23	-537.36	0.00	0.00	0.00	0.00	0.00	0.00		1,349.51		
5008	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	152.44	0.00	0.00	0.00	0.00	0.00		152.44		
5015	SOBRA PREG 14-20 FE M	13,787.75	23,661.11	17,363.81	20,572.40	21,240.59	21,377.45	21,399.44	22,645.70	23,812.37	25,142.99	0.00	0.00		211,003.61		
5017	SOBRA PREG 21-44 FE
M	98,441.12	121,849.94	90,725.43	101,452.49	131,038.29	88,816.19	88,586.38	114,789.49	133,725.20	113,410.65	0.00	0.00		1,082,835.18		
5018	SOBRA PREG 45-64 FE M	2,413.43	0.00	-303.98	31,322.77	-2,003.01	214.19	0.00	-30,658.75	0.00	2,726.71	0.00	0.00		3,711.36		
SUBTOTAL:	463,842.7	2	667,369.67	412,449.2	3	436,946.45	605,842.36	448,821.37	545,359.56	565,252.56	551,162.31	759,577.30	0.00	0.00		5,456,623.53		

1106	TANF EXPANDED 21-44	104.15	947.17	99.88	0.00	498.14	0.00	0.00	0.00	41.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	542.71	32.47	74.88	99.53	31.01	381.94	73.17	42.58	1,523.74	1,210.57	0.00	0.00	
1108	TANF EXPANDED 45-64	265.37	1,939.82	1,140.09	226.85	1,583.45	7,633.01	3,894.73	1.85	2,109.76	3,515.73	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	2,993.18	184.79	1.71	2,336.56	1,345.40	1,349.64	1,426.99	1,165.01	2,001.07	338.08	0.00	0.00	
1114	TANF EXPANDED 14-20	474.32	1,814.19	4,318.14	5,081.16	2,358.27	2,496.06	12,985.10	310.23	802.65	-11,269.16	0.00	0.00	

 
1,690.34	
4,012.60	
22,310.66	
13,142.43	
19,370.96	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	137.25	1,384.15	172.55	1,350.00	4,106.70	0.00	141.24	2,187.60	442.56	137.54	0.00	0.00		10,059.59		
1116	TANF EXPANDED 21-44	30,766.72	42,100.58	40,777.56	47,876.31	39,619.04	58,126.25	56,795.19	103,852.79	66,340.74	17,894.13	0.00	0.00		504,149.31		
1117	TANF EXPANDED 21-44	60,793.79	137,059.00	46,206.44	62,701.45	65,632.59	44,395.16	41,110.62	26,088.38	36,421.32	48,983.56	0.00	0.00		569,392.31		
1118	TANF EXPANDED 45-64	24,143.24	60,240.06	31,368.57	16,935.53	53,196.31	21,693.99	13,940.15	15,601.89	23,038.07	50,980.56	0.00	0.00		311,138.37		
1127	TANF EXPANDED 21-44	34.42	39.13	0.00	0.00	0.00	0.00	0.00	0.00	14.51	0.00	0.00	0.00		88.06		
1128	TANF EXPANDED 45-64	0.00	368.00	13.09	47.75	135.01	444.68	591.91	0.00	32.64	68.63	0.00	0.00		1,701.71		
1129	TANF EXPANDED 65+ M
&	435.37	125.38	989.79	0.00	1,482.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,033.06		
2400	SSI AGED EXPANDED WI	17,993.30	15,628.68	14,955.56	14,352.12	-38,593.96	21,900.47	5,691.88	5,860.54	6,090.88	17,613.64	0.00	0.00		81,493.11		
2410	SSI AGED EXPANDED N
O	0.00	0.00	0.00	0.00	1,564.00	782.00	0.00	0.00	0.00	0.00	0.00	0.00		2,346.00		
2420	SSI AGED EXPANDED WI	25.94	2,104.32	1,601.87	305.37	325.31	681.10	483.78	511.94	432.77	287.36	0.00	0.00		6,759.76		
2600	SSI DISABLED EXPAND
E	3,603.28	4,730.53	7,569.31	10,531.09	6,191.13	3,088.86	7,327.41	4,705.86	5,856.81	5,696.01	0.00	0.00		59,300.29		
2610	SSI DISABLED EXPAND E	7,174.68	629.11	532.66	2,248.67	8,033.48	5,099.96	1,629.38	5,474.56	3,322.71	136.05	0.00	0.00		34,281.26		
2620	SSI DISABLED EXPAND
E	423.01	1,356.66	473.59	261.52	5,323.17	321.09	96.73	1,718.76	255.49	1,149.97	0.00	0.00		11,379.99		
SUBTOTAL:	149,910.7	3	270,684.04	150,295.6	9	164,353.91	152,831.57	168,394.21	146,188.28	167,521.99	148,726.72	136,742.67	0.00	0.00		1,655,649.81		

3506	ADULT 40-100% MALE 2	120.85	2,659.71	0.00	20.08	0.00	0.00	0.00	0.00	0.00	1,106.50	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	624.07	0.00	510.23	100.44	0.00	0.00	27.33	340.41	723.24	0.00	0.00	
3508	ADULT 40-100% M&F 45	239.04	1,314.43	88.70	0.00	61.18	0.00	0.00	0.00	137.25	653.03	0.00	0.00	
3514	ADULT 40-100% MALE 1	13,594.81	4,428.49	1,888.11	8,026.52	39,794.57	2,684.22	2,095.62	4,498.38	4,355.55	4,562.54	0.00	0.00	
3515	ADULT 40-100% FEMAL E	4,133.27	4,086.31	3,095.55	5,821.19	6,508.29	6,700.75	2,418.26	1,693.28	3,110.95	6,802.88	0.00	0.00	
3516	ADULT 40-100% MALE 2	91,283.78	55,263.14	70,389.31	39,057.73	143,187.22	88,099.26	44,279.54	38,654.14	49,535.26	56,397.98	0.00	0.00	
3517	ADULT 40-100% FEMAL E	25,916.64	26,658.91	33,198.57	13,829.62	33,017.50	32,824.05	25,604.84	28,050.30	81,250.57	33,391.93	0.00	0.00	
3518	ADULT 40-100% M&F 45	100,927.35	257,736.44	102,691.59	106,073.37	106,512.79	91,149.71	112,712.36	46,537.98	100,865.63	101,833.58	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.65	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	594.00	222.75	0.00	760.54	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	137.25	314.90	0.00	0.00	0.00	0.00	0.00	0.00	160.76	26.98	0.00	0.00	
3708	ADULT <40% EXP M&F
4	111.36	100.29	2,057.79	480.08	282.74	516.33	27.25	0.00	0.00	1,049.73	0.00	0.00	
3714	ADULT <40% EXP MALE	16,238.85	19,414.27	12,185.44	15,187.79	40,886.37	18,434.78	11,634.83	7,865.49	27,902.22	33,457.95	0.00	0.00	
3715	ADULT <40% EXP FEMA L	10,768.18	7,658.17	3,363.94	7,332.32	8,539.87	16,435.62	12,580.69	12,987.68	27,995.22	16,612.87	0.00	0.00	
3716	ADULT <40% EXP MALE	261,422.48	400,621.91	188,657.56	308,116.40	357,643.51	193,379.17	240,878.73	191,209.64	257,039.03	308,311.17	0.00	0.00	
3717	ADULT <40% EXP FEMA L	128,226.62	216,375.93	175,768.53	243,863.07	167,205.62	96,458.87	157,980.52	106,384.63	117,122.82	153,492.22	0.00	0.00	
3718	ADULT <40% EXP M&F
4	286,377.69	405,922.93	326,291.80	249,076.69	382,550.39	260,670.64	432,445.53	291,024.50	353,203.24	356,980.07	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	843.09	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	2,139.24	7.42	0.00	918.83	0.00	0.00	0.00	0.00	
SUBTOTAL:	939,849.7	1,403,179.90	919,676.8	997,395.09	1,288,429.73	807,360.82	1,044,095.26	730,074.93	1,023,018.91	1,076,179.86	0.00	0.00	

 
3,907.14	
2,325.72	
2,493.63	
85,928.81	
44,370.73	
676,147.36	
333,742.93	
1,127,040.80	
16.65	
1,577.29	
0.00	
639.89	
4,625.57	
203,207.99	
124,274.56	
2,707,279.60	
1,562,878.83	
3,344,543.48	
843.09	
3,417.10	
10,229,261.17	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	476.83	131.53	0.00	91.19	0.00	100.54	0.00	0.00		800.09		
3908	NEWLY ELIGIBLE M&F 4	1,402.06	21.50	25.22	0.00	0.00	54.31	0.00	23.67	4,249.16	1,606.11	0.00	0.00		7,382.03		
3914	NEWLY ELIGIBLE MALE	2,389.35	13,710.72	1,432.78	14,467.18	7,101.05	14,801.55	3,602.08	4,323.79	3,024.21	573.18	0.00	0.00		65,425.89		
3915	NEWLY ELIGIBLE FEMA L	3,322.65	5,661.12	2,242.43	1,467.06	2,125.28	910.19	4,397.86	3,190.95	13,792.03	1,430.19	0.00	0.00		38,539.76		
3916	NEWLY ELIGIBLE MALE	72,134.95	95,036.78	89,553.29	80,668.64	58,796.90	50,242.90	105,348.83	60,770.27	61,208.08	43,703.66	0.00	0.00		717,464.30		
3917	NEWLY ELIGIBLE FEMA L	56,888.09	108,315.27	33,891.18	28,235.70	37,233.51	47,909.40	29,269.60	28,817.10	58,484.53	88,488.70	0.00	0.00		517,533.08		
3918	NEWLY ELIGIBLE M&F
4	214,461.35	323,475.34	274,544.94	77,485.14	131,336.80	148,062.30	220,016.73	165,297.45	138,783.69	199,486.97	0.00	0.00		1,892,950.71		
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		63.43		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	54.91	0.00	0.00	0.00	0.00	1,371.15	0.00	0.00		1,426.06		
SUBTOTAL:	350,598.4	5	546,220.73	401,753.2	7	202,323.72	237,125.28	262,112.18	362,635.10	262,514.42	279,541.70	336,760.50	0.00	0.00		3,241,585.35		

8700	SSI DISABLED FREEDO M	250.85	2,220.64	2,804.73	2,869.91	890.04	1,598.04	322.64	79.15	2,984.72	3,310.64	0.00	0.00	
8710	SSI DISABLED FREEDO
M	338.21	234.90	119.52	5,801.63	270.14	6,079.08	10,480.61	1,169.90	61,310.39	1,601.67	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	89.20	47.62	0.00	0.00	0.00	678.65	0.00	0.00	0.00	
SUBTOTAL:	589.06	2,455.54	2,924.2	5	8,760.74	1,207.80	7,677.12	10,803.25	1,249.05	64,973.76	4,912.31	0.00	0.00	

17,331.36	
87,406.05	
815.47	
105,552.88	

4413	SOBRA 100-133% M&F
6	6,531.52	45,078.74	16,197.89	12,011.60	10,716.94	15,539.34	16,726.78	2,529.56	15,705.09	17,063.94	0.00	0.00	
4414	SOBRA 100-133% MALE	1,324.01	14,768.16	1,335.06	1,212.31	9,531.33	4,205.91	1,931.76	9,085.07	4,286.94	2,863.03	0.00	0.00	
4415	SOBRA 100-133% FEMA L	5,359.35	2,711.50	3,802.07	5,227.83	2,360.74	4,804.68	19,414.92	6,904.15	6,963.08	4,745.18	0.00	0.00	
SUBTOTAL:	13,214.88	62,558.40	21,335.0	2	18,451.74	22,609.01	24,549.93	38,073.46	18,518.78	26,955.11	24,672.15	0.00	0.00	

 
158,101.40	
50,543.58	
62,293.50	
270,938.48	

TOTAL:	1,918,005.62	2,952,468.28	1,908,434.35	1,828,231.65	2,308,045.75	1,718,915.63	2,147,154.91	1,745,131.73	2,094,378.51	2,338,844.79	0.00	0.00		20,959,611.22		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending April 30, 2018	
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	113.18	0.00	0.00	2,823.32	0.00	53.17	0.00	0.00	0.00		13,929.47		
SUBTOTAL:	607.14	0.00	10,332.66	113.18	0.00	0.00	2,823.32	0.00	53.17	0.00	0.00	0.00		13,929.47		

13,929.47

607.14	0.00	10,332.66	113.18	0.00	0.00	2,823.32	0.00	53.17	0.00	0.00	0.00	

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending April 30, 2018	
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	47.58	0.00	0.00	0.00		47.58		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	1,372.32	802.35	3,961.29	754.87	612.46	0.00	0.00	0.00	0.00		7,503.29		
1008	TANF 45-64 M & F WIT	630.24	620.59	0.00	0.00	0.00	0.00	0.00	0.00	621.11	0.00	0.00	0.00		1,871.94		
1011	TANF <1 M & F NON-ME	1,217.98	0.00	0.00	0.00	80.87	1,031.60	338.90	0.00	0.00	1,532.79	0.00	0.00		4,202.14		
1012	TANF 01-05 M & F NON	53,550.51	33,460.95	5,471.52	14,841.82	14,920.39	19,088.02	26,663.74	47,464.11	16,784.37	13,650.67	0.00	0.00		245,896.10		
1013	TANF 06-13 M & F NON	72,651.17	167,216.49	110,029.89	60,909.28	35,385.47	81,555.21	56,152.20	61,639.74	52,010.99	49,463.43	0.00	0.00		747,013.87		
1014	TANF 14-20 MALE NON-	103,021.56	260,724.26	94,070.49	60,210.72	163,902.90	112,406.76	50,543.11	59,697.65	177,706.36	177,443.62	0.00	0.00		1,259,727.43		
1015	TANF 14-20 FEMALE N O	361,349.27	528,169.17	198,133.38	362,300.89	396,809.48	384,047.41	414,654.56	253,568.90	256,970.49	317,689.09	0.00	0.00		3,473,692.64		
1016	TANF 21-44 MALE NON-	171.94	27,657.57	4,550.16	13,991.77	1,013.38	1,666.20	340.32	2,590.86	226.62	100.55	0.00	0.00		52,309.37		
1017	TANF 21-44 FEMALE N O	2,700,519.09	4,054,600.83	1,094,597.67	2,286,127.10	2,526,791.57	2,500,719.47	2,103,989.80	1,981,938.89	1,782,495.50	1,997,489.31	0.00	0.00		23,029,269.23		
1018	TANF 45-64 M & F NON	32,916.39	90,936.34	28,223.78	13,284.12	11,263.09	28,533.44	4,950.00	40,081.02	17,570.52	22,070.76	0.00	0.00		289,829.46		
2100	SSI AGED WITH MEDIC A	51,503.65	80,558.51	18,023.42	3,223.31	5,061.24	5,528.70	3,839.14	10,470.92	5,032.31	4,912.00	0.00	0.00		188,153.20		
2110	SSI AGED NON-MEDICA
R	1,449,964.08	1,564,496.95	776,470.73	726,301.25	1,381,337.78	1,178,939.59	1,506,303.39	1,232,663.33	1,267,123.86	1,319,967.54	0.00	0.00		12,403,568.50		
2120	SSI AGED WITH QMB	99.26	8,828.69	1,302.84	1,998.66	145.90	10.52	996.18	137.25	908.52	1,523.01	0.00	0.00		15,950.83		
2200	SSI DISABLED WITH M E	12,126.62	7,473.51	8,506.99	3,002.78	16,838.72	10,490.51	18,701.43	6,752.08	7,840.50	3,840.73	0.00	0.00		95,573.87		
2210	SSI DISABLED NON-ME
D	253,261.18	373,683.27	136,989.00	146,079.00	198,594.66	157,016.22	179,551.44	167,441.49	170,189.72	192,248.97	0.00	0.00		1,975,054.95		
SUBTOTAL:	5,092,982.94	7,198,427.13	2,476,369.8	7	3,693,643.02	4,752,947.80	4,484,994.94	4,367,779.08	3,865,058.70	3,755,528.45	4,101,932.47	0.00	0.00		43,789,664.40		

17,970.65

3906	NEWLY ELIGIBLE MALE	1,021.74	2,141.12	5.29	24.36	1,040.71	0.00	2,705.36	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	32.66	738.10	0.00	241.96	197.86	3,107.43	4,109.88	3,813.23	2,113.73	3,615.80	0.00	0.00	

6,938.58

1106	TANF EXPANDED 21-44	56.86	5,273.18	818.79	-2,369.91	1,732.21	215.66	692.50	819.03	782.90	721.46	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	-654.80	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	399.51	14,866.05	14,204.13	289.21	4,571.90	12,510.65	409.85	892.07	717.73	10,208.51	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	613.54	4,701.08	177.80	447.44	1,253.57	301.88	3,121.40	0.00	112.04	17.70	0.00	0.00	
1114	TANF EXPANDED 14-20	2,565.40	320.54	1,122.36	389.14	3,220.61	403.13	1,179.61	8,021.83	2,695.15	219.13	0.00	0.00	
1115	TANF EXPANDED 14-20	26,635.69	37,853.47	5,936.98	12,981.15	29,641.58	1,954.43	16,311.96	7,938.82	32,726.09	27,789.53	0.00	0.00	
1116	TANF EXPANDED 21-44	826,854.00	1,421,530.19	542,697.03	621,876.18	981,123.13	669,031.23	638,331.09	746,423.30	1,025,730.61	597,482.31	0.00	0.00	
1117	TANF EXPANDED 21-44	2,135,572.36	3,034,778.96	1,296,650.79	1,421,584.36	2,093,811.19	1,881,753.63	1,688,432.01	1,369,885.47	1,639,331.03	1,422,949.26	0.00	0.00	
1118	TANF EXPANDED 45-64	1,061,403.35	1,427,245.50	581,214.51	624,903.37	1,086,185.64	898,076.37	787,899.61	1,116,112.95	775,907.94	859,116.89	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	18,877.09	27,888.93	11,298.22	9,581.34	18,287.72	54,713.89	19,825.30	22,613.10	17,082.63	49,791.35	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	1,398.10	0.00	0.00	2,053.73	1,459.84	3,238.44	5,132.43	3,212.10	851.96	0.00	0.00	
2410	SSI AGED EXPANDED N
O	3,771.50	18,467.70	14,952.88	1,095.03	1,981.95	10,753.79	3,021.68	20,562.81	14,259.13	-122.41	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,712.11	7,161.76	4,208.94	2,236.65	7,058.18	2,098.05	9,028.08	2,441.41	3,024.01	257.96	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	7.77	365.23	219.48	740.04	5,320.09	8,925.13	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	-17.96	0.00	0.00	0.00	
SUBTOTAL:	4,079,461.41	6,001,485.46	2,473,282.4	2,693,013.96	4,230,929.18	3,533,637.78	3,171,056.21	3,301,583.26	3,520,883.49	2,978,208.78	0.00	0.00	

 
8,742.68	
-654.80	
59,069.61	
10,746.45	
20,136.90	
199,769.70	
8,071,079.07	
17,984,749.06	
9,218,066.13	
249,959.57	
17,346.60	
88,744.06	
40,227.15	
15,577.74	
-17.96	
35,983,541.96	

FEDERAL EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	124,589.01	188,655.12	92,782.95	10,182.93	91,253.69	125,860.34	83,490.10	76,811.81	81,915.89	61,556.61	0.00	0.00		937,098.45		
3915	NEWLY ELIGIBLE FEMA L	60,822.10	251,110.90	92,823.30	49,103.56	73,155.74	50,298.67	99,186.66	56,283.76	28,502.19	39,306.54	0.00	0.00		800,593.42		
3916	NEWLY ELIGIBLE MALE	1,062,047.66	1,877,746.60	708,155.76	926,641.25	1,069,189.77	1,142,535.82	960,264.62	636,879.30	650,153.13	838,930.60	0.00	0.00		9,872,544.51		
3917	NEWLY ELIGIBLE FEMA L	600,175.18	766,277.48	337,834.36	285,813.80	719,043.85	634,151.01	760,195.11	452,424.88	511,138.26	453,746.69	0.00	0.00		5,520,800.62		
3918	NEWLY ELIGIBLE M&F
4	2,696,799.28	4,203,036.42	1,687,224.95	1,759,346.88	3,101,024.95	2,679,736.32	2,852,002.49	2,257,233.37	2,525,441.59	2,741,655.31	0.00	0.00		26,503,501.56		
3919	NEWLY ELIGIBLE M&F 6	10,249.05	36,165.04	7,053.59	4,431.10	13,800.61	10,177.87	12,846.59	8,563.19	7,839.58	919.14	0.00	0.00		112,045.76		
SUBTOTAL:	4,555,736.68	7,325,870.78	2,925,880.2	0	3,035,785.84	5,068,707.18	4,645,867.46	4,774,800.81	3,492,009.54	3,807,104.37	4,139,730.69	0.00	0.00		43,771,493.55		

TOTAL:	13,728,181.03	20,525,783.37	7,875,532.50	9,422,442.82	14,052,584.16	12,664,500.18	12,313,636.10	10,658,651.50	11,083,516.31	11,219,871.94	0.00	0.00		123,544,699.91		

QMB - FEE FOR SERVICE
For The Period Ending April 30, 2018	
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	414,948.58	457,637.96	622,993.76	569,210.79	673,670.49	637,828.03	613,631.13	557,322.30	0.00	0.00		5,737,801.62		
8040	SLMB	0.00	0.00	0.00	0.00	104.07	75.93	0.00	0.00	179.36	0.00	0.00	0.00		359.36		
8050	QI1	0.00	0.00	576.06	56.86	0.00	722.26	-722.26	0.00	0.00	16.64	0.00	0.00		649.56		
SUBTOTAL:	489,557.8	7	701,000.71	415,524.6	4	457,694.82	623,097.83	570,008.98	672,948.23	637,828.03	613,810.49	557,338.94	0.00	0.00		5,738,810.54		

0.00

0.00

613,810.49

457,694.82

TOTAL:

489,557.87

701,000.71	415,524.64

623,097.83	570,008.98	672,948.23	637,828.03

557,338.94

5,738,810.54

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2018	
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	427.00	0.00	0.00	0.00		427.00		
1007	TANF 21-44 FEMALE WI	72.68	774.31	304.75	23.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,175.49		
1011	TANF <1 M & F NON-ME	2,225.53	3,895.14	1,431.02	1,526.80	1,873.00	136.41	2,138.10	160.86	3,265.24	866.01	0.00	0.00		17,518.11		
1012	TANF 01-05 M & F NON	37,646.36	36,850.01	33,191.56	21,973.16	62,034.28	10,234.91	14,794.86	8,576.79	7,329.36	7,853.07	0.00	0.00		240,484.36		
1013	TANF 06-13 M & F NON	128,263.92	193,268.15	96,268.57	113,334.60	125,437.55	97,868.07	142,796.08	114,208.25	87,181.05	114,371.41	0.00	0.00		1,212,997.65		
1014	TANF 14-20 MALE NON-	48,337.90	47,383.00	45,995.79	114,347.06	77,444.08	57,084.42	51,728.37	40,763.80	27,008.47	16,770.06	0.00	0.00		526,862.95		
1015	TANF 14-20 FEMALE N O	71,871.24	74,760.14	97,556.36	96,474.79	93,916.49	51,775.02	92,129.63	109,933.83	80,637.49	143,203.74	0.00	0.00		912,258.73		
1016	TANF 21-44 MALE NON-	526,340.17	530,196.38	487,128.28	377,134.36	615,335.09	544,204.95	617,453.18	601,922.38	585,195.79	423,628.79	0.00	0.00		5,308,539.37		
1017	TANF 21-44 FEMALE N O	1,657,566.19	1,783,786.44	1,378,116.05	1,303,090.95	1,582,783.93	1,284,872.44	1,545,787.55	1,469,456.06	1,422,824.20	1,130,797.84	0.00	0.00		14,559,081.65		
1018	TANF 45-64 M & F NON	304,329.16	286,978.40	196,863.92	126,124.82	175,785.37	115,725.79	191,831.43	250,953.12	278,432.52	228,654.55	0.00	0.00		2,155,679.08		
1026	TANF 21-44 MALE WITH	0.00	0.00	750.81	1,741.20	2,030.26	775.92	594.86	261.26	311.62	491.88	0.00	0.00		6,957.81		
1027	TANF 21-44 FEMALE WI	0.00	118.15	139.61	70.89	136.08	213.84	0.00	0.00	23.63	62.51	0.00	0.00		764.71		
2100	SSI AGED WITH MEDIC A	6,043.44	4,391.82	6,288.05	6,955.66	11,335.22	16,255.35	16,091.53	14,103.21	21,296.53	17,972.20	0.00	0.00		120,733.01		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	1,173.00	391.00	391.00	0.00	2,908.28	3,289.60	2,960.64	2,960.64	0.00	0.00		14,074.16		
2120	SSI AGED WITH QMB	12,745.09	25,137.79	18,028.33	20,205.51	12,350.98	15,231.07	22,984.48	15,957.62	21,224.88	14,820.90	0.00	0.00		178,686.65		
2200	SSI DISABLED WITH M E	22,244.82	32,885.03	23,408.57	18,408.67	23,996.36	32,972.79	38,582.32	22,767.69	33,571.25	39,381.02	0.00	0.00		288,218.52		
2210	SSI DISABLED NON-ME
D	1,848,011.72	2,445,227.21	2,015,665.13	1,605,115.54	2,065,434.18	1,863,930.43	1,958,269.38	1,828,000.36	1,930,152.24	1,773,771.48	0.00	0.00		19,333,577.67		
2220	SSI DISABLED WITH Q M	244,729.87	318,582.73	260,878.37	242,445.09	320,879.21	252,337.12	270,396.72	230,350.66	325,056.33	280,056.73	0.00	0.00		2,745,712.83		
2310	SSI BLIND NON-MEDIC
A	4,323.76	8,552.27	10,988.26	8,492.30	14,130.72	18,645.38	16,499.85	27,287.96	35,261.70	14,566.45	0.00	0.00		158,748.65		
2320	SSI BLIND WITH QMB	840.76	1,979.14	578.96	1,998.68	1,397.30	901.19	1,655.14	467.42	1,345.74	946.53	0.00	0.00		12,110.86		
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	2,988.02	2,760.10	2,942.64	6,239.45	10,325.25	4,088.59	2,653.40	0.00	0.00		55,572.28		
4312	SOBRA CHILD 01-05 M	173,404.17	220,673.14	162,567.76	166,357.37	210,210.68	171,250.80	206,238.00	216,724.53	178,677.85	188,894.92	0.00	0.00		1,894,999.22		
4313	SOBRA CHILD 06-13 M	3,398,748.51	4,311,852.91	3,015,010.82	2,974,606.84	3,396,438.64	2,774,046.27	3,465,917.78	3,173,940.24	3,206,641.75	3,600,912.10	0.00	0.00		33,318,115.86		
4314	SOBRA CHILD 14-20 MA	705,666.83	1,292,395.95	1,061,627.67	815,774.06	913,490.17	810,263.57	843,011.80	693,919.70	1,026,083.15	1,041,356.78	0.00	0.00		9,203,589.68		
4315	SOBRA CHILD 14-20 FE	1,409,888.39	1,269,627.57	978,059.09	939,329.41	1,100,327.90	779,048.93	1,295,430.68	1,142,605.88	1,014,170.45	1,190,133.78	0.00	0.00		11,118,622.08		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.27	0.00	0.00	0.00		26.27		
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	1,281.00	0.00	0.00		1,281.00		
5015	SOBRA PREG 14-20 FE M	22,369.78	34,154.22	28,722.89	18,379.90	13,034.86	7,585.17	14,970.60	19,056.99	17,951.86	10,428.62	0.00	0.00		186,654.89		
5017	SOBRA PREG 21-44 FE
M	245,508.84	263,390.81	257,152.09	188,603.19	271,005.85	169,412.56	221,643.34	202,529.71	196,387.34	129,263.30	0.00	0.00		2,144,897.03		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	10.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.22		
SUBTOTAL:	10,876,719.1	3 13,195,800.73	10,189,336.5	2	9,165,893.62	11,093,969.52	9,077,715.04	11,040,093.41	10,197,563.17	10,507,532.94	10,376,099.71	0.00	0.00		105,720,723.79		

568.65

168.10

1106	TANF EXPANDED 21-44	251.01	237.62	10.22	69.80	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	62.59	0.00	52.37	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,003.97	1,158.71	361.94	480.49	328.64	1,221.26	90.74	405.97	2,584.24	486.52	0.00	0.00	

8,122.48

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	125.75	0.00	0.00	0.00	28.65	0.00	0.00	0.00		154.40		
1114	TANF EXPANDED 14-20	0.00	0.00	5,491.20	0.00	810.54	0.00	0.00	0.00	0.00	391.00	0.00	0.00		6,692.74		
1115	TANF EXPANDED 14-20	2,043.45	2,836.72	946.72	133.00	461.89	782.00	1,461.20	5,197.35	560.00	1,778.89	0.00	0.00		16,201.22		
1116	TANF EXPANDED 21-44	206,693.38	290,344.07	206,200.95	159,405.02	164,587.32	137,947.73	101,383.75	192,806.11	167,936.81	152,484.17	0.00	0.00		1,779,789.31		
1117	TANF EXPANDED 21-44	582,408.48	448,662.96	492,893.91	326,868.86	398,063.84	329,169.08	298,579.88	467,188.04	402,130.80	374,929.20	0.00	0.00		4,120,895.05		
1118	TANF EXPANDED 45-64	202,226.77	145,351.59	153,277.93	140,965.63	138,888.65	123,204.98	119,092.76	189,227.60	154,739.30	118,673.90	0.00	0.00		1,485,649.11		
1126	TANF EXPANDED 21-44	331.99	2,174.75	1,549.55	5,029.39	2,056.02	-1,499.27	2,218.14	531.18	522.39	361.61	0.00	0.00		13,275.75		
1127	TANF EXPANDED 21-44	1,429.72	10,646.79	9,971.78	10,494.48	181.40	699.46	2,445.58	946.51	1,592.35	1,781.09	0.00	0.00		40,189.16		
1128	TANF EXPANDED 45-64	1,143.92	1,376.86	1,514.49	2,078.08	2,313.16	1,875.55	3,754.83	1,698.91	2,964.75	1,467.94	0.00	0.00		20,188.49		
1129	TANF EXPANDED 65+ M
&	109.11	69.80	0.00	0.00	37.60	0.00	0.00	28.65	906.90	86.14	0.00	0.00		1,238.20		
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	12,314.54	20,068.64	18,127.86	13,715.98	16,559.95	13,845.14	11,110.18	0.00	0.00		149,344.62		
2600	SSI DISABLED EXPAND E	262.30	227.63	262.80	67.04	133.77	61.92	1,819.76	84.36	543.45	4,760.70	0.00	0.00		8,223.73		
2610	SSI DISABLED EXPAND
E	7,367.02	10,021.65	20,057.69	19,747.87	10,895.28	13,377.22	13,449.78	4,032.62	559.71	1,222.80	0.00	0.00		100,731.64		
2620	SSI DISABLED EXPAND E	42,920.78	65,547.02	58,633.32	54,724.60	65,158.05	56,963.44	74,052.56	68,858.69	82,461.72	64,566.52	0.00	0.00		633,886.70		
SUBTOTAL:	1,058,406.37	991,738.44	971,922.2	3	732,378.80	804,110.55	681,931.23	632,127.55	947,565.94	831,428.58	734,100.66	0.00	0.00		8,385,710.35		

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	12.63	69.80	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	1,917.53	10,400.54	13,918.71	9,057.26	5,465.58	41,682.37	3,704.40	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1,679.70	3,811.04	3,526.10	4,401.63	4,455.65	4,832.33	3,699.06	2,952.56	2,163.03	1,655.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	35,276.13	73,528.89	27,183.56	42,126.70	55,041.99	41,552.13	38,902.62	55,062.79	53,149.23	31,114.94	0.00	0.00	

82.43	
101,506.46	
33,176.10	
452,938.98	

3508	ADULT 40-100% M&F 45	-368.00	0.00	391.00	0.00	0.00	147.06	0.00	0.00	0.00	181.33	0.00	0.00	
3514	ADULT 40-100% MALE 1	13,135.27	20,731.56	9,803.20	8,437.36	2,346.00	2,716.85	3,991.90	7,334.57	5,692.80	3,047.21	0.00	0.00	
3515	ADULT 40-100% FEMAL E	35,764.55	66,257.20	30,322.49	13,780.45	19,182.22	29,458.90	28,011.45	27,754.01	30,331.65	25,840.46	0.00	0.00	
3516	ADULT 40-100% MALE 2	246,082.11	245,977.75	194,553.11	131,467.89	177,028.93	98,775.44	100,930.58	130,560.89	117,034.44	99,904.32	0.00	0.00	
3517	ADULT 40-100% FEMAL E	64,497.56	70,223.15	49,018.02	54,777.78	82,589.80	67,055.51	68,108.54	82,311.64	221,473.57	95,682.30	0.00	0.00	
3518	ADULT 40-100% M&F 45	84,172.14	119,930.46	115,822.37	89,168.51	129,596.94	85,432.88	111,129.85	158,584.04	101,440.64	94,940.85	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	42.58	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	144.23	391.00	0.00	391.00	0.00	0.00	
3714	ADULT <40% EXP MALE	202,765.41	143,906.96	116,921.70	178,314.96	213,024.77	180,015.40	187,950.50	144,154.99	163,939.27	126,916.88	0.00	0.00	
3715	ADULT <40% EXP FEMA L	83,487.39	155,990.38	87,196.08	145,198.86	134,633.61	74,137.73	146,532.17	114,502.77	109,710.08	93,032.23	0.00	0.00	
3716	ADULT <40% EXP MALE	2,123,297.17	2,393,602.77	2,046,629.09	1,881,370.63	1,991,566.59	1,803,375.41	2,279,920.91	2,109,231.70	2,137,299.63	1,898,931.65	0.00	0.00	
3717	ADULT <40% EXP FEMA L	985,282.52	1,174,938.57	982,120.80	951,238.63	1,072,174.37	796,908.27	1,104,039.10	1,154,298.99	1,291,646.98	1,332,821.76	0.00	0.00	
3718	ADULT <40% EXP M&F
4	1,246,326.78	1,249,929.10	1,040,998.04	958,350.88	1,175,973.29	1,033,040.21	1,361,076.05	1,257,159.41	1,302,193.15	1,069,749.27	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	255.52	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,084,892.74	5,641,487.90	4,673,775.9	0	4,412,105.95	4,998,116.52	4,171,106.24	5,391,835.28	5,186,539.53	5,480,762.21	4,841,439.26	0.00	0.00	

 
351.39	
77,236.72	
306,703.38	
1,542,315.46	
855,737.87	
1,090,218.68	
42.58	
1,376.07	
1,657,910.84	
1,144,421.30	
20,665,225.55	
10,845,469.99	
11,694,796.18	
255.52	
49,882,061.53	

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	39,566.89	58,110.12	50,964.86	28,425.79	20,781.87	21,642.42	22,155.12	27,614.86	67,679.28	43,372.45	0.00	0.00		380,313.66		
3918	NEWLY ELIGIBLE M&F
4	65,086.20	65,328.46	66,559.87	52,258.47	56,705.53	37,846.43	33,584.99	97,748.40	56,983.53	49,548.63	0.00	0.00		581,650.51		
SUBTOTAL:	144,138.2	1	202,842.01	159,014.3	0	129,199.92	147,385.58	119,792.02	107,399.05	188,844.19	221,657.44	129,395.42	0.00	0.00		1,549,668.14		

8700	SSI DISABLED FREEDO M	458.48	186.31	68.72	85.65	0.00	23.63	0.00	0.00	0.00	23.63	0.00	0.00	
8710	SSI DISABLED FREEDO
M	23.63	23.63	161.08	47.26	368.00	391.00	0.00	391.00	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	471.88	0.00	0.00	
SUBTOTAL:	2,314.87	1,916.83	229.8	0	132.91	368.00	414.63	0.00	391.00	0.00	495.51	0.00	0.00	

846.42	
1,405.60	
4,011.53	
6,263.55	

4413	SOBRA 100-133% M&F
6	89,140.44	118,536.69	53,052.50	75,663.54	129,625.77	94,041.87	141,623.65	132,065.88	133,941.19	176,818.90	0.00	0.00	
4414	SOBRA 100-133% MALE	52,645.65	80,242.01	239,205.59	47,900.18	37,173.53	25,656.89	50,984.80	27,144.06	37,588.04	38,963.71	0.00	0.00	
4415	SOBRA 100-133% FEMA L	44,171.47	94,883.00	115,271.31	43,661.27	92,218.93	40,533.21	68,306.60	96,828.43	60,383.02	57,091.47	0.00	0.00	
SUBTOTAL:	185,957.5	6	293,661.70	407,529.4	0	167,224.99	259,018.23	160,231.97	260,915.05	256,038.37	231,912.25	272,874.08	0.00	0.00	

 
1,144,510.43	
637,504.46	
713,348.71	
2,495,363.60	

TOTAL:	17,352,428.88	20,327,447.61	16,401,808.15	14,606,936.19	17,302,968.40	14,211,191.13	17,432,370.34	16,776,942.20	17,273,293.42	16,354,404.64	0.00	0.00		168,039,790.96		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	4,081.95	4,745.30	1,632.78	11,276.42	7,347.51	5,714.73	5,255.61	0.00	0.00		40,054.30		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	20,409.75	3,265.56	16,914.63	13,878.63	7,351.59	7,359.75	19,621.92	0.00	0.00		88,801.83		
2200	SSI DISABLED WITH M
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,316.00	0.00	0.00	0.00	0.00		1,316.00		
2210	SSI DISABLED NON-ME D	6,531.12	0.00	2,449.17	0.00	35,691.60	56,330.91	46,670.10	9,025.17	17,989.14	36,790.59	0.00	0.00		211,477.80		
2220	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	1,316.00	1,316.00	0.00	0.00	2,656.00	2,680.00	0.00	0.00		7,968.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	8,163.90	0.00	0.00	0.00	0.00	0.00	0.00		8,163.90		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	2,449.17	0.00	0.00	0.00	816.39	0.00	0.00	0.00	0.00		3,265.56		
SUBTOTAL:	6,531.12	0.00	2,449.1	7	26,940.87	45,018.46	84,358.22	71,825.15	25,856.66	33,719.62	64,348.12	0.00	0.00		361,047.39		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,316.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	816.39	0.00	0.00	0.00	3,265.56	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	1,839.66	0.00	0.00	3,265.56	5,714.73	0.00	2,449.17	4,081.95	4,081.95	0.00	0.00	
1118	TANF EXPANDED 45-64	816.39	0.00	0.00	0.00	816.39	5,714.73	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	1,316.00	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	1,316.00	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	6,531.12	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	0.00	2,632.00	0.00	2,632.00	2,605.72	0.00	0.00	1,316.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	816.39	4,471.66	0.0	0	2,632.00	7,504.06	17,960.58	2,632.00	3,765.17	8,663.51	4,081.95	0.00	0.00	

 
1,316.00	
4,081.95	
21,433.02	
7,347.51	
1,316.00	
1,316.00	
6,531.12	
9,185.72	
52,527.32	

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	4,081.95	5,714.73	0.00	4,898.34	5,714.73	816.39	816.39	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	6,531.12	0.00	816.39	19,185.93	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	3,265.56	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	9,796.68	6,531.12	28,191.05	144,934.82	80,363.49	74,143.53	58,900.63	57,683.42	86,907.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	21,226.14	51,432.57	40,172.15	52,248.96	23,703.87	37,594.74	31,336.21	0.00	0.00	
3718	ADULT <40% EXP M&F
4	2,449.17	0.00	0.00	4,898.34	37,094.82	11,429.46	14,711.34	24,491.70	9,796.68	15,511.41	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	1,316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,449.17	9,796.68	6,531.1	2	59,713.48	239,176.94	131,965.10	152,533.29	112,810.93	109,973.18	153,756.94	0.00	0.00	

 
22,042.53	
26,533.44	
3,265.56	
547,451.74	
257,714.64	
120,382.92	
1,316.00	
978,706.83	

3916	NEWLY ELIGIBLE MALE	0.00	3,265.56	0.00	0.00	3,265.56	16,327.80	-13,878.63	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	7,347.51	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	37,553.94	0.00	0.00	15,868.68	13,878.63	10,613.07	0.00	0.00	9,025.17	0.00	0.00	
SUBTOTAL:	0.00	53,881.74	0.0	0	0.00	19,134.24	30,206.43	-3,265.56	0.00	7,347.51	9,025.17	0.00	0.00	

 
8,980.29	
20,409.75	
86,939.49	
116,329.53	

1,508,611.07

9,796.68	68,150.08	8,980.29	89,286.35	310,833.70	264,490.33	223,724.88	142,432.76	159,703.82	231,212.18	0.00	0.00	

TOTAL:

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
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	4,651.64	0.00	2,206.22	108.22	0.00	0.00	0.00	0.00	0.00	0.00		6,966.08		
2100	SSI AGED WITH MEDIC
A	15,377.05	33,561.22	38,831.77	21,930.97	75,734.03	76,474.04	21,300.60	12,319.60	29,570.69	24,673.39	0.00	0.00		349,773.36		
2110	SSI AGED NON-MEDICA R	177,423.98	68,832.10	46,369.00	39,201.53	85,844.18	49,284.63	72,811.37	121,651.41	95,350.45	99,003.09	0.00	0.00		855,771.74		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	3,105.94	0.00	0.00	0.00	0.00	0.00	0.00		3,105.94		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	33,989.51	1,873.83	2,802.40	1,970.44	16,690.07	803.43	0.00	0.00		58,129.68		
2210	SSI DISABLED NON-ME
D	5,645.08	13,622.78	1,493.09	18,842.65	3,116.38	0.00	17,900.70	16,170.93	397.12	887.30	0.00	0.00		78,076.03		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	2,582.21	28,776.91	518.44	0.00	0.00	0.00	0.00	0.00		31,877.56		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,398.21	4,854.21	0.00	0.00	0.00		6,252.42		
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		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	2,468.86	919.19	0.00	0.00	0.00	0.00	0.00	0.00		3,388.05		
5017	SOBRA PREG 21-44 FE
M	24,901.43	31,636.93	10,420.50	6,162.50	17,417.71	19,352.17	10,651.57	15,692.68	7,379.74	6,936.17	0.00	0.00		150,551.40		
SUBTOTAL:	223,347.5	4	131,891.22	101,766.0	0	86,137.65	223,359.10	179,894.93	125,985.08	169,203.27	154,242.28	132,303.38	0.00	0.00		1,528,130.45		

4,008.62

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	5,731.85	0.00	0.00	0.00	9,998.73	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	2,705.73	0.00	0.00	0.00	409.88	138.79	375.69	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	4,526.68	190.66	0.00	86.57	423.88	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	58,454.33	12,529.30	6,420.51	61,265.81	0.00	624.01	1,722.91	13,144.76	14,449.42	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	3,428.50	2,306.68	0.00	529.61	6,483.98	0.00	0.00	176.95	409.88	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	47,375.99	49,885.78	12,816.66	21,136.54	101,380.88	5,145.15	48,230.43	40,932.98	72,483.42	47,501.41	0.00	0.00	
3714	ADULT <40% EXP MALE	328.84	80.16	261.87	0.00	11,577.49	0.00	3,337.74	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	0.00	0.00	0.00	470.90	3,311.66	0.00	387.80	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	405,461.03	295,360.98	107,838.75	162,424.05	252,117.59	178,654.93	366,328.43	281,900.60	269,793.17	286,592.95	0.00	0.00	
3717	ADULT <40% EXP FEMA L	37,835.08	29,296.66	999.96	4,134.24	26,343.98	5,209.28	28,969.33	21,999.29	12,423.42	37,120.83	0.00	0.00	
3718	ADULT <40% EXP M&F
4	468,306.67	320,396.72	219,017.00	439,805.55	572,394.29	445,606.44	544,456.87	266,592.94	588,955.98	428,148.31	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	1,610.61	0.00	15,489.27	0.00	0.00	0.00	
SUBTOTAL:	1,021,190.44	712,562.01	351,881.4	3	689,957.36	973,609.87	641,468.11	995,606.79	625,123.21	974,004.56	809,362.23	0.00	0.00	

15,730.58	
3,630.09	
5,227.79	
168,611.05	
13,335.60	
446,889.24	
15,586.10	
4,170.36	
2,606,472.48	
204,332.07	
4,293,680.77	
17,099.88	
7,794,766.01	

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	2,077.96	15,203.00	17,915.25	3,975.57	19,899.12	4,118.35	7,076.05	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	75.65	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	13,375.75	40,495.50	5,078.78	31,287.93	9,680.15	29,520.15	6,776.78	0.00	0.00	
SUBTOTAL:	84,703.01	44,767.49	3,220.1	4	15,529.36	55,698.50	22,994.03	35,263.50	29,579.27	33,638.50	13,852.83	0.00	0.00	

8,152.60	
136,461.12	
75.65	
194,557.26	
339,246.63	

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	4,008.62	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	4,008.62	0.00	0.00	0.00	0.00	0.00	

 
4,008.62

TOTAL:	1,329,240.99	889,220.72	456,867.57	791,624.37	1,252,667.47	844,357.07	1,160,863.99	823,905.75	1,161,885.34	955,518.44	0.00	0.00		9,666,151.71		

COCHISE COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
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 MALE	0.00	1,483.41	0.00	85.00	0.00	0.00	2,849.43	1,343.71	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	1,483.41	0.00	85.00	0.00	0.00	2,849.43	1,343.71	0.00	0.00	0.00	0.00	

 
5,761.55

5,761.55

4,781.67

0.00	1,483.41	-979.88	85.00	0.00	0.00	2,849.43	1,343.71	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	8.40	637.10	0.00	0.00	6,753.47	6,691.35	0.00	0.00		14,090.32		
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	414.16	0.00	5,728.79	0.00	0.00	0.00		6,142.95		
SUBTOTAL:	0.00	0.00	0.00	0.00	8.40	637.10	414.16	0.00	12,482.26	6,691.35	0.00	0.00		20,233.27		

TOTAL:	0.00	0.00	0.00	0.00	8.40	637.10	414.16	0.00	12,482.26	6,691.35	0.00	0.00		20,233.27		

GRAHAM COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	71.20	4,682.14	0.00	160.34	0.00	0.00	0.00	0.00	0.00		4,913.68		
SUBTOTAL:	0.00	0.00	0.00	71.20	4,682.14	0.00	160.34	0.00	0.00	0.00	0.00	0.00		4,913.68		

4,913.68

0.00	0.00	0.00	71.20	4,682.14	0.00	160.34	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	2,712.43	0.00	0.00	0.00	0.00	0.00		2,712.43		
1016	TANF 21-44 MALE NON-	171.60	1,342.11	10,405.73	5,238.57	31,190.62	0.00	3,790.29	1,374.87	0.00	4,381.63	0.00	0.00		57,895.42		
1017	TANF 21-44 FEMALE N O	6,455.31	3,931.00	0.00	0.00	0.00	297.62	7,091.20	3,263.28	0.00	0.00	0.00	0.00		21,038.41		
1018	TANF 45-64 M & F NON	0.00	0.00	4,135.38	0.00	0.00	0.00	-4,135.38	0.00	0.00	0.00	0.00	0.00		0.00		
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	109.01	0.00	0.00	0.00	0.00	0.00		210.33		
2210	SSI DISABLED NON-ME
D	15,929.93	31.16	1,849.24	331.55	4,609.09	194.58	0.00	153.67	3,948.75	0.00	0.00	0.00		27,047.97		
2220	SSI DISABLED WITH Q M	12,271.60	16,645.72	5,503.47	527.16	1,190.46	1,815.39	5,655.68	89.42	165.72	0.00	0.00	0.00		43,864.62		
4314	SOBRA CHILD 14-20 MA	0.00	1,487.29	545.83	0.00	772.68	3,531.47	0.00	0.00	0.00	0.00	0.00	0.00		6,337.27		
4315	SOBRA CHILD 14-20 FE	22,968.07	0.00	91.10	0.00	0.00	0.00	3,709.72	470.90	0.00	0.00	0.00	0.00		27,239.79		
5015	SOBRA PREG 14-20 FE M	8,096.59	38.79	235.45	470.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,841.73		
5017	SOBRA PREG 21-44 FE
M	2,545.71	1,163.40	0.00	0.00	0.00	0.00	8,425.61	8,707.77	3,387.29	249.30	0.00	0.00		24,479.08		
SUBTOTAL:	68,685.83	30,039.35	22,867.5	2	6,568.18	37,762.85	5,839.06	27,358.56	14,059.91	7,501.76	4,630.93	0.00	0.00		225,313.95		

3516	ADULT 40-100% MALE 2	7,986.74	160.34	696.87	7,374.72	3,499.75	5,798.33	4,074.50	2,225.90	20,030.16	528.61	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	15,966.79	177.20	3,767.16	470.90	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	121.63	0.00	0.00	218.83	4,795.50	114.10	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	122.26	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	26,893.55	3,203.60	165.72	259.05	3,062.12	33,714.97	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	1,580.63	14,083.13	57.13	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	208,629.72	93,904.97	39,790.60	80,057.73	76,431.51	82,444.55	96,075.93	52,462.74	112,532.19	59,658.51	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,399.45	21,413.18	12,565.34	3,792.79	2,149.45	16,449.46	30,747.31	18,362.15	5,010.68	17,994.95	0.00	0.00	
3718	ADULT <40% EXP M&F
4	31,242.46	28,604.39	35,997.15	25,987.42	32,863.27	12,830.24	65,055.27	66,042.91	30,971.49	13,041.67	0.00	0.00	
SUBTOTAL:	258,655.9	3	188,622.89	92,487.8	1	121,267.17	117,254.56	134,790.09	229,943.94	143,889.20	168,658.62	91,223.74	0.00	0.00	

52,375.92	
20,382.05	
16,384.34	
122.26	
67,299.01	
15,720.89	
901,988.45	
129,884.76	
342,636.27	
1,546,793.95	

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	217.46	4,695.83	4,125.95	0.00	5,111.28	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	10,112.35	3,450.08	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	217.46	4,695.83	4,125.95	0.00	15,223.63	3,450.08	0.00	0.00	

14,150.52	
13,562.43	
27,712.95	

TOTAL:

115,455.58

155,234.87

145,356.14

267,416.97

158,006.16

101,075.17

1,816,009.94

219,904.83

333,763.85

0.00	0.00

191,961.02

127,835.35

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	31.16	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	4,021.80	894.58	100.25	0.00	0.00	0.00	0.00	57.05	0.00	1,001.44	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	5,957.36	0.00	577.01	768.98	0.00	0.00	
2620	SSI DISABLED EXPAND E	2,400.29	348.01	0.00	0.00	0.00	31.16	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,422.09	1,242.59	100.2	5	0.00	0.00	31.16	5,988.52	57.05	577.01	1,770.42	0.00	0.00	

 
31.16	
6,075.12	
7,303.35	
2,779.46	
16,189.09	

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	3,527.93	0.00	0.00	1,103.05	379.92	0.00	0.00	0.00	0.00	0.00	0.00		5,010.90		
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	0.0	0	0.00	1,103.05	379.92	0.00	0.00	0.00	0.00	0.00	0.00		7,696.83		

3716	ADULT <40% EXP MALE	0.00	0.00	246.80	378.99	710.57	9,143.83	1,268.62	0.00	6,576.55	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	2,443.92	0.00	7,927.53	363.60	274.84	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	589.25	0.00	0.00	0.00	15,806.37	0.00	0.00	0.00	
SUBTOTAL:	0.00	4,601.43	246.8	0	8,306.52	1,663.42	9,418.67	1,268.62	0.00	22,382.92	0.00	0.00	0.00	

 
18,325.36	
11,009.89	
18,553.13	
47,888.38	

3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	11,635.95	0.00	554.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	11,635.95	0.00	554.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,190.45

12,190.45

67,775.66

0.00	10,815.29	11,882.75	8,306.52	3,320.97	9,798.59	1,268.62	0.00	22,382.92	0.00	0.00	0.00	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	690.05	0.00	0.00	0.00	1,108.78	6,405.04	16,471.21	431.05	13,570.79	0.00	0.00		38,676.92		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,867.53	4,589.07	0.00	0.00	0.00		9,456.60		
2200	SSI DISABLED WITH M
E	0.00	0.00	0.00	0.00	0.00	0.00	69.63	108.22	0.00	0.00	0.00	0.00		177.85		
2210	SSI DISABLED NON-ME D	564.31	0.00	0.00	217.71	2,711.29	12,659.57	90.66	3,451.08	3,155.09	1,116.71	0.00	0.00		23,966.42		
2220	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	125.31	471.57	1.85	1,302.84	0.00	0.00	0.00	0.00		1,901.57		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	1,384.49	0.00	0.00	6,168.93	0.00	0.00	0.00	0.00	0.00		7,553.42		
SUBTOTAL:	564.31	690.05	0.0	0	1,602.20	2,836.60	14,239.92	12,736.11	26,200.88	8,175.21	14,687.50	0.00	0.00		81,732.78		

3516	ADULT 40-100% MALE 2	0.00	0.00	71,944.37	0.00	0.00	0.00	385.13	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	252.30	8,199.53	1,021.96	57.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	5,931.58	6,252.27	4,191.52	91.10	61.20	1,114.60	22,555.17	6,524.09	8,544.39	13,500.72	0.00	0.00	
3717	ADULT <40% EXP FEMA L	3,058.04	7,602.61	2,345.59	765.02	11,040.05	450.72	9,220.40	842.80	12,043.37	658.28	0.00	0.00	
3718	ADULT <40% EXP M&F
4	6,153.29	17,799.17	4,264.15	35,092.04	21,313.78	8,827.05	4,729.43	10,195.05	9,784.15	3,690.65	0.00	0.00	
SUBTOTAL:	15,142.91	31,906.35	90,945.1	6	36,970.12	32,472.08	10,392.37	36,890.13	17,561.94	30,371.91	17,849.65	0.00	0.00	

72,329.50	
9,530.84	
68,766.64	
48,026.88	
121,848.76	
320,502.62	

3916	NEWLY ELIGIBLE MALE	398.34	0.00	0.00	1,766.43	2,836.94	1,171.96	2,697.72	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	6,561.69	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	2,702.07	0.00	0.00	0.00	4,343.31	0.00	0.00	
SUBTOTAL:	593.70	387.80	6,951.1	0	1,766.43	2,836.94	3,874.03	9,259.41	0.00	0.00	4,343.31	0.00	0.00	

8,871.39	
14,095.95	
7,045.38	
30,012.72	

TOTAL:

110,834.06

38,145.62

30,652.67

63,556.11

45,069.51

36,880.46

454,206.69

32,984.20

16,300.92

0.00	0.00

38,547.12

41,236.02

1116	TANF EXPANDED 21-44	0.00	0.00	12,937.80	530.85	0.00	107.31	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	4,670.46	1,306.69	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	366.42	0.00	2,039.04	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	12,937.8	0	897.27	0.00	2,146.35	4,670.46	1,306.69	0.00	0.00	0.00	0.00	

 
13,575.96	
5,977.15	
2,405.46	
21,958.57	

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	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	12,815.34	0.00	132.43	1,455.17	113.93	0.00	0.00	
SUBTOTAL:	498.60	0.00	0.0	0	0.00	0.00	12,815.34	0.00	132.43	1,455.17	113.93	0.00	0.00	

 
0.00

15,015.47

15,015.47

15,015.47

0.00	0.00	0.00	12,815.34	0.00	132.43	1,455.17	113.93	0.00	0.00	

TOTAL:

498.60

0.00

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	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	3,084.29	0.00	0.00	0.00	0.00	0.00		3,084.29		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	3,084.29	0.00	0.00	0.00	0.00	0.00		3,084.29		

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,259.97	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	634.76	0.00	268.11	0.00	0.00	1,343.71	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	3,991.59	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	634.76	0.00	268.11	0.00	9,251.56	1,343.71	0.00	0.00	

 
5,259.97	
2,246.58	
3,991.59	
11,498.14	

TOTAL:	0.00	0.00	0.00	0.00	634.76	0.00	3,352.40	0.00	9,251.56	1,343.71	0.00	0.00		14,582.43		

YUMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	4,135.38	0.00	0.00	0.00	0.00	0.00		4,135.38		
2200	SSI DISABLED WITH M E	0.00	0.00	76.98	1,376.82	0.00	11,786.26	722.55	145.34	626.56	-229.57	0.00	0.00		14,504.94		
SUBTOTAL:	0.00	0.00	76.9	8	1,376.82	0.00	11,786.26	4,857.93	145.34	626.56	-229.57	0.00	0.00		18,640.32		

11,733.78

2610	SSI DISABLED EXPAND E	0.00	0.00	138.05	1,266.33	0.00	10,329.40	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	138.05	1,266.33	0.00	10,329.40	0.00	0.00	0.00	0.00	0.00	0.00	

11,733.78

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	1,561.92	11,968.71	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	3,051.29	685.70	139.62	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	1,561.92	15,020.00	685.70	139.62	0.00	0.00	0.00	0.00	

13,530.63	
3,876.61	
17,407.24	

47,781.34

0.00	0.00	215.03	2,643.15	1,561.92	37,135.66	5,543.63	284.96	626.56	-229.57	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending April 30, 2018	
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	1,303.33	1,392.25	1,829.60	0.00	0.00		4,916.18		
2100	SSI AGED WITH MEDIC A	2,701,850.75	3,388,420.91	2,666,400.83	2,364,081.96	2,973,270.42	2,637,161.67	3,261,528.33	2,598,829.04	2,893,640.51	2,545,312.01	0.00	0.00		28,030,496.43		
2110	SSI AGED NON-MEDICA
R	234,576.01	198,055.36	101,326.66	112,090.13	104,687.06	184,232.36	173,770.69	104,942.23	111,764.87	94,542.56	0.00	0.00		1,419,987.93		
2120	SSI AGED WITH QMB	3,395,570.95	4,480,987.35	3,484,574.71	3,469,160.26	4,137,089.02	3,730,582.28	4,190,801.53	3,412,309.79	3,644,824.27	3,454,319.35	0.00	0.00		37,400,219.51		
2200	SSI DISABLED WITH M E	733,207.80	846,565.16	666,437.18	694,296.28	890,883.24	823,827.23	838,147.63	750,991.84	869,013.70	796,439.82	0.00	0.00		7,909,809.88		
2210	SSI DISABLED NON-ME
D	3,088,233.12	4,441,270.19	3,132,513.55	2,761,419.31	3,546,522.19	3,369,831.98	3,596,121.01	2,943,751.21	3,502,466.69	3,460,029.20	0.00	0.00		33,842,158.45		
2220	SSI DISABLED WITH Q M	873,654.11	1,373,064.23	945,797.30	974,691.00	1,041,940.34	996,777.51	1,189,598.95	961,434.60	1,048,093.98	957,959.43	0.00	0.00		10,363,011.45		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,513.57	4,749.59	4,674.37	0.00	0.00		12,937.53		
2310	SSI BLIND NON-MEDIC A	37,466.58	37,722.68	22,861.38	21,866.87	23,619.01	20,273.96	25,381.11	19,144.18	29,279.47	22,777.91	0.00	0.00		260,393.15		
2320	SSI BLIND WITH QMB	8,806.95	8,742.05	4,353.11	10,235.02	12,635.67	11,487.41	14,967.39	10,419.22	12,222.82	8,402.05	0.00	0.00		102,271.69		
SUBTOTAL:	11,073,366.2	7 14,775,218.93	11,024,264.7	2 10,407,840.83	12,730,646.95	11,774,174.40	13,290,316.64	10,806,639.01	12,117,448.15	11,346,286.30	0.00	0.00		119,346,202.20		

8710	SSI DISABLED FREEDO M	0.00	1,326.10	6,033.96	2,935.44	3,090.17	338.11	6,810.97	3,075.30	2,790.72	3,084.48	0.00	0.00	
8720	SSI DISABLED FREEDO
M	2,533.80	3,044.16	3,424.68	1,522.08	851.64	983.01	1,980.12	1,326.51	688.50	481.14	0.00	0.00	
SUBTOTAL:	2,533.80	4,370.26	9,458.6	4	4,457.52	3,941.81	1,321.12	8,791.09	4,401.81	3,479.22	3,565.62	0.00	0.00	

 
29,485.25	
16,835.64	
46,320.89	

TOTAL:	11,075,900.07	14,779,589.19	11,033,723.36	10,412,298.35	12,734,588.76	11,775,495.52	13,299,107.73	10,811,040.82	12,120,927.37	11,349,851.92	0.00	0.00		119,392,523.09		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2018	
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	26,273.45	40,111.18	20,655.52	24,267.27	10,366.52	16,137.74	32,532.25	0.00	0.00		251,567.52		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	1,516.80	4,827.10	0.00	76,406.93	0.00	0.00	0.00	0.00	0.00		82,750.83		
2120	SSI AGED WITH QMB	636.37	359.89	0.00	222.25	0.00	556.43	101.64	150.68	0.00	0.00	0.00	0.00		2,027.26		
2200	SSI DISABLED WITH M E	2,582.24	3,739.00	5,497.46	11,445.43	2,289.19	3,967.53	5,845.32	12,809.01	1,494.64	5,402.24	0.00	0.00		55,072.06		
2210	SSI DISABLED NON-ME
D	1,948.84	324.93	1,867.73	25,418.27	11,269.66	1,958.16	13,123.33	6,326.32	2,969.82	2,488.00	0.00	0.00		67,695.06		
SUBTOTAL:	31,030.84	30,710.69	36,438.5	2	64,876.20	58,497.13	27,137.64	119,744.49	29,652.53	20,602.20	40,422.49	0.00	0.00		459,112.73		

459,112.73

36,438.52	64,876.20	58,497.13	27,137.64	119,744.49	29,652.53	20,602.20	40,422.49	0.00	0.00	

TOTAL:

31,030.84

30,710.69

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending April 30, 2018	
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	114.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		886.51		
SUBTOTAL:	165.72	0.00	606.69	0.00	114.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		886.51		

TOTAL:

606.69

114.10

0.00

0.00

0.00

0.00

886.51

0.00

165.72

0.00	0.00

0.00

0.00

PIMA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending April 30, 2018	
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		

1,679.82

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	

TOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending April 30, 2018	
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	14,067.92	17,101.40	17,125.21	20,881.01	29,647.89	31,733.97	33,034.40	0.00	0.00		196,687.36		
1013	TANF 06-13 M & F NON	48,993.85	20,403.99	5,549.71	58,079.70	50,908.20	54,305.39	71,846.82	76,046.38	83,080.23	97,122.73	0.00	0.00		566,337.00		
1014	TANF 14-20 MALE NON-	4,535.34	2,295.55	669.16	2,473.27	4,275.22	3,968.22	9,026.95	5,914.10	8,437.97	8,490.82	0.00	0.00		50,086.60		
1015	TANF 14-20 FEMALE N O	2,237.61	2,032.01	414.43	2,073.45	2,155.89	2,266.30	4,262.62	2,680.18	1,894.88	3,583.70	0.00	0.00		23,601.07		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-35.48	0.00	0.00	0.00	0.00		-35.48		
2200	SSI DISABLED WITH M E	42.96	0.00	0.00	0.00	358.60	1,115.93	221.93	523.63	126.82	0.00	0.00	0.00		2,389.87		
2210	SSI DISABLED NON-ME
D	246,230.53	103,186.78	31,635.23	180,876.04	198,103.19	276,665.77	324,881.03	266,311.43	287,133.29	392,876.40	0.00	0.00		2,307,899.69		
2220	SSI DISABLED WITH Q M	481.95	67.45	0.00	601.41	43.98	90.62	43.32	0.00	0.00	0.00	0.00	0.00		1,328.73		
2310	SSI BLIND NON-MEDIC
A	3,023.33	882.72	608.41	2,138.15	1,422.86	1,757.64	2,795.61	2,183.23	2,230.18	3,057.82	0.00	0.00		20,099.95		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	27.78	13.56	7.22	40.68	0.00	0.00	0.00		89.24		
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	23,330.87	29,208.43	32,049.58	35,210.50	134,806.51	184,654.99	178,662.27	0.00	0.00		661,299.04		
4313	SOBRA CHILD 06-13 M	108,381.63	49,032.65	18,221.85	89,919.72	115,020.31	109,675.08	136,205.73	246,342.53	325,320.53	327,915.28	0.00	0.00		1,526,035.31		
4314	SOBRA CHILD 14-20 MA	10,627.54	4,788.70	2,674.44	7,030.24	7,808.89	7,781.99	12,316.35	11,114.72	23,137.01	18,087.59	0.00	0.00		105,367.47		
4315	SOBRA CHILD 14-20 FE	3,879.34	1,247.64	710.15	3,999.15	5,427.99	5,316.76	6,782.74	7,446.58	8,220.94	11,666.71	0.00	0.00		54,698.00		
5015	SOBRA PREG 14-20 FE M	143.36	0.00	0.00	0.00	0.00	0.00	0.00	79.80	27.89	55.78	0.00	0.00		306.83		
SUBTOTAL:	471,068.1	5	209,579.29	69,018.0	2	384,589.92	431,834.96	512,146.27	624,488.17	783,068.72	956,039.38	1,074,553.50	0.00	0.00		5,516,386.38		

3514	ADULT 40-100% MALE 1	65.76	0.00	0.00	75.50	0.00	0.00	137.66	0.00	98.79	179.35	0.00	0.00	
3515	ADULT 40-100% FEMAL E	65.76	0.00	0.00	35.85	35.85	72.72	113.08	32.66	248.57	213.22	0.00	0.00	
3714	ADULT <40% EXP MALE	198.82	0.00	0.00	124.16	116.40	32.93	112.54	14.05	96.71	133.58	0.00	0.00	
3715	ADULT <40% EXP FEMA L	485.53	0.00	32.88	62.10	38.96	0.00	69.03	65.20	43.39	9.87	0.00	0.00	
3717	ADULT <40% EXP FEMA
L	0.00	431.12	0.00	162.87	0.00	0.00	58.17	853.75	0.00	0.00	0.00	0.00	
SUBTOTAL:	815.87	431.12	32.8	8	460.48	191.21	105.65	490.48	965.66	487.46	536.02	0.00	0.00	

557.06	
817.71	
829.19	
806.96	
1,505.91	
4,516.83	

3914	NEWLY ELIGIBLE MALE	10.30	0.00	0.00	32.33	39.78	167.50	374.79	85.45	89.76	54.66	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	77.40	15.20	0.00	0.00	
SUBTOTAL:	29.26	0.00	0.0	0	32.33	39.78	167.50	374.79	85.45	167.16	69.86	0.00	0.00	

854.57	
111.56	
966.13	

4413	SOBRA 100-133% M&F
6	24,577.42	7,963.33	4,305.52	238,987.90	30,930.94	32,699.89	40,091.51	50,592.36	77,385.93	83,557.62	0.00	0.00	
4414	SOBRA 100-133% MALE	2,590.74	1,053.70	298.19	29,002.10	1,753.55	2,226.38	2,500.12	8,417.65	10,779.91	7,822.39	0.00	0.00	
4415	SOBRA 100-133% FEMA L	379.24	201.19	378.71	6,676.95	889.95	701.04	1,575.96	1,088.72	2,114.56	1,241.03	0.00	0.00	
SUBTOTAL:	27,547.40	9,218.22	4,982.4	2	274,666.95	33,574.44	35,627.31	44,167.59	60,098.73	90,280.40	92,621.04	0.00	0.00	

591,092.42	
66,444.73	
15,247.35	
672,784.50	

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	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82.85	0.00	0.00	
SUBTOTAL:	80.72	16.89	16.8	9	0.00	0.00	0.00	0.00	0.00	0.00	82.85	0.00	0.00	

 
114.50	
82.85	
197.35	

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	499,541.40	219,245.52	74,050.21	659,749.68	465,640.39	548,046.73	669,521.03	844,218.56	1,046,974.40	1,167,863.27	0.00	0.00		6,194,851.19		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,547.22	891.11	520.61	2,024.22	2,554.25	1,241.13	3,291.22	1,152.50	116.08	1,922.08	0.00	0.00		15,260.42		
1010	TANF NON-MEDICARE	46,160.98	19,385.59	4,338.29	35,916.66	31,523.51	31,823.59	49,946.10	31,476.66	45,401.78	51,505.84	0.00	0.00		347,479.00		
2200	SSI DISABLED WITH M E	2,162.91	1,390.87	0.00	1,088.76	875.41	1,207.95	3,240.42	1,901.13	1,654.74	2,067.01	0.00	0.00		15,589.20		
2210	SSI DISABLED NON-ME
D	1,473,846.63	806,564.90	195,436.94	1,158,559.67	1,372,876.89	1,698,487.20	2,021,407.81	1,268,016.38	1,439,729.16	2,045,379.34	0.00	0.00		13,480,304.92		
2220	SSI DISABLED WITH Q M	6,290.82	5,411.38	84.63	4,173.38	3,573.08	3,836.88	3,932.99	1,822.85	2,289.42	6,304.56	0.00	0.00		37,719.99		
2310	SSI BLIND NON-MEDIC
A	10,493.31	3,206.46	423.03	7,094.28	11,986.71	15,295.70	16,120.46	9,345.71	9,519.26	12,875.91	0.00	0.00		96,360.83		
SUBTOTAL:	1,540,501.87	836,850.31	200,803.5	0	1,208,856.97	1,423,389.85	1,751,892.45	2,097,939.00	1,313,715.23	1,498,710.44	2,120,054.74	0.00	0.00		13,992,714.36		

13,992,714.36

1,540,501.87	836,850.31	200,803.50	1,208,856.97	1,423,389.85	1,751,892.45	2,097,939.00	1,313,715.23	1,498,710.44	2,120,054.74	0.00	0.00	

TOTAL:

ACUTE REINSURANCE
For The Period Ending April 30, 2018	
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	43.67	48.43	0.00	0.00	0.00	0.00	0.00	0.00		92.10		
1007	TANF 21-44 FEMALE WI	0.00	0.00	61.56	0.00	206.49	6.50	0.00	0.00	0.00	2,740.43	0.00	0.00		3,014.98		
1008	TANF 45-64 M & F WIT	76.49	0.00	54,908.50	0.00	0.00	0.00	-55,469.18	0.00	0.00	1,727.37	0.00	0.00		1,243.18		
1011	TANF <1 M & F NON-ME	792,098.45	731,912.14	596,578.37	805,269.16	544,439.52	610,730.60	440,518.77	484,834.26	469,471.30	1,309,049.99	0.00	0.00		6,784,902.56		
1012	TANF 01-05 M & F NON	93,618.58	43,751.24	42,582.10	26,771.54	55,217.85	97,912.93	-29,557.08	-749.19	20,275.96	63,818.50	0.00	0.00		413,642.43		
1013	TANF 06-13 M & F NON	97,360.29	42,224.52	76,495.84	199,678.74	216,374.59	52,704.86	81,268.08	48,103.71	150,842.35	204,685.85	0.00	0.00		1,169,738.83		
1014	TANF 14-20 MALE NON-	100,226.61	93.17	24,182.74	118,788.65	0.00	-64,788.57	116,073.07	191,365.11	0.00	114,574.57	0.00	0.00		600,515.35		
1015	TANF 14-20 FEMALE N O	12,664.01	47,657.93	16.75	52,150.82	45,868.89	12,751.51	989,417.75	291,383.46	486,357.88	414,155.26	0.00	0.00		2,352,424.26		
1016	TANF 21-44 MALE NON-	78,305.08	-358.12	111,189.86	93,883.79	94,689.32	48,501.16	159,314.87	316,543.45	182,367.15	336,440.83	0.00	0.00		1,420,877.39		
1017	TANF 21-44 FEMALE N O	385,737.83	168,770.57	373,755.04	450,626.06	528,358.14	279,014.09	473,852.24	146,037.65	295,974.99	487,467.95	0.00	0.00		3,589,594.56		
1018	TANF 45-64 M & F NON	496,933.25	25,280.46	270,049.67	163,422.85	157,737.95	181,453.60	80,876.24	185,941.65	7,055.68	314,432.05	0.00	0.00		1,883,183.40		
2100	SSI AGED WITH MEDIC A	24,935.52	11,582.57	6,213.82	115,263.43	12,603.87	25,714.69	29,130.18	20,321.70	9,432.72	65,407.56	0.00	0.00		320,606.06		
2110	SSI AGED NON-MEDICA
R	229,962.20	84,260.00	237,253.58	183,602.79	171,072.65	181,941.06	64,653.45	217,623.00	89,394.73	430,518.97	0.00	0.00		1,890,282.43		
2200	SSI DISABLED WITH M E	9,940.06	79,656.86	50,495.73	63,347.17	108,760.82	100,205.03	278,864.98	38,890.76	29,423.55	42,598.15	0.00	0.00		802,183.11		
2210	SSI DISABLED NON-ME
D	7,086,206.83	5,515,241.43	4,779,443.21	7,483,621.13	5,130,840.31	6,378,442.05	4,790,477.84	3,795,358.35	5,669,280.81	5,130,464.58	0.00	0.00		55,759,376.54		
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	4,291.28	8,543.42	37,343.56	0.00	36,104.24	6,443.91	199,716.48	0.00	0.00		310,947.40		
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	39,464.28	-27,175.09	-3,846.59	0.00	0.00	0.00		8,442.60		
4311	SOBRA CHILD <1 M & F	1,999,947.14	1,220,733.66	1,185,900.93	2,043,179.70	2,148,777.43	1,477,403.43	1,705,327.54	828,898.47	1,169,667.42	1,566,174.78	0.00	0.00		15,346,010.50		
4312	SOBRA CHILD 01-05 M	462,002.32	404,898.03	810,857.00	390,108.50	379,926.36	3,247,187.80	578,820.44	694,237.36	611,388.51	915,756.46	0.00	0.00		8,495,182.78		
4313	SOBRA CHILD 06-13 M	676,994.95	300,678.65	943,155.64	773,473.96	535,449.37	365,694.18	550,610.41	357,730.52	497,741.94	900,516.64	0.00	0.00		5,902,046.26		
4314	SOBRA CHILD 14-20 MA	868,929.19	329,418.01	248,345.39	597,510.47	499,755.37	207,970.40	332,276.77	183,640.33	244,415.69	995,813.80	0.00	0.00		4,508,075.42		
4315	SOBRA CHILD 14-20 FE	203,212.23	283,295.58	299,543.69	220,288.41	138,964.78	118,257.89	90,301.37	196,556.05	140,491.56	269,267.59	0.00	0.00		1,960,179.15		
5015	SOBRA PREG 14-20 FE M	47,663.05	0.00	9,350.63	386.57	5,503.79	-2,299.13	0.00	0.00	0.00	0.00	0.00	0.00		60,604.91		
5017	SOBRA PREG 21-44 FE
M	34,632.31	31,320.85	55,833.20	96,335.70	14,435.14	26,663.02	21,735.29	40,854.44	21,461.06	34,708.76	0.00	0.00		377,979.77		
5018	SOBRA PREG 45-64 FE M	8,570.09	0.00	0.00	0.00	0.00	0.00	1,098.28	0.00	0.00	0.00	0.00	0.00		9,668.37		
SUBTOTAL:	13,710,016.4	8	9,325,598.19	10,191,193.9	4 13,882,000.72	10,797,569.73	13,382,859.09	10,739,055.59	8,046,500.23	10,097,640.62	13,800,036.57	0.00	0.00		113,972,471.16		

1106	TANF EXPANDED 21-44	111.02	111.55	136.89	614.73	58.67	225.40	0.00	459.75	-46.42	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	15,859.69	0.00	241.30	3,982.30	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	251.21	-35.95	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	13,362.46	0.00	0.00	3,082.02	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	180,654.25	175,659.86	226,323.63	294,297.48	344,687.10	218,618.99	93,542.36	29,532.42	112,873.91	419,456.45	0.00	0.00	
1117	TANF EXPANDED 21-44	231,889.35	96,585.68	161,316.76	122,751.33	228,807.69	214,816.00	138,293.33	198,964.41	265,127.65	345,623.87	0.00	0.00	

1,671.59	
20,083.29	
215.26	
16,444.48	
2,095,646.45	
2,004,176.07	

3100	TRANSPLANT OPTION 1	0.00	0.00	0.00	0.00	1,470.70	267.82	1,207.50	3,738.71	54,980.52	7,656.07	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	1,470.70	267.82	1,207.50	3,738.71	54,980.52	7,656.07	0.00	0.00	

 
69,321.32

69,321.32

ACUTE REINSURANCE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	35,705.65	166,748.45	184,003.28	237,067.32	146,880.12	150,748.00	124,111.33	448,361.57	334,435.44	306,279.47	0.00	0.00		2,134,340.63		
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	11,211.88	3,111.26	11,443.31	4,642.41	7,923.17	0.00	0.00		38,332.03		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	13,190.18	46.05	-8,030.68	12,310.79	0.00	74.85	0.00	0.00		17,591.19		
2410	SSI AGED EXPANDED N
O	0.00	0.00	2,847.67	431.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,278.69		
2600	SSI DISABLED EXPAND E	3,865.29	-2,181.93	2,264.03	161.33	1,135.43	0.00	0.00	3,077.23	263.84	2,955.96	0.00	0.00		11,541.18		
2610	SSI DISABLED EXPAND
E	99,989.18	-94,492.58	65,448.58	388,919.80	58,339.14	139,260.29	25,626.79	136,133.85	45,871.44	149,408.70	0.00	0.00		1,014,505.19		
SUBTOTAL:	552,214.7	4	342,431.03	642,340.8	4	1,044,243.01	806,460.79	751,037.51	376,618.44	843,606.65	767,150.57	1,231,722.47	0.00	0.00		7,357,826.05		

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	2,268.92	0.00	0.00	1,636.51	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	8,952.17	0.00	0.00	0.00	0.00	-47.83	30,346.36	41,046.00	11,572.71	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	193,608.25	27,647.28	229,531.66	303,903.47	203,815.70	227,199.81	117,240.42	116,243.94	241,338.63	84,309.57	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	59,730.80	-38,365.56	125,725.05	161,493.45	129,301.87	9,807.01	1,705.84	27,995.64	39,416.93	68,950.95	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	276,143.01	108,976.70	379,461.96	487,686.50	262,030.32	1,197,895.19	171,960.50	574,453.55	551,903.55	438,556.85	0.00	0.00	
SUBTOTAL:	529,482.0	6	119,226.14	735,845.6	7	953,083.42	595,147.89	1,437,170.93	290,858.93	749,039.49	875,341.62	603,390.08	0.00	0.00	

382.09	
16,665.89	
91,869.41	
1,744,838.73	
585,761.98	
4,449,068.13	
6,888,586.23	

4413	SOBRA 100-133% M&F
6	88,977.54	47,399.25	106,171.13	142,602.01	133,465.06	26,555.25	100,123.46	25,997.94	148,734.64	99,510.91	0.00	0.00	
4414	SOBRA 100-133% MALE	150,883.37	13,995.09	228,193.40	197,213.60	52,000.36	51,306.92	20,162.67	78.10	321,665.46	75,273.42	0.00	0.00	
4415	SOBRA 100-133% FEMA L	56,178.29	56,758.41	0.00	16,917.60	14,658.37	3,366.15	131.28	0.00	1,772.54	18,747.68	0.00	0.00	
SUBTOTAL:	296,039.2	0	118,152.75	334,364.5	3	356,733.21	200,123.79	81,228.32	120,417.41	26,076.04	472,172.64	193,532.01	0.00	0.00	

919,537.19	
1,110,772.39	
168,530.32	
2,198,839.90	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,425.14	0.00	0.00	0.00	
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	689.03	6,539.05	0.00	-25,399.38	2,126.50	-3,526.22	0.00	0.00	
3514	ADULT 40-100% MALE 1	8.44	0.00	0.00	0.00	0.00	16,962.34	0.00	27,158.74	84,458.59	9,948.88	0.00	0.00	
3515	ADULT 40-100% FEMAL E	13,969.80	0.00	18,706.21	23,125.68	0.00	7,244.29	69,519.25	0.00	0.00	-7,380.42	0.00	0.00	
3516	ADULT 40-100% MALE 2	267,573.16	141,658.94	148,273.71	124,596.71	69,664.49	97,450.88	108,104.32	76,655.23	85,667.22	265,289.84	0.00	0.00	
3517	ADULT 40-100% FEMAL E	11,751.92	75,057.61	33,064.32	47,312.32	44,060.64	255,557.86	344,638.75	25,595.78	26,402.49	187,793.64	0.00	0.00	
3518	ADULT 40-100% M&F 45	788,762.31	418,359.11	584,915.13	955,036.70	848,981.09	765,357.11	359,748.36	376,748.37	472,067.67	923,211.86	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	180.58	-2,106.23	0.00	-14,758.22	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	-2,793.83	8,981.14	17,351.20	0.00	0.00	-961.31	11,225.31	4,363.52	7,206.89	-4,376.89	0.00	0.00	
3714	ADULT <40% EXP MALE	228,452.96	-120,588.20	231,517.32	156,661.40	42,819.18	382,194.03	102,706.11	41,897.30	113,771.98	78,248.42	0.00	0.00	
3715	ADULT <40% EXP FEMA L	14,127.00	305.69	13,029.65	9,719.37	16,512.77	31,853.65	76,360.11	34,703.86	58,405.91	9,039.33	0.00	0.00	
3716	ADULT <40% EXP MALE	1,495,808.20	651,446.24	1,280,749.32	1,302,114.92	1,126,441.37	740,692.45	616,648.86	600,011.31	1,490,291.01	1,183,564.92	0.00	0.00	
3717	ADULT <40% EXP FEMA L	414,152.76	223,792.96	319,025.48	345,436.34	368,025.36	450,061.87	222,596.51	420,965.43	235,337.30	353,224.90	0.00	0.00	
3718	ADULT <40% EXP M&F
4	2,435,047.46	1,657,445.29	2,161,371.25	2,543,765.45	2,066,103.41	2,075,557.19	911,637.44	1,374,320.38	1,924,060.76	2,045,438.80	0.00	0.00	
SUBTOTAL:	5,666,860.18	3,056,458.78	4,834,644.9	5,507,768.89	4,583,477.92	4,826,403.18	2,823,185.02	2,942,262.32	4,503,221.46	5,040,477.06	0.00	0.00	

 
3,425.14	
1,242.01	
5,828.36	
138,536.99	
125,184.81	
1,384,934.50	
1,051,235.33	
6,493,187.71	
-16,683.87	
40,996.03	
1,257,680.50	
264,057.34	
10,487,768.60	
3,352,618.91	
19,194,747.43	
43,784,759.79	

ACUTE REINSURANCE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8700	SSI DISABLED FREEDO M	0.00	317.33	0.00	3,644.66	0.00	0.00	0.00	20,767.53	0.00	0.00	0.00	0.00		24,729.52		
8710	SSI DISABLED FREEDO
M	88,742.04	14,509.56	23,440.70	2,814.72	0.00	2,814.72	27,313.35	-15,109.58	8,516.49	0.00	0.00	0.00		153,042.00		
SUBTOTAL:	88,742.04	14,826.89	23,440.7	0	6,459.38	0.00	2,814.72	27,313.35	5,657.95	8,516.49	0.00	0.00	0.00		177,771.52		

TOTAL:	20,843,354.70	12,976,693.78	16,761,830.66	21,750,288.63	16,984,250.82	20,481,781.57	14,378,656.24	12,616,881.39	16,779,023.92	20,876,814.26	0.00	0.00		174,449,575.97		

LONG TERM CARE REINSURANCE
For The Period Ending April 30, 2018	
RATE CODE	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	28,782.69	37,968.66	894.29	0.00	0.00	0.00	102,906.08	0.00	0.00		173,325.40		
2100	SSI AGED WITH MEDIC A	502,760.84	215,750.35	394,825.30	445,716.39	306,857.25	361,488.83	328,612.45	229,123.67	326,061.82	396,413.64	0.00	0.00		3,507,610.54		
2110	SSI AGED NON-MEDICA
R	266,303.82	119,525.30	179,490.55	200,381.43	102,395.64	365,598.53	61,793.42	14,244.67	74,472.33	128,131.21	0.00	0.00		1,512,336.90		
2200	SSI DISABLED WITH M E	791,017.80	929,431.22	947,140.60	677,334.06	468,396.71	437,230.56	591,438.52	587,851.99	632,814.46	1,014,943.74	0.00	0.00		7,077,599.66		
2210	SSI DISABLED NON-ME
D	7,130,392.69	5,130,860.15	6,388,967.96	5,751,764.89	4,479,145.57	4,419,384.75	2,912,435.46	2,347,084.84	2,343,999.61	3,134,873.33	0.00	0.00		44,038,909.25		
2310	SSI BLIND NON-MEDIC A	17,679.65	34,070.17	34,867.42	5,342.36	7,738.37	7,715.15	703.33	13,401.65	12,912.29	4,221.65	0.00	0.00		138,652.04		
SUBTOTAL:	8,708,154.80	6,429,637.19	7,948,065.5	1	7,109,321.82	5,402,502.20	5,592,312.11	3,894,983.18	3,191,706.82	3,390,260.51	4,781,489.65	0.00	0.00		56,448,433.79		

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	1,128.39	400.25	249.29	0.00	5,937.28	451.06	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	1,128.39	400.25	249.29	0.00	5,937.28	451.06	0.00	0.00	0.00	

 
8,166.27

8,166.27

56,456,600.06

8,708,154.80	6,429,637.19	7,948,065.51	7,110,450.21	5,402,902.45	5,592,561.40	3,894,983.18	3,197,644.10	3,390,711.57	4,781,489.65	0.00	0.00	

TOTAL:

ACUTE SMIB
For The Period Ending April 30, 2018	
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	43,366.20	50,172.70	55,828.00	48,589.50	54,148.20	52,260.00	49,580.00	0.00	0.00		498,865.70		
1010	TANF NON-MEDICARE	804.00	938.00	4,130.10	804.00	670.00	1,340.00	1,072.00	1,072.00	1,340.00	1,742.00	0.00	0.00		13,912.10		
1020	TANF WITH QMB	41,088.00	44,170.00	47,368.00	48,418.00	53,106.00	49,086.00	51,314.00	54,262.00	51,314.00	51,030.00	0.00	0.00		491,156.00		
2100	SSI AGED WITH MEDIC A	91,554.30	80,144.00	71,804.70	65,507.30	61,584.90	53,193.50	51,156.50	56,032.50	55,018.50	48,326.50	0.00	0.00		634,322.70		
2110	SSI AGED NON-MEDICA
R	556,826.60	577,728.60	545,065.70	561,058.00	557,253.00	554,394.10	554,321.60	556,989.40	554,112.80	577,215.30	0.00	0.00		5,594,965.10		
2120	SSI AGED WITH QMB	3,808,373.40	3,854,498.10	3,886,638.30	3,896,902.50	3,939,036.40	3,954,764.30	3,995,188.30	4,021,433.90	4,044,845.90	4,071,818.90	0.00	0.00		39,473,500.00		
2200	SSI DISABLED WITH M E	127,371.30	120,530.00	116,529.20	110,585.20	117,964.40	107,937.70	104,610.00	102,442.10	94,166.00	99,703.60	0.00	0.00		1,101,839.50		
2210	SSI DISABLED NON-ME
D	422,855.00	441,700.40	442,809.00	447,438.20	442,200.00	439,788.00	444,210.00	447,560.00	443,004.00	449,363.00	0.00	0.00		4,420,927.60		
2220	SSI DISABLED WITH Q M	3,959,927.70	3,927,844.40	3,958,180.30	3,956,915.30	3,969,835.70	3,975,374.90	3,955,588.20	3,959,861.60	3,970,756.40	3,958,937.30	0.00	0.00		39,593,221.80		
2300	SSI BLIND WITH MEDIC	402.00	134.00	134.00	134.00	134.00	134.00	134.00	268.00	268.00	268.00	0.00	0.00		2,010.00		
2310	SSI BLIND NON-MEDIC A	3,886.00	3,618.00	3,752.00	4,154.00	3,752.00	3,752.00	3,886.00	3,752.00	3,618.00	3,618.00	0.00	0.00		37,788.00		
2320	SSI BLIND WITH QMB	34,170.00	35,778.00	34,438.00	34,706.00	34,974.00	35,510.00	35,242.00	35,108.00	36,180.00	34,170.00	0.00	0.00		350,276.00		
4300	SOBRA CHILD WITH ME D	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	536.00	402.00	402.00	402.00	402.00	402.00	536.00	0.00	0.00		4,154.00		
5020	SOBRA PREGNANT WO MAN	5,494.00	6,298.00	5,494.00	4,690.00	5,628.00	7,638.00	6,164.00	4,824.00	6,298.00	6,164.00	0.00	0.00		58,692.00		
8000	SMIB ONLY NOT ELIGIB	0.00	-268.00	-268.00	0.00	0.00	0.00	0.00	-268.00	-268.00	-536.00	0.00	0.00		-1,608.00		
8020	QMB ONLY	987,237.40	1,001,287.10	1,000,696.90	998,209.50	1,020,193.50	1,016,231.70	990,875.30	1,027,345.70	1,037,886.20	1,002,770.10	0.00	0.00		10,082,733.40		
8040	SLMB	4,832,276.40	4,846,587.90	4,845,005.30	4,881,619.30	4,875,797.50	4,970,873.10	4,975,957.60	5,143,398.50	5,151,172.20	5,226,255.70	0.00	0.00		49,748,943.50		
8888	SMIB ONLY NOT ELIGIB	-62,604.00	-43,500.20	-36,118.20	-25,832.00	-19,168.00	-32,148.00	-19,261.00	-12,528.50	-40,187.00	-1,615.00	0.00	0.00		-292,961.90		
9999	SMIB ONLY NOT ELIGIB	-44,786.20	51,555.80	49,571.00	123,043.40	87,240.70	168,716.20	198,476.70	124,239.30	213,041.70	201,625.90	0.00	0.00		1,172,724.50		
SUBTOTAL:	14,812,761.3	0 15,000,133.80	15,022,650.3	0 15,152,254.90	15,200,776.80	15,362,815.50	15,397,926.70	15,580,342.70	15,675,228.70	15,780,973.30	0.00	0.00		152,985,864.00		

1100	TANF EXPANDED FPR FI	305,316.20	277,543.60	253,306.40	246,479.40	241,136.20	233,217.60	229,092.00	222,928.00	221,194.00	223,382.30	0.00	0.00	
1110	TANF EXPANDED FOR
FI	670.00	536.00	402.00	536.00	670.00	1,072.00	804.00	536.00	402.00	-2,446.30	0.00	0.00	
1120	TANF EXPANDED FOR FI	808,222.30	831,224.80	863,549.20	870,980.50	886,383.70	878,803.30	887,980.40	881,184.60	873,937.60	868,107.20	0.00	0.00	
2400	SSI AGED EXPANDED
WI	-804.00	0.00	-268.00	87,100.00	24,230.00	18,400.00	20,734.00	22,302.00	24,739.00	21,657.00	0.00	0.00	
2410	SSI AGED EXPANDED N O	0.00	0.00	0.00	1,608.00	804.00	-134.00	0.00	268.00	268.00	402.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	3,072,858.80	3,099,648.20	3,116,388.10	3,155,014.60	3,147,337.70	3,174,712.90	3,208,918.60	3,245,156.50	3,209,965.40	3,277,984.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	134.00	134.00	134.00	134.00	134.00	134.00	134.00	134.00	134.00	134.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	-536.00	-134.00	134.00	96,882.00	16,884.00	12,462.00	18,626.00	18,760.00	18,492.00	16,884.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	2,308,863.50	2,412,953.30	2,385,890.90	2,476,955.50	2,407,519.10	2,402,454.20	2,445,353.40	2,392,834.40	2,397,711.00	2,378,459.10	0.00	0.00	
SUBTOTAL:	6,494,724.80	6,621,905.90	6,619,536.6	0	6,935,690.00	6,725,098.70	6,721,122.00	6,811,642.40	6,784,103.50	6,746,843.00	6,784,563.30	0.00	0.00	

 
2,453,595.70	
3,181.70	
8,650,373.60	
218,090.00	
3,216.00	
31,707,984.80	
1,340.00	
198,454.00	
24,008,994.40	
67,245,230.20	

3520	ADULT 40-100% FOR FI	134.00	268.00	2,546.00	670.00	1,206.00	134.00	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	134.00	0.00	134.00	670.00	536.00	268.00	0.00	0.00	0.00	
SUBTOTAL:	1,206.00	1,072.00	5,506.0	0	804.00	1,206.00	268.00	670.00	536.00	268.00	0.00	0.00	0.00	

 
4,958.00	
6,578.00	
11,536.00	

3900	NEWLY ELIGIBLE FOR
F

0.00	0.00	0.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	134.00

ACUTE SMIB
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3920	NEWLY ELIGIBLE FOR F	268.00	511.60	670.00	2,010.00	804.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,263.60		
SUBTOTAL:	268.00	511.60	670.00	2,144.00	804.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,397.60		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	-1,340.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	28,660.00	30,276.00	31,482.00	32,018.00	30,812.00	29,346.00	29,346.00	27,872.00	30,150.00	31,088.00	0.00	0.00	
SUBTOTAL:	28,660.00	30,276.00	31,482.0	0	32,018.00	30,812.00	29,346.00	28,006.00	27,872.00	30,150.00	31,088.00	0.00	0.00	

 
-1,340.00	
301,050.00	
299,710.00	

TOTAL:	21,337,620.10	21,653,899.30	21,679,844.90	22,122,910.90	21,958,697.50	22,113,551.50	22,238,245.10	22,392,854.20	22,452,489.70	22,596,624.60	0.00	0.00		220,546,737.80		

ACUTE HIB
For The Period Ending April 30, 2018	
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	454.30	454.30	696.20	464.20	464.20	464.20	0.00	0.00		2,997.40		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	454.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454.30		
1020	TANF WITH QMB	-1,239.00	-2,041.00	1,362.90	0.00	0.00	0.00	0.00	-232.00	696.00	-1,113.00	0.00	0.00		-2,566.10		
2100	SSI AGED WITH MEDIC A	2,065.00	2,065.00	7,557.90	0.00	1,984.30	1,571.30	2,811.40	5,639.60	2,449.60	3,251.40	0.00	0.00		29,395.50		
2110	SSI AGED NON-MEDICA
R	0.00	6,422.00	0.00	8,854.30	2,478.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,754.30		
2120	SSI AGED WITH QMB	353,535.60	402,764.90	397,160.70	386,967.60	373,419.20	400,962.30	425,397.60	424,115.80	416,710.20	426,529.80	0.00	0.00		4,007,563.70		
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	5,583.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,875.40		
2220	SSI DISABLED WITH Q M	175,048.90	190,674.90	190,265.00	179,225.60	189,546.20	192,106.20	193,859.20	196,368.00	189,428.00	180,230.80	0.00	0.00		1,876,752.80		
2320	SSI BLIND WITH QMB	867.30	867.30	867.30	1,548.30	1,094.30	1,094.30	1,118.20	1,118.20	1,118.20	1,118.20	0.00	0.00		10,811.60		
8000	SMIB ONLY NOT ELIGIB	0.00	1,239.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,239.00		
8020	QMB ONLY	5,843.80	4,439.60	4,439.60	4,439.60	913.60	5,038.30	4,304.20	3,391.20	4,726.20	4,304.20	0.00	0.00		41,840.30		
9999	SMIB ONLY NOT ELIGIB	-5,513.40	-2,601.60	-3,966.70	-1,837.70	-10,779.30	-144.10	-975.30	-4,490.20	-6,341.40	-3,643.40	0.00	0.00		-40,293.10		
SUBTOTAL:	530,608.2	0	606,349.10	597,686.7	0	585,235.40	559,110.60	601,082.60	627,211.50	626,374.80	609,251.00	611,142.20	0.00	0.00		5,954,052.10		

1120	TANF EXPANDED FOR FI	681.00	681.00	681.00	681.00	681.00	681.00	464.00	464.00	464.00	696.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	3,881.90	4,294.90	3,468.90	5,533.90	4,294.90	4,294.90	4,388.60	5,079.60	4,578.40	3,882.40	0.00	0.00	
SUBTOTAL:	4,562.90	4,975.90	4,149.9	0	6,214.90	4,975.90	4,975.90	4,852.60	5,543.60	5,042.40	4,578.40	0.00	0.00	

 
6,174.00	
43,698.40	
49,872.40	

6,003,924.50

535,171.10	611,325.00	601,836.60	591,450.30	564,086.50	606,058.50	632,064.10	631,918.40	614,293.40	615,720.60	0.00	0.00	

TOTAL:

Q1
For The Period Ending April 30, 2018	
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	2,641,199.00	2,729,898.60	2,764,791.50	67,522.30	2,321,604.10	2,331,295.90	2,404,856.40	0.00	0.00		23,190,165.30		
9999	SMIB ONLY NOT ELIGIB	-31,415.00	-9,770.20	-3,944.20	-8,962.00	-6,944.00	-9,292.00	2,472,197.00	266,375.50	-425,412.70	-5,280.00	0.00	0.00		2,237,552.40		
SUBTOTAL:	2,585,545.40	2,637,259.70	2,661,063.0	0	2,632,237.00	2,722,954.60	2,755,499.50	2,539,719.30	2,587,979.60	1,905,883.20	2,399,576.40	0.00	0.00		25,427,717.70		

TOTAL:	2,585,545.40	2,637,259.70	2,661,063.00	2,632,237.00	2,722,954.60	2,755,499.50	2,539,719.30	2,587,979.60	1,905,883.20	2,399,576.40	0.00	0.00		25,427,717.70		

LTC SMIB
For The Period Ending April 30, 2018	
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	804.00	804.00	2,010.00	938.00	938.00	1,206.00	938.00	0.00	0.00		10,318.00		
1020	TANF WITH QMB	536.00	402.00	670.00	536.00	536.00	536.00	402.00	402.00	402.00	536.00	0.00	0.00		4,958.00		
2100	SSI AGED WITH MEDIC A	1,098,996.50	1,086,174.30	1,089,530.50	1,094,085.10	1,105,126.50	1,081,557.10	1,108,262.60	1,091,842.60	1,066,064.60	1,085,676.10	0.00	0.00		10,907,315.90		
2110	SSI AGED NON-MEDICA
R	205,154.00	207,846.00	206,481.80	206,360.00	207,164.00	207,834.00	206,494.00	207,639.00	206,494.00	206,896.00	0.00	0.00		2,068,362.80		
2120	SSI AGED WITH QMB	1,000,128.60	1,012,229.40	1,016,303.80	1,022,134.00	1,031,532.00	1,028,533.60	1,033,115.60	1,024,184.00	1,017,437.00	1,018,843.00	0.00	0.00		10,204,441.00		
2200	SSI DISABLED WITH M E	418,872.80	414,703.80	419,209.80	413,644.20	410,886.00	410,316.00	418,722.00	426,220.00	431,040.00	427,646.00	0.00	0.00		4,191,260.60		
2210	SSI DISABLED NON-ME
D	27,872.00	30,150.00	30,552.00	31,892.00	31,356.00	31,624.00	32,696.00	33,232.00	34,170.00	36,314.00	0.00	0.00		319,858.00		
2220	SSI DISABLED WITH Q M	934,051.30	940,261.70	941,869.90	943,663.30	947,331.70	949,007.70	959,455.40	952,631.10	957,043.50	960,697.40	0.00	0.00		9,486,013.00		
2300	SSI BLIND WITH MEDIC	1,206.00	1,206.00	1,608.00	1,742.00	1,608.00	1,474.00	2,278.00	2,010.00	1,742.00	1,742.00	0.00	0.00		16,616.00		
2310	SSI BLIND NON-MEDIC A	268.00	268.00	268.00	268.00	268.00	134.00	402.00	268.00	268.00	268.00	0.00	0.00		2,680.00		
2320	SSI BLIND WITH QMB	5,888.00	5,888.00	6,424.00	6,156.00	6,290.00	6,290.00	6,156.00	6,156.00	6,558.00	6,424.00	0.00	0.00		62,230.00		
SUBTOTAL:	3,693,777.20	3,700,201.20	3,713,721.8	0	3,721,284.60	3,742,902.20	3,719,316.40	3,768,921.60	3,745,522.70	3,722,425.10	3,745,980.50	0.00	0.00		37,274,053.30		

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

 
8,308.00

8,308.00

37,282,361.30

3,694,581.20	3,701,005.20	3,714,793.80	3,722,088.60	3,743,706.20	3,720,120.40	3,769,725.60	3,746,326.70	3,723,229.10	3,746,784.50	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	413.00	413.00	0.00	413.00	413.00	0.00	0.00	0.00	0.00	844.00	0.00	0.00		2,496.00		
2110	SSI AGED NON-MEDICA
R	0.00	1,239.00	0.00	3,572.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,811.30		
2120	SSI AGED WITH QMB	267,064.80	266,940.60	267,930.90	265,660.00	268,134.20	269,623.20	277,024.20	273,502.00	274,341.00	269,213.80	0.00	0.00		2,699,434.70		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	413.00	413.00	826.00	0.00	0.00	0.00	0.00	0.00	0.00		1,652.00		
2210	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		
2220	SSI DISABLED WITH Q M	13,492.00	18,254.00	18,667.00	18,440.00	17,201.00	17,800.00	15,864.00	18,791.00	20,298.00	18,188.00	0.00	0.00		176,995.00		
SUBTOTAL:	280,969.8	0	287,259.60	286,597.9	0	288,498.30	286,161.20	288,249.20	292,888.20	292,293.00	294,639.00	288,245.80	0.00	0.00		2,885,802.00		

TOTAL:	280,969.80	287,259.60	286,597.90	288,498.30	286,161.20	288,249.20	292,888.20	292,293.00	294,639.00	288,245.80	0.00	0.00		2,885,802.00		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
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	1,623.07	1,022.92	1,244.30	1,393.12	1,289.69	1,075.23	3,192.35	0.00	0.00		16,553.06		
1007	TANF 21-44 FEMALE WI	119.92	1,352.36	1,041.12	1,034.33	572.15	479.71	366.37	1,139.30	2,025.40	227.68	0.00	0.00		8,358.34		
1008	TANF 45-64 M & F WIT	799.65	7,922.51	4,571.03	4,433.33	2,646.38	6,953.60	3,385.02	4,291.88	2,991.36	4,062.81	0.00	0.00		42,057.57		
1009	TANF 65+ M & F WITH	1,384.02	4,601.39	1,499.92	6,271.84	3,776.90	4,997.30	3,586.67	1,062.40	3,515.86	2,414.49	0.00	0.00		33,110.79		
1011	TANF <1 M & F NON-ME	669,157.30	792,264.35	457,388.40	389,161.37	506,516.75	537,830.53	832,846.26	685,426.84	932,226.26	756,016.40	0.00	0.00		6,558,834.46		
1012	TANF 01-05 M & F NON	243,450.23	314,582.73	261,200.01	255,576.99	358,589.49	375,121.71	505,389.08	491,168.38	290,496.32	287,994.50	0.00	0.00		3,383,569.44		
1013	TANF 06-13 M & F NON	207,131.18	326,430.54	263,286.14	217,101.84	295,690.27	281,770.64	331,206.16	337,920.51	287,798.44	247,971.64	0.00	0.00		2,796,307.36		
1014	TANF 14-20 MALE NON-	68,592.28	129,798.34	88,283.50	62,000.56	104,054.07	64,152.64	79,559.68	69,873.90	59,871.43	51,373.07	0.00	0.00		777,559.47		
1015	TANF 14-20 FEMALE N O	162,337.41	244,265.26	223,888.84	172,599.84	174,922.77	193,741.07	245,714.60	207,115.04	167,267.34	181,222.07	0.00	0.00		1,973,074.24		
1016	TANF 21-44 MALE NON-	879,640.25	1,273,282.25	966,650.65	783,862.01	912,735.58	843,282.17	991,894.61	981,889.30	1,059,956.33	921,404.00	0.00	0.00		9,614,597.15		
1017	TANF 21-44 FEMALE N O	3,360,795.09	5,320,801.86	3,832,644.20	3,010,789.27	3,563,133.33	3,632,731.74	4,702,309.11	4,289,700.13	4,234,555.58	3,891,042.47	0.00	0.00		39,838,502.78		
1018	TANF 45-64 M & F NON	1,438,361.58	2,211,724.85	1,587,736.04	1,272,302.17	1,463,882.73	1,540,095.67	1,877,210.21	1,660,339.34	1,860,738.07	1,582,005.25	0.00	0.00		16,494,395.91		
1019	TANF 65+ M & F NON-M	4,301.00	5,474.00	2,346.00	1,173.00	3,128.00	3,128.00	6,081.00	6,616.00	1,245.00	4,661.00	0.00	0.00		38,153.00		
1026	TANF 21-44 MALE WITH	205.10	1,202.12	880.89	551.17	278.38	726.85	498.12	1,018.39	548.66	586.45	0.00	0.00		6,496.13		
1027	TANF 21-44 FEMALE WI	225.00	1,046.60	1,214.81	1,437.54	986.32	136.80	498.76	592.07	2,456.45	1,865.89	0.00	0.00		10,460.24		
1028	TANF 45-64 M & F WIT	3,286.56	11,252.41	2,284.01	4,870.03	7,075.30	8,179.26	9,574.76	2,720.91	7,033.53	5,620.73	0.00	0.00		61,897.50		
1029	TANF 65+ M & F WITH	15.72	1,008.22	1,084.33	842.18	1,498.86	945.95	575.12	1,456.13	694.55	1,174.49	0.00	0.00		9,295.55		
2100	SSI AGED WITH MEDIC A	31,295.11	144,458.04	80,235.98	62,592.38	61,470.65	56,738.73	68,456.48	68,792.02	73,869.53	83,777.35	0.00	0.00		731,686.27		
2110	SSI AGED NON-MEDICA
R	54,723.22	112,881.02	47,844.50	35,856.74	128,309.37	45,076.51	68,089.16	167,203.51	96,733.65	67,265.14	0.00	0.00		823,982.82		
2120	SSI AGED WITH QMB	134,473.34	821,999.36	320,961.00	307,789.68	257,602.52	277,883.21	299,516.39	299,727.72	322,305.25	380,006.05	0.00	0.00		3,422,264.52		
2200	SSI DISABLED WITH M E	81,771.02	418,355.55	180,533.34	164,521.54	142,080.90	183,121.15	155,979.69	185,699.65	187,663.70	254,988.57	0.00	0.00		1,954,715.11		
2210	SSI DISABLED NON-ME
D	4,257,729.54	6,230,255.10	4,448,727.53	3,966,835.75	4,038,460.29	4,320,211.51	4,801,682.62	4,662,466.53	4,883,026.70	4,790,989.18	0.00	0.00		46,400,384.75		
2220	SSI DISABLED WITH Q M	253,351.98	1,279,413.90	562,631.90	550,132.05	481,901.43	503,074.87	548,049.01	542,671.85	607,708.47	675,178.50	0.00	0.00		6,004,113.96		
2300	SSI BLIND WITH MEDIC	0.00	1,813.13	60.90	782.00	495.08	85.25	133.97	580.92	86.24	172.52	0.00	0.00		4,210.01		
2310	SSI BLIND NON-MEDIC A	58,144.64	56,537.66	36,611.74	45,148.58	49,608.59	49,043.54	65,156.50	70,052.73	74,803.79	66,503.34	0.00	0.00		571,611.11		
2320	SSI BLIND WITH QMB	3,118.22	16,427.75	7,367.65	6,547.08	6,297.57	7,357.89	8,021.20	8,114.38	6,534.19	11,930.23	0.00	0.00		81,716.16		
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	8.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		790.29		
4311	SOBRA CHILD <1 M & F	1,660,593.03	1,978,758.02	1,503,412.38	1,250,211.69	1,665,207.27	1,813,777.29	2,614,772.85	2,310,341.38	2,126,617.06	1,768,760.14	0.00	0.00		18,692,451.11		
4312	SOBRA CHILD 01-05 M	2,593,837.97	3,894,121.09	2,989,969.08	2,768,501.55	3,210,439.41	3,649,256.26	4,231,189.05	4,245,860.19	3,785,317.28	3,230,581.96	0.00	0.00		34,599,073.84		
4313	SOBRA CHILD 06-13 M	3,472,830.09	5,542,229.60	4,399,591.67	3,575,792.73	4,219,322.05	4,178,072.42	4,591,301.99	4,771,241.45	4,248,643.11	3,991,176.60	0.00	0.00		42,990,201.71		
4314	SOBRA CHILD 14-20 MA	804,131.34	1,755,777.83	1,072,149.57	778,897.16	1,073,788.41	884,630.51	1,187,319.41	1,062,449.83	1,065,535.10	913,846.83	0.00	0.00		10,598,525.99		
4315	SOBRA CHILD 14-20 FE	1,152,566.55	1,806,830.05	1,674,900.75	1,073,787.12	1,330,510.95	1,225,608.77	1,394,527.25	1,509,384.74	1,265,818.38	1,343,304.64	0.00	0.00		13,777,239.20		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	782.00	1,261.91	477.76	2,196.92	525.71	683.14	474.54	0.00	0.00		6,401.98		
5007	SOBRA PREG 21-44 FE M	43.82	15.74	408.14	165.61	35.58	0.00	0.00	0.00	184.09	34.04	0.00	0.00		887.02		
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		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5015	SOBRA PREG 14-20 FE M	210,587.60	391,120.50	349,910.40	172,098.82	240,549.33	208,522.36	285,556.12	347,108.20	273,164.29	212,132.75	0.00	0.00		2,690,750.37		
5017	SOBRA PREG 21-44 FE
M	1,360,375.53	2,160,266.36	1,522,594.00	1,234,789.30	1,503,722.89	1,410,486.31	1,973,018.53	1,761,652.14	1,498,621.54	1,376,335.32	0.00	0.00		15,801,861.92		
5018	SOBRA PREG 45-64 FE M	1,207.05	18,210.16	1,870.85	2,883.04	2,579.39	1,168.11	3,255.07	782.00	0.00	0.00	0.00	0.00		31,955.67		
5027	SOBRA PREG 21-44 FE
M	1,074.17	153.93	244.90	551.64	132.77	704.57	1,545.36	0.00	0.00	0.00	0.00	0.00		4,407.34		
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:	23,171,656.5	1 37,278,986.17	26,900,536.9	6 22,184,305.29	25,814,286.56	26,310,814.96	31,891,856.22	30,758,275.16	29,431,811.32	27,110,292.99	0.00	0.00		280,852,822.14		

1106	TANF EXPANDED 21-44	1,954.28	10,071.27	2,943.39	4,290.26	6,184.71	5,679.41	3,346.17	4,180.72	3,480.67	2,808.85	0.00	0.00	
1107	TANF EXPANDED 21-44	5,399.39	16,109.41	7,021.44	4,533.65	7,819.75	5,707.94	5,508.31	3,681.57	2,207.62	2,214.89	0.00	0.00	
1108	TANF EXPANDED 45-64	10,741.76	84,024.05	27,554.87	20,597.84	16,327.13	20,011.00	18,301.60	19,596.24	27,301.20	31,010.50	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	7,083.35	57,989.57	23,535.61	25,539.07	18,842.42	12,404.15	16,421.92	21,678.17	19,996.02	22,334.29	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	1,564.00	0.00	0.00	0.00	368.00	0.00	0.00	0.00	427.00	0.00	0.00	
1113	TANF EXPANDED 06-13	782.00	1,564.00	391.00	782.00	1,564.00	4,316.54	0.00	0.00	1,287.21	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	4,133.16	4,278.00	1,955.00	2,346.00	2,003.58	1,643.80	2,021.51	2,063.00	2,517.94	2,063.00	0.00	0.00	
1115	TANF EXPANDED 14-20	22,923.43	39,526.84	25,334.17	20,224.21	15,705.81	16,015.10	18,409.44	31,585.12	32,354.29	22,524.83	0.00	0.00	
1116	TANF EXPANDED 21-44	380,303.68	569,632.95	508,818.78	350,622.52	491,015.87	423,299.56	468,294.30	446,220.55	433,508.06	491,889.81	0.00	0.00	
1117	TANF EXPANDED 21-44	1,458,286.64	2,182,855.90	1,728,741.35	1,455,750.31	1,576,185.47	1,540,307.25	1,987,333.35	1,986,923.84	1,713,485.25	1,602,317.38	0.00	0.00	
1118	TANF EXPANDED 45-64	1,042,573.24	1,615,251.08	1,132,434.00	1,102,927.07	1,124,121.92	1,112,758.27	1,272,348.53	1,651,153.98	1,198,995.53	1,212,070.88	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	4,278.00	2,737.00	2,737.00	-736.00	782.00	1,173.00	782.00	1,281.00	2,526.00	1,708.00	0.00	0.00	
1126	TANF EXPANDED 21-44	2,224.93	10,854.84	6,263.26	6,206.01	2,322.00	5,917.05	6,171.19	4,914.86	7,495.85	7,684.46	0.00	0.00	
1127	TANF EXPANDED 21-44	41,966.63	62,586.16	43,408.78	46,098.56	24,663.65	14,175.00	10,235.98	11,562.57	11,937.97	12,265.52	0.00	0.00	
1128	TANF EXPANDED 45-64	21,576.93	102,299.56	58,997.47	61,071.36	55,927.14	48,242.57	71,102.12	72,623.46	68,513.96	62,432.07	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	8,682.76	47,760.16	28,749.77	31,932.32	32,410.69	28,194.81	31,523.48	36,718.97	39,550.67	38,841.74	0.00	0.00	
2400	SSI AGED EXPANDED WI	6,608.02	23,412.86	7,767.53	6,671.31	9,552.09	8,206.08	9,200.76	6,721.15	9,854.51	7,448.02	0.00	0.00	
2410	SSI AGED EXPANDED N
O	5,865.00	17,498.00	5,912.61	6,233.00	8,996.21	11,033.52	13,483.65	9,785.00	7,187.00	8,504.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	123,814.65	718,272.06	289,808.28	271,784.53	264,492.71	229,448.31	286,508.04	289,147.44	303,222.70	331,190.23	0.00	0.00	
2600	SSI DISABLED EXPAND
E	6,118.03	15,641.70	6,571.36	3,619.18	5,280.32	3,136.42	6,051.06	1,993.58	3,140.31	3,202.81	0.00	0.00	
2610	SSI DISABLED EXPAND E	67,360.42	111,811.73	78,550.32	123,090.55	196,614.02	120,243.68	86,952.14	77,807.37	71,956.43	64,282.50	0.00	0.00	
2620	SSI DISABLED EXPAND
E	83,403.79	362,726.92	165,242.07	179,331.78	151,206.66	178,166.31	194,937.16	158,419.96	206,950.94	195,811.55	0.00	0.00	
SUBTOTAL:	3,306,080.09	6,058,468.06	4,152,738.0	3,722,915.53	4,012,018.15	3,790,447.77	4,508,932.71	4,838,058.55	4,167,470.13	4,123,032.33	0.00	0.00	

 
44,939.73	
60,203.97	
275,466.19	
225,824.57	
2,359.00	
10,686.75	
25,024.99	
244,603.24	
4,563,606.08	
17,232,186.74	
12,464,634.50	
17,268.00	
60,054.45	
278,900.82	
622,786.64	
324,365.37	
95,442.33	
94,497.99	
3,107,688.95	
54,754.77	
998,669.16	
1,876,197.14	
42,680,161.38	

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	-289.00	0.00	-588.00	0.00	-294.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	-1,450.00	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	-2,342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-2,027.0	0	-4,081.00	0.00	-588.00	0.00	-294.00	0.00	0.00	0.00	0.00	

 
0.00	
-1,759.00	
-1,450.00	
-3,781.00	
-6,990.00	

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	-268.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3616	AHC CARE/MI MALE 21-	0.00	0.00	-2,058.00	-7,868.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-10,256.00		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	-7,903.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,903.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-2,876.00	-14,002.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-17,208.00		
SUBTOTAL:	0.00	0.00	-5,202.0	0	-29,773.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-35,635.00		

3906	NEWLY ELIGIBLE MALE	79.82	368.00	0.00	0.00	0.00	0.00	0.00	0.00	391.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	470.82	923.80	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	856.33	847.03	1,781.30	2,179.73	683.64	732.45	933.04	780.43	1,253.89	52.37	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	782.00	1,173.00	391.00	487.64	391.00	78.86	278.75	0.00	91.50	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	12,058.51	16,416.32	14,540.56	15,134.23	13,088.26	19,954.00	16,895.03	18,352.42	16,399.05	18,900.49	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	33,141.95	52,556.64	44,448.21	31,541.37	36,593.89	38,011.00	36,234.10	43,453.25	38,018.75	45,279.60	0.00	0.00	

838.82	
1,394.62	
10,100.21	
3,673.75	
161,738.87	
399,278.76	

3506	ADULT 40-100% MALE 2	0.00	0.00	391.00	391.00	0.00	69.80	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	4,177.40	-17.42	2,894.84	1,209.00	1,278.80	818.00	1,672.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	368.00	0.00	41.76	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	46,943.02	43,375.33	31,518.52	46,420.02	59,390.34	38,737.33	48,882.78	0.00	0.00	
3515	ADULT 40-100% FEMAL E	51,718.89	83,600.35	95,968.79	63,090.76	71,502.29	85,334.55	85,159.78	77,238.20	85,638.76	81,420.21	0.00	0.00	
3516	ADULT 40-100% MALE 2	588,598.71	538,680.44	421,178.57	329,000.01	361,130.66	436,379.37	441,939.95	638,853.44	442,723.38	514,006.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	386,981.88	547,597.65	451,432.33	346,641.39	489,188.72	410,795.74	541,998.32	538,541.34	505,414.27	466,607.59	0.00	0.00	
3518	ADULT 40-100% M&F 45	1,409,825.64	2,348,203.04	1,514,075.75	1,341,312.45	1,487,114.97	1,503,502.83	1,782,935.61	1,629,995.59	1,451,763.01	1,618,022.51	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	391.00	1,173.00	391.00	782.00	782.00	0.00	427.00	854.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.00	0.00	0.00	
3706	ADULT <40% EXP MALE	391.00	1,472.00	0.00	0.00	782.00	-321.20	272.54	0.00	1,209.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	30.08	368.00	961.26	2,730.96	1,950.81	2,016.06	5,371.00	1,672.00	782.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	8,651.55	9,951.21	2,516.37	2,539.77	6,754.24	5,852.08	1,738.44	3,528.22	1,707.40	5,996.50	0.00	0.00	
3709	ADULT <40% EXP M&F 6	8.80	1,224.49	0.00	414.00	0.00	0.00	0.00	476.67	69.80	224.89	0.00	0.00	
3714	ADULT <40% EXP MALE	131,790.54	260,483.45	182,802.15	138,966.93	171,223.27	210,000.35	216,284.52	215,785.59	195,528.01	181,012.56	0.00	0.00	
3715	ADULT <40% EXP FEMA L	219,854.84	382,376.05	275,570.69	247,693.95	219,865.54	229,417.43	259,032.29	312,364.06	256,238.79	301,590.23	0.00	0.00	
3716	ADULT <40% EXP MALE	3,044,533.55	4,454,722.96	3,529,656.85	2,770,395.43	3,028,489.16	3,184,531.50	3,754,660.11	3,242,599.24	3,547,015.69	3,497,922.56	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,830,294.46	2,982,824.72	2,268,039.56	1,875,366.98	2,306,097.47	2,139,899.12	2,408,850.91	2,221,964.67	2,232,855.77	2,283,260.66	0.00	0.00	
3718	ADULT <40% EXP M&F
4	4,987,186.75	8,416,095.80	5,398,793.88	4,732,088.74	4,647,739.12	5,339,459.71	6,412,135.04	5,821,503.98	5,678,780.97	6,041,528.96	0.00	0.00	
3719	ADULT <40% EXP M&F 6	5,494.46	5,230.07	782.00	454.98	782.00	1,594.30	1,636.00	1,672.00	2,845.00	391.00	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	63.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F
4	0.00	601.37	0.00	368.00	1,104.00	797.73	427.00	125.06	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,711,842.6	20,085,495.42	14,213,579.6	11,902,020.83	12,838,316.81	13,584,459.48	15,957,497.59	14,770,688.20	14,443,871.18	15,044,601.45	0.00	0.00	

 
851.80	
13,796.40	
409.76	
483,661.56	
780,672.58	
4,712,490.53	
4,685,199.23	
16,086,751.40	
4,800.00	
427.00	
3,805.34	
15,882.17	
49,235.78	
2,418.65	
1,903,877.37	
2,704,003.87	
34,054,527.05	
22,549,454.32	
57,475,312.95	
20,881.81	
63.50	
427.00	
3,423.16	
145,552,373.23	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	224,823.53	369,878.69	283,250.04	208,185.44	224,343.45	246,030.12	278,758.28	288,519.04	286,065.79	286,936.05	0.00	0.00		2,696,790.43		
3917	NEWLY ELIGIBLE FEMA L	402,318.88	658,995.27	503,390.18	387,872.11	418,191.55	422,836.30	485,892.30	472,997.73	537,334.14	404,402.17	0.00	0.00		4,694,230.63		
3918	NEWLY ELIGIBLE M&F
4	992,370.83	1,367,232.30	977,921.83	748,361.12	849,808.50	873,668.97	969,442.63	1,036,573.30	946,711.83	956,912.25	0.00	0.00		9,719,003.56		
3919	NEWLY ELIGIBLE M&F 6	782.00	0.00	782.00	-659.00	0.00	0.00	0.00	0.00	854.00	854.00	0.00	0.00		2,613.00		
3927	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	1,666,431.85	2,467,076.25	1,827,287.1	2	1,393,006.00	1,543,196.93	1,602,094.66	1,789,158.04	1,860,954.92	1,827,028.45	1,713,428.43	0.00	0.00		17,689,662.65		

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	368.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	310,311.87	528,458.09	410,612.29	351,684.68	420,496.94	381,471.57	413,236.53	434,117.01	354,726.57	356,353.81	0.00	0.00	
4414	SOBRA 100-133% MALE	113,097.49	148,640.71	121,334.01	79,358.44	97,190.69	76,107.06	84,097.97	85,815.44	83,204.17	89,818.46	0.00	0.00	
4415	SOBRA 100-133% FEMA L	116,076.61	191,884.48	142,492.50	116,266.50	157,029.69	121,806.23	133,923.86	155,937.24	132,453.67	126,329.48	0.00	0.00	
SUBTOTAL:	539,485.9	7	868,983.28	674,438.8	0	547,309.62	674,717.32	579,752.86	631,258.36	675,869.69	570,384.41	572,501.75	0.00	0.00	

 
368.00	
3,961,469.36	
978,664.44	
1,394,200.26	
6,334,702.06	

4518	BC PATIENT FEMALE 4 5	2,714.00	1,173.00	1,932.00	7,429.00	11,809.80	3,128.00	2,385.46	1,317.00	3,771.00	854.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	0.00	782.00	782.00	391.00	782.00	391.00	427.00	0.00	0.00	1,281.00	0.00	0.00	
SUBTOTAL:	2,714.00	1,955.00	2,714.0	0	7,820.00	12,591.80	3,519.00	2,812.46	1,317.00	3,771.00	2,135.00	0.00	0.00	

 
36,513.26	
4,836.00	
41,349.26	

8700	SSI DISABLED FREEDO M	3,694.24	7,214.57	9,729.88	5,524.87	7,462.80	5,625.60	3,433.56	5,533.20	4,176.33	6,616.27	0.00	0.00	
8710	SSI DISABLED FREEDO
M	3,910.00	5,474.00	3,519.00	3,519.00	3,128.00	8,464.00	6,117.00	10,598.00	6,652.00	8,859.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	378.79	4,172.39	391.00	2,439.42	260.24	795.24	1,303.09	2,744.57	391.00	984.83	0.00	0.00	
SUBTOTAL:	7,983.03	16,860.96	13,639.8	8	11,483.29	10,851.04	14,884.84	10,853.65	18,875.77	11,219.33	16,460.10	0.00	0.00	

 
59,011.32	
60,240.00	
13,860.57	
133,111.89	

493,241,557.61

41,406,194.12	66,777,825.14	47,777,705.42	39,735,006.56	44,905,318.61	45,885,385.57	54,792,369.03	52,923,745.29	50,455,555.82	48,582,452.05	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
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	1,489.21	1,205.89	2,805.43	2,596.20	185.17	1,589.04	2,454.57	0.00	0.00		19,582.92		
1007	TANF 21-44 FEMALE WI	769.18	3,113.26	32.47	854.09	962.38	516.65	472.02	1,001.63	2,768.62	4,295.50	0.00	0.00		14,785.80		
1008	TANF 45-64 M & F WIT	1,699.93	6,488.98	2,266.03	3,490.75	5,500.20	3,785.57	5,009.57	5,301.10	4,922.08	6,859.71	0.00	0.00		45,323.92		
1009	TANF 65+ M & F WITH	726.82	579.18	-85.07	256.77	529.45	1,786.40	624.39	1,665.55	8,478.64	195.70	0.00	0.00		14,757.83		
1011	TANF <1 M & F NON-ME	555,896.87	302,399.18	302,105.67	499,226.02	279,601.73	299,224.27	377,741.23	357,143.86	400,106.54	578,512.72	0.00	0.00		3,951,958.09		
1012	TANF 01-05 M & F NON	59,694.66	92,475.03	57,268.10	55,477.45	82,247.51	107,815.57	119,853.13	69,915.35	92,122.35	44,472.66	0.00	0.00		781,341.81		
1013	TANF 06-13 M & F NON	38,035.56	82,126.82	46,348.92	55,425.45	56,281.73	55,607.59	58,633.75	49,144.50	49,103.72	43,921.79	0.00	0.00		534,629.83		
1014	TANF 14-20 MALE NON-	17,080.83	27,466.67	23,610.41	24,560.85	26,073.25	31,181.25	29,613.23	18,055.54	16,619.47	19,706.12	0.00	0.00		233,967.62		
1015	TANF 14-20 FEMALE N O	43,026.56	64,965.99	42,566.58	62,092.38	54,270.33	68,970.09	57,379.82	67,199.36	84,062.62	74,559.57	0.00	0.00		619,093.30		
1016	TANF 21-44 MALE NON-	674,056.38	825,020.24	541,751.51	536,250.54	802,374.84	551,840.34	702,242.99	514,093.33	715,298.66	607,747.10	0.00	0.00		6,470,675.93		
1017	TANF 21-44 FEMALE N O	1,618,662.59	1,904,822.56	1,795,733.09	1,227,302.42	1,916,547.86	1,559,627.42	1,917,700.15	1,680,066.64	1,839,422.72	1,555,533.91	0.00	0.00		17,015,419.36		
1018	TANF 45-64 M & F NON	707,361.29	856,387.57	748,150.58	570,767.71	748,982.04	643,338.66	792,512.06	716,693.35	771,362.65	643,686.28	0.00	0.00		7,199,242.19		
1019	TANF 65+ M & F NON-M	1,237.38	1,058.19	573.26	3,702.56	3,775.56	9,139.28	9,444.61	12,254.83	8,617.92	48,161.42	0.00	0.00		97,965.01		
1026	TANF 21-44 MALE WITH	949.63	2,269.45	184.44	675.41	626.63	1,057.70	79.11	160.22	1,682.31	1,973.89	0.00	0.00		9,658.79		
1027	TANF 21-44 FEMALE WI	826.61	1,825.06	119.20	705.11	862.61	4,962.89	1,403.25	1,838.57	2,126.46	2,543.46	0.00	0.00		17,213.22		
1028	TANF 45-64 M & F WIT	2,948.86	7,504.88	2,118.21	4,403.90	4,995.79	5,366.50	12,358.60	11,715.00	6,694.87	10,103.92	0.00	0.00		68,210.53		
1029	TANF 65+ M & F WITH	131.08	686.19	831.90	264.60	327.44	942.49	1,261.28	0.00	489.27	3,257.41	0.00	0.00		8,191.66		
2100	SSI AGED WITH MEDIC A	47,536.22	47,910.79	84,244.98	77,180.94	169,555.69	51,910.12	73,147.42	75,016.31	77,351.57	96,654.32	0.00	0.00		800,508.36		
2110	SSI AGED NON-MEDICA
R	31,124.19	52,905.15	27,285.90	58,546.21	31,480.11	37,487.51	52,782.59	79,112.05	55,870.19	44,131.68	0.00	0.00		470,725.58		
2120	SSI AGED WITH QMB	252,430.74	285,929.28	215,441.95	250,857.76	314,248.84	298,293.92	332,791.02	302,829.03	312,373.14	267,126.14	0.00	0.00		2,832,321.82		
2200	SSI DISABLED WITH M E	188,471.15	329,014.83	214,323.05	238,712.63	350,489.26	230,767.64	241,759.68	374,418.94	351,003.68	270,816.74	0.00	0.00		2,789,777.60		
2210	SSI DISABLED NON-ME
D	3,560,015.67	5,381,468.95	3,610,921.10	3,160,802.37	4,622,516.64	3,742,566.56	4,460,428.95	3,939,888.35	4,397,530.77	3,469,459.43	0.00	0.00		40,345,598.79		
2220	SSI DISABLED WITH Q M	805,895.33	1,037,192.12	679,746.60	726,857.44	963,576.72	877,165.80	1,019,677.08	801,868.04	940,717.89	850,297.45	0.00	0.00		8,702,994.47		
2300	SSI BLIND WITH MEDIC	136.94	175.99	0.00	410.44	2,202.11	1,142.01	996.82	3,102.01	1,272.57	5,259.41	0.00	0.00		14,698.30		
2310	SSI BLIND NON-MEDIC A	141,080.44	58,653.33	25,709.02	40,393.70	61,946.41	38,438.95	44,631.36	33,910.52	53,016.73	41,547.85	0.00	0.00		539,328.31		
2320	SSI BLIND WITH QMB	11,776.25	11,684.64	5,363.09	14,911.62	16,996.08	15,300.61	23,990.53	17,278.64	26,252.88	17,673.47	0.00	0.00		161,227.81		
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	2,126.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,164.22		
4311	SOBRA CHILD <1 M & F	606,521.98	1,227,639.88	711,424.09	1,182,910.25	867,866.97	1,551,827.82	977,739.96	867,485.25	1,402,378.91	960,899.33	0.00	0.00		10,356,694.44		
4312	SOBRA CHILD 01-05 M	850,944.83	931,330.75	671,986.98	851,679.92	942,425.88	798,027.11	983,579.57	1,053,843.84	977,758.91	949,871.11	0.00	0.00		9,011,448.90		
4313	SOBRA CHILD 06-13 M	902,187.02	1,402,010.55	1,015,872.00	1,536,067.35	1,318,265.13	913,016.34	1,160,907.44	1,071,221.39	1,110,247.05	975,271.56	0.00	0.00		11,405,065.83		
4314	SOBRA CHILD 14-20 MA	255,662.66	585,835.60	325,093.71	304,929.49	402,290.84	449,569.04	380,595.81	308,523.40	405,434.35	369,593.75	0.00	0.00		3,787,528.65		
4315	SOBRA CHILD 14-20 FE	392,742.97	435,763.11	306,418.54	325,382.32	420,944.23	384,631.26	594,860.20	501,360.54	517,729.55	540,368.96	0.00	0.00		4,420,201.68		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	70.78	15.45	22.27	21.50	2,013.43	0.00	0.00	0.00	0.00		2,143.43		
5007	SOBRA PREG 21-44 FE M	21.46	142.93	0.00	0.00	29.52	0.00	161.42	161.42	175.72	166.01	0.00	0.00		858.48		
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	109.40	0.00	0.00		109.40		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5015	SOBRA PREG 14-20 FE M	106,140.82	128,457.54	40,024.26	144,912.89	148,564.29	97,105.05	144,793.01	89,058.00	96,987.22	88,676.58	0.00	0.00		1,084,719.66		
5017	SOBRA PREG 21-44 FE
M	711,030.95	951,398.01	571,217.76	674,672.81	847,116.72	629,023.29	934,202.67	666,105.53	835,322.17	719,476.50	0.00	0.00		7,539,566.41		
5018	SOBRA PREG 45-64 FE M	6,314.07	1,544.55	34,338.68	320.00	6,285.57	8,096.69	3,467.33	167.54	0.00	151.77	0.00	0.00		60,686.20		
5027	SOBRA PREG 21-44 FE
M	55.50	36.96	1,481.27	185.90	718.43	482.35	797.92	493.81	0.00	161.42	0.00	0.00		4,413.56		
5028	SOBRA PREG 45-64 FE M	0.00	56.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.69		
SUBTOTAL:	12,594,527.3	4 17,052,474.58	12,106,557.2	0 12,638,876.54	15,472,700.13	13,472,842.44	15,520,257.67	13,694,292.04	15,566,891.24	13,315,698.61	0.00	0.00		141,435,117.79		

1106	TANF EXPANDED 21-44	5,267.22	4,642.17	4,347.95	3,932.39	7,283.08	4,345.57	5,212.91	731.32	4,465.79	2,575.84	0.00	0.00	
1107	TANF EXPANDED 21-44	2,097.10	10,512.11	3,690.50	8,407.64	11,212.04	7,247.07	11,696.62	7,979.22	3,896.11	4,396.37	0.00	0.00	
1108	TANF EXPANDED 45-64	26,369.87	42,521.41	30,351.35	29,228.57	20,232.98	19,899.26	28,932.92	20,968.09	32,472.06	26,907.61	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	5,801.81	10,221.56	8,417.64	8,150.07	11,618.21	9,362.67	11,820.83	8,202.93	8,109.26	13,453.45	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	719.33	206.37	0.00	0.00	9.59	3,814.85	421.77	0.00	0.00	
1115	TANF EXPANDED 14-20	10,834.96	38,061.99	1,567.91	5,074.87	4,593.75	1,967.36	5,797.30	6,641.54	7,058.91	6,720.66	0.00	0.00	
1116	TANF EXPANDED 21-44	310,874.32	341,304.71	186,446.71	143,805.16	275,391.04	294,010.33	255,061.00	153,840.42	155,532.73	212,166.32	0.00	0.00	
1117	TANF EXPANDED 21-44	462,224.08	651,418.05	466,940.90	455,893.38	688,570.52	541,105.53	575,714.47	468,108.17	594,976.69	617,091.37	0.00	0.00	
1118	TANF EXPANDED 45-64	455,775.55	648,987.83	443,217.17	461,645.92	538,779.95	556,321.97	558,503.51	356,276.67	429,836.96	405,842.82	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	12,941.61	7,779.13	8,763.35	9,294.61	17,939.41	7,846.98	9,954.90	0.00	0.00	
1127	TANF EXPANDED 21-44	27,947.66	26,939.58	14,675.52	24,164.55	24,940.95	15,130.72	22,908.00	30,490.10	23,929.41	24,488.30	0.00	0.00	
1128	TANF EXPANDED 45-64	92,078.67	113,294.98	61,730.37	66,970.10	100,045.76	81,722.60	91,736.66	78,627.91	78,044.27	65,338.43	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	22,852.09	30,903.05	15,467.27	30,061.39	28,844.18	18,570.07	24,923.98	27,091.28	30,382.03	23,554.92	0.00	0.00	
2400	SSI AGED EXPANDED WI	1,255.12	2,635.56	1,754.13	2,739.29	680.56	1,810.25	5,617.73	8,997.31	2,951.41	8,958.69	0.00	0.00	
2410	SSI AGED EXPANDED N
O	2,724.87	1,210.33	20.12	1,130.52	1,322.41	1,845.55	746.25	5,591.11	1,551.41	5,160.87	0.00	0.00	
2420	SSI AGED EXPANDED WI	167,163.34	241,087.48	167,204.95	185,194.86	248,974.88	214,607.68	242,882.55	211,440.92	223,509.59	211,803.24	0.00	0.00	
2600	SSI DISABLED EXPAND
E	9,321.18	16,641.74	4,126.94	10,326.70	2,090.38	5,217.90	2,999.35	6,495.59	1,874.87	4,325.23	0.00	0.00	
2610	SSI DISABLED EXPAND E	104,807.20	77,155.74	124,225.52	136,712.09	152,397.86	119,008.53	102,783.86	59,802.87	133,296.83	107,978.49	0.00	0.00	
2620	SSI DISABLED EXPAND
E	219,922.00	281,504.14	184,131.22	191,199.62	263,229.33	218,774.10	302,714.70	234,966.87	230,850.86	262,478.81	0.00	0.00	
SUBTOTAL:	1,942,361.40	2,562,277.67	1,736,118.4	1,778,298.06	2,388,193.38	2,119,710.51	2,259,347.25	1,704,201.32	1,974,401.02	2,013,618.09	0.00	0.00	

 
42,804.24	
71,134.78	
277,884.12	
95,158.43	
0.00	
0.00	
5,331.75	
88,319.25	
2,328,432.74	
5,522,043.16	
4,855,188.35	
822.22	
129,619.76	
235,614.79	
829,589.75	
252,650.26	
37,400.05	
21,303.44	
2,113,869.49	
63,419.88	
1,118,168.99	
2,389,771.65	
20,478,527.10	

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	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	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	
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	0.00

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-55.23	0.00	0.00		-55.23		
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.85	0.00	-211.07	0.00	0.00		-175.22		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-8.78	0.00	0.00	-572.50	0.00	0.00	0.00	0.00	0.00	0.00		-581.28		
SUBTOTAL:	0.00	0.00	-8.7	8	0.00	0.00	-572.50	0.00	35.85	0.00	-266.30	0.00	0.00		-811.73		

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	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	761.60	339.13	326.52	917.13	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	281.40	1,677.14	112.62	267.67	1,838.86	1,741.28	2,621.21	2,494.06	744.73	183.21	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	1,306.18	494.08	125.68	40.67	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	3,775.48	18,428.96	14,842.75	4,461.07	2,621.16	5,691.64	8,847.66	5,712.58	5,219.44	3,131.60	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,687.39	14,808.15	10,500.33	8,907.20	32,357.65	4,058.05	4,418.04	6,296.68	13,861.68	13,081.72	0.00	0.00	

0.00	
2,344.38	
11,962.18	
1,966.61	
72,732.34	
111,976.89	

3506	ADULT 40-100% MALE 2	7.64	-7.64	0.00	838.49	1,274.47	1,418.21	406.64	0.00	0.00	21.50	0.00	0.00	
3508	ADULT 40-100% M&F 45	2,469.55	2,436.98	3,000.86	3,280.41	184.59	4,092.74	5,242.96	4,179.53	27,561.32	3,700.20	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	6,481.44	11,312.59	12,350.35	22,347.81	15,695.04	14,898.54	8,644.85	0.00	0.00	
3515	ADULT 40-100% FEMAL E	11,963.08	23,715.95	24,761.15	18,833.21	23,419.99	36,339.70	9,935.76	17,708.35	44,963.25	23,093.39	0.00	0.00	
3516	ADULT 40-100% MALE 2	396,654.33	509,637.36	404,798.12	269,488.61	411,802.40	242,413.50	236,867.25	260,372.50	355,652.60	395,894.63	0.00	0.00	
3517	ADULT 40-100% FEMAL E	116,409.54	130,347.81	96,351.92	105,712.96	101,828.24	79,327.90	94,404.35	88,709.21	117,863.53	112,990.31	0.00	0.00	
3518	ADULT 40-100% M&F 45	549,945.01	899,294.77	652,416.88	587,555.16	1,155,697.65	698,582.42	672,010.37	598,624.37	891,926.70	711,792.86	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	811.09	153.00	185.14	598.68	612.76	1,561.29	304.84	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	681.88	56.79	0.00	0.00	
3707	ADULT <40% EXP FEMA L	71.15	330.09	34.73	715.81	2,007.47	715.59	1,056.09	830.35	613.47	54.14	0.00	0.00	
3708	ADULT <40% EXP M&F
4	6,279.49	2,605.30	2,228.45	1,273.62	502.27	1,668.76	1,363.11	1,645.11	776.13	3,798.32	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	503.17	27.48	0.00	0.00	
3714	ADULT <40% EXP MALE	131,971.66	151,697.37	64,261.99	172,071.93	177,604.12	127,009.62	91,313.08	73,322.58	28,164.56	125,723.39	0.00	0.00	
3715	ADULT <40% EXP FEMA L	75,020.79	101,153.74	111,189.37	76,869.68	119,844.42	96,319.32	129,499.28	91,129.09	122,706.15	123,616.85	0.00	0.00	
3716	ADULT <40% EXP MALE	2,730,749.40	3,606,658.24	2,858,839.94	2,560,393.25	3,616,263.14	3,084,037.97	3,694,949.17	2,494,111.22	2,915,852.47	2,991,689.93	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,133,060.95	1,543,151.07	1,103,446.60	912,979.45	1,708,600.10	991,087.05	1,472,189.57	1,145,347.01	1,147,706.28	1,123,455.41	0.00	0.00	
3718	ADULT <40% EXP M&F
4	3,507,314.89	4,693,205.15	3,341,660.62	3,082,318.96	4,663,857.14	3,636,117.48	4,391,871.13	3,562,008.04	3,864,605.11	4,060,966.42	0.00	0.00	
3719	ADULT <40% EXP M&F 6	7.42	0.00	0.00	0.00	480.76	1,222.15	1,629.08	1,957.66	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEMA L	0.00	0.00	0.00	1,109.20	0.00	60.10	0.00	218.04	122.19	58.42	0.00	0.00	
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	598.92	47.75	703.09	0.00	0.00	0.00	
SUBTOTAL:	8,675,140.04	11,676,711.58	8,677,002.5	7,800,733.27	11,994,832.35	9,012,948.00	10,826,283.25	8,356,518.61	9,536,861.73	9,685,889.73	0.00	0.00	

 
3,959.31	
56,149.14	
0.00	
131,443.04	
234,733.83	
3,483,581.30	
1,043,945.77	
7,417,846.19	
4,226.80	
0.00	
738.67	
6,428.89	
22,140.56	
530.65	
1,143,140.30	
1,047,348.69	
30,553,544.73	
12,281,023.49	
38,803,924.94	
5,297.07	
0.00	
1,567.95	
1,349.76	
96,242,921.08	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	226,498.59	256,828.14	185,789.12	157,716.93	174,981.06	169,986.93	204,937.07	120,839.80	117,183.44	134,172.69	0.00	0.00		1,748,933.77		
3917	NEWLY ELIGIBLE FEMA L	119,886.27	155,178.52	126,873.16	105,937.51	133,098.81	162,793.72	104,989.66	102,966.06	124,345.18	207,135.46	0.00	0.00		1,343,204.35		
3918	NEWLY ELIGIBLE M&F
4	481,953.69	514,219.92	408,493.43	382,200.93	640,424.99	516,853.54	462,437.96	356,714.57	531,225.33	385,511.77	0.00	0.00		4,680,036.13		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,294.85	103.90	0.00	0.00		3,398.75		
3927	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		167.54		
SUBTOTAL:	836,082.8	2	961,140.83	746,778.9	5	659,491.31	986,628.71	862,380.84	788,716.41	595,390.94	796,791.78	743,320.35	0.00	0.00		7,976,722.94		

4518	BC PATIENT FEMALE 4 5	219.81	0.00	75.93	14.80	168.80	3,135.34	7,698.89	240.11	13,924.45	75.90	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	75.9	3	14.80	168.80	3,135.34	7,698.89	240.11	13,924.45	75.90	0.00	0.00	

25,554.03	
0.00	
25,554.03	

8700	SSI DISABLED FREEDO M	4,147.91	4,266.99	3,127.93	1,447.48	7,457.77	4,630.96	11,149.01	7,651.41	10,419.73	9,710.99	0.00	0.00	
8710	SSI DISABLED FREEDO
M	6,950.39	6,582.09	2,201.84	553.91	2,012.21	415.68	959.62	4,288.87	1,751.03	4,103.89	0.00	0.00	
8720	SSI DISABLED FREEDO M	393.30	257.81	87.98	133.50	101.25	336.90	61.21	1,522.35	187.36	0.00	0.00	0.00	
SUBTOTAL:	11,491.60	11,106.89	5,417.7	5	2,134.89	9,571.23	5,383.54	12,169.84	13,462.63	12,358.12	13,814.88	0.00	0.00	

64,010.18	
29,819.53	
3,081.66	
96,911.37	

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	43,636.60	84,967.13	85,784.25	82,912.29	134,379.65	68,483.19	83,561.03	63,553.18	94,638.03	69,729.81	0.00	0.00	
4414	SOBRA 100-133% MALE	24,543.55	37,596.63	94,686.31	20,176.16	29,834.89	21,786.55	41,471.62	32,732.85	30,072.70	22,469.01	0.00	0.00	
4415	SOBRA 100-133% FEMA L	34,922.68	42,295.42	42,910.85	37,023.21	38,368.57	36,931.35	39,554.49	66,743.47	31,218.63	41,386.58	0.00	0.00	
SUBTOTAL:	103,102.8	3	164,859.18	223,381.4	1	140,111.66	202,583.11	127,201.09	164,587.14	163,029.50	155,929.36	133,585.40	0.00	0.00	

 
0.00	
811,645.16	
355,370.27	
411,355.25	
1,578,370.68	

TOTAL:	24,162,925.84	32,428,570.73	23,495,323.38	23,019,660.53	31,054,677.71	25,603,029.26	29,579,060.45	24,527,171.00	28,057,157.70	25,905,736.66	0.00	0.00		267,833,313.26		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4323	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		
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		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	0.0	0	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 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	
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	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	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	
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	0.00

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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		

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	
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	
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	

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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP 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	
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 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	
3715	ADULT <40% EXP 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	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP 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	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP 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	
3727	ADULT <40% EXP 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	
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	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3927	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	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% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	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	0.0	0	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	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

0.00

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:

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
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	18.28	46.45	76.06	0.00	0.00	0.00	0.00	0.00	0.00		140.79		
1008	TANF 45-64 M & F WIT	25.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.93	0.00	0.00	0.00		31.15		
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	2,024.39	5,518.61	3,555.93	9,006.74	13,311.60	14,781.58	8,238.96	0.00	0.00		103,884.97		
1012	TANF 01-05 M & F NON	1,121.82	365.02	152.63	1,856.45	230.24	1,668.35	1,965.37	540.94	0.00	-32.69	0.00	0.00		7,868.13		
1013	TANF 06-13 M & F NON	1,153.16	369.75	51.54	787.71	468.13	357.72	617.42	46.39	464.31	81.06	0.00	0.00		4,397.19		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	1,327.49	0.00	0.00	0.00	2,049.74	0.00	0.00	0.00	0.00		3,377.23		
1015	TANF 14-20 FEMALE N O	967.45	3,191.49	224.28	0.00	744.57	2,854.00	0.00	2,049.05	48.91	557.58	0.00	0.00		10,637.33		
1016	TANF 21-44 MALE NON-	3,273.11	3,331.61	2,604.68	452.46	5,645.68	8,163.10	5,986.48	11,297.74	4,554.40	7,530.33	0.00	0.00		52,839.59		
1017	TANF 21-44 FEMALE N O	13,274.38	18,656.14	10,419.20	17,602.65	36,929.76	11,439.85	3,024.82	14,245.54	14,241.30	14,498.11	0.00	0.00		154,331.75		
1018	TANF 45-64 M & F NON	176.95	12,819.05	4,538.72	8,229.35	9,235.64	7,749.34	1,576.88	3,167.23	978.77	13,187.74	0.00	0.00		61,659.67		
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	3.33	0.00	0.00	0.00	0.00	0.00		3.33		
2100	SSI AGED WITH MEDIC A	2,075.98	2,566.51	1,276.20	2,047.51	1,000.03	1,203.13	210.49	4,684.09	6,441.44	2,954.82	0.00	0.00		24,460.20		
2110	SSI AGED NON-MEDICA
R	14,911.75	7,451.72	21,990.19	3,899.34	2,011.75	5,275.02	254.60	9,690.24	11,515.66	5,229.47	0.00	0.00		82,229.74		
2120	SSI AGED WITH QMB	66.89	1,627.32	65.79	-216.55	276.86	1,949.36	553.88	635.16	26.51	42.29	0.00	0.00		5,027.51		
2200	SSI DISABLED WITH M E	1,060.56	715.68	3,609.69	516.57	2,042.01	1,594.44	2,276.99	4,664.18	691.13	2,064.65	0.00	0.00		19,235.90		
2210	SSI DISABLED NON-ME
D	12,553.06	29,633.79	9,983.68	8,306.42	5,223.09	716.93	55,436.27	1,861.32	2,703.65	12,720.09	0.00	0.00		139,138.30		
2220	SSI DISABLED WITH Q M	4,921.08	1,324.16	59.58	105.61	23,342.36	3,874.68	1,300.77	1,641.63	24,487.95	12,233.84	0.00	0.00		73,291.66		
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	22.29	0.00	0.00	0.00	0.00		37.74		
4311	SOBRA CHILD <1 M & F	223.89	9,298.07	37,890.47	11,084.77	4,077.99	914.69	1,790.71	3,313.81	180.82	1,189.62	0.00	0.00		69,964.84		
4312	SOBRA CHILD 01-05 M	3,710.57	11,062.83	9,008.38	18,715.69	5,719.74	15,662.15	4,536.38	9,155.98	10,768.14	11,078.24	0.00	0.00		99,418.10		
4313	SOBRA CHILD 06-13 M	1,132.85	15,512.06	3,580.12	3,578.39	3,689.00	4,032.36	3,181.50	1,786.24	22,473.30	8,816.20	0.00	0.00		67,782.02		
4314	SOBRA CHILD 14-20 MA	865.72	-6,401.24	558.92	517.01	30,590.75	2,022.90	2,361.83	0.00	4,295.87	3,407.82	0.00	0.00		38,219.58		
4315	SOBRA CHILD 14-20 FE	9,007.12	691.46	8,774.64	6,917.01	13,023.16	6,042.89	-373.61	1,966.87	10,905.76	4,395.86	0.00	0.00		61,351.16		
4323	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		
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		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5015	SOBRA PREG 14-20 FE M	10,581.18	7,900.25	167.54	4,600.51	5,900.86	6,160.15	22,130.10	4,977.49	4,414.57	6,021.60	0.00	0.00		72,854.25		
5017	SOBRA PREG 21-44 FE
M	17,136.09	25,400.95	16,156.47	23,625.31	22,133.22	22,833.13	40,900.32	23,012.11	17,136.61	25,609.91	0.00	0.00		233,944.12		
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:	116,219.5	2	149,595.22	156,536.0	5	115,996.37	177,849.90	108,146.18	156,741.27	114,119.64	151,116.61	139,825.50	0.00	0.00		1,386,146.26		

1106	TANF EXPANDED 21-44	52.14	36.83	10.43	0.00	0.00	0.00	0.00	607.28	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	1,501.20	285.27	16.99	302.20	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	47.15	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	939.65	1,405.60	5,542.77	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	7.42	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	2,105.97	6,094.96	6,564.13	825.59	7,211.42	4,335.04	4,399.77	4,466.72	4,178.55	9,562.16	0.00	0.00	
1117	TANF EXPANDED 21-44	7,631.53	3,213.93	5,378.05	9,170.51	9,593.41	1,479.88	5,908.96	2,868.72	5,915.08	4,354.48	0.00	0.00	
1118	TANF EXPANDED 45-64	262.45	6,142.98	2,754.83	891.39	5,339.97	471.71	533.07	13,773.21	552.50	4,506.61	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	169.10	35.79	0.00	0.00	121.77	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	34.70	33.65	0.00	1.55	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	135.99	38.85	0.00	0.00	0.00	6.66	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	121.06	108.12	48.58	0.00	1,480.44	3,336.15	599.02	0.00	0.00	
2410	SSI AGED EXPANDED N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,730.86	166.20	291.75	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	26.21	0.00	80.54	80.54	246.97	142.92	117.81	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	96.65	644.29	2,153.80	193.15	591.99	140.51	160.50	15.72	107.51	5,645.18	0.00	0.00	
2610	SSI DISABLED EXPAND E	942.94	0.00	0.00	0.00	0.00	0.00	144.48	0.00	3,248.50	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	255.22	10.37	181.31	0.00	0.00	
SUBTOTAL:	11,878.02	17,405.60	18,132.5	12,783.44	23,379.82	6,810.17	12,571.86	26,721.58	23,235.52	25,140.51	0.00	0.00	

 
706.68	
201.80	
3,864.26	
121.40	
21.08	
0.00	
7,888.02	
7.42	
49,744.31	
55,514.55	
35,228.72	
0.00	
326.66	
69.90	
181.50	
0.00	
6,616.06	
2,188.81	
694.99	
9,749.30	
4,335.92	
597.73	
178,059.11	

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	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-115.4	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-115.41	
0.00	
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	0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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		

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	
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	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	60.58	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	415.47	49.03	742.62	0.00	92.78	288.69	-38.80	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	9,129.20	83.72	328.88	0.00	814.55	136.91	-48.00	866.95	365.01	0.00	0.00	

0.00	
0.00	
60.58	
0.00	
1,824.38	
11,677.22	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	123.52	1,469.45	0.00	171.56	8,833.87	0.00	0.00	100.24	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	398.32	9,993.11	667.35	979.07	220.75	0.00	0.00	32.69	2,993.37	620.08	0.00	0.00	
3516	ADULT 40-100% MALE 2	12,549.57	15,771.47	17,060.08	19,695.89	18,074.68	6,588.54	637.20	8,898.58	5,119.76	4,487.81	0.00	0.00	
3517	ADULT 40-100% FEMAL E	2,510.06	8,276.62	3,395.55	683.38	4,069.56	1,846.78	2,592.96	838.08	7,071.07	6,801.64	0.00	0.00	
3518	ADULT 40-100% M&F 45	25,805.10	28,273.66	13,541.97	12,147.02	8,641.88	118,267.91	41,734.59	45,098.85	70,522.96	22,400.43	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-25.98	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP 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	
3708	ADULT <40% EXP M&F
4	393.78	17,888.32	2,607.08	0.00	-20,889.18	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 MALE	348.69	6,913.18	2,389.13	3,875.07	10,204.90	3,932.08	459.62	11,459.59	26,292.60	6,340.60	0.00	0.00	
3715	ADULT <40% EXP FEMA L	2,830.60	6,412.32	873.57	141.64	713.61	1,300.03	2,883.42	424.88	6,605.95	83.50	0.00	0.00	
3716	ADULT <40% EXP MALE	66,956.56	93,175.44	47,069.14	52,976.41	63,746.71	84,621.16	65,221.23	80,941.39	79,868.64	104,975.59	0.00	0.00	
3717	ADULT <40% EXP FEMA L	28,458.42	36,366.56	34,684.03	15,184.04	62,483.21	14,302.48	66,383.42	62,253.81	26,384.78	55,564.50	0.00	0.00	
3718	ADULT <40% EXP M&F
4	122,869.32	164,344.52	75,348.19	36,206.84	135,418.89	137,489.31	52,764.09	64,488.97	87,701.70	172,383.30	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP 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	
3727	ADULT <40% EXP 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	
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:	263,243.9	388,884.65	197,636.0	142,060.92	291,518.88	368,348.29	232,676.53	274,511.10	312,560.83	373,657.45	0.00	0.00	

 
0.00	
0.00	
0.00	
10,698.64	
15,904.74	
108,883.58	
38,085.70	
386,434.37	
0.00	
0.00	
-25.98	
0.00	
0.00	
0.00	
72,215.46	
22,269.52	
739,552.27	
402,065.25	
1,049,015.13	
0.00	
0.00	
0.00	
0.00	
2,845,098.68	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	3,477.45	1,757.55	14,542.36	13,653.71	1,213.95	6,800.38	1,239.67	1,033.13	9,461.08	5,566.66	0.00	0.00		58,745.94		
3917	NEWLY ELIGIBLE FEMA L	14,387.60	710.48	1,641.52	3,759.47	4,132.68	1,610.74	4,767.85	4,322.99	3,746.84	27,846.42	0.00	0.00		66,926.59		
3918	NEWLY ELIGIBLE M&F
4	32,724.28	9,297.59	4,631.81	3,799.20	38,761.34	18,593.93	37,697.47	12,499.13	17,279.65	11,501.22	0.00	0.00		186,785.62		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83.75	0.00	0.00	0.00	0.00		83.75		
3927	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.56	0.00	0.00	0.00		5.56		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	50,589.33	21,169.41	20,899.4	1	21,956.73	44,157.00	28,562.22	43,902.48	17,983.78	31,648.77	45,240.51	0.00	0.00		326,109.64		

4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	39.93	315.62	0.00	148.40	0.00	0.00	16.66	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	0.0	0	39.93	315.62	0.00	148.40	0.00	0.00	16.66	0.00	0.00	

520.61	
0.00	
520.61	

8700	SSI DISABLED FREEDO M	0.00	0.00	668.70	38.60	3,559.19	174.79	0.00	34.37	-11.26	49.31	0.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,546.04	0.00	639.12	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	668.7	0	38.60	3,559.19	174.79	0.00	1,580.41	-11.26	688.43	0.00	0.00	

4,513.70	
2,185.16	
0.00	
6,698.86	

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	6,524.44	214.62	647.28	1,082.47	143.00	191.74	1,373.25	0.00	9,761.95	2,095.96	0.00	0.00	
4414	SOBRA 100-133% MALE	49.03	3,537.66	11,070.24	0.00	188.37	0.00	0.00	562.20	150.35	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	149.18	0.00	0.00	0.00	67.76	188.79	219.63	624.33	635.98	926.39	0.00	0.00	
SUBTOTAL:	6,722.65	3,752.28	11,717.5	2	1,082.47	399.13	380.53	1,592.88	1,186.53	10,548.28	3,022.35	0.00	0.00	

 
0.00	
22,034.71	
15,557.85	
2,812.06	
40,404.62	

TOTAL:	448,653.46	580,807.16	405,474.95	293,958.46	541,179.54	512,422.18	447,633.42	436,103.04	529,098.75	587,591.41	0.00	0.00		4,782,922.37		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
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	44,174.57	50,903.15	52,548.70	61,900.09	57,685.42	68,350.31	58,431.31	0.00	0.00		595,391.28		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	0.00	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	6	49,660.41	44,174.57	50,903.15	52,548.70	61,900.09	57,685.42	68,350.31	58,431.31	0.00	0.00		595,391.28		

0.00

0.00

68,350.31

44,174.57

TOTAL:

38,229.76

113,507.56	49,660.41

50,903.15	52,548.70	61,900.09	57,685.42

58,431.31

595,391.28

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	104.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.07		
8050	QI1	0.00	0.00	308.30	56.86	0.00	722.26	-722.26	0.00	0.00	0.00	0.00	0.00		365.16		
SUBTOTAL:	0.00	0.0	308.30	56.86	104.07	722.26	-722.26	0.00	0.00	0.00	0.00	0.00		469.23		

TOTAL:	0.00	0.00	308.30	56.86	104.07	722.26	-722.26	0.00	0.00	0.00	0.00	0.00		469.23		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
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	365,288.17	413,463.39	572,090.61	516,584.29	611,714.90	579,952.28	545,232.34	498,890.99	0.00	0.00		5,141,958.04		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	75.93	0.00	0.00	179.36	0.00	0.00	0.00		255.29		
8050	QI1	0.00	0.00	267.76	0.00	0.00	0.00	0.00	0.00	0.00	16.64	0.00	0.00		284.40		
SUBTOTAL:	451,294.58	587,446.49	365,555.9	3	413,463.39	572,090.61	516,660.22	611,714.90	579,952.28	545,411.70	498,907.63	0.00	0.00		5,142,497.73		

0.00

0.00

545,411.70

413,463.39

TOTAL:

451,294.58

587,446.49	365,555.93

572,090.61	516,660.22	611,714.90	579,952.28

498,907.63

5,142,497.73

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
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	56.86	47.75	56.86	56.86	56.86	202.45	127.98	0.00	0.00		776.20		
1007	TANF 21-44 FEMALE WI	127.81	104.61	0.00	0.00	0.00	0.00	41.31	132.00	405.47	591.66	0.00	0.00		1,402.86		
1008	TANF 45-64 M & F WIT	1,538.48	0.00	24.64	25.63	0.00	25.22	0.00	0.00	0.00	0.00	0.00	0.00		1,613.97		
1009	TANF 65+ M & F WITH	-281.37	15.77	55.48	0.00	0.00	313.01	0.00	0.00	0.00	0.00	0.00	0.00		102.89		
1011	TANF <1 M & F NON-ME	41,353.18	83,524.87	45,851.57	32,193.98	144,457.44	66,824.78	61,014.90	57,626.39	34,594.20	45,854.61	0.00	0.00		613,295.92		
1012	TANF 01-05 M & F NON	2,416.45	5,049.59	5,005.65	1,141.47	4,304.91	6,374.12	6,285.55	7,145.34	524.19	945.95	0.00	0.00		39,193.22		
1013	TANF 06-13 M & F NON	17,904.47	5,731.28	1,371.88	2,283.57	10,421.17	5,823.92	2,051.49	8,141.27	1,980.10	5,896.87	0.00	0.00		61,606.02		
1014	TANF 14-20 MALE NON-	637.52	3,544.55	163.38	2,807.43	547.50	444.54	1,618.38	372.06	433.77	11,560.66	0.00	0.00		22,129.79		
1015	TANF 14-20 FEMALE N O	473.36	9,088.52	4,205.69	956.18	442.87	1,535.69	599.28	519.18	3,789.86	1,961.86	0.00	0.00		23,572.49		
1016	TANF 21-44 MALE NON-	48,175.44	44,624.89	55,073.14	32,591.88	28,379.90	38,926.60	47,226.01	147,733.14	20,437.68	26,811.87	0.00	0.00		489,980.55		
1017	TANF 21-44 FEMALE N O	118,892.96	155,104.03	80,082.27	98,946.27	126,825.66	100,818.47	168,181.46	192,621.88	135,780.69	158,748.34	0.00	0.00		1,336,002.03		
1018	TANF 45-64 M & F NON	27,646.03	65,670.84	68,847.80	40,481.25	39,026.33	41,414.48	53,844.68	29,588.55	31,314.33	32,853.41	0.00	0.00		430,687.70		
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	56.86	448.51	157.84	14.51	47.02	62.25	0.00	0.00	0.00		983.77		
1028	TANF 45-64 M & F WIT	261.59	132.00	168.16	114.41	56.86	606.20	216.20	1,402.16	2,756.76	240.70	0.00	0.00		5,955.04		
1029	TANF 65+ M & F WITH	21.07	148.62	0.00	0.00	0.00	0.00	11.03	91.38	0.00	0.00	0.00	0.00		272.10		
2100	SSI AGED WITH MEDIC A	5,726.74	3,782.63	1,296.85	663.21	8,422.20	2,053.26	7,688.10	517.75	1,328.62	1,460.55	0.00	0.00		32,939.91		
2110	SSI AGED NON-MEDICA
R	233.62	202.56	106.82	352.25	1,261.54	0.00	883.11	0.00	1,389.53	19,823.42	0.00	0.00		24,252.85		
2120	SSI AGED WITH QMB	10,874.03	11,181.21	8,341.30	7,645.52	18,404.12	5,972.09	11,794.88	7,422.36	15,443.08	9,037.41	0.00	0.00		106,116.00		
2200	SSI DISABLED WITH M E	8,331.34	6,667.68	8,218.92	4,813.08	13,726.74	3,483.45	22,398.46	3,653.72	19,845.04	32,587.61	0.00	0.00		123,726.04		
2210	SSI DISABLED NON-ME
D	269,492.24	321,140.24	256,038.87	238,683.04	375,136.94	262,793.46	330,919.52	900,335.95	318,788.20	208,011.02	0.00	0.00		3,481,339.48		
2220	SSI DISABLED WITH Q M	30,051.08	42,118.54	23,981.67	34,779.46	38,101.22	27,773.38	44,147.94	30,313.28	45,174.26	46,050.21	0.00	0.00		362,491.04		
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	49.79	92.78	0.00	0.00	1,457.82	863.49	0.00	0.00	0.00		18,687.02		
2320	SSI BLIND WITH QMB	52.29	333.79	1,316.00	362.90	136.75	342.87	1,949.01	189.57	430.02	51.89	0.00	0.00		5,165.09		
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	27,601.10	116,064.26	269,353.87	114,969.89	99,309.33	158,904.74	84,653.45	0.00	0.00		1,217,114.10		
4312	SOBRA CHILD 01-05 M	40,550.75	187,610.82	74,555.39	38,570.00	38,561.99	55,219.66	275,211.01	54,952.94	50,911.53	89,499.58	0.00	0.00		905,643.67		
4313	SOBRA CHILD 06-13 M	34,283.16	66,111.59	48,413.66	31,509.94	35,648.14	117,972.27	47,020.64	26,783.06	47,931.95	15,321.04	0.00	0.00		470,995.45		
4314	SOBRA CHILD 14-20 MA	10,028.07	22,322.48	11,914.76	17,117.95	13,157.30	18,094.08	11,828.97	13,253.02	6,485.05	54,225.36	0.00	0.00		178,427.04		
4315	SOBRA CHILD 14-20 FE	16,595.83	66,226.90	10,390.30	22,899.03	20,786.75	14,233.72	28,186.46	17,045.18	2,660.31	14,507.31	0.00	0.00		213,531.79		
4323	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		
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		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5015	SOBRA PREG 14-20 FE M	8,490.98	26,483.90	26,630.88	17,412.11	16,828.99	23,401.23	13,301.46	14,342.15	8,993.77	7,036.29	0.00	0.00		162,921.76		
5017	SOBRA PREG 21-44 FE
M	106,165.33	159,784.86	53,222.09	94,171.71	116,680.11	118,888.43	136,559.23	134,290.51	117,764.93	102,511.02	0.00	0.00		1,140,038.22		
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:	862,902.6	0	1,389,238.80	989,502.6	6	748,286.88	1,167,968.73	1,182,903.50	1,388,020.34	1,749,343.87	1,029,196.27	970,370.07	0.00	0.00		11,477,733.72		

1106	TANF EXPANDED 21-44	23.54	94.05	166.86	30.55	1,425.12	54.99	29.11	130.05	317.35	2,224.95	0.00	0.00	
1107	TANF EXPANDED 21-44	208.96	280.92	704.76	229.47	223.45	113.72	179.56	109.05	76.81	56.79	0.00	0.00	
1108	TANF EXPANDED 45-64	2,320.64	2,168.84	198.15	1,957.77	396.92	1,357.78	592.10	348.24	584.12	1,652.70	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	360.87	297.29	846.58	24.85	927.30	1,148.54	1,878.66	48.45	21.25	128.90	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	-281.13	0.00	0.00	254.80	362.69	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	33,104.75	35,481.16	23,471.26	39,659.17	20,335.85	8,034.45	23,048.79	24,452.54	27,659.56	19,441.20	0.00	0.00	
1117	TANF EXPANDED 21-44	41,327.06	122,045.87	53,849.45	28,715.45	63,868.89	54,159.05	76,961.52	49,823.43	105,888.29	103,219.41	0.00	0.00	
1118	TANF EXPANDED 45-64	28,983.88	31,297.28	25,664.10	17,767.93	42,596.29	31,411.42	40,870.75	36,839.37	35,841.26	15,282.24	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	637.46	498.79	-792.14	577.15	481.27	287.33	244.18	0.00	0.00	
1127	TANF EXPANDED 21-44	1,508.49	1,182.60	1,097.16	477.12	938.68	350.37	1,381.97	681.98	454.83	1,024.56	0.00	0.00	
1128	TANF EXPANDED 45-64	3,794.41	5,586.68	2,652.81	3,772.80	2,389.02	1,641.18	6,596.54	3,359.01	5,223.89	5,084.86	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	2,455.65	546.45	-20.72	81.81	156.26	255.57	682.91	305.48	605.91	108.14	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	585.50	0.00	40.36	0.00	0.00	28.95	62.85	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,055.57	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	12,372.38	10,795.99	11,582.18	5,891.33	7,712.55	5,049.57	10,126.86	8,931.56	11,443.46	11,060.77	0.00	0.00	
2600	SSI DISABLED EXPAND
E	1,061.87	2,087.19	56.86	0.00	648.99	186.08	182.49	380.78	329.05	806.49	0.00	0.00	
2610	SSI DISABLED EXPAND E	1,073.13	1,017.46	3,467.26	8,995.35	19,339.97	4,875.15	6,316.96	3,150.43	9,396.10	3,696.52	0.00	0.00	
2620	SSI DISABLED EXPAND
E	5,813.54	10,465.18	3,579.14	7,813.95	22,653.97	12,384.87	21,388.46	8,432.00	16,154.24	8,816.97	0.00	0.00	
SUBTOTAL:	138,893.3	225,344.85	128,090.5	115,814.24	184,112.05	120,230.60	191,097.58	138,954.75	214,283.45	172,848.68	0.00	0.00	

 
4,496.57	
2,183.49	
11,577.26	
5,682.69	
0.00	
0.00	
0.00	
4,772.28	
254,688.73	
699,858.42	
306,554.52	
0.00	
4,169.39	
9,097.76	
40,101.20	
5,177.46	
717.66	
1,055.57	
94,966.65	
5,739.80	
61,328.33	
117,502.32	
1,629,670.10	

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	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	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	
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	0.00

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	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		

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	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	55.88	0.00	0.00	1,262.80	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	243.16	0.00	0.00	23,862.33	0.00	48.91	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	105.50	2,348.58	232.62	194.51	1,373.33	5,399.20	1,177.97	386.32	825.63	0.00	0.00	0.00	

0.00	
1,318.68	
0.00	
0.00	
40,861.86	
12,043.66	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	41.97	56.86	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	215.47	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	173.62	88.87	786.41	147.04	335.54	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	373.66	3,495.94	1,432.55	1,368.85	1,366.58	2,068.00	562.52	2,056.24	8,387.01	54.26	0.00	0.00	
3516	ADULT 40-100% MALE 2	34,329.72	28,807.75	211,786.16	16,651.49	36,900.77	11,878.18	28,716.66	43,971.52	60,712.15	104,428.25	0.00	0.00	
3517	ADULT 40-100% FEMAL E	61,948.12	7,061.45	13,176.02	14,264.81	15,652.66	16,382.82	27,520.36	8,749.67	15,408.66	6,135.18	0.00	0.00	
3518	ADULT 40-100% M&F 45	86,825.25	98,535.70	128,234.27	40,662.00	101,903.24	84,010.40	40,077.76	82,351.76	102,590.27	119,310.19	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	194.15	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	101.75	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 MALE	2,368.59	13,631.78	20,079.85	972.51	14,818.84	9,764.27	4,988.60	847.39	5,938.33	11,826.16	0.00	0.00	
3715	ADULT <40% EXP FEMA L	10,881.58	4,587.91	-712.20	5,301.94	7,243.32	1,508.52	9,865.24	5,168.07	8,293.75	3,910.10	0.00	0.00	
3716	ADULT <40% EXP MALE	217,280.78	338,036.75	146,991.32	166,516.45	254,356.01	172,428.42	214,409.15	170,775.36	154,850.34	164,569.89	0.00	0.00	
3717	ADULT <40% EXP FEMA L	265,106.48	120,807.87	91,145.50	39,158.68	138,323.83	111,647.15	278,893.71	75,245.14	93,282.60	117,588.42	0.00	0.00	
3718	ADULT <40% EXP M&F
4	241,419.48	189,212.30	193,413.38	109,036.50	325,031.74	134,800.56	357,993.03	393,424.58	159,483.27	199,278.98	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP 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	
3727	ADULT <40% EXP 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	
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:	922,529.7	804,515.00	805,610.8	393,975.20	895,827.47	544,577.19	964,007.59	782,736.77	609,599.14	727,101.43	0.00	0.00	

 
98.83	
215.47	
0.00	
3,901.94	
21,165.61	
578,182.65	
186,299.75	
884,500.84	
0.00	
0.00	
0.00	
194.15	
128.88	
0.00	
85,236.32	
56,048.23	
2,000,214.47	
1,331,199.38	
2,303,093.82	
0.00	
0.00	
0.00	
0.00	
7,450,480.34	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	25,177.90	62,754.37	13,202.86	10,489.83	8,934.78	33,584.73	39,428.43	15,027.94	22,525.75	11,845.64	0.00	0.00		242,972.23		
3917	NEWLY ELIGIBLE FEMA L	8,157.64	35,110.39	10,539.94	15,145.12	30,809.34	29,130.61	25,250.01	5,188.33	109,697.49	14,077.93	0.00	0.00		283,106.80		
3918	NEWLY ELIGIBLE M&F
4	47,909.97	59,251.26	91,059.97	21,254.78	12,598.68	19,770.09	34,475.50	73,130.75	37,457.21	29,581.12	0.00	0.00		426,489.33		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.89	0.00	0.00		15.89		
3927	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	81,351.01	159,565.66	131,641.7	9	47,084.24	53,959.29	87,940.51	100,331.91	117,595.67	171,768.88	55,569.49	0.00	0.00		1,006,808.45		

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	0.0	0	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	171.04	1,906.13	102.39	65.14	720.57	44.47	85.28	0.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	137.48	0.00	714.81	81.50	272.83	0.00	0.00	
8720	SSI DISABLED FREEDO M	94.16	202.88	28.95	0.00	53.76	28.95	0.00	143.26	0.00	53.26	0.00	0.00	
SUBTOTAL:	954.40	2,267.29	99.2	5	171.04	1,959.89	268.82	65.14	1,578.64	125.97	411.37	0.00	0.00	

6,089.97	
1,206.62	
605.22	
7,901.81	

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	5,767.98	4,841.65	5,090.37	11,971.69	1,092.18	1,936.86	3,684.61	13,141.25	1,897.52	2,635.78	0.00	0.00	
4414	SOBRA 100-133% MALE	5,966.40	5,291.00	1,719.59	2,782.66	629.79	1,064.43	503.96	355.67	1,780.71	262.48	0.00	0.00	
4415	SOBRA 100-133% FEMA L	54.32	401.73	0.00	200.29	2,265.33	189.77	1,573.22	1,576.61	1,153.97	984.32	0.00	0.00	
SUBTOTAL:	11,788.70	10,534.38	6,809.9	6	14,954.64	3,987.30	3,191.06	5,761.79	15,073.53	4,832.20	3,882.58	0.00	0.00	

 
0.00	
52,059.89	
20,356.69	
8,399.56	
80,816.14	

TOTAL:	2,018,419.79	2,591,465.98	2,061,755.03	1,320,286.24	2,307,814.73	1,939,111.68	2,649,284.35	2,805,283.23	2,029,805.91	1,930,183.62	0.00	0.00		21,653,410.56		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2018	
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	854.00	1,281.00	1,708.00	0.00	0.00		4,234.00		
2100	SSI AGED WITH MEDIC A	282,362.60	593,435.89	190,117.04	202,161.20	195,263.13	160,240.96	279,552.10	172,302.42	199,380.32	230,727.30	0.00	0.00		2,505,542.96		
2110	SSI AGED NON-MEDICA
R	114,115.36	33,424.06	8,840.05	19,606.34	16,292.86	32,120.45	17,615.89	12,782.48	29,604.56	13,650.53	0.00	0.00		298,052.58		
2120	SSI AGED WITH QMB	106,974.53	642,052.72	246,548.60	289,195.66	243,847.03	209,123.39	260,370.15	251,079.81	250,716.32	288,152.01	0.00	0.00		2,788,060.22		
2200	SSI DISABLED WITH M E	20,587.92	133,462.59	59,877.14	57,225.70	73,936.98	69,616.36	63,840.95	64,062.33	71,989.34	75,887.51	0.00	0.00		690,486.82		
2210	SSI DISABLED NON-ME
D	690,412.33	1,298,812.40	863,430.80	646,231.92	774,505.45	844,315.42	947,788.68	854,287.21	863,166.17	845,970.32	0.00	0.00		8,628,920.70		
2220	SSI DISABLED WITH Q M	50,835.89	253,878.80	110,857.85	119,325.56	84,280.54	87,172.52	95,390.70	99,351.71	113,845.81	113,868.55	0.00	0.00		1,128,807.93		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.60	0.00	0.00		76.60		
2310	SSI BLIND NON-MEDIC A	8,165.00	27,468.40	8,993.00	11,694.57	11,361.96	9,369.09	9,708.00	9,286.00	22,117.72	13,439.11	0.00	0.00		131,602.85		
2320	SSI BLIND WITH QMB	79.82	10.22	180.19	446.36	506.77	0.00	456.40	106.22	887.80	286.00	0.00	0.00		2,959.78		
SUBTOTAL:	1,273,533.45	2,982,936.08	1,488,844.6	7	1,345,887.31	1,399,994.72	1,411,958.19	1,674,722.87	1,464,112.18	1,552,989.04	1,583,765.93	0.00	0.00		16,178,744.44		

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	338.11	728.77	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	0.0	0	0.00	0.00	338.11	728.77	0.00	0.00	0.00	0.00	0.00	

 
1,066.88	
0.00	
1,066.88	

16,179,811.32

1,273,533.45	2,982,936.08	1,488,844.67	1,345,887.31	1,399,994.72	1,412,296.30	1,675,451.64	1,464,112.18	1,552,989.04	1,583,765.93	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending April 30, 2018	
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	449.33	111.25	0.00	0.00	0.00		560.58		
2100	SSI AGED WITH MEDIC A	2,365,886.89	2,765,480.64	2,423,012.36	2,154,064.27	2,737,795.93	2,436,063.51	2,936,472.42	2,376,738.43	2,620,190.68	2,291,156.00	0.00	0.00		25,106,861.13		
2110	SSI AGED NON-MEDICA
R	114,010.42	163,832.12	93,510.35	85,837.52	83,214.38	148,822.83	151,950.26	89,133.55	75,869.92	78,280.66	0.00	0.00		1,084,462.01		
2120	SSI AGED WITH QMB	3,278,193.16	3,816,786.21	3,229,736.85	3,170,014.61	3,869,614.96	3,504,100.75	3,913,028.49	3,146,858.71	3,376,330.49	3,146,511.93	0.00	0.00		34,451,176.16		
2200	SSI DISABLED WITH M E	705,967.24	704,921.23	598,366.54	632,531.23	813,958.02	740,616.69	759,342.05	676,720.78	784,295.01	716,068.93	0.00	0.00		7,132,787.72		
2210	SSI DISABLED NON-ME
D	2,342,483.57	3,086,839.40	2,211,571.00	2,048,283.63	2,657,359.50	2,400,915.22	2,540,976.73	2,012,253.14	2,505,325.88	2,481,976.23	0.00	0.00		24,287,984.30		
2220	SSI DISABLED WITH Q M	816,372.82	1,114,191.87	823,596.65	850,216.54	951,368.57	901,890.01	1,085,672.73	854,465.66	930,259.35	836,150.27	0.00	0.00		9,164,184.47		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,513.57	4,749.59	4,597.77	0.00	0.00		12,860.93		
2310	SSI BLIND NON-MEDIC A	29,301.58	10,254.28	13,868.38	10,172.30	12,257.05	10,904.87	15,673.11	9,858.18	7,106.09	9,338.80	0.00	0.00		128,734.64		
2320	SSI BLIND WITH QMB	8,700.00	8,731.83	4,039.07	9,788.66	12,128.90	11,487.41	14,510.99	10,313.00	11,335.02	8,116.05	0.00	0.00		99,150.93		
SUBTOTAL:	9,660,915.68	11,671,037.58	9,397,701.2	0	8,960,908.76	11,137,697.31	10,154,801.29	11,417,626.78	9,180,304.35	10,315,573.28	9,572,196.64	0.00	0.00		101,468,762.87		

8710	SSI DISABLED FREEDO M	0.00	1,326.10	6,033.96	2,935.44	3,090.17	0.00	6,082.20	3,075.30	2,790.72	3,084.48	0.00	0.00	
8720	SSI DISABLED FREEDO
M	2,533.80	3,044.16	3,424.68	1,522.08	851.64	983.01	1,980.12	1,326.51	688.50	481.14	0.00	0.00	
SUBTOTAL:	2,533.80	4,370.26	9,458.6	4	4,457.52	3,941.81	983.01	8,062.32	4,401.81	3,479.22	3,565.62	0.00	0.00	

 
28,418.37	
16,835.64	
45,254.01	

TOTAL:	9,663,449.48	11,675,407.84	9,407,159.84	8,965,366.28	11,141,639.12	10,155,784.30	11,425,689.10	9,184,706.16	10,319,052.50	9,575,762.26	0.00	0.00		101,514,016.88		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2018	
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	121.60	0.00	0.00		121.60		
2100	SSI AGED WITH MEDIC A	34,978.33	15,196.53	42,569.20	-1,622.35	17,233.87	34,587.57	24,701.55	37,589.89	37,302.20	15,499.67	0.00	0.00		258,036.46		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	-1,217.09	6,571.61	4,567.84	3,112.43	4,204.54	3,026.20	6,290.39	2,611.37	0.00	0.00		29,167.29		
2120	SSI AGED WITH QMB	597.24	3,085.15	1,027.00	2,818.99	1,302.84	6,967.27	876.17	1,284.98	-43.84	20.95	0.00	0.00		17,936.75		
2200	SSI DISABLED WITH M E	1,957.19	904.21	6,282.21	2,150.62	319.06	7,421.92	728.10	5,373.44	6,842.82	823.01	0.00	0.00		32,802.58		
2210	SSI DISABLED NON-ME
D	23,421.88	43,085.97	23,457.03	26,756.29	33,245.07	43,619.07	31,086.42	18,892.46	44,862.42	49,063.82	0.00	0.00		337,490.43		
2220	SSI DISABLED WITH Q M	2,389.71	-3,161.19	7,839.61	1,690.56	1,518.63	1,911.84	-675.67	57.33	516.15	1,791.64	0.00	0.00		13,878.61		
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	55.66	0.00	0.00	0.00		55.66		
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	79,957.9	6	38,365.72	58,187.31	97,620.10	60,921.11	66,224.30	95,825.80	69,932.06	0.00	0.00		689,489.38		

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	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	

689,489.38

63,344.35	59,110.67	79,957.96	38,365.72	58,187.31	97,620.10	60,921.11	66,224.30	95,825.80	69,932.06	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending April 30, 2018	
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	9,478.84	22,977.49	6,269.63	20,802.26	12,198.30	36,767.31	7,929.04	0.00	0.00		160,055.88		
2110	SSI AGED NON-MEDICA
R	6,450.23	799.18	193.35	74.66	611.98	176.65	0.00	0.00	0.00	0.00	0.00	0.00		8,306.05		
2120	SSI AGED WITH QMB	9,806.02	19,063.27	7,262.26	7,131.00	22,324.19	10,390.87	16,526.72	13,086.29	17,821.30	19,634.46	0.00	0.00		143,046.38		
2200	SSI DISABLED WITH M E	4,695.45	7,277.13	1,911.29	2,388.73	2,669.18	6,172.26	14,236.53	4,835.29	5,886.53	3,660.37	0.00	0.00		53,732.76		
2210	SSI DISABLED NON-ME
D	31,915.34	12,532.42	34,054.72	40,147.47	81,412.17	80,982.27	76,269.18	58,318.40	89,112.22	83,018.83	0.00	0.00		587,763.02		
2220	SSI DISABLED WITH Q M	4,055.69	8,154.75	3,503.19	3,458.34	4,772.60	5,803.14	9,211.19	7,559.90	3,472.67	6,148.97	0.00	0.00		56,140.44		
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	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	57,760.8	9	62,679.04	134,767.61	109,794.82	137,045.88	95,998.18	153,060.03	120,391.67	0.00	0.00		1,009,205.51		

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	0.0	0	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:	75,572.79	62,134.60	57,760.89	62,679.04	134,767.61	109,794.82	137,045.88	95,998.18	153,060.03	120,391.67	0.00	0.00		1,009,205.51		

KidsCare - CAPITATION AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	128,128.56	120,248.37	125,035.30	115,215.71	110,171.75	115,946.47	118,171.09	100,336.39	107,326.86	115,566.77	0.00	0.00		1,156,147.27		
6012	KIDS 1-5 M & F NON-M	708,271.37	724,951.56	732,818.83	726,565.69	736,764.23	751,024.74	780,362.47	768,654.02	808,455.38	867,801.84	0.00	0.00		7,605,670.13		
6013	KIDS 6-13 M & F NON-	1,262,579.15	1,291,637.47	1,329,185.99	1,358,873.22	1,392,657.62	1,437,932.87	1,506,805.19	1,515,939.09	1,564,836.42	1,658,414.52	0.00	0.00		14,318,861.54		
6014	KIDS 14-19 MALE NON-	428,391.90	442,663.87	457,866.18	495,894.34	492,764.48	515,364.35	544,560.97	558,802.63	567,573.25	604,285.14	0.00	0.00		5,108,167.11		
6015	KIDS 14-19 FEMALE NO	697,874.36	706,401.17	729,116.53	754,493.89	757,621.85	786,334.28	822,592.53	843,013.48	854,796.63	899,893.13	0.00	0.00		7,852,137.85		
9960	KIDSCARE KICK PAYME N	12,541.03	0.00	12,776.56	6,279.40	6,283.92	6,279.40	6,316.03	5,536.46	25,262.72	12,105.20	0.00	0.00		93,380.72		
SUBTOTAL:	3,237,786.37	3,285,902.44	3,386,799.3	9	3,457,322.25	3,496,263.85	3,612,882.11	3,778,808.28	3,792,282.07	3,928,251.26	4,158,066.60	0.00	0.00		36,134,364.62		

36,134,364.62

3,237,786.37	3,285,902.44	3,386,799.39	3,457,322.25	3,496,263.85	3,612,882.11	3,778,808.28	3,792,282.07	3,928,251.26	4,158,066.60	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	271.65	255.00	264.93	264.33	252.96	267.04	249.46	224.66	239.92	257.68	0.00	0.00		2,547.63		
6012	KIDS 1-5 M & F NON-M	5,792.97	5,917.72	6,012.77	6,059.11	6,132.47	6,276.64	6,254.83	6,286.76	6,662.36	7,137.20	0.00	0.00		62,532.83		
6013	KIDS 6-13 M & F NON-	10,227.66	10,484.79	10,776.20	11,040.42	11,322.94	11,680.39	11,678.79	11,856.84	12,286.79	13,066.14	0.00	0.00		114,420.96		
6014	KIDS 14-19 MALE NON-	2,555.62	2,642.57	2,724.33	2,792.72	2,809.47	2,951.67	3,000.69	3,124.11	3,184.15	3,418.46	0.00	0.00		29,203.79		
6015	KIDS 14-19 FEMALE NO	2,628.75	2,664.75	2,749.04	2,863.55	2,873.97	2,996.18	2,983.94	3,111.62	3,176.58	3,345.04	0.00	0.00		29,393.42		
9960	KIDSCARE KICK PAYME N	2.00	0.00	2.00	1.00	1.00	1.00	1.00	1.00	4.00	2.00	0.00	0.00		15.00		
SUBTOTAL:	21,478.65	21,964.83	22,529.2	7	23,021.13	23,392.81	24,172.92	24,168.71	24,604.99	25,553.80	27,226.52	0.00	0.00		238,113.63		

TOTAL:	21,478.65	21,964.83	22,529.27	23,021.13	23,392.81	24,172.92	24,168.71	24,604.99	25,553.80	27,226.52	0.00	0.00		238,113.63		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	10,726.93	10,265.27	10,828.48	11,415.52	10,993.11	11,502.08	10,775.99	9,796.35	10,379.24	11,083.80	0.00	0.00		107,766.77		
6012	KIDS 1-5 M & F NON-M	226,209.16	230,820.68	235,254.69	252,386.25	255,143.48	261,300.23	260,145.08	261,773.03	277,122.86	296,832.76	0.00	0.00		2,556,988.22		
6013	KIDS 6-13 M & F NON-	397,354.76	406,599.10	418,704.86	455,848.76	467,488.25	482,309.25	482,512.15	488,778.28	504,614.15	536,949.38	0.00	0.00		4,641,158.94		
6014	KIDS 14-19 MALE NON-	107,522.67	110,080.27	113,538.42	131,331.43	131,746.69	140,431.29	140,881.51	147,436.71	150,579.66	161,934.38	0.00	0.00		1,335,483.03		
6015	KIDS 14-19 FEMALE NO	110,518.36	111,678.66	115,455.84	134,498.58	134,720.43	140,946.32	140,505.80	145,866.84	149,909.50	157,182.95	0.00	0.00		1,341,283.28		
SUBTOTAL:	852,331.8	8	869,443.98	893,782.2	9	985,480.54	1,000,091.96	1,036,489.17	1,034,820.53	1,053,651.21	1,092,605.41	1,163,983.27	0.00	0.00		9,982,680.24		

9,982,680.24

893,782.29	985,480.54	1,000,091.96	1,036,489.17	1,034,820.53	1,053,651.21	1,092,605.41	1,163,983.27	0.00	0.00	

TOTAL:

852,331.88

869,443.98

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	534.00	380.00	699.00	489.00	455.00	515.00	459.00	626.00	780.00	444.00	0.00	0.00		5,381.00		
6012	KIDS 1-5 M & F NON-M	11,318.00	11,772.00	13,478.00	12,421.00	10,866.00	11,570.00	8,907.00	19,781.00	17,665.00	10,797.00	0.00	0.00		128,575.00		
6013	KIDS 6-13 M & F NON-	20,771.00	20,367.00	26,440.00	23,116.00	19,018.00	21,756.00	18,942.00	37,364.00	33,518.00	19,263.00	0.00	0.00		240,555.00		
6014	KIDS 14-19 MALE NON-	5,346.00	4,920.00	6,137.00	5,502.00	4,701.00	5,491.00	4,618.00	9,901.00	8,651.00	5,175.00	0.00	0.00		60,442.00		
6015	KIDS 14-19 FEMALE NO	5,466.00	5,738.00	7,239.00	5,970.00	5,103.00	5,441.00	4,956.00	9,916.00	8,385.00	5,280.00	0.00	0.00		63,494.00		
SUBTOTAL:	43,435.00	43,177.00	53,993.0	0	47,498.00	40,143.00	44,773.00	37,882.00	77,588.00	68,999.00	40,959.00	0.00	0.00		498,447.00		

TOTAL:	43,435.00	43,177.00	53,993.00	47,498.00	40,143.00	44,773.00	37,882.00	77,588.00	68,999.00	40,959.00	0.00	0.00		498,447.00		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending April 30, 2018	
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	4,352.93	3,780.45	3,780.45	2,392.56	2,796.65	2,990.70	3,588.84	0.00	0.00		31,909.97		
6013	KIDS 6-13 M & F NON-	1,500.27	1,500.27	1,500.27	572.48	1,144.96	1,144.96	1,794.42	1,849.47	1,794.42	2,990.70	0.00	0.00		15,792.22		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	598.14	598.14	0.00	0.00		1,196.28		
SUBTOTAL:	3,000.54	4,863.83	4,863.83	4,925.41	4,925.41	4,925.41	4,186.98	4,646.12	5,383.26	7,177.68	0.00	0.00		48,898.47		

0.00

0.00

5,383.26

4,925.41

TOTAL:

3,000.54

4,863.83	4,863.83

4,925.41	4,925.41	4,186.98	4,646.12

7,177.68

48,898.47

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2018	
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	7.00	6.00	6.00	4.00	4.00	5.00	6.00	0.00	0.00		53.00		
6013	KIDS 6-13 M & F NON-	3.00	3.00	3.00	1.00	2.00	2.00	3.00	3.00	3.00	5.00	0.00	0.00		28.00		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		2.00		
SUBTOTAL:	6.00	9.0	9.00	8.00	8.00	8.00	7.00	7.00	9.00	12.00	0.00	0.00		83.00		

TOTAL:	6.00	9.00	9.00	8.00	8.00	8.00	7.00	7.00	9.00	12.00	0.00	0.00		83.00		

KidsCare - FEE FOR SERVICE
For The Period Ending April 30, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	435.91	95.22	2,623.44	155.32	208.12	910.20	760.93	6,831.76	285.29	323.64	0.00	0.00		12,629.83		
6012	KIDS 1-5 M & F NON-M	17,818.20	23,910.93	41,066.47	10,852.14	23,200.54	30,924.13	15,084.25	18,192.21	27,107.41	25,020.69	0.00	0.00		233,176.97		
6013	KIDS 6-13 M & F NON-	21,381.26	42,458.84	32,205.69	36,184.67	48,662.03	65,580.26	43,289.81	61,904.18	80,840.20	52,914.92	0.00	0.00		485,421.86		
6014	KIDS 14-19 MALE NON-	4,092.52	9,111.78	7,520.30	8,179.81	15,900.23	26,536.66	53,254.15	62,744.54	29,036.72	7,948.18	0.00	0.00		224,324.89		
6015	KIDS 14-19 FEMALE NO	11,360.35	9,833.55	11,394.99	5,975.88	21,952.80	9,855.95	9,882.29	25,223.58	17,052.34	14,446.16	0.00	0.00		136,977.89		
SUBTOTAL:	55,088.24	85,410.32	94,810.8	9	61,347.82	109,923.72	133,807.20	122,271.43	174,896.27	154,321.96	100,653.59	0.00	0.00		1,092,531.44		

1,092,531.44

94,810.89	61,347.82	109,923.72	133,807.20	122,271.43	174,896.27	154,321.96	100,653.59	0.00	0.00	

TOTAL:

55,088.24

85,410.32

KidsCare - REINSURANCE
For The Period Ending April 30, 2018	
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	5,713.98	374.97	11,385.41	7,669.48	-2,505.57	0.00	7,485.87	0.00	0.00		86,156.60		
6013	KIDS 6-13 M & F NON-	23,428.15	0.01	255.09	24,441.89	101.23	21,913.86	22,070.66	30,978.95	77,811.71	94,759.76	0.00	0.00		295,761.31		
6014	KIDS 14-19 MALE NON-	11,115.43	438.49	14,379.19	93,503.73	8,087.98	8,236.95	64,477.22	79,980.96	62,326.51	86,915.49	0.00	0.00		429,461.95		
6015	KIDS 14-19 FEMALE NO	0.00	651,203.92	0.00	0.00	3,758.45	87.35	52.21	0.00	0.00	0.00	0.00	0.00		655,101.93		
SUBTOTAL:	90,333.62	651,642.42	14,876.7	0	123,659.60	12,322.63	41,623.57	94,269.57	108,454.34	140,138.22	189,161.12	0.00	0.00		1,466,481.79		

TOTAL:	90,333.62	651,642.42	14,876.70	123,659.60	12,322.63	41,623.57	94,269.57	108,454.34	140,138.22	189,161.12	0.00	0.00		1,466,481.79		

4

5

SUBTOTAL:	31,009.73	31,125.62	31,205.80	31,361.04	31,500.98	31,585.53	31,706.98	31,842.08	31,973.54	32,136.15	0.00	0.00	315,447.45	
TOTAL:	31,009.73	31,125.62	31,205.80	31,361.0	31,500.98	31,585.53	31,706.98	31,842.08	31,973.54	32,136.1	0.00	0.00	315,447.45	

110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending April 30, 2018

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending April 30, 2018

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	401,207.40	400,674.28	400,066.04	396,494.84	400,414.71	399,696.98	398,642.93	0.00	0.00	3,997,643.73	
EPD	93,545,138.25	113,163,312.12	94,414,604.50	95,289,234.86	114,510,953.41	97,418,381.78	95,579,360.18	95,960,152.99	95,680,821.38	96,354,859.87	0.00	0.00	991,916,819.34	
TOTAL AHCCCS LTC	93,942,173.84	113,565,283.47	94,816,044.11	95,690,442.26	114,911,627.69	97,818,447.82	95,975,855.02	96,360,567.70	96,080,518.36	96,753,502.80	0.00	0.00	995,914,463.07	
DES/DD	112,834,320.04	113,252,020.57	113,539,308.13	115,757,014.71	116,277,092.27	116,593,965.04	138,064,532.23	121,154,619.37	121,661,219.68	122,276,805.64	0.00	0.00	1,191,410,897.68	
TOTAL DES LTC	112,834,320.04	113,252,020.57	113,539,308.13	115,757,014.71	116,277,092.27	116,593,965.04	138,064,532.23	121,154,619.37	121,661,219.68	122,276,805.64	0.00	0.00	1,191,410,897.68	
TOTAL LTC - CAP	206,776,493.88	226,817,304.04	208,355,352.24	211,447,456.97	231,188,719.96	214,412,412.86	234,040,387.25	217,515,187.07	217,741,738.04	219,030,308.44	0.00	0.00	2,187,325,360.75	

EPD/DD FEE-FOR-SERVICE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	11,075,900.07	14,779,589.19	11,033,723.36	10,412,298.35	12,734,588.76	11,775,495.52	13,299,107.73	10,811,040.82	12,120,927.37	11,349,851.92	0.00	0.00	119,392,523.09	
DES/DD	0.00	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 DES LTC	0.00	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	10,412,298.35	12,734,588.76	11,775,495.52	13,299,107.73	10,811,040.82	12,120,927.37	11,349,851.92	0.00	0.00	119,392,523.09	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	6,523,382.52	5,627,350.86	6,940,934.55	6,625,898.42	5,569,701.20	4,894,726.40	3,316,088.51	1,780,547.32	2,764,665.36	3,840,196.35	0.00	0.00	47,883,491.49	
DES/DD	2,184,772.28	802,286.33	1,007,130.96	484,551.79	(166,798.75)	697,835.00	578,894.67	1,417,096.78	626,046.21	941,293.30	0.00	0.00	8,573,108.57	
TOTAL DES LTC	2,184,772.28	802,286.33	1,007,130.96	484,551.79	(166,798.75)	697,835.00	578,894.67	1,417,096.78	626,046.21	941,293.30	0.00	0.00	8,573,108.57	
TOTAL LTC - REIN	8,708,154.80	6,429,637.19	7,948,065.51	7,110,450.21	5,402,902.45	5,592,561.40	3,894,983.18	3,197,644.10	3,390,711.57	4,781,489.65	0.00	0.00	56,456,600.06	

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	4,010,586.90	4,029,867.40	4,008,369.60	4,062,613.80	4,038,619.70	4,017,868.10	4,035,030.30	0.00	0.00	40,168,163.30	

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.

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending March 31, 2018

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	15,618,725.24	15,573,347.90	15,435,687.84	16,096,492.06	17,711,228.65	15,837,282.25	15,748,431.33	0.00	0.00	155,812,048.85	
010145	CRS ACUTE SEMI INTEGRATED - CAP	107,432.99	107,327.28	109,527.17	176,736.78	176,800.34	179,559.38	188,515.73	205,705.59	188,675.54	188,812.55	0.00	0.00	1,629,093.35	
999125	CRS SEMI INTEGRATED PLAN - CAP	5,627,771.65	5,652,158.42	5,654,094.27	5,982,688.40	6,001,026.22	6,008,949.05	6,321,699.71	7,015,957.74	6,324,617.87	6,311,862.71	0.00	0.00	60,900,826.04	
999135	CRS ONLY PLAN - CAP	549,147.69	552,857.53	553,002.70	635,452.80	630,300.48	630,300.48	650,178.18	709,720.40	642,402.36	642,402.36	0.00	0.00	6,195,764.98	
Subtotal	20,947,188.37	20,920,181.10	20,836,803.81	22,413,603.22	22,381,474.94	22,254,496.75	23,256,885.68	25,642,612.38	22,992,978.02	22,891,508.95	0.00	0.00	224,537,733.22	

999155	CRS REINSURANCE ONLY	2,281,891.03	2,401,136.52	2,189,272.25	3,602,112.00	1,225,677.04	4,658,867.95	3,576,024.19	1,281,511.01	2,326,460.24	3,545,167.14	0.00	0.00	27,088,119.37	
Subtotal	2,281,891.03	2,401,136.52	2,189,272.25	3,602,112.00	1,225,677.04	4,658,867.95	3,576,024.19	1,281,511.01	2,326,460.24	3,545,167.14	0.00	0.00	27,088,119.37	

23,229,079.40	23,321,317.62	23,026,076.06	26,015,715.22	23,607,151.98	26,913,364.70	26,832,909.87	26,924,123.39	25,319,438.26	26,436,676.09	0.00	0.00	251,625,852.59	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending April 30, 2018

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	16,313.75	16,268.09	16,115.94	15,981.51	15,735.49	15,660.38	15,558.73	0.00	0.00	160,942.37	
010145	CRS ACUTE SEMI INTEGRATED - MM	195.65	195.43	199.53	196.15	195.13	198.20	198.61	199.70	199.33	198.52	0.00	0.00	1,976.25	
999125	CRS SEMI INTEGRATED PLAN - MM	6,511.77	6,545.15	6,549.73	6,512.81	6,535.43	6,541.34	6,554.01	6,524.45	6,560.04	6,547.43	0.00	0.00	65,382.16	
999135	CRS ONLY PLAN - MM	1,088.48	1,097.02	1,097.63	1,103.00	1,094.00	1,094.00	1,080.00	1,078.00	1,065.00	1,062.00	0.00	0.00	10,859.13	
Subtotal	24,318.08	24,286.33	24,184.46	24,125.71	24,092.65	23,949.48	23,814.13	23,537.64	23,484.75	23,366.68	0.00	0.00	239,159.91	

24,318.08	24,286.33	24,184.46	24,125.71	24,092.65	23,949.48	23,814.13	23,537.64	23,484.75	23,366.68	0.00	0.00	239,159.91	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS
For the Period Ending April 30, 2018

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	-2,220.45	0.00	0.00	0.00	0.00	-13,658.86	
010715	HEALTH CHOICE INTEGRATED - CAP	10,197,580.04	10,274,195.37	10,255,273.22	8,373,890.55	8,366,509.79	8,298,139.64	8,403,803.81	8,427,778.97	8,431,142.52	8,359,725.78	0.00	0.00	89,388,039.69	
010725	CENPATICO INTEGRATED - CAP	-783.94	-24,049.79	0.00	-4,860.42	-2,052.18	0.00	0.00	-4,860.42	0.00	0.00	0.00	0.00	-36,606.75	
010735	CENPATICO INTEGRATED - CAP	22,400,947.95	22,510,414.85	22,416,469.76	22,091,028.68	22,072,263.54	22,170,428.26	22,150,987.83	22,158,834.98	22,264,151.63	22,125,566.69	0.00	0.00	222,361,094.17	
010795	MERCY MARICOPA INTEGRATED - CAP	50,665,969.36	51,176,641.74	51,188,836.00	51,303,200.80	51,261,845.56	51,196,742.47	51,530,063.54	51,688,961.37	52,106,689.17	51,940,932.69	0.00	0.00	514,059,882.70	
078999	MERCY MARICOPA INTEGRATED - CAP	-20,396.68	-50,403.75	-2,242.66	-24,305.07	-6,767.58	-3,660.95	-6,767.58	0.00	-7,786.36	-6,767.58	0.00	0.00	-129,098.21	
Subtotal	83,243,316.73	83,875,360.01	83,858,336.32	81,738,954.54	81,691,799.13	81,661,649.42	82,078,087.60	82,268,494.45	82,794,196.96	82,419,457.58	0.00	0.00	825,629,652.74	

83,243,316.73	83,875,360.01	83,858,336.32	81,738,954.54	81,691,799.13	81,661,649.42	82,078,087.60	82,268,494.45	82,794,196.96	82,419,457.58	0.00	0.00	825,629,652.74	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS
For the Period Ending April 30, 2018

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	-1.30	0.00	0.00	0.00	0.00	-8.19	
010715	HEALTH CHOICE INTEGRATED - MM	5,773.09	5,816.79	5,807.77	5,834.93	5,837.96	5,794.55	5,861.27	5,878.72	5,879.44	5,831.24	0.00	0.00	58,315.76	
010725	CENPATICO INTEGRATED - MM	-0.48	-15.26	0.00	-2.99	-1.26	0.00	0.00	-3.00	0.00	0.00	0.00	0.00	-22.99	
010735	CENPATICO INTEGRATED - MM	13,605.33	13,671.75	13,615.72	13,643.72	13,634.31	13,694.07	13,681.08	13,686.50	13,750.73	13,666.22	0.00	0.00	136,649.43	
010795	MERCY MARICOPA INTEGRATED - MM	21,387.32	21,602.60	21,609.35	21,699.60	21,684.36	21,654.54	21,795.39	21,864.18	22,040.18	21,970.54	0.00	0.00	217,308.06	
078999	MERCY MARICOPA INTEGRATED - MM	-9.09	-22.49	-0.99	-10.76	-3.00	-3.00	-3.00	0.00	-3.45	-3.00	0.00	0.00	-58.78	
Subtotal	40,756.17	41,046.50	41,031.85	41,164.50	41,152.37	41,140.16	41,334.74	41,425.10	41,666.90	41,465.00	0.00	0.00	412,183.29	

40,756.17	41,046.50	41,031.85	41,164.50	41,152.37	41,140.16	41,334.74	41,425.10	41,666.90	41,465.00	0.00	0.00	412,183.29	

GRAND TOTAL

Behavioral Health Expenditures by RHBA
For the Period Ending April 30, 2018

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

010705	KC - HEALTH CHOICE RBHA- BHCAP	
130,214.18	132,840.19	133,937.90	138,409.04	142,097.56	146,420.71	143,376.81	147,456.33	151,103.25	159,715.71	0.00	0.00	1,425,571.68	
010705	HEALTH CHOICE RBHA- BHCAP	12,219,678.67	11,888,800.32	11,848,495.84	12,784,338.76	13,273,469.98	12,669,734.04	12,903,058.36	12,483,253.74	12,349,844.65	12,375,166.91	0.00	0.00	124,795,841.27	
010730	KC - CENPATICO RBHA - BHCAP	305,454.94	307,418.81	321,499.61	320,344.77	320,344.19	333,591.42	333,319.09	339,582.79	350,405.72	374,917.03	0.00	0.00	3,306,878.37	
010730	CENPATICO RBHA - BHCAP	30,350,921.56	30,432,248.88	30,197,062.83	35,964,000.97	35,541,597.13	34,285,917.24	34,463,282.71	33,641,991.12	33,738,920.00	33,414,408.93	0.00	0.00	332,030,351.37	
010789	KC - MERCY MARICOPA RBHA - BHCAP	416,639.57	429,267.84	438,344.78	526,726.73	537,582.55	556,179.50	558,124.63	566,578.26	591,041.45	629,350.53	0.00	0.00	5,249,835.84	
010789	MERCY MARICOPA RBHA - BHCAP	45,266,368.31	45,513,994.33	45,107,285.50	55,063,984.96	55,356,770.57	54,859,943.42	54,415,112.34	53,750,189.24	53,585,507.85	53,013,898.22	0.00	0.00	515,933,054.74	
Subtotal	88,689,277.23	
88,704,570.37	
88,046,626.46	
104,797,805.23	
105,171,861.98	
102,851,786.33	102,816,273.94	
100,929,051.48	100,766,822.92	
99,967,457.33	
0.00	
0.00	
982,741,533.27	

010700	HEALTH CHOICE INTEGRATED - CAP	0.00	-11,438.41	0.00	0.00	0.00	0.00	0.00	-2,220.45	0.00	0.00	0.00	0.00	-13,658.86	
010715	HEALTH CHOICE INTEGRATED - CAP	10,197,580.04	10,274,195.37	10,255,273.22	8,373,890.55	8,366,509.79	8,298,139.64	8,403,803.81	8,427,778.97	8,431,142.52	8,359,725.78	0.00	0.00	89,388,039.69	
010725	CENPATICO INTEGRATED - CAP	-783.94	-24,049.79	0.00	-4,860.42	-2,052.18	0.00	0.00	-4,860.42	0.00	0.00	0.00	0.00	-36,606.75	
010735	CENPATICO INTEGRATED - CAP	22,400,947.95	22,510,414.85	22,416,469.76	22,091,028.68	22,072,263.54	22,170,428.26	22,150,987.83	22,158,834.98	22,264,151.63	22,125,566.69	0.00	0.00	222,361,094.17	
010795	MERCY MARICOPA INTEGRATED - CAP	50,665,969.36	51,176,641.74	51,188,836.00	51,303,200.80	51,261,845.56	51,196,742.47	51,530,063.54	51,688,961.37	52,106,689.17	51,940,932.69	0.00	0.00	514,059,882.70	
078999	MERCY MARICOPA INTEGRATED - CAP	-20,396.68	-50,403.75	-2,242.66	-24,305.07	-6,767.58	-3,660.95	-6,767.58	0.00	-7,786.36	-6,767.58	0.00	0.00	-129,098.21	
Subtotal	83,243,316.73	83,875,360.01	83,858,336.32	81,738,954.54	81,691,799.13	81,661,649.42	82,078,087.60	82,268,494.45	82,794,196.96	82,419,457.58	0.00	0.00	825,629,652.74	

171,932,593.96

172,579,930.38 171,904,962.78 186,536,759.77 186,863,661.11 184,513,435.75 184,894,361.54 183,197,545.93 183,561,019.88 182,386,914.91

0.00

0.00

1,808,371,186.01

GRAND TOTAL