August 27, 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 2019 Appropriation Status Report for the Period Ended July 31, 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 July 31, 2018.

Status Summary – AHCCCS is in the process of finalizing its Fiscal Year 2020 budget request, including an update of Fiscal Year 2019 for submission to the Governor’s Office of Strategic Planning and Budgeting pursuant to A.R.S. § 35-113. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

Enrollment Update – July 2018 enrollment is 1,854,438 members, a 5,345 member increase over the prior month. Enrollment for August 2018 increased to 1,861,352 members, a 6,914 member change.

Major August 2018 changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 2,516; Supplemental Security Income – increase of 221; Prop 204 Restoration - increase of 1,153; Adult Expansion – increase of 350; Medicare Cost Sharing – increase of 502; KidsCare – increase of 456; and Federal Emergency Services - decrease of 1,311.

Tobacco Funds Revenue Update - Tobacco tax collections through July 2018 are $1.7 million more  than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2019 appropriations.

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

Sincerely,

Thomas J. Betlach Director

Enclosure

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 August 27, 2018
Page 2

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 2019
Through July 31, 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 2019…	2
Appropriated Expenditures by Funding Source…	3
Appropriated Revenue Received Detail Schedule…	5
FOOTNOTES	7
CASELOAD AND EXPENDITURES BY RATE CODE	10

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 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	$	88,785,300	$	4,848,437	$	4,848,437	$	-	$	88,785,300	$	-	
AHCCCS Prop 204 Administration	14,171,100	1,170,016	1,170,016	-	14,171,100	-	
DES Eligibility	91,874,500	6,259,440	6,259,440	-	91,874,500	-	
DES Prop 204 Eligibility	44,358,700	1,733,228	1,733,228	-	44,358,700	-	
ADOA Data Center	19,325,800	-	-	-	19,325,800	-	
School District Suicide Prevention Coordinator	100,000	-	-	-	100,000	-	

TOTAL ADMINISTRATION	 	258,615,400	 	14,011,121	 	14,011,121	 	-		 	258,615,400	 	-	

Traditional Medicaid Services	5,345,876,000	418,099,640	418,099,640	-	5,345,876,000	-	
Proposition 204 Services	3,953,396,600	300,357,652	300,357,652	-	3,953,396,600	-	
ACA Adult Expansion	565,675,000	41,272,670	41,272,670	-	565,675,000	-	
KidsCare Services	81,846,900	6,237,585	6,237,585	-	81,846,900	-	
ALTCS Services	1,605,757,300	120,379,895	120,379,895	-	1,605,757,300	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	28,612,400	-	-	-	28,612,400	-	
Voluntary Political Subdivision Programs	296,390,800	34,083,779	34,083,779	-	296,390,800	-	
CMDP	199,914,500	14,292,115	14,292,115	-	199,914,500	-	
BHS - Public Schools	9,943,700	-	-	-	9,943,700	-	
Targeted Investment Program	70,000,000	-	-	-	70,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	6,096,843	6,096,843	-	77,646,900	-	
Supported Housing	5,324,800	393,733	393,733	-	5,324,800	-	
Crisis Services	16,391,300	1,358,858	1,358,858	-	16,391,300	-	

TOTAL PROGRAMMATIC	 	12,261,863,300	 	942,572,769	 	942,572,769	 	-		 	12,261,863,300	 	-	

TOTAL EXPENDITURES

  $	12,520,478,700

$	956,583,890

$	956,583,890	$

-	$   12,520,478,700	$	-

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 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	$	60,399,500	$	3,768,625	$	3,768,625	-	$	60,399,500	$	-	
Proposition 204 - Administrative Expenditures	21,685,600	1,064,022	1,064,022	-	21,685,600	-	
Programmatic Expenditures				
Traditional Medicaid Services	1,217,983,500	95,963,479	95,963,479	-	1,217,983,500	-	
Proposition 204 Services	102,608,900	6,539,018	6,539,018	-	102,608,900	-	
ACA Adult Expansion	6,461,300	131,507	131,507	-	6,461,300	-	
KidsCare Services	-	1,195	1,195	-	-	-	
ALTCS Services	198,722,900	16,560,242	16,560,242	-	198,722,900	-	
DSH and Rural Hospitals	8,905,100	-	-	-	8,905,100	-	
CMDP	60,213,900	4,312,252	4,312,252	-	60,213,900	-	
BHS - Public Schools	3,000,000	-	-	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	6,096,843	6,096,843	-	77,646,900	-	
Supported Housing	5,324,800	393,733	393,733	-	5,324,800	-	
Crisis Services	 	14,141,100	 	1,171,342	 	1,171,342	 	-	 	14,141,100	 	- 	
TOTAL GF EXPENDITURES	1,777,093,500	136,002,259	136,002,259	-	1,777,093,500	-	

FEDERAL		
Administrative Expenditures	139,025,200	7,337,163	7,337,163	-	139,025,200	-	
Proposition 204 - Administrative Expenditures	33,027,100	1,839,222	1,839,222	-	33,027,100	-	
Programmatic Expenditures				
Traditional Medicaid Services	3,345,433,900	278,591,500	278,591,500	-	3,345,433,900	-	
Proposition 204 Services	3,424,557,600	259,565,873	259,565,873	-	3,424,557,600	-	
ACA Adult Expansion	530,669,800	38,908,702	38,908,702	-	530,669,800	-	
KidsCare Services	69,695,600	5,604,611	5,604,611	-	69,695,600	-	
ALTCS Services and Nursing Facility Assessment	1,003,709,000	80,869,849	80,869,849	-	1,003,709,000	-	
DSH and Rural Hospitals	24,794,400	-	-	-	24,794,400	-	
CMDP	139,700,600	9,979,863	9,979,863	-	139,700,600	-	
BHS - Public Schools	6,943,700	-	-	-	6,943,700	-	
Targeted Investment Program	48,226,900	-	-	-	48,226,900	-	
Voluntary Political Subdivision Programs - See Note 5	 	206,683,800	 	23,574,942	 	23,574,942	 	-	 	206,683,800	 	- 	
TOTAL FEDERAL EXPENDITURES	8,972,467,600	706,271,725	706,271,725	-	8,972,467,600	-	

Administrative Expenditures Proposition 204 - BNCF	

COUNTY

3,756,200	

-	-	-	3,756,200	-	
Programmatic Expenditures						
Traditional Medicaid Services Acute Care	49,687,700	3,876,075	3,876,075	-	49,687,700	-	
ALTCS Services	 	249,980,000	 	21,041,236	 	21,041,236	 	-	 	249,980,000	 	- 	
TOTAL COUNTY EXPENDITURES	303,423,900	24,917,311	24,917,311	-	303,423,900	-	

TOBACCO FUNDS		
Programmatic Expenditures						
Traditional Medicaid Services - Medically Needy	68,040,500	6,028,304	6,028,304	-	68,040,500	-	
Proposition 204 Services - Emergency Health Services	17,966,100	1,653,481	1,653,481	-	17,966,100	-	
Proposition 204 Services - Proposition 204 Protection	37,728,900	3,472,311	3,472,311	-	37,728,900	-	
Proposition 204 Services - ATLSF	 	87,000,000	 	- 	 	- 	 	-	 	87,000,000	 	- 	
TOTAL TOBACCO EXPENDITURES	210,735,500	11,154,097	11,154,097	-	210,735,500	-	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 2018 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

	OTHER			

Administrative Expenditures				
Prescription Drug Rebate Program	721,800	2,089	2,089	-	721,800	-	
Programmatic Expenditures						
Traditional Medicaid Services - IGA Fund	10,260,700	-	-	-	10,260,700	-	
Acute Care - Prescription Drug Rebate Program State Match	140,158,600	11,679,883	11,679,883	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	514,085,200	21,911,442	21,911,442	-	514,085,200	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	631,533	631,533	-	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	1,223,016	1,223,016	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment & IGA Fund	283,535,100	29,126,969	29,126,969	-	283,535,100	-	
ACA Adult Expansion - Hospital Assessment & IGA Fund	28,543,900	2,232,461	2,232,461	-	28,543,900	-	
Traditional Medicaid Services - TPL	194,700	42,072	42,072	-	194,700	-	
ALTCS Services - TPL	-	54,018	54,018	-	-	-	
ALTCS Services - Nursing Facility Assessment	109,345,000	-	-	-	109,345,000	-	
Targeted Investment Program	21,773,100	-	-	-	21,773,100	-	
KidsCare Services Premiums	12,151,300	631,779	631,779	-	12,151,300	-	
Freedom to Work Premiums	31,200	6,884	6,884	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	187,517	187,517	-	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	89,707,000	 	10,508,837	 	10,508,837	 	-	 	89,707,000	 	- 	
TOTAL OTHER EXPENDITURES	1,256,758,200	78,238,499	78,238,499	-	1,256,758,200	-	

TOTAL		
Administrative Expenditures	258,615,400	14,011,121	14,011,121	-	258,615,400	-	
Acute Care	10,656,106,000	822,192,875	822,192,875	-	10,656,106,000	-	
Long Term Care	 	1,605,757,300	 	120,379,895	 	120,379,895	 	-	 	1,605,757,300	 	- 	
TOTAL EXPENDITURES	  $	12,520,478,700	$	956,583,890	$	956,583,890	$	-	$	12,520,478,700	$	-	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending July 31, 2018

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,296,749,400	$	99,863,611	$	99,732,104	
Proposition 204 Services & Administrative	124,294,500	7,603,040	7,603,040	
KidsCare Services	-	1,195	1,195	
ALTCS Services	198,722,900	16,560,242	16,560,242	
Behavioral Health Traditional Medicaid Services	 	157,326,700	 	11,974,170	 	11,974,170	
TOTAL	1,777,093,500	136,002,259	135,870,751	

FEDERAL:
Acute & Administrative	7,759,362,400	609,817,402	612,884,069	
KidsCare Services	69,695,600	5,604,610.79	6,303,862	
ALTCS Services	1,003,709,000	80,869,849.33	80,869,849	
Behavioral Health Traditional Medicaid Services	 	139,700,600	 	9,979,863	 	9,989,765	
TOTAL	8,972,467,600	706,271,725	710,047,545	

COUNTY:				
Acute & Administrative	53,443,900		3,876,075		2,206,787	
ALTCS Services	 	249,980,000		 	21,041,236		 	23,379,565	
TOTAL	303,423,900		24,917,311		25,586,352	

TOBACCO FUNDS:						
Traditional Medicaid Services	68,040,500		6,028,304		6,028,304	
Proposition 204 Services	 	142,695,000		 	5,125,793		 	5,125,793	
TOTAL	210,735,500		11,154,097		11,154,097	

OTHER:

Administrative	721,800	2,089	2,089	
Traditional Medicaid Services - IGA Fund	10,260,700	-		
Acute Care - Prescription Drug Rebate Program	654,243,800	33,591,325	33,591,325	
Long Term Care - Prescription Drug Rebate Program	44,000,400	1,854,549	1,854,549	
Hospital Assessment	312,079,000	31,359,430	-	
ALTCS - Nursing Facility Assessment	109,345,000	-	-	
Acute TPL - Note 1	194,700	42,072	42,072	
LTC TPL - Note 1	-	54,018	54,018	
KidsCare TPL - Note 1	-	-	-	
Member Premiums - CHIP	12,151,300	631,779	631,779	
Member Premiums - Freedom to Work	31,200	6,884	6,884	
Targeted Investment Program	21,773,100	-	-	
Behavioral Health Traditional Medicaid Services	2,250,200	187,517	-	
Voluntary Political Subdivision - State Match	 	89,707,000	 	10,508,837	 	14,383,636	
TOTAL	1,256,758,200	78,238,499	50,566,352	

TOTAL REVENUE

$	12,520,478,700

$	956,583,890

$	933,225,097

5

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 2018	
Note 1:	Third Party Liability Collections:	July 2018		July 2017		July 1, 2018		July 1, 2017	
	Gross Collections:					July 31, 2018		July 31, 2017	
	Acute	$	511,802		$	698,612		$	511,802		$	698,612	
	LTC	255,878		895,987		255,878		895,987	
	KidsCare	-		85		-		85	
	Total TPL Collections	  $	767,680		$	1,594,684		$	767,680		$	1,594,684	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	42,072		$	56,619		$	42,072		$	56,619		
LTC	54,018		203,730		54,018		203,730		
KidsCare	-		17		-		17		
Total Expenditure Offsets	  $	96,090		$	260,366		$	96,090		$	260,366		

FY 19 Total		
Note 2:	Authorized Positions	1,188.0		
	Actual Positions as of July 31, 2018	1,074.0		

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 2018

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2018	$	3,749,445	
	Revenues	600,541	
	Transfers-In	 	47,712	
	Total Revenues	 	648,252	
	Expenditures Transfers-out
Total Expenditures	531,494
 	-	
 	531,494	
	Ending Balance July 31, 2018	  $	3,866,203	

Of the $3,866,203 ending balance, $1,153,206 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through August 2018.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.
Schedule of Outstanding Liabilities
As of July 31, 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 July 31, 2018 Expenditures

State Match	Federal	Total

DSH Voluntary	$	1,000,000	$	2,250,975	$	3,250,975	
GME Voluntary	9,508,837	21,323,967	30,832,804	

Total Voluntary Political Subdivision Program Expenditure $

10,508,837	$

23,574,942 $

34,083,779

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending July 31, 2018

TITLE XIX TRADITIONAL

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

TOTAL

CAPITATION - ACUTE	275,524,500	0	0	0	0	0	0	0	0	0	0	0	275,524,500	
CAPITATION - AIMHS	26,685	0	0	0	0	0	0	0	0	0	0	0	26,685	
CAPITATION - LTC	225,067,725	0	0	0	0	0	0	0	0	0	0	0	225,067,725	
MENTAL HEALTH - CHILD	27,816,533	0	0	0	0	0	0	0	0	0	0	0	27,816,533	
MENTAL HEALTH - ADULT	502,900	0	0	0	0	0	0	0	0	0	0	0	502,900	
MENTAL HEALTH - GENERAL	16,629,284	0	0	0	0	0	0	0	0	0	0	0	16,629,284	
MENTAL HEALTH - CMDP	10,235,716	0	0	0	0	0	0	0	0	0	0	0	10,235,716	
MENTAL HEALTH - DD	5,967,451	0	0	0	0	0	0	0	0	0	0	0	5,967,451	
CHILDREN'S REHAB SERVICES	6,969,555	0	0	0	0	0	0	0	0	0	0	0	6,969,555	
FEE FOR SERVICE - ACUTE	37,223,809	0	0	0	0	0	0	0	0	0	0	0	37,223,809	
FFS - PRIOR QUARTER COVERAGE	548,797	0	0	0	0	0	0	0	0	0	0	0	548,797	
EMERGENCY SERVICES - FEDERAL	3,335,843	0	0	0	0	0	0	0	0	0	0	0	3,335,843	
FFS MEDICAID IN PUBLIC SCHOOLS	611,834	0	0	0	0	0	0	0	0	0	0	0	611,834	
QMB - FEE FOR SERVICE	620,783	0	0	0	0	0	0	0	0	0	0	0	620,783	
INPATIENT INMATES FFS	52,966	0	0	0	0	0	0	0	0	0	0	0	52,966	
FFS TRBHA FEE FOR SERVICE	11,384,976	0	0	0	0	0	0	0	0	0	0	0	11,384,976	
STATE ONLY TRBHA FFS	80,691	0	0	0	0	0	0	0	0	0	0	0	80,691	
PINAL COUNTY INMATES FFS	293	0	0	0	0	0	0	0	0	0	0	0	293	
YUMA COUNTY INMATES FFS	106	0	0	0	0	0	0	0	0	0	0	0	106	
PIMA COUNTY INMATES FFS	0	0	0	0	0	0	0	0	0	0	0	0	0	
MARICOPA CTY INMATES FFS	13,281	0	0	0	0	0	0	0	0	0	0	0	13,281	
FEE FOR SERVICE - LTC	10,718,670	0	0	0	0	0	0	0	0	0	0	0	10,718,670	
LFFS - PRIOR QUARTER COVERAGE	48,459	0	0	0	0	0	0	0	0	0	0	0	48,459	
INPATIENT INMATES LTC FFS	21	0	0	0	0	0	0	0	0	0	0	0	21	
MARICOPA CTY INMATES LTC FFS	223	0	0	0	0	0	0	0	0	0	0	0	223	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,240,312	0	0	0	0	0	0	0	0	0	0	0	1,240,312	
REINSURANCE - ACUTE	16,535,933	0	0	0	0	0	0	0	0	0	0	0	16,535,933	
REINSURANCE - LTC	5,446,473	0	0	0	0	0	0	0	0	0	0	0	5,446,473	
SMIB - ACUTE	15,670,269	0	0	0	0	0	0	0	0	0	0	0	15,670,269	
HIB - ACUTE	661,993	0	0	0	0	0	0	0	0	0	0	0	661,993	
Q1	2,598,480	0	0	0	0	0	0	0	0	0	0	0	2,598,480	
SMIB - LTC	3,797,393	0	0	0	0	0	0	0	0	0	0	0	3,797,393	
HIB - LTC	344,054	0	0	0	0	0	0	0	0	0	0	0	344,054	
SUBTOTAL	679,676,008	0	0	0	0	0	0	0	0	0	0	0	679,676,008	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending July 31, 2018

TITLE XIX PROP 204

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

TOTAL

CAPITATION - ACUTE	219,877,148	0	0	0	0	0	0	0	0	0	0	0	219,877,148	
CAPITATION - AIMHS	7,757	0	0	0	0	0	0	0	0	0	0	0	7,757	
MENTAL HEALTH - CHILD	838	0	0	0	0	0	0	0	0	0	0	0	838	
MENTAL HEALTH - ADULT	794,879	0	0	0	0	0	0	0	0	0	0	0	794,879	
MENTAL HEALTH - GENERAL	30,005,430	0	0	0	0	0	0	0	0	0	0	0	30,005,430	
MENTAL HEALTH - CMDP	529	0	0	0	0	0	0	0	0	0	0	0	529	
CHILDREN'S REHAB SERVICES	25,122	0	0	0	0	0	0	0	0	0	0	0	25,122	
FEE FOR SERVICE - ACUTE	28,102,125	0	0	0	0	0	0	0	0	0	0	0	28,102,125	
FFS - PRIOR QUARTER COVERAGE	1,195,983	0	0	0	0	0	0	0	0	0	0	0	1,195,983	
EMERGENCY SERVICES - FEDERAL	2,496,925	0	0	0	0	0	0	0	0	0	0	0	2,496,925	
FFS MEDICAID IN PUBLIC SCHOOLS	278	0	0	0	0	0	0	0	0	0	0	0	278	
INPATIENT INMATES FFS	567,184	0	0	0	0	0	0	0	0	0	0	0	567,184	
FFS TRBHA FEE FOR SERVICE	6,471,241	0	0	0	0	0	0	0	0	0	0	0	6,471,241	
STATE ONLY TRBHA FFS	188,380	0	0	0	0	0	0	0	0	0	0	0	188,380	
COCONINO COUNTY INMATES FFS	4,817	0	0	0	0	0	0	0	0	0	0	0	4,817	
YUMA COUNTY INMATES FFS	380	0	0	0	0	0	0	0	0	0	0	0	380	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	0	0	0	0	0	0	0	0	0	
PINAL COUNTY INMATES FFS	4,804	0	0	0	0	0	0	0	0	0	0	0	4,804	
MARICOPA CTY INMATES FFS	83,205	0	0	0	0	0	0	0	0	0	0	0	83,205	
PIMA COUNTY INMATES FFS	6,512	0	0	0	0	0	0	0	0	0	0	0	6,512	
REINSURANCE - ACUTE	6,285,338	0	0	0	0	0	0	0	0	0	0	0	6,285,338	
SMIB - ACUTE	6,797,934	0	0	0	0	0	0	0	0	0	0	0	6,797,934	
HIB - ACUTE	6,350	0	0	0	0	0	0	0	0	0	0	0	6,350	
SUBTOTAL	302,923,157	0	0	0	0	0	0	0	0	0	0	0	302,923,157	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending July 31, 2018

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

TOTAL

CAPITATION - ACUTE	28,491,857	0	0	0	0	0	0	0	0	0	0	0	28,491,857	
CAPITATION - AIMHS	606	0	0	0	0	0	0	0	0	0	0	0	606	
MENTAL HEALTH - ADULT	46,413	0	0	0	0	0	0	0	0	0	0	0	46,413	
MENTAL HEALTH - GENERAL	5,571,389	0	0	0	0	0	0	0	0	0	0	0	5,571,389	
CHILDREN'S REHAB SERVICES	2,393	0	0	0	0	0	0	0	0	0	0	0	2,393	
FEE FOR SERVICE - ACUTE	2,226,936	0	0	0	0	0	0	0	0	0	0	0	2,226,936	
FFS - PRIOR QUARTER COVERAGE	320,363	0	0	0	0	0	0	0	0	0	0	0	320,363	
EMERGENCY SERVICES - FEDERAL	3,121,276	0	0	0	0	0	0	0	0	0	0	0	3,121,276	
FFS MEDICAID IN PUBLIC SCHOOLS	32	0	0	0	0	0	0	0	0	0	0	0	32	
INPATIENT INMATES FFS	38,006	0	0	0	0	0	0	0	0	0	0	0	38,006	
FFS TRBHA FEE FOR SERVICE	168,451	0	0	0	0	0	0	0	0	0	0	0	168,451	
MARICOPA CTY INMATES FFS	3,611	0	0	0	0	0	0	0	0	0	0	0	3,611	
REINSURANCE - ACUTE	535,179	0	0	0	0	0	0	0	0	0	0	0	535,179	
	40,526,512	0	0	0	0	0	0	0	0	0	0	0	40,526,512	
	1,023,125,676	0	0	0	0	0	0	0	0	0	0	0	1,023,125,676	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
CAPITATION - AIMHS	80	0	0	0	0	0	0	0	0	0	0	0	80	
MENTAL HEALTH - CHILD	28	0	0	0	0	0	0	0	0	0	0	0	28	
MENTAL HEALTH - CMDP	-1,172	0	0	0	0	0	0	0	0	0	0	0	-1,172	
KidsCare - CAPITATION	4,425,409	0	0	0	0	0	0	0	0	0	0	0	4,425,409	
KidsCare - FEE FOR SERVICE	227,481	0	0	0	0	0	0	0	0	0	0	0	227,481	
KidsCare - MENTAL HEALTH	1,239,709	0	0	0	0	0	0	0	0	0	0	0	1,239,709	
KidsCare - REINSURANCE	238,957	0	0	0	0	0	0	0	0	0	0	0	238,957	
KidsCare - CHILD REHAB SERVICES	6,580	0	0	0	0	0	0	0	0	0	0	0	6,580	

6,137,071	0	0	0	0	0	0	0	0	0	0	0	6,137,071	

TOTAL TITLE XXI

1,029,262,747	0	0	0	0	0	0	0	0	0	0	0	1,029,262,747	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	49,121.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,121.18		
1007	TANF 21-44 FEMALE WI	72,257.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,257.76		
1008	TANF 45-64 M & F WIT	120,673.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,673.88		
1009	TANF 65+ M & F WITH	40,453.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,453.77		
100F	TANF 21-44 MALE WITH	4,453.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,453.29		
100G	TANF 21-44 FEMALE WI	405.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		405.14		
100H	TANF 45-64 M & F WIT	543.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		543.50		
100J	TANF 65+ M & F WITH	579.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		579.98		
1011	TANF <1 M & F NON-ME	4,923,029.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,923,029.72		
1012	TANF 01-05 M & F NON	2,455,010.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,455,010.89		
1013	TANF 06-13 M & F NON	4,179,744.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,179,744.92		
1014	TANF 14-20 MALE NON-	1,669,137.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,669,137.78		
1015	TANF 14-20 FEMALE N O	3,072,044.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,072,044.25		
1016	TANF 21-44 MALE NON-	4,618,080.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,618,080.17		
1017	TANF 21-44 FEMALE N O	23,256,202.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,256,202.53		
1018	TANF 45-64 M & F NON	9,538,179.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,538,179.97		
1019	TANF 65+ M & F NON-M	33,831.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,831.66		
101A	TANF < 1 M & F NON-M	412,738.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		412,738.62		
101B	TANF 01-05 M & F NON	8,213.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,213.25		
101C	TANF 06-13 M & F NON	6,283.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,283.96		
101D	TANF 14-20 MALE NON-	12,206.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,206.42		
101E	TANF 14-20 FEMALE N O	25,265.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,265.59		
101F	TANF 21-44 MALE NON-	118,532.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,532.60		
101G	TANF 21-44 FEMALE N O	377,363.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		377,363.34		
101H	TANF 44-64 M & F NON	90,148.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,148.09		
101J	TANF 65+ N & F NON-M	439.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		439.07		
1023	TANF 06-13 M & F WIT	114.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.55		
1025	TANF 14-20 FEMALE WI	532.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		532.34		
1026	TANF 21-44 MALE WITH	28,765.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,765.75		
1027	TANF 21-44 FEMALE WI	52,705.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,705.40		
1028	TANF 45-64 M & F WIT	77,124.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,124.38		
1029	TANF 65+ M & F WITH	33,801.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,801.77		
102F	TANF 21-44 MALE WITH	341.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		341.36		
102G	TANF 21-44 FEMALE WI	33.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.76		
102H	TANF 44-64 M & F WIT	167.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.76		
2100	SSI AGED WITH MEDIC A	709,220.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		709,220.28		

ACUTE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	31,093.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,093.15		
2110	SSI AGED NON-MEDICA
R	6,592,077.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,592,077.68		
211Z	SSI AGED NON-MEDICA R	83,027.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,027.56		
2120	SSI AGED WITH QMB	5,248,445.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,248,445.46		
212Z	SSI AGED WITH QMB P P	7,287.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,287.70		
2200	SSI DISABLED WITH M
E	1,659,152.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,659,152.59		
220Z	SSI DISABLED WITH M E	85,255.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,255.38		
2210	SSI DISABLED NON-ME
D	63,366,536.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,366,536.41		
221Z	SSI DISABLED NON-ME D	453,135.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453,135.12		
2220	SSI DISABLED WITH Q
M	15,296,127.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,296,127.40		
222Z	SSI DISABLED WITH Q M	14,341.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,341.02		
2300	SSI BLIND WITH MEDIC	9,264.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,264.92		
2310	SSI BLIND NON-MEDIC A	547,114.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		547,114.60		
231Z	SSI BLIND NON-MEDIC
A	2,043.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,043.29		
2320	SSI BLIND WITH QMB	49,144.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,144.44		
4301	SOBRA CHILD <1 M & F	442.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		442.86		
4302	SOBRA CHILD 01-05 M	5,159.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,159.40		
4303	SOBRA CHILD 06-13 M	3,139.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,139.48		
4304	SOBRA CHILD 14-20 MA	1,089.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,089.93		
4305	SOBRA CHILD 14-20 FE	2,794.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,794.02		
4311	SOBRA CHILD <1 M & F	15,876,503.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,876,503.58		
4312	SOBRA CHILD 01-05 M	21,930,498.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,930,498.29		
4313	SOBRA CHILD 06-13 M	28,371,187.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,371,187.60		
4314	SOBRA CHILD 14-20 MA	10,250,435.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,250,435.20		
4315	SOBRA CHILD 14-20 FE	15,089,068.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,089,068.23		
431A	SOBRA CHILD < 1 M &	127,910.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,910.44		
431B	SOBRA CHILD 01-05 M	221,960.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221,960.40		
431C	SOBRA CHILD 6-13 M&F	224,066.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,066.77		
431D	SOBRA CHILD 14-20 MA	176,040.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,040.96		
431E	SOBRA CHILD 14-20 FE	237,700.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237,700.73		
4322	SOBRA CHILD 01-05 M	454.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454.24		
4323	SOBRA CHILD 06-13 M	115.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.02		
4324	SOBRA CHILD 14-20 MA	169.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169.78		
4325	SOBRA CHILD 14-20 FE	230.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230.43		
5005	SOBRA PREG 14-20 FE M	266.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		266.17		
5007	SOBRA PREG 21-44 FE
M	21,170.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,170.46		

ACUTE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5008	SOBRA PREG 45-64 FE M	1,135.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,135.88		
500G	SOBRA PREG 21-44 FE
M	435.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		435.21		
500H	SOBRA PREG 45-64 FE M	439.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		439.07		
5013	SOBRA PREG 09-13 FE
M	215.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215.68		
5015	SOBRA PREG 14-20 FE M	852,527.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852,527.19		
5017	SOBRA PREG 21-44 FE
M	4,605,937.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,605,937.24		
5018	SOBRA PREG 45-64 FE M	19,914.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,914.87		
501E	SOBRA PREG 14-20 FE
M	47,493.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,493.67		
501G	SOBRA PREG 21-44 FE M	209,922.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,922.82		
501H	SOBRA PREG 45-64 FE
M	878.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		878.94		
5027	SOBRA PREG 21-44 FE M	22,924.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,924.89		
5028	SOBRA PREG 45-64 FE
M	2,363.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,363.74		
502G	SOBRA PREG 21-44 FE M	155.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155.24		
SUBTOTAL:	247,736,543.8	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,736,543.83		

1106	TANF EXPANDED 21-44	70,273.75	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	262,271.15	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	775,922.44	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
&	279,722.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	5,436.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	21,689.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	16,922.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	6,933.80	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	209.81	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	2,451.20	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	54,619.14	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	391,160.64	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	4,723,664.44	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	18,274,687.63	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	10,957,250.85	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
&	29,230.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

70,273.75	
262,271.15	
775,922.44	
279,722.70	
5,436.65	
21,689.44	
16,922.37	
6,933.80	
209.81	
2,451.20	
54,619.14	
391,160.64	
4,723,664.44	
18,274,687.63	
10,957,250.85	
29,230.75	

9910	TANF & SOBRA CHILDR E	1,566,824.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	24,386.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	107,966.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	12,526,470.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,225,646.7	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,566,824.34	
24,386.16	
107,966.05	
12,526,470.22	
14,225,646.77	

ACUTE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111D	TANF EXPANDED 14-20	3,527.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,527.61		
111E	TANF EXPANDED 14-20	6,692.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,692.13		
111F	TANF EXPANDED 21-44	126,877.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,877.50		
111G	TANF EXPANDED 21-44	282,393.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		282,393.11		
111H	TANF EXPANDED 45-64	122,461.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,461.87		
111J	TANF EXPANDED 65+ M
&	487.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		487.88		
1126	TANF EXPANDED 21-44	329,068.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		329,068.29		
1127	TANF EXPANDED 21-44	989,036.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989,036.79		
1128	TANF EXPANDED 45-64	1,543,278.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,543,278.97		
1129	TANF EXPANDED 65+ M
&	616,303.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		616,303.36		
112F	TANF EXPANDED 21-44	559.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		559.74		
112G	TANF EXPANDED 21-44	7,333.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,333.37		
112H	TANF EXPANDED 45-64	3,692.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,692.73		
112J	TANF EXPANDED 65+ M
&	1,155.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,155.86		
2400	SSI AGED EXPANDED WI	39,565.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,565.65		
240Z	SSI AGED EXPANDED
WI	27,316.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,316.98		
2410	SSI AGED EXPANDED N O	94,343.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,343.54		
241Z	SSI AGED EXPANDED N
O	3,257.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,257.97		
2420	SSI AGED EXPANDED WI	5,031,817.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,031,817.51		
242Z	SSI AGED EXPANDED
WI	4,679.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,679.60		
2600	SSI DISABLED EXPAND E	133,143.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133,143.35		
260Z	SSI DISABLED EXPAND
E	53,091.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,091.11		
2610	SSI DISABLED EXPAND E	1,681,462.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,681,462.82		
261Z	SSI DISABLED EXPAND
E	14,120.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,120.97		
2620	SSI DISABLED EXPAND E	10,663,975.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,663,975.16		
262Z	SSI DISABLED EXPAND
E	12,749.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,749.14		
SUBTOTAL:	57,664,839.7	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,664,839.77		

3504	ADULT 40-100% MALE 1	1,968.98	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	2,759.32	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	611.46	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	10,535.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	1,466.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,968.98	
2,759.32	
611.46	
10,535.82	
1,466.66	

9911	SB PAYMENT FOR TAN F	983,153.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	11,801.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	994,954.9	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
983,153.34	
11,801.65	
994,954.99	

ACUTE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
350H	ADULT 40-100% M&F 45	5,154.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,154.56		
3514	ADULT 40-100% MALE 1	2,845,519.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,845,519.41		
3515	ADULT 40-100% FEMAL E	3,072,774.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,072,774.76		
3516	ADULT 40-100% MALE 2	9,977,987.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,977,987.83		
3517	ADULT 40-100% FEMAL E	8,386,323.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,386,323.38		
3518	ADULT 40-100% M&F 45	19,918,279.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,918,279.36		
3519	ADULT 40-100% M&F 65	2,483.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,483.91		
351D	ADULT 40-100% MALE 1	77,272.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,272.85		
351E	ADULT 40-100% FEMAL E	97,130.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,130.22		
351F	ADULT 40-100% MALE 2	334,430.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334,430.46		
351G	ADULT 40-100% FEMAL E	259,135.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259,135.65		
351H	ADULT 40-100% M&F 45	537,529.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		537,529.45		
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		0.00		
3526	ADULT 40-100% MALE 2	1,479.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,479.44		
3527	ADULT 40-100% FEMAL E	939.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		939.87		
3529	ADULT 40-100% M&F 65	479.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		479.69		
352F	ADULT 40-100% MALE 2	1,386.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,386.98		
352G	ADULT 40-100% FEMAL E	678.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		678.80		
3705	ADULT <40% EXP FEMA
L	241.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241.60		
3706	ADULT <40% EXP MALE	6,634.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,634.62		
3707	ADULT <40% EXP FEMA L	7,737.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,737.99		
3708	ADULT <40% EXP M&F
4	8,526.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,526.04		
3709	ADULT <40% EXP M&F 6	872.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		872.68		
370F	ADULT <40% EXP MALE	1,663.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,663.65		
370G	ADULT <40% EXP FEMA L	9,948.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,948.52		
370H	ADULT <40% EXP M&F
4	4,127.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,127.71		
3714	ADULT <40% EXP MALE	5,253,165.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,253,165.59		
3715	ADULT <40% EXP FEMA L	4,697,295.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,697,295.30		
3716	ADULT <40% EXP MALE	35,701,388.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,701,388.63		
3717	ADULT <40% EXP FEMA L	21,640,367.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,640,367.01		
3718	ADULT <40% EXP M&F
4	42,836,702.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,836,702.21		
3719	ADULT <40% EXP M&F 6	11,355.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,355.36		
371D	ADULT <40% EXP MALE	207,217.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,217.97		
371E	ADULT <40% EXP FEMA L	185,752.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,752.11		
371F	ADULT <40% EXP MALE	1,852,063.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,852,063.30		
371G	ADULT <40% EXP FEMA L	1,096,410.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,096,410.83		

ACUTE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371H	ADULT <40% EXP M&F 4	1,511,524.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,511,524.26		
371J	ADULT <40% EXP M&F
6	1,562.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,562.82		
3726	ADULT <40% EXP MALE	512.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		512.97		
3727	ADULT <40% EXP FEMA L	811.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		811.52		
3728	ADULT <40% EXP M&F
4	1,563.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,563.39		
372G	ADULT <40% EXP FEMA L	957.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		957.86		
SUBTOTAL:	160,574,732.8	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,574,732.80		

248,881.78

3906	NEWLY ELIGIBLE MALE	1,351.75	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	870.61	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	15,087.06	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	2,842.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA
L	175.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	356.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,116,598.97	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	1,278,614.86	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	6,239,438.48	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	8,967,501.97	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	9,756,943.06	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	3,501.58	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	34,779.16	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	31,597.11	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	206,907.63	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	311,512.22	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	274,500.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	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	197.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	198.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,242,975.1	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,351.75	
870.61	
15,087.06	
2,842.79	
175.22	
356.87	
1,116,598.97	
1,278,614.86	
6,239,438.48	
8,967,501.97	
9,756,943.06	
3,501.58	
34,779.16	
31,597.11	
206,907.63	
311,512.22	
274,500.37	
0.00	
197.40	
0.00	
198.06	
28,242,975.17	

9939	BIRTH SUPP PAYMENT N	248,881.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	248,881.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

248,881.78

9935	BIRTH SUPP PAYMENT A	205,781.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	436,839.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	642,620.3	4	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
205,781.14	
436,839.20	
642,620.34	

ACUTE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4404	SOBRA 100-133% MALE	156.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156.35		
4413	SOBRA 100-133% M&F
6	5,672,058.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,672,058.64		
4414	SOBRA 100-133% MALE	2,129,249.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,129,249.04		
4415	SOBRA 100-133% FEMA L	3,036,152.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,036,152.98		
441C	SOBRA 100-133% M&F
6	53,617.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,617.91		
441D	SOBRA 100-133% MALE	41,497.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,497.28		
441E	SOBRA 100-133% FEMA L	52,971.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,971.55		
SUBTOTAL:	10,985,703.7	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,985,703.75		

9944	BIRTH SUPP PAYMENT S	25,159.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,159.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,159.98

25,159.98

4517	BC PATIENT FEMALE 2 1	5,417.23	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	45,038.46	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	165.56	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	-5,197.54	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	4,249.82	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	4,460.71	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	224.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	54,358.45	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,417.23	
45,038.46	
165.56	
-5,197.54	
4,249.82	
4,460.71	
224.21	
54,358.45	

8600	SSI BLIND FREEDOM/W O	3,796.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W
O	165.41	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	1,754,134.21	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	32,077.92	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	494,255.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	19,175.47	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	193,122.80	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	358.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,497,087.34	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,796.95	
165.41	
1,754,134.21	
32,077.92	
494,255.91	
19,175.47	
193,122.80	
358.67	
2,497,087.34	

523,893,504.97

523,893,504.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	84.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84.41		
1007	TANF 21-44 FEMALE WI	130.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.34		
1008	TANF 45-64 M & F WIT	213.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213.69		
1009	TANF 65+ M & F WITH	92.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.24		
100F	TANF 21-44 MALE WITH	2.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.57		
100G	TANF 21-44 FEMALE WI	1.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.92		
100H	TANF 45-64 M & F WIT	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.67		
100J	TANF 65+ M & F WITH	3.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.73		
1011	TANF <1 M & F NON-ME	11,017.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,017.50		
1012	TANF 01-05 M & F NON	19,008.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,008.00		
1013	TANF 06-13 M & F NON	32,007.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,007.97		
1014	TANF 14-20 MALE NON-	8,747.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,747.23		
1015	TANF 14-20 FEMALE N O	11,247.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,247.71		
1016	TANF 21-44 MALE NON-	25,347.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,347.52		
1017	TANF 21-44 FEMALE N O	82,425.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,425.80		
1018	TANF 45-64 M & F NON	20,379.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,379.55		
1019	TANF 65+ M & F NON-M	71.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.48		
101A	TANF < 1 M & F NON-M	956.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		956.78		
101B	TANF 01-05 M & F NON	156.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156.06		
101C	TANF 06-13 M & F NON	115.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.92		
101D	TANF 14-20 MALE NON-	58.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.19		
101E	TANF 14-20 FEMALE N O	127.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.15		
101F	TANF 21-44 MALE NON-	704.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		704.65		
101G	TANF 21-44 FEMALE N O	1,759.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,759.37		
101H	TANF 44-64 M & F NON	320.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320.02		
101J	TANF 65+ N & F NON-M	1.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.51		
1023	TANF 06-13 M & F WIT	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1025	TANF 14-20 FEMALE WI	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1026	TANF 21-44 MALE WITH	68.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.12		
1027	TANF 21-44 FEMALE WI	113.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.41		
1028	TANF 45-64 M & F WIT	119.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119.20		
1029	TANF 65+ M & F WITH	77.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.00		
102F	TANF 21-44 MALE WITH	1.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.87		
102G	TANF 21-44 FEMALE WI	0.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.16		
102H	TANF 44-64 M & F WIT	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	4,176.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,176.51		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	245.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		245.48		
2110	SSI AGED NON-MEDICA
R	6,259.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,259.71		
211Z	SSI AGED NON-MEDICA R	148.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148.41		
2120	SSI AGED WITH QMB	29,956.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,956.77		
212Z	SSI AGED WITH QMB P P	59.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.79		
2200	SSI DISABLED WITH M
E	3,486.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,486.08		
220Z	SSI DISABLED WITH M E	190.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190.54		
2210	SSI DISABLED NON-ME
D	52,332.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,332.20		
221Z	SSI DISABLED NON-ME D	697.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697.62		
2220	SSI DISABLED WITH Q
M	26,997.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,997.33		
222Z	SSI DISABLED WITH Q M	39.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.44		
2300	SSI BLIND WITH MEDIC	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
2310	SSI BLIND NON-MEDIC A	507.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507.76		
231Z	SSI BLIND NON-MEDIC
A	3.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.82		
2320	SSI BLIND WITH QMB	224.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224.99		
4301	SOBRA CHILD <1 M & F	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4302	SOBRA CHILD 01-05 M	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00		
4303	SOBRA CHILD 06-13 M	27.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.15		
4304	SOBRA CHILD 14-20 MA	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
4305	SOBRA CHILD 14-20 FE	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
4311	SOBRA CHILD <1 M & F	35,058.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,058.63		
4312	SOBRA CHILD 01-05 M	172,167.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172,167.95		
4313	SOBRA CHILD 06-13 M	215,942.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,942.10		
4314	SOBRA CHILD 14-20 MA	55,854.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,854.27		
4315	SOBRA CHILD 14-20 FE	55,885.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,885.49		
431A	SOBRA CHILD < 1 M &	298.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298.08		
431B	SOBRA CHILD 01-05 M	3,988.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,988.50		
431C	SOBRA CHILD 6-13 M&F	4,063.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,063.34		
431D	SOBRA CHILD 14-20 MA	1,078.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,078.33		
431E	SOBRA CHILD 14-20 FE	1,168.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,168.36		
4322	SOBRA CHILD 01-05 M	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4323	SOBRA CHILD 06-13 M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4324	SOBRA CHILD 14-20 MA	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4325	SOBRA CHILD 14-20 FE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
5005	SOBRA PREG 14-20 FE M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
5007	SOBRA PREG 21-44 FE
M	34.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.81		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5008	SOBRA PREG 45-64 FE M	2.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.48		
500G	SOBRA PREG 21-44 FE
M	2.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.08		
500H	SOBRA PREG 45-64 FE M	1.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.51		
5013	SOBRA PREG 09-13 FE
M	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5015	SOBRA PREG 14-20 FE M	3,175.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,175.39		
5017	SOBRA PREG 21-44 FE
M	17,106.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,106.35		
5018	SOBRA PREG 45-64 FE M	39.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.78		
501E	SOBRA PREG 14-20 FE
M	238.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238.44		
501G	SOBRA PREG 21-44 FE M	979.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		979.10		
501H	SOBRA PREG 45-64 FE
M	3.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.18		
5027	SOBRA PREG 21-44 FE M	44.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.21		
5028	SOBRA PREG 45-64 FE
M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
502G	SOBRA PREG 21-44 FE M	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.77		
SUBTOTAL:	907,939.4	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		907,939.49		

1106	TANF EXPANDED 21-44	250.08	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	518.35	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	1,295.07	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
&	625.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	8.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	34.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	49.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	32.89	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	2.00	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	14.00	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	316.58	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	1,480.23	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	27,236.57	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	67,974.34	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	24,170.25	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
&	65.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

250.08	
518.35	
1,295.07	
625.28	
8.55	
34.70	
49.74	
32.89	
2.00	
14.00	
316.58	
1,480.23	
27,236.57	
67,974.34	
24,170.25	
65.57	

9910	TANF & SOBRA CHILDR E	257.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,079.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,358.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
257.00	
4.00	
18.00	
2,079.00	
2,358.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111D	TANF EXPANDED 14-20	21.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.24		
111E	TANF EXPANDED 14-20	32.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.75		
111F	TANF EXPANDED 21-44	758.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		758.18		
111G	TANF EXPANDED 21-44	1,310.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,310.31		
111H	TANF EXPANDED 45-64	469.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		469.75		
111J	TANF EXPANDED 65+ M
&	2.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.41		
1126	TANF EXPANDED 21-44	832.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		832.10		
1127	TANF EXPANDED 21-44	1,691.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,691.85		
1128	TANF EXPANDED 45-64	2,481.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,481.86		
1129	TANF EXPANDED 65+ M
&	1,349.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,349.11		
112F	TANF EXPANDED 21-44	3.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.54		
112G	TANF EXPANDED 21-44	6.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.93		
112H	TANF EXPANDED 45-64	13.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.05		
112J	TANF EXPANDED 65+ M
&	4.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.63		
2400	SSI AGED EXPANDED WI	231.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		231.60		
240Z	SSI AGED EXPANDED
WI	178.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178.66		
2410	SSI AGED EXPANDED N O	85.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.53		
241Z	SSI AGED EXPANDED N
O	6.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.22		
2420	SSI AGED EXPANDED WI	24,113.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,113.73		
242Z	SSI AGED EXPANDED
WI	38.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.31		
2600	SSI DISABLED EXPAND E	217.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217.26		
260Z	SSI DISABLED EXPAND
E	134.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134.96		
2610	SSI DISABLED EXPAND E	1,460.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,460.45		
261Z	SSI DISABLED EXPAND
E	24.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.07		
2620	SSI DISABLED EXPAND E	16,945.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,945.02		
262Z	SSI DISABLED EXPAND
E	24.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.45		
SUBTOTAL:	176,512.1	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,512.17		

3504	ADULT 40-100% MALE 1	1.99	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	2.00	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	0.73	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	20.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	1.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.99	
2.00	
0.73	
20.56	
1.25	

9911	SB PAYMENT FOR TAN F	163.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	165.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
163.00	
2.00	
165.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
350H	ADULT 40-100% M&F 45	4.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.40		
3514	ADULT 40-100% MALE 1	5,604.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,604.83		
3515	ADULT 40-100% FEMAL E	6,062.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,062.39		
3516	ADULT 40-100% MALE 2	18,785.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,785.56		
3517	ADULT 40-100% FEMAL E	15,773.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,773.50		
3518	ADULT 40-100% M&F 45	38,601.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,601.45		
3519	ADULT 40-100% M&F 65	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
351D	ADULT 40-100% MALE 1	105.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105.63		
351E	ADULT 40-100% FEMAL E	138.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.29		
351F	ADULT 40-100% MALE 2	459.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		459.37		
351G	ADULT 40-100% FEMAL E	352.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		352.13		
351H	ADULT 40-100% M&F 45	766.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		766.85		
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		0.00		
3526	ADULT 40-100% MALE 2	1.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.03		
3527	ADULT 40-100% FEMAL E	0.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.58		
3529	ADULT 40-100% M&F 65	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
352F	ADULT 40-100% MALE 2	0.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.96		
352G	ADULT 40-100% FEMAL E	0.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.41		
3705	ADULT <40% EXP FEMA
L	0.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.48		
3706	ADULT <40% EXP MALE	8.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.87		
3707	ADULT <40% EXP FEMA L	6.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.38		
3708	ADULT <40% EXP M&F
4	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.96		
3709	ADULT <40% EXP M&F 6	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
370F	ADULT <40% EXP MALE	2.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.12		
370G	ADULT <40% EXP FEMA L	6.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.59		
370H	ADULT <40% EXP M&F
4	5.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.25		
3714	ADULT <40% EXP MALE	10,089.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,089.04		
3715	ADULT <40% EXP FEMA L	8,920.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,920.42		
3716	ADULT <40% EXP MALE	62,012.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,012.36		
3717	ADULT <40% EXP FEMA L	36,532.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,532.66		
3718	ADULT <40% EXP M&F
4	75,882.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,882.36		
3719	ADULT <40% EXP M&F 6	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
371D	ADULT <40% EXP MALE	286.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286.90		
371E	ADULT <40% EXP FEMA L	256.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256.11		
371F	ADULT <40% EXP MALE	2,465.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,465.20		
371G	ADULT <40% EXP FEMA L	1,439.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,439.34		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371H	ADULT <40% EXP M&F 4	2,055.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,055.68		
371J	ADULT <40% EXP M&F
6	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
3726	ADULT <40% EXP MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3727	ADULT <40% EXP FEMA L	1.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.77		
3728	ADULT <40% EXP M&F
4	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		
372G	ADULT <40% EXP FEMA L	1.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.22		
SUBTOTAL:	286,708.6	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,708.62		

41.00

3906	NEWLY ELIGIBLE MALE	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	2.53	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	42.80	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	8.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA
L	0.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	0.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	3,049.98	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	3,531.41	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	16,854.19	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	24,434.24	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	26,059.28	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	10.00	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	88.14	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	86.05	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	540.59	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	784.50	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	687.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	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	0.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	76,185.75	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
2.53	
42.80	
8.25	
0.45	
0.92	
3,049.98	
3,531.41	
16,854.19	
24,434.24	
26,059.28	
10.00	
88.14	
86.05	
540.59	
784.50	
687.43	
0.00	
0.48	
0.00	
0.51	
76,185.75	

9939	BIRTH SUPP PAYMENT N	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

41.00

9935	BIRTH SUPP PAYMENT A	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	72.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	106.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
34.00	
72.00	
106.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4404	SOBRA 100-133% MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4413	SOBRA 100-133% M&F
6	44,135.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,135.08		
4414	SOBRA 100-133% MALE	11,766.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,766.33		
4415	SOBRA 100-133% FEMA L	11,388.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,388.18		
441C	SOBRA 100-133% M&F
6	1,021.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,021.53		
441D	SOBRA 100-133% MALE	259.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.77		
441E	SOBRA 100-133% FEMA L	262.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262.97		
SUBTOTAL:	68,834.86	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,834.86		

4517	BC PATIENT FEMALE 2 1	21.19	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	101.73	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	0.80	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	-14.44	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	9.00	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	10.22	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	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	129.27	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

21.19	
101.73	
0.80	
-14.44	
9.00	
10.22	
0.77	
129.27	

8600	SSI BLIND FREEDOM/W O	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W
O	1.00	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	2,223.69	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	50.08	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	423.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	25.03	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	285.36	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	3.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,014.56	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
1.00	
2,223.69	
50.08	
423.80	
25.03	
285.36	
3.60	
3,014.56	

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

 
4.00

4.00

TOTAL:	1,521,998.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,521,998.72		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1009	TANF 65+ M & F WITH	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.96		
1011	TANF <1 M & F NON-ME	702.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		702.24		
1012	TANF 01-05 M & F NON	367.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		367.08		
1013	TANF 06-13 M & F NON	478.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		478.80		
1014	TANF 14-20 MALE NON-	31.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.92		
1015	TANF 14-20 FEMALE N O	271.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.32		
1016	TANF 21-44 MALE NON-	239.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.40		
1017	TANF 21-44 FEMALE N O	3,112.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,112.20		
1018	TANF 45-64 M & F NON	861.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		861.84		
2100	SSI AGED WITH MEDIC A	47.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.88		
2120	SSI AGED WITH QMB	414.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414.96		
2200	SSI DISABLED WITH M E	319.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		319.20		
2210	SSI DISABLED NON-ME
D	2,713.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,713.20		
2220	SSI DISABLED WITH Q M	1,197.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,197.00		
2310	SSI BLIND NON-MEDIC
A	31.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.92		
2320	SSI BLIND WITH QMB	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.96		
4311	SOBRA CHILD <1 M & F	2,058.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,058.84		
4312	SOBRA CHILD 01-05 M	5,410.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,410.44		
4313	SOBRA CHILD 06-13 M	4,197.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,197.48		
4314	SOBRA CHILD 14-20 MA	813.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		813.96		
4315	SOBRA CHILD 14-20 FE	1,053.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,053.36		
5015	SOBRA PREG 14-20 FE M	239.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.40		
5017	SOBRA PREG 21-44 FE
M	1,197.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,197.00		
SUBTOTAL:	25,791.36	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,791.36		

1108	TANF EXPANDED 45-64	63.84	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	31.92	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	239.40	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	1,292.76	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	494.76	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	47.88	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	95.76	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
&	47.88	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	223.44	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	31.92	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	255.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
63.84	
31.92	
239.40	
1,292.76	
494.76	
47.88	
95.76	
47.88	
223.44	
31.92	
255.36	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,824.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,824.92		

3514	ADULT 40-100% MALE 1	15.96	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	95.76	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	95.76	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	143.64	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	542.64	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	95.76	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	271.32	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	893.76	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	941.64	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	1,835.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,931.64	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
15.96	
95.76	
95.76	
143.64	
542.64	
95.76	
271.32	
893.76	
941.64	
1,835.40	
4,931.64	

3915	NEWLY ELIGIBLE FEMA L	31.92	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	111.72	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	271.32	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	191.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	606.48	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
31.92	
111.72	
271.32	
191.52	
606.48	

4413	SOBRA 100-133% M&F
6	574.56	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	63.84	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	255.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	893.76	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
574.56	
63.84	
255.36	
893.76	

6012	KIDS 1-5 M & F NON-M	15.96	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-	47.88	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	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	79.80	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
15.96	
47.88	
15.96	
79.80	

35,127.96

35,127.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1009	TANF 65+ M & F WITH	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1011	TANF <1 M & F NON-ME	44.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.00		
1012	TANF 01-05 M & F NON	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.00		
1013	TANF 06-13 M & F NON	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
1014	TANF 14-20 MALE NON-	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1015	TANF 14-20 FEMALE N O	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1016	TANF 21-44 MALE NON-	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
1017	TANF 21-44 FEMALE N O	195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195.00		
1018	TANF 45-64 M & F NON	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.00		
2100	SSI AGED WITH MEDIC A	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		
2120	SSI AGED WITH QMB	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
2200	SSI DISABLED WITH M E	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
2210	SSI DISABLED NON-ME
D	170.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170.00		
2220	SSI DISABLED WITH Q M	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.00		
2310	SSI BLIND NON-MEDIC
A	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2320	SSI BLIND WITH QMB	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4311	SOBRA CHILD <1 M & F	129.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129.00		
4312	SOBRA CHILD 01-05 M	339.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339.00		
4313	SOBRA CHILD 06-13 M	263.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		263.00		
4314	SOBRA CHILD 14-20 MA	51.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.00		
4315	SOBRA CHILD 14-20 FE	66.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.00		
5015	SOBRA PREG 14-20 FE M	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
5017	SOBRA PREG 21-44 FE
M	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.00		
SUBTOTAL:	1,616.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,616.00		

1108	TANF EXPANDED 45-64	4.00	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	2.00	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	15.00	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	81.00	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	31.00	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	3.00	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	6.00	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
&	3.00	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	14.00	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	2.00	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	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4.00	
2.00	
15.00	
81.00	
31.00	
3.00	
6.00	
3.00	
14.00	
2.00	
16.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	177.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177.00		

3915	NEWLY ELIGIBLE FEMA L	2.00	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	7.00	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	17.00	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	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	38.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
7.00	
17.00	
12.00	
38.00	

4413	SOBRA 100-133% M&F
6	36.00	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	4.00	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	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

36.00	
4.00	
16.00	
56.00	

6012	KIDS 1-5 M & F NON-M	1.00	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-	3.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
3.00	
1.00	
5.00	

3514	ADULT 40-100% MALE 1	1.00	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	6.00	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	6.00	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	9.00	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	34.00	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	6.00	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	17.00	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	56.00	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	59.00	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	115.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	309.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
6.00	
6.00	
9.00	
34.00	
6.00	
17.00	
56.00	
59.00	
115.00	
309.00	

TOTAL:	2,201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,201.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	22,764.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,764.83		
1010	TANF NON-MEDICARE	2,605,295.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,605,295.71		
1020	TANF WITH QMB	19,460.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,460.70		
2100	SSI AGED WITH MEDIC A	32,815,971.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,815,971.54		
210Z	SSI AGED WITH MEDIC
A	619,102.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		619,102.28		
2110	SSI AGED NON-MEDICA R	3,434,158.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,434,158.85		
211Z	SSI AGED NON-MEDICA
R	11,704.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,704.38		
2120	SSI AGED WITH QMB	22,419,410.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,419,410.53		
212Z	SSI AGED WITH QMB P P	10,939.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,939.38		
2200	SSI DISABLED WITH M
E	16,009,290.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,009,290.62		
220Z	SSI DISABLED WITH M E	93,673.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,673.54		
2210	SSI DISABLED NON-ME
D	120,794,909.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,794,909.41		
221Z	SSI DISABLED NON-ME D	37,010.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,010.83		
2220	SSI DISABLED WITH Q
M	25,497,207.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,497,207.44		
222Z	SSI DISABLED WITH Q M	3,631.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,631.33		
2300	SSI BLIND WITH MEDIC	61,100.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,100.26		
2310	SSI BLIND NON-MEDIC A	264,951.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264,951.61		
2320	SSI BLIND WITH QMB	84,130.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,130.00		
SUBTOTAL:	224,804,713.2	4	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,804,713.24		

8700	SSI DISABLED FREEDO M	98,465.19	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	140,148.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	24,397.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	263,011.4	6	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
98,465.19	
140,148.96	
0.00	
24,397.31	
263,011.46	

225,067,724.70

225,067,724.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1010	TANF NON-MEDICARE	665.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		665.19		
1020	TANF WITH QMB	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC A	11,273.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,273.89		
210Z	SSI AGED WITH MEDIC
A	653.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		653.12		
2110	SSI AGED NON-MEDICA R	550.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		550.05		
211Z	SSI AGED NON-MEDICA
R	11.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.39		
2120	SSI AGED WITH QMB	8,167.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,167.76		
212Z	SSI AGED WITH QMB P P	11.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.88		
2200	SSI DISABLED WITH M
E	4,808.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,808.58		
220Z	SSI DISABLED WITH M E	100.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.54		
2210	SSI DISABLED NON-ME
D	29,046.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,046.39		
221Z	SSI DISABLED NON-ME D	40.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.11		
2220	SSI DISABLED WITH Q
M	7,307.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,307.02		
222Z	SSI DISABLED WITH Q M	3.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.98		
2300	SSI BLIND WITH MEDIC	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
2310	SSI BLIND NON-MEDIC A	63.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.16		
2320	SSI BLIND WITH QMB	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
SUBTOTAL:	62,755.06	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,755.06		

8700	SSI DISABLED FREEDO M	28.00	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	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	59.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
28.00	
23.00	
0.00	
8.00	
59.00	

TOTAL:	62,814.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,814.06		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	3,099,224.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,099,224.83		
1011	TANF <1 M & F NON-ME	20,092.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,092.78		
1012	TANF 01-05 M & F NON	4,576.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,576.00		
1013	TANF 06-13 M & F NON	5,280.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,280.87		
1014	TANF 14-20 MALE NON-	-958.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-958.84		
1015	TANF 14-20 FEMALE N O	2,369.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,369.26		
101A	TANF < 1 M & F NON-M	44,422.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,422.68		
101B	TANF 01-05 M & F NON	7,098.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,098.70		
101C	TANF 06-13 M & F NON	4,339.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,339.43		
101D	TANF 14-20 MALE NON-	949.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		949.44		
101E	TANF 14-20 FEMALE N O	1,382.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,382.01		
1020	TANF WITH QMB	33.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.83		
2200	SSI DISABLED WITH M E	33.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.83		
2210	SSI DISABLED NON-ME
D	339,676.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339,676.61		
221Z	SSI DISABLED NON-ME D	3,510.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,510.56		
2220	SSI DISABLED WITH Q
M	266.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		266.46		
2310	SSI BLIND NON-MEDIC A	1,727.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,727.32		
4300	SOBRA CHILD WITH ME
D	3,172.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,172.78		
4303	SOBRA CHILD 06-13 M	-22.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-22.21		
4310	SOBRA CHILD NON-ME DI	20,843,552.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,843,552.98		
4311	SOBRA CHILD <1 M & F	73,572.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,572.72		
4312	SOBRA CHILD 01-05 M	102,709.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,709.89		
4313	SOBRA CHILD 06-13 M	114,717.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,717.87		
4314	SOBRA CHILD 14-20 MA	22,663.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,663.65		
4315	SOBRA CHILD 14-20 FE	23,824.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,824.20		
431A	SOBRA CHILD < 1 M &	12,969.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,969.72		
431B	SOBRA CHILD 01-05 M	160,415.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,415.96		
431C	SOBRA CHILD 6-13 M&F	161,414.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,414.95		
431D	SOBRA CHILD 14-20 MA	33,253.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,253.15		
431E	SOBRA CHILD 14-20 FE	35,016.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,016.82		
4320	SOBRA CHILD WITH Q MB	317.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		317.67		
5010	SOBRA PREGNANT WO
MAN	18,798.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,798.09		
5015	SOBRA PREG 14-20 FE M	984.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		984.07		
501E	SOBRA PREG 14-20 FE
M	1,560.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,560.47		
SUBTOTAL:	25,142,948.5	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,142,948.55		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1110	TANF EXPANDED FOR FI	837.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		837.59		
SUBTOTAL:	837.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		837.59		

4410	SOBRA 100-133% FOR F	2,576,543.61	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	25,896.60	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	6,103.13	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	5,718.94	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	41,526.23	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	8,652.93	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	9,143.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,673,584.61	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,576,543.61	
25,896.60	
6,103.13	
5,718.94	
41,526.23	
8,652.93	
9,143.17	
2,673,584.61	

6013	KIDS 6-13 M & F NON-	28.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

28.45

28.45

27,817,399.20

27,817,399.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending July 31, 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	
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	
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101E

1020	TANF 14-20 FEMALE N O
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

0.00	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	

SSI DISABLED NON-ME

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

501E	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	M														

221Z															
				
2220	SSI DISABLED 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	
M	
2310	SSI BLIND NON-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	
	A															
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	
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	
4320	SOBRA CHILD 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	
	MB															
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	

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		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		

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	
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

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	
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	
441C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
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

Current and prior month data is under revision.

0.00

0.00

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	38,299.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,299.47		
1014	TANF 14-20 MALE NON-	929.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		929.17		
1016	TANF 21-44 MALE NON-	-3,007.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,007.29		
1017	TANF 21-44 FEMALE N O	9,489.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,489.76		
1018	TANF 45-64 M & F NON	-1,988.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,988.68		
101G	TANF 21-44 FEMALE N O	676.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		676.93		
2120	SSI AGED WITH QMB	6,959.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,959.75		
2200	SSI DISABLED WITH M E	6,264.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,264.14		
220Z	SSI DISABLED WITH M
E	5,153.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,153.61		
2210	SSI DISABLED NON-ME D	250,005.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250,005.66		
221Z	SSI DISABLED NON-ME
D	45,791.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,791.77		
2220	SSI DISABLED WITH Q M	66,508.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,508.51		
2310	SSI BLIND NON-MEDIC
A	1,356.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,356.24		
4310	SOBRA CHILD NON-ME DI	2,642.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,642.18		
4314	SOBRA CHILD 14-20 MA	24,304.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,304.45		
4315	SOBRA CHILD 14-20 FE	13,297.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,297.63		
431D	SOBRA CHILD 14-20 MA	2,067.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,067.51		
5017	SOBRA PREG 21-44 FE M	727.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		727.57		
501G	SOBRA PREG 21-44 FE
M	4,274.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,274.47		
SUBTOTAL:	473,752.8	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		473,752.85		

1100	TANF EXPANDED FPR FI	8,315.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	2,190.60	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	24,983.12	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	636.62	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	1,182.30	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	-187.96	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	4,119.86	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	2,642.18	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	14,890.11	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	25,600.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112H	TANF EXPANDED 45-64	350.00	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	437.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
240Z	SSI AGED EXPANDED
WI	918.74	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	6,546.65	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	1,973.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,315.99	
2,190.60	
24,983.12	
636.62	
1,182.30	
-187.96	
4,119.86	
2,642.18	
14,890.11	
25,600.13	
350.00	
437.50	
918.74	
6,546.65	
1,973.53	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
260Z	SSI DISABLED EXPAND E	4,938.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,938.38		
2610	SSI DISABLED EXPAND
E	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,819.33		
2620	SSI DISABLED EXPAND E	40,303.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,303.04		
SUBTOTAL:	142,660.1	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,660.12		

3910	NEWLY ELIGIBLE FOR F	19,486.46	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	43.75	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	10,755.43	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	2,452.45	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	4,365.41	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	2,819.33	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	3,670.53	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	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	46,412.69	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

19,486.46	
43.75	
10,755.43	
2,452.45	
4,365.41	
2,819.33	
3,670.53	
2,819.33	
46,412.69	

4414	SOBRA 100-133% MALE	90.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

90.95

3507	ADULT 40-100% FEMAL E	440.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL
E	880.73	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	57,209.99	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	9,743.32	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	1,022.78	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	-9,021.87	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	1,879.55	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	699.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	213,719.30	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	16,477.31	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	1,727.98	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	110,595.16	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	61,977.08	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	80,228.90	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	10,706.98	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	545.68	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	35,306.26	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 L	16,659.07	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	41,419.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	652,218.5	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
440.36	
880.73	
57,209.99	
9,743.32	
1,022.78	
-9,021.87	
1,879.55	
699.99	
213,719.30	
16,477.31	
1,727.98	
110,595.16	
61,977.08	
80,228.90	
10,706.98	
545.68	
35,306.26	
16,659.07	
41,419.95	
652,218.52	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	90.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.95		

8700	SSI DISABLED FREEDO M	25,325.42	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	911.41	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	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29,056.16	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,325.42	
911.41	
2,819.33	
29,056.16	

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

1,344,191.29

TOTAL:

1,344,191.29

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

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	
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	
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	

For The Period Ending July 31, 2018

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	
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	
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	
220Z

2210	SSI DISABLED WITH M
E
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	

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	
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	

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	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
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

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

5017	SOBRA PREG 21-44 FE
M
501G	SOBRA PREG 21-44 FE
M
SUBTOTAL:

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	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
112H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	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	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 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	

0.00	
0.00	
0.00	
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 July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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
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 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		

L
3716	ADULT <40% EXP MALE

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	
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	
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	

3510	E
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	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3710	AHC CARE 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	

3714	FO
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	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	
3718	ADULT <40% EXP 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	
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
L	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
L	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	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	

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	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	

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

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 July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	743.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		743.35		
1008	TANF 45-64 M & F WIT	271.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.01		
1010	TANF NON-MEDICARE	9,782,255.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,782,255.69		
1014	TANF 14-20 MALE NON-	1,920.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,920.38		
1015	TANF 14-20 FEMALE N O	4,215.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,215.79		
1016	TANF 21-44 MALE NON-	30,559.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,559.31		
1017	TANF 21-44 FEMALE N O	82,903.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,903.94		
1018	TANF 45-64 M & F NON	17,062.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,062.72		
1019	TANF 65+ M & F NON-M	-32.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-32.73		
101D	TANF 14-20 MALE NON-	2,263.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,263.51		
101E	TANF 14-20 FEMALE N O	6,063.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,063.63		
101F	TANF 21-44 MALE NON-	49,948.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,948.44		
101G	TANF 21-44 FEMALE N O	122,069.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,069.48		
101H	TANF 44-64 M & F NON	22,645.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,645.65		
101J	TANF 65+ N & F NON-M	106.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.93		
1020	TANF WITH QMB	442.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		442.85		
1027	TANF 21-44 FEMALE WI	-425.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-425.76		
2100	SSI AGED WITH MEDIC A	8,557.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,557.84		
2110	SSI AGED NON-MEDICA
R	448,777.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448,777.49		
211Z	SSI AGED NON-MEDICA R	10,752.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,752.26		
2120	SSI AGED WITH QMB	41,643.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,643.94		
2200	SSI DISABLED WITH M E	15,741.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,741.04		
2210	SSI DISABLED NON-ME
D	2,388,281.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,388,281.92		
221Z	SSI DISABLED NON-ME D	37,694.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,694.51		
2220	SSI DISABLED WITH Q
M	53,830.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,830.16		
2300	SSI BLIND WITH MEDIC	141.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141.92		
2310	SSI BLIND NON-MEDIC A	29,895.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,895.63		
231Z	SSI BLIND NON-MEDIC
A	272.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272.22		
2320	SSI BLIND WITH QMB	1,177.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,177.44		
4310	SOBRA CHILD NON-ME DI	1,498,864.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,498,864.65		
4314	SOBRA CHILD 14-20 MA	9,312.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,312.68		
4315	SOBRA CHILD 14-20 FE	12,440.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,440.21		
431D	SOBRA CHILD 14-20 MA	15,921.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,921.94		
431E	SOBRA CHILD 14-20 FE	19,882.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,882.62		
5010	SOBRA PREGNANT WO MAN	1,394,704.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,394,704.48		
5015	SOBRA PREG 14-20 FE
M	10,033.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,033.94		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	49,743.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,743.43		
5018	SOBRA PREG 45-64 FE
M	132.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132.74		
501E	SOBRA PREG 14-20 FE M	14,716.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,716.29		
501G	SOBRA PREG 21-44 FE
M	69,865.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,865.25		
501H	SOBRA PREG 45-64 FE M	229.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229.10		
5027	SOBRA PREG 21-44 FE
M	-20.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-20.60		
SUBTOTAL:	16,255,607.2	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,255,607.29		

1100	TANF EXPANDED FPR FI	4,195.09	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	56.58	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	12.83	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
&	50.05	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	8,816,697.06	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	487.52	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	1,026.60	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	30,145.35	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	63,803.22	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	21,605.25	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
&	-20.57	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	1,583.13	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	2,348.69	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	54,795.63	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	93,521.61	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	33,910.12	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
&	184.11	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	11,715.76	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	102.80	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	27.30	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	11.38	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	171.92	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	6,133.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
241Z	SSI AGED EXPANDED N O	456.25	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	33,662.51	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	150.25	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	98,233.68	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 E	1,762.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,195.09	
56.58	
12.83	
50.05	
8,816,697.06	
487.52	
1,026.60	
30,145.35	
63,803.22	
21,605.25	
-20.57	
1,583.13	
2,348.69	
54,795.63	
93,521.61	
33,910.12	
184.11	
11,715.76	
102.80	
27.30	
11.38	
171.92	
6,133.05	
456.25	
33,662.51	
150.25	
98,233.68	
1,762.46	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2620	SSI DISABLED EXPAND E	18,184.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,184.98		
SUBTOTAL:	9,295,014.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,295,014.61		

3910	NEWLY ELIGIBLE FOR F	5,326,495.72	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	2,480.38	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	3,794.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,326,495.72	
2,480.38	
3,794.78	

3508	ADULT 40-100% M&F 45	68.67	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	6,132,985.72	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	3,978.14	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	5,563.22	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	14,591.57	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	14,101.53	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	30,836.64	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	6,909.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	9,982.01	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	32,692.91	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	24,535.71	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	56,717.88	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	
3706	ADULT <40% EXP MALE	43.23	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	41.15	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	104.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	13,667,606.67	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	10,379.04	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	10,053.15	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	95,592.62	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	53,638.01	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	88,757.54	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	19,843.54	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	18,450.86	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	169,051.65	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 L	98,395.06	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	145,352.68	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	141.06	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	
SUBTOTAL:	20,710,414.9	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
68.67	
6,132,985.72	
3,978.14	
5,563.22	
14,591.57	
14,101.53	
30,836.64	
6,909.99	
9,982.01	
32,692.91	
24,535.71	
56,717.88	
0.00	
43.23	
41.15	
104.66	
13,667,606.67	
10,379.04	
10,053.15	
95,592.62	
53,638.01	
88,757.54	
19,843.54	
18,450.86	
169,051.65	
98,395.06	
145,352.68	
141.06	
0.00	
20,710,414.91	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	21,847.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,847.70		
3917	NEWLY ELIGIBLE FEMA L	33,156.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,156.94		
3918	NEWLY ELIGIBLE M&F
4	25,942.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,942.10		
391D	NEWLY ELIGIBLE MALE	6,181.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,181.24		
391E	NEWLY ELIGIBLE FEMA L	6,405.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,405.61		
391F	NEWLY ELIGIBLE MALE	38,771.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,771.67		
391G	NEWLY ELIGIBLE FEMA L	57,199.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,199.13		
391H	NEWLY ELIGIBLE M&F
4	49,113.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,113.47		
SUBTOTAL:	5,571,388.74	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,571,388.74		

4400	SOBRA 100-133% FOR F	79.72	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	320,411.40	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	2,585.05	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	2,682.51	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	3,444.90	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	3,012.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	332,216.1	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
79.72	
320,411.40	
2,585.05	
2,682.51	
3,444.90	
3,012.55	
332,216.13	

4510	BC PATIENT FOR FINA N	9,220.45	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	13.73	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	144.32	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	57.23	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	327.00	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	1,326.40	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	15.93	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	54.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,159.66	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,220.45	
13.73	
144.32	
57.23	
327.00	
1,326.40	
15.93	
54.60	
11,159.66	

8700	SSI DISABLED FREEDO M	1,398.78	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	27,327.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	1,574.97	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:	30,301.17	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,398.78	
27,327.42	
1,574.97	
0.00	
30,301.17	

52,206,102.51

52,206,102.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending July 31, 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	
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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
O
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
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

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

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	
2110

211Z	SSI AGED NON-MEDICA
R
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	

101J	TANF 65+ N & F NON-M

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n.0.00 	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
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q

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

231Z	SSI BLIND NON-MEDIC A
SSI BLIND NON-MEDIC
A	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
5010	SOBRA PREGNANT WO	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending July 31, 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	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		
501E	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		
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		
501H	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		
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	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	FI
TANF EXPANDED 21-44	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	0.00	0.00

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

1115	TANF EXPANDED 14-20	
1116		
1117	TANF EXPANDED 21-44	

0.00	0.00	0.00

TANF EXPANDED 21-44	C

r r0e.00   vis0i.0o0

n.0.00

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

111D	&
TANF EXPANDED 14-20	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	
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	
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	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

241Z	O
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	
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 - GENERAL
For The Period Ending July 31, 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		
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		

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	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	E
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	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	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	
351D	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL	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	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	

Current and prior month data is unde

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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	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	4
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	
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	
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	
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	

371H	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	
371J	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	

3727	6
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													
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	

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending July 31, 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		
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		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		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		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		0.00		
391H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

441D

SOBRA 100-133% MALE

441E

SOBRA 100-133% FEMA

Current and

0.00	0.00	0.00

0.00

0.00

0.00

0.00

0.00

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

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

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	
4517	BC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	
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	
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	
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	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	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	

4400	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	

4410	F
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	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	

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 July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	822,978.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		822,978.58		
1011	TANF <1 M & F NON-ME	2,708.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,708.55		
1012	TANF 01-05 M & F NON	-5,476.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,476.49		
1013	TANF 06-13 M & F NON	-40.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-40.48		
1014	TANF 14-20 MALE NON-	890.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		890.55		
1015	TANF 14-20 FEMALE N O	971.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		971.51		
101A	TANF < 1 M & F NON-M	1,457.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,457.26		
101B	TANF 01-05 M & F NON	936.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		936.60		
101C	TANF 06-13 M & F NON	-627.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-627.43		
101D	TANF 14-20 MALE NON-	568.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		568.06		
2210	SSI DISABLED NON-ME D	182,177.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,177.17		
221Z	SSI DISABLED NON-ME
D	417.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417.06		
4300	SOBRA CHILD WITH ME D	627.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		627.43		
4310	SOBRA CHILD NON-ME
DI	9,180,293.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,180,293.18		
4311	SOBRA CHILD <1 M & F	26,675.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,675.98		
4312	SOBRA CHILD 01-05 M	-37,293.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-37,293.39		
4313	SOBRA CHILD 06-13 M	-64,080.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-64,080.03		
4314	SOBRA CHILD 14-20 MA	-23,193.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-23,193.15		
4315	SOBRA CHILD 14-20 FE	-16,461.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-16,461.87		
431A	SOBRA CHILD < 1 M &	8,525.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,525.24		
431B	SOBRA CHILD 01-05 M	43,243.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,243.66		
431C	SOBRA CHILD 6-13 M&F	37,854.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,854.08		
431D	SOBRA CHILD 14-20 MA	15,859.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,859.30		
431E	SOBRA CHILD 14-20 FE	21,929.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,929.33		
5010	SOBRA PREGNANT WO MAN	11,084.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,084.05		
5015	SOBRA PREG 14-20 FE
M	-700.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-700.19		
SUBTOTAL:	10,211,324.5	6	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,211,324.56		

4410	SOBRA 100-133% FOR F	19,453.05	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	2,678.25	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	894.84	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	474.95	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	890.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

19,453.05	
2,678.25	
894.84	
474.95	
890.26	

3716	ADULT <40% EXP MALE	453.83	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	75.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	529.47	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
453.83	
75.64	
529.47	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	24,391.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,391.35		

6013	KIDS 6-13 M & F NON-	-1,172.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-1,172.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

-1,172.40

-1,172.40

0.00

0.00

0.00

0.00

TOTAL:

10,235,072.98

0.00	0.00

0.00	0.00	0.00	0.00

0.00

10,235,072.98

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending July 31, 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	
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	
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

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	0.00	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	

4311	SOBRA CHILD <1 M & F

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n.0.00 	0.00

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

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	

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	
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	
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	

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	
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	
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	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

0.00

0.00

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	319.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		319.94		
1010	TANF NON-MEDICARE	105,712.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,712.34		
1020	TANF WITH QMB	478.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		478.09		
2100	SSI AGED WITH MEDIC A	44,133.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,133.86		
2110	SSI AGED NON-MEDICA
R	1,916.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,916.00		
2120	SSI AGED WITH QMB	69,460.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,460.16		
2200	SSI DISABLED WITH M E	382,132.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382,132.58		
2210	SSI DISABLED NON-ME
D	4,533,394.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,533,394.57		
2220	SSI DISABLED WITH Q M	815,415.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		815,415.52		
2300	SSI BLIND WITH MEDIC	1,824.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,824.16		
2310	SSI BLIND NON-MEDIC A	5,681.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,681.94		
2320	SSI BLIND WITH QMB	3,316.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,316.23		
SUBTOTAL:	5,963,785.39	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,963,785.39		

8700	SSI DISABLED FREEDO M	2,547.37	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	554.73	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	563.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,665.34	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,547.37	
554.73	
563.24	
3,665.34	

5,967,450.73

5,967,450.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending July 31, 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		
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	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

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	0.00	0.00	0.00	0.00

SSI DISABLED FREEDO M

8720

SSI DISABLED FREEDO M

8710

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SSI DISABLED FREEDO M

8700

0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

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 July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,927.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,927.64		
1010	TANF NON-MEDICARE	238,296.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238,296.00		
1011	TANF <1 M & F NON-ME	15,253.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,253.92		
1012	TANF 01-05 M & F NON	8,274.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,274.72		
1013	TANF 06-13 M & F NON	5,748.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,748.94		
1014	TANF 14-20 MALE NON-	5,383.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,383.26		
1015	TANF 14-20 FEMALE N O	2,990.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,990.70		
1017	TANF 21-44 FEMALE N
O	1,196.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,196.28		
1020	TANF WITH QMB	963.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		963.82		
2200	SSI DISABLED WITH M E	38,785.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,785.26		
2210	SSI DISABLED NON-ME
D	5,915,870.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,915,870.99		
2220	SSI DISABLED WITH Q M	125,628.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,628.30		
2300	SSI BLIND WITH MEDIC	963.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		963.82		
2310	SSI BLIND NON-MEDIC A	19,375.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,375.64		
4311	SOBRA CHILD <1 M & F	20,637.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,637.18		
4312	SOBRA CHILD 01-05 M	153,798.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,798.04		
4313	SOBRA CHILD 06-13 M	256,308.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,308.49		
4314	SOBRA CHILD 14-20 MA	69,656.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,656.08		
4315	SOBRA CHILD 14-20 FE	70,551.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,551.94		
5015	SOBRA PREG 14-20 FE M	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		598.14		
SUBTOTAL:	6,952,209.16	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,952,209.16		

3514	ADULT 40-100% MALE 1	1,196.28	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	598.14	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	598.14	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	10,168.38	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	8,972.10	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	1,794.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	23,327.46	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,196.28	
598.14	
598.14	
10,168.38	
8,972.10	
1,794.42	
23,327.46	

3914	NEWLY ELIGIBLE MALE	598.14	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	1,196.28	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	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

598.14	
1,196.28	
598.14	

1115	TANF EXPANDED 14-20	1,196.28	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	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,794.42	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,196.28	
598.14	
1,794.42	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,392.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,392.56		

4413	SOBRA 100-133% M&F
6	11,364.66	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	2,990.70	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	2,990.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	17,346.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,364.66	
2,990.70	
2,990.70	
17,346.06	

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

6,997,069.66

TOTAL:

6,997,069.66

0.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1010	TANF NON-MEDICARE	248.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248.00		
1011	TANF <1 M & F NON-ME	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
1012	TANF 01-05 M & F NON	11.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.77		
1013	TANF 06-13 M & F NON	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1014	TANF 14-20 MALE NON-	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1015	TANF 14-20 FEMALE N O	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1017	TANF 21-44 FEMALE N
O	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1020	TANF WITH QMB	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2200	SSI DISABLED WITH M E	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
2210	SSI DISABLED NON-ME
D	6,283.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,283.26		
2220	SSI DISABLED WITH Q M	133.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133.00		
2300	SSI BLIND WITH MEDIC	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2310	SSI BLIND NON-MEDIC A	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
4311	SOBRA CHILD <1 M & F	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
4312	SOBRA CHILD 01-05 M	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218.00		
4313	SOBRA CHILD 06-13 M	361.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361.74		
4314	SOBRA CHILD 14-20 MA	92.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.00		
4315	SOBRA CHILD 14-20 FE	99.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.00		
5015	SOBRA PREG 14-20 FE M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	7,588.77	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,588.77		

3514	ADULT 40-100% MALE 1	2.00	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	1.00	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	1.00	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	17.00	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	15.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
1.00	
1.00	
17.00	
15.00	
3.00	
39.00	

3914	NEWLY ELIGIBLE MALE	1.00	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	2.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
2.00	
1.00	

1115	TANF EXPANDED 14-20	2.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
1.00	
3.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		

4413	SOBRA 100-133% M&F
6	19.00	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	5.00	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	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19.00	
5.00	
5.00	
29.00	

TOTAL:	7,663.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,663.77		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	64.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.27		
1007	TANF 21-44 FEMALE WI	2,779.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,779.92		
1008	TANF 45-64 M & F WIT	11,291.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,291.57		
1009	TANF 65+ M & F WITH	7,080.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,080.93		
1011	TANF <1 M & F NON-ME	1,097,793.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,097,793.02		
1012	TANF 01-05 M & F NON	258,113.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258,113.97		
1013	TANF 06-13 M & F NON	279,530.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		279,530.59		
1014	TANF 14-20 MALE NON-	80,615.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,615.15		
1015	TANF 14-20 FEMALE N O	224,066.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,066.64		
1016	TANF 21-44 MALE NON-	1,462,397.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,462,397.99		
1017	TANF 21-44 FEMALE N O	4,955,722.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,955,722.81		
1018	TANF 45-64 M & F NON	2,183,248.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,183,248.97		
1019	TANF 65+ M & F NON-M	2,934.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,934.41		
1026	TANF 21-44 MALE WITH	1,357.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,357.60		
1027	TANF 21-44 FEMALE WI	6,393.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,393.80		
1028	TANF 45-64 M & F WIT	16,376.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,376.86		
1029	TANF 65+ M & F WITH	3,021.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,021.80		
2100	SSI AGED WITH MEDIC A	154,652.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,652.01		
2110	SSI AGED NON-MEDICA
R	110,434.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,434.83		
2120	SSI AGED WITH QMB	563,573.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		563,573.87		
2200	SSI DISABLED WITH M E	444,274.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		444,274.71		
2210	SSI DISABLED NON-ME
D	7,575,600.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,575,600.97		
2220	SSI DISABLED WITH Q M	1,311,020.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,311,020.36		
2300	SSI BLIND WITH MEDIC	2,715.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,715.71		
2310	SSI BLIND NON-MEDIC A	94,572.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,572.77		
2320	SSI BLIND WITH QMB	25,387.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,387.22		
4311	SOBRA CHILD <1 M & F	2,744,181.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,744,181.25		
4312	SOBRA CHILD 01-05 M	3,415,194.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,415,194.97		
4313	SOBRA CHILD 06-13 M	4,527,795.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,527,795.53		
4314	SOBRA CHILD 14-20 MA	1,133,047.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,133,047.15		
4315	SOBRA CHILD 14-20 FE	1,422,456.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,422,456.44		
5007	SOBRA PREG 21-44 FE M	318.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318.55		
5015	SOBRA PREG 14-20 FE
M	358,380.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		358,380.97		
5017	SOBRA PREG 21-44 FE M	2,037,823.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,037,823.46		
5018	SOBRA PREG 45-64 FE
M	3,075.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,075.69		
5027	SOBRA PREG 21-44 FE M	484.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		484.26		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	36,517,781.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,517,781.02		

3506	ADULT 40-100% MALE 2	52.90	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	1,886.71	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	51.35	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	53,585.47	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	100,817.06	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	771,180.72	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	493,585.01	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	2,260,650.72	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	8,266.64	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	307,300.59	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	310,211.15	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	6,023,811.40	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	3,523,898.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

52.90	
1,886.71	
51.35	
53,585.47	
100,817.06	
771,180.72	
493,585.01	
2,260,650.72	
8,266.64	
307,300.59	
310,211.15	
6,023,811.40	
3,523,898.11	

1106	TANF EXPANDED 21-44	6,903.54	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	9,863.24	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	44,707.75	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
&	15,732.50	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	5,242.71	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	29,725.53	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	687,192.92	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	2,136,319.90	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	1,427,393.60	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
&	1,626.42	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	14,909.43	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	26,677.32	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	129,892.71	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
&	56,963.70	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	7,714.68	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	15,750.54	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	457,355.76	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	12,186.84	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	185,828.54	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	385,320.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,657,308.34	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,903.54	
9,863.24	
44,707.75	
15,732.50	
5,242.71	
29,725.53	
687,192.92	
2,136,319.90	
1,427,393.60	
1,626.42	
14,909.43	
26,677.32	
129,892.71	
56,963.70	
7,714.68	
15,750.54	
457,355.76	
12,186.84	
185,828.54	
385,320.71	
5,657,308.34	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3718	ADULT <40% EXP M&F 4	8,587,427.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,587,427.95		
3719	ADULT <40% EXP M&F
6	1,226.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,226.37		
3727	ADULT <40% EXP FEMA L	437.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		437.33		
3728	ADULT <40% EXP M&F
4	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.00		
SUBTOTAL:	22,444,816.4	8	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,444,816.48		

3907	NEWLY ELIGIBLE FEMA L	995.90	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	493.69	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	16,577.58	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	50,539.59	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	371,374.74	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	638,821.34	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	1,147,202.88	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	929.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,226,935.62	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
995.90	
493.69	
16,577.58	
50,539.59	
371,374.74	
638,821.34	
1,147,202.88	
929.90	
2,226,935.62	

4413	SOBRA 100-133% M&F
6	416,723.18	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	110,528.71	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	145,691.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	672,943.2	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
416,723.18	
110,528.71	
145,691.33	
672,943.22	

4518	BC PATIENT FEMALE 4 5	6,148.89	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	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,575.89	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,148.89	
427.00	
6,575.89	

8700	SSI DISABLED FREEDO M	14,200.47	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	10,612.04	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	1,696.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	26,508.76	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14,200.47	
10,612.04	
1,696.25	
26,508.76	

67,552,869.33

67,552,869.33	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 - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	82.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.25		
1007	TANF 21-44 FEMALE WI	39.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.84		
1011	TANF <1 M & F NON-ME	1,645.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,645.11		
1012	TANF 01-05 M & F NON	510.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		510.37		
1014	TANF 14-20 MALE NON-	3,217.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,217.73		
1015	TANF 14-20 FEMALE N O	1,261.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,261.12		
1016	TANF 21-44 MALE NON-	25,236.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,236.24		
1017	TANF 21-44 FEMALE N O	49,969.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,969.09		
1018	TANF 45-64 M & F NON	25,853.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,853.67		
2100	SSI AGED WITH MEDIC A	8,948.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,948.54		
2110	SSI AGED NON-MEDICA
R	27,266.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,266.66		
2120	SSI AGED WITH QMB	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.00		
2200	SSI DISABLED WITH M E	2,281.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,281.61		
2210	SSI DISABLED NON-ME
D	20,619.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,619.79		
2220	SSI DISABLED WITH Q M	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
4311	SOBRA CHILD <1 M & F	43,959.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,959.44		
4312	SOBRA CHILD 01-05 M	83,611.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,611.98		
4313	SOBRA CHILD 06-13 M	25,834.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,834.10		
4314	SOBRA CHILD 14-20 MA	28,981.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,981.47		
4315	SOBRA CHILD 14-20 FE	23,575.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,575.75		
5015	SOBRA PREG 14-20 FE M	50,353.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,353.69		
5017	SOBRA PREG 21-44 FE
M	99,435.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,435.96		
SUBTOTAL:	522,757.4	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		522,757.41		

1107	TANF EXPANDED 21-44	111.86	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	2,231.06	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
&	262.85	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	504.14	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	1,124.74	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	26,042.14	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	51,162.10	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	48,172.97	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	79.51	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	4,523.21	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	236.30	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	3,835.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
111.86	
2,231.06	
262.85	
504.14	
1,124.74	
26,042.14	
51,162.10	
48,172.97	
79.51	
4,523.21	
236.30	
3,835.27	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2610	SSI DISABLED EXPAND E	357.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		357.95		
2620	SSI DISABLED EXPAND
E	2,422.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,422.63		
SUBTOTAL:	141,066.7	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,066.73		

3908	NEWLY ELIGIBLE M&F 4	345.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,876.28	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	8,084.57	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	101,110.64	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	100,349.87	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	108,581.21	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	14.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	320,363.2	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

345.83	
1,876.28	
8,084.57	
101,110.64	
100,349.87	
108,581.21	
14.81	
320,363.21	

4413	SOBRA 100-133% M&F
6	6,086.08	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	3,573.99	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	6,117.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,777.35	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,086.08	
3,573.99	
6,117.28	
15,777.35	

8700	SSI DISABLED FREEDO M	3,279.71	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	6,752.04	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	230.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,261.75	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,279.71	
6,752.04	
230.00	
10,261.75	

3508	ADULT 40-100% M&F 45	1,483.92	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	6,460.92	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	1,195.29	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	37,882.54	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	40,082.72	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	137,649.00	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	1,213.85	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	1,322.61	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	31,029.15	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	44,103.08	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	245,668.95	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	143,010.96	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	363,813.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,054,916.54	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,483.92	
6,460.92	
1,195.29	
37,882.54	
40,082.72	
137,649.00	
1,213.85	
1,322.61	
31,029.15	
44,103.08	
245,668.95	
143,010.96	
363,813.55	
1,054,916.54	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	2,065,142.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,065,142.99		

FEDERAL EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	2,331.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,331.64		
1007	TANF 21-44 FEMALE WI	66.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.72		
1011	TANF <1 M & F NON-ME	75.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.46		
1012	TANF 01-05 M & F NON	10,032.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,032.52		
1013	TANF 06-13 M & F NON	55,253.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,253.93		
1014	TANF 14-20 MALE NON-	100,182.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,182.76		
1015	TANF 14-20 FEMALE N O	233,623.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233,623.79		
1016	TANF 21-44 MALE NON-	7,593.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,593.13		
1017	TANF 21-44 FEMALE N O	1,694,509.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,694,509.66		
1018	TANF 45-64 M & F NON	11,506.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,506.24		
2100	SSI AGED WITH MEDIC A	3,244.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,244.68		
2110	SSI AGED NON-MEDICA
R	1,121,446.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,121,446.00		
2120	SSI AGED WITH QMB	138.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.97		
2200	SSI DISABLED WITH M E	11,519.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,519.68		
2210	SSI DISABLED NON-ME
D	84,283.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,283.42		
5017	SOBRA PREG 21-44 FE M	34.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.61		
SUBTOTAL:	3,335,843.21	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,335,843.21		

3908	NEWLY ELIGIBLE M&F 4	57.58	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	76,108.18	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	83,570.35	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	534,581.63	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	624,582.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

57.58	
76,108.18	
83,570.35	
534,581.63	
624,582.36	

1108	TANF EXPANDED 45-64	3,645.14	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
&	1,809.61	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	48.91	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	10,893.56	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	581,996.63	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	1,231,827.93	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	637,323.75	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
&	18,009.37	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	3,204.54	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	183.26	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	6,381.58	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	1,600.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,496,925.20	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,645.14	
1,809.61	
48.91	
10,893.56	
581,996.63	
1,231,827.93	
637,323.75	
18,009.37	
3,204.54	
183.26	
6,381.58	
1,600.92	
2,496,925.20	

FEDERAL EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3918	NEWLY ELIGIBLE M&F 4	1,793,345.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,793,345.32		
3919	NEWLY ELIGIBLE M&F
6	9,030.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,030.78		
SUBTOTAL:	3,121,276.20	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,121,276.20		

8,954,044.61

8,954,044.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	620,715.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		620,715.19		
8050	QI1	68.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.23		
SUBTOTAL:	620,783.42	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		620,783.42		

TOTAL:	620,783.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		620,783.42		

FFS TRBHA FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	76.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.60		
1009	TANF 65+ M & F WITH	87.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.98		
1011	TANF <1 M & F NON-ME	2,747.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,747.82		
1012	TANF 01-05 M & F NON	13,143.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,143.77		
1013	TANF 06-13 M & F NON	218,801.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,801.71		
1014	TANF 14-20 MALE NON-	16,179.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,179.78		
1015	TANF 14-20 FEMALE N O	125,023.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,023.80		
1016	TANF 21-44 MALE NON-	529,489.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		529,489.74		
1017	TANF 21-44 FEMALE N O	1,164,015.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,164,015.57		
1018	TANF 45-64 M & F NON	213,834.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213,834.54		
2100	SSI AGED WITH MEDIC A	8,512.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,512.47		
2110	SSI AGED NON-MEDICA
R	4,930.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,930.99		
2120	SSI AGED WITH QMB	17,608.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,608.95		
2200	SSI DISABLED WITH M E	53,361.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,361.22		
2210	SSI DISABLED NON-ME
D	1,663,776.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,663,776.48		
2220	SSI DISABLED WITH Q M	269,255.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269,255.92		
2310	SSI BLIND NON-MEDIC
A	20,833.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,833.76		
2320	SSI BLIND WITH QMB	945.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		945.26		
4311	SOBRA CHILD <1 M & F	17,699.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,699.86		
4312	SOBRA CHILD 01-05 M	145,743.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,743.83		
4313	SOBRA CHILD 06-13 M	4,235,083.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,235,083.20		
4314	SOBRA CHILD 14-20 MA	1,111,452.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,111,452.87		
4315	SOBRA CHILD 14-20 FE	1,136,461.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,136,461.92		
5013	SOBRA PREG 09-13 FE M	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.00		
5015	SOBRA PREG 14-20 FE
M	13,165.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,165.38		
5017	SOBRA PREG 21-44 FE M	130,369.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,369.95		
5018	SOBRA PREG 45-64 FE
M	4,288.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,288.24		
SUBTOTAL:	11,117,318.6	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,117,318.61		

1108	TANF EXPANDED 45-64	184.01	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	2,600.86	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	132,900.36	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	330,923.61	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	127,317.08	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	1,242.45	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	6,783.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
184.01	
2,600.86	
132,900.36	
330,923.61	
127,317.08	
1,242.45	
6,783.03	

FFS TRBHA FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	2,135.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,135.58		
1129	TANF EXPANDED 65+ M
&	335.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		335.08		
2410	SSI AGED EXPANDED N O	4.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.02		
2420	SSI AGED EXPANDED
WI	16,856.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,856.33		
2600	SSI DISABLED EXPAND E	34.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.36		
2610	SSI DISABLED EXPAND
E	3,212.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,212.21		
2620	SSI DISABLED EXPAND E	86,428.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,428.45		
SUBTOTAL:	710,957.4	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		710,957.43		

3514	ADULT 40-100% MALE 1	4,692.85	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	15,939.50	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	158,151.60	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	66,409.98	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	78,607.32	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	136,450.77	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	117,289.45	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	2,551,810.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,399,164.79	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	1,231,629.73	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	136.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,760,283.46	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,692.85	
15,939.50	
158,151.60	
66,409.98	
78,607.32	
136,450.77	
117,289.45	
2,551,810.53	
1,399,164.79	
1,231,629.73	
136.94	
5,760,283.46	

3914	NEWLY ELIGIBLE MALE	31,466.18	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	3,396.00	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	32,180.67	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	35,370.17	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	66,038.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	168,451.1	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
31,466.18	
3,396.00	
32,180.67	
35,370.17	
66,038.09	
168,451.11	

4413	SOBRA 100-133% M&F
6	183,265.65	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	30,782.44	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	53,126.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	267,174.7	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
183,265.65	
30,782.44	
53,126.70	
267,174.79	

8700	SSI DISABLED FREEDO M	482.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	482.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

482.92

482.92

18,024,668.32

18,024,668.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	10,383.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,383.51		
1017	TANF 21-44 FEMALE N O	21,378.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,378.33		
2210	SSI DISABLED NON-ME
D	46,249.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,249.55		
2220	SSI DISABLED WITH Q M	2,680.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,680.00		
SUBTOTAL:	80,691.39	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,691.39		

3516	ADULT 40-100% MALE 2	2,449.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	18,050.34	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	82,139.07	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	56,330.91	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	22,355.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	181,325.4	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,449.17	
18,050.34	
82,139.07	
56,330.91	
22,355.92	
181,325.41	

1117	TANF EXPANDED 21-44	5,714.73	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	1,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,054.73	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,714.73	
1,340.00	
7,054.73	

TOTAL:	269,071.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269,071.53		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	170.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170.94		
2100	SSI AGED WITH MEDIC
A	16,135.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,135.95		
2110	SSI AGED NON-MEDICA R	22,432.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,432.29		
2200	SSI DISABLED WITH M
E	147.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147.01		
5017	SOBRA PREG 21-44 FE M	14,080.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,080.22		
SUBTOTAL:	52,966.41	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,966.41		

3518	ADULT 40-100% M&F 45	1,200.57	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	43,344.90	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	12,739.14	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	148,337.54	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	29,781.34	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	331,780.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	567,184.0	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,200.57	
43,344.90	
12,739.14	
148,337.54	
29,781.34	
331,780.58	
567,184.07	

3916	NEWLY ELIGIBLE MALE	37,301.33	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	704.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	38,006.04	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
37,301.33	
704.71	
38,006.04	

658,156.52

658,156.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3706	ADULT <40% EXP MALE	4,816.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,816.81		
SUBTOTAL:	4,816.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,816.81		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

4,816.81

0.00

4,816.81

0.00	0.00

0.00

0.00

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	57.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.40		
1017	TANF 21-44 FEMALE N O	3,222.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,222.63		
1018	TANF 45-64 M & F NON	1,623.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,623.32		
2220	SSI DISABLED WITH Q M	4,042.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,042.07		
5017	SOBRA PREG 21-44 FE
M	4,335.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,335.15		
SUBTOTAL:	13,280.57	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,280.57		

3516	ADULT 40-100% MALE 2	2,731.97	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	51,830.92	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	3,378.84	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	25,263.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	83,204.75	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,731.97	
51,830.92	
3,378.84	
25,263.02	
83,204.75	

3916	NEWLY ELIGIBLE MALE	3,611.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,611.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,611.36

3,611.36

100,096.68

100,096.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 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	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		

20.90

3714	ADULT <40% EXP MALE	523.06	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	827.95	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	76.39	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	5,063.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,490.70	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

523.06	
827.95	
76.39	
5,063.30	
6,490.70	

2620	SSI DISABLED EXPAND E	20.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
20.90

TOTAL:	6,511.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,511.60		

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1016	TANF 21-44 MALE NON-	160.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.31		
2210	SSI DISABLED NON-ME D	132.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132.43		
SUBTOTAL:	292.74	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.74		

4,803.59

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

5,096.33

3718	ADULT <40% EXP M&F 4	4,803.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,803.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,803.59

TOTAL:

5,096.33

0.00

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

YUMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2200	SSI DISABLED WITH M E	106.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.17		
SUBTOTAL:	106.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.17		

3717	ADULT <40% EXP FEMA L	379.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	379.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
379.71

379.71

485.88

485.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	2,135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,135.00		
2100	SSI AGED WITH MEDIC A	2,690,045.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,690,045.71		
2110	SSI AGED NON-MEDICA
R	129,486.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129,486.77		
2120	SSI AGED WITH QMB	3,501,420.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,501,420.19		
2200	SSI DISABLED WITH M E	601,859.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		601,859.98		
2210	SSI DISABLED NON-ME
D	2,935,385.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,935,385.90		
2220	SSI DISABLED WITH Q M	849,428.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		849,428.99		
2310	SSI BLIND NON-MEDIC
A	5,515.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,515.00		
2320	SSI BLIND WITH QMB	347.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347.83		
SUBTOTAL:	10,715,625.3	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,715,625.37		

8720	SSI DISABLED FREEDO M	3,044.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,044.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,044.16

3,044.16

TOTAL:	10,718,669.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,718,669.53		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	15,242.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,242.83		
2120	SSI AGED WITH QMB	1,819.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,819.81		
2200	SSI DISABLED WITH M E	5,271.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,271.41		
2210	SSI DISABLED NON-ME
D	26,125.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,125.15		
SUBTOTAL:	48,459.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,459.20		

48,459.20

48,459.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	20.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.58		
SUBTOTAL:	20.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.58		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

20.58

0.00

20.58

0.00	0.00

0.00

0.00

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	222.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222.75		
SUBTOTAL:	222.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222.75		

222.75

222.75	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 MEDICAID IN PUBLIC SCHOOLS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	23,803.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,803.30		
1013	TANF 06-13 M & F NON	46,103.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,103.20		
1014	TANF 14-20 MALE NON-	3,875.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,875.77		
1015	TANF 14-20 FEMALE N O	1,059.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,059.25		
2210	SSI DISABLED NON-ME
D	195,372.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,372.83		
2220	SSI DISABLED WITH Q M	40.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.22		
2310	SSI BLIND NON-MEDIC
A	2,012.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,012.88		
4302	SOBRA CHILD 01-05 M	27.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.12		
4312	SOBRA CHILD 01-05 M	133,360.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133,360.63		
4313	SOBRA CHILD 06-13 M	158,588.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,588.60		
4314	SOBRA CHILD 14-20 MA	10,083.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,083.50		
4315	SOBRA CHILD 14-20 FE	4,583.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,583.50		
SUBTOTAL:	578,910.8	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		578,910.80		

3914	NEWLY ELIGIBLE MALE	24.80	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	7.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	32.40	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

24.80	
7.60	
32.40	

4413	SOBRA 100-133% M&F
6	30,197.25	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	1,739.45	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	986.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	32,923.17	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

30,197.25	
1,739.45	
986.47	
32,923.17	

3514	ADULT 40-100% MALE 1	9.87	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	104.87	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	96.81	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	66.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	277.95	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9.87	
104.87	
96.81	
66.40	
277.95	

TOTAL:	612,144.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		612,144.32		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	60.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.95		
1010	TANF NON-MEDICARE	40,228.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,228.81		
2200	SSI DISABLED WITH M E	2,528.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,528.24		
2210	SSI DISABLED NON-ME
D	1,187,559.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,187,559.37		
2220	SSI DISABLED WITH Q M	4,979.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,979.23		
2310	SSI BLIND NON-MEDIC
A	4,955.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,955.34		
SUBTOTAL:	1,240,311.94	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,240,311.94		

1,240,311.94

1,240,311.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE REINSURANCE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	1,965.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,965.89		
1008	TANF 45-64 M & F WIT	-32,709.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-32,709.37		
1011	TANF <1 M & F NON-ME	1,367,464.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,367,464.17		
1012	TANF 01-05 M & F NON	220,883.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,883.34		
1013	TANF 06-13 M & F NON	541,569.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		541,569.53		
1014	TANF 14-20 MALE NON-	8,935.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,935.26		
1015	TANF 14-20 FEMALE N O	43,754.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,754.39		
1016	TANF 21-44 MALE NON-	314,141.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,141.01		
1017	TANF 21-44 FEMALE N O	65,459.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,459.28		
1018	TANF 45-64 M & F NON	257,482.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257,482.04		
1019	TANF 65+ M & F NON-M	736.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.61		
2100	SSI AGED WITH MEDIC A	-51,204.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-51,204.98		
2110	SSI AGED NON-MEDICA
R	136,832.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,832.77		
2200	SSI DISABLED WITH M E	165,164.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,164.34		
2210	SSI DISABLED NON-ME
D	6,629,461.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,629,461.86		
2310	SSI BLIND NON-MEDIC A	6,373.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,373.16		
4311	SOBRA CHILD <1 M & F	2,433,634.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,433,634.85		
4312	SOBRA CHILD 01-05 M	2,169,529.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,169,529.06		
4313	SOBRA CHILD 06-13 M	894,827.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		894,827.48		
4314	SOBRA CHILD 14-20 MA	364,934.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364,934.32		
4315	SOBRA CHILD 14-20 FE	334,736.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334,736.84		
5017	SOBRA PREG 21-44 FE M	25,593.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,593.87		
SUBTOTAL:	15,899,565.7	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,899,565.72		

-26,819.24

3100	TRANSPLANT OPTION 1	-26,819.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-26,819.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-26,819.24

1106	TANF EXPANDED 21-44	26,859.21	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	-31,095.43	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	422,095.71	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	186,242.11	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	187,595.93	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
&	7,539.14	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	24.58	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	15,709.73	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	362.04	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	129,876.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

26,859.21	
-31,095.43	
422,095.71	
186,242.11	
187,595.93	
7,539.14	
24.58	
15,709.73	
362.04	
129,876.21	

ACUTE REINSURANCE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	945,209.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		945,209.23		

3514	ADULT 40-100% MALE 1	70,821.21	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	1,443.66	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	138,432.26	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	295,157.21	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	735,462.12	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	-1,751.04	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	114,945.66	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	131,460.17	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	1,626,527.25	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	312,636.20	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	1,914,993.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,340,128.61	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
70,821.21	
1,443.66	
138,432.26	
295,157.21	
735,462.12	
-1,751.04	
114,945.66	
131,460.17	
1,626,527.25	
312,636.20	
1,914,993.91	
5,340,128.61	

3906	NEWLY ELIGIBLE MALE	1,009.14	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	431.66	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	64,834.53	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	7,280.14	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	138,451.69	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	20,458.27	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	302,713.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	535,178.5	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,009.14	
431.66	
64,834.53	
7,280.14	
138,451.69	
20,458.27	
302,713.09	
535,178.52	

4413	SOBRA 100-133% M&F
6	399,630.02	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	192,612.37	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	45,366.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	637,608.6	8	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
399,630.02	
192,612.37	
45,366.29	
637,608.68	

25,577.76

25,577.76

25,577.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
25,577.76	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	0
M
SUBTOTAL:

TOTAL:	23,356,449.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,356,449.28		

LONG TERM CARE REINSURANCE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,194.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,194.61		
2100	SSI AGED WITH MEDIC A	323,595.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323,595.92		
2110	SSI AGED NON-MEDICA
R	53,483.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,483.73		
2200	SSI DISABLED WITH M E	750,334.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		750,334.85		
2210	SSI DISABLED NON-ME
D	4,294,544.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,294,544.57		
2310	SSI BLIND NON-MEDIC A	23,280.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,280.32		
SUBTOTAL:	5,446,434.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,446,434.00		

8710	SSI DISABLED FREEDO M	39.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
39.30

39.30

5,446,473.30

5,446,473.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE SMIB
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	55,736.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,736.00		
1010	TANF NON-MEDICARE	938.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938.00		
1020	TANF WITH QMB	47,404.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,404.00		
2100	SSI AGED WITH MEDIC A	45,901.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,901.50		
2110	SSI AGED NON-MEDICA
R	519,350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		519,350.00		
2120	SSI AGED WITH QMB	4,138,319.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,138,319.10		
2200	SSI DISABLED WITH M E	81,776.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,776.80		
2210	SSI DISABLED NON-ME
D	447,158.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		447,158.00		
2220	SSI DISABLED WITH Q M	3,939,195.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,939,195.80		
2300	SSI BLIND WITH MEDIC	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.00		
2310	SSI BLIND NON-MEDIC A	3,886.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,886.00		
2320	SSI BLIND WITH QMB	35,778.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,778.00		
4320	SOBRA CHILD WITH Q MB	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		670.00		
5020	SOBRA PREGNANT WO
MAN	6,566.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,566.00		
8000	SMIB ONLY NOT ELIGIB	-268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-268.00		
8010	SMIB ONLY NOT ELIGIB	-268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-268.00		
8020	QMB ONLY	918,379.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918,379.70		
8040	SLMB	5,318,204.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,318,204.60		
8888	SMIB ONLY NOT ELIGIB	-57,211.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-57,211.50		
9999	SMIB ONLY NOT ELIGIB	133,242.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133,242.60		
SUBTOTAL:	15,635,026.6	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,635,026.60		

3520	ADULT 40-100% FOR FI	402.00	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	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	670.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

402.00	
268.00	
670.00	

8720	SSI DISABLED FREEDO M	35,242.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

35,242.00

1100	TANF EXPANDED FPR FI	219,940.40	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	670.00	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	875,874.70	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	22,891.00	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	1,474.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	3,349,234.70	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	18,492.00	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	2,308,687.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,797,263.90	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
219,940.40	
670.00	
875,874.70	
22,891.00	
1,474.00	
3,349,234.70	
18,492.00	
2,308,687.10	
6,797,263.90	

ACUTE SMIB
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	35,242.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,242.00		

TOTAL:	22,468,202.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,468,202.50		

ACUTE HIB
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	1,688.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,688.00		
2120	SSI AGED WITH QMB	462,515.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462,515.60		
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		
2220	SSI DISABLED WITH Q
M	195,874.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,874.60		
2320	SSI BLIND WITH QMB	1,118.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,118.20		
8020	QMB ONLY	6,414.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,414.20		
9999	SMIB ONLY NOT ELIGIB	-5,617.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,617.70		
SUBTOTAL:	661,992.9	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		661,992.90		

1120	TANF EXPANDED FOR FI	2,426.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	3,924.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,350.40	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,426.00	
3,924.40	
6,350.40	

668,343.30

668,343.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

Q1
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	2,606,430.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,606,430.60		
9999	SMIB ONLY NOT ELIGIB	-7,950.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,950.50		
SUBTOTAL:	2,598,480.10	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,598,480.10		

TOTAL:	2,598,480.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,598,480.10		

LTC SMIB
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	804.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		804.00		
1020	TANF WITH QMB	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		670.00		
2100	SSI AGED WITH MEDIC A	1,096,576.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,096,576.60		
2110	SSI AGED NON-MEDICA
R	209,710.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,710.00		
2120	SSI AGED WITH QMB	1,074,969.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,074,969.00		
2200	SSI DISABLED WITH M E	420,258.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		420,258.00		
2210	SSI DISABLED NON-ME
D	17,688.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,688.00		
2220	SSI DISABLED WITH Q M	969,891.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		969,891.50		
2300	SSI BLIND WITH MEDIC	1,608.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,608.00		
2320	SSI BLIND WITH QMB	4,548.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,548.00		
SUBTOTAL:	3,796,723.10	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,796,723.10		

8720	SSI DISABLED FREEDO M	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

670.00

670.00

3,797,393.10

3,797,393.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	232.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232.00		
2120	SSI AGED WITH QMB	327,512.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327,512.40		
2220	SSI DISABLED WITH Q M	16,310.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,310.00		
SUBTOTAL:	344,054.4	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		344,054.40		

TOTAL:	344,054.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		344,054.40		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	16.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.51		
1007	TANF 21-44 FEMALE WI	2,283.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,283.75		
1008	TANF 45-64 M & F WIT	3,061.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,061.28		
1009	TANF 65+ M & F WITH	4,002.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,002.34		
1011	TANF <1 M & F NON-ME	438,462.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		438,462.25		
1012	TANF 01-05 M & F NON	209,316.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,316.34		
1013	TANF 06-13 M & F NON	232,327.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232,327.66		
1014	TANF 14-20 MALE NON-	55,054.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,054.04		
1015	TANF 14-20 FEMALE N O	152,740.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152,740.73		
1016	TANF 21-44 MALE NON-	906,065.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906,065.94		
1017	TANF 21-44 FEMALE N O	3,518,326.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,518,326.14		
1018	TANF 45-64 M & F NON	1,548,916.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,548,916.81		
1019	TANF 65+ M & F NON-M	2,926.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,926.95		
1026	TANF 21-44 MALE WITH	1,357.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,357.60		
1027	TANF 21-44 FEMALE WI	2,745.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,745.49		
1028	TANF 45-64 M & F WIT	4,656.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,656.56		
1029	TANF 65+ M & F WITH	2,925.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,925.62		
2100	SSI AGED WITH MEDIC A	64,149.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,149.88		
2110	SSI AGED NON-MEDICA
R	79,413.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,413.88		
2120	SSI AGED WITH QMB	290,760.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		290,760.68		
2200	SSI DISABLED WITH M E	154,559.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,559.77		
2210	SSI DISABLED NON-ME
D	4,304,299.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,304,299.04		
2220	SSI DISABLED WITH Q M	481,923.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		481,923.72		
2300	SSI BLIND WITH MEDIC	145.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145.59		
2310	SSI BLIND NON-MEDIC A	57,555.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,555.11		
2320	SSI BLIND WITH QMB	7,924.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,924.82		
4311	SOBRA CHILD <1 M & F	1,677,976.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,677,976.34		
4312	SOBRA CHILD 01-05 M	2,809,942.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,809,942.41		
4313	SOBRA CHILD 06-13 M	3,644,238.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,644,238.08		
4314	SOBRA CHILD 14-20 MA	884,065.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		884,065.34		
4315	SOBRA CHILD 14-20 FE	1,073,552.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,073,552.01		
5007	SOBRA PREG 21-44 FE M	318.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318.55		
5015	SOBRA PREG 14-20 FE
M	246,785.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246,785.09		
5017	SOBRA PREG 21-44 FE M	1,276,069.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,276,069.88		
5018	SOBRA PREG 45-64 FE
M	854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		854.00		
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		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	24,139,720.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,139,720.20		

3506	ADULT 40-100% MALE 2	52.90	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	51.35	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	36,258.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	65,614.38	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	402,116.04	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	331,378.79	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	1,508,595.02	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	862.29	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	177,706.60	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	221,380.53	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	3,106,912.99	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	2,314,016.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

52.90	
0.00	
51.35	
36,258.98	
65,614.38	
402,116.04	
331,378.79	
1,508,595.02	
862.29	
177,706.60	
221,380.53	
3,106,912.99	
2,314,016.16	

1106	TANF EXPANDED 21-44	4,134.08	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	6,688.52	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	12,996.09	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
&	9,620.18	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	1,624.00	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	28,165.36	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	488,120.18	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	1,498,155.48	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	1,034,257.41	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
&	854.00	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	4,604.09	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	12,505.08	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	50,388.63	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
&	30,366.97	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	2,774.49	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	11,956.00	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	230,048.61	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	6,294.92	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	76,117.46	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	146,922.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,656,593.59	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,134.08	
6,688.52	
12,996.09	
9,620.18	
1,624.00	
28,165.36	
488,120.18	
1,498,155.48	
1,034,257.41	
854.00	
4,604.09	
12,505.08	
50,388.63	
30,366.97	
2,774.49	
11,956.00	
230,048.61	
6,294.92	
76,117.46	
146,922.04	
3,656,593.59	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3718	ADULT <40% EXP M&F 4	5,349,628.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,349,628.51		
3719	ADULT <40% EXP M&F
6	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.00		
3727	ADULT <40% EXP FEMA L	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.00		
3728	ADULT <40% EXP M&F
4	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.00		
SUBTOTAL:	13,515,855.5	4	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,515,855.54		

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	391.00	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	13,108.08	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	38,550.18	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	250,292.84	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	498,173.17	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	820,122.35	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	854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,621,491.62	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	
391.00	
13,108.08	
38,550.18	
250,292.84	
498,173.17	
820,122.35	
854.00	
1,621,491.62	

4413	SOBRA 100-133% M&F
6	363,232.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	82,847.74	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	116,229.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	562,309.3	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
363,232.38	
82,847.74	
116,229.21	
562,309.33	

4518	BC PATIENT FEMALE 4 5	5,978.00	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	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,405.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,978.00	
427.00	
6,405.00	

8700	SSI DISABLED FREEDO M	3,424.04	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	6,660.50	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	593.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,678.24	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,424.04	
6,660.50	
593.70	
10,678.24	

43,513,053.52

43,513,053.52	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 - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending July 31, 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	454.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454.16		
1008	TANF 45-64 M & F WIT	8,199.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,199.13		
1009	TANF 65+ M & F WITH	3,078.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,078.59		
1011	TANF <1 M & F NON-ME	571,877.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		571,877.30		
1012	TANF 01-05 M & F NON	47,354.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,354.77		
1013	TANF 06-13 M & F NON	46,888.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,888.70		
1014	TANF 14-20 MALE NON-	25,522.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,522.58		
1015	TANF 14-20 FEMALE N O	58,399.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,399.10		
1016	TANF 21-44 MALE NON-	528,281.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		528,281.17		
1017	TANF 21-44 FEMALE N O	1,351,952.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,351,952.87		
1018	TANF 45-64 M & F NON	493,706.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		493,706.62		
1019	TANF 65+ M & F NON-M	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.46		
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	1,852.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,852.95		
1028	TANF 45-64 M & F WIT	11,663.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,663.51		
1029	TANF 65+ M & F WITH	96.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.18		
2100	SSI AGED WITH MEDIC A	63,979.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,979.58		
2110	SSI AGED NON-MEDICA
R	30,607.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,607.02		
2120	SSI AGED WITH QMB	262,680.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,680.34		
2200	SSI DISABLED WITH M E	276,643.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		276,643.75		
2210	SSI DISABLED NON-ME
D	2,898,858.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,898,858.52		
2220	SSI DISABLED WITH Q M	798,769.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		798,769.02		
2300	SSI BLIND WITH MEDIC	2,568.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,568.27		
2310	SSI BLIND NON-MEDIC A	26,569.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,569.90		
2320	SSI BLIND WITH QMB	17,412.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,412.79		
4311	SOBRA CHILD <1 M & F	912,418.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		912,418.33		
4312	SOBRA CHILD 01-05 M	607,631.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		607,631.65		
4313	SOBRA CHILD 06-13 M	841,559.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		841,559.09		
4314	SOBRA CHILD 14-20 MA	241,357.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241,357.49		
4315	SOBRA CHILD 14-20 FE	337,284.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		337,284.98		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	93,227.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,227.02		
5017	SOBRA PREG 21-44 FE M	630,985.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		630,985.09		
5018	SOBRA PREG 45-64 FE
M	2,221.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,221.69		
5027	SOBRA PREG 21-44 FE M	484.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		484.26		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	11,194,593.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,194,593.88		

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	1,886.71	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	16,678.83	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	31,936.08	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	304,239.86	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	146,702.52	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	598,169.70	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	7,404.35	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	123,122.81	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	74,725.01	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	2,515,586.40	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	968,205.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
1,886.71	
0.00	
16,678.83	
31,936.08	
304,239.86	
146,702.52	
598,169.70	
7,404.35	
123,122.81	
74,725.01	
2,515,586.40	
968,205.74	

1106	TANF EXPANDED 21-44	2,667.91	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	3,025.07	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	29,889.37	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
&	6,047.32	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	3,618.71	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	1,467.39	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	184,720.78	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	483,760.66	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	364,411.61	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
&	772.42	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	9,266.38	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	14,081.44	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	77,804.12	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
&	26,196.55	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	3,630.15	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	3,794.54	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	216,396.75	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	4,177.59	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	100,036.04	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	231,770.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,767,535.29	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,667.91	
3,025.07	
29,889.37	
6,047.32	
3,618.71	
1,467.39	
184,720.78	
483,760.66	
364,411.61	
772.42	
9,266.38	
14,081.44	
77,804.12	
26,196.55	
3,630.15	
3,794.54	
216,396.75	
4,177.59	
100,036.04	
231,770.49	
1,767,535.29	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3718	ADULT <40% EXP M&F 4	2,956,002.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,956,002.31		
3719	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEMA L	10.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.33		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	7,744,670.65	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,744,670.65		

4413	SOBRA 100-133% M&F
6	39,529.77	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	27,425.93	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	23,956.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	90,912.54	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

39,529.77	
27,425.93	
23,956.84	
90,912.54	

4518	BC PATIENT FEMALE 4 5	170.89	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:	170.89	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

170.89	
0.00	
170.89	

8700	SSI DISABLED FREEDO M	6,312.17	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	3,944.08	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	210.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,467.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,312.17	
3,944.08	
210.75	
10,467.00	

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	102.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	3,469.50	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	8,139.44	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	89,081.61	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	118,147.17	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	315,084.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	534,024.5	6	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	
102.69	
3,469.50	
8,139.44	
89,081.61	
118,147.17	
315,084.15	
0.00	
534,024.56	

TOTAL:	21,342,374.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,342,374.81		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 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		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	
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	
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	

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

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3719	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

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	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	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	

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	

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 July 31, 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	2,071.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,071.96		
1012	TANF 01-05 M & F NON	201.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201.51		
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	573.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		573.09		
1016	TANF 21-44 MALE NON-	4,620.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,620.19		
1017	TANF 21-44 FEMALE N O	5,557.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,557.26		
1018	TANF 45-64 M & F NON	3,997.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,997.36		
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	20.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.41		
2110	SSI AGED NON-MEDICA
R	194.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194.04		
2120	SSI AGED WITH QMB	198.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198.85		
2200	SSI DISABLED WITH M E	1,747.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,747.14		
2210	SSI DISABLED NON-ME
D	2,333.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,333.96		
2220	SSI DISABLED WITH Q M	297.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		297.04		
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	0.00	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		
4311	SOBRA CHILD <1 M & F	78,114.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,114.20		
4312	SOBRA CHILD 01-05 M	6,421.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,421.00		
4313	SOBRA CHILD 06-13 M	-41.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-41.10		
4314	SOBRA CHILD 14-20 MA	1,411.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,411.35		
4315	SOBRA CHILD 14-20 FE	1,217.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,217.15		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	2,910.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,910.15		
5017	SOBRA PREG 21-44 FE M	24,515.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,515.25		
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		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	136,360.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,360.81		

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	2,509.47	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	9,418.22	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	1,794.58	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	34,842.80	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	
3714	ADULT <40% EXP MALE	1,416.26	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	7,077.31	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	173,548.28	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	49,254.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
2,509.47	
9,418.22	
1,794.58	
34,842.80	
0.00	
1,416.26	
7,077.31	
173,548.28	
49,254.97	

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	
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	352.93	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	8,138.72	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	1,886.10	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	307.71	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	3.33	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	1,328.31	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	20.90	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	1,350.94	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	92.78	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	132.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,614.09	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	
352.93	
8,138.72	
1,886.10	
0.00	
307.71	
0.00	
3.33	
0.00	
1,328.31	
0.00	
20.90	
1,350.94	
92.78	
132.37	
13,614.09	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3718	ADULT <40% EXP M&F 4	69,464.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,464.99		
3719	ADULT <40% EXP M&F
6	799.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		799.37		
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:	350,126.2	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350,126.25		

4413	SOBRA 100-133% M&F
6	12,662.89	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	48.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,711.80	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,662.89	
0.00	
48.91	
12,711.80	

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	7.46	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:	7.46	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	
7.46	
0.00	
7.46	

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	
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	582.12	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	13,827.40	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	1,936.66	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	3,783.85	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	75.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,205.93	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	
582.12	
13,827.40	
1,936.66	
3,783.85	
75.90	
20,205.93	

TOTAL:	533,026.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		533,026.34		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	52,876.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,876.69		
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:	52,876.69	0.0	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,876.69		

52,876.69

52,876.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending July 31, 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		
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:	0.00	0.0	0.0	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		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	567,786.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567,786.98		
8050	QI1	68.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.23		
SUBTOTAL:	567,855.2	0.0	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567,855.21		

567,855.21

567,855.21	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 - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	47.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.76		
1007	TANF 21-44 FEMALE WI	42.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.01		
1008	TANF 45-64 M & F WIT	31.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.16		
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	85,381.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,381.51		
1012	TANF 01-05 M & F NON	1,241.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,241.35		
1013	TANF 06-13 M & F NON	314.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.23		
1014	TANF 14-20 MALE NON-	38.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.53		
1015	TANF 14-20 FEMALE N O	12,353.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,353.72		
1016	TANF 21-44 MALE NON-	23,430.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,430.69		
1017	TANF 21-44 FEMALE N O	79,886.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,886.54		
1018	TANF 45-64 M & F NON	136,628.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,628.18		
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	1,795.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,795.36		
1028	TANF 45-64 M & F WIT	56.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.79		
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	26,502.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,502.14		
2110	SSI AGED NON-MEDICA
R	219.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		219.89		
2120	SSI AGED WITH QMB	9,934.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,934.00		
2200	SSI DISABLED WITH M E	11,324.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,324.05		
2210	SSI DISABLED NON-ME
D	182,500.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,500.45		
2220	SSI DISABLED WITH Q M	30,030.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,030.58		
2300	SSI BLIND WITH MEDIC	1.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.85		
2310	SSI BLIND NON-MEDIC A	4,516.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,516.76		
2320	SSI BLIND WITH QMB	49.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.61		
4311	SOBRA CHILD <1 M & F	75,672.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,672.38		
4312	SOBRA CHILD 01-05 M	43,251.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,251.91		
4313	SOBRA CHILD 06-13 M	42,039.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,039.46		
4314	SOBRA CHILD 14-20 MA	6,212.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,212.97		
4315	SOBRA CHILD 14-20 FE	10,402.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,402.30		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	15,458.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,458.71		
5017	SOBRA PREG 21-44 FE M	106,253.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,253.24		
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		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	905,618.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		905,618.13		

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	647.66	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	757.13	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	55,406.60	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	13,709.12	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	54,935.20	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	
3714	ADULT <40% EXP MALE	5,054.92	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	7,028.30	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	122,279.73	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	134,244.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
647.66	
757.13	
55,406.60	
13,709.12	
54,935.20	
0.00	
5,054.92	
7,028.30	
122,279.73	
134,244.24	

1106	TANF EXPANDED 21-44	101.55	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	149.65	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	1,822.29	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
&	65.00	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	92.78	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	13,999.03	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	52,923.04	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	26,838.48	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	731.25	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	90.80	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	1,696.63	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
&	400.18	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	-18.27	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	10,889.50	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	363.39	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	9,582.26	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	6,495.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	126,223.3	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
101.55	
149.65	
1,822.29	
65.00	
0.00	
92.78	
13,999.03	
52,923.04	
26,838.48	
0.00	
731.25	
90.80	
1,696.63	
400.18	
-18.27	
0.00	
10,889.50	
363.39	
9,582.26	
6,495.81	
126,223.37	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3718	ADULT <40% EXP M&F 4	154,155.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,155.14		
3719	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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:	548,218.0	4	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		548,218.04		

4413	SOBRA 100-133% M&F
6	1,298.14	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	255.04	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	5,456.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,009.55	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,298.14	
255.04	
5,456.37	
7,009.55	

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	4,464.26	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	891.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,356.06	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,464.26	
0.00	
891.80	
5,356.06	

3907	NEWLY ELIGIBLE FEMA L	995.90	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	
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	3,267.85	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	18,172.89	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	20,564.34	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	8,212.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	51,213.51	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
995.90	
0.00	
0.00	
3,267.85	
18,172.89	
20,564.34	
8,212.53	
0.00	
51,213.51	

TOTAL:	1,643,638.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,643,638.66		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	2,135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,135.00		
2100	SSI AGED WITH MEDIC A	156,640.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,640.61		
2110	SSI AGED NON-MEDICA
R	14,737.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,737.61		
2120	SSI AGED WITH QMB	223,757.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,757.27		
2200	SSI DISABLED WITH M E	57,027.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,027.10		
2210	SSI DISABLED NON-ME
D	770,298.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		770,298.39		
2220	SSI DISABLED WITH Q M	100,994.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,994.37		
2310	SSI BLIND NON-MEDIC
A	5,515.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,515.00		
2320	SSI BLIND WITH QMB	292.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.83		
SUBTOTAL:	1,331,398.18	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,331,398.18		

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

 
0.00

0.00

1,331,398.18

1,331,398.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending July 31, 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	2,424,505.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,424,505.57		
2110	SSI AGED NON-MEDICA
R	107,506.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,506.07		
2120	SSI AGED WITH QMB	3,259,048.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,259,048.04		
2200	SSI DISABLED WITH M E	536,288.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		536,288.21		
2210	SSI DISABLED NON-ME
D	2,054,430.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,054,430.35		
2220	SSI DISABLED WITH Q M	742,283.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		742,283.47		
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	55.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
SUBTOTAL:	9,124,116.71	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,124,116.71		

8720	SSI DISABLED FREEDO M	3,044.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,044.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,044.16

3,044.16

TOTAL:	9,127,160.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,127,160.87		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 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	103,818.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,818.39		
2110	SSI AGED NON-MEDICA
R	6,828.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,828.03		
2120	SSI AGED WITH QMB	1,251.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,251.92		
2200	SSI DISABLED WITH M E	5,422.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,422.20		
2210	SSI DISABLED NON-ME
D	42,117.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,117.76		
2220	SSI DISABLED WITH Q M	2,533.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,533.82		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	161,972.12	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,972.12		

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

 
0.00

0.00

161,972.12

161,972.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending July 31, 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	5,081.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,081.14		
2110	SSI AGED NON-MEDICA
R	415.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415.06		
2120	SSI AGED WITH QMB	17,362.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,362.96		
2200	SSI DISABLED WITH M E	3,122.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,122.47		
2210	SSI DISABLED NON-ME
D	68,539.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,539.40		
2220	SSI DISABLED WITH Q M	3,617.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,617.33		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	98,138.36	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,138.36		

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

 
0.00

0.00

TOTAL:	98,138.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,138.36		

KidsCare - CAPITATION AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	119,251.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,251.39		
6012	KIDS 1-5 M & F NON-M	930,841.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		930,841.31		
6013	KIDS 6-13 M & F NON-	1,769,582.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,769,582.94		
6014	KIDS 14-19 MALE NON-	645,960.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		645,960.88		
6015	KIDS 14-19 FEMALE NO	953,492.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		953,492.75		
9960	KIDSCARE KICK PAYME N	6,279.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,279.40		
SUBTOTAL:	4,425,408.67	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,425,408.67		

4,425,408.67

4,425,408.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	262.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262.07		
6012	KIDS 1-5 M & F NON-M	7,628.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,628.26		
6013	KIDS 6-13 M & F NON-	13,979.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,979.68		
6014	KIDS 14-19 MALE NON-	3,647.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,647.77		
6015	KIDS 14-19 FEMALE NO	3,569.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,569.17		
9960	KIDSCARE KICK PAYME N	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	29,087.95	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,087.95		

TOTAL:	29,087.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,087.95		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	11,163.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,163.91		
6012	KIDS 1-5 M & F NON-M	315,349.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315,349.20		
6013	KIDS 6-13 M & F NON-	574,129.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		574,129.11		
6014	KIDS 14-19 MALE NON-	171,357.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,357.69		
6015	KIDS 14-19 FEMALE NO	167,709.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,709.13		
SUBTOTAL:	1,239,709.04	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,239,709.04		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

1,239,709.04

TOTAL:

1,239,709.04

0.00

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	356.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		356.00		
6012	KIDS 1-5 M & F NON-M	11,533.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,533.00		
6013	KIDS 6-13 M & F NON-	21,426.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,426.00		
6014	KIDS 14-19 MALE NON-	5,386.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,386.00		
6015	KIDS 14-19 FEMALE NO	5,353.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,353.00		
SUBTOTAL:	44,054.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,054.00		

TOTAL:	44,054.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,054.00		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending July 31, 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	1,794.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,794.42		
6013	KIDS 6-13 M & F NON-	2,990.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,990.70		
6014	KIDS 14-19 MALE NON-	1,196.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,196.28		
6015	KIDS 14-19 FEMALE NO	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		598.14		
SUBTOTAL:	6,579.54	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,579.54		

6,579.54

6,579.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending July 31, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
6013	KIDS 6-13 M & F NON-	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
6014	KIDS 14-19 MALE NON-	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
6015	KIDS 14-19 FEMALE NO	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	11.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		

TOTAL:	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		

KidsCare - FEE FOR SERVICE
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	162.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.49		
6012	KIDS 1-5 M & F NON-M	10,139.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,139.27		
6013	KIDS 6-13 M & F NON-	82,808.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,808.67		
6014	KIDS 14-19 MALE NON-	13,580.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,580.70		
6015	KIDS 14-19 FEMALE NO	120,789.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,789.67		
SUBTOTAL:	227,480.8	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227,480.80		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

227,480.80

TOTAL:

227,480.80

0.00

KidsCare - REINSURANCE
For The Period Ending July 31, 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	8,845.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,845.88		
6013	KIDS 6-13 M & F NON-	155,090.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,090.01		
6014	KIDS 14-19 MALE NON-	69,646.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,646.87		
6015	KIDS 14-19 FEMALE NO	5,374.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,374.05		
SUBTOTAL:	238,956.8	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238,956.81		

TOTAL:	238,956.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238,956.81		

110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending July 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	
1000	TANF WITH MEDICARE	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
1010	TANF NON-MEDICARE	657.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	657.19	
1020	TANF WITH QMB	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
2100	SSI AGED WITH MEDICA	221.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	221.85	
2110	SSI AGED NON-MEDICAR	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00	
2120	SSI AGED WITH QMB	337.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	337.61	
2200	SSI DISABLED WITH ME	2,046.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,046.96	
2210	SSI DISABLED NON-MED	24,762.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24,762.26	
2220	SSI DISABLED WITH QM	4,454.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,454.67	
2300	SSI BLIND WITH MEDIC	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00	
2310	SSI BLIND NON-MEDICA	51.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.00	
2320	SSI BLIND WITH QMB	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.00	
8700	SSI DISABLED FREEDOM	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00	
8710	SSI DISABLED FREEDOM	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	
8720	SSI DISABLED FREEDOM	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	
SUBTOTAL:	32,598.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32,598.54	
TOTAL:	32,598.54	0.00	0.00	0.	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	32,598.54	

00

00

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending July 31, 2018

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	402,320.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	402,320.34	
EPD	97,705,021.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,705,021.68	
TOTAL AHCCCS LTC	98,107,342.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98,107,342.02	
DES/DD	126,960,382.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,960,382.68	
TOTAL DES LTC	126,960,382.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	126,960,382.68	
TOTAL LTC - CAP	225,067,724.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	225,067,724.70	

EPD/DD FEE-FOR-SERVICE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	10,718,669.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,718,669.53	
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	10,718,669.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,718,669.53	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	4,537,399.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,537,399.02	
DES/DD	909,074.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	909,074.28	
TOTAL DES LTC	909,074.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	909,074.28	
TOTAL LTC - REIN	5,446,473.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,446,473.30	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	4,141,447.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,141,447.50	

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

126

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

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

010115	CRS FULLY INTEGRATED PLAN - CAP	15,749,747.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,749,747.00	
010145	CRS ACUTE SEMI INTEGRATED - CAP	188,385.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	188,385.93	
999125	CRS SEMI INTEGRATED PLAN - CAP	6,356,658.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,356,658.85	
999135	CRS ONLY PLAN - CAP	646,990.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	646,990.35	
Subtotal	22,941,782.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,941,782.13	

999155	CRS REINSURANCE ONLY	6,201,695.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,201,695.95	
Subtotal	6,201,695.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,201,695.95	

29,143,478.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	29,143,478.08	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending July 31, 2018

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

010115	CRS FULLY INTEGRATED PLAN - MM	15,509.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,509.20	
010145	CRS ACUTE SEMI INTEGRATED - MM	196.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	196.02	
999125	CRS SEMI INTEGRATED PLAN - MM	6,593.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,593.46	
999135	CRS ONLY PLAN - MM	1,070.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,070.31	
Subtotal	23,368.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,368.99	

23,368.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,368.99	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS
For the Period Ending July 31, 2018

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

010715	HEALTH CHOICE INTEGRATED - CAP	8,385,057.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,385,057.71	
010735	CENPATICO INTEGRATED - CAP	22,003,091.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,003,091.75	
010795	MERCY MARICOPA INTEGRATED - CAP	52,370,328.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,370,328.29	
078999	MERCY MARICOPA INTEGRATED - CAP	-6,767.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-6,767.58	
Subtotal	82,751,710.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82,751,710.17	

82,751,710.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82,751,710.17	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS
For the Period Ending July 31, 2018

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

010715	HEALTH CHOICE INTEGRATED - MM	5,809.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,809.39	
010735	CENPATICO INTEGRATED - MM	13,447.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,447.32	
010795	MERCY MARICOPA INTEGRATED - MM	21,992.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,992.24	
078999	MERCY MARICOPA INTEGRATED - MM	-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	
Subtotal	41,245.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,245.95	

41,245.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,245.95	

GRAND TOTAL

Behavioral Health Expenditures by RHBA
For the Period Ending July 31, 2018

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

010705	HEALTH CHOICE RBHA- BHCAP	12,113,957.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,113,957.19	
010730	CENPATICO RBHA - BHCAP	33,034,410.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,034,410.12	
010789	MERCY MARICOPA RBHA - BHCAP	52,422,993.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,422,993.35	
Subtotal	97,571,360.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97,571,360.66	

010715	HEALTH CHOICE INTEGRATED - CAP	8,385,057.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,385,057.71	
010735	CENPATICO INTEGRATED - CAP	22,003,091.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,003,091.75	
010795	MERCY MARICOPA INTEGRATED - CAP	52,370,328.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52,370,328.29	
078999	MERCY MARICOPA INTEGRATED - CAP	-6,767.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-6,767.58	
Subtotal	82,751,710.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	82,751,710.17	

180,323,070.83

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

180,323,070.83

GRAND TOTAL