September 28, 2018

The Honorable Steve Yarbrough Arizona State Senate
1700 West Washington
Phoenix, Arizona 85007

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

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

SUBJECT: FY 2019 Appropriation Status Report for the Period Ended August 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 August 31, 2018.

Status Summary – As part of the FY 2020 budget request to the Governor’s Office of Strategic Planning and Budgeting, a FY 2019 rebase was prepared. Based on that rebase, AHCCCS believes the FY 2019 appropriations will be sufficient. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

There are several issues this fiscal year that have the potential to affect the projected shortfall. They include:
Volatility in caseload growth.
Final Medicare Premium rate increases.
Potential Agency audit liabilities, which are detailed in the ASR.

AHCCCS also intends to utilize surplus FY 2018 General Fund and Expenditure Authority for administrative adjustments of expenditures with dates of service prior to July 1, 2018.

Enrollment Update – August 2018 enrollment is 1,861,352 members, a 6,914 member increase over the prior month. Enrollment for September 2018 increased to 1,865,574 members, a 4,222 member change.

Major September 2018 changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 1,140; Supplemental Security Income – increase of 364; Prop 204 Restoration - increase of 851; Adult Expansion – decrease of 59; Medicare Cost Sharing – increase of 398; KidsCare – increase of 373; and Federal Emergency Services - increase of 738.

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

The Honorable Steve Yarbrough The Honorable J.D. Mesnard September 28, 2018
Page 2

Tobacco Funds Revenue Update - Tobacco tax collections through August 2018 are $411,000 less than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 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

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 August 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 August 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	$	14,239,441	$	14,239,441	$	-	$	88,785,300	$	-	
AHCCCS Prop 204 Administration	14,171,100	3,493,485	3,493,485	-	14,171,100	-	
DES Eligibility	91,874,500	14,011,390	14,011,390	-	91,874,500	-	
DES Prop 204 Eligibility	44,358,700	4,528,896	4,528,896	-	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	 	36,273,212	 	36,273,212	 	-		 	258,615,400	 	-	

Traditional Medicaid Services	5,345,876,000	884,933,179	884,933,179	-	5,345,876,000	-	
Proposition 204 Services	3,953,396,600	618,931,033	618,931,033	-	3,953,396,600	-	
ACA Adult Expansion	565,675,000	85,135,095	85,135,095	-	565,675,000	-	
KidsCare Services	81,846,900	11,910,251	11,910,251	-	81,846,900	-	
ALTCS Services	1,605,757,300	269,039,827	269,039,827	-	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	44,784,168	44,784,168	-	296,390,800	-	
CMDP	199,914,500	28,171,104	28,171,104	-	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	12,193,686	12,193,686	-	77,646,900	-	
Supported Housing	5,324,800	787,467	787,467	-	5,324,800	-	
Crisis Services	16,391,300	2,717,717	2,717,717	-	16,391,300	-	

TOTAL PROGRAMMATIC	 	12,261,863,300	 	1,958,603,526	 	1,958,603,526	 	-		 	12,261,863,300	 	-	

TOTAL EXPENDITURES

  $	12,520,478,700

$	1,994,876,738

$	1,994,876,738	$

-	$   12,520,478,700	$	-

2

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	$	9,726,079	$	9,726,079	-	$	60,399,500	$	-	
Proposition 204 - Administrative Expenditures	21,685,600	2,879,678	2,879,678	-	21,685,600	-	
Programmatic Expenditures				
Traditional Medicaid Services	1,217,983,500	211,626,151	211,626,151	-	1,217,983,500	-	
Proposition 204 Services	102,608,900	13,100,265	13,100,265	-	102,608,900	-	
ACA Adult Expansion	6,461,300	266,967	266,967	-	6,461,300	-	
KidsCare Services	-	223,291	223,291	-	-	-	
ALTCS Services	198,722,900	33,120,483	33,120,483	-	198,722,900	-	
DSH and Rural Hospitals	8,905,100	-	-	-	8,905,100	-	
CMDP	60,213,900	8,526,083	8,526,083	-	60,213,900	-	
BHS - Public Schools	3,000,000	-	-	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	12,193,686	12,193,686	-	77,646,900	-	
Supported Housing	5,324,800	787,467	787,467	-	5,324,800	-	
Crisis Services	 	14,141,100	 	2,342,683	 	2,342,683	 	-	 	14,141,100	 	- 	
TOTAL GF EXPENDITURES	1,777,093,500	294,792,832	294,792,832	-	1,777,093,500	-	

FEDERAL		
Administrative Expenditures	139,025,200	18,521,873	18,521,873	-	139,025,200	-	
Proposition 204 - Administrative Expenditures	33,027,100	5,142,704	5,142,704	-	33,027,100	-	
Programmatic Expenditures				
Traditional Medicaid Services	3,345,433,900	483,919,122	483,919,122	-	3,345,433,900	-	
Proposition 204 Services	3,424,557,600	518,619,827	518,619,827	-	3,424,557,600	-	
ACA Adult Expansion	530,669,800	79,793,438	79,793,438	-	530,669,800	-	
KidsCare Services	69,695,600	10,371,883	10,371,883	-	69,695,600	-	
ALTCS Services and Nursing Facility Assessment	1,003,709,000	159,839,059	159,839,059	-	1,003,709,000	-	
DSH and Rural Hospitals	24,794,400	-	-	-	24,794,400	-	
CMDP	139,700,600	19,645,020	19,645,020	-	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	 	30,975,331	 	30,975,331	 	-	 	206,683,800	 	- 	
TOTAL FEDERAL EXPENDITURES	8,972,467,600	1,326,828,258	1,326,828,258	-	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	7,752,150	7,752,150	-	49,687,700	-	
ALTCS Services	 	249,980,000	 	42,972,711	 	42,972,711	 	-	 	249,980,000	 	- 	
TOTAL COUNTY EXPENDITURES	303,423,900	50,724,861	50,724,861	-	303,423,900	-	

TOBACCO FUNDS		
Programmatic Expenditures						
Traditional Medicaid Services - Medically Needy	68,040,500	10,741,384	10,741,384	-	68,040,500	-	
Proposition 204 Services - Emergency Health Services	17,966,100	2,951,611	2,951,611	-	17,966,100	-	
Proposition 204 Services - Proposition 204 Protection	37,728,900	6,198,384	6,198,384	-	37,728,900	-	
Proposition 204 Services - ATLSF	 	87,000,000	 	- 	 	- 	 	-	 	87,000,000	 	- 	
TOTAL TOBACCO EXPENDITURES	210,735,500	19,891,380	19,891,380	-	210,735,500	-	

	(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	2,879	2,879	-	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	23,359,767	23,359,767	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority		514,085,200	147,318,204	147,318,204	-	514,085,200	-	
Long Term Care - Prescription Drug Rebate Program State Match		7,578,400	1,263,067	1,263,067	-	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority		36,422,000	7,525,209	7,525,209	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment & IGA Fund		283,535,100	78,060,945	78,060,945	-	283,535,100	-	
ACA Adult Expansion - Hospital Assessment & IGA Fund		28,543,900	5,074,690	5,074,690	-	28,543,900	-	
Traditional Medicaid Services - TPL		194,700	202,193	202,193	-	194,700	-	
ALTCS Services - TPL		-	133,603	133,603	-	-	-	
ALTCS Services - Nursing Facility Assessment
Targeted Investment Program		109,345,000
21,773,100	24,185,695
-	24,185,695
-	-	109,345,000
-	21,773,100	-
-	
KidsCare Services Premiums	12,151,300	1,315,077	1,315,077	-	12,151,300	-	
Freedom to Work Premiums	31,200	14,208	14,208	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	375,033	375,033	-	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	89,707,000	 	13,808,837	 	13,808,837	 	-	 	89,707,000	 	- 	
TOTAL OTHER EXPENDITURES	1,256,758,200	302,639,408	302,639,408	-	1,256,758,200	-	

TOTAL		
Administrative Expenditures	258,615,400	36,273,212	36,273,212	-	258,615,400	-	
Acute Care	10,656,106,000	1,689,563,699	1,689,563,699	-	10,656,106,000	-	
Long Term Care	 	1,605,757,300	 	269,039,827	 	269,039,827	 	-	 	1,605,757,300	 	- 	
TOTAL EXPENDITURES	  $	12,520,478,700	$	1,994,876,738	$	1,994,876,738	$	-	$	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 August 31, 2018

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,296,749,400	$	221,619,196	$	221,352,230	
Proposition 204 Services & Administrative	124,294,500	15,979,942	15,979,942	
KidsCare Services	-	223,291	223,291	
ALTCS Services	198,722,900	33,120,483	33,120,483	
Behavioral Health Traditional Medicaid Services	 	157,326,700	 	23,849,919	 	23,849,919	
TOTAL	1,777,093,500	294,792,832	294,525,866	

FEDERAL:
Acute & Administrative	7,759,362,400	1,136,972,296	1,145,041,939	
KidsCare Services	69,695,600	10,371,882.55	11,969,286	
ALTCS Services	1,003,709,000	159,839,059.12	183,893,500	
Behavioral Health Traditional Medicaid Services	 	139,700,600	 	19,645,020	 	19,690,580	
TOTAL	8,972,467,600	1,326,828,258	1,360,595,306	

COUNTY:				
Acute & Administrative	53,443,900		7,752,150		5,186,742	
ALTCS Services	 	249,980,000		 	42,972,711		 	46,759,130	
TOTAL	303,423,900		50,724,861		51,945,872	

TOBACCO FUNDS:						
Traditional Medicaid Services	68,040,500		10,741,384		10,741,384	
Proposition 204 Services	 	142,695,000		 	9,149,995		 	9,149,995	
TOTAL	210,735,500		19,891,380		19,891,380	

OTHER:

Administrative	721,800	2,879	2,879	
Traditional Medicaid Services - IGA Fund	10,260,700	-		
Acute Care - Prescription Drug Rebate Program	654,243,800	170,677,970	170,677,970	
Long Term Care - Prescription Drug Rebate Program	44,000,400	8,788,276	8,788,276	
Hospital Assessment	312,079,000	83,135,636	71,470,812	
ALTCS - Nursing Facility Assessment	109,345,000	24,185,695	72,233	
Acute TPL - Note 1	194,700	202,193	202,193	
LTC TPL - Note 1	-	133,603	133,603	
KidsCare TPL - Note 1	-	-	(22.00)	
Member Premiums - CHIP	12,151,300	1,315,077	1,315,077	
Member Premiums - Freedom to Work	31,200	14,208	14,208	
Targeted Investment Program	21,773,100	-	-	
Behavioral Health Traditional Medicaid Services	2,250,200	375,033	150,507	
Voluntary Political Subdivision - State Match	 	89,707,000	 	13,808,837	 	20,983,636	
TOTAL	1,256,758,200	302,639,408	273,811,373	

TOTAL REVENUE

$	12,520,478,700

$	1,994,876,738

$	2,000,769,796

5

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 2018	
Note 1:	Third Party Liability Collections:	August 2018		August 2017		July 1, 2018		July 1, 2017	
	Gross Collections:					August 31, 2018		August 31, 2017	
	Acute	$	1,444,541		$	413,294		$	1,956,342		$	1,111,906	
	LTC	363,406		386,182		619,284		1,282,168	
	KidsCare	517		-		517		85	
	Total TPL Collections	  $	1,808,464		$	799,476		$	2,576,143		$	2,394,159	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	160,120		$	40,516		$	202,193		$	97,135		
LTC	79,585		89,119		133,603		292,849		
KidsCare	(22)		-		(22)		17		
Total Expenditure Offsets	  $	239,683		$	129,635		$	335,774		$	390,001		

FY 19 Total

Note 2:    Authorized Positions	1,188.0
Actual Positions as of August 31, 2018	1,097.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2018	$	3,749,445	
	Revenues	602,024	
	Transfers-In	 	117,192	
	Total Revenues	 	719,215	
	Expenditures Transfers-out
Total Expenditures	1,028,179
 	-	
 	1,028,179	
	Ending Balance August 31, 2018	  $	3,440,482	

Of the $3,440,482 ending balance, $658,004 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through September 2018.

Note 4:

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

State Match	Federal	Total

DSH Voluntary	$	1,000,000	$	2,250,975	$	3,250,975	
GME Voluntary	12,808,837	28,724,356	41,533,193	

Total Voluntary Political Subdivision Program Expenditure $

13,808,837	$

30,975,331 $

44,784,168

Appropriation Status Report
Caseload and Expenditures by Rate Code

TITLE XIX TRADITIONAL

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

TOTAL

CAPITATION - ACUTE	275,524,500	272,008,729	0	0	0	0	0	0	0	0	0	0	547,533,229	
CAPITATION - AIMHS	26,685	48,199	0	0	0	0	0	0	0	0	0	0	74,884	
CAPITATION - LTC	225,067,725	226,240,986	0	0	0	0	0	0	0	0	0	0	451,308,710	
MENTAL HEALTH - CHILD	27,816,533	28,188,900	0	0	0	0	0	0	0	0	0	0	56,005,433	
MENTAL HEALTH - ADULT	502,900	466,904	0	0	0	0	0	0	0	0	0	0	969,804	
MENTAL HEALTH - GENERAL	16,629,284	16,828,876	0	0	0	0	0	0	0	0	0	0	33,458,160	
MENTAL HEALTH - CMDP	10,235,716	9,847,115	0	0	0	0	0	0	0	0	0	0	20,082,831	
MENTAL HEALTH - DD	5,967,451	5,965,326	0	0	0	0	0	0	0	0	0	0	11,932,777	
CHILDREN'S REHAB SERVICES	6,969,555	6,972,507	0	0	0	0	0	0	0	0	0	0	13,942,062	
FEE FOR SERVICE - ACUTE	37,223,809	56,393,518	0	0	0	0	0	0	0	0	0	0	93,617,327	
FFS - PRIOR QUARTER COVERAGE	548,797	935,952	0	0	0	0	0	0	0	0	0	0	1,484,748	
EMERGENCY SERVICES - FEDERAL	3,335,843	4,756,919	0	0	0	0	0	0	0	0	0	0	8,092,762	
FFS MEDICAID IN PUBLIC SCHOOLS	611,834	428,512	0	0	0	0	0	0	0	0	0	0	1,040,346	
STATE ONLY TRBHA FFS	80,691	98,188	0	0	0	0	0	0	0	0	0	0	178,879	
INPATIENT INMATES FFS	52,966	155,038	0	0	0	0	0	0	0	0	0	0	208,005	
FFS TRBHA FEE FOR SERVICE	11,384,976	15,543,554	0	0	0	0	0	0	0	0	0	0	26,928,530	
QMB - FEE FOR SERVICE	620,783	664,537	0	0	0	0	0	0	0	0	0	0	1,285,320	
PIMA COUNTY INMATES FFS	0	3,908	0	0	0	0	0	0	0	0	0	0	3,908	
MOHAVE COUNTY INMATES FFS	0	321	0	0	0	0	0	0	0	0	0	0	321	
PINAL COUNTY INMATES FFS	293	2,674	0	0	0	0	0	0	0	0	0	0	2,966	
YUMA COUNTY INMATES FFS	106	0	0	0	0	0	0	0	0	0	0	0	106	
MARICOPA CTY INMATES FFS	13,281	19,856	0	0	0	0	0	0	0	0	0	0	33,136	
FEE FOR SERVICE - LTC	10,718,670	14,462,690	0	0	0	0	0	0	0	0	0	0	25,181,360	
LFFS - PRIOR QUARTER COVERAGE	48,459	125,358	0	0	0	0	0	0	0	0	0	0	173,817	
INPATIENT INMATES LTC FFS	21	24,970	0	0	0	0	0	0	0	0	0	0	24,991	
MARICOPA CTY INMATES LTC FFS	223	17,419	0	0	0	0	0	0	0	0	0	0	17,641	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,240,312	938,507	0	0	0	0	0	0	0	0	0	0	2,178,819	
REINSURANCE - ACUTE	16,535,933	13,118,083	0	0	0	0	0	0	0	0	0	0	29,654,016	
REINSURANCE - LTC	5,446,473	3,415,013	0	0	0	0	0	0	0	0	0	0	8,861,487	
SMIB - ACUTE	15,670,269	15,795,835	0	0	0	0	0	0	0	0	0	0	31,466,103	
HIB - ACUTE	661,993	690,553	0	0	0	0	0	0	0	0	0	0	1,352,546	
Q1	2,598,480	2,633,334	0	0	0	0	0	0	0	0	0	0	5,231,814	
SMIB - LTC	3,797,393	3,805,148	0	0	0	0	0	0	0	0	0	0	7,602,541	
HIB - LTC	344,054	344,160	0	0	0	0	0	0	0	0	0	0	688,215	
SUBTOTAL	679,676,008	700,941,587	0	0	0	0	0	0	0	0	0	0	1,380,617,595	

TITLE XIX PROP 204

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

TOTAL

CAPITATION - ACUTE	219,877,148	216,708,770	0	0	0	0	0	0	0	0	0	0	436,585,918	
CAPITATION - AIMHS	7,757	14,811	0	0	0	0	0	0	0	0	0	0	22,567	
MENTAL HEALTH - CHILD	838	859	0	0	0	0	0	0	0	0	0	0	1,696	
MENTAL HEALTH - ADULT	794,879	777,940	0	0	0	0	0	0	0	0	0	0	1,572,819	
MENTAL HEALTH - GENERAL	30,005,430	30,460,612	0	0	0	0	0	0	0	0	0	0	60,466,041	
MENTAL HEALTH - CMDP	529	1,172	0	0	0	0	0	0	0	0	0	0	1,702	
CHILDREN'S REHAB SERVICES	25,122	26,916	0	0	0	0	0	0	0	0	0	0	52,038	
FEE FOR SERVICE - ACUTE	28,102,125	39,247,407	0	0	0	0	0	0	0	0	0	0	67,349,532	
FFS - PRIOR QUARTER COVERAGE	1,195,983	1,530,976	0	0	0	0	0	0	0	0	0	0	2,726,959	
FFS - PRESUMPTIVE ELIGIBILITY	0	736	0	0	0	0	0	0	0	0	0	0	736	
EMERGENCY SERVICES - FEDERAL	2,496,925	4,177,483	0	0	0	0	0	0	0	0	0	0	6,674,408	
FFS MEDICAID IN PUBLIC SCHOOLS	278	849	0	0	0	0	0	0	0	0	0	0	1,127	
INPATIENT INMATES FFS	567,184	930,016	0	0	0	0	0	0	0	0	0	0	1,497,200	
STATE ONLY TRBHA FFS	188,380	265,393	0	0	0	0	0	0	0	0	0	0	453,773	
FFS TRBHA FEE FOR SERVICE	6,471,241	7,963,744	0	0	0	0	0	0	0	0	0	0	14,434,985	
MARICOPA CTY INMATES FFS	83,205	308,501	0	0	0	0	0	0	0	0	0	0	391,705	
YUMA COUNTY INMATES FFS	380	623	0	0	0	0	0	0	0	0	0	0	1,003	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	0	0	0	0	0	0	0	0	0	
PINAL COUNTY INMATES FFS	4,804	1,281	0	0	0	0	0	0	0	0	0	0	6,085	
MOHAVE COUNTY INMATES FFS	0	3,281	0	0	0	0	0	0	0	0	0	0	3,281	
COCONINO COUNTY INMATES FFS	4,817	1,083	0	0	0	0	0	0	0	0	0	0	5,900	
PIMA COUNTY INMATES FFS	6,512	80,905	0	0	0	0	0	0	0	0	0	0	87,417	
REINSURANCE - ACUTE	6,285,338	5,286,543	0	0	0	0	0	0	0	0	0	0	11,571,881	
SMIB - ACUTE	6,797,934	6,805,330	0	0	0	0	0	0	0	0	0	0	13,603,264	
HIB - ACUTE	6,350	5,042	0	0	0	0	0	0	0	0	0	0	11,393	
SUBTOTAL	302,923,157	314,600,274	0	0	0	0	0	0	0	0	0	0	617,523,431	

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

TOTAL

CAPITATION - ACUTE	28,491,857	28,821,741	0	0	0	0	0	0	0	0	0	0	57,313,598	
CAPITATION - AIMHS	606	1,037	0	0	0	0	0	0	0	0	0	0	1,644	
MENTAL HEALTH - ADULT	46,413	30,326	0	0	0	0	0	0	0	0	0	0	76,739	
MENTAL HEALTH - GENERAL	5,571,389	5,666,401	0	0	0	0	0	0	0	0	0	0	11,237,789	
CHILDREN'S REHAB SERVICES	2,393	2,991	0	0	0	0	0	0	0	0	0	0	5,383	
FEE FOR SERVICE - ACUTE	2,226,936	3,250,949	0	0	0	0	0	0	0	0	0	0	5,477,884	
FFS - PRIOR QUARTER COVERAGE	320,363	361,717	0	0	0	0	0	0	0	0	0	0	682,080	
EMERGENCY SERVICES - FEDERAL	3,121,276	5,289,801	0	0	0	0	0	0	0	0	0	0	8,411,077	
FFS MEDICAID IN PUBLIC SCHOOLS	32	169	0	0	0	0	0	0	0	0	0	0	201	
FFS TRBHA FEE FOR SERVICE	168,451	163,702	0	0	0	0	0	0	0	0	0	0	332,153	
STATE ONLY TRBHA FFS	0	5,743	0	0	0	0	0	0	0	0	0	0	5,743	
INPATIENT INMATES FFS	38,006	8,108	0	0	0	0	0	0	0	0	0	0	46,115	
MARICOPA CTY INMATES FFS	3,611	2,869	0	0	0	0	0	0	0	0	0	0	6,481	
REINSURANCE - ACUTE	535,179	804,872	0	0	0	0	0	0	0	0	0	0	1,340,050	
	40,526,512	44,410,427	0	0	0	0	0	0	0	0	0	0	84,936,939	
	1,023,125,676	1,059,952,288	0	0	0	0	0	0	0	0	0	0	2,083,077,964	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
CAPITATION - AIMHS	80	64	0	0	0	0	0	0	0	0	0	0	144	
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	4,378,727	0	0	0	0	0	0	0	0	0	0	8,804,135	
KidsCare - FEE FOR SERVICE	227,481	123,157	0	0	0	0	0	0	0	0	0	0	350,638	
KidsCare - MENTAL HEALTH	1,239,709	1,252,330	0	0	0	0	0	0	0	0	0	0	2,492,039	
KidsCare - REINSURANCE	238,957	199,692	0	0	0	0	0	0	0	0	0	0	438,649	
KidsCare - CHILD REHAB SERVICES	6,580	4,187	0	0	0	0	0	0	0	0	0	0	10,767	

6,137,071	5,958,155	0	0	0	0	0	0	0	0	0	0	12,095,226	

TOTAL TITLE XXI

1,029,262,747	1,065,910,443	0	0	0	0	0	0	0	0	0	0	2,095,173,190	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	17.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.64		
1002	TANF 01-05 M & F WIT	0.00	-18.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-18.17		
1003	TANF 06-13 M & F WIT	0.00	-119.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-119.12		
1004	TANF 14-20 MALE WITH	0.00	53.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.48		
1005	TANF 14-20 FEMALE WI	0.00	-33.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-33.33		
1006	TANF 21-44 MALE WITH	49,121.18	52,104.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,226.16		
1007	TANF 21-44 FEMALE WI	72,257.76	74,525.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,783.32		
1008	TANF 45-64 M & F WIT	120,673.88	107,934.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228,608.03		
1009	TANF 65+ M & F WITH	40,453.77	34,027.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,481.21		
100F	TANF 21-44 MALE WITH	4,453.29	742.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,195.46		
100G	TANF 21-44 FEMALE WI	405.14	2,107.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,512.51		
100H	TANF 45-64 M & F WIT	543.50	1,698.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,241.74		
100J	TANF 65+ M & F WITH	579.98	1,298.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,878.90		
1011	TANF <1 M & F NON-ME	4,923,029.72	4,990,957.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,913,987.16		
1012	TANF 01-05 M & F NON	2,455,010.89	2,370,397.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,825,408.42		
1013	TANF 06-13 M & F NON	4,179,744.92	4,118,701.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,298,446.04		
1014	TANF 14-20 MALE NON-	1,669,137.78	1,589,645.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,258,782.90		
1015	TANF 14-20 FEMALE N O	3,072,044.25	2,939,087.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,011,131.58		
1016	TANF 21-44 MALE NON-	4,618,080.17	4,475,347.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,093,428.03		
1017	TANF 21-44 FEMALE N O	23,256,202.53	22,621,270.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,877,473.07		
1018	TANF 45-64 M & F NON	9,538,179.97	8,937,776.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,475,956.48		
1019	TANF 65+ M & F NON-M	33,831.66	30,991.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,823.08		
101A	TANF < 1 M & F NON-M	412,738.62	549,318.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		962,057.28		
101B	TANF 01-05 M & F NON	8,213.25	14,105.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,318.43		
101C	TANF 06-13 M & F NON	6,283.96	6,727.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,011.07		
101D	TANF 14-20 MALE NON-	12,206.42	13,657.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,863.52		
101E	TANF 14-20 FEMALE N O	25,265.59	31,989.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,255.05		
101F	TANF 21-44 MALE NON-	118,532.60	152,453.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270,985.60		
101G	TANF 21-44 FEMALE N O	377,363.34	508,652.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		886,015.73		
101H	TANF 44-64 M & F NON	90,148.09	132,960.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,108.46		
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	-18.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.93		
1024	TANF 14-20 MALE WITH	0.00	150.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150.52		
1025	TANF 14-20 FEMALE WI	532.34	253.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785.91		
1026	TANF 21-44 MALE WITH	28,765.75	24,312.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,078.00		
1027	TANF 21-44 FEMALE WI	52,705.40	52,056.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,761.67		

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	77,124.38	71,064.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148,189.21		
1029	TANF 65+ M & F WITH	33,801.77	35,032.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,834.38		
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	635.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		669.75		
102H	TANF 44-64 M & F WIT	167.76	289.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457.36		
2100	SSI AGED WITH MEDIC A	709,220.28	688,718.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,397,939.16		
210Z	SSI AGED WITH MEDIC
A	31,093.15	32,880.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,973.37		
2110	SSI AGED NON-MEDIC AR	6,592,077.68	6,504,288.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,096,365.86		
211Z	SSI AGED NON-MEDIC
AR	83,027.56	106,675.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,703.33		
2120	SSI AGED WITH QMB	5,248,445.46	5,068,145.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,316,590.95		
212Z	SSI AGED WITH QMB P P	7,287.70	6,117.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,404.84		
2200	SSI DISABLED WITH M
E	1,659,152.59	1,627,652.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,286,804.65		
220Z	SSI DISABLED WITH M E	85,255.38	166,531.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,786.43		
2210	SSI DISABLED NON-ME
D	63,366,536.41	61,056,340.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,422,876.44		
221Z	SSI DISABLED NON-ME D	453,135.12	738,540.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,191,675.62		
2220	SSI DISABLED WITH Q
M	15,296,127.40	15,144,583.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,440,711.22		
222Z	SSI DISABLED WITH Q M	14,341.02	18,901.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,242.70		
2300	SSI BLIND WITH MEDIC	9,264.92	9,473.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,738.75		
2310	SSI BLIND NON-MEDIC A	547,114.60	528,115.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,075,230.45		
231Z	SSI BLIND NON-MEDIC
A	2,043.29	24,544.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,587.44		
2320	SSI BLIND WITH QMB	49,144.44	46,857.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,002.41		
4301	SOBRA CHILD <1 M & F	442.86	699.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,142.00		
4302	SOBRA CHILD 01-05 M	5,159.40	462.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,622.10		
4303	SOBRA CHILD 06-13 M	3,139.48	-831.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,308.39		
4304	SOBRA CHILD 14-20 MA	1,089.93	-3,016.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,926.48		
4305	SOBRA CHILD 14-20 FE	2,794.02	1,032.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,826.95		
430C	SOBRA CHILD 06-13 M	0.00	50.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.71		
4311	SOBRA CHILD <1 M & F	15,876,503.58	16,299,837.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,176,341.46		
4312	SOBRA CHILD 01-05 M	21,930,498.29	21,487,502.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,418,000.67		
4313	SOBRA CHILD 06-13 M	28,371,187.60	27,819,054.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,190,241.88		
4314	SOBRA CHILD 14-20 MA	10,250,435.20	9,791,649.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,042,084.93		
4315	SOBRA CHILD 14-20 FE	15,089,068.23	14,561,954.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,651,022.66		
431A	SOBRA CHILD < 1 M &	127,910.44	179,717.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		307,628.22		
431B	SOBRA CHILD 01-05 M	221,960.40	271,902.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		493,863.22		
431C	SOBRA CHILD 6-13 M& F	224,066.77	289,550.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		513,617.75		
431D	SOBRA CHILD 14-20 MA	176,040.96	249,408.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425,449.59		

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431E	SOBRA CHILD 14-20 FE	237,700.73	305,502.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		543,203.36		
4322	SOBRA CHILD 01-05 M	454.24	222.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		676.37		
4323	SOBRA CHILD 06-13 M	115.02	-14.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.57		
4324	SOBRA CHILD 14-20 MA	169.78	261.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430.92		
4325	SOBRA CHILD 14-20 FE	230.43	217.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		447.74		
5005	SOBRA PREG 14-20 FE M	266.17	-3.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262.57		
5007	SOBRA PREG 21-44 FE
M	21,170.46	18,663.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,834.39		
5008	SOBRA PREG 45-64 FE M	1,135.88	1,171.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,307.55		
500G	SOBRA PREG 21-44 FE
M	435.21	3,518.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,953.91		
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	109.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		324.73		
5015	SOBRA PREG 14-20 FE M	852,527.19	833,480.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,686,007.28		
5017	SOBRA PREG 21-44 FE
M	4,605,937.24	4,383,257.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,989,194.69		
5018	SOBRA PREG 45-64 FE M	19,914.87	18,697.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,612.37		
501C	SOBRA PREG 09-13 FE
M	0.00	27.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.05		
501E	SOBRA PREG 14-20 FE M	47,493.67	56,756.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,250.39		
501G	SOBRA PREG 21-44 FE
M	209,922.82	233,732.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		443,654.98		
501H	SOBRA PREG 45-64 FE M	878.94	188.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,067.22		
5025	SOBRA PREG 14-20 FE
M	0.00	246.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246.14		
5027	SOBRA PREG 21-44 FE M	22,924.89	26,018.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,943.64		
5028	SOBRA PREG 45-64 FE
M	2,363.74	2,336.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,699.96		
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	3 242,543,886.87	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		490,280,430.70		

1104	TANF EXPANDED 14-20	0.00	-19.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1105	TANF EXPANDED 14-20	0.00	105.58	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	70,273.75	55,179.81	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	241,322.50	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	729,950.53	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	263,370.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110E	TANF EXPANDED 14-20	0.00	94.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-19.23	
105.58	
125,453.56	
503,593.65	
1,505,872.97	
543,092.97	
94.53	

9910	TANF & SOBRA CHILDR E	1,566,824.34	1,731,513.97	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	47,389.06	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 KI C	107,966.05	178,834.59	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	14,106,089.72	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 16,063,827.34	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,298,338.31	
71,775.22	
286,800.64	
26,632,559.94	
30,289,474.11	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110F	TANF EXPANDED 21-44	5,436.65	4,673.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,109.77		
110G	TANF EXPANDED 21-44	21,689.44	12,711.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,400.92		
110H	TANF EXPANDED 45-64	16,922.37	17,124.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,046.68		
110J	TANF EXPANDED 65+
M&	6,933.80	8,320.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,254.12		
1112	TANF EXPANDED 01-05	209.81	204.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414.48		
1113	TANF EXPANDED 06-13	2,451.20	2,178.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,629.49		
1114	TANF EXPANDED 14-20	54,619.14	52,858.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,477.58		
1115	TANF EXPANDED 14-20	391,160.64	383,953.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		775,114.02		
1116	TANF EXPANDED 21-44	4,723,664.44	4,593,382.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,317,047.26		
1117	TANF EXPANDED 21-44	18,274,687.63	17,672,381.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,947,069.45		
1118	TANF EXPANDED 45-64	10,957,250.85	10,216,164.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,173,415.18		
1119	TANF EXPANDED 65+
M&	29,230.75	26,932.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,162.95		
111D	TANF EXPANDED 14-20	3,527.61	2,709.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,237.55		
111E	TANF EXPANDED 14-20	6,692.13	8,190.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,882.59		
111F	TANF EXPANDED 21-44	126,877.50	157,206.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,084.36		
111G	TANF EXPANDED 21-44	282,393.11	348,535.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		630,928.70		
111H	TANF EXPANDED 45-64	122,461.87	143,174.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		265,636.45		
111J	TANF EXPANDED 65+
M&	487.88	1,000.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,487.98		
1125	TANF EXPANDED 14-20	0.00	-41.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-41.80		
1126	TANF EXPANDED 21-44	329,068.29	319,037.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		648,105.73		
1127	TANF EXPANDED 21-44	989,036.79	959,592.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,948,629.23		
1128	TANF EXPANDED 45-64	1,543,278.97	1,470,040.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,013,319.34		
1129	TANF EXPANDED 65+
M&	616,303.36	575,686.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,191,989.50		
112F	TANF EXPANDED 21-44	559.74	270.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		829.77		
112G	TANF EXPANDED 21-44	7,333.37	8,229.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,562.42		
112H	TANF EXPANDED 45-64	3,692.73	8,381.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,074.44		
112J	TANF EXPANDED 65+
M&	1,155.86	1,463.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,619.55		
2400	SSI AGED EXPANDED WI	39,565.65	42,651.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,216.66		
240Z	SSI AGED EXPANDED
WI	27,316.98	25,268.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,585.31		
2410	SSI AGED EXPANDED NO	94,343.54	90,789.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,132.87		
241Z	SSI AGED EXPANDED
NO	3,257.97	931.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,189.67		
2420	SSI AGED EXPANDED WI	5,031,817.51	4,817,759.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,849,576.71		
242Z	SSI AGED EXPANDED
WI	4,679.60	2,943.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,623.26		
2520	SSI BLIND EXPANDED W	0.00	4.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.38		
2600	SSI DISABLED EXPAND
E	133,143.35	111,614.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,758.31		
260Z	SSI DISABLED EXPAND E	53,091.11	47,795.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,886.60		

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2610	SSI DISABLED EXPAND E	1,681,462.82	1,568,269.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,249,732.24		
261Z	SSI DISABLED EXPAND
E	14,120.97	10,512.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,633.48		
2620	SSI DISABLED EXPAND E	10,663,975.16	10,451,748.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,115,723.89		
262Z	SSI DISABLED EXPAND
E	12,749.14	22,320.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,069.92		
SUBTOTAL:	57,664,839.7	7 55,476,975.27	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,141,815.04		

3504	ADULT 40-100% MALE 1	1,968.98	-139.69	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	2,348.10	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	1,038.24	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	7,960.91	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	1,922.82	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	564.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	5,154.56	2,215.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	2,845,519.41	2,672,293.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	3,072,774.76	2,882,794.52	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	9,977,987.83	9,875,661.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	8,386,323.38	8,250,785.05	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	19,918,279.36	19,791,930.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	2,483.91	2,353.51	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	77,272.85	74,288.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	97,130.22	117,796.26	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	334,430.46	394,390.94	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	259,135.65	347,383.31	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	537,529.45	641,405.58	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	2,199.75	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	465.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	939.87	1,914.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	-30.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	479.69	420.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352F	ADULT 40-100% MALE 2	1,386.98	488.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352G	ADULT 40-100% FEMAL E	678.80	2,924.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	0.00	352.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3704	ADULT <40% EXP MALE	0.00	-8.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,829.29	
5,107.42	
1,649.70	
18,496.73	
1,922.82	
2,031.49	
7,370.55	
5,517,813.35	
5,955,569.28	
19,853,649.21	
16,637,108.43	
39,710,209.89	
4,837.42	
151,561.74	
214,926.48	
728,821.40	
606,518.96	
1,178,935.03	
2,199.75	
1,944.57	
2,854.35	
-30.45	
900.17	
1,875.45	
3,602.85	
352.87	
-8.25	

9911	SB PAYMENT FOR TAN F	983,153.34	1,173,355.54	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	1,173,355.54	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,156,508.88	
11,801.65	
2,168,310.53	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3705	ADULT <40% EXP FEM AL	241.60	5.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246.72		
3706	ADULT <40% EXP MALE	6,634.62	3,759.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,394.37		
3707	ADULT <40% EXP FEM AL	7,737.99	2,886.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,624.87		
3708	ADULT <40% EXP M&F
4	8,526.04	14,866.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,392.54		
3709	ADULT <40% EXP M&F 6	872.68	367.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,239.85		
370F	ADULT <40% EXP MALE	1,663.65	30,316.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,979.77		
370G	ADULT <40% EXP FEM AL	9,948.52	352.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,301.41		
370H	ADULT <40% EXP M&F
4	4,127.71	6,825.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,953.11		
3714	ADULT <40% EXP MALE	5,253,165.59	4,955,925.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,209,091.26		
3715	ADULT <40% EXP FEM AL	4,697,295.30	4,433,506.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,130,801.66		
3716	ADULT <40% EXP MALE	35,701,388.63	35,014,468.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,715,857.55		
3717	ADULT <40% EXP FEM AL	21,640,367.01	21,263,056.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,903,423.59		
3718	ADULT <40% EXP M&F
4	42,836,702.21	42,229,231.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,065,933.89		
3719	ADULT <40% EXP M&F 6	11,355.36	15,812.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,167.38		
371D	ADULT <40% EXP MALE	207,217.97	224,842.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		432,060.79		
371E	ADULT <40% EXP FEM AL	185,752.11	235,476.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		421,228.42		
371F	ADULT <40% EXP MALE	1,852,063.30	2,307,266.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,159,330.02		
371G	ADULT <40% EXP FEM AL	1,096,410.83	1,301,002.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,397,413.04		
371H	ADULT <40% EXP M&F
4	1,511,524.26	2,096,422.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,607,946.92		
371J	ADULT <40% EXP M&F 6	1,562.82	2,592.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,155.62		
3726	ADULT <40% EXP MALE	512.97	3,002.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,515.77		
3727	ADULT <40% EXP FEM AL	811.52	639.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,451.33		
3728	ADULT <40% EXP M&F
4	1,563.39	2,009.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,572.68		
3729	ADULT <40% EXP M&F 6	0.00	-12.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-12.92		
372F	ADULT <40% EXP MALE	0.00	397.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		397.74		
372G	ADULT <40% EXP FEM AL	957.86	554.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,512.41		
372H	ADULT <40% EXP M&F
4	0.00	1,181.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,181.20		
SUBTOTAL:	160,574,732.8	0 159,222,478.69	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		319,797,211.49		

3906	NEWLY ELIGIBLE MALE	1,351.75	867.69	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	575.50	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	13,541.10	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	3,469.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,219.44	
1,446.11	
28,628.16	
6,312.33	

9935	BIRTH SUPP PAYMENT A	205,781.14	260,905.33	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	575,055.22	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	835,960.55	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
466,686.47	
1,011,894.42	
1,478,580.89	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390G	NEWLY ELIGIBLE FEMA L	175.22	29.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204.71		
390H	NEWLY ELIGIBLE M&F
4	356.87	2,773.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,129.97		
390J	NEWLY ELIGIBLE M&F 6	0.00	7,912.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,912.00		
3914	NEWLY ELIGIBLE MALE	1,116,598.97	1,120,864.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,237,463.16		
3915	NEWLY ELIGIBLE FEMA L	1,278,614.86	1,253,510.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,532,125.60		
3916	NEWLY ELIGIBLE MALE	6,239,438.48	6,211,612.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,451,051.40		
3917	NEWLY ELIGIBLE FEMA L	8,967,501.97	8,900,096.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,867,598.41		
3918	NEWLY ELIGIBLE M&F
4	9,756,943.06	9,817,126.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,574,069.38		
3919	NEWLY ELIGIBLE M&F 6	3,501.58	3,873.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,375.48		
391D	NEWLY ELIGIBLE MALE	34,779.16	36,852.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,631.97		
391E	NEWLY ELIGIBLE FEMA L	31,597.11	31,852.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,449.33		
391F	NEWLY ELIGIBLE MALE	206,907.63	280,803.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		487,711.21		
391G	NEWLY ELIGIBLE FEMA L	311,512.22	416,679.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		728,191.62		
391H	NEWLY ELIGIBLE M&F
4	274,500.37	280,185.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		554,685.46		
391J	NEWLY ELIGIBLE M&F 6	0.00	387.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		387.99		
3926	NEWLY ELIGIBLE MALE	0.00	113.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.31		
3927	NEWLY ELIGIBLE FEMA L	0.00	159.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159.75		
3928	NEWLY ELIGIBLE M&F
4	197.40	1,999.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,197.00		
3929	NEWLY ELIGIBLE M&F 6	0.00	310.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310.17		
392F	NEWLY ELIGIBLE MALE	0.00	300.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		300.38		
392G	NEWLY ELIGIBLE FEMA L	0.00	212.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212.77		
392H	NEWLY ELIGIBLE M&F
4	198.06	798.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		996.95		
SUBTOTAL:	28,242,975.1	7 28,386,908.89	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,629,884.06		

683,714.05

9939	BIRTH SUPP PAYMENT N	248,881.78	434,832.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	248,881.78	434,832.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

683,714.05

4403	SOBRA 100-133% M&F
6	0.00	-133.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	156.35	7.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4405	SOBRA 100-133% FEMA L	0.00	-7.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	120.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	5,672,058.64	5,610,085.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,129,249.04	2,049,678.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	3,036,152.98	2,954,635.89	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	53,617.91	71,112.37	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	41,497.28	51,549.87	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	52,971.55	75,692.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-133.01	
164.30	
-7.82	
120.75	
11,282,143.97	
4,178,927.92	
5,990,788.87	
124,730.28	
93,047.15	
128,663.56	

ACUTE CAPITATION - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4424	SOBRA 100-133% MALE	0.00	-2.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2.40		
SUBTOTAL:	10,985,703.75	10,812,739.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,798,443.57		

66,992.44

9944	BIRTH SUPP PAYMENT S	25,159.98	41,832.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,159.98	41,832.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
66,992.44

4517	BC PATIENT FEMALE 2 1	5,417.23	5,957.92	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	42,574.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	-29.50	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	297.10	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	2,068.10	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	4,515.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	4,460.71	4,307.71	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	59,691.09	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,375.15	
87,612.48	
-29.50	
462.66	
-3,129.44	
8,765.56	
8,768.42	
224.21	
114,049.54	

8600	SSI BLIND FREEDOM/W O	3,796.95	3,920.26	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	165.41	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	1,762,074.04	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	32,915.46	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	470,672.46	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	12,288.62	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	196,794.73	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	7,920.00	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	2,486,750.98	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,717.21	
330.82	
3,516,208.25	
64,993.38	
964,928.37	
31,464.09	
389,917.53	
8,278.67	
4,983,838.32	

1,041,432,744.74

523,893,504.97	517,539,239.77	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 August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 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		
1002	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1003	TANF 06-13 M & F WIT	0.00	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1.00		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1005	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1006	TANF 21-44 MALE WITH	84.41	85.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169.58		
1007	TANF 21-44 FEMALE WI	130.34	138.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269.20		
1008	TANF 45-64 M & F WIT	213.69	203.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417.24		
1009	TANF 65+ M & F WITH	92.24	83.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.54		
100F	TANF 21-44 MALE WITH	2.57	2.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.27		
100G	TANF 21-44 FEMALE WI	1.92	2.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.47		
100H	TANF 45-64 M & F WIT	0.67	2.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.56		
100J	TANF 65+ M & F WITH	3.73	4.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.33		
1011	TANF <1 M & F NON-ME	11,017.50	11,086.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,104.38		
1012	TANF 01-05 M & F NON	19,008.00	19,016.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,024.07		
1013	TANF 06-13 M & F NON	32,007.97	32,298.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,306.71		
1014	TANF 14-20 MALE NON-	8,747.23	8,746.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,493.28		
1015	TANF 14-20 FEMALE N O	11,247.71	11,274.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,521.98		
1016	TANF 21-44 MALE NON-	25,347.52	25,494.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,841.80		
1017	TANF 21-44 FEMALE N O	82,425.80	83,540.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,966.35		
1018	TANF 45-64 M & F NON	20,379.55	20,434.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,814.19		
1019	TANF 65+ M & F NON-M	71.48	68.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.60		
101A	TANF < 1 M & F NON-M	956.78	1,262.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,219.31		
101B	TANF 01-05 M & F NON	156.06	267.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		423.77		
101C	TANF 06-13 M & F NON	115.92	125.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241.69		
101D	TANF 14-20 MALE NON-	58.19	73.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132.17		
101E	TANF 14-20 FEMALE N O	127.15	158.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285.16		
101F	TANF 21-44 MALE NON-	704.65	874.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,579.56		
101G	TANF 21-44 FEMALE N O	1,759.37	2,318.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,077.67		
101H	TANF 44-64 M & F NON	320.02	486.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		806.29		
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		
1024	TANF 14-20 MALE WITH	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1025	TANF 14-20 FEMALE WI	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1026	TANF 21-44 MALE WITH	68.12	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137.12		
1027	TANF 21-44 FEMALE WI	113.41	116.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229.46		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	119.20	137.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256.20		
1029	TANF 65+ M & F WITH	77.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.00		
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	3.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.77		
102H	TANF 44-64 M & F WIT	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2100	SSI AGED WITH MEDIC A	4,176.51	4,200.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,377.30		
210Z	SSI AGED WITH MEDIC
A	245.48	303.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		548.76		
2110	SSI AGED NON-MEDIC AR	6,259.71	6,412.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,672.62		
211Z	SSI AGED NON-MEDIC
AR	148.41	185.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334.25		
2120	SSI AGED WITH QMB	29,956.77	30,317.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,274.74		
212Z	SSI AGED WITH QMB P P	59.79	56.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.50		
2200	SSI DISABLED WITH M
E	3,486.08	3,507.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,993.12		
220Z	SSI DISABLED WITH M E	190.54	330.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521.35		
2210	SSI DISABLED NON-ME
D	52,332.20	52,322.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,654.61		
221Z	SSI DISABLED NON-ME D	697.62	977.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,675.56		
2220	SSI DISABLED WITH Q
M	26,997.33	27,021.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,018.59		
222Z	SSI DISABLED WITH Q M	39.44	60.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.04		
2300	SSI BLIND WITH MEDIC	26.00	27.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.99		
2310	SSI BLIND NON-MEDIC A	507.76	506.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,014.57		
231Z	SSI BLIND NON-MEDIC
A	3.82	33.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.47		
2320	SSI BLIND WITH QMB	224.99	227.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		452.49		
4301	SOBRA CHILD <1 M & F	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4302	SOBRA CHILD 01-05 M	31.00	5.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.52		
4303	SOBRA CHILD 06-13 M	27.15	-4.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.24		
4304	SOBRA CHILD 14-20 MA	7.00	-17.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-10.35		
4305	SOBRA CHILD 14-20 FE	11.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
430C	SOBRA CHILD 06-13 M	0.00	0.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.96		
4311	SOBRA CHILD <1 M & F	35,058.63	35,759.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,817.69		
4312	SOBRA CHILD 01-05 M	172,167.95	173,794.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345,962.29		
4313	SOBRA CHILD 06-13 M	215,942.10	217,915.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433,857.12		
4314	SOBRA CHILD 14-20 MA	55,854.27	56,481.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,335.77		
4315	SOBRA CHILD 14-20 FE	55,885.49	56,613.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,499.12		
431A	SOBRA CHILD < 1 M &	298.08	424.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		722.57		
431B	SOBRA CHILD 01-05 M	3,988.50	4,928.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,917.30		
431C	SOBRA CHILD 6-13 M& F	4,063.34	5,362.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,425.38		
431D	SOBRA CHILD 14-20 MA	1,078.33	1,524.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,602.63		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431E	SOBRA CHILD 14-20 FE	1,168.36	1,498.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,667.10		
4322	SOBRA CHILD 01-05 M	4.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4325	SOBRA CHILD 14-20 FE	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5005	SOBRA PREG 14-20 FE M	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	33.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.27		
5008	SOBRA PREG 45-64 FE M	2.48	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.48		
500G	SOBRA PREG 21-44 FE
M	2.08	4.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.25		
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	1.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.48		
5015	SOBRA PREG 14-20 FE M	3,175.39	3,235.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,411.09		
5017	SOBRA PREG 21-44 FE
M	17,106.35	17,031.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,138.27		
5018	SOBRA PREG 45-64 FE M	39.78	39.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.95		
501C	SOBRA PREG 09-13 FE
M	0.00	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.51		
501E	SOBRA PREG 14-20 FE M	238.44	257.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		495.63		
501G	SOBRA PREG 21-44 FE
M	979.10	1,126.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,105.93		
501H	SOBRA PREG 45-64 FE M	3.18	0.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.04		
5025	SOBRA PREG 14-20 FE
M	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
5027	SOBRA PREG 21-44 FE M	44.21	44.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89.19		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
502G	SOBRA PREG 21-44 FE M	0.77	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	921,034.28	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,828,973.77		

1104	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	
1105	TANF EXPANDED 14-20	0.00	0.54	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	250.08	242.98	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	528.10	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	1,321.46	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	624.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110E	TANF EXPANDED 14-20	0.00	0.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.54	
493.06	
1,046.45	
2,616.53	
1,250.27	
0.45	

9910	TANF & SOBRA CHILDR E	257.00	286.00	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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KI C	18.00	30.00	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	2,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,358.00	2,664.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
543.00	
12.00	
48.00	
4,419.00	
5,022.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110F	TANF EXPANDED 21-44	8.55	14.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.45		
110G	TANF EXPANDED 21-44	34.70	23.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.67		
110H	TANF EXPANDED 45-64	49.74	54.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.51		
110J	TANF EXPANDED 65+
M&	32.89	39.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.24		
1112	TANF EXPANDED 01-05	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1113	TANF EXPANDED 06-13	14.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.00		
1114	TANF EXPANDED 14-20	316.58	321.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		637.65		
1115	TANF EXPANDED 14-20	1,480.23	1,516.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,996.68		
1116	TANF EXPANDED 21-44	27,236.57	27,445.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,682.29		
1117	TANF EXPANDED 21-44	67,974.34	68,675.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,649.94		
1118	TANF EXPANDED 45-64	24,170.25	24,302.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,473.11		
1119	TANF EXPANDED 65+
M&	65.57	68.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133.58		
111D	TANF EXPANDED 14-20	21.24	16.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.92		
111E	TANF EXPANDED 14-20	32.75	40.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.94		
111F	TANF EXPANDED 21-44	758.18	949.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,707.61		
111G	TANF EXPANDED 21-44	1,310.31	1,719.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,029.57		
111H	TANF EXPANDED 45-64	469.75	558.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,028.43		
111J	TANF EXPANDED 65+
M&	2.41	4.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.58		
1125	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		
1126	TANF EXPANDED 21-44	832.10	831.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,663.32		
1127	TANF EXPANDED 21-44	1,691.85	1,691.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,383.75		
1128	TANF EXPANDED 45-64	2,481.86	2,523.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,005.76		
1129	TANF EXPANDED 65+
M&	1,349.11	1,380.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,729.13		
112F	TANF EXPANDED 21-44	3.54	1.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.36		
112G	TANF EXPANDED 21-44	6.93	10.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.62		
112H	TANF EXPANDED 45-64	13.05	14.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.30		
112J	TANF EXPANDED 65+
M&	4.63	5.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.43		
2400	SSI AGED EXPANDED WI	231.60	267.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.69		
240Z	SSI AGED EXPANDED
WI	178.66	203.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.23		
2410	SSI AGED EXPANDED NO	85.53	89.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.12		
241Z	SSI AGED EXPANDED
NO	6.22	2.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.30		
2420	SSI AGED EXPANDED WI	24,113.73	24,390.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,504.63		
242Z	SSI AGED EXPANDED
WI	38.31	26.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.59		
2520	SSI BLIND EXPANDED W	0.00	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	217.26	225.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		442.62		
260Z	SSI DISABLED EXPAND E	134.96	186.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321.83		

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2610	SSI DISABLED EXPAND E	1,460.45	1,434.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,895.15		
261Z	SSI DISABLED EXPAND
E	24.07	19.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.40		
2620	SSI DISABLED EXPAND E	16,945.02	16,927.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,872.14		
262Z	SSI DISABLED EXPAND
E	24.45	57.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81.88		
SUBTOTAL:	176,512.1	7	178,774.55	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355,286.72		

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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.73	2.25	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	14.25	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	4.00	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	1.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	4.40	3.39	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	5,604.83	5,716.59	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	6,062.39	6,191.65	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	18,785.56	19,061.31	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	15,773.50	15,954.59	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	38,601.45	38,912.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	5.00	6.00	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	105.63	105.66	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	138.29	167.28	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	459.37	548.98	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	352.13	475.32	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	766.85	899.11	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	3.00	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	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.58	1.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352F	ADULT 40-100% MALE 2	0.96	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352G	ADULT 40-100% FEMAL E	0.41	1.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	0.00	0.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.99	
3.00	
2.98	
34.81	
4.00	
2.34	
7.79	
11,321.42	
12,254.04	
37,846.87	
31,728.09	
77,513.66	
11.00	
211.29	
305.57	
1,008.35	
827.45	
1,665.96	
3.00	
2.09	
1.77	
0.12	
2.00	
1.89	
2.21	
0.54	
0.00	

9911	SB PAYMENT FOR TAN F	163.00	193.00	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	193.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
356.00	
2.00	
358.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3705	ADULT <40% EXP FEM AL	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	6.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.23		
3707	ADULT <40% EXP FEM AL	6.38	3.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.92		
3708	ADULT <40% EXP M&F
4	15.96	27.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.64		
3709	ADULT <40% EXP M&F 6	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
370F	ADULT <40% EXP MALE	2.12	22.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.69		
370G	ADULT <40% EXP FEM AL	6.59	0.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.04		
370H	ADULT <40% EXP M&F
4	5.25	9.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.42		
3714	ADULT <40% EXP MALE	10,089.04	10,277.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,366.95		
3715	ADULT <40% EXP FEM AL	8,920.42	9,132.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,052.50		
3716	ADULT <40% EXP MALE	62,012.36	63,321.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,333.79		
3717	ADULT <40% EXP FEM AL	36,532.66	37,224.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,757.28		
3718	ADULT <40% EXP M&F
4	75,882.36	77,152.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,035.12		
3719	ADULT <40% EXP M&F 6	22.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
371D	ADULT <40% EXP MALE	286.90	308.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		595.11		
371E	ADULT <40% EXP FEM AL	256.11	316.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572.54		
371F	ADULT <40% EXP MALE	2,465.20	3,042.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,507.45		
371G	ADULT <40% EXP FEM AL	1,439.34	1,694.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,133.39		
371H	ADULT <40% EXP M&F
4	2,055.68	2,804.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,859.69		
371J	ADULT <40% EXP M&F 6	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
3726	ADULT <40% EXP MALE	1.00	2.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.41		
3727	ADULT <40% EXP FEM AL	1.77	1.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.05		
3728	ADULT <40% EXP M&F
4	3.00	3.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.50		
3729	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		
372F	ADULT <40% EXP MALE	0.00	0.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.57		
372G	ADULT <40% EXP FEM AL	1.22	0.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.92		
372H	ADULT <40% EXP M&F
4	0.00	1.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.15		
SUBTOTAL:	286,708.6	2	293,455.45	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		580,164.07		

3906	NEWLY ELIGIBLE MALE	4.00	2.00	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	1.90	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	37.62	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	9.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6.00	
4.43	
80.42	
18.14	

9935	BIRTH SUPP PAYMENT A	34.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	72.00	94.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	106.00	137.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
77.00	
166.00	
243.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390G	NEWLY ELIGIBLE FEMA L	0.45	0.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.54		
390H	NEWLY ELIGIBLE M&F
4	0.92	7.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.30		
390J	NEWLY ELIGIBLE M&F 6	0.00	23.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.08		
3914	NEWLY ELIGIBLE MALE	3,049.98	3,132.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,182.71		
3915	NEWLY ELIGIBLE FEMA L	3,531.41	3,582.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,113.46		
3916	NEWLY ELIGIBLE MALE	16,854.19	17,068.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,922.96		
3917	NEWLY ELIGIBLE FEMA L	24,434.24	24,850.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,285.16		
3918	NEWLY ELIGIBLE M&F
4	26,059.28	26,284.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,343.29		
3919	NEWLY ELIGIBLE M&F 6	10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
391D	NEWLY ELIGIBLE MALE	88.14	98.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186.49		
391E	NEWLY ELIGIBLE FEMA L	86.05	84.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170.51		
391F	NEWLY ELIGIBLE MALE	540.59	723.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,264.52		
391G	NEWLY ELIGIBLE FEMA L	784.50	1,041.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,826.17		
391H	NEWLY ELIGIBLE M&F
4	687.43	742.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,430.23		
391J	NEWLY ELIGIBLE M&F 6	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3926	NEWLY ELIGIBLE MALE	0.00	0.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.22		
3927	NEWLY ELIGIBLE FEMA L	0.00	0.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.45		
3928	NEWLY ELIGIBLE M&F
4	0.48	1.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.88		
3929	NEWLY ELIGIBLE M&F 6	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
392F	NEWLY ELIGIBLE MALE	0.00	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.77		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.54		
392H	NEWLY ELIGIBLE M&F
4	0.51	0.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.09		
SUBTOTAL:	76,185.75	77,706.61	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,892.36		

113.00

9939	BIRTH SUPP PAYMENT N	41.00	72.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	41.00	72.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

113.00

4403	SOBRA 100-133% M&F
6	0.00	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4405	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	1.00	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	44,135.08	44,679.66	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	11,766.33	11,924.95	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	11,388.18	11,604.46	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	1,021.53	1,349.42	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	259.77	322.84	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	262.97	373.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-1.00	
1.00	
0.00	
1.00	
88,814.74	
23,691.28	
22,992.64	
2,370.95	
582.61	
636.36	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	68,834.86	70,254.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139,089.58		

11.00

4517	BC PATIENT FEMALE 2 1	21.19	23.57	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	106.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.80	1.41	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	10.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	9.00	9.00	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	10.00	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	160.93	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

44.76	
208.48	
0.00	
2.21	
-4.24	
18.00	
20.22	
0.77	
290.20	

8600	SSI BLIND FREEDOM/W O	2.00	3.00	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	1.00	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	2,293.07	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	86.18	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	417.03	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	20.91	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	300.10	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	15.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,014.56	3,137.08	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00	
2.00	
4,516.76	
136.26	
840.83	
45.94	
585.46	
19.39	
6,151.64	

9944	BIRTH SUPP PAYMENT S	4.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11.00

TOTAL:	1,521,998.72	1,547,596.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,069,595.34		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending August 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	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.92		
1011	TANF <1 M & F NON-ME	702.24	957.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,659.84		
1012	TANF 01-05 M & F NON	367.08	702.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,069.32		
1013	TANF 06-13 M & F NON	478.80	766.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,244.88		
1014	TANF 14-20 MALE NON-	31.92	95.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.68		
1015	TANF 14-20 FEMALE N O	271.32	462.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		734.16		
1016	TANF 21-44 MALE NON-	239.40	638.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		877.80		
1017	TANF 21-44 FEMALE N O	3,112.20	4,931.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,043.84		
1018	TANF 45-64 M & F NON	861.84	1,611.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,473.80		
2100	SSI AGED WITH MEDIC A	47.88	159.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207.48		
2110	SSI AGED NON-MEDIC
AR	0.00	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.96		
2120	SSI AGED WITH QMB	414.96	1,101.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,516.20		
2200	SSI DISABLED WITH M E	319.20	670.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989.52		
2210	SSI DISABLED NON-ME
D	2,713.20	4,724.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,437.36		
2220	SSI DISABLED WITH Q M	1,197.00	1,851.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,048.36		
2310	SSI BLIND NON-MEDIC
A	31.92	47.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.80		
2320	SSI BLIND WITH QMB	15.96	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.92		
4311	SOBRA CHILD <1 M & F	2,058.84	3,638.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,697.72		
4312	SOBRA CHILD 01-05 M	5,410.44	9,208.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,619.36		
4313	SOBRA CHILD 06-13 M	4,197.48	9,320.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,518.12		
4314	SOBRA CHILD 14-20 MA	813.96	1,947.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,761.08		
4315	SOBRA CHILD 14-20 FE	1,053.36	2,170.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,223.92		
5015	SOBRA PREG 14-20 FE M	239.40	191.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430.92		
5017	SOBRA PREG 21-44 FE
M	1,197.00	1,197.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,394.00		
SUBTOTAL:	25,791.36	46,443.60	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,234.96		

1108	TANF EXPANDED 45-64	63.84	95.76	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	63.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	239.40	526.68	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	2,074.80	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	957.60	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	63.84	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	95.76	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	143.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	31.92	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	446.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
159.60	
95.76	
766.08	
3,367.56	
1,452.36	
111.72	
191.52	
191.52	
31.92	
670.32	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2610	SSI DISABLED EXPAND E	31.92	31.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.84		
2620	SSI DISABLED EXPAND
E	255.36	399.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		654.36		
SUBTOTAL:	2,824.92	4,931.64	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,756.56		

3514	ADULT 40-100% MALE 1	15.96	31.92	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	191.52	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	175.56	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	143.64	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	973.56	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	111.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	271.32	526.68	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	2,457.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	941.64	1,659.84	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	3,606.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,931.64	9,879.24	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
47.88	
287.28	
271.32	
287.28	
1,516.20	
207.48	
798.00	
3,351.60	
2,601.48	
5,442.36	
14,810.88	

3915	NEWLY ELIGIBLE FEMA L	31.92	31.92	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	175.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	271.32	430.92	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	399.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	606.48	1,037.40	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
63.84	
287.28	
702.24	
590.52	
1,643.88	

4413	SOBRA 100-133% M&F
6	574.56	1,101.24	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	223.44	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	430.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	893.76	1,755.60	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,675.80	
287.28	
686.28	
2,649.36	

6012	KIDS 1-5 M & F NON-M	15.96	15.96	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	31.92	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	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	79.80	63.84	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
31.92	
79.80	
31.92	
143.64	

99,239.28

35,127.96	64,111.32	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 August 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1011	TANF <1 M & F NON-ME	44.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.00		
1012	TANF 01-05 M & F NON	23.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.00		
1013	TANF 06-13 M & F NON	30.00	48.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.00		
1014	TANF 14-20 MALE NON-	2.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1015	TANF 14-20 FEMALE N O	17.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46.00		
1016	TANF 21-44 MALE NON-	15.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
1017	TANF 21-44 FEMALE N O	195.00	309.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		504.00		
1018	TANF 45-64 M & F NON	54.00	101.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155.00		
2100	SSI AGED WITH MEDIC A	3.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
2110	SSI AGED NON-MEDIC
AR	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2120	SSI AGED WITH QMB	26.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.00		
2200	SSI DISABLED WITH M E	20.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		
2210	SSI DISABLED NON-ME
D	170.00	296.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		466.00		
2220	SSI DISABLED WITH Q M	75.00	116.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.00		
2310	SSI BLIND NON-MEDIC
A	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2320	SSI BLIND WITH QMB	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4311	SOBRA CHILD <1 M & F	129.00	228.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		357.00		
4312	SOBRA CHILD 01-05 M	339.00	577.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		916.00		
4313	SOBRA CHILD 06-13 M	263.00	584.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		847.00		
4314	SOBRA CHILD 14-20 MA	51.00	122.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173.00		
4315	SOBRA CHILD 14-20 FE	66.00	136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202.00		
5015	SOBRA PREG 14-20 FE M	15.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.00		
5017	SOBRA PREG 21-44 FE
M	75.00	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150.00		
SUBTOTAL:	1,616.00	2,910.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,526.00		

1108	TANF EXPANDED 45-64	4.00	6.00	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	4.00	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	33.00	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	130.00	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	60.00	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	4.00	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	6.00	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	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	2.00	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	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10.00	
6.00	
48.00	
211.00	
91.00	
7.00	
12.00	
12.00	
2.00	
42.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2610	SSI DISABLED EXPAND E	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2620	SSI DISABLED EXPAND
E	16.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
SUBTOTAL:	177.00	309.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		486.00		

3915	NEWLY ELIGIBLE FEMA L	2.00	2.00	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	11.00	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	27.00	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	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	38.00	65.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
18.00	
44.00	
37.00	
103.00	

4413	SOBRA 100-133% M&F
6	36.00	69.00	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	14.00	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	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56.00	110.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

105.00	
18.00	
43.00	
166.00	

6012	KIDS 1-5 M & F NON-M	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6013	KIDS 6-13 M & F NON-	3.00	2.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5.00	4.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
5.00	
2.00	
9.00	

3514	ADULT 40-100% MALE 1	1.00	2.00	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	12.00	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	11.00	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	9.00	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	61.00	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	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	17.00	33.00	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	154.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	59.00	104.00	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	226.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	309.00	619.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
18.00	
17.00	
18.00	
95.00	
13.00	
50.00	
210.00	
163.00	
341.00	
928.00	

TOTAL:	2,201.00	4,017.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,218.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending August 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	22,764.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,529.66		
1010	TANF NON-MEDICARE	2,605,295.71	2,562,367.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,167,663.40		
1020	TANF WITH QMB	19,460.70	15,568.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,029.26		
2100	SSI AGED WITH MEDIC A	32,815,971.54	32,979,207.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,795,178.63		
210Z	SSI AGED WITH MEDIC
A	619,102.28	817,504.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,436,606.90		
2110	SSI AGED NON-MEDIC AR	3,434,158.85	3,394,065.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,828,224.39		
211Z	SSI AGED NON-MEDIC
AR	11,704.38	18,653.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,358.12		
2120	SSI AGED WITH QMB	22,419,410.53	22,710,039.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,129,449.87		
212Z	SSI AGED WITH QMB P P	10,939.38	9,161.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,100.65		
2200	SSI DISABLED WITH M
E	16,009,290.62	15,956,797.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,966,087.81		
220Z	SSI DISABLED WITH M E	93,673.54	102,616.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196,289.85		
2210	SSI DISABLED NON-ME
D	120,794,909.41	121,239,001.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242,033,911.26		
221Z	SSI DISABLED NON-ME D	37,010.83	29,568.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,578.92		
2220	SSI DISABLED WITH Q
M	25,497,207.44	25,693,149.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,190,356.94		
222Z	SSI DISABLED WITH Q M	3,631.33	7,560.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,192.18		
2300	SSI BLIND WITH MEDIC	61,100.26	61,100.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,200.52		
2310	SSI BLIND NON-MEDIC A	264,951.61	256,432.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521,384.38		
2320	SSI BLIND WITH QMB	84,130.00	82,346.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,476.15		
SUBTOTAL:	224,804,713.2	4 225,957,905.65	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		450,762,618.89		

8700	SSI DISABLED FREEDO M	98,465.19	98,658.42	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	849.26	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	155,397.28	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	3,777.75	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	24,397.31	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	283,080.02	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
197,123.61	
849.26	
295,546.24	
3,777.75	
48,794.62	
546,091.48	

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

451,308,710.37

TOTAL:	225,067,724.70 226,240,985.67

LONG TERM CARE MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1010	TANF NON-MEDICARE	665.19	651.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,316.47		
1020	TANF WITH QMB	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
2100	SSI AGED WITH MEDIC A	11,273.89	11,502.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,776.34		
210Z	SSI AGED WITH MEDIC
A	653.12	877.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,531.00		
2110	SSI AGED NON-MEDIC AR	550.05	564.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,114.11		
211Z	SSI AGED NON-MEDIC
AR	11.39	19.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.63		
2120	SSI AGED WITH QMB	8,167.76	8,394.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,562.03		
212Z	SSI AGED WITH QMB P P	11.88	9.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.75		
2200	SSI DISABLED WITH M
E	4,808.58	4,816.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,624.95		
220Z	SSI DISABLED WITH M E	100.54	111.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211.87		
2210	SSI DISABLED NON-ME
D	29,046.39	29,196.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,243.26		
221Z	SSI DISABLED NON-ME D	40.11	31.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.91		
2220	SSI DISABLED WITH Q
M	7,307.02	7,412.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,719.16		
222Z	SSI DISABLED WITH Q M	3.98	8.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.22		
2300	SSI BLIND WITH MEDIC	17.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
2310	SSI BLIND NON-MEDIC A	63.16	59.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.15		
2320	SSI BLIND WITH QMB	24.00	23.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.48		
SUBTOTAL:	62,755.06	63,706.27	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,461.33		

8700	SSI DISABLED FREEDO M	28.00	28.18	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	0.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	23.00	25.38	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	4.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	59.00	66.63	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
56.18	
0.92	
48.38	
4.15	
16.00	
125.63	

TOTAL:	62,814.06	63,772.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,586.96		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending August 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	3,105,361.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,204,586.72		
1011	TANF <1 M & F NON-ME	20,092.78	23,450.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,542.86		
1012	TANF 01-05 M & F NON	4,576.00	4,125.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,701.07		
1013	TANF 06-13 M & F NON	5,280.87	6,219.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,499.99		
1014	TANF 14-20 MALE NON-	-958.84	1,397.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		439.09		
1015	TANF 14-20 FEMALE N O	2,369.26	-327.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,041.54		
101A	TANF < 1 M & F NON-M	44,422.68	53,377.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,800.05		
101B	TANF 01-05 M & F NON	7,098.70	11,059.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,158.56		
101C	TANF 06-13 M & F NON	4,339.43	5,147.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,486.82		
101D	TANF 14-20 MALE NON-	949.44	1,163.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,112.64		
101E	TANF 14-20 FEMALE N O	1,382.01	1,964.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,346.68		
1020	TANF WITH QMB	33.83	33.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.66		
2200	SSI DISABLED WITH M E	33.83	33.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.66		
2210	SSI DISABLED NON-ME
D	339,676.61	337,001.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		676,677.91		
221Z	SSI DISABLED NON-ME D	3,510.56	5,818.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,328.83		
2220	SSI DISABLED WITH Q
M	266.46	232.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		499.09		
2310	SSI BLIND NON-MEDIC A	1,727.32	1,717.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,444.82		
231Z	SSI BLIND NON-MEDIC
A	0.00	33.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.83		
4300	SOBRA CHILD WITH M ED	3,172.78	2,220.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,393.68		
4302	SOBRA CHILD 01-05 M	0.00	-160.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-160.45		
4303	SOBRA CHILD 06-13 M	-22.21	-15.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-37.90		
4304	SOBRA CHILD 14-20 MA	0.00	-12.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-12.83		
4305	SOBRA CHILD 14-20 FE	0.00	-34.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-34.37		
430C	SOBRA CHILD 06-13 M	0.00	32.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.74		
4310	SOBRA CHILD NON-ME DI	20,843,552.98	20,902,700.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,746,253.95		
4311	SOBRA CHILD <1 M & F	73,572.72	82,929.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,502.29		
4312	SOBRA CHILD 01-05 M	102,709.89	145,805.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248,514.98		
4313	SOBRA CHILD 06-13 M	114,717.87	161,930.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		276,648.53		
4314	SOBRA CHILD 14-20 MA	22,663.65	33,700.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,363.98		
4315	SOBRA CHILD 14-20 FE	23,824.20	34,345.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,169.64		
431A	SOBRA CHILD < 1 M &	12,969.72	16,358.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,328.00		
431B	SOBRA CHILD 01-05 M	160,415.96	198,857.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		359,273.37		
431C	SOBRA CHILD 6-13 M& F	161,414.95	217,281.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		378,696.73		
431D	SOBRA CHILD 14-20 MA	33,253.15	44,378.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,631.83		
431E	SOBRA CHILD 14-20 FE	35,016.82	46,978.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,995.30		
4320	SOBRA CHILD WITH Q MB	317.67	220.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		537.83		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5010	SOBRA PREGNANT WO MAN	18,798.09	17,883.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,681.45		
5013	SOBRA PREG 09-13 FE
M	0.00	16.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.37		
5015	SOBRA PREG 14-20 FE M	984.07	920.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,904.14		
501C	SOBRA PREG 09-13 FE
M	0.00	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.46		
501E	SOBRA PREG 14-20 FE M	1,560.47	1,210.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,771.16		
SUBTOTAL:	25,142,948.5	5 25,465,375.15	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,608,323.70		

1,696.34

1,696.34

837.59	858.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
837.59	858.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1110	TANF EXPANDED FOR	0
FI
SUBTOTAL:

4403	SOBRA 100-133% M&F
6	0.00	-109.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR F	2,576,543.61	2,593,108.74	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	37,773.58	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	6,467.95	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	7,704.29	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	55,509.07	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	10,727.09	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	12,344.03	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	2,723,524.77	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-109.98	
5,169,652.35	
63,670.18	
12,571.08	
13,423.23	
97,035.30	
19,380.02	
21,487.20	
5,397,109.38	

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

56,007,157.87

27,817,399.20	28,189,758.67	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 August 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	TANF 14-20 FEMALE N
O

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

1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2200	SSI DISABLED WITH M
E
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
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

221Z	SSI DISABLED NON-ME
D

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

2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
231Z	SSI BLIND NON-MEDIC
A
4300	SOBRA CHILD WITH M
ED

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

4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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
MB

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
501C	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
501E	SOBRA PREG 14-20 FE M	0.00	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	0.0	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1110	TANF EXPANDED FOR	0
FI
SUBTOTAL:

Current and

0.00

0.00

0.00

prior m

0.00

0.00

0.00

onth

0.00

data is

0.00

0.00

0.00

under re

0.00

0.00

visio

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

n.

0.00

0.00

441E

SOBRA 100-133% FEMA

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA 100-133% MALE

441D

SOBRA 100-133% M&F
6

441C

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA 100-133% FEMA L

4415

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA 100-133% MALE

4414

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA 100-133% M&F
6

4413

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA 100-133% FOR F

4410

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA 100-133% M&F
6

4403

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		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 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		
100F	TANF 21-44 MALE WITH	0.00	1,356.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,356.24		
1010	TANF NON-MEDICARE	38,299.47	35,480.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,779.61		
1014	TANF 14-20 MALE NON-	929.17	454.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,383.90		
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	10,825.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,315.74		
1018	TANF 45-64 M & F NON	-1,988.68	6,731.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,742.59		
101G	TANF 21-44 FEMALE N O	676.93	2,566.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,243.18		
2120	SSI AGED WITH QMB	6,959.75	6,959.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,919.50		
2200	SSI DISABLED WITH M E	6,264.14	18,012.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,277.10		
220Z	SSI DISABLED WITH M
E	5,153.61	2,391.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,545.49		
2210	SSI DISABLED NON-ME D	250,005.66	212,319.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462,324.97		
221Z	SSI DISABLED NON-ME
D	45,791.77	2,637.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,429.22		
2220	SSI DISABLED WITH Q M	66,508.51	124,531.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,040.31		
222Z	SSI DISABLED WITH Q
M	0.00	90.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.95		
2310	SSI BLIND NON-MEDIC A	1,356.24	1,356.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,712.48		
4310	SOBRA CHILD NON-ME
DI	2,642.18	2,642.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,284.36		
4314	SOBRA CHILD 14-20 MA	24,304.45	1,161.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,466.07		
4315	SOBRA CHILD 14-20 FE	13,297.63	22,355.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,653.15		
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		
431E	SOBRA CHILD 14-20 FE	0.00	1,412.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,412.04		
5010	SOBRA PREGNANT WO MAN	0.00	1,356.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,356.24		
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		
8020	QMB ONLY	0.00	2,712.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,712.48		
SUBTOTAL:	473,752.8	5	457,355.03	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		931,107.88		

1100	TANF EXPANDED FPR FI	8,315.99	5,496.66	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	
110H	TANF EXPANDED 45-64	0.00	767.08	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	17,846.22	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	1,727.98	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	10,806.17	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	2,819.33	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	4,992.88	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	8,793.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,812.65	
2,190.60	
767.08	
42,829.34	
1,727.98	
11,442.79	
4,001.63	
4,804.92	
8,793.69	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		4,119.86		
1120	TANF EXPANDED FOR FI	2,642.18	2,642.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,284.36		
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		14,890.11		
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		25,600.13		
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		350.00		
2400	SSI AGED EXPANDED WI	437.50	2,000.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,438.31		
240Z	SSI AGED EXPANDED
WI	918.74	2,134.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,052.95		
2420	SSI AGED EXPANDED WI	6,546.65	5,322.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,869.37		
2600	SSI DISABLED EXPAND
E	1,973.53	2,131.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,104.54		
260Z	SSI DISABLED EXPAND E	4,938.38	2,772.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,710.51		
2610	SSI DISABLED EXPAND
E	2,819.33	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,638.66		
2620	SSI DISABLED EXPAND E	40,303.04	160,386.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,689.71		
262Z	SSI DISABLED EXPAND
E	0.00	1,071.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,071.23		
SUBTOTAL:	142,660.1	2	234,530.30	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		377,190.42		

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	27,802.45	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	1,091.35	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	5,045.78	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	63,248.33	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	2,455.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	2,546.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	0.00	5,634.08	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	90.95	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	167,644.63	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	545.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	1,727.98	9,444.34	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	6,793.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	61,977.08	69,801.82	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	140,521.84	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	3,092.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371E	ADULT <40% EXP FEM AL	545.68	2,728.38	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	6,118.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEM AL	16,659.07	19,810.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
440.36	
880.73	
85,012.44	
10,834.67	
6,068.56	
54,226.46	
1,879.55	
3,155.54	
2,546.49	
5,634.08	
90.95	
381,363.93	
17,022.99	
11,172.32	
117,389.11	
131,778.90	
220,750.74	
13,799.15	
3,274.06	
41,424.53	
36,469.35	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 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	41,419.95	8,993.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,413.80		
SUBTOTAL:	652,218.52	543,410.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,195,628.71		

3910	NEWLY ELIGIBLE FOR F	19,486.46	20,949.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	43.75	181.89	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	8,194.63	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	1,000.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	46,412.69	30,326.48	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
40,436.01	
225.64	
10,755.43	
2,452.45	
12,560.04	
2,819.33	
3,670.53	
3,819.74	
76,739.17	

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	
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	5,547.71	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	1,182.30	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	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29,056.16	9,549.34	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
30,873.13	
2,093.71	
5,638.66	
38,605.50	

90.95

2,619,362.63

1,344,191.29	1,275,171.34	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 - ADULT
For The Period Ending August 31, 2018

RATE CODE	DESCRIPTION 1006	TANF 21-44 MALE WITH
100F	TANF 21-44 MALE WITH

1010	TANF NON-MEDICARE

1014	TANF 14-20 MALE NON-

1016	TANF 21-44 MALE NON-

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

101G	TANF 21-44 FEMALE N
O
2120	SSI AGED WITH QMB

2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
Cu0.00rren0.00t an0.0d0	pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0      n.0.00 	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	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
4310	SOBRA CHILD NON-ME
DI
4314	SOBRA CHILD 14-20 MA

4315	SOBRA CHILD 14-20 FE

431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

5010	SOBRA PREGNANT WO
MAN
5017	SOBRA PREG 21-44 FE
M
501G	SOBRA PREG 21-44 FE
M
8020	QMB ONLY

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

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	
110H	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	
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	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
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 August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		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		0.00		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		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		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		0.00		
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2610	SSI DISABLED EXPAND
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		
262Z	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3507	ADULT 40-100% FEMAL
E

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

350G	ADULT 40-100% FEMAL
E

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

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

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

351G	ADULT 40-100% FEMAL
E

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

351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3708	ADULT <40% EXP M&F
4
3710	AHC CARE EXPANDED
FO

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

0.00	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 FEM
AL

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

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3717	ADULT <40% EXP FEM
AL
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	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 FEM
AL

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

371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 FEM
AL

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending August 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	0.00	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		

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	
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

Cu

0.00

rren

0.00

t an

0.00

0.0

d

0

pr

0i

0.00

.00or m

0.00 ont0h

0.00

0.00

.00

da

0.0t

0.00

0 a is

0.00 und0.00

0.00

0.00

er r

0.00

0

e

.00 vis

0.00

0

i

.0

o

0      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

0.00

0.00

0.00

SSI DISABLED FREEDO M

8720

SSI DISABLED FREEDO M

870Z

SSI DISABLED FREEDO M

8700

0.00

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		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	743.35	832.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,575.61		
1006	TANF 21-44 MALE WITH	0.00	46.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46.29		
1007	TANF 21-44 FEMALE WI	0.00	38.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.68		
1008	TANF 45-64 M & F WIT	271.01	84.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355.45		
1010	TANF NON-MEDICARE	9,782,255.69	9,811,193.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,593,449.19		
1012	TANF 01-05 M & F NON	0.00	-141.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-141.06		
1014	TANF 14-20 MALE NON-	1,920.38	635.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,556.16		
1015	TANF 14-20 FEMALE N O	4,215.79	5,299.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,515.17		
1016	TANF 21-44 MALE NON-	30,559.31	40,540.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,099.78		
1017	TANF 21-44 FEMALE N O	82,903.94	111,517.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194,421.81		
1018	TANF 45-64 M & F NON	17,062.72	24,164.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,227.26		
1019	TANF 65+ M & F NON-M	-32.73	18.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-13.85		
101D	TANF 14-20 MALE NON-	2,263.51	3,088.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,352.19		
101E	TANF 14-20 FEMALE N O	6,063.63	7,959.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,023.36		
101F	TANF 21-44 MALE NON-	49,948.44	62,208.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,156.96		
101G	TANF 21-44 FEMALE N O	122,069.48	162,772.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,841.90		
101H	TANF 44-64 M & F NON	22,645.65	34,688.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,333.93		
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	451.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		894.46		
1026	TANF 21-44 MALE WITH	0.00	70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.53		
1027	TANF 21-44 FEMALE WI	-425.76	84.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-340.90		
2100	SSI AGED WITH MEDIC A	8,557.84	8,379.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,937.10		
2110	SSI AGED NON-MEDIC
AR	448,777.49	452,563.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901,341.10		
211Z	SSI AGED NON-MEDIC AR	10,752.26	13,418.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,170.49		
2120	SSI AGED WITH QMB	41,643.94	41,513.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,157.83		
2200	SSI DISABLED WITH M E	15,741.04	15,577.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,318.84		
2210	SSI DISABLED NON-ME
D	2,388,281.92	2,375,550.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,763,832.75		
221Z	SSI DISABLED NON-ME D	37,694.51	48,238.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,933.14		
2220	SSI DISABLED WITH Q
M	53,830.16	53,862.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,692.99		
2300	SSI BLIND WITH MEDIC	141.92	141.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.84		
2310	SSI BLIND NON-MEDIC A	29,895.63	29,764.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,660.52		
231Z	SSI BLIND NON-MEDIC
A	272.22	2,283.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,556.02		
2320	SSI BLIND WITH QMB	1,177.44	1,177.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,354.88		
4310	SOBRA CHILD NON-ME DI	1,498,864.65	1,498,027.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,996,891.70		
4314	SOBRA CHILD 14-20 MA	9,312.68	18,188.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,500.95		
4315	SOBRA CHILD 14-20 FE	12,440.21	19,489.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,929.93		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431D	SOBRA CHILD 14-20 MA	15,921.94	28,667.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,589.35		
431E	SOBRA CHILD 14-20 FE	19,882.62	25,170.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,053.05		
5010	SOBRA PREGNANT WO MAN	1,394,704.48	1,374,426.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,769,130.68		
5015	SOBRA PREG 14-20 FE
M	10,033.94	13,827.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,861.62		
5017	SOBRA PREG 21-44 FE M	49,743.43	66,574.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,317.93		
5018	SOBRA PREG 45-64 FE
M	132.74	90.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223.37		
501E	SOBRA PREG 14-20 FE M	14,716.29	16,325.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,041.36		
501G	SOBRA PREG 21-44 FE
M	69,865.25	80,167.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,032.95		
501H	SOBRA PREG 45-64 FE M	229.10	64.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293.70		
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		
5510	SOBRA FPS FEMALE W IT	0.00	-70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-70.53		
SUBTOTAL:	16,255,607.2	9 16,448,977.52	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,704,584.81		

-79.72

-141.06

3010	MN/MI NON-MEDICARE	0.00	-79.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4110	EAC NON-MEDICARE	0.00	-141.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-220.78	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-220.78

1100	TANF EXPANDED FPR FI	4,195.09	3,982.64	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	239.16	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	90.60	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	-60.80	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	-39.30	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	8,834,300.06	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	646.01	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	1,944.17	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	37,476.03	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	85,539.81	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	26,934.32	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	-91.89	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	1,222.46	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	2,907.27	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	67,580.75	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	123,890.17	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	40,470.34	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	174.68	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	11,750.39	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	43.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,177.73	
239.16	
147.18	
-47.97	
10.75	
17,650,997.12	
1,133.53	
2,970.77	
67,621.38	
149,343.03	
48,539.57	
-112.46	
2,805.59	
5,255.96	
122,376.38	
217,411.78	
74,380.46	
358.79	
23,466.15	
146.03	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	27.30	21.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.16		
1128	TANF EXPANDED 45-64	11.38	127.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.79		
2400	SSI AGED EXPANDED WI	171.92	244.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		416.12		
2410	SSI AGED EXPANDED
NO	6,133.05	5,844.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,977.46		
241Z	SSI AGED EXPANDED NO	456.25	163.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		619.87		
2420	SSI AGED EXPANDED
WI	33,662.51	33,736.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,399.12		
2600	SSI DISABLED EXPAND E	150.25	220.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371.03		
2610	SSI DISABLED EXPAND
E	98,233.68	95,973.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194,206.72		
261Z	SSI DISABLED EXPAND E	1,762.46	1,243.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,005.68		
2620	SSI DISABLED EXPAND
E	18,184.98	18,155.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,340.40		
SUBTOTAL:	9,295,014.61	9,394,730.67	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,689,745.28		

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	6,160,149.74	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	5,130.83	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	7,721.66	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	22,348.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	14,101.53	18,970.82	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	39,488.15	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	7,801.96	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	12,273.81	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	39,502.13	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	33,727.84	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	65,234.48	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	212.02	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 FEM AL	41.15	36.40	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	-389.46	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	13,700,642.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	10,379.04	13,492.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	10,053.15	15,626.36	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	153,754.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	53,638.01	77,939.98	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	124,669.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

68.67	
12,293,135.46	
9,108.97	
13,284.88	
36,940.51	
33,072.35	
70,324.79	
14,711.95	
22,255.82	
72,195.04	
58,263.55	
121,952.36	
212.02	
43.23	
77.55	
-284.80	
27,368,249.45	
23,871.15	
25,679.51	
249,347.09	
131,577.99	
213,426.91	

3318	AHC CARE M&F 45-64 N	0.00	-70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

-70.53

-70.53

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371D	ADULT <40% EXP MALE	19,843.54	22,122.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,965.55		
371E	ADULT <40% EXP FEM AL	18,450.86	22,487.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,937.86		
371F	ADULT <40% EXP MALE	169,051.65	210,581.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		379,633.22		
371G	ADULT <40% EXP FEM AL	98,395.06	115,940.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214,335.59		
371H	ADULT <40% EXP M&F
4	145,352.68	196,149.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		341,502.22		
371J	ADULT <40% EXP M&F 6	141.06	300.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441.56		
3727	ADULT <40% EXP FEM
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.00		
SUBTOTAL:	20,710,414.9	1 21,065,951.54	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,776,366.45		

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	323,433.06	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	2,247.67	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	3,253.83	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	4,168.64	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	5,249.67	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	338,352.87	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

79.72	
643,844.46	
4,832.72	
5,936.34	
7,613.54	
8,262.22	
670,569.00	

4510	BC PATIENT FOR FINA N	9,220.45	9,521.38	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	111.48	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	213.87	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	100.11	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	795.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18,741.83	
125.21	
358.19	
157.34	
1,122.35	

3908	NEWLY ELIGIBLE M&F 4	0.00	81.90	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	5,326,495.72	5,351,489.11	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	3,741.91	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	4,731.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	21,847.70	30,438.42	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	33,156.94	48,986.91	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	25,942.10	32,823.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	6,181.24	7,194.46	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	6,405.61	6,227.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	38,771.67	51,515.41	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	57,199.13	73,737.22	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	49,113.47	55,362.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,571,388.74	5,666,400.72	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
81.90	
10,677,984.83	
6,222.29	
8,526.08	
52,286.12	
82,143.85	
58,765.73	
13,375.70	
12,632.96	
90,287.08	
130,936.35	
104,476.04	
70.53	
11,237,789.46	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4610	CC PATIENT FOR FINA N	1,326.40	1,325.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,652.37		
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		15.93		
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		54.60		
SUBTOTAL:	11,159.66	12,068.16	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,227.82		

8700	SSI DISABLED FREEDO M	1,398.78	1,467.03	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	26,669.16	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	1,482.54	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	79.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30,301.17	29,698.45	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,865.81	
53,996.58	
3,057.51	
79.72	
59,999.62	

105,161,991.13

52,206,102.51	52,955,888.62	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 August 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
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
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
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
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

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

101F	TANF 21-44 MALE NON-	Cu0.00rren0.00t an0.0d0	pr0i.00or m0.00 ont0h.00	da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0      n.0.00 	0.00
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M

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

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

2310	SSI BLIND NON-MEDIC
A
231Z	SSI BLIND NON-MEDIC
A

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

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

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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

SUBTOTAL:

Cu0.0r0   ren0.0t0      an0.d00

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

EAC NON-MEDICARE

4110

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

MN/MI NON-MEDICARE

3010

0.00

0.00

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		0.00		
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
241Z	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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		
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00

3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	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

3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3515	ADULT 40-100% FEMAL
E

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

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3517	ADULT 40-100% FEMAL
E

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

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

351D	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

351E	ADULT 40-100% FEMAL
E

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

351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

351G	ADULT 40-100% FEMAL
E

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

351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3710	AHC CARE EXPANDED
FO

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

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

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 FEM
AL

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

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3717	ADULT <40% EXP FEM
AL
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	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 August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR
F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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	

0.00	
0.00	
0.00	
0.00	
0.00	

3908

3910

3914

3915

3916

3917

3918	NEWLY ELIGIBLE M&F 4
NEWLY ELIGIBLE FOR
F
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE M&F
4	0.00

0.00

0.00

0.00

0.00
Cu0.00r
0.00	0.00

0.00

0.00

0.00

0.00
ren0.00
0.00	0.00

0.00

0.00

0.00

0.00
t an0.0d0
0.00	0.00

0.00

0.00

0.00

0.00
pr0i.00o
0.00	0.00

0.00

0.00

0.00

0.00
r m0.00
0.00	0.00

0.00

0.00

0.00

0.00
ont0h.00
0.00	0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00
da0.0t0 a is0.00
0.00	0.00	0.00

0.00

0.00

0.00

0.00
und0.00e
0.00	0.00

0.00

0.00

0.00

0.00
r r0e.00
0.00	0.00

0.00

0.00

0.00

0.00
vis0i.0o0
0.00	0.00

0.00

0.00

0.00

0.00
n.0.00
0.00	
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4610	CC PATIENT FOR FINA N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
461H	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	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	0.0	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	

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 - CMDP
For The Period Ending August 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	830,090.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,653,068.94		
1011	TANF <1 M & F NON-ME	2,708.55	15,092.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,801.07		
1012	TANF 01-05 M & F NON	-5,476.49	-19,306.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-24,783.04		
1013	TANF 06-13 M & F NON	-40.48	8,295.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,254.55		
1014	TANF 14-20 MALE NON-	890.55	4,851.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,741.61		
1015	TANF 14-20 FEMALE N O	971.51	2,567.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,538.65		
101A	TANF < 1 M & F NON-M	1,457.26	-1,333.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.38		
101B	TANF 01-05 M & F NON	936.60	-1,369.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-432.72		
101C	TANF 06-13 M & F NON	-627.43	-627.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,254.86		
101D	TANF 14-20 MALE NON-	568.06	378.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		946.25		
2210	SSI DISABLED NON-ME D	182,177.17	169,523.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		351,700.49		
221Z	SSI DISABLED NON-ME
D	417.06	2,365.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,782.10		
4300	SOBRA CHILD WITH M ED	627.43	627.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,254.86		
4303	SOBRA CHILD 06-13 M	0.00	-20.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-20.24		
4310	SOBRA CHILD NON-ME DI	9,180,293.18	8,849,862.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,030,155.43		
4311	SOBRA CHILD <1 M & F	26,675.98	26,487.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,163.21		
4312	SOBRA CHILD 01-05 M	-37,293.39	-60,745.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-98,039.32		
4313	SOBRA CHILD 06-13 M	-64,080.03	-52,295.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-116,375.64		
4314	SOBRA CHILD 14-20 MA	-23,193.15	-30,502.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-53,695.68		
4315	SOBRA CHILD 14-20 FE	-16,461.87	-27,125.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-43,587.19		
431A	SOBRA CHILD < 1 M &	8,525.24	21,159.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,684.71		
431B	SOBRA CHILD 01-05 M	43,243.66	28,250.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,494.12		
431C	SOBRA CHILD 6-13 M& F	37,854.08	15,353.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,207.22		
431D	SOBRA CHILD 14-20 MA	15,859.30	16,330.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,189.46		
431E	SOBRA CHILD 14-20 FE	21,929.33	10,131.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,060.51		
5010	SOBRA PREGNANT WO MAN	11,084.05	10,164.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,248.16		
5015	SOBRA PREG 14-20 FE
M	-700.19	-178.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-878.80		
SUBTOTAL:	10,211,324.5	6	9,818,022.67	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,029,347.23		

4410	SOBRA 100-133% FOR F	19,453.05	25,267.56	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	2,535.01	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	344.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

44,720.61	
5,213.26	
1,238.92	

3710	AHC CARE EXPANDED FO	0.00	1,172.40	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	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	1,172.40	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,172.40	
453.83	
75.64	
1,701.87	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	474.95	945.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,420.43		
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		890.26		
SUBTOTAL:	24,391.35	29,092.13	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,483.48		

-1,172.40

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

20,083,360.18

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

TOTAL:

10,235,072.98

9,848,287.20

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending August 31, 2018

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

1012	TANF 01-05 M & F NON

1013	TANF 06-13 M & F NON

1014	TANF 14-20 MALE NON-

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

101B	TANF 01-05 M & F NON

101C	TANF 06-13 M & F NON

101D	TANF 14-20 MALE NON-

2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
4300	SOBRA CHILD WITH M
ED
4303	SOBRA CHILD 06-13 M

4310	SOBRA CHILD NON-ME
DI

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

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

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

4313	SOBRA CHILD 06-13 M

4314	SOBRA CHILD 14-20 MA

4315	SOBRA CHILD 14-20 FE

431A	SOBRA CHILD < 1 M &

431B	SOBRA CHILD 01-05 M

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

431E	SOBRA CHILD 14-20 FE

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

3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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		

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

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 August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	319.94	319.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		639.88		
1010	TANF NON-MEDICARE	105,712.34	100,084.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205,796.58		
1020	TANF WITH QMB	478.09	478.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		956.18		
2100	SSI AGED WITH MEDIC A	44,133.86	44,161.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,295.09		
2110	SSI AGED NON-MEDIC
AR	1,916.00	1,916.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,832.00		
2120	SSI AGED WITH QMB	69,460.16	71,850.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,311.12		
2200	SSI DISABLED WITH M E	382,132.58	380,029.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		762,162.37		
2210	SSI DISABLED NON-ME
D	4,533,394.57	4,534,531.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,067,925.97		
2220	SSI DISABLED WITH Q M	815,415.52	817,872.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,633,287.81		
2300	SSI BLIND WITH MEDIC	1,824.16	1,824.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,648.32		
2310	SSI BLIND NON-MEDIC A	5,681.94	5,276.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,958.13		
2320	SSI BLIND WITH QMB	3,316.23	3,316.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,632.46		
SUBTOTAL:	5,963,785.39	5,961,660.52	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,925,445.91		

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

 
5,094.74	
1,109.46	
1,126.48	
7,330.68	

11,932,776.59

5,967,450.73	5,965,325.86	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 August 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-MEDIC
AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

M

Current and prior month data is under revision.

8700	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			
														
8710	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00													
	M													
8720	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00													

SUBTOTAL	M
:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00													

 
0.00	
0.00	
0.00	
0.00	

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

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending August 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	1,927.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,855.28		
1010	TANF NON-MEDICARE	238,296.00	198,779.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		437,075.38		
1011	TANF <1 M & F NON-ME	15,253.92	15,021.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,275.38		
1012	TANF 01-05 M & F NON	8,274.72	11,764.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,039.04		
1013	TANF 06-13 M & F NON	5,748.94	8,274.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,023.66		
1014	TANF 14-20 MALE NON-	5,383.26	4,785.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,168.38		
1015	TANF 14-20 FEMALE N O	2,990.70	4,186.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,177.68		
1017	TANF 21-44 FEMALE N
O	1,196.28	1,196.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,392.56		
1020	TANF WITH QMB	963.82	963.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,927.64		
2200	SSI DISABLED WITH M E	38,785.26	35,295.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,080.92		
2210	SSI DISABLED NON-ME
D	5,915,870.99	5,960,555.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,876,426.15		
2220	SSI DISABLED WITH Q M	125,628.30	133,937.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259,565.30		
2300	SSI BLIND WITH MEDIC	963.82	963.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,927.64		
2310	SSI BLIND NON-MEDIC A	19,375.64	17,448.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,823.64		
4311	SOBRA CHILD <1 M & F	20,637.18	20,039.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,676.22		
4312	SOBRA CHILD 01-05 M	153,798.04	146,121.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299,919.50		
4313	SOBRA CHILD 06-13 M	256,308.49	251,799.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		508,107.65		
4314	SOBRA CHILD 14-20 MA	69,656.08	67,960.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,616.98		
4315	SOBRA CHILD 14-20 FE	70,551.94	71,748.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,300.16		
5015	SOBRA PREG 14-20 FE M	598.14	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,196.28		
SUBTOTAL:	6,952,209.16	6,953,366.28	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,905,575.44		

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

 
1,794.42	
598.14	
1,196.28	
3,588.84	

3514	ADULT 40-100% MALE 1	1,196.28	598.14	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	598.14	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	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	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	11,962.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	8,972.10	9,570.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM
AL	1,794.42	1,794.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	23,327.46	25,121.88	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,794.42	
1,196.28	
598.14	
598.14	
22,131.18	
18,542.34	
3,588.84	
48,449.34	

1,196.28

3914	NEWLY ELIGIBLE MALE	598.14	598.14	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	1,794.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,990.70

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	598.14	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,196.28		
SUBTOTAL:	2,392.56	2,990.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,383.26		

4413	SOBRA 100-133% M&F
6	11,364.66	12,560.94	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	3,588.84	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	2,990.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	17,346.06	19,140.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
23,925.60	
6,579.54	
5,981.40	
36,486.54	

13,999,483.42

6,997,069.66	7,002,413.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1010	TANF NON-MEDICARE	248.00	207.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
1011	TANF <1 M & F NON-ME	20.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
1012	TANF 01-05 M & F NON	11.77	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.77		
1013	TANF 06-13 M & F NON	9.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1014	TANF 14-20 MALE NON-	9.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1015	TANF 14-20 FEMALE N O	5.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1017	TANF 21-44 FEMALE N
O	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1020	TANF WITH QMB	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2200	SSI DISABLED WITH M E	41.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.00		
2210	SSI DISABLED NON-ME
D	6,283.26	6,324.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,607.85		
2220	SSI DISABLED WITH Q M	133.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		275.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2310	SSI BLIND NON-MEDIC A	22.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
4311	SOBRA CHILD <1 M & F	29.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.00		
4312	SOBRA CHILD 01-05 M	218.00	207.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425.00		
4313	SOBRA CHILD 06-13 M	361.74	357.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		719.03		
4314	SOBRA CHILD 14-20 MA	92.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183.00		
4315	SOBRA CHILD 14-20 FE	99.00	101.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200.00		
5015	SOBRA PREG 14-20 FE M	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
SUBTOTAL:	7,588.77	7,583.88	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,172.65		

1115	TANF EXPANDED 14-20	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
1.00	
2.00	
6.00	

3514	ADULT 40-100% MALE 1	2.00	1.00	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	1.00	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	1.00	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	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	15.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM
AL	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39.00	42.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
2.00	
1.00	
1.00	
37.00	
31.00	
6.00	
81.00	

2.00

3914	NEWLY ELIGIBLE MALE	1.00	1.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
SUBTOTAL:	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		

4413	SOBRA 100-133% M&F
6	19.00	21.00	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	6.00	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	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
40.00	
11.00	
10.00	
61.00	

TOTAL:	7,663.77	7,665.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,329.65		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 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	4,995.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,059.53		
1007	TANF 21-44 FEMALE WI	2,779.92	5,310.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,089.96		
1008	TANF 45-64 M & F WIT	11,291.57	15,679.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,970.81		
1009	TANF 65+ M & F WITH	7,080.93	7,837.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,918.33		
1011	TANF <1 M & F NON-ME	1,097,793.02	1,427,856.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,525,649.07		
1012	TANF 01-05 M & F NON	258,113.97	381,102.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		639,216.72		
1013	TANF 06-13 M & F NON	279,530.59	485,623.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		765,154.16		
1014	TANF 14-20 MALE NON-	80,615.15	107,150.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		187,765.33		
1015	TANF 14-20 FEMALE N O	224,066.64	355,973.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		580,039.81		
1016	TANF 21-44 MALE NON-	1,462,397.99	2,172,953.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,635,351.58		
1017	TANF 21-44 FEMALE N O	4,955,722.81	7,235,825.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,191,548.02		
1018	TANF 45-64 M & F NON	2,183,248.97	3,211,799.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,395,048.69		
1019	TANF 65+ M & F NON-M	2,934.41	3,807.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,741.41		
1026	TANF 21-44 MALE WITH	1,357.60	854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,211.60		
1027	TANF 21-44 FEMALE WI	6,393.80	11,610.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,003.80		
1028	TANF 45-64 M & F WIT	16,376.86	14,455.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,832.82		
1029	TANF 65+ M & F WITH	3,021.80	667.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,688.84		
2100	SSI AGED WITH MEDIC A	154,652.01	173,183.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327,835.40		
2110	SSI AGED NON-MEDIC
AR	110,434.83	169,816.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		280,250.90		
2120	SSI AGED WITH QMB	563,573.87	806,055.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,369,629.86		
2200	SSI DISABLED WITH M E	444,274.71	703,326.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,147,601.20		
2210	SSI DISABLED NON-ME
D	7,575,600.97	11,234,543.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,810,144.67		
2220	SSI DISABLED WITH Q M	1,311,020.36	1,953,141.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,264,161.75		
2300	SSI BLIND WITH MEDIC	2,715.71	4,128.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,843.92		
2310	SSI BLIND NON-MEDIC A	94,572.77	149,624.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,197.61		
2320	SSI BLIND WITH QMB	25,387.22	36,834.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,221.32		
4302	SOBRA CHILD 01-05 M	0.00	100.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.12		
4311	SOBRA CHILD <1 M & F	2,744,181.25	3,363,111.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,107,293.09		
4312	SOBRA CHILD 01-05 M	3,415,194.97	5,544,812.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,960,007.15		
4313	SOBRA CHILD 06-13 M	4,527,795.53	7,639,549.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,167,345.41		
4314	SOBRA CHILD 14-20 MA	1,133,047.15	2,055,550.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,188,597.69		
4315	SOBRA CHILD 14-20 FE	1,422,456.44	2,441,363.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,863,819.71		
5007	SOBRA PREG 21-44 FE M	318.55	319.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		638.29		
5013	SOBRA PREG 09-13 FE
M	0.00	1,456.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,456.06		
5015	SOBRA PREG 14-20 FE M	358,380.97	500,891.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		859,272.07		
5017	SOBRA PREG 21-44 FE
M	2,037,823.46	3,054,712.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,092,536.21		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	3,075.69	1,818.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,894.67		
5027	SOBRA PREG 21-44 FE
M	484.26	1,280.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,765.23		
SUBTOTAL:	36,517,781.0	2 55,279,121.79	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,796,902.81		

3506	ADULT 40-100% MALE 2	52.90	10.27	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	3,748.84	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	82.14	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	69,899.82	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	132,536.02	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	1,065,112.78	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	690,483.40	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	3,046,508.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	580.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

63.17	
5,635.55	
133.49	
123,485.29	
233,353.08	
1,836,293.50	
1,184,068.41	
5,307,159.54	
427.00	
580.20	

1106	TANF EXPANDED 21-44	6,903.54	6,090.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	9,863.24	6,233.75	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	54,712.80	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	40,358.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	1,281.00	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	5,659.15	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	41,843.22	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	852,411.74	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	2,895,369.89	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	2,314,029.66	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	10,314.64	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	19,555.66	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	41,413.01	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	173,304.51	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	98,571.39	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	17,864.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	15,750.54	28,700.97	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	657,744.56	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	14,358.17	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	218,387.94	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	606,257.42	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	8,104,462.72	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,993.63	
16,096.99	
99,420.55	
56,091.11	
1,281.00	
10,901.86	
71,568.75	
1,539,604.66	
5,031,689.79	
3,741,423.26	
11,941.06	
34,465.09	
68,090.33	
303,197.22	
155,535.09	
25,579.22	
44,451.51	
1,115,100.32	
26,545.01	
404,216.48	
991,578.13	
13,761,771.06	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3707	ADULT <40% EXP FEM AL	0.00	1,493.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,493.45		
3708	ADULT <40% EXP M&F
4	8,266.64	5,658.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,924.64		
3709	ADULT <40% EXP M&F 6	0.00	1,907.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,907.91		
3714	ADULT <40% EXP MALE	307,300.59	512,466.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		819,767.57		
3715	ADULT <40% EXP FEM AL	310,211.15	501,147.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		811,358.70		
3716	ADULT <40% EXP MALE	6,023,811.40	8,210,087.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,233,898.58		
3717	ADULT <40% EXP FEM AL	3,523,898.11	4,432,990.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,956,888.36		
3718	ADULT <40% EXP M&F
4	8,587,427.95	12,464,587.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,052,015.52		
3719	ADULT <40% EXP M&F 6	1,226.37	19.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,245.88		
3727	ADULT <40% EXP FEM
AL	437.33	1,470.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,907.60		
3728	ADULT <40% EXP M&F 4	427.00	1,726.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,153.78		
SUBTOTAL:	22,444,816.4	8 31,142,944.74	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,587,761.22		

4413	SOBRA 100-133% M&F
6	416,723.18	618,558.98	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	193,925.32	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	253,960.14	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	1,066,444.44	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,035,282.16	
304,454.03	
399,651.47	
1,739,387.66	

4518	BC PATIENT FEMALE 4 5	6,148.89	8,660.46	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	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,575.89	9,087.46	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14,809.35	
854.00	
15,663.35	

8700	SSI DISABLED FREEDO M	14,200.47	18,544.94	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	16,225.81	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	4,093.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	26,508.76	38,864.71	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

32,745.41	
26,837.85	
5,790.21	
65,373.47	

3907	NEWLY ELIGIBLE FEMA L	995.90	759.47	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	2,700.43	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	21,882.24	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	63,893.79	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	587,839.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	638,821.34	772,821.13	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	1,798,872.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	929.90	854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	0.00	1,326.60	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	3,250,948.80	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,755.37	
3,194.12	
38,459.82	
114,433.38	
959,213.81	
1,411,642.47	
2,946,074.95	
1,783.90	
1,326.60	
5,477,884.42	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	67,552,869.33	98,891,874.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,444,743.99		

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 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	203.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285.44		
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	75.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,720.56		
1012	TANF 01-05 M & F NON	510.37	13.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		523.74		
1013	TANF 06-13 M & F NON	0.00	458.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		458.07		
1014	TANF 14-20 MALE NON-	3,217.73	161.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,379.51		
1015	TANF 14-20 FEMALE N O	1,261.12	5,233.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,494.54		
1016	TANF 21-44 MALE NON-	25,236.24	43,573.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,810.07		
1017	TANF 21-44 FEMALE N O	49,969.09	96,662.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,631.69		
1018	TANF 45-64 M & F NON	25,853.67	50,784.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,638.48		
1019	TANF 65+ M & F NON-M	0.00	604.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		604.14		
2100	SSI AGED WITH MEDIC A	8,948.54	19,860.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,808.88		
2110	SSI AGED NON-MEDIC
AR	27,266.66	79,448.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,715.02		
2120	SSI AGED WITH QMB	56.00	165.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221.73		
2200	SSI DISABLED WITH M E	2,281.61	2,635.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,917.14		
2210	SSI DISABLED NON-ME
D	20,619.79	18,095.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,715.30		
2220	SSI DISABLED WITH Q M	17.00	208.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.87		
4311	SOBRA CHILD <1 M & F	43,959.44	56,118.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,077.51		
4312	SOBRA CHILD 01-05 M	83,611.98	144,428.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228,040.04		
4313	SOBRA CHILD 06-13 M	25,834.10	76,289.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,123.14		
4314	SOBRA CHILD 14-20 MA	28,981.47	24,362.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,344.20		
4315	SOBRA CHILD 14-20 FE	23,575.75	79,561.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,137.11		
5015	SOBRA PREG 14-20 FE M	50,353.69	24,929.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,283.54		
5017	SOBRA PREG 21-44 FE
M	99,435.96	156,694.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,130.75		
5018	SOBRA PREG 45-64 FE M	0.00	-69.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-69.76		
SUBTOTAL:	522,757.4	1	880,499.14	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,403,256.55		

1106	TANF EXPANDED 21-44	0.00	186.26	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	111.86	2,746.81	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	3,215.80	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	457.33	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	3,498.68	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	43,961.45	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	121,760.74	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	72,325.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
186.26	
2,858.67	
5,446.86	
720.18	
504.14	
4,623.42	
70,003.59	
172,922.84	
120,498.82	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	0.00	36.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.34		
1128	TANF EXPANDED 45-64	79.51	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.51		
1129	TANF EXPANDED 65+
M&	0.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.00		
2400	SSI AGED EXPANDED WI	4,523.21	3,165.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,688.41		
2420	SSI AGED EXPANDED
WI	236.30	132.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		369.01		
2600	SSI DISABLED EXPAND E	3,835.27	5,548.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,383.81		
2610	SSI DISABLED EXPAND
E	357.95	2,833.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,191.67		
2620	SSI DISABLED EXPAND E	2,422.63	96.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,519.44		
SUBTOTAL:	141,066.7	3	260,417.24	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		401,483.97		

3906	NEWLY ELIGIBLE MALE	0.00	72.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	345.83	363.88	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	6,951.00	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	9,627.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	101,110.64	68,371.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	100,349.87	52,982.04	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	223,229.68	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	118.89	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	361,717.13	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

72.12	
709.71	
8,827.28	
17,712.23	
169,482.50	
153,331.91	
331,810.89	
133.70	
682,080.34	

4413	SOBRA 100-133% M&F
6	6,086.08	23,544.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	3,573.99	12,967.46	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	16,210.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

29,631.05	
16,541.45	
22,327.28	

3508	ADULT 40-100% M&F 45	1,483.92	1,266.99	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	11,575.79	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	7,022.32	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	56,781.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	40,082.72	31,094.20	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	144,579.46	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	129.50	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	32,585.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	44,103.08	14,816.62	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	316,455.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	143,010.96	176,838.47	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	477,412.99	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	1,270,558.50	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,750.91	
18,036.71	
8,217.61	
94,663.98	
71,176.92	
282,228.46	
1,343.35	
1,322.61	
63,614.23	
58,919.70	
562,124.59	
319,849.43	
841,226.54	
2,325,475.04	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	15,777.35	52,722.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,499.78		

8700	SSI DISABLED FREEDO M	3,279.71	1,938.22	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	96.26	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	695.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,261.75	2,730.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,217.93	
6,848.30	
925.64	
12,991.87	

TOTAL:	2,065,142.99	2,828,644.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,893,787.55		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
9000	PRESUMPTIVE ELIGIBI L	0.00	736.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.18		
SUBTOTAL:	0.00	736.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.18		

736.18

0.00	736.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL EMERGENCY SERVICES
For The Period Ending August 31, 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	114.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,445.90		
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	1,752.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,827.48		
1012	TANF 01-05 M & F NON	10,032.52	29,000.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,032.99		
1013	TANF 06-13 M & F NON	55,253.93	54,959.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,213.19		
1014	TANF 14-20 MALE NON-	100,182.76	172,011.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,194.53		
1015	TANF 14-20 FEMALE N O	233,623.79	405,870.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		639,493.95		
1016	TANF 21-44 MALE NON-	7,593.13	19,176.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,770.06		
1017	TANF 21-44 FEMALE N O	1,694,509.66	2,323,676.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,018,185.75		
1018	TANF 45-64 M & F NON	11,506.24	17,833.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,339.40		
2100	SSI AGED WITH MEDIC A	3,244.68	2,229.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,473.91		
2110	SSI AGED NON-MEDIC
AR	1,121,446.00	1,529,923.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,651,369.00		
2120	SSI AGED WITH QMB	138.97	63.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202.45		
2200	SSI DISABLED WITH M E	11,519.68	19,385.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,905.38		
2210	SSI DISABLED NON-ME
D	84,283.42	180,923.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		265,206.76		
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	4,756,918.87	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,092,762.08		

3908	NEWLY ELIGIBLE M&F 4	57.58	1,933.27	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	101,862.52	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	73,531.08	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	1,626,371.52	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	551,982.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,990.85	
177,970.70	
157,101.43	
2,160,953.15	
1,176,564.71	

1108	TANF EXPANDED 45-64	3,645.14	2,760.56	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	1,646.57	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	2,784.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	10,893.56	39,060.89	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	783,927.81	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	2,035,472.08	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	1,284,640.72	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	9,472.43	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	5,101.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	183.26	12,551.24	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	63.84	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	4,177,482.55	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,405.70	
3,456.18	
2,833.45	
49,954.45	
1,365,924.44	
3,267,300.01	
1,921,964.47	
27,481.80	
8,306.41	
12,734.50	
6,445.42	
1,600.92	
6,674,407.75	

FEDERAL EMERGENCY SERVICES
For The Period Ending August 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	2,932,482.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,725,828.04		
3919	NEWLY ELIGIBLE M&F
6	9,030.78	1,637.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,668.04		
SUBTOTAL:	3,121,276.20	5,289,800.72	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,411,076.92		

TOTAL:	8,954,044.61	14,224,202.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,178,246.75		

QMB - FEE FOR SERVICE
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	620,715.19	664,536.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,285,251.70		
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	664,536.51	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,285,319.93		

1,285,319.93

620,783.42	664,536.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 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	2,112.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,200.22		
1011	TANF <1 M & F NON-ME	2,747.82	2,358.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,106.10		
1012	TANF 01-05 M & F NON	13,143.77	89,337.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,481.11		
1013	TANF 06-13 M & F NON	218,801.71	269,117.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		487,919.30		
1014	TANF 14-20 MALE NON-	16,179.78	16,331.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,511.41		
1015	TANF 14-20 FEMALE N O	125,023.80	361,168.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		486,192.65		
1016	TANF 21-44 MALE NON-	529,489.74	703,037.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,232,527.44		
1017	TANF 21-44 FEMALE N O	1,164,015.57	1,664,491.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,828,507.29		
1018	TANF 45-64 M & F NON	213,834.54	268,539.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		482,374.01		
2100	SSI AGED WITH MEDIC A	8,512.47	13,947.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,460.35		
2110	SSI AGED NON-MEDIC
AR	4,930.99	5,793.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,724.51		
2120	SSI AGED WITH QMB	17,608.95	19,368.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,977.59		
2200	SSI DISABLED WITH M E	53,361.22	46,758.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,119.75		
2210	SSI DISABLED NON-ME
D	1,663,776.48	2,136,780.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,800,556.75		
2220	SSI DISABLED WITH Q M	269,255.92	345,020.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		614,276.42		
2300	SSI BLIND WITH MEDIC	0.00	12.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.02		
2310	SSI BLIND NON-MEDIC A	20,833.76	14,294.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,127.87		
2320	SSI BLIND WITH QMB	945.26	2,411.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,356.88		
4311	SOBRA CHILD <1 M & F	17,699.86	5,459.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,159.69		
4312	SOBRA CHILD 01-05 M	145,743.83	279,287.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425,031.53		
4313	SOBRA CHILD 06-13 M	4,235,083.20	4,798,839.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,033,923.10		
4314	SOBRA CHILD 14-20 MA	1,111,452.87	1,748,980.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,860,433.03		
4315	SOBRA CHILD 14-20 FE	1,136,461.92	1,990,746.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,127,208.36		
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	11,137.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,302.48		
5017	SOBRA PREG 21-44 FE M	130,369.95	208,077.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338,447.68		
5018	SOBRA PREG 45-64 FE
M	4,288.24	861.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,149.58		
5027	SOBRA PREG 21-44 FE M	0.00	14.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.60		
SUBTOTAL:	11,117,318.6	1 15,004,286.71	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,121,605.32		

1107	TANF EXPANDED 21-44	0.00	34.36	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	184.01	163.47	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	260.57	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	2,259.44	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	2,562.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
34.36	
347.48	
260.57	
2,259.44	
5,162.86	

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	132,900.36	189,630.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322,530.44		
1117	TANF EXPANDED 21-44	330,923.61	494,956.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		825,880.09		
1118	TANF EXPANDED 45-64	127,317.08	166,400.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293,717.60		
1126	TANF EXPANDED 21-44	1,242.45	1,826.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,068.54		
1127	TANF EXPANDED 21-44	6,783.03	3,251.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,034.45		
1128	TANF EXPANDED 45-64	2,135.58	2,187.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,322.61		
1129	TANF EXPANDED 65+
M&	335.08	449.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		784.35		
2410	SSI AGED EXPANDED NO	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	20,278.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,134.39		
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	3,081.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,293.56		
2620	SSI DISABLED EXPAND E	86,428.45	99,354.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,782.51		
SUBTOTAL:	710,957.4	3	986,694.20	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,697,651.63		

3914	NEWLY ELIGIBLE MALE	31,466.18	6,399.25	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	3,792.97	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	30,773.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	35,370.17	72,760.71	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	49,975.40	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	163,702.19	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

37,865.43	
7,188.97	
62,954.53	
108,130.88	
116,013.49	
332,153.30	

4413	SOBRA 100-133% M&F
6	183,265.65	213,401.61	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	266,300.69	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	59,050.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

396,667.26	
297,083.13	
112,177.42	

3514	ADULT 40-100% MALE 1	4,692.85	4,568.83	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	22,057.52	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	203,011.89	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	67,130.33	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	111,883.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	136,450.77	203,154.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	117,289.45	110,476.78	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	2,809,702.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,399,164.79	1,778,856.06	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	1,665,796.66	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	410.82	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	6,977,049.92	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,261.68	
37,997.02	
361,163.49	
133,540.31	
190,491.10	
339,605.69	
227,766.23	
5,361,512.86	
3,178,020.85	
2,897,426.39	
547.76	
12,737,333.38	

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	267,174.79	538,753.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		805,927.81		

8700	SSI DISABLED FREEDO M	482.92	513.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	482.92	513.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

996.79

996.79

TOTAL:	18,024,668.32	23,670,999.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,695,668.23		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending August 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	37,582.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,960.83		
1018	TANF 45-64 M & F NON	0.00	4,081.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,081.95		
2210	SSI DISABLED NON-ME D	46,249.55	54,820.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,070.08		
2220	SSI DISABLED WITH Q
M	2,680.00	1,702.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,382.52		
SUBTOTAL:	80,691.39	98,187.50	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178,878.89		

1116	TANF EXPANDED 21-44	0.00	9,817.08	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	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	9,817.08	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,817.08	
5,714.73	
1,340.00	
16,871.81	

3516	ADULT 40-100% MALE 2	2,449.17	9,974.01	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	5,743.29	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	134,557.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	56,330.91	40,634.82	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	64,666.26	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	255,575.77	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,423.18	
23,793.63	
216,696.46	
96,965.73	
87,022.18	
436,901.18	

3916	NEWLY ELIGIBLE MALE	0.00	5,743.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	5,743.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,743.29

5,743.29

638,395.17

269,071.53	369,323.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending August 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	3,171.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,342.48		
2100	SSI AGED WITH MEDIC
A	16,135.95	43,527.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,663.35		
2110	SSI AGED NON-MEDIC AR	22,432.29	74,325.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,757.73		
2200	SSI DISABLED WITH M
E	147.01	1,691.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,838.66		
2210	SSI DISABLED NON-ME D	0.00	5,393.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,393.17		
4314	SOBRA CHILD 14-20 MA	0.00	15,349.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,349.35		
5017	SOBRA PREG 21-44 FE M	14,080.22	11,579.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,659.93		
SUBTOTAL:	52,966.41	155,038.26	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,004.67		

3916	NEWLY ELIGIBLE MALE	37,301.33	2,765.31	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	5,343.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	38,006.04	8,108.46	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

40,066.64	
6,047.86	
46,114.50	

3518	ADULT 40-100% M&F 45	1,200.57	19,076.91	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	5,930.66	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	18,166.86	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	436.78	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	564,555.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	29,781.34	26,333.88	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	295,515.58	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	930,015.67	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
20,277.48	
49,275.56	
30,906.00	
436.78	
712,892.54	
56,115.22	
627,296.16	
1,497,199.74	

TOTAL:	658,156.52	1,093,162.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,751,318.91		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 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	1,083.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,899.87		
SUBTOTAL:	4,816.81	1,083.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,899.87		

5,899.87

4,816.81	1,083.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 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	165.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222.75		
1017	TANF 21-44 FEMALE N O	3,222.63	8,856.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,079.04		
1018	TANF 45-64 M & F NON	1,623.32	222.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,845.86		
2210	SSI DISABLED NON-ME D	0.00	90.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.81		
2220	SSI DISABLED WITH Q
M	4,042.07	282.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,324.08		
5017	SOBRA PREG 21-44 FE M	4,335.15	10,238.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,573.62		
SUBTOTAL:	13,280.57	19,855.59	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,136.16		

3516	ADULT 40-100% MALE 2	2,731.97	2,018.55	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	5,810.22	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	62,846.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,378.84	137,279.05	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	100,341.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	83,204.75	308,296.32	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,750.52	
5,810.22	
114,677.45	
140,657.89	
125,604.99	
391,501.07	

3914	NEWLY ELIGIBLE MALE	0.00	57.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	3,611.36	2,811.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,611.36	2,869.37	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

57.40	
6,423.33	
6,480.73	

2620	SSI DISABLED EXPAND E	0.00	204.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	204.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
204.29

204.29

TOTAL:	100,096.68	331,225.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		431,322.25		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 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	320.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320.62		
SUBTOTAL:	0.00	320.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320.62		

3716	ADULT <40% EXP MALE	0.00	3,281.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	3,281.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,281.32

3,281.32

3,601.94

0.00	3,601.94	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 August 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	3,615.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,615.67		
2210	SSI DISABLED NON-ME D	0.00	292.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.71		
SUBTOTAL:	0.00	3,908.38	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,908.38		

22.60

2620	SSI DISABLED EXPAND E	20.90	1.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20.90	1.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.60

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	9,658.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	76.39	39,245.88	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	31,999.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,490.70	80,903.43	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

523.06	
10,486.50	
39,322.27	
37,062.30	
87,394.13	

TOTAL:	6,511.60	84,813.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,325.11		

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 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		
1017	TANF 21-44 FEMALE N O	0.00	2,226.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,226.58		
2210	SSI DISABLED NON-ME
D	132.43	447.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		579.58		
SUBTOTAL:	292.74	2,673.73	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,966.47		

3716	ADULT <40% EXP MALE	0.00	569.80	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	4,803.59	711.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,803.59	1,281.05	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
569.80	
5,514.84	
6,084.64	

9,051.11

5,096.33	3,954.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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 August 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 FEM AL	379.71	622.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	379.71	622.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,002.69

1,002.69

1,108.86

485.88	622.98	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 August 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	2,135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,270.00		
2100	SSI AGED WITH MEDIC A	2,690,045.71	3,458,961.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,149,006.95		
2110	SSI AGED NON-MEDIC
AR	129,486.77	186,218.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315,705.57		
2120	SSI AGED WITH QMB	3,501,420.19	4,598,930.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,100,351.11		
2200	SSI DISABLED WITH M E	601,859.98	829,591.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,431,451.66		
2210	SSI DISABLED NON-ME
D	2,935,385.90	4,204,211.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,139,597.29		
2220	SSI DISABLED WITH Q M	849,428.99	1,159,391.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,008,820.82		
2310	SSI BLIND NON-MEDIC
A	5,515.00	17,274.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,789.14		
2320	SSI BLIND WITH QMB	347.83	2,170.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,517.86		
SUBTOTAL:	10,715,625.3	7 14,458,885.03	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,174,510.40		

8720	SSI DISABLED FREEDO M	3,044.16	3,805.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,044.16	3,805.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,849.36

6,849.36

TOTAL:	10,718,669.53	14,462,690.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,181,359.76		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 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	112,153.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,396.75		
2120	SSI AGED WITH QMB	1,819.81	401.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,220.81		
2200	SSI DISABLED WITH M E	5,271.41	4,872.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,143.94		
2210	SSI DISABLED NON-ME
D	26,125.15	7,930.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,055.46		
SUBTOTAL:	48,459.20	125,357.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173,816.96		

173,816.96

48,459.20	125,357.76	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 August 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	24,970.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,990.71		
SUBTOTAL:	20.58	24,970.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,990.71		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

24,990.71

24,970.13

20.58

0.00	0.00

0.00

0.00

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending August 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	17,418.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,641.39		
SUBTOTAL:	222.75	17,418.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,641.39		

17,641.39

222.75	17,418.64	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 August 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	17,173.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,976.96		
1013	TANF 06-13 M & F NON	46,103.20	34,730.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,833.44		
1014	TANF 14-20 MALE NON-	3,875.77	3,846.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,722.68		
1015	TANF 14-20 FEMALE N O	1,059.25	519.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,578.48		
2200	SSI DISABLED WITH M
E	0.00	12.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.68		
2210	SSI DISABLED NON-ME D	195,372.83	153,569.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		348,941.94		
2220	SSI DISABLED WITH Q
M	40.22	122.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.84		
2310	SSI BLIND NON-MEDIC A	2,012.88	532.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,545.25		
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	86,061.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		219,421.81		
4313	SOBRA CHILD 06-13 M	158,588.60	93,813.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252,401.88		
4314	SOBRA CHILD 14-20 MA	10,083.50	9,168.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,252.18		
4315	SOBRA CHILD 14-20 FE	4,583.50	4,492.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,075.61		
SUBTOTAL:	578,910.8	0	404,042.07	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		982,952.87		

3914	NEWLY ELIGIBLE MALE	24.80	99.24	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	69.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	32.40	168.74	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

124.04	
77.10	
201.14	

4413	SOBRA 100-133% M&F
6	30,197.25	21,259.92	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	2,316.23	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	893.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	32,923.17	24,470.13	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

51,457.17	
4,055.68	
1,880.45	
57,393.30	

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	276.53	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	538.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	66.40	33.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	277.95	848.72	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9.87	
381.40	
635.80	
99.60	
1,126.67	

TOTAL:	612,144.32	429,529.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,041,673.98		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	60.95	60.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121.88		
1010	TANF NON-MEDICARE	40,228.81	25,108.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,336.98		
2200	SSI DISABLED WITH M E	2,528.24	4,052.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,580.39		
2210	SSI DISABLED NON-ME
D	1,187,559.37	898,408.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,085,968.32		
2220	SSI DISABLED WITH Q M	4,979.23	6,006.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,985.30		
2310	SSI BLIND NON-MEDIC
A	4,955.34	4,870.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,825.91		
SUBTOTAL:	1,240,311.94	938,506.84	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,178,818.78		

2,178,818.78

1,240,311.94	938,506.84	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 August 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	1.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.45		
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	672,730.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,040,194.65		
1012	TANF 01-05 M & F NON	220,883.34	62,299.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283,182.36		
1013	TANF 06-13 M & F NON	541,569.53	146,433.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		688,002.94		
1014	TANF 14-20 MALE NON-	8,935.26	150,685.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,621.00		
1015	TANF 14-20 FEMALE N O	43,754.39	49,414.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,169.04		
1016	TANF 21-44 MALE NON-	314,141.01	335,519.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		649,660.66		
1017	TANF 21-44 FEMALE N O	65,459.28	733,363.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		798,822.43		
1018	TANF 45-64 M & F NON	257,482.04	736,288.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		993,770.70		
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	13,404.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-37,800.69		
2110	SSI AGED NON-MEDIC
AR	136,832.77	177,312.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,144.77		
2200	SSI DISABLED WITH M E	165,164.34	39,836.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205,001.21		
2210	SSI DISABLED NON-ME
D	6,629,461.86	6,463,509.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,092,971.62		
2310	SSI BLIND NON-MEDIC A	6,373.16	5.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,378.23		
4311	SOBRA CHILD <1 M & F	2,433,634.85	1,173,216.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,606,850.96		
4312	SOBRA CHILD 01-05 M	2,169,529.06	574,786.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,744,315.70		
4313	SOBRA CHILD 06-13 M	894,827.48	845,658.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,740,486.07		
4314	SOBRA CHILD 14-20 MA	364,934.32	508,718.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		873,652.83		
4315	SOBRA CHILD 14-20 FE	334,736.84	203,009.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		537,746.39		
5017	SOBRA PREG 21-44 FE M	25,593.87	30,906.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,499.97		
SUBTOTAL:	15,899,565.7	2 12,917,099.70	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,816,665.42		

-26,819.24	28,546.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
-26,819.24	28,546.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3100	TRANSPLANT OPTION
1
SUBTOTAL:

0	1,727.32

1,727.32

1106	TANF EXPANDED 21-44	26,859.21	-459.75	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	17,575.28	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	148,722.48	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	486,367.80	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	25,923.98	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	12.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	15,709.73	1,485.73	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	108.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
26,399.46	
-31,095.43	
439,670.99	
334,964.59	
673,963.73	
33,463.12	
37.51	
17,195.46	
470.29	

ACUTE REINSURANCE
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2610	SSI DISABLED EXPAND E	129,876.21	65,714.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,590.79		
SUBTOTAL:	945,209.23	745,451.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,690,660.51		

3906	NEWLY ELIGIBLE MALE	1,009.14	536.76	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	2,027.77	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	102,807.47	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	42,880.51	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	656,619.04	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	804,871.55	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,545.90	
2,459.43	
64,834.53	
7,280.14	
241,259.16	
63,338.78	
959,332.13	
1,340,050.07	

4413	SOBRA 100-133% M&F
6	399,630.02	68,444.29	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	48,239.21	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	36,682.43	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	153,365.93	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

468,074.31	
240,851.58	
82,048.72	
790,974.61	

8710	SSI DISABLED FREEDO M	25,577.76	19,070.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,577.76	19,070.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

44,648.72

44,648.72

3514	ADULT 40-100% MALE 1	70,821.21	35,931.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,443.66	8,839.06	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	232,727.22	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	138,044.63	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	559,454.79	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	6,701.45	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	66,170.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	131,460.17	23,362.93	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	955,278.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	312,636.20	618,946.44	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	1,894,005.26	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	1,630.30	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	4,541,092.12	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
106,752.89	
10,282.72	
371,159.48	
433,201.84	
1,294,916.91	
4,950.41	
181,115.84	
154,823.10	
2,581,805.43	
931,582.64	
3,808,999.17	
1,630.30	
9,881,220.73	

TOTAL:	23,356,449.28	19,209,498.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,565,947.38		

LONG TERM CARE REINSURANCE
For The Period Ending August 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	5,549.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,743.76		
2100	SSI AGED WITH MEDIC A	323,595.92	208,487.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		532,083.87		
2110	SSI AGED NON-MEDIC
AR	53,483.73	112,426.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,910.13		
2200	SSI DISABLED WITH M E	750,334.85	433,812.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,184,147.60		
2210	SSI DISABLED NON-ME
D	4,294,544.57	2,622,802.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,917,346.94		
2310	SSI BLIND NON-MEDIC A	23,280.32	31,872.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,152.90		
SUBTOTAL:	5,446,434.00	3,414,951.20	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,861,385.20		

8710	SSI DISABLED FREEDO M	39.30	62.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39.30	62.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
101.44

101.44

8,861,486.64

5,446,473.30	3,415,013.34	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 August 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	51,850.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,586.00		
1010	TANF NON-MEDICARE	938.00	1,072.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,010.00		
1020	TANF WITH QMB	47,404.00	53,340.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,744.20		
2100	SSI AGED WITH MEDIC A	45,901.50	43,140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,041.50		
2110	SSI AGED NON-MEDIC
AR	519,350.00	541,431.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,060,781.60		
2120	SSI AGED WITH QMB	4,138,319.10	4,157,505.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,295,824.50		
2200	SSI DISABLED WITH M E	81,776.80	79,942.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,719.00		
2210	SSI DISABLED NON-ME
D	447,158.00	453,992.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901,150.00		
2220	SSI DISABLED WITH Q M	3,939,195.80	3,948,725.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,887,921.00		
2300	SSI BLIND WITH MEDIC	268.00	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		536.00		
2310	SSI BLIND NON-MEDIC A	3,886.00	4,020.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,906.00		
2320	SSI BLIND WITH QMB	35,778.00	35,644.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,422.00		
4320	SOBRA CHILD WITH Q MB	670.00	402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,072.00		
5020	SOBRA PREGNANT WO
MAN	6,566.00	7,236.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,802.00		
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	895,723.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,814,103.40		
8040	SLMB	5,318,204.60	5,374,555.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,692,759.90		
8888	SMIB ONLY NOT ELIGIB	-57,211.50	-38,551.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-95,763.00		
9999	SMIB ONLY NOT ELIGIB	133,242.60	150,028.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283,271.00		
SUBTOTAL:	15,635,026.6	0 15,760,324.50	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,395,351.10		

1100	TANF EXPANDED FPR FI	219,940.40	208,614.00	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	670.00	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	885,677.20	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	16,590.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	1,474.00	536.00	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	3,378,807.00	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	14,606.00	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	2,299,428.10	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	6,804,928.30	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
428,554.40	
1,340.00	
1,761,551.90	
39,481.00	
2,010.00	
6,728,041.70	
33,098.00	
4,608,115.20	
13,602,192.20	

3520	ADULT 40-100% FOR FI	402.00	134.00	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	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	670.00	402.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
536.00	
536.00	
1,072.00	

134.00

8620	SSI BLIND FREEDOM/W O	0.00	134.00	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	35,242.00	35,376.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

70,618.00

ACUTE SMIB
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	35,242.00	35,510.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,752.00		

TOTAL:	22,468,202.50	22,601,164.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,069,367.30		

ACUTE HIB
For The Period Ending August 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	844.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,532.00		
2120	SSI AGED WITH QMB	462,515.60	483,493.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		946,009.20		
2200	SSI DISABLED WITH M E	0.00	-422.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-422.00		
2220	SSI DISABLED WITH Q
M	195,874.60	202,605.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		398,480.00		
2320	SSI BLIND WITH QMB	1,118.20	1,118.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,236.40		
8020	QMB ONLY	6,414.20	5,232.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,646.80		
9999	SMIB ONLY NOT ELIGIB	-5,617.70	-2,318.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,936.50		
SUBTOTAL:	661,992.9	0	690,553.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,352,545.90		

1120	TANF EXPANDED FOR FI	2,426.00	1,118.00	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	3,924.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,350.40	5,042.40	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,544.00	
7,848.80	
11,392.80	

1,363,938.70

668,343.30	695,595.40	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 August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	2,606,430.60	2,638,564.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,244,995.10		
9999	SMIB ONLY NOT ELIGIB	-7,950.50	-5,230.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-13,181.00		
SUBTOTAL:	2,598,480.10	2,633,334.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,231,814.10		

TOTAL:	2,598,480.10	2,633,334.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,231,814.10		

LTC SMIB
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	804.00	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,474.00		
1020	TANF WITH QMB	670.00	670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,340.00		
2100	SSI AGED WITH MEDIC A	1,096,576.60	1,089,558.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,186,135.20		
2110	SSI AGED NON-MEDIC
AR	209,710.00	212,658.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		422,368.00		
2120	SSI AGED WITH QMB	1,074,969.00	1,094,220.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,169,189.00		
2200	SSI DISABLED WITH M E	420,258.00	408,716.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		828,974.00		
2210	SSI DISABLED NON-ME
D	17,688.00	17,420.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,108.00		
2220	SSI DISABLED WITH Q M	969,891.50	976,143.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,946,035.00		
2300	SSI BLIND WITH MEDIC	1,608.00	1,474.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,082.00		
2320	SSI BLIND WITH QMB	4,548.00	2,948.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,496.00		
SUBTOTAL:	3,796,723.10	3,804,478.10	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,601,201.20		

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

 

1,340.00

1,340.00

7,602,541.20

3,797,393.10	3,805,148.10	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 August 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	-654.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-422.00		
2120	SSI AGED WITH QMB	327,512.40	327,576.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		655,088.40		
2220	SSI DISABLED WITH Q M	16,310.00	17,238.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,548.40		
SUBTOTAL:	344,054.4	0	344,160.40	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		688,214.80		

TOTAL:	344,054.40	344,160.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		688,214.80		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 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	596.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		613.22		
1007	TANF 21-44 FEMALE WI	2,283.75	1,165.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,449.65		
1008	TANF 45-64 M & F WIT	3,061.28	5,198.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,259.41		
1009	TANF 65+ M & F WITH	4,002.34	6,741.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,744.00		
1011	TANF <1 M & F NON-ME	438,462.25	726,489.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,164,951.26		
1012	TANF 01-05 M & F NON	209,316.34	317,460.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		526,776.80		
1013	TANF 06-13 M & F NON	232,327.66	418,575.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		650,903.42		
1014	TANF 14-20 MALE NON-	55,054.04	87,809.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,863.51		
1015	TANF 14-20 FEMALE N O	152,740.73	273,508.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		426,248.97		
1016	TANF 21-44 MALE NON-	906,065.94	1,335,943.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,242,009.27		
1017	TANF 21-44 FEMALE N O	3,518,326.14	4,923,784.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,442,110.95		
1018	TANF 45-64 M & F NON	1,548,916.81	2,174,660.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,723,577.44		
1019	TANF 65+ M & F NON-M	2,926.95	3,807.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,733.95		
1026	TANF 21-44 MALE WITH	1,357.60	854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,211.60		
1027	TANF 21-44 FEMALE WI	2,745.49	2,481.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,227.06		
1028	TANF 45-64 M & F WIT	4,656.56	4,761.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,418.27		
1029	TANF 65+ M & F WITH	2,925.62	648.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,574.41		
2100	SSI AGED WITH MEDIC A	64,149.88	95,842.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,992.14		
2110	SSI AGED NON-MEDIC
AR	79,413.88	84,382.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,795.91		
2120	SSI AGED WITH QMB	290,760.68	432,849.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		723,610.30		
2200	SSI DISABLED WITH M E	154,559.77	283,892.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		438,451.83		
2210	SSI DISABLED NON-ME
D	4,304,299.04	5,946,246.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,250,545.62		
2220	SSI DISABLED WITH Q M	481,923.72	732,574.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,214,498.55		
2300	SSI BLIND WITH MEDIC	145.59	1,613.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,758.94		
2310	SSI BLIND NON-MEDIC A	57,555.11	73,645.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,200.45		
2320	SSI BLIND WITH QMB	7,924.82	11,139.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,064.18		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	1,677,976.34	2,054,348.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,732,324.47		
4312	SOBRA CHILD 01-05 M	2,809,942.41	4,361,706.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,171,648.94		
4313	SOBRA CHILD 06-13 M	3,644,238.08	6,107,659.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,751,898.00		
4314	SOBRA CHILD 14-20 MA	884,065.34	1,486,833.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,370,898.98		
4315	SOBRA CHILD 14-20 FE	1,073,552.01	1,876,676.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,950,228.99		
5007	SOBRA PREG 21-44 FE M	318.55	319.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		638.29		
5013	SOBRA PREG 09-13 FE
M	0.00	854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		854.00		
5015	SOBRA PREG 14-20 FE M	246,785.09	310,209.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		556,994.90		
5017	SOBRA PREG 21-44 FE
M	1,276,069.88	1,991,824.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,267,894.71		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	854.00	861.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,715.46		
5027	SOBRA PREG 21-44 FE
M	0.00	173.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173.98		
SUBTOTAL:	24,139,720.2	0 36,138,141.63	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,277,861.83		

3506	ADULT 40-100% MALE 2	52.90	10.27	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	2,966.92	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	82.14	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	46,072.57	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	103,089.07	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	593,927.91	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	464,998.33	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	2,016,178.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	580.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

63.17	
2,966.92	
133.49	
82,331.55	
168,703.45	
996,043.95	
796,377.12	
3,524,773.86	
427.00	
580.20	

1106	TANF EXPANDED 21-44	4,134.08	2,705.16	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	2,667.05	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	26,164.72	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	15,474.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	1,281.00	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	3,809.62	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	35,343.48	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	554,264.00	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	2,182,687.61	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	1,680,616.36	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	2,135.00	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	8,198.95	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	14,749.30	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	84,837.04	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	45,468.31	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	8,436.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	11,956.00	15,388.90	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	370,147.14	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	8,670.33	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	80,138.61	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	232,897.97	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	5,376,081.37	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,839.24	
9,355.57	
39,160.81	
25,094.74	
1,281.00	
5,433.62	
63,508.84	
1,042,384.18	
3,680,843.09	
2,714,873.77	
2,989.00	
12,803.04	
27,254.38	
135,225.67	
75,835.28	
11,210.75	
27,344.90	
600,195.75	
14,965.25	
156,256.07	
379,820.01	
9,032,674.96	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3707	ADULT <40% EXP FEM AL	0.00	617.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617.12		
3708	ADULT <40% EXP M&F
4	862.29	3,097.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,959.57		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	177,706.60	316,453.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		494,159.64		
3715	ADULT <40% EXP FEM AL	221,380.53	349,532.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		570,913.50		
3716	ADULT <40% EXP MALE	3,106,912.99	4,266,639.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,373,552.91		
3717	ADULT <40% EXP FEM AL	2,314,016.16	2,934,420.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,248,436.18		
3718	ADULT <40% EXP M&F
4	5,349,628.51	7,252,971.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,602,600.19		
3719	ADULT <40% EXP M&F 6	427.00	19.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446.51		
3727	ADULT <40% EXP FEM
AL	427.00	1,281.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,708.00		
3728	ADULT <40% EXP M&F 4	427.00	1,718.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,145.39		
SUBTOTAL:	13,515,855.5	4 18,355,084.18	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,870,939.72		

4413	SOBRA 100-133% M&F
6	363,232.38	542,207.93	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	163,344.50	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	197,653.19	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	903,205.62	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

905,440.31	
246,192.24	
313,882.40	
1,465,514.95	

4518	BC PATIENT FEMALE 4 5	5,978.00	7,937.14	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	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,405.00	8,364.14	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13,915.14	
854.00	
14,769.14	

8700	SSI DISABLED FREEDO M	3,424.04	6,292.23	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	11,384.12	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	3,831.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,678.24	21,508.02	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,716.27	
18,044.62	
4,425.37	
32,186.26	

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	2,739.60	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	16,885.45	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	46,478.63	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	318,900.93	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	589,867.10	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	1,210,264.84	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	854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,621,491.62	2,185,990.55	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
3,130.60	
29,993.53	
85,028.81	
569,193.77	
1,088,040.27	
2,030,387.19	
1,708.00	
0.00	
3,807,482.17	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	43,513,053.52	62,988,375.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,501,429.03		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 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	4,258.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,258.16		
1007	TANF 21-44 FEMALE WI	454.16	4,096.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,550.67		
1008	TANF 45-64 M & F WIT	8,199.13	8,827.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,026.14		
1009	TANF 65+ M & F WITH	3,078.59	1,095.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,174.33		
1011	TANF <1 M & F NON-ME	571,877.30	644,943.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,216,820.92		
1012	TANF 01-05 M & F NON	47,354.77	60,050.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,405.41		
1013	TANF 06-13 M & F NON	46,888.70	64,945.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,834.25		
1014	TANF 14-20 MALE NON-	25,522.58	18,539.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,062.19		
1015	TANF 14-20 FEMALE N O	58,399.10	78,472.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,872.08		
1016	TANF 21-44 MALE NON-	528,281.17	776,938.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,305,219.26		
1017	TANF 21-44 FEMALE N O	1,351,952.87	2,171,130.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,523,083.42		
1018	TANF 45-64 M & F NON	493,706.62	978,197.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,471,903.80		
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	8,527.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,380.48		
1028	TANF 45-64 M & F WIT	11,663.51	9,682.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,345.61		
1029	TANF 65+ M & F WITH	96.18	18.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.43		
2100	SSI AGED WITH MEDIC A	63,979.58	62,813.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,793.37		
2110	SSI AGED NON-MEDIC
AR	30,607.02	80,075.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,682.24		
2120	SSI AGED WITH QMB	262,680.34	362,468.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		625,148.49		
2200	SSI DISABLED WITH M E	276,643.75	414,486.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		691,130.50		
2210	SSI DISABLED NON-ME
D	2,898,858.52	4,815,298.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,714,156.58		
2220	SSI DISABLED WITH Q M	798,769.02	1,173,070.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,971,839.39		
2300	SSI BLIND WITH MEDIC	2,568.27	2,336.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,904.31		
2310	SSI BLIND NON-MEDIC A	26,569.90	75,886.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,455.95		
2320	SSI BLIND WITH QMB	17,412.79	25,646.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,059.77		
4302	SOBRA CHILD 01-05 M	0.00	100.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.12		
4311	SOBRA CHILD <1 M & F	912,418.33	1,194,989.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,107,408.04		
4312	SOBRA CHILD 01-05 M	607,631.65	1,115,643.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,723,275.09		
4313	SOBRA CHILD 06-13 M	841,559.09	1,473,345.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,314,904.38		
4314	SOBRA CHILD 14-20 MA	241,357.49	525,940.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		767,297.93		
4315	SOBRA CHILD 14-20 FE	337,284.98	534,427.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		871,712.91		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	602.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		602.06		
5015	SOBRA PREG 14-20 FE M	93,227.02	175,280.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268,507.38		
5017	SOBRA PREG 21-44 FE
M	630,985.09	906,932.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,537,917.82		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	2,221.69	957.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,179.21		
5027	SOBRA PREG 21-44 FE
M	484.26	1,106.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,591.25		
SUBTOTAL:	11,194,593.8	8 17,771,131.52	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,965,725.40		

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	781.92	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	23,780.83	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	28,731.55	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	389,171.84	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	172,768.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	598,169.70	895,892.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP 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	
2,668.63	
0.00	
40,459.66	
60,667.63	
693,411.70	
319,470.66	
1,494,062.35	
0.00	
0.00	

1106	TANF EXPANDED 21-44	2,667.91	3,332.99	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	3,462.15	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	26,388.76	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	24,688.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	3,618.71	1,849.53	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	6,015.17	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	280,855.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	483,760.66	650,162.28	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	579,978.45	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	8,179.64	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	10,804.64	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	26,559.56	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	85,675.23	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	51,136.52	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	9,333.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	3,794.54	13,312.07	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	269,587.10	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	5,626.39	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	127,967.88	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	355,032.36	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	2,539,947.64	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,000.90	
6,487.22	
56,278.13	
30,735.72	
0.00	
5,468.24	
7,482.56	
465,575.97	
1,133,922.94	
944,390.06	
8,952.06	
20,071.02	
40,641.00	
163,479.35	
77,333.07	
12,963.48	
17,106.61	
485,983.85	
9,803.98	
228,003.92	
586,802.85	
4,307,482.93	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3707	ADULT <40% EXP FEM AL	0.00	876.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		876.33		
3708	ADULT <40% EXP M&F
4	7,404.35	2,309.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,713.64		
3709	ADULT <40% EXP M&F 6	0.00	1,907.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,907.91		
3714	ADULT <40% EXP MALE	123,122.81	188,838.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		311,961.76		
3715	ADULT <40% EXP FEM AL	74,725.01	132,282.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,007.22		
3716	ADULT <40% EXP MALE	2,515,586.40	3,677,729.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,193,316.20		
3717	ADULT <40% EXP FEM AL	968,205.74	1,362,903.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,331,109.58		
3718	ADULT <40% EXP M&F
4	2,956,002.31	4,338,234.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,294,236.53		
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 FEM
AL	10.33	189.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.60		
3728	ADULT <40% EXP M&F 4	0.00	8.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.39		
SUBTOTAL:	7,744,670.65	11,216,407.14	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,961,077.79		

4413	SOBRA 100-133% M&F
6	39,529.77	67,885.29	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	26,846.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	23,956.84	54,121.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	90,912.54	148,853.76	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

107,415.06	
54,272.63	
78,078.61	
239,766.30	

4518	BC PATIENT FEMALE 4 5	170.89	723.32	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	723.32	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

894.21	
0.00	
894.21	

8700	SSI DISABLED FREEDO M	6,312.17	11,013.30	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	4,075.74	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	233.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,467.00	15,322.37	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17,325.47	
8,019.82	
444.08	
25,789.37	

3907	NEWLY ELIGIBLE FEMA L	0.00	722.57	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	-39.17	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	4,858.55	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	13,216.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	89,081.61	238,959.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	118,147.17	159,149.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	315,084.15	487,633.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	534,024.5	6	904,500.22	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
722.57	
63.52	
8,328.05	
21,355.56	
328,041.36	
277,296.56	
802,717.16	
0.00	
0.00	
1,438,524.78	

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	21,342,374.81	32,596,885.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,939,260.78		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 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-MEDIC
AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP 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	

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	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

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	

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	
3928	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	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	

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

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 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	56.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.79		
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	10,408.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,480.10		
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	369.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		369.10		
1015	TANF 14-20 FEMALE N O	573.09	87.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		660.21		
1016	TANF 21-44 MALE NON-	4,620.19	11,482.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,103.15		
1017	TANF 21-44 FEMALE N O	5,557.26	8,987.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,545.03		
1018	TANF 45-64 M & F NON	3,997.36	1,945.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,942.80		
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	816.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		836.81		
2110	SSI AGED NON-MEDIC
AR	194.04	5,039.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,233.50		
2120	SSI AGED WITH QMB	198.85	222.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		421.14		
2200	SSI DISABLED WITH M E	1,747.14	659.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,406.33		
2210	SSI DISABLED NON-ME
D	2,333.96	7,354.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,688.10		
2220	SSI DISABLED WITH Q M	297.04	2,509.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,806.62		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	78,114.20	48,745.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,859.73		
4312	SOBRA CHILD 01-05 M	6,421.00	13,238.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,659.64		
4313	SOBRA CHILD 06-13 M	-41.10	2,379.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,338.16		
4314	SOBRA CHILD 14-20 MA	1,411.35	9,954.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,366.31		
4315	SOBRA CHILD 14-20 FE	1,217.15	12,831.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,048.60		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	2,910.15	4,926.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,836.22		
5017	SOBRA PREG 21-44 FE
M	24,515.25	41,701.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,216.94		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	136,360.8	1	183,715.98	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320,076.79		

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	57,796.91	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	3,255.10	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	39,914.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP 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	
2,509.47	
67,215.13	
5,049.68	
74,757.43	
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	56.79	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	47.76	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	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	391.79	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	4,052.54	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	8,941.52	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	4,062.15	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	-193.98	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	142.96	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	55.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	20.90	5.72	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	34.56	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	344.65	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	15.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,614.09	17,957.09	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
56.79	
47.76	
0.00	
0.00	
0.00	
391.79	
4,405.47	
17,080.24	
5,948.25	
0.00	
113.73	
0.00	
3.33	
142.96	
1,383.81	
0.00	
26.62	
1,385.50	
437.43	
147.50	
31,571.18	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	1,416.26	5,826.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,242.67		
3715	ADULT <40% EXP FEM AL	7,077.31	8,750.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,828.25		
3716	ADULT <40% EXP MALE	173,548.28	57,099.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230,647.97		
3717	ADULT <40% EXP FEM AL	49,254.97	14,283.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,538.48		
3718	ADULT <40% EXP M&F
4	69,464.99	248,049.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		317,514.43		
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 FEM
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	434,976.63	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785,102.88		

4413	SOBRA 100-133% M&F
6	12,662.89	387.76	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	2,418.52	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	39.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,711.80	2,846.03	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13,050.65	
2,418.52	
88.66	
15,557.83	

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	82.50	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	28.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7.46	111.46	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
89.96	
28.96	
118.92	

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	4,199.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	13,827.40	14,575.05	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	9,381.21	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	61,423.60	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	
3928	NEWLY ELIGIBLE M&F
4	0.00	1,326.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,205.93	90,905.50	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	
4,781.16	
28,402.45	
11,317.87	
65,207.45	
75.90	
1,326.60	
111,111.43	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	533,026.34	730,512.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,263,539.03		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	52,876.69	100,586.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,463.22		
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	100,586.5	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,463.22		

153,463.22

52,876.69	100,586.53	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 August 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 August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	567,786.98	563,949.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,131,736.96		
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:	567,855.21	563,949.9	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,131,805.19		

1,131,805.19

567,855.21	563,949.98	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 August 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	83.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131.36		
1007	TANF 21-44 FEMALE WI	42.01	47.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89.64		
1008	TANF 45-64 M & F WIT	31.16	1,654.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,685.26		
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	46,015.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,396.79		
1012	TANF 01-05 M & F NON	1,241.35	3,591.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,833.00		
1013	TANF 06-13 M & F NON	314.23	2,102.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,416.49		
1014	TANF 14-20 MALE NON-	38.53	432.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		470.53		
1015	TANF 14-20 FEMALE N O	12,353.72	3,904.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,258.55		
1016	TANF 21-44 MALE NON-	23,430.69	48,589.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,019.90		
1017	TANF 21-44 FEMALE N O	79,886.54	131,922.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,808.62		
1018	TANF 45-64 M & F NON	136,628.18	56,996.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,624.65		
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	600.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,396.26		
1028	TANF 45-64 M & F WIT	56.79	12.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.94		
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	13,710.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,213.08		
2110	SSI AGED NON-MEDIC
AR	219.89	319.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539.25		
2120	SSI AGED WITH QMB	9,934.00	10,515.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,449.93		
2200	SSI DISABLED WITH M E	11,324.05	4,288.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,612.54		
2210	SSI DISABLED NON-ME
D	182,500.45	323,971.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		506,471.47		
2220	SSI DISABLED WITH Q M	30,030.58	44,986.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,017.19		
2300	SSI BLIND WITH MEDIC	1.85	178.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180.67		
2310	SSI BLIND NON-MEDIC A	4,516.76	93.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,610.21		
2320	SSI BLIND WITH QMB	49.61	47.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97.37		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	75,672.38	65,028.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,700.85		
4312	SOBRA CHILD 01-05 M	43,251.91	54,223.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,475.48		
4313	SOBRA CHILD 06-13 M	42,039.46	56,165.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,204.87		
4314	SOBRA CHILD 14-20 MA	6,212.97	32,821.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,034.47		
4315	SOBRA CHILD 14-20 FE	10,402.30	17,426.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,829.21		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	15,458.71	10,474.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,933.57		
5017	SOBRA PREG 21-44 FE
M	106,253.24	114,253.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,506.74		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	905,618.1	3	1,044,458.76	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,950,076.89		

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	46.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	757.13	715.40	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	24,216.12	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	49,461.83	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	94,522.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP 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	
694.08	
1,472.53	
79,622.72	
63,170.95	
149,457.90	
0.00	
0.00	

1106	TANF EXPANDED 21-44	101.55	51.94	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	47.76	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	2,111.56	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	195.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	92.78	92.78	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	13,240.01	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	53,578.48	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	49,372.70	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	746.05	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	104.15	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	2,792.24	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	1,823.60	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	39.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	10,889.50	18,004.60	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	26.89	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	9,936.80	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	18,311.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	126,223.3	170,476.62	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
153.49	
197.41	
3,933.85	
260.65	
0.00	
0.00	
185.56	
27,239.04	
106,501.52	
76,211.18	
0.00	
1,477.30	
194.95	
4,488.87	
2,223.78	
21.18	
0.00	
28,894.10	
390.28	
19,519.06	
24,807.77	
296,699.99	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3708	ADULT <40% EXP M&F
4	0.00	251.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251.43		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	5,054.92	1,348.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,403.50		
3715	ADULT <40% EXP FEM AL	7,028.30	10,581.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,609.73		
3716	ADULT <40% EXP MALE	122,279.73	208,617.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		330,897.50		
3717	ADULT <40% EXP FEM AL	134,244.24	121,382.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,627.12		
3718	ADULT <40% EXP M&F
4	154,155.14	597,088.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		751,243.33		
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 FEM
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	1,108,232.75	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,656,450.79		

4413	SOBRA 100-133% M&F
6	1,298.14	8,078.00	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	1,315.60	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	2,145.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,009.55	11,539.03	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,376.14	
1,570.64	
7,601.80	
18,548.58	

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	1,239.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	683.45	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	1,922.86	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,703.67	
683.45	
891.80	
7,278.92	

3907	NEWLY ELIGIBLE FEMA L	995.90	36.90	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	138.24	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	15,403.34	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	14,423.43	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	39,550.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	51,213.51	69,552.53	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,032.80	
0.00	
138.24	
3,267.85	
33,576.23	
34,987.77	
47,763.15	
0.00	
0.00	
120,766.04	

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	1,643,638.66	2,406,182.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,049,821.21		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending August 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	2,135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,270.00		
2100	SSI AGED WITH MEDIC A	156,640.61	282,159.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		438,800.18		
2110	SSI AGED NON-MEDIC
AR	14,737.61	47,435.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,172.98		
2120	SSI AGED WITH QMB	223,757.27	338,596.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		562,353.51		
2200	SSI DISABLED WITH M E	57,027.10	75,836.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,863.31		
2210	SSI DISABLED NON-ME
D	770,298.39	1,132,850.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,903,149.09		
2220	SSI DISABLED WITH Q M	100,994.37	138,713.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239,707.83		
2310	SSI BLIND NON-MEDIC
A	5,515.00	17,097.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,612.00		
2320	SSI BLIND WITH QMB	292.83	62.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355.70		
SUBTOTAL:	1,331,398.18	2,034,886.42	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,366,284.60		

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

3,366,284.60

1,331,398.18	2,034,886.42	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 August 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	3,025,153.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,449,658.77		
2110	SSI AGED NON-MEDIC
AR	107,506.07	133,529.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241,035.41		
2120	SSI AGED WITH QMB	3,259,048.04	4,237,115.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,496,163.90		
2200	SSI DISABLED WITH M E	536,288.21	705,290.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,241,578.60		
2210	SSI DISABLED NON-ME
D	2,054,430.35	2,957,586.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,012,016.44		
2220	SSI DISABLED WITH Q M	742,283.47	1,007,324.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,749,607.59		
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	2,107.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,162.16		
SUBTOTAL:	9,124,116.71	12,068,106.16	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,192,222.87		

8720	SSI DISABLED FREEDO M	3,044.16	3,805.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,044.16	3,805.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,849.36

6,849.36

TOTAL:	9,127,160.87	12,071,911.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,199,072.23		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 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	109,726.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213,545.29		
2110	SSI AGED NON-MEDIC
AR	6,828.03	5,254.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,082.12		
2120	SSI AGED WITH QMB	1,251.92	1,221.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,473.84		
2200	SSI DISABLED WITH M E	5,422.20	5,346.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,768.91		
2210	SSI DISABLED NON-ME
D	42,117.76	62,467.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,585.36		
2220	SSI DISABLED WITH Q M	2,533.82	5,296.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,830.55		
2310	SSI BLIND NON-MEDIC
A	0.00	177.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177.14		
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	189,491.09	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		351,463.21		

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

351,463.21

161,972.12	189,491.09	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 August 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	41,921.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,002.71		
2110	SSI AGED NON-MEDIC
AR	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	21,996.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,359.86		
2200	SSI DISABLED WITH M E	3,122.47	43,118.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,240.84		
2210	SSI DISABLED NON-ME
D	68,539.40	51,307.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,846.40		
2220	SSI DISABLED WITH Q M	3,617.33	8,057.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,674.85		
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	166,401.36	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264,539.72		

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	166,401.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264,539.72		

KidsCare - CAPITATION AMOUNTS
For The Period Ending August 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	132,207.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,458.80		
6012	KIDS 1-5 M & F NON-M	930,841.31	933,412.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,864,253.72		
6013	KIDS 6-13 M & F NON-	1,769,582.94	1,750,229.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,519,812.43		
6014	KIDS 14-19 MALE NON-	645,960.88	629,453.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,275,414.55		
6015	KIDS 14-19 FEMALE NO	953,492.75	920,800.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,874,292.75		
9960	KIDSCARE KICK PAYM EN	6,279.40	12,623.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,903.04		
SUBTOTAL:	4,425,408.67	4,378,726.62	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,804,135.29		

8,804,135.29

4,425,408.67	4,378,726.62	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 August 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	266.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		529.00		
6012	KIDS 1-5 M & F NON-M	7,628.26	7,790.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,419.09		
6013	KIDS 6-13 M & F NON-	13,979.68	14,154.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,134.01		
6014	KIDS 14-19 MALE NON-	3,647.77	3,669.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,317.37		
6015	KIDS 14-19 FEMALE NO	3,569.17	3,563.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,132.73		
9960	KIDSCARE KICK PAYM EN	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	29,087.95	29,447.25	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,535.20		

TOTAL:	29,087.95	29,447.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,535.20		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending August 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	11,228.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,392.01		
6012	KIDS 1-5 M & F NON-M	315,349.20	320,984.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		636,333.91		
6013	KIDS 6-13 M & F NON-	574,129.11	581,246.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,155,375.55		
6014	KIDS 14-19 MALE NON-	171,357.69	172,136.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343,493.74		
6015	KIDS 14-19 FEMALE NO	167,709.13	166,734.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334,443.33		
SUBTOTAL:	1,239,709.04	1,252,329.50	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,492,038.54		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

2,492,038.54

TOTAL:

1,239,709.04

1,252,329.50

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending August 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	332.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		688.00		
6012	KIDS 1-5 M & F NON-M	11,533.00	10,639.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,172.00		
6013	KIDS 6-13 M & F NON-	21,426.00	19,863.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,289.00		
6014	KIDS 14-19 MALE NON-	5,386.00	5,737.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,123.00		
6015	KIDS 14-19 FEMALE NO	5,353.00	5,582.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,935.00		
SUBTOTAL:	44,054.00	42,153.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,207.00		

TOTAL:	44,054.00	42,153.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,207.00		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending August 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	1,794.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,588.84		
6013	KIDS 6-13 M & F NON-	2,990.70	1,794.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,785.12		
6014	KIDS 14-19 MALE NON-	1,196.28	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,794.42		
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	4,186.9	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,766.52		

10,766.52

6,579.54	4,186.98	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 August 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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
6013	KIDS 6-13 M & F NON-	5.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
6014	KIDS 14-19 MALE NON-	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
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	7.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		

TOTAL:	11.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		

KidsCare - FEE FOR SERVICE
For The Period Ending August 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	914.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,076.54		
6012	KIDS 1-5 M & F NON-M	10,139.27	14,689.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,828.66		
6013	KIDS 6-13 M & F NON-	82,808.67	78,365.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,174.30		
6014	KIDS 14-19 MALE NON-	13,580.70	16,404.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,985.38		
6015	KIDS 14-19 FEMALE NO	120,789.67	12,782.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133,572.64		
SUBTOTAL:	227,480.8	0	123,156.72	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350,637.52		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

350,637.52

TOTAL:

227,480.80

123,156.72

KidsCare - REINSURANCE
For The Period Ending August 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	103,124.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,970.30		
6013	KIDS 6-13 M & F NON-	155,090.01	41,927.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197,017.77		
6014	KIDS 14-19 MALE NON-	69,646.87	50,443.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,090.62		
6015	KIDS 14-19 FEMALE NO	5,374.05	4,195.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,569.89		
SUBTOTAL:	238,956.8	1	199,691.77	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		438,648.58		

TOTAL:	238,956.81	199,691.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		438,648.58		

110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending August 31, 2018	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	
1000	TANF WITH MEDICARE	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.00	
1010	TANF NON-MEDICARE	657.19	640.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,297.47	
1020	TANF WITH QMB	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.00	
2100	SSI AGED WITH MEDICA	221.85	222.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	443.99	
2110	SSI AGED NON-MEDICAR	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20.00	
2120	SSI AGED WITH QMB	337.61	352.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	690.36	
2200	SSI DISABLED WITH ME	2,046.96	2,037.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,084.23	
2210	SSI DISABLED NON-MED	24,762.26	24,814.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49,576.56	
2220	SSI DISABLED WITH QM	4,454.67	4,495.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,950.49	
2300	SSI BLIND WITH MEDIC	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.00	
2310	SSI BLIND NON-MEDICA	51.00	47.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	98.99	
2320	SSI BLIND WITH QMB	16.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	32.00	
8700	SSI DISABLED FREEDOM	14.00	13.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.99	
8710	SSI DISABLED FREEDOM	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
SUBTOTAL:	32,598.54	32,676.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65,275.08	
TOTAL:	32,598.54	32,676.54	0.00	0.	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	65,275.08	

00

00

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

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	402,320.34	398,481.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	800,801.70	
EPD	97,705,021.68	98,655,671.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	196,360,692.77	
TOTAL AHCCCS LTC	98,107,342.02	99,054,152.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	197,161,494.47	
DES/DD	126,960,382.68	127,186,833.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	254,147,215.90	
TOTAL DES LTC	126,960,382.68	127,186,833.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	254,147,215.90	
TOTAL LTC - CAP	225,067,724.70	226,240,985.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	451,308,710.37	

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	14,462,690.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,181,359.76	
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	14,462,690.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	25,181,359.76	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	4,537,399.02	2,920,225.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,457,624.54	
DES/DD	909,074.28	494,787.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,403,862.10	
TOTAL DES LTC	909,074.28	494,787.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,403,862.10	
TOTAL LTC - REIN	5,446,473.30	3,415,013.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,861,486.64	

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	4,149,308.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,290,756.00	

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.

139

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

010115	CRS FULLY INTEGRATED PLAN - CAP	15,749,747.00	15,864,326.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,614,073.91	
010145	CRS ACUTE SEMI INTEGRATED - CAP	188,385.93	185,623.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	374,009.06	
999125	CRS SEMI INTEGRATED PLAN - CAP	6,356,658.85	6,362,828.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,719,487.34	
999135	CRS ONLY PLAN - CAP	646,990.35	643,772.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,290,762.60	
Subtotal	22,941,782.13	23,056,550.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,998,332.91	

999155	CRS REINSURANCE ONLY	6,201,695.95	2,319,668.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,521,364.02	
Subtotal	6,201,695.95	2,319,668.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,521,364.02	

29,143,478.08	25,376,218.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	54,519,696.93	

GRAND TOTAL

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

010115	CRS FULLY INTEGRATED PLAN - MM	15,509.20	15,640.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,149.86	
010145	CRS ACUTE SEMI INTEGRATED - MM	196.02	192.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	388.11	
999125	CRS SEMI INTEGRATED PLAN - MM	6,593.46	6,597.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,190.76	
999135	CRS ONLY PLAN - MM	1,070.31	1,068.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,138.89	
Subtotal	23,368.99	23,498.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,867.62	

23,368.99	23,498.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46,867.62	

GRAND TOTAL

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

010715	HEALTH CHOICE INTEGRATED - CAP	8,385,057.71	8,384,767.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,769,824.72	
010735	CENPATICO INTEGRATED - CAP	22,003,091.75	22,099,206.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,102,297.94	
010795	MERCY MARICOPA INTEGRATED - CAP	52,370,328.29	52,671,346.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105,041,674.66	
078999	MERCY MARICOPA INTEGRATED - CAP	-6,767.58	-6,767.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13,535.16	
Subtotal	82,751,710.17	83,148,551.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165,900,262.16	

82,751,710.17	83,148,551.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	165,900,262.16	

GRAND TOTAL

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

010715	HEALTH CHOICE INTEGRATED - MM	5,809.39	5,846.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,655.60	
010735	CENPATICO INTEGRATED - MM	13,447.32	13,649.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27,096.69	
010795	MERCY MARICOPA INTEGRATED - MM	21,992.24	22,279.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	44,271.72	
078999	MERCY MARICOPA INTEGRATED - MM	-3.00	-3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-6.00	
Subtotal	41,245.95	41,772.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83,018.01	

41,245.95	41,772.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83,018.01	

GRAND TOTAL