HCCCS

Arizona Health Care Cost Containment System

Douglas A. Ducey, Governor Jami Snyder, Director

..••...•....•...••..•••••..•.........•..••..••.••.•••.••.••.•..........•...........•.................•...••........••.....

June 25, 2019

The Honorable Karen Fann Arizona State Senate
1700 W. Washington
Phoenix, AZ 85007

The Honorable Russell "Rusty" Bowers Speaker of the House
Arizona House of Representatives 1700 W. Washington
Phoenix, AZ 85007

SUBJECT: FY 2019 Appropriation Status Report for the Period Ended May 31, 2019

Dear President Fann and Speaker Bowers:

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 May 31, 2019.

Status Summary - Based on expenditure patterns through May and caseload  declines, AHCCCS is projecting a potential surplus of $399.1 million Total Fund ($36.6 million General Fund, $44.9 million Hospital Assessment expenditure authority, $9.4 million CHIP Fund, and
$308.2 million Federal and other expenditure authority).

HB2747, Section 102, includes a FY19 General Fund appropriation reduction of $36,564,900 which eliminates the projected General Fund surplus.

AHCCCS will be utilizing the other surplus funding to administratively adjust qualifying expenditures with dates of service from FY 2019.

Volatility in caseload growth and final tobacco revenue collections has the potential to affect the projected surplus amounts this fiscal year.

AHCCCS administratively adjusted $311.5 million Total Fund of Fiscal Year 2019 date of service expenditures back to the Fiscal Year 2018 appropriation in December 2018. These administrative adjustments have been taken into account in projecting sufficient balances for FY 2019. The line item detail for these transactions is included in Note 5 of this report.

Enrollment Update- May 2019 enrollment is 1,876,881 members, a 227 member increase over the prior month. Enrollment for June 2019 decreased to 1,872,169 members, a 4,712 member change.

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

The Honorable Karen Fann
The Honorable Russell "Rusty" Bowers June 25, 2019
Page 2

Major June 2019 changes by eligibility category include: 1931 for Families and Children/SOBRA - decrease of 4,122; Supplemental Security Income - increase of 199; Prop 204 Restoration- decrease of 328; Adult Expansion- decrease of 663; Medicare Cost Sharing.:_ increase of 370; KidsCare -increase of2; and Federal Emergency Services-decrease of 288.

Tobacco Funds Revenue Update - Tobacco tax collections through May 2019 are $5.4 million 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) 417-4458 or Jeffery Tegen at (602) 417-4705.

Sincerely,
(J-4/4/4/"
Jami Snyder
Director

Enclosure

cc: The Honorable Douglas A. Ducey, Governor
The Honorable, David Gowan, Chairman, Senate Appropriations Committee The Honorable Regina E. Cobb, Chairman, House Appropriations Committee
The Honorable Kate Brophy McGee, Chairman, Senate Health and Human Services Committee
The Honorable Nancy Barto, Chairman, House Health and Human Services 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 May 31, 2019

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	11

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending May 31, 2019
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	$	90,785,300		$	95,988,000		$	74,812,371		$	21,175,629		$	90,785,300		$	-		
AHCCCS Prop 204 Administration	23,171,100		12,591,400		15,783,019		(3,191,619)		23,171,100		-		
DES Eligibility	91,874,500		82,077,400		76,874,553		5,202,847		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		40,890,400		29,955,513		10,934,887		44,358,700		-		
ADOA Data Center	19,325,800		17,715,000		10,527,392		7,187,608		17,495,800		1,830,000		
School District Suicide Prevention Coordinator	100,000		72,700		54,521		18,179		100,000		-		
TOTAL ADMINISTRATION	 	269,615,400		 	249,334,900		 	208,007,369		 	41,327,531		 	267,785,400		 	1,830,000		

Traditional Medicaid Services	5,349,876,000	4,909,371,400	4,755,155,563	154,215,837	5,162,342,300	187,533,700	
Proposition 204 Services	3,953,396,600	3,546,947,800	3,524,337,807	22,609,993	3,850,953,000	102,443,600	
ACA Adult Expansion	525,675,000	519,398,400	424,713,913	94,684,487	464,620,300	61,054,700	
KidsCare Services	81,846,900	73,634,600	64,862,816	8,771,784	72,345,800	9,501,100	
ALTCS Services	1,630,757,300	1,480,692,500	1,466,159,555	14,532,945	1,616,178,100	14,579,200	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	28,612,400	28,612,400	28,612,316	84	28,612,400	-	
Voluntary Political Subdivision Programs	356,848,000	272,610,200	272,610,248	(48)	356,848,000	-	
CMDP	199,914,500	182,849,000	162,359,543	20,489,457	177,717,500	22,197,000	
Behavioral Health Services - in Schools	9,943,700	7,457,700	9,943,700	(2,486,000)	9,943,700	-	
Targeted Investment Program	70,000,000	70,000,000	65,903,463	4,096,537	70,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	69,927,045	75,604,365	(5,677,320)	77,646,900	-	
Supported Housing	5,324,800	4,330,700	4,724,800	(394,100)	5,324,800	-	
Crisis Services	16,391,300	15,024,900	16,306,300	(1,281,400)	16,391,300	-	
TOTAL PROGRAMMATIC	 	12,311,320,500		 	11,180,856,645		 	10,871,294,390		 	309,562,255		 	11,914,011,200		 	397,309,300	

TOTAL EXPENDITURES

  $	12,580,935,900

$ 11,430,191,545

$ 11,079,301,759

$	350,889,786

$ 12,181,796,600

$	399,139,300

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	$	59,452,200	$	49,143,955	10,308,245	$	59,683,100	$	716,400	
Proposition 204 - Administrative Expenditures	21,685,600	19,851,600	11,671,646	8,179,954	21,685,600	-	

Programmatic Expenditures							
Traditional Medicaid Services	1,217,983,500	1,123,125,100	1,115,581,653	7,543,447	1,188,881,100	29,102,400	
Proposition 204 Services	102,608,900	95,030,000	94,054,722	975,278	102,608,900	-	
ACA Adult Expansion	6,461,300	5,890,200	5,922,858	(32,658)	6,461,300	-	
KidsCare Services	-	-	5,048	(5,048)	-	-	
ALTCS Services	198,722,900	181,954,900	182,162,658	(207,758)	198,722,900	-	
DSH and Rural Hospitals	8,905,100	8,638,000	8,638,000	-	8,905,100	-	
CMDP	60,213,900	55,070,300	48,934,055	6,136,245	53,467,800	6,746,100	
Behavior Health Services - in Schools	3,000,000	2,250,000	3,000,000	(750,000)	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	69,927,045	75,604,365	(5,677,320)	77,646,900	-	
Supported Housing	5,324,800	4,330,700	4,724,800	(394,100)	5,324,800	-	
Crisis Services	 	14,141,100	 	12,962,400	 	14,056,100	 	(1,093,700)	 	14,141,100	 	- 	
TOTAL GF EXPENDITURES	1,777,093,500	1,638,482,445	1,613,499,862	24,982,583	1,740,528,600	36,564,900	

FEDERAL		
Administrative Expenditures	141,025,200	135,756,900	112,781,445	22,975,455	139,911,600	1,113,600	
Proposition 204 - Administrative Expenditures	42,027,100	30,167,700	30,866,051	(698,351)	42,027,100	-	
Programmatic Expenditures							
Traditional Medicaid Services	3,257,608,700	3,070,957,400	2,884,797,744	186,159,656	3,099,208,600	158,400,100	
Proposition 204 Services	3,424,557,600	3,139,825,800	3,079,461,811	60,363,989	3,363,929,400	60,628,200	
ACA Adult Expansion	490,669,800	487,500,200	394,840,615	92,659,585	432,664,600	58,005,200	
KidsCare Services	69,695,600	62,678,000	57,032,385	5,645,615	64,520,418.08	5,175,182	
ALTCS Services and Nursing Facility Assessment	1,010,134,200	903,606,100	908,565,912	(4,959,812)	997,134,400	12,999,800	
DSH and Rural Hospitals	24,794,400	19,974,400	19,974,316	84	24,794,400	-	
CMDP	139,700,600	127,778,700	113,425,489	14,353,211	124,249,700	15,450,900	
Behavior Health Services - in Schools	6,943,700	5,207,700	6,943,700	(1,736,000)	6,943,700	-	
Targeted Investment Program	48,226,900	48,226,900	49,945,588	(1,718,688)	48,226,900	-	
Voluntary Political Subdivision Programs - See Note 5	 	248,603,700	 	189,158,000	 	189,158,017	 	(17)	 	248,603,700	 	- 	
TOTAL FEDERAL EXPENDITURES	8,903,987,500	8,220,837,800	7,847,793,072	373,044,727	8,592,214,518	311,772,982	

COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,756,200	3,462,500	3,139,935	322,565	3,756,200	-	
Programmatic Expenditures							
Traditional Medicaid Services Acute Care	46,512,900	42,920,000	42,920,000	-	46,512,900	-	
ALTCS Services	 	268,554,800	 	245,439,100	 	245,312,413	 	126,687	 	268,554,800	 	- 	
TOTAL COUNTY EXPENDITURES	318,823,900	291,821,600	291,372,348	449,252	318,823,900	-	

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

TOBACCO FUNDS		
Programmatic Expenditures							
Traditional Medicaid Services - Medically Needy	68,040,500	62,784,900	57,492,056	5,292,844	68,040,500	-	
Proposition 204 Services - Emergency Health Services	17,966,100	16,637,700	15,790,795	846,905	17,966,100	-	
Proposition 204 Services - Proposition 204 Protection	37,728,900	34,939,100	33,160,670	1,778,430	37,728,900	-	
Proposition 204 Services - ATLSF	 	87,000,000	 	87,000,000	 	87,000,000	 	- 	 	87,000,000	 	- 	
TOTAL TOBACCO EXPENDITURES	210,735,500	201,361,700	193,443,521	7,918,179	210,735,500	-	

OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program	721,800	644,000	404,337	239,663	721,800	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	10,260,700	9,468,100	10,260,700	(792,600)	10,260,700	-	
Acute Care - Prescription Drug Rebate Program State Match	140,158,600	129,332,600	128,478,717	853,883	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	609,085,200	470,603,500	514,085,200	(43,481,700)	609,085,200	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	6,939,700	6,946,867	(7,167)	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	33,407,700	32,189,199	1,218,501	34,842,600	1,579,400	
Proposition 204 Services - Hospital Assessment	281,603,200	171,726,100	212,937,909	(41,211,809)	239,787,800	41,815,400	
Proposition 204 Services - IGA Fund	1,931,900	1,789,100	1,931,900	(142,800)	1,931,900	-	
ACA Adult Expansion - Hospital Assessment	28,420,100	25,895,100	23,826,640	2,068,460	25,370,600	3,049,500	
ACA Adult Expansion - IGA Fund	123,800	112,900	123,800	(10,900)	123,800	-	
Traditional Medicaid Services - TPL	194,700	179,800	1,450,562	(1,270,762)	194,700	-	
ALTCS Services - TPL	-	-	1,673,092	(1,673,092)	-	-	
ALTCS Services - Nursing Facility Assessment	109,345,000	109,345,000	89,309,413	20,035,587	109,345,000	-	
Targeted Investment Program	21,773,100	21,773,100	15,957,875	5,815,225	21,773,100	-	
KidsCare Services Premiums	12,151,300	10,956,600	7,825,382	3,131,218	7,825,382	4,325,918	
Freedom to Work Premiums	31,200	-	88,932	(88,932)	-	31,200	
Crisis Services - Substance Abuse Services Fund	2,250,200	2,062,500	2,250,200	(187,700)	2,250,200	-	
Voluntary Political Subdivision Programs - See Note 5	 	108,244,300	 	83,452,200	 	83,452,231	 	(31)	 	108,244,300	 	- 	
TOTAL OTHER EXPENDITURES	1,370,295,500	1,077,688,000	1,133,192,955	(55,504,955)	1,319,494,082	50,801,400	

TOTAL		
Administrative Expenditures	269,615,400	249,334,900	208,007,369	41,327,531	267,785,400	1,830,000	
Acute Care	10,680,563,200	9,700,164,145	9,405,134,835	295,029,310	10,297,833,100	382,730,100	
Long Term Care	 	1,630,757,300	 	1,480,692,500	 	1,466,159,555	 	14,532,945	 	1,616,178,100	 	14,579,200	
TOTAL EXPENDITURES	  $	12,580,935,900	  $	11,430,191,545	  $	11,079,301,759	  $	350,889,786	  $	12,181,796,600	  $	399,139,300	

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

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,296,749,400	$	1,199,355,500	$	1,176,363,608	
Proposition 204 Services & Administrative	124,294,500	114,881,600	107,658,268	
KidsCare Services	-	-	5,048	
ALTCS Services	198,722,900	181,954,900	182,162,658	
Behavioral Health Traditional Medicaid Services	 	157,326,700	 	142,290,445	 	143,319,320	
TOTAL	1,777,093,500	1,638,482,445	1,609,508,903	

FEDERAL:
Acute & Administrative	7,684,457,100	7,126,775,000	6,916,794,651	
KidsCare Services	69,695,600	62,678,000	62,263,958	
ALTCS Services	1,010,134,200	903,606,100	1,005,703,053	
Behavioral Health Traditional Medicaid Services	 	139,700,600	 	127,778,700	 	120,414,739	
TOTAL	8,903,987,500	8,220,837,800	8,105,176,401	

COUNTY:				
Acute & Administrative	50,269,100		46,382,500		44,704,581	
ALTCS Services	 	268,554,800		 	245,439,100		 	246,175,215	
TOTAL	318,823,900		291,821,600		290,879,796	

TOBACCO FUNDS:						
Traditional Medicaid Services	68,040,500		62,784,900		57,492,056	
Proposition 204 Services	 	142,695,000		 	138,576,800		 	135,951,465	
TOTAL	210,735,500		201,361,700		193,443,521	

OTHER:

Administrative	721,800	644,000	343,437	
Traditional Medicaid Services - IGA Fund	10,260,700	9,468,100		
Acute Care - Prescription Drug Rebate Program	749,243,800	599,936,100	642,563,917	
Long Term Care - Prescription Drug Rebate Program	44,000,400	40,347,400	39,136,066	
Hospital Assessment	312,079,000	199,523,200	286,189,785	
ALTCS - Nursing Facility Assessment	109,345,000	109,345,000	268,055	
Acute TPL - Note 1	194,700	179,800	1,450,562	
LTC TPL - Note 1	-	-	1,673,092	
KidsCare TPL - Note 1	-	-	(157.00)	
Member Premiums - CHIP	12,151,300	10,956,600	7,825,382	
Member Premiums - Freedom to Work	31,200	-	88,932	
Targeted Investment Program	21,773,100	21,773,100	71,677,505	
Behavioral Health Traditional Medicaid Services	2,250,200	2,062,500	1,645,307	
Voluntary Political Subdivision - State Match	 	108,244,300	 	83,452,200	 	180,282,918	
TOTAL	1,370,295,500	1,077,688,000	1,233,144,801	

TOTAL REVENUE

$	12,580,935,900

$	11,430,191,545

$	11,432,153,422

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2019 APPROPRIATION STATUS REPORT
For the Period Ending May 31, 2019	
Note 1:	Third Party Liability Collections:	May 2019		May 2018		July 1, 2018		July 1, 2017	
	Gross Collections:					May 31, 2019		May 31, 2018	
	Acute	$	1,672,137		$	2,789,498		$	14,711,312		$	10,113,645	
	LTC	1,029,741		1,241,252		7,444,588		5,300,732	
	KidsCare	3,456		327		12,108		8,142	
	Total TPL Collections	  $	2,705,334		$	4,031,077		$	22,168,008		$	15,422,519	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	121,874		$	243,822		$	1,450,562		$	966,350		
LTC	194,416		318,508		1,673,092		1,199,705		
KidsCare	(145)		(13)		(157)		1,144		
Total Expenditure Offsets	  $	316,145		$	562,317		$	3,123,497		$	2,167,199		

FY 19 Total		
Note 2:	Authorized Positions	1,188.0		
	Actual Positions as of May 31, 2019	1,125.0		

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2018	$	3,749,445	
	Revenues	8,045,198	
	Transfers-In	 	681,704	
	Total Revenues	 	8,726,902	
	Expenditures	7,434,424	
	Transfers-out	 	1,483,453	
	Total Expenditures	 	8,917,877	
	Ending Balance May 31, 2019	  $	3,558,469	

Of the $3,558,469 ending balance, $1,547,683 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through June 2019.

Note 4:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of May 31, 2019 Expenditures

State Match	Federal	Total

DSH Voluntary	$	2,104,000	$	2,564,949	$	4,668,949	
GME Voluntary	81,348,231	186,593,068	267,941,299	

Total Voluntary Political Subdivision Program Expenditure $

83,452,231	$

189,158,017 $

272,610,248

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

Note 5:

The following is a summary of $311,537,256 Total Fund ($66,698,799 General Fund, ALTCS EPD General Fund/County ALTCS contribution state match and $4,595,792 Hospital Assessment Fund) administrative adjustment transactions for medical service claims processed through December 2018 that either pay for or transfer expenditures with dates of service prior to June 30, 2018.

FY 2018 YTD May 31, 2019	
State Match	Expenditure	ALTCS	Total	
Funds	Authority Funds	Fund	Fund	

Traditional Medicaid Services	
$	60,319,599	
$	164,261,008	
$	-	$	224,580,607	
Proposition 204 Services	5,911,016	47,833,788	-	53,744,804	
ACA Adult Expansion	(121,765)	18,421,146	-	18,299,381	
KidsCare - Children Services	1,054	1,481,518	-	1,482,572	
Long Term Care	-	-	13,429,892	13,429,892

Total

$	66,109,904	$

231,997,460	$

13,429,892	$

311,537,256

Appropriation Status Report
Caseload and Expenditures by Rate Code

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL
TITLE XIX TRADITIONAL
CAPITATION - ACC	275,524,500	272,008,729	276,809,610	326,080,697	325,044,483	334,983,973	326,481,832	364,169,194	323,572,877	320,388,192	322,610,455	0	3,467,674,541	
CAPITATION - AIMHS	26,685	48,199	67,144	78,699	130,535	151,954	180,743	197,631	214,506	238,137	267,809	0	1,602,041	
CAPITATION - LTC	225,067,725	226,240,986	226,835,424	236,582,013	239,501,763	244,562,168	243,334,683	243,567,914	251,638,743	259,201,940	248,826,714	0	2,645,360,073	
MENTAL HEALTH - CHILD	27,816,533	28,188,900	27,931,339	-4,600	30	4,294,635	-359	-19,370	-507	-1,660	-1,246	0	88,203,696	
MENTAL HEALTH - ADULT	502,900	466,904	687,254	659,433	605,444	744,543	693,256	395,587	367,376	362,239	355,370	0	5,840,307	
MENTAL HEALTH - GENERAL	16,629,284	16,828,876	16,589,323	-13,276	-5,059	2,232,717	-4,435	28,849	-4,768	4,722	1,865	0	52,288,098	
MENTAL HEALTH - CMDP	10,235,716	9,847,115	9,728,922	11,246,338	11,129,736	12,680,473	10,942,948	10,940,793	10,968,160	11,013,060	10,995,018	0	119,728,279	
MENTAL HEALTH - DD	5,967,451	5,965,326	6,096,687	7,109,819	7,155,015	7,901,527	7,244,179	7,244,429	7,300,949	7,332,375	7,332,205	0	76,649,962	
MENTAL HEALTH - RBHA CRISIS	0	0	0	3,226,614	3,222,561	3,218,955	3,216,474	3,219,073	3,212,138	3,206,011	3,204,125	0	25,725,950	
CHILDREN'S REHAB SERVICES	6,969,555	6,972,507	6,944,670	0	0	0	0	0	0	0	0	0	20,886,732	
FEE FOR SERVICE - ACUTE	37,223,809	56,393,839	43,187,240	56,291,686	42,494,297	43,055,840	49,306,710	47,826,536	52,660,706	47,379,431	61,981,473	0	537,801,567	
FFS - PRIOR QUARTER COVERAGE	548,797	935,952	585,188	656,968	572,617	584,869	549,165	647,324	602,223	625,927	970,873	0	7,279,903	
EMERGENCY SERVICES - FEDERAL	3,335,843	4,756,919	4,377,237	4,882,480	3,540,413	4,189,613	4,816,959	3,768,095	3,723,666	3,857,671	4,559,735	0	45,808,630	
EMERGENCY SERVICES - STATE	0	0	0	0	0	0	0	0	0	0	-101	0	-101	
FFS MEDICAID IN PUBLIC SCHOOLS	611,834	428,512	301,831	1,200,820	497,412	863,810	1,464,366	688,320	1,373,602	1,235,103	1,691,449	0	10,357,060	
STATE ONLY TRBHA FFS	80,691	98,188	71,884	96,095	109,043	78,977	110,697	122,816	107,373	180,113	131,798	0	1,187,674	
QMB - FEE FOR SERVICE	620,783	664,537	463,147	924,871	574,857	644,258	699,029	603,351	615,253	215,823	78,916	0	6,104,824	
INPATIENT INMATES FFS	52,966	155,038	195,653	111,423	140,423	218,447	138,485	71,741	180,360	75,903	124,076	0	1,464,517	
FFS TRBHA FEE FOR SERVICE	11,384,976	15,543,554	10,745,311	13,427,436	11,010,384	9,381,131	11,923,244	10,697,815	10,565,726	11,217,950	11,886,555	0	127,784,081	
PINAL COUNTY INMATES FFS	293	2,674	0	286	0	0	0	0	0	0	0	0	3,253	
MARICOPA CTY INMATES FFS	13,281	19,856	4,726	33,624	10,319	22,718	56,153	2,600	7,562	11,246	33,674	0	215,759	
YAVAPAI COUNTY INMATES FFS	0	0	0	21	0	990	-617	0	83	0	0	0	476	
YUMA COUNTY INMATES FFS	106	0	0	-255	-11,786	0	-256	-10,790	0	0	0	0	-22,981	
MOHAVE COUNTY INMATES FFS	0	321	571	9,435	56	0	706	8,807	51	3,359	5,985	0	29,292	
PIMA COUNTY INMATES FFS	0	3,908	27,272	8,483	3,714	6,045	1,409	8,390	-422	814	11,227	0	70,839	
FEE FOR SERVICE - LTC	10,718,670	14,462,690	12,007,360	14,064,411	9,975,388	13,039,943	13,892,091	11,666,028	11,931,282	11,930,942	13,755,652	0	137,444,458	
LFFS - PRIOR QUARTER COVERAGE	48,459	125,358	71,487	124,413	31,804	61,556	52,523	83,898	65,516	115,465	165,287	0	945,765	
INPATIENT INMATES LTC FFS	21	24,970	2,152	0	339	6,090	0	0	0	0	0	0	33,572	
MARICOPA CTY INMATES LTC FFS	223	17,419	140	0	0	0	0	0	8	0	0	0	17,789	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,240,312	938,507	494,055	1,867,805	795,436	1,458,363	2,134,091	995,479	2,096,806	1,890,402	2,601,994	0	16,513,251	
REINSURANCE - ACC	16,535,933	13,118,083	13,915,132	17,568,464	14,281,312	18,674,599	6,679,988	9,545,044	11,533,269	9,247,973	10,385,395	0	141,485,192	
REINSURANCE - LTC	5,446,473	3,415,013	6,252,002	6,271,893	6,607,799	5,211,883	4,145,311	5,005,070	3,297,533	1,654,045	3,868,984	0	51,176,005	
SMIB - ACC	15,670,269	15,795,835	15,789,289	15,838,475	15,967,585	15,810,178	15,978,796	15,900,882	15,838,856	15,907,934	15,933,261	0	174,431,358	
HIB - ACC	661,993	690,553	695,416	716,897	710,722	721,239	730,096	737,973	745,131	779,049	753,096	0	7,942,165	
Q1	2,598,480	2,633,334	2,692,184	2,711,498	2,730,638	2,774,398	2,881,113	2,988,158	2,333,078	2,865,999	2,892,097	0	30,100,977	
SMIB - LTC	3,797,393	3,805,148	3,859,022	3,886,979	3,894,550	3,932,735	3,967,907	4,034,260	4,022,627	4,056,112	4,052,134	0	43,308,865	
HIB - LTC	344,054	344,160	336,374	342,029	348,571	346,799	347,072	356,385	364,312	441,863	381,330	0	3,952,950	
SUBTOTAL	679,676,008	700,941,908	687,765,045	726,001,974	701,070,402	731,855,425	711,964,359	745,492,283	719,334,071	715,438,142	729,857,205	0	7,849,396,821	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL
TITLE XIX PROP 204
CAPITATION - ACC	219,877,148	216,708,770	220,251,930	269,935,387	269,582,441	275,679,778	275,331,564	311,276,256	274,185,723	273,499,186	275,977,372	0	2,882,305,555	
CAPITATION - AIMHS	7,757	14,811	20,812	25,584	48,205	59,069	75,038	83,830	93,440	105,225	121,441	0	655,210	
MENTAL HEALTH - CHILD	838	859	635	0	0	428	0	-88	0	0	0	0	2,671	
MENTAL HEALTH - ADULT	794,879	777,940	1,232,066	879,872	685,654	726,127	671,346	555,687	392,547	397,845	439,504	0	7,553,467	
MENTAL HEALTH - GENERAL	30,005,430	30,460,612	30,083,108	-31,580	-27,213	4,341,579	-13,851	-21,579	-11,771	-11,461	-6,395	0	94,766,879	
MENTAL HEALTH - CMDP	529	1,172	977	1,278	1,524	1,033	1,524	1,242	1,732	1,799	0	0	12,813	
MENTAL HEALTH - RBHA CRISIS	0	0	0	3,531,104	3,543,573	3,566,763	3,580,054	3,601,555	3,608,447	3,612,631	3,610,946	0	28,655,073	
CHILDREN'S REHAB SERVICES	25,122	26,916	26,318	0	0	0	0	0	0	0	0	0	78,356	
FEE FOR SERVICE - ACUTE	28,102,125	39,247,407	30,522,216	41,170,212	30,478,639	32,281,218	37,086,249	34,178,856	38,091,283	34,259,577	47,103,921	0	392,521,703	
FFS - PRIOR QUARTER COVERAGE	1,195,983	1,530,976	1,195,872	1,317,163	1,136,685	1,198,586	1,285,352	1,349,217	1,373,517	1,415,494	1,800,191	0	14,799,037	
FFS - PRESUMPTIVE ELIGIBILITY	0	736	1,633	0	0	0	0	0	0	0	0	0	2,369	
EMERGENCY SERVICES - FEDERAL	2,496,925	4,177,483	3,319,066	3,932,782	3,101,685	2,962,984	3,928,761	2,922,397	2,893,425	3,419,194	4,281,096	0	37,435,799	
FFS MEDICAID IN PUBLIC SCHOOLS	278	849	529	295	185	416	1,848	1,157	1,352	874	1,579	0	9,361	
STATE ONLY TRBHA FFS	188,380	265,393	135,096	219,497	130,808	247,203	424,498	264,994	264,497	355,055	428,754	0	2,924,175	
FFS TRBHA FEE FOR SERVICE	6,471,241	7,963,744	6,508,987	7,734,689	5,743,198	5,785,600	6,202,330	6,082,248	6,197,375	7,112,117	7,041,362	0	72,842,891	
INPATIENT INMATES FFS	567,184	930,016	902,144	596,380	327,966	750,808	785,926	480,226	348,240	690,379	930,430	0	7,309,699	
MARICOPA CTY INMATES FFS	83,205	308,501	97,389	225,432	176,885	140,692	230,675	261,768	105,611	150,505	94,678	0	1,875,340	
YUMA COUNTY INMATES FFS	380	623	904	0	0	0	0	0	0	0	0	0	1,907	
YAVAPAI COUNTY INMATES FFS	0	0	-3,992	0	0	277	29,623	23	132	0	568	0	26,632	
PINAL COUNTY INMATES FFS	4,804	1,281	586	12,601	11,472	14,769	8,780	0	7,580	-408	13,855	0	75,320	
MOHAVE COUNTY INMATES FFS	0	3,281	1,438	9,147	7,224	6,225	13,652	7,010	6,061	5,029	26,231	0	85,298	
COCONINO COUNTY INMATES FFS	4,817	1,083	151	0	0	0	0	0	0	0	0	0	6,050	
PIMA COUNTY INMATES FFS	6,512	80,905	38,731	15,720	47,531	11,376	49,290	13,999	6,198	17,638	38,213	0	326,114	
REINSURANCE - ACC	6,285,338	5,286,543	6,103,124	7,531,043	7,554,100	6,447,539	5,347,303	3,794,469	4,092,725	6,303,583	5,230,502	0	63,976,269	
SMIB - ACC	6,797,934	6,805,330	6,869,643	6,869,072	6,905,176	6,892,457	6,957,494	7,035,028	7,045,935	7,096,302	7,071,679	0	76,346,049	
HIB - ACC	6,350	5,042	6,730	5,232	5,042	5,654	4,241	6,233	4,937	4,500	4,740	0	58,705	
SUBTOTAL	302,923,157	314,600,274	307,316,094	343,980,911	329,460,780	341,120,582	342,001,697	371,894,529	338,708,987	338,435,064	354,210,669	0	3,684,652,743	

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

CAPITATION - ACC	28,491,857	28,821,741	28,754,941	33,496,622	33,400,580	33,884,413	34,074,180	39,642,746	33,910,797	33,709,283	33,737,101	0	361,924,264	
CAPITATION - AIMHS	606	1,037	1,404	1,676	3,580	4,979	6,243	7,264	8,284	9,429	10,766	0	55,268	
MENTAL HEALTH - CHILD	0	0	0	0	0	0	0	-111	0	0	0	0	-111	
MENTAL HEALTH - ADULT	46,413	30,326	38,837	31,881	36,939	60,998	60,785	34,509	12,063	39,559	74,938	0	467,247	
MENTAL HEALTH - GENERAL	5,571,389	5,666,401	5,583,834	-4,123	-467	819,532	-2,465	-85	-3,110	-1,419	-2,139	0	17,627,348	
MENTAL HEALTH - RBHA CRISIS	0	0	0	575,065	576,013	577,812	579,856	585,049	584,825	583,214	580,150	0	4,641,983	
CHILDREN'S REHAB SERVICES	2,393	2,991	4,187	0	0	0	0	0	0	0	0	0	9,570	
FEE FOR SERVICE - ACUTE	2,226,936	3,250,949	2,593,069	3,294,911	2,434,928	2,965,867	3,111,954	2,829,869	3,049,044	2,708,662	4,105,270	0	32,571,459	
FFS - PRIOR QUARTER COVERAGE	320,363	361,717	336,078	307,823	269,362	261,460	237,936	280,180	264,732	279,867	359,757	0	3,279,275	
EMERGENCY SERVICES - FEDERAL	3,121,276	5,289,801	3,877,611	4,727,413	3,233,377	3,907,819	4,829,171	3,434,426	4,016,283	4,796,820	6,020,456	0	47,254,453	
FFS MEDICAID IN PUBLIC SCHOOLS	32	169	0	106	0	86	204	0	206	286	172	0	1,261	
STATE ONLY TRBHA FFS	0	5,743	48,191	18,969	24,840	15,038	27,224	9,210	17,208	26,938	33,653	0	227,015	
INPATIENT INMATES FFS	38,006	8,108	42,955	56,656	19,134	160,983	3,312	31,801	26,044	84,981	54,589	0	526,569	
FFS TRBHA FEE FOR SERVICE	168,451	163,702	140,625	172,911	126,334	117,384	170,685	155,783	167,907	294,420	231,327	0	1,909,529	
MARICOPA CTY INMATES FFS	3,611	2,869	3,452	313	6,497	652	0	0	0	91	5,865	0	23,351	
PIMA COUNTY INMATES FFS	0	0	116	60	91	2,121	0	-1,980	0	0	0	0	408	
REINSURANCE - ACC	535,179	804,872	744,886	1,394,164	833,505	1,004,832	413,949	750,470	617,932	691,020	806,269	0	8,597,078	
SMIB - ACC	0	0	0	0	0	0	0	271	134	678	271	0	1,354	
	40,526,512	44,410,427	42,170,189	44,074,448	40,964,712	43,783,978	43,513,033	47,759,402	42,672,350	43,223,829	46,018,445	0	479,117,323	
	1,023,125,676	1,059,952,609	1,037,251,328	1,114,057,333	1,071,495,893	1,116,759,985	1,097,479,088	1,165,146,213	1,100,715,408	1,097,097,035	1,130,086,319	0	12,013,166,887	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
CAPITATION - ACC	0	0	0	3,132	4,736	4,736	-1,069	1,938	0	0	-993	0	12,480	
CAPITATION - AIMHS	80	64	112	16	24	0	0	0	0	0	0	0	295	
MENTAL HEALTH - CHILD	28	0	0	0	0	32	0	0	0	0	0	0	61	
MENTAL HEALTH - CMDP	-1,172	0	0	0	0	0	0	0	0	0	0	0	-1,172	
MENTAL HEALTH - RBHA CRISIS	0	0	0	1	5	2	7	10	13	15	17	0	70	
FEE FOR SERVICE - ACUTE	0	0	0	0	0	0	0	427	0	0	0	0	427	
FFS TRBHA FEE FOR SERVICE	0	0	0	0	0	0	0	0	0	-1,422	0	0	-1,422	
KidsCare - CAPITATION	4,425,409	4,378,727	4,614,195	5,922,936	5,653,836	5,871,676	5,753,682	6,481,779	5,972,901	5,993,859	6,071,887	0	61,140,884	
KidsCare - FEE FOR SERVICE	227,481	123,157	100,499	154,921	162,475	119,405	119,548	216,458	164,187	182,251	284,112	0	1,854,494	
KidsCare - MENTAL HEALTH	1,239,709	1,252,330	1,293,391	57,034	52,885	191,687	54,134	54,280	54,471	56,661	56,307	0	4,362,888	
KidsCare - REINSURANCE	238,957	199,692	234,057	112,973	146,731	96,165	16,634	119,542	99,216	82,717	95,465	0	1,442,148	
KidsCare - CHILD REHAB SERVICES	6,580	4,187	3,589	0	0	0	0	0	0	0	0	0	14,355	

6,137,071	5,958,155	6,245,842	6,251,012	6,020,692	6,283,704	5,942,936	6,874,433	6,290,787	6,314,081	6,506,795	0	68,825,508	

TOTAL TITLE XXI

1,029,262,747	1,065,910,764	1,043,497,169	1,120,308,345	1,077,516,585	1,123,043,689	1,103,422,024	1,172,020,646	1,107,006,195	1,103,411,116	1,136,593,114	0	12,081,992,395	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
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	142.79	0.00	0.00	0.00	0.00		160.43		
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	114.55	0.00	0.00	0.00	0.00	67.50	0.00	0.00	0.00	0.00		62.93		
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	86.27	0.00	0.00	0.00	0.00		52.94		
1006	TANF 21-44 MALE WITH	49,121.18	52,104.98	49,735.13	41,776.92	44,706.28	47,537.78	43,209.69	45,486.49	43,208.58	41,528.12	47,802.52	0.00		506,217.67		
1007	TANF 21-44 FEMALE WI	72,257.76	74,525.56	81,194.65	73,137.65	65,713.74	66,761.33	63,004.21	60,615.33	46,523.15	45,687.45	45,850.23	0.00		695,271.06		
1008	TANF 45-64 M & F WIT	120,673.88	107,934.15	117,784.62	60,052.58	58,966.01	62,416.50	58,908.73	72,044.72	66,317.18	68,514.71	69,962.81	0.00		863,575.89		
1009	TANF 65+ M & F WITH	40,453.77	34,027.44	38,803.04	13,534.46	15,641.00	17,053.81	17,479.15	24,832.52	17,311.08	17,153.45	17,600.31	0.00		253,890.03		
100F	TANF 21-44 MALE WITH	4,453.29	742.17	318.39	318.60	2,171.88	1,291.98	223.29	315.97	3,838.01	382.91	1,371.96	0.00		15,428.45		
100G	TANF 21-44 FEMALE WI	405.14	2,107.37	2,613.57	632.54	213.93	3,236.35	2,050.15	322.29	3,234.93	902.45	357.80	0.00		16,076.52		
100H	TANF 45-64 M & F WIT	543.50	1,698.24	1,148.74	0.00	233.93	1,120.31	4,469.75	579.61	4,987.61	579.15	754.91	0.00		16,115.75		
100J	TANF 65+ M & F WITH	579.98	1,298.92	0.00	0.00	86.60	220.61	0.00	121.41	359.78	64.62	207.44	0.00		2,939.36		
1011	TANF <1 M & F NON-ME	4,923,029.72	4,990,957.44	4,781,134.75	5,913,932.42	5,815,335.93	5,746,416.31	5,752,982.36	6,700,378.97	5,633,335.76	5,594,158.34	5,621,831.56	0.00		61,473,493.56		
1012	TANF 01-05 M & F NON	2,455,010.89	2,370,397.53	2,429,778.47	3,393,107.33	3,456,329.89	3,562,137.78	3,450,776.81	3,951,729.00	3,454,704.14	3,436,818.55	3,440,912.45	0.00		35,401,702.84		
1013	TANF 06-13 M & F NON	4,179,744.92	4,118,701.12	4,262,225.66	5,827,110.71	5,815,866.66	6,101,039.58	5,933,312.37	6,740,041.95	6,062,784.96	6,150,476.83	6,182,434.41	0.00		61,373,739.17		
1014	TANF 14-20 MALE NON-	1,669,137.78	1,589,645.12	1,652,893.50	1,671,145.30	1,631,273.48	1,725,993.94	1,682,604.48	2,023,545.13	1,852,487.71	1,877,329.79	1,910,536.85	0.00		19,286,593.08		
1015	TANF 14-20 FEMALE N O	3,072,044.25	2,939,087.33	3,084,706.64	2,092,701.07	2,096,229.44	2,228,917.65	2,162,460.68	2,810,784.91	2,293,447.48	2,314,077.88	2,335,905.28	0.00		27,430,362.61		
1016	TANF 21-44 MALE NON-	4,618,080.17	4,475,347.86	4,538,554.51	9,510,790.22	9,469,061.45	9,455,523.94	9,410,470.32	10,272,556.41	9,331,536.15	9,315,495.57	9,335,303.34	0.00		89,732,719.94		
1017	TANF 21-44 FEMALE N O	23,256,202.53	22,621,270.54	23,433,053.99	32,556,745.58	32,479,797.66	32,641,706.18	32,475,079.26	36,628,659.55	32,381,426.63	32,305,879.14	32,426,216.63	0.00		333,206,037.69		
1018	TANF 45-64 M & F NON	9,538,179.97	8,937,776.51	9,492,618.22	7,993,981.41	7,842,308.97	7,866,603.20	7,819,836.02	9,623,917.13	7,722,490.45	7,752,399.94	7,777,793.14	0.00		92,367,904.96		
1019	TANF 65+ M & F NON-M	33,831.66	30,991.42	33,399.89	30,432.51	28,103.94	28,293.75	28,299.43	36,704.18	29,879.86	31,799.51	31,538.32	0.00		343,274.47		
101A	TANF < 1 M & F NON-M	412,738.62	549,318.66	356,156.52	354,236.99	385,549.83	345,014.04	388,836.96	282,033.26	330,947.32	299,672.93	331,955.70	0.00		4,036,460.83		
101B	TANF 01-05 M & F NON	8,213.25	14,105.18	11,402.56	17,637.44	22,659.70	24,635.91	28,784.04	27,935.84	26,971.03	24,597.39	26,693.04	0.00		233,635.38		
101C	TANF 06-13 M & F NON	6,283.96	6,727.11	4,853.71	11,853.18	17,224.43	24,445.56	29,545.52	24,046.96	24,266.81	25,124.32	22,774.54	0.00		197,146.10		
101D	TANF 14-20 MALE NON-	12,206.42	13,657.10	7,786.97	7,970.43	11,765.85	8,721.78	12,305.15	31,585.09	8,567.53	16,839.21	9,308.92	0.00		140,714.45		
101E	TANF 14-20 FEMALE N O	25,265.59	31,989.46	18,243.70	22,410.04	18,507.27	20,002.02	25,365.81	21,109.24	19,518.49	16,105.03	17,036.40	0.00		235,553.05		
101F	TANF 21-44 MALE NON-	118,532.60	152,453.00	117,074.91	185,033.58	236,940.37	201,901.89	296,415.94	237,419.22	256,808.29	199,140.18	242,976.83	0.00		2,244,696.81		
101G	TANF 21-44 FEMALE N O	377,363.34	508,652.39	370,634.98	518,789.53	538,019.35	579,793.37	693,383.78	541,339.91	578,997.49	470,611.50	660,392.35	0.00		5,837,977.99		
101H	TANF 44-64 M & F NON	90,148.09	132,960.37	108,352.91	122,483.90	131,884.02	156,287.30	172,438.07	117,004.60	115,124.03	121,189.19	141,873.39	0.00		1,409,745.87		
101J	TANF 65+ N & F NON-M	439.07	0.00	762.61	479.90	330.02	599.61	338.75	821.56	0.00	294.00	861.62	0.00		4,927.14		
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	169.78	132.15	132.15	132.15	129.53	129.53	129.53	129.25	129.25	0.00		1,363.84		
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	28,073.62	27,271.23	24,197.75	20,928.13	18,206.67	21,035.61	22,727.21	24,043.14	27,766.12	0.00		267,327.48		
1027	TANF 21-44 FEMALE WI	52,705.40	52,056.27	55,646.98	48,081.36	51,971.38	58,782.61	54,416.90	57,305.64	51,186.82	42,036.34	37,256.25	0.00		561,445.95		

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
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	83,490.93	40,818.73	38,102.69	44,767.42	33,875.59	44,138.48	26,344.10	30,291.60	31,592.58	0.00		521,611.33		
1029	TANF 65+ M & F WITH	33,801.77	35,032.61	32,806.74	9,367.36	9,312.71	8,973.70	7,620.53	15,460.53	9,453.22	8,340.08	9,804.14	0.00		179,973.39		
102F	TANF 21-44 MALE WITH	341.36	0.00	0.00	48.09	0.00	14.99	93.34	0.00	103.64	0.00	0.00	0.00		601.42		
102G	TANF 21-44 FEMALE WI	33.76	635.99	0.00	1,136.54	0.00	541.04	455.86	0.00	0.00	105.39	0.00	0.00		2,908.58		
102H	TANF 44-64 M & F WIT	167.76	289.60	183.41	42.55	531.59	20.39	62.68	0.00	0.00	8.69	462.47	0.00		1,769.14		
102J	TANF 65+ M & F WITH	0.00	0.00	0.00	148.80	0.00	23.09	0.00	45.09	0.00	8.51	268.12	0.00		493.61		
2100	SSI AGED WITH MEDIC A	709,220.28	688,718.88	707,090.14	728,871.08	715,563.12	724,825.55	722,019.22	836,410.25	717,069.94	703,940.99	712,513.76	0.00		7,966,243.21		
210Z	SSI AGED WITH MEDIC
A	31,093.15	32,880.22	22,637.86	42,921.31	29,118.74	43,749.75	45,645.22	36,214.64	55,809.26	28,072.89	44,539.58	0.00		412,682.62		
2110	SSI AGED NON-MEDIC AR	6,592,077.68	6,504,288.18	6,682,122.95	8,112,018.19	8,188,109.03	8,200,674.91	8,269,087.21	9,512,803.93	8,392,081.44	8,394,871.35	8,399,349.10	0.00		87,247,483.97		
211Z	SSI AGED NON-MEDIC
AR	83,027.56	106,675.77	63,348.40	131,047.90	166,784.23	152,620.58	174,310.31	194,853.22	200,703.05	120,686.94	141,894.12	0.00		1,535,952.08		
2120	SSI AGED WITH QMB	5,248,445.46	5,068,145.49	5,311,924.19	5,258,863.24	5,305,045.32	5,448,225.76	5,353,292.26	6,254,102.57	5,368,676.63	5,389,183.67	5,407,392.10	0.00		59,413,296.69		
212Z	SSI AGED WITH QMB P P	7,287.70	6,117.14	4,332.00	4,345.48	8,560.19	6,525.00	7,980.60	7,017.32	8,831.89	5,007.51	10,939.76	0.00		76,944.59		
2200	SSI DISABLED WITH M
E	1,659,152.59	1,627,652.06	1,644,726.35	1,670,766.21	1,640,759.29	1,784,807.68	1,710,353.27	1,769,230.36	1,696,970.27	1,730,684.90	1,721,549.48	0.00		18,656,652.46		
220Z	SSI DISABLED WITH M E	85,255.38	166,531.05	130,549.54	52,470.25	62,873.45	133,921.68	125,734.81	93,739.49	85,239.60	85,337.46	98,512.11	0.00		1,120,164.82		
2210	SSI DISABLED NON-ME
D	63,366,536.41	61,056,340.03	63,129,103.17	71,573,508.92	71,609,916.77	74,773,185.19	71,440,884.60	79,891,002.05	71,192,235.34	70,996,920.07	71,079,243.48	0.00		770,108,876.03		
221Z	SSI DISABLED NON-ME D	453,135.12	738,540.50	377,701.43	402,895.49	798,423.58	777,861.03	716,944.69	804,428.20	998,404.33	808,567.62	928,251.87	0.00		7,805,153.86		
2220	SSI DISABLED WITH Q
M	15,296,127.40	15,144,583.82	15,353,896.51	15,406,358.51	15,428,042.95	16,775,161.61	15,357,166.18	15,935,530.72	15,113,271.91	15,040,341.71	15,020,290.09	0.00		169,870,771.41		
222Z	SSI DISABLED WITH Q M	14,341.02	18,901.68	55,689.10	40,397.03	29,679.15	52,515.22	32,342.71	47,249.58	25,048.22	7,487.72	56,908.24	0.00		380,559.67		
2300	SSI BLIND WITH MEDIC	9,264.92	9,473.83	9,465.70	8,197.94	8,432.44	9,022.24	6,624.06	8,730.85	8,282.01	8,198.00	7,925.61	0.00		93,617.60		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	944.37	441.96	180.50	55.64	1,337.46	70.48	0.00	39.53	0.00	0.00		3,069.94		
2310	SSI BLIND NON-MEDIC A	547,114.60	528,115.85	550,404.01	638,837.21	647,614.52	656,783.64	628,713.82	711,628.55	635,585.37	630,023.97	631,096.80	0.00		6,805,918.34		
231Z	SSI BLIND NON-MEDIC
A	2,043.29	24,544.15	4,015.06	3,859.76	956.62	0.00	6,851.33	3,609.54	53,179.34	3,704.13	10,447.96	0.00		113,211.18		
2320	SSI BLIND WITH QMB	49,144.44	46,857.97	49,046.21	49,904.04	48,295.76	51,781.25	49,395.25	57,242.29	49,702.39	47,628.74	50,124.73	0.00		549,123.07		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	76.39	0.00		76.39		
4301	SOBRA CHILD <1 M & F	442.86	699.14	442.86	233.73	151.25	536.08	157.50	561.62	157.50	148.76	148.76	0.00		3,680.06		
4302	SOBRA CHILD 01-05 M	5,159.40	462.70	2,397.58	264.26	396.41	1,191.71	259.06	1,631.52	259.06	258.50	258.50	0.00		12,538.70		
4303	SOBRA CHILD 06-13 M	3,139.48	-831.09	2,011.61	769.07	769.07	1,166.72	512.42	1,498.27	544.81	616.63	664.82	0.00		10,861.81		
4304	SOBRA CHILD 14-20 MA	1,089.93	-3,016.41	748.62	0.00	0.00	0.00	0.00	562.33	0.00	102.26	139.45	0.00		-373.82		
4305	SOBRA CHILD 14-20 FE	2,794.02	1,032.93	2,261.68	320.47	320.47	320.47	454.02	840.46	454.02	461.55	600.74	0.00		9,860.83		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	43.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.91		
430C	SOBRA CHILD 06-13 M	0.00	50.71	0.00	0.00	0.00	0.00	0.00	0.00	32.39	4.65	0.00	0.00		87.75		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.65	0.00	0.00		4.65		
4311	SOBRA CHILD <1 M & F	15,876,503.58	16,299,837.88	16,051,525.47	20,112,347.22	20,209,941.67	20,444,873.57	20,494,500.23	23,522,617.22	20,464,236.41	20,155,704.12	20,150,679.03	0.00		213,782,766.40		
4312	SOBRA CHILD 01-05 M	21,930,498.29	21,487,502.38	21,867,736.38	30,944,938.63	31,151,713.33	32,010,064.29	30,964,800.33	34,703,825.54	30,712,972.45	30,460,537.37	30,374,844.67	0.00		316,609,433.66		
4313	SOBRA CHILD 06-13 M	28,371,187.60	27,819,054.28	28,345,035.11	39,405,623.52	39,206,071.34	40,733,943.18	39,048,735.32	43,655,886.47	38,642,361.40	38,689,341.92	38,807,821.59	0.00		402,725,061.73		
4314	SOBRA CHILD 14-20 MA	10,250,435.20	9,791,649.73	10,286,798.28	10,613,118.99	10,434,823.30	10,911,856.65	10,448,272.22	12,208,217.87	10,401,944.15	10,644,563.26	10,664,594.39	0.00		116,656,274.04		

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	15,089,068.23	14,561,954.43	15,252,168.29	10,655,133.70	10,462,443.05	10,974,173.53	10,543,995.22	13,223,260.86	10,456,120.91	10,669,095.61	10,713,200.56	0.00		132,600,614.39		
431A	SOBRA CHILD < 1 M &	127,910.44	179,717.78	159,276.51	204,639.90	227,706.01	211,978.69	230,034.65	200,322.44	204,116.60	196,118.44	259,241.00	0.00		2,201,062.46		
431B	SOBRA CHILD 01-05 M	221,960.40	271,902.82	212,021.72	511,536.25	636,889.44	594,998.09	786,770.92	659,256.87	741,345.03	595,880.67	713,014.57	0.00		5,945,576.78		
431C	SOBRA CHILD 6-13 M& F	224,066.77	289,550.98	234,820.83	504,359.50	599,997.58	583,505.23	715,395.09	613,884.36	665,193.21	561,692.20	641,681.62	0.00		5,634,147.37		
431D	SOBRA CHILD 14-20 MA	176,040.96	249,408.63	186,474.64	195,188.29	190,484.23	168,486.96	206,247.04	181,372.92	175,319.26	150,124.50	176,548.21	0.00		2,055,695.64		
431E	SOBRA CHILD 14-20 FE	237,700.73	305,502.63	234,648.39	236,024.48	197,333.68	199,341.88	218,422.62	174,248.92	179,457.45	150,535.51	184,968.50	0.00		2,318,184.79		
4321	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.36	0.00	0.00	0.00	0.00		27.36		
4322	SOBRA CHILD 01-05 M	454.24	222.13	114.63	200.55	200.55	200.55	200.80	297.72	200.80	197.60	197.60	0.00		2,487.17		
4323	SOBRA CHILD 06-13 M	115.02	-14.45	0.00	0.00	0.00	0.00	0.00	67.23	0.00	197.60	197.60	0.00		563.00		
4324	SOBRA CHILD 14-20 MA	169.78	261.14	0.00	0.00	0.00	0.00	0.00	55.69	0.00	0.00	0.00	0.00		486.61		
4325	SOBRA CHILD 14-20 FE	230.43	217.31	230.43	143.18	333.46	269.57	141.85	141.85	141.85	139.19	139.19	0.00		2,128.31		
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	19,308.03	13,882.95	10,054.69	13,432.49	12,426.05	15,487.21	12,755.44	14,923.87	17,328.40	0.00		169,433.52		
5008	SOBRA PREG 45-64 FE M	1,135.88	1,171.67	1,378.43	275.89	275.89	275.89	271.99	724.50	271.99	268.70	268.70	0.00		6,319.53		
500G	SOBRA PREG 21-44 FE
M	435.21	3,518.70	299.99	740.96	61.68	1,109.10	2,209.37	3,044.78	189.74	126.55	5,149.99	0.00		16,886.07		
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	215.76	167.02	159.16	345.03	346.81	483.50	554.97	525.67	363.94	0.00		3,486.59		
5015	SOBRA PREG 14-20 FE M	852,527.19	833,480.09	839,592.04	577,629.40	582,260.92	570,312.94	548,977.86	707,650.01	539,069.58	517,277.12	530,882.12	0.00		7,099,659.27		
5017	SOBRA PREG 21-44 FE
M	4,605,937.24	4,383,257.45	4,463,808.68	6,390,355.47	6,219,445.12	5,974,754.78	5,909,015.03	6,746,028.37	5,725,308.10	5,715,220.27	5,786,586.18	0.00		61,919,716.69		
5018	SOBRA PREG 45-64 FE M	19,914.87	18,697.50	18,910.72	12,524.15	12,628.91	12,005.25	12,546.21	16,383.84	14,364.05	15,742.65	14,293.97	0.00		168,012.12		
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	43,617.71	40,822.00	43,556.22	49,550.16	47,096.58	45,019.83	37,001.29	45,299.64	44,929.21	0.00		501,143.03		
501G	SOBRA PREG 21-44 FE
M	209,922.82	233,732.16	196,846.60	316,369.04	385,272.67	388,673.80	445,918.17	408,252.19	412,694.07	372,439.88	428,689.24	0.00		3,798,810.64		
501H	SOBRA PREG 45-64 FE M	878.94	188.28	337.87	1,529.82	722.25	1,013.59	1,510.16	0.00	2,353.64	1,413.91	1,219.20	0.00		11,167.66		
5025	SOBRA PREG 14-20 FE
M	0.00	246.14	246.14	126.39	126.39	126.39	126.96	126.96	126.96	0.00	0.00	0.00		1,252.33		
5027	SOBRA PREG 21-44 FE M	22,924.89	26,018.75	25,697.03	21,899.14	25,802.70	24,056.51	20,926.86	21,280.25	15,292.96	15,891.05	10,512.68	0.00		230,302.82		
5028	SOBRA PREG 45-64 FE
M	2,363.74	2,336.22	2,363.74	4,736.32	4,736.32	4,736.32	2,368.16	2,368.16	2,368.16	2,368.16	2,368.16	0.00		33,113.46		
502G	SOBRA PREG 21-44 FE M	155.24	0.00	0.00	45.29	0.00	1,087.68	1,426.10	0.00	0.00	19.76	0.00	0.00		2,734.07		
SUBTOTAL:	247,736,543.8	3 242,543,886.87	247,744,051.4	1 295,439,035.11	295,602,203.32	304,521,959.83	295,980,190.42	333,693,633.85	294,427,318.21	293,209,724.58	294,660,119.45	0.00		3,145,558,666.88		

3100	TRANSPLANT OPTION 1	0.00	0.00	0.00	16.50	18.15	39.38	16.50	66.00	66.00	66.00	66.00	0.00	

354.53

9910	TANF & SOBRA CHILDR E	1,566,824.34	1,731,513.97	1,673,460.08	1,727,064.88	1,553,091.76	1,656,193.63	1,925,998.24	1,595,072.73	1,643,751.15	1,515,160.17	1,760,256.62	0.00	
9920	SSI W/MEDICARE KICK	24,386.16	47,389.06	24,395.85	11,645.52	34,577.29	35,056.47	47,002.26	22,591.10	52,416.04	28,354.37	23,471.17	0.00	
9921	SSI W/O MEDICARE KI C	107,966.05	178,834.59	155,349.25	106,063.40	118,530.66	140,961.03	93,432.00	123,065.33	124,116.10	142,471.56	123,767.22	0.00	
9950	S.O.B.R.A. KICK PAYM	12,526,470.22	14,106,089.72	13,526,078.08	13,693,798.30	12,616,294.43	12,786,487.97	13,057,256.51 11,195,341.43	11,865,356.68	10,308,676.04	11,058,136.97	0.00	
SUBTOTAL:	14,225,646.7	7 16,063,827.34	15,379,283.2	6 15,538,572.10	14,322,494.14	14,618,699.10	15,123,689.01	12,936,070.59	13,685,639.97	11,994,662.14	12,965,631.98	0.00	

 
18,348,387.57	
351,285.29	
1,414,557.19	
136,739,986.35	
156,854,216.40	

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
310Z	TRANSPLANT OPTION 1	0.00	0.00	0.00	0.00	31.35	26.62	49.50	0.00	0.00	0.00	0.00	0.00		107.47		
SUBTOTAL:	0.00	0.00	0.00	16.50	49.50	66.00	66.00	66.00	66.00	66.00	66.00	0.00		462.00		

1104	TANF EXPANDED 14-20	0.00	-19.23	0.00	0.00	0.00	0.00	0.00	55.69	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	86.27	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	70,273.75	55,179.81	63,421.44	59,013.17	56,407.20	59,908.64	56,122.50	64,275.15	58,057.61	58,265.68	62,994.14	0.00	
1107	TANF EXPANDED 21-44	262,271.15	241,322.50	238,491.01	199,910.90	188,848.41	200,922.06	185,834.98	216,444.78	190,337.15	182,202.59	182,180.95	0.00	
1108	TANF EXPANDED 45-64	775,922.44	729,950.53	747,404.40	406,151.73	397,661.92	427,868.43	402,472.28	527,264.81	400,779.50	404,674.48	412,558.64	0.00	
1109	TANF EXPANDED 65+
M&	279,722.70	263,370.27	282,485.63	98,461.19	97,660.43	96,457.33	97,546.84	152,459.86	96,276.89	95,608.00	96,275.19	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	
110F	TANF EXPANDED 21-44	5,436.65	4,673.12	7,615.88	2,383.37	1,927.44	3,324.35	2,344.25	1,035.32	4,109.76	3,902.02	4,512.57	0.00	
110G	TANF EXPANDED 21-44	21,689.44	12,711.48	9,469.28	8,110.75	5,851.05	13,873.51	3,906.20	2,316.82	8,423.63	4,862.02	14,041.19	0.00	
110H	TANF EXPANDED 45-64	16,922.37	17,124.31	8,785.56	9,353.71	7,884.36	15,320.03	12,839.65	7,043.92	12,686.74	8,862.29	8,924.19	0.00	
110J	TANF EXPANDED 65+
M&	6,933.80	8,320.32	7,330.18	6,550.26	2,462.79	6,818.17	4,652.49	3,561.02	2,647.59	3,352.57	4,889.26	0.00	
1112	TANF EXPANDED 01-05	209.81	204.67	106.84	185.87	185.87	185.87	186.78	315.69	186.78	187.25	187.25	0.00	
1113	TANF EXPANDED 06-13	2,451.20	2,178.29	2,221.94	2,129.09	2,129.09	2,931.52	2,041.27	2,656.03	1,777.32	1,599.10	1,422.41	0.00	
1114	TANF EXPANDED 14-20	54,619.14	52,858.44	58,251.51	49,143.97	51,936.87	50,911.41	47,761.10	61,552.03	43,241.09	41,087.45	41,674.14	0.00	
1115	TANF EXPANDED 14-20	391,160.64	383,953.38	396,137.29	257,180.12	271,911.43	276,533.49	273,247.56	357,183.81	278,882.75	270,940.14	271,697.35	0.00	
1116	TANF EXPANDED 21-44	4,723,664.44	4,593,382.82	4,727,206.69	10,172,041.12	10,135,297.47	10,159,889.54	10,101,971.39	11,020,523.86	9,999,795.90	9,950,556.49	9,971,289.15	0.00	
1117	TANF EXPANDED 21-44	18,274,687.63	17,672,381.82	18,390,243.60	26,205,631.33	26,388,847.02	26,737,310.99	26,743,131.98	30,262,848.51	26,766,632.39	26,835,295.49	26,960,071.32	0.00	
1118	TANF EXPANDED 45-64	10,957,250.85	10,216,164.33	10,930,258.08	9,248,581.29	9,190,497.31	9,248,127.80	9,177,425.03	11,360,075.92	9,120,640.01	9,183,534.21	9,158,625.11	0.00	
1119	TANF EXPANDED 65+
M&	29,230.75	26,932.20	31,683.08	23,717.29	24,591.07	25,107.84	26,391.35	31,259.49	25,792.90	27,785.61	27,266.57	0.00	
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	91.02	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	3,527.61	2,709.94	1,465.15	2,371.88	2,378.57	1,176.97	1,549.57	3,779.50	896.44	1,848.92	1,381.83	0.00	
111E	TANF EXPANDED 14-20	6,692.13	8,190.46	6,000.49	7,527.41	7,016.89	5,532.62	5,779.52	5,088.61	7,806.91	6,596.85	6,586.88	0.00	
111F	TANF EXPANDED 21-44	126,877.50	157,206.86	123,517.51	206,243.92	236,015.85	247,073.24	319,241.82	252,144.21	291,840.59	224,460.23	260,173.18	0.00	
111G	TANF EXPANDED 21-44	282,393.11	348,535.59	290,982.04	445,859.81	488,646.69	487,834.55	610,380.66	478,857.71	507,337.67	412,787.00	529,500.41	0.00	
111H	TANF EXPANDED 45-64	122,461.87	143,174.58	111,735.01	163,169.18	173,640.04	203,955.77	197,236.33	155,431.96	162,824.29	147,680.06	176,088.23	0.00	
111J	TANF EXPANDED 65+
M&	487.88	1,000.10	0.00	934.85	2,237.09	498.18	0.00	883.59	431.40	0.00	923.83	0.00	
1125	TANF EXPANDED 14-20	0.00	-41.80	252.34	119.92	119.92	517.57	126.26	212.53	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	329,068.29	319,037.44	325,391.25	326,551.74	322,192.82	351,264.95	322,279.78	351,668.96	322,536.62	321,861.40	309,258.50	0.00	
1127	TANF EXPANDED 21-44	989,036.79	959,592.44	983,701.96	842,921.57	816,254.17	873,072.17	811,213.83	889,039.73	801,440.21	789,815.61	783,493.50	0.00	
1128	TANF EXPANDED 45-64	1,543,278.97	1,470,040.37	1,554,746.49	889,109.16	893,019.63	970,663.49	921,189.32	1,131,582.80	909,548.23	907,791.65	891,677.20	0.00	
1129	TANF EXPANDED 65+
M&	616,303.36	575,686.14	631,949.68	237,351.73	241,795.78	248,089.59	230,893.17	353,187.21	243,070.32	249,262.70	250,397.99	0.00	
112F	TANF EXPANDED 21-44	559.74	270.03	4,125.72	834.19	285.40	1,468.38	1,419.37	740.77	1,992.71	167.54	277.63	0.00	
112G	TANF EXPANDED 21-44	7,333.37	8,229.05	3,909.58	1,289.43	3,350.60	3,776.29	10,579.85	843.56	584.43	10,673.38	7,844.39	0.00	

 
36.46	
191.85	
663,919.09	
2,288,766.48	
5,632,709.16	
1,656,324.33	
94.53	
41,264.73	
105,255.37	
125,747.13	
57,518.45	
2,142.68	
23,537.26	
553,037.15	
3,428,827.96	
95,555,618.87	
271,237,082.08	
107,791,179.94	
299,758.15	
91.02	
23,086.38	
72,818.77	
2,444,794.91	
4,883,115.24	
1,757,397.32	
7,396.92	
1,306.74	
3,601,111.75	
9,539,581.98	
12,082,647.31	
3,877,987.67	
12,141.48	
58,413.93	

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
112H	TANF EXPANDED 45-64	3,692.73	8,381.71	-291.27	3,813.33	5,147.82	4,179.69	4,836.75	516.92	5,263.76	11,766.60	2,816.14	0.00		50,124.18		
112J	TANF EXPANDED 65+
M&	1,155.86	1,463.69	974.15	1,015.98	878.55	603.24	1,649.74	1,545.98	752.87	464.61	342.65	0.00		10,847.32		
2400	SSI AGED EXPANDED WI	39,565.65	42,651.01	35,126.90	43,283.08	35,120.51	33,116.40	38,806.93	49,666.47	40,411.65	40,241.45	40,676.15	0.00		438,666.20		
240Z	SSI AGED EXPANDED
WI	27,316.98	25,268.33	21,586.77	35,460.92	31,432.06	26,755.62	36,282.13	35,813.62	37,002.73	34,389.08	37,149.23	0.00		348,457.47		
2410	SSI AGED EXPANDED NO	94,343.54	90,789.33	80,560.30	102,571.79	116,679.35	113,524.71	105,940.41	124,687.59	106,100.96	109,672.12	120,407.17	0.00		1,165,277.27		
241Z	SSI AGED EXPANDED
NO	3,257.97	931.70	2,359.37	4,185.50	4,098.69	15,977.85	5,304.12	4,595.86	10,352.67	13,685.11	4,764.93	0.00		69,513.77		
2420	SSI AGED EXPANDED WI	5,031,817.51	4,817,759.20	5,070,624.93	5,043,155.04	5,091,754.05	5,298,041.50	5,125,195.19	5,913,397.42	5,261,936.80	5,288,313.14	5,318,019.94	0.00		57,260,014.72		
242Z	SSI AGED EXPANDED
WI	4,679.60	2,943.66	7,305.52	7,122.20	6,800.07	6,571.42	4,217.01	11,004.51	7,397.60	7,223.83	10,192.20	0.00		75,457.62		
2520	SSI BLIND EXPANDED W	0.00	4.38	0.00	0.00	0.00	0.00	0.00	237.56	200.80	197.60	197.60	0.00		837.94		
2600	SSI DISABLED EXPAND
E	133,143.35	111,614.96	104,857.22	121,327.85	134,504.33	117,558.92	105,920.83	113,762.80	116,627.37	104,450.57	116,740.19	0.00		1,280,508.39		
260Z	SSI DISABLED EXPAND E	53,091.11	47,795.49	44,811.52	32,924.10	104,832.61	77,765.32	50,989.63	57,576.34	59,145.99	50,469.79	69,195.08	0.00		648,596.98		
2610	SSI DISABLED EXPAND
E	1,681,462.82	1,568,269.42	1,625,261.32	1,825,868.18	1,812,780.31	1,844,905.32	1,772,604.88	2,082,822.39	1,746,123.66	1,822,998.61	1,896,192.68	0.00		19,679,289.59		
261Z	SSI DISABLED EXPAND E	14,120.97	10,512.51	13,631.96	26,477.72	56,213.87	32,089.96	41,922.71	38,497.25	35,512.71	43,592.33	48,904.58	0.00		361,476.57		
2620	SSI DISABLED EXPAND
E	10,663,975.16	10,451,748.73	10,571,273.61	10,745,528.51	10,739,675.35	11,739,347.67	10,769,631.81	11,211,629.77	10,762,128.85	10,660,397.52	10,603,851.27	0.00		118,919,188.25		
262Z	SSI DISABLED EXPAND E	12,749.14	22,320.78	23,568.54	12,291.60	4,472.50	33,872.96	29,818.49	19,855.51	26,833.98	37,208.79	32,431.28	0.00		255,423.57		
SUBTOTAL:	57,664,839.7	7 55,476,975.27	57,540,540.4	7 67,877,855.75	68,155,443.25	70,064,725.33	68,662,976.78	77,360,030.11	68,476,370.23	68,370,731.88	68,738,094.09	0.00		728,388,582.93		

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	513.07	823.28	582.75	0.00	830.91	603.42	0.00	2,258.29	3,893.44	0.00	
3507	ADULT 40-100% FEMAL E	611.46	1,038.24	1,347.27	0.00	0.00	898.53	0.00	5,173.58	5,865.92	3,713.16	4,841.71	0.00	
3508	ADULT 40-100% M&F 45	10,535.82	7,960.91	11,017.87	9,746.11	8,405.79	10,313.30	11,318.66	24,559.72	22,749.67	18,738.88	20,974.15	0.00	
3509	ADULT 40-100% M&F 65	0.00	1,922.82	1,568.31	3,794.89	2,949.85	1,689.08	2,605.87	2,561.22	1,216.56	3,774.14	2,591.07	0.00	
350F	ADULT 40-100% MALE 2	0.00	0.00	0.00	452.80	543.33	0.00	2,093.63	0.00	0.00	84.93	1,714.33	0.00	
350G	ADULT 40-100% FEMAL E	1,466.66	564.83	0.00	0.00	0.00	122.77	0.00	0.00	229.18	701.67	0.00	0.00	
350H	ADULT 40-100% M&F 45	5,154.56	2,215.99	1,197.18	691.96	906.48	3,534.82	2,473.36	5,691.24	908.64	0.00	1,118.74	0.00	
350J	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	781.41	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	2,845,519.41	2,672,293.94	2,893,966.97	3,513,664.55	3,585,633.41	3,681,238.53	3,664,813.14	4,280,920.84	3,670,322.91	3,509,827.58	3,546,558.18	0.00	
3515	ADULT 40-100% FEMAL E	3,072,774.76	2,882,794.52	3,143,813.37	3,908,304.45	4,027,702.75	4,082,952.34	4,031,688.59	4,677,040.33	4,028,615.75	3,908,613.18	3,911,076.34	0.00	
3516	ADULT 40-100% MALE 2	9,977,987.83	9,875,661.38	10,030,537.02	12,789,982.74	12,557,708.61	12,643,079.10	12,560,273.47	14,538,909.57	12,365,941.46	12,392,410.39	12,367,786.95	0.00	
3517	ADULT 40-100% FEMAL E	8,386,323.38	8,250,785.05	8,408,122.95	10,649,420.51	10,489,755.05	10,572,668.03	10,444,640.31	12,158,293.12	10,345,299.65	10,390,491.30	10,348,968.51	0.00	
3518	ADULT 40-100% M&F 45	19,918,279.36	19,791,930.53	19,808,275.51	24,962,728.57	24,673,449.58	24,886,548.06	24,622,219.98	28,604,792.01	24,435,654.64	24,365,046.85	24,369,419.85	0.00	
3519	ADULT 40-100% M&F 65	2,483.91	2,353.51	3,470.70	7,418.71	3,648.07	3,648.07	3,681.91	6,736.65	3,584.02	3,593.34	4,203.21	0.00	

1,829.29	
14,612.58	
23,489.87	
156,320.88	
24,673.81	
4,889.02	
3,085.11	
23,892.97	
781.41	
37,864,759.46	
41,675,376.38	
132,100,278.52	
110,444,767.86	
260,438,344.94	
44,822.10	

9911	SB PAYMENT FOR TAN F	983,153.34	1,173,355.54	1,101,057.64	969,439.21	1,043,041.02	1,114,451.49	1,094,332.25	907,963.51	1,177,136.08	1,085,909.42	1,030,557.13	0.00	
9922	SB PAYMENT FOR SSI
E	11,801.65	0.00	0.00	5,529.73	0.00	0.00	11,529.45	0.00	6,000.27	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	0.00	0.00	5,529.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	994,954.9	9	1,173,355.54	1,101,057.6	4	974,968.94	1,048,570.75	1,114,451.49	1,105,861.70	907,963.51	1,183,136.35	1,085,909.42	1,030,557.13	0.00	

 
11,680,396.63	
34,861.10	
5,529.73	
11,720,787.46	

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351D	ADULT 40-100% MALE 1	77,272.85	74,288.89	72,759.19	77,794.75	80,517.15	56,115.86	72,892.89	46,716.68	66,635.62	41,459.28	53,477.03	0.00		719,930.19		
351E	ADULT 40-100% FEMAL E	97,130.22	117,796.26	89,805.23	92,309.77	71,277.63	97,173.22	95,938.47	87,044.75	74,277.18	71,525.82	89,898.58	0.00		984,177.13		
351F	ADULT 40-100% MALE 2	334,430.46	394,390.94	322,071.78	361,494.99	290,332.87	333,041.96	374,889.63	272,021.10	310,627.50	274,715.91	308,921.60	0.00		3,576,938.74		
351G	ADULT 40-100% FEMAL E	259,135.65	347,383.31	284,838.54	271,213.01	293,357.28	296,709.06	372,560.52	237,670.77	241,220.53	204,056.16	302,834.39	0.00		3,110,979.22		
351H	ADULT 40-100% M&F 45	537,529.45	641,405.58	504,965.26	529,044.90	458,984.49	651,905.86	714,157.75	492,284.51	482,149.03	441,556.89	522,039.52	0.00		5,976,023.24		
351J	ADULT 40-100% M&F 65	0.00	2,199.75	7,032.69	8,719.72	0.00	3,136.11	1,086.66	9,029.27	0.00	0.00	565.31	0.00		31,769.51		
3525	ADULT 40-100% FEMAL E	0.00	0.00	984.49	583.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,568.16		
3526	ADULT 40-100% MALE 2	1,479.44	465.13	1,618.67	0.00	488.86	1,481.12	0.00	29.28	637.48	0.00	0.00	0.00		6,199.98		
3527	ADULT 40-100% FEMAL E	939.87	1,914.48	0.00	0.00	0.00	0.00	0.00	0.00	275.20	537.11	0.00	0.00		3,666.66		
3528	ADULT 40-100% M&F 45	0.00	-30.45	303.28	-52.56	490.21	4,385.83	2,364.84	622.35	2,613.83	365.42	0.00	0.00		11,062.75		
3529	ADULT 40-100% M&F 65	479.69	420.48	479.69	0.00	0.00	0.00	0.00	292.97	581.91	565.31	565.31	0.00		3,385.36		
352F	ADULT 40-100% MALE 2	1,386.98	488.47	0.00	0.00	977.72	436.18	0.00	0.00	0.00	0.00	0.00	0.00		3,289.35		
352G	ADULT 40-100% FEMAL E	678.80	2,924.05	0.00	0.00	0.00	0.00	0.00	0.00	1,431.05	230.19	0.00	0.00		5,264.09		
352H	ADULT 40-100% M&F 45	0.00	352.87	120.16	0.00	827.69	1,132.93	2,359.16	0.00	388.98	211.56	0.00	0.00		5,393.35		
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		-8.25		
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	11,148.09	10,757.49	2,927.87	5,495.80	5,428.31	9,883.47	14,207.37	21,223.53	21,329.91	0.00		112,796.21		
3707	ADULT <40% EXP FEM AL	7,737.99	2,886.88	1,618.67	2,065.44	3,956.48	1,869.67	2,811.45	4,201.84	4,449.06	4,604.53	7,342.52	0.00		43,544.53		
3708	ADULT <40% EXP M&F
4	8,526.04	14,866.50	8,484.43	12,998.50	9,609.93	6,136.63	22,484.12	15,176.77	30,225.71	31,356.01	43,193.30	0.00		203,057.94		
3709	ADULT <40% EXP M&F 6	872.68	367.17	0.00	762.91	762.91	0.00	634.65	954.09	1,200.09	1,153.96	1,153.96	0.00		7,862.42		
370F	ADULT <40% EXP MALE	1,663.65	30,316.12	4,401.02	4,891.51	2,889.33	2,351.60	1,998.90	6,356.26	7,450.52	3,107.95	3,663.00	0.00		69,089.86		
370G	ADULT <40% EXP FEM AL	9,948.52	352.89	3,145.15	1,047.57	1,017.18	1,741.11	3,022.85	1,676.65	1,631.22	210.05	0.00	0.00		23,793.19		
370H	ADULT <40% EXP M&F
4	4,127.71	6,825.40	3,390.94	1,837.96	6,024.28	3,795.16	20,122.22	3,840.78	9,694.43	6,474.64	6,442.30	0.00		72,575.82		
3714	ADULT <40% EXP MALE	5,253,165.59	4,955,925.67	5,327,780.05	6,483,930.47	6,749,468.94	6,826,477.77	6,855,575.16	7,902,896.37	6,767,120.48	6,517,385.72	6,519,594.49	0.00		70,159,320.71		
3715	ADULT <40% EXP FEM AL	4,697,295.30	4,433,506.36	4,808,032.07	5,806,377.58	5,976,951.70	6,061,549.70	6,102,615.71	7,036,514.48	6,015,048.90	5,873,459.90	5,866,241.58	0.00		62,677,593.28		
3716	ADULT <40% EXP MALE	35,701,388.63	35,014,468.92	35,742,587.41	45,139,338.73	45,172,579.11	46,225,263.32	46,709,417.98	53,185,496.55	47,183,048.06	47,507,973.94	48,065,114.75	0.00		485,646,677.40		
3717	ADULT <40% EXP FEM AL	21,640,367.01	21,263,056.58	21,939,925.32	27,233,329.05	27,275,079.95	28,024,606.00	28,137,796.56	31,990,715.37	28,560,603.44	28,687,180.69	28,954,193.49	0.00		293,706,853.46		
3718	ADULT <40% EXP M&F
4	42,836,702.21	42,229,231.68	42,929,148.76	53,921,029.24	53,756,968.15	54,880,179.12	54,864,369.97	62,857,788.42	55,459,045.04	55,899,582.19	56,228,480.21	0.00		575,862,524.99		
3719	ADULT <40% EXP M&F 6	11,355.36	15,812.02	12,335.62	14,233.58	8,947.40	8,184.49	10,545.61	13,222.80	10,954.70	9,828.59	8,759.71	0.00		124,179.88		
371D	ADULT <40% EXP MALE	207,217.97	224,842.82	183,395.03	217,912.92	168,433.87	183,602.21	251,884.72	169,519.32	182,895.37	119,514.09	165,498.35	0.00		2,074,716.67		
371E	ADULT <40% EXP FEM AL	185,752.11	235,476.31	157,614.42	150,936.01	170,822.41	156,299.79	193,628.53	166,325.90	147,839.20	119,737.98	143,661.78	0.00		1,828,094.44		
371F	ADULT <40% EXP MALE	1,852,063.30	2,307,266.72	1,672,807.71	1,733,734.20	1,629,413.46	1,618,552.93	1,789,497.06	1,461,915.42	1,363,842.36	1,240,557.43	1,561,636.28	0.00		18,231,286.87		
371G	ADULT <40% EXP FEM AL	1,096,410.83	1,301,002.21	1,047,073.28	1,002,875.11	927,698.02	968,489.56	1,119,361.87	833,047.34	791,966.37	717,029.99	827,422.32	0.00		10,632,376.90		
371H	ADULT <40% EXP M&F
4	1,511,524.26	2,096,422.66	1,472,369.82	1,493,552.93	1,313,559.50	1,594,951.19	1,813,953.14	1,283,339.01	1,262,352.15	1,046,087.76	1,339,063.23	0.00		16,227,175.65		
371J	ADULT <40% EXP M&F 6	1,562.82	2,592.80	3,116.56	0.00	0.00	0.00	1,029.98	0.00	0.00	0.00	636.97	0.00		8,939.13		
3726	ADULT <40% EXP MALE	512.97	3,002.80	1,575.83	3,623.15	291.38	-1,575.83	552.79	842.55	3,237.92	2,656.11	7,681.33	0.00		22,401.00		

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3727	ADULT <40% EXP FEM AL	811.52	639.81	2,236.70	554.99	543.69	0.00	1,079.41	1,317.66	5,683.38	2,347.74	2,852.13	0.00		18,067.03		
3728	ADULT <40% EXP M&F
4	1,563.39	2,009.29	3,573.62	576.29	6,782.53	4,072.86	1,292.12	3,533.92	5,526.07	10,111.78	5,902.47	0.00		44,944.34		
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	1,757.02	1,724.59	2,363.74	0.00	728.55	0.00	818.82	2,979.30	0.00		10,769.76		
372G	ADULT <40% EXP FEM AL	957.86	554.55	2,372.88	0.00	0.00	0.00	777.05	591.95	1,172.01	1,267.10	1,222.28	0.00		8,915.68		
372H	ADULT <40% EXP M&F
4	0.00	1,181.20	2,189.57	843.16	1,735.73	796.63	12,339.72	611.17	5,586.41	452.21	696.43	0.00		26,432.23		
SUBTOTAL:	160,574,732.8	0 159,222,478.69	160,929,132.1	5 200,427,102.63	199,736,727.98	203,907,414.21	204,905,109.63	232,402,271.43	203,896,006.97	203,458,600.07	205,646,210.31	0.00		2,135,105,786.87		

3906	NEWLY ELIGIBLE MALE	1,351.75	867.69	1,907.92	835.79	1,028.92	4,000.62	4,772.96	4,358.73	4,876.75	4,188.39	5,954.97	0.00	
3907	NEWLY ELIGIBLE FEMA L	870.61	575.50	465.34	374.82	374.82	1,415.40	553.39	1,279.84	2,851.16	1,856.79	5,114.91	0.00	
3908	NEWLY ELIGIBLE M&F
4	15,087.06	13,541.10	10,030.34	8,083.84	9,797.22	7,443.77	9,196.61	26,968.55	29,002.43	25,126.05	21,290.70	0.00	
3909	NEWLY ELIGIBLE M&F 6	2,842.79	3,469.54	4,065.87	5,321.75	3,576.80	3,586.98	2,696.89	4,598.18	2,719.77	10,941.04	7,458.47	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	0.00	2,307.23	0.00	160.02	39.66	440.32	214.83	633.50	0.00	45.51	0.00	
390G	NEWLY ELIGIBLE FEMA L	175.22	29.49	219.86	0.00	0.00	2,736.12	220.20	2,559.38	0.00	6,456.83	569.98	0.00	
390H	NEWLY ELIGIBLE M&F
4	356.87	2,773.10	1,614.64	798.49	5,597.73	2,845.42	1,407.20	2,894.06	0.00	2,018.74	3,201.35	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	7,912.00	646.65	0.00	0.00	0.00	0.00	0.00	0.00	1,251.25	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,116,598.97	1,120,864.19	1,133,570.52	1,252,886.68	1,289,436.21	1,298,069.67	1,291,606.83	1,540,819.77	1,313,425.28	1,288,945.45	1,279,903.37	0.00	
3915	NEWLY ELIGIBLE FEMA L	1,278,614.86	1,253,510.74	1,303,730.92	1,435,190.13	1,499,508.71	1,521,337.27	1,510,529.92	1,778,800.52	1,524,920.10	1,478,033.88	1,481,931.77	0.00	
3916	NEWLY ELIGIBLE MALE	6,239,438.48	6,211,612.92	6,289,380.91	7,360,792.73	7,318,314.32	7,393,592.60	7,371,638.08	8,722,973.34	7,353,882.64	7,365,182.56	7,386,600.17	0.00	
3917	NEWLY ELIGIBLE FEMA L	8,967,501.97	8,900,096.44	9,062,484.86	10,654,292.37	10,616,670.96	10,767,110.21	10,843,458.33	12,790,820.14	10,945,046.91	10,983,712.41	10,966,233.64	0.00	
3918	NEWLY ELIGIBLE M&F
4	9,756,943.06	9,817,126.32	9,759,971.12	11,402,509.56	11,285,528.39	11,481,289.68	11,413,471.94	13,440,961.93	11,358,001.58	11,305,253.85	11,288,841.58	0.00	
3919	NEWLY ELIGIBLE M&F 6	3,501.58	3,873.90	3,137.68	4,614.23	1,699.22	801.92	895.86	1,354.30	-79.09	884.02	470.24	0.00	
391D	NEWLY ELIGIBLE MALE	34,779.16	36,852.81	21,956.20	27,120.90	24,905.15	25,493.40	39,735.49	32,631.05	30,375.79	26,836.09	25,329.31	0.00	
391E	NEWLY ELIGIBLE FEMA L	31,597.11	31,852.22	24,669.47	35,634.41	31,669.04	40,907.77	43,183.12	41,559.17	33,664.30	30,432.84	38,461.52	0.00	
391F	NEWLY ELIGIBLE MALE	206,907.63	280,803.58	215,480.95	269,082.81	240,730.29	251,842.17	307,386.76	219,968.09	261,667.54	232,849.11	241,469.55	0.00	
391G	NEWLY ELIGIBLE FEMA L	311,512.22	416,679.40	333,932.83	343,825.09	386,912.67	386,224.63	439,714.99	384,818.64	387,882.79	304,570.26	369,690.25	0.00	
391H	NEWLY ELIGIBLE M&F
4	274,500.37	280,185.09	258,843.18	300,679.59	271,936.30	367,665.87	413,453.70	288,658.81	279,688.24	231,469.56	301,326.50	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	387.99	1,551.96	0.00	0.00	0.00	14.00	0.00	-14.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	113.31	358.09	0.00	86.53	0.00	407.92	0.00	0.00	0.00	218.63	0.00	
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	
3928	NEWLY ELIGIBLE M&F
4	197.40	1,999.60	55.76	132.98	0.00	0.00	790.71	1,300.49	372.24	367.26	470.24	0.00	
3929	NEWLY ELIGIBLE M&F 6	0.00	310.17	0.00	0.00	0.00	0.00	0.00	0.00	382.84	379.65	763.77	0.00	
392F	NEWLY ELIGIBLE MALE	0.00	300.38	0.00	0.00	346.11	0.00	358.48	0.00	0.00	0.00	233.21	0.00	

34,144.49	
15,732.58	
175,567.67	
51,278.08	
3,841.07	
12,967.08	
23,507.60	
9,809.90	
13,926,126.94	
16,066,108.82	
79,013,408.75	
115,497,428.24	
122,309,899.01	
21,153.86	
326,015.35	
383,630.97	
2,728,188.48	
4,065,763.77	
3,268,407.21	
1,939.95	
1,184.48	
159.75	
5,686.68	
1,836.43	
1,238.18	

9935	BIRTH SUPP PAYMENT A	205,781.14	260,905.33	181,122.91	204,143.00	200,628.50	159,164.98	169,835.20	221,336.99	186,521.81	235,009.87	182,521.53	0.00	
9937	BIRTH SUPP PAYMENT
A	436,839.20	575,055.22	500,076.57	451,317.17	441,070.29	434,022.12	487,780.40	384,653.81	443,687.60	348,934.83	379,989.01	0.00	
SUBTOTAL:	642,620.3	4	835,960.55	681,199.4	8	655,460.17	641,698.79	593,187.10	657,615.60	605,990.80	630,209.41	583,944.70	562,510.54	0.00	

 
2,206,971.26	
4,883,426.22	
7,090,397.48	

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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	323.33	387.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,708.27		
SUBTOTAL:	28,242,975.1	7 28,386,908.89	28,430,705.6	3 33,102,564.16	32,988,279.41	33,556,403.16	33,695,933.70	39,287,539.82	33,529,300.77	33,300,756.03	33,425,579.64	0.00		357,946,946.38		

3,977,317.24

9939	BIRTH SUPP PAYMENT N	248,881.78	434,832.27	324,235.72	394,058.10	412,301.05	328,010.22	378,246.53	355,206.50	381,496.63	408,527.09	311,521.35	0.00	
SUBTOTAL:	248,881.78	434,832.27	324,235.72	394,058.10	412,301.05	328,010.22	378,246.53	355,206.50	381,496.63	408,527.09	311,521.35	0.00	

3,977,317.24

4403	SOBRA 100-133% M&F
6	0.00	-133.01	112.94	0.00	0.00	0.00	0.00	114.38	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	57.26	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	78.25	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	178.74	0.00	65.75	178.62	176.69	0.00	0.00	
4413	SOBRA 100-133% M&F
6	5,672,058.64	5,610,085.33	5,689,586.74	7,871,672.40	7,941,766.34	8,329,425.87	8,039,794.25	9,115,926.26	8,107,346.69	7,920,397.60	7,735,832.81	0.00	
4414	SOBRA 100-133% MALE	2,129,249.04	2,049,678.88	2,138,901.81	2,190,696.64	2,154,342.84	2,253,728.86	2,201,075.70	2,615,110.84	2,210,413.81	2,213,359.46	2,189,217.58	0.00	
4415	SOBRA 100-133% FEMA L	3,036,152.98	2,954,635.89	3,087,266.12	2,112,773.45	2,076,564.99	2,181,835.56	2,126,593.21	2,753,139.03	2,157,668.44	2,153,157.99	2,114,869.65	0.00	
441C	SOBRA 100-133% M&F
6	53,617.91	71,112.37	53,564.50	139,301.54	170,779.97	176,523.91	229,444.28	179,818.93	179,597.58	150,901.68	177,697.87	0.00	
441D	SOBRA 100-133% MALE	41,497.28	51,549.87	43,159.10	56,097.52	46,009.55	47,998.26	58,613.46	41,738.38	57,225.74	41,809.26	48,816.00	0.00	
441E	SOBRA 100-133% FEMA L	52,971.55	75,692.01	47,189.05	56,521.84	45,569.26	51,650.45	53,754.30	54,331.00	46,294.82	38,246.11	51,665.28	0.00	
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	
SUBTOTAL:	10,985,703.7	5 10,812,739.82	11,059,780.2	6 12,427,063.39	12,435,032.95	13,041,341.65	12,709,275.20	14,760,380.08	12,758,725.70	12,518,048.79	12,318,099.19	0.00	

94.31	
221.56	
70.43	
720.55	
82,033,892.93	
24,345,775.46	
26,754,657.31	
1,582,360.54	
534,514.42	
573,885.67	
-2.40	
135,826,190.78	

9944	BIRTH SUPP PAYMENT S	25,159.98	41,832.46	30,190.17	35,762.32	40,825.68	12,000.54	17,471.45	34,945.64	40,409.24	35,881.01	24,001.08	0.00	
SUBTOTAL:	25,159.98	41,832.46	30,190.17	35,762.32	40,825.68	12,000.54	17,471.45	34,945.64	40,409.24	35,881.01	24,001.08	0.00	

338,479.57

338,479.57

4517	BC PATIENT FEMALE 2 1	5,417.23	5,957.92	5,626.53	7,445.84	7,868.17	7,707.89	7,735.70	8,563.34	7,819.02	8,940.68	9,454.65	0.00	
4518	BC PATIENT FEMALE 4
5	45,038.46	42,574.02	48,401.72	41,508.92	42,552.47	42,316.77	43,001.04	49,868.15	43,842.23	44,963.89	46,895.63	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	-29.50	0.00	0.00	0.00	0.00	0.00	120.65	332.48	330.69	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	165.56	297.10	0.00	326.20	311.63	134.42	1,175.37	1,399.06	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	-5,197.54	2,068.10	287.76	0.00	4,013.75	3,894.72	4,353.63	1,165.36	3,401.93	412.99	1,592.95	0.00	
4617	CC PATIENT FEMALE 2
1	4,249.82	4,515.74	4,249.82	5,429.71	5,429.71	5,076.12	5,238.00	5,838.52	4,774.97	4,447.21	5,106.15	0.00	
4618	CC PATIENT FEMALE 4 5	4,460.71	4,307.71	4,415.91	3,311.61	3,311.61	3,665.20	3,270.38	4,133.44	2,769.96	2,705.91	2,430.34	0.00	
461G	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	504.44	0.00	0.00	0.00	2,095.88	0.00	
461H	CC PATIENT FEMALE 4 5	224.21	0.00	0.00	0.00	0.00	0.00	96.58	225.73	0.00	0.00	636.68	0.00	
SUBTOTAL:	54,358.45	59,691.09	62,981.7	4	58,022.28	63,487.34	62,795.12	65,375.14	71,314.25	62,940.59	61,801.37	68,212.28	0.00	

 
82,536.97	
490,963.30	
754.32	
3,809.34	
15,993.65	
54,355.77	
38,782.78	
2,600.32	
1,183.20	
690,979.65	

8600	SSI BLIND FREEDOM/W O	3,796.95	3,920.26	3,920.26	3,977.92	3,977.92	4,428.64	3,976.59	3,976.59	3,976.59	3,973.93	2,507.35	0.00	
8620	SSI BLIND FREEDOM/W
O	165.41	165.41	165.41	200.55	200.55	200.55	200.80	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,754,134.21	1,762,074.04	1,761,367.77	1,750,303.98	1,732,518.47	1,812,760.69	1,708,818.95	1,732,276.22	1,704,096.78	1,693,944.22	1,729,850.69	0.00	
870Z	SSI DISABLED FREEDO
M	32,077.92	32,915.46	66,115.19	30,530.88	32,912.95	69,015.67	77,327.17	66,900.44	90,997.97	72,367.41	59,057.72	0.00	
8710	SSI DISABLED FREEDO M	494,255.91	470,672.46	490,155.26	558,966.70	555,290.53	556,757.58	538,910.20	599,115.84	520,480.30	529,129.06	509,475.89	0.00	

42,433.00	
1,298.68	
19,142,146.02	
630,218.78	
5,823,209.73	

ACC CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
871Z	SSI DISABLED FREEDO M	19,175.47	12,288.62	7,463.15	18,613.11	31,321.83	48,497.45	34,047.71	27,034.64	37,784.22	9,223.65	19,019.27	0.00		264,469.12		
8720	SSI DISABLED FREEDO
M	193,122.80	196,794.73	201,133.04	218,993.24	223,747.45	230,720.24	220,772.32	235,567.52	231,268.66	240,786.04	253,803.29	0.00		2,446,709.33		
872Z	SSI DISABLED FREEDO M	358.67	7,920.00	3,002.83	638.75	420.54	4,729.75	1,711.10	7,911.96	9,172.64	18,584.29	610.56	0.00		55,061.09		
SUBTOTAL:	2,497,087.34	2,486,750.98	2,533,322.9	1	2,582,225.13	2,580,390.24	2,727,110.57	2,585,764.84	2,672,783.21	2,597,777.16	2,568,008.60	2,574,324.77	0.00		28,405,545.75		

6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	3,132.08	4,736.32	4,736.32	-1,069.49	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,937.55	0.00	0.00	-993.10	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	3,132.08	4,736.32	4,736.32	-1,069.49	1,937.55	0.00	0.00	-993.10	0.00	

 
11,535.23	
944.45	
12,479.68	

6,711,916,839.07

523,893,504.97	517,539,239.77	525,816,480.84	629,515,838.66	628,032,240.72	644,552,900.64	635,886,506.51	715,090,133.34	631,669,397.23	627,596,661.68	632,323,934.71	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	84.99	70.90	73.35	68.02	72.29	79.06	82.35	90.77	90.06	0.00		881.37		
1007	TANF 21-44 FEMALE WI	130.34	138.86	131.77	146.47	129.80	114.96	112.21	104.94	96.55	103.28	101.56	0.00		1,310.74		
1008	TANF 45-64 M & F WIT	213.69	203.55	209.01	212.00	225.48	227.19	220.53	218.97	214.89	218.00	213.06	0.00		2,376.37		
1009	TANF 65+ M & F WITH	92.24	83.30	88.13	91.65	93.50	105.38	109.00	107.10	99.79	98.23	102.17	0.00		1,070.49		
100F	TANF 21-44 MALE WITH	2.57	2.70	2.16	1.86	5.62	0.96	1.70	1.91	3.63	2.71	0.93	0.00		26.75		
100G	TANF 21-44 FEMALE WI	1.92	2.55	5.38	3.96	1.06	6.30	7.75	2.02	5.23	2.30	2.40	0.00		40.87		
100H	TANF 45-64 M & F WIT	0.67	2.89	3.95	0.00	1.45	7.17	5.43	3.93	2.27	4.41	5.88	0.00		38.05		
100J	TANF 65+ M & F WITH	3.73	4.60	0.00	0.00	0.50	1.60	0.00	0.88	2.18	0.50	1.41	0.00		15.40		
1011	TANF <1 M & F NON-ME	11,017.50	11,086.88	10,769.92	10,679.65	10,477.15	10,243.81	10,303.99	10,079.37	10,038.95	9,976.77	10,016.18	0.00		114,690.17		
1012	TANF 01-05 M & F NON	19,008.00	19,016.07	18,938.44	18,667.55	19,005.01	18,894.15	19,017.52	19,060.24	18,998.22	18,838.33	18,910.10	0.00		208,353.63		
1013	TANF 06-13 M & F NON	32,007.97	32,298.74	32,509.94	32,548.18	32,491.54	32,559.97	33,114.07	33,533.43	33,811.15	34,266.52	34,469.46	0.00		363,610.97		
1014	TANF 14-20 MALE NON-	8,747.23	8,746.05	8,796.78	8,899.28	8,753.69	8,780.99	8,958.56	9,216.86	9,621.13	9,788.51	9,931.30	0.00		100,240.38		
1015	TANF 14-20 FEMALE N O	11,247.71	11,274.27	11,314.35	11,228.09	11,221.30	11,332.27	11,491.01	11,777.20	12,053.89	12,166.78	12,265.19	0.00		127,372.06		
1016	TANF 21-44 MALE NON-	25,347.52	25,494.28	25,080.96	25,018.18	24,885.31	24,631.32	24,677.74	24,573.65	24,405.77	24,306.83	24,383.72	0.00		272,805.28		
1017	TANF 21-44 FEMALE N O	82,425.80	83,540.55	83,075.64	83,074.37	82,834.80	82,405.71	82,787.71	82,662.74	82,408.77	82,264.27	82,610.51	0.00		910,090.87		
1018	TANF 45-64 M & F NON	20,379.55	20,434.64	20,264.98	20,338.35	19,932.29	19,768.14	19,885.12	19,834.87	19,707.40	19,770.17	19,825.49	0.00		220,141.00		
1019	TANF 65+ M & F NON-M	71.48	68.12	70.22	78.44	72.06	72.24	72.08	75.67	76.60	81.62	80.76	0.00		819.29		
101A	TANF < 1 M & F NON-M	956.78	1,262.53	827.84	772.13	770.37	650.60	712.51	501.46	569.53	529.92	579.64	0.00		8,133.31		
101B	TANF 01-05 M & F NON	156.06	267.71	211.86	202.62	199.19	182.15	194.04	220.08	156.05	163.38	161.20	0.00		2,114.34		
101C	TANF 06-13 M & F NON	115.92	125.77	94.20	96.69	105.54	144.99	163.02	147.89	126.34	129.31	122.68	0.00		1,372.35		
101D	TANF 14-20 MALE NON-	58.19	73.98	49.79	46.25	62.44	47.01	58.91	134.29	34.44	93.33	49.64	0.00		708.27		
101E	TANF 14-20 FEMALE N O	127.15	158.01	90.47	115.53	101.62	97.06	115.68	116.60	105.39	87.35	79.42	0.00		1,194.28		
101F	TANF 21-44 MALE NON-	704.65	874.91	696.66	642.50	657.73	603.49	857.00	626.01	683.55	535.79	669.88	0.00		7,552.17		
101G	TANF 21-44 FEMALE N O	1,759.37	2,318.30	1,720.54	1,669.64	1,480.51	1,628.00	1,894.45	1,495.45	1,548.26	1,264.96	1,659.65	0.00		18,439.13		
101H	TANF 44-64 M & F NON	320.02	486.27	387.20	376.85	347.19	409.37	454.19	315.71	289.95	313.87	363.72	0.00		4,064.34		
101J	TANF 65+ N & F NON-M	1.51	0.00	2.63	1.31	0.93	1.57	0.90	2.30	0.00	0.86	2.06	0.00		14.07		
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	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00		10.00		
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	78.00	81.05	75.06	73.08	68.31	62.92	64.28	62.00	66.43	0.00		768.25		
1027	TANF 21-44 FEMALE WI	113.41	116.05	119.29	124.06	138.90	139.82	134.59	131.14	129.32	112.46	104.00	0.00		1,363.04		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
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	141.15	136.21	139.09	141.41	132.50	132.00	121.39	120.93	116.63	0.00		1,437.51		
1029	TANF 65+ M & F WITH	77.00	85.00	75.00	64.24	63.00	56.83	51.70	60.64	65.00	56.86	52.54	0.00		707.81		
102F	TANF 21-44 MALE WITH	1.87	0.00	0.00	0.45	0.00	0.09	0.67	0.00	0.51	0.00	0.00	0.00		3.59		
102G	TANF 21-44 FEMALE WI	0.16	3.61	0.00	5.93	0.00	0.41	3.22	0.00	0.00	0.53	0.00	0.00		13.86		
102H	TANF 44-64 M & F WIT	1.00	1.00	0.63	0.35	2.89	0.16	0.48	0.00	0.00	0.06	0.22	0.00		6.79		
102J	TANF 65+ M & F WITH	0.00	0.00	0.00	0.74	0.00	0.16	0.00	0.35	0.00	0.06	1.96	0.00		3.27		
2100	SSI AGED WITH MEDIC A	4,176.51	4,200.79	4,148.02	4,207.12	4,143.47	4,109.10	4,131.19	4,134.71	4,153.47	4,123.33	4,171.50	0.00		45,699.21		
210Z	SSI AGED WITH MEDIC
A	245.48	303.28	205.63	271.52	206.45	272.80	305.64	221.28	304.69	180.25	256.45	0.00		2,773.47		
2110	SSI AGED NON-MEDIC AR	6,259.71	6,412.91	6,378.31	6,477.93	6,541.96	6,544.93	6,603.49	6,707.96	6,709.61	6,731.40	6,735.36	0.00		72,103.57		
211Z	SSI AGED NON-MEDIC
AR	148.41	185.84	108.40	150.22	152.39	148.05	146.84	171.96	149.27	97.51	113.76	0.00		1,572.65		
2120	SSI AGED WITH QMB	29,956.77	30,317.97	30,567.73	30,632.60	30,816.78	30,978.16	31,164.89	31,185.63	31,291.48	31,294.74	31,417.44	0.00		339,624.19		
212Z	SSI AGED WITH QMB P P	59.79	56.71	41.40	32.70	68.90	33.66	54.93	51.57	73.14	37.41	66.58	0.00		576.79		
2200	SSI DISABLED WITH M
E	3,486.08	3,507.04	3,510.41	3,500.31	3,499.43	3,506.91	3,542.90	3,518.51	3,527.02	3,545.51	3,562.61	0.00		38,706.73		
220Z	SSI DISABLED WITH M E	190.54	330.81	206.45	153.91	169.62	224.67	236.44	211.53	170.81	201.16	215.66	0.00		2,311.60		
2210	SSI DISABLED NON-ME
D	52,332.20	52,322.41	52,304.73	52,017.34	52,051.96	51,878.67	51,892.43	51,743.89	51,705.72	51,556.06	51,610.29	0.00		571,415.70		
221Z	SSI DISABLED NON-ME D	697.62	977.94	615.00	492.31	833.60	805.45	654.47	724.12	762.49	707.57	822.95	0.00		8,093.52		
2220	SSI DISABLED WITH Q
M	26,997.33	27,021.26	27,123.98	26,970.13	27,051.49	27,007.41	26,979.81	26,849.15	26,706.62	26,568.53	26,511.53	0.00		295,787.24		
222Z	SSI DISABLED WITH Q M	39.44	60.60	91.33	77.43	51.35	51.10	70.71	61.86	38.37	39.19	63.64	0.00		645.02		
2300	SSI BLIND WITH MEDIC	26.00	27.99	27.53	29.29	31.20	31.61	19.38	29.00	30.16	29.86	27.99	0.00		310.01		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	8.46	3.70	0.90	0.38	12.00	0.50	0.00	0.26	0.00	0.00		26.20		
2310	SSI BLIND NON-MEDIC A	507.76	506.81	511.60	502.72	510.47	499.38	496.75	491.90	501.17	496.57	497.97	0.00		5,523.10		
231Z	SSI BLIND NON-MEDIC
A	3.82	33.65	7.52	4.98	0.76	0.00	8.02	3.05	28.08	2.55	9.07	0.00		101.50		
2320	SSI BLIND WITH QMB	224.99	227.50	226.70	224.33	223.92	228.32	231.00	229.85	228.37	227.12	230.06	0.00		2,502.16		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00		0.03		
4301	SOBRA CHILD <1 M & F	1.00	1.00	1.00	1.70	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00		11.70		
4302	SOBRA CHILD 01-05 M	31.00	5.52	14.00	2.00	3.00	3.00	2.00	2.00	2.00	2.00	2.00	0.00		68.52		
4303	SOBRA CHILD 06-13 M	27.15	-4.91	17.00	6.00	6.00	6.00	4.00	4.00	4.16	4.73	5.00	0.00		79.13		
4304	SOBRA CHILD 14-20 MA	7.00	-17.35	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.73	1.00	0.00		-3.62		
4305	SOBRA CHILD 14-20 FE	11.00	4.00	9.00	2.00	2.00	2.00	3.00	3.00	3.00	3.00	4.00	0.00		46.00		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.29		
430C	SOBRA CHILD 06-13 M	0.00	0.96	0.00	0.00	0.00	0.00	0.00	0.00	0.16	0.03	0.00	0.00		1.15		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00		0.03		
4311	SOBRA CHILD <1 M & F	35,058.63	35,759.06	35,697.72	35,647.05	35,864.85	36,040.64	36,304.86	36,120.87	36,217.46	35,739.03	35,760.97	0.00		394,211.14		
4312	SOBRA CHILD 01-05 M	172,167.95	173,794.34	172,632.59	170,765.35	171,989.21	170,926.87	170,882.60	170,125.59	169,364.11	167,381.81	167,227.82	0.00		1,877,258.24		
4313	SOBRA CHILD 06-13 M	215,942.10	217,915.02	216,795.96	217,704.25	216,664.34	215,974.29	215,898.74	214,323.03	213,586.05	213,228.50	214,240.12	0.00		2,372,272.40		
4314	SOBRA CHILD 14-20 MA	55,854.27	56,481.50	56,374.86	57,799.27	56,732.86	56,853.45	56,829.07	56,606.15	56,532.42	57,590.16	57,911.64	0.00		625,565.65		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	55,885.49	56,613.63	56,604.26	58,049.03	57,011.31	57,145.54	57,370.22	56,939.32	56,910.28	57,803.37	58,126.89	0.00		628,459.34		
431A	SOBRA CHILD < 1 M &	298.08	424.49	372.11	409.80	422.43	373.94	395.93	348.21	348.20	346.38	456.13	0.00		4,195.70		
431B	SOBRA CHILD 01-05 M	3,988.50	4,928.80	3,836.29	4,133.34	3,847.22	3,829.69	4,703.27	3,932.67	4,192.30	3,334.78	3,936.26	0.00		44,663.12		
431C	SOBRA CHILD 6-13 M& F	4,063.34	5,362.04	4,143.92	4,134.96	3,570.40	3,696.10	4,255.54	3,646.56	3,619.19	3,184.20	3,512.59	0.00		43,188.84		
431D	SOBRA CHILD 14-20 MA	1,078.33	1,524.30	1,146.13	1,103.92	1,028.10	934.34	1,104.28	949.44	949.24	818.27	952.65	0.00		11,589.00		
431E	SOBRA CHILD 14-20 FE	1,168.36	1,498.74	1,147.28	1,199.12	1,034.54	1,061.68	1,152.56	937.39	968.86	815.66	984.97	0.00		11,969.16		
4321	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4322	SOBRA CHILD 01-05 M	4.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00		15.00		
4323	SOBRA CHILD 06-13 M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00		3.00		
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	1.00	1.00	2.60	2.00	1.00	1.00	1.00	1.00	1.00	0.00		13.60		
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	34.80	30.27	23.42	22.97	25.01	21.71	19.79	20.23	24.53	0.00		291.00		
5008	SOBRA PREG 45-64 FE M	2.48	3.00	3.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00		24.48		
500G	SOBRA PREG 21-44 FE
M	2.08	4.17	1.46	2.11	0.43	2.38	3.94	1.28	1.35	0.86	12.08	0.00		32.14		
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	2.00	1.00	1.00	2.00	2.00	2.00	3.00	3.00	2.00	0.00		21.48		
5015	SOBRA PREG 14-20 FE M	3,175.39	3,235.70	3,106.60	3,029.11	3,053.55	2,934.46	2,936.30	2,852.81	2,843.88	2,732.48	2,757.39	0.00		32,657.67		
5017	SOBRA PREG 21-44 FE
M	17,106.35	17,031.92	16,618.30	16,882.98	16,423.32	15,690.40	15,621.20	15,405.45	15,192.47	15,149.85	15,317.32	0.00		176,439.56		
5018	SOBRA PREG 45-64 FE M	39.78	39.17	37.83	33.76	33.79	30.96	30.39	28.00	30.68	33.95	32.78	0.00		371.09		
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	218.41	215.07	240.11	264.61	257.81	248.62	204.04	227.23	243.41	0.00		2,614.94		
501G	SOBRA PREG 21-44 FE
M	979.10	1,126.83	926.28	1,033.54	1,010.39	1,102.35	1,187.65	1,117.58	1,089.15	1,001.59	1,170.38	0.00		11,744.84		
501H	SOBRA PREG 45-64 FE M	3.18	0.86	1.16	4.19	1.93	3.01	6.54	0.00	5.27	4.02	3.17	0.00		33.33		
5025	SOBRA PREG 14-20 FE
M	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00		8.00		
5027	SOBRA PREG 21-44 FE M	44.21	44.98	42.00	41.64	43.00	39.43	41.44	44.00	37.99	32.90	25.96	0.00		437.55		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	2.00	2.00	2.00	1.00	1.00	1.00	1.00	1.00	0.00		14.00		
502G	SOBRA PREG 21-44 FE M	0.77	0.00	0.00	0.35	0.00	1.63	1.43	0.00	0.00	0.10	0.00	0.00		4.28		
SUBTOTAL:	907,939.4	9	921,034.28	911,720.0	4	913,384.12	909,720.82	906,668.72	911,257.55	905,283.83	904,036.30	900,757.58	906,071.80	0.00		9,997,874.53		

3100	TRANSPLANT OPTION 1	0.00	0.00	0.00	1.00	1.10	2.38	1.00	4.00	4.00	4.00	4.00	0.00	

21.48

9910	TANF & SOBRA CHILDR E	257.00	286.00	276.00	293.00	265.00	283.00	328.00	271.00	279.00	258.00	300.00	0.00	
9920	SSI W/MEDICARE KICK	4.00	8.00	4.00	2.00	6.00	6.00	8.00	4.00	9.00	5.00	4.00	0.00	
9921	SSI W/O MEDICARE KI C	18.00	30.00	26.00	18.00	20.00	24.00	16.00	21.00	21.00	24.00	21.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,079.00	2,340.00	2,243.00	2,333.00	2,155.00	2,180.00	2,228.00	1,909.00	2,025.00	1,759.00	1,887.00	0.00	
SUBTOTAL:	2,358.00	2,664.00	2,549.0	0	2,646.00	2,446.00	2,493.00	2,580.00	2,205.00	2,334.00	2,046.00	2,212.00	0.00	

 
3,096.00	
60.00	
239.00	
23,138.00	
26,533.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
310Z	TRANSPLANT OPTION 1	0.00	0.00	0.00	0.00	1.90	1.60	3.00	0.00	0.00	0.00	0.00	0.00		6.50		
SUBTOTAL:	0.00	0.00	0.00	1.00	3.00	3.98	4.00	4.00	4.00	4.00	4.00	0.00		27.98		

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	227.32	229.03	224.44	217.98	220.75	222.86	220.86	213.52	219.43	0.00	
1107	TANF EXPANDED 21-44	518.35	528.10	512.09	503.29	482.75	484.90	467.62	467.64	453.94	430.34	441.82	0.00	
1108	TANF EXPANDED 45-64	1,295.07	1,321.46	1,265.78	1,269.10	1,262.77	1,256.42	1,272.56	1,256.00	1,227.25	1,237.08	1,233.29	0.00	
1109	TANF EXPANDED 65+
M&	625.28	624.99	631.28	646.93	643.45	629.59	639.67	634.56	633.77	631.78	633.53	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	
110F	TANF EXPANDED 21-44	8.55	14.90	12.09	13.45	12.89	13.87	14.81	7.73	11.99	8.13	10.76	0.00	
110G	TANF EXPANDED 21-44	34.70	23.97	22.99	36.79	19.21	29.13	15.73	16.77	28.06	16.64	32.53	0.00	
110H	TANF EXPANDED 45-64	49.74	54.77	37.48	39.87	35.56	35.05	46.95	33.97	27.24	38.87	47.33	0.00	
110J	TANF EXPANDED 65+
M&	32.89	39.35	26.31	26.52	17.27	29.63	30.50	24.50	18.62	24.00	35.38	0.00	
1112	TANF EXPANDED 01-05	2.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	
1113	TANF EXPANDED 06-13	14.00	13.00	12.00	12.00	12.00	12.00	11.48	11.00	10.00	9.00	8.00	0.00	
1114	TANF EXPANDED 14-20	316.58	321.07	314.15	270.91	286.81	267.93	263.56	262.81	238.60	226.48	229.48	0.00	
1115	TANF EXPANDED 14-20	1,480.23	1,516.45	1,501.53	1,389.90	1,472.43	1,466.13	1,486.69	1,481.31	1,500.16	1,460.18	1,467.90	0.00	
1116	TANF EXPANDED 21-44	27,236.57	27,445.72	27,226.88	27,322.14	27,176.21	27,054.16	27,037.53	26,905.20	26,771.61	26,638.62	26,674.63	0.00	
1117	TANF EXPANDED 21-44	67,974.34	68,675.60	68,700.06	69,232.31	69,549.52	69,902.80	70,377.95	70,128.22	70,287.63	70,476.78	70,811.54	0.00	
1118	TANF EXPANDED 45-64	24,170.25	24,302.86	24,153.13	24,551.10	24,406.45	24,371.99	24,322.05	24,218.06	24,161.82	24,297.17	24,219.64	0.00	
1119	TANF EXPANDED 65+
M&	65.57	68.01	72.00	65.47	67.98	69.67	73.00	74.64	70.96	75.00	74.12	0.00	
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.51	0.00	0.00	0.00	0.00	0.00	
111D	TANF EXPANDED 14-20	21.24	16.68	9.29	13.90	13.42	6.45	8.50	22.33	4.96	10.17	7.53	0.00	
111E	TANF EXPANDED 14-20	32.75	40.19	29.44	37.54	38.84	30.64	31.66	28.42	42.90	33.20	35.75	0.00	
111F	TANF EXPANDED 21-44	758.18	949.43	720.71	762.71	669.46	728.55	936.45	706.63	813.30	623.81	707.89	0.00	
111G	TANF EXPANDED 21-44	1,310.31	1,719.26	1,354.93	1,501.67	1,377.88	1,373.30	1,702.39	1,281.51	1,355.27	1,133.13	1,425.95	0.00	
111H	TANF EXPANDED 45-64	469.75	558.68	428.25	494.30	486.74	517.59	545.77	421.68	439.65	383.89	482.22	0.00	
111J	TANF EXPANDED 65+
M&	2.41	4.17	0.00	2.50	5.99	1.30	0.00	2.34	1.02	0.00	2.85	0.00	
1125	TANF EXPANDED 14-20	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	832.10	831.22	829.15	837.15	836.11	835.93	835.52	828.97	818.95	785.10	771.60	0.00	
1127	TANF EXPANDED 21-44	1,691.85	1,691.90	1,699.59	1,669.78	1,669.72	1,674.12	1,680.89	1,670.93	1,670.75	1,668.59	1,663.71	0.00	
1128	TANF EXPANDED 45-64	2,481.86	2,523.90	2,518.64	2,523.45	2,511.03	2,519.88	2,528.50	2,524.50	2,532.27	2,522.04	2,508.00	0.00	
1129	TANF EXPANDED 65+
M&	1,349.11	1,380.02	1,387.54	1,406.91	1,423.94	1,427.40	1,421.80	1,438.04	1,455.57	1,479.68	1,489.13	0.00	
112F	TANF EXPANDED 21-44	3.54	1.82	12.53	5.83	1.79	1.85	9.52	0.67	11.38	1.30	1.76	0.00	
112G	TANF EXPANDED 21-44	6.93	10.69	6.54	8.77	5.15	9.49	25.21	4.91	0.60	13.58	5.68	0.00	

 
0.00	
0.54	
2,489.25	
5,290.84	
13,896.78	
6,974.83	
0.45	
129.17	
276.52	
446.83	
304.97	
13.00	
124.48	
2,998.38	
16,222.91	
297,489.27	
766,116.75	
267,174.52	
776.42	
0.51	
134.47	
381.33	
8,377.12	
15,535.60	
5,228.52	
22.58	
6.00	
9,041.80	
18,451.83	
27,694.07	
15,659.14	
51.99	
97.55	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
112H	TANF EXPANDED 45-64	13.05	14.25	2.39	8.96	11.50	7.66	21.04	3.03	14.72	6.90	3.73	0.00		107.23		
112J	TANF EXPANDED 65+
M&	4.63	5.80	3.99	6.57	5.31	3.52	9.92	10.32	1.43	3.69	2.42	0.00		57.60		
2400	SSI AGED EXPANDED WI	231.60	267.09	206.76	244.02	208.73	200.87	220.39	222.28	209.44	224.92	236.81	0.00		2,472.91		
240Z	SSI AGED EXPANDED
WI	178.66	203.57	185.72	169.75	183.94	164.01	208.83	205.60	196.19	182.38	194.48	0.00		2,073.13		
2410	SSI AGED EXPANDED NO	85.53	89.59	76.35	81.16	92.12	89.70	84.53	86.20	85.84	88.72	97.64	0.00		957.38		
241Z	SSI AGED EXPANDED
NO	6.22	2.08	4.72	5.29	3.75	18.22	4.41	3.75	2.94	10.25	4.02	0.00		65.65		
2420	SSI AGED EXPANDED WI	24,113.73	24,390.90	24,581.34	24,735.68	24,944.44	25,061.57	25,194.04	25,362.04	25,621.31	25,724.38	25,884.29	0.00		275,613.72		
242Z	SSI AGED EXPANDED
WI	38.31	26.28	45.38	62.40	52.17	50.03	29.89	46.55	36.01	50.84	49.50	0.00		487.36		
2520	SSI BLIND EXPANDED W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00		4.00		
2600	SSI DISABLED EXPAND
E	217.26	225.36	197.83	222.93	229.03	211.51	238.54	215.58	205.44	195.11	206.12	0.00		2,364.71		
260Z	SSI DISABLED EXPAND E	134.96	186.87	114.08	107.31	144.02	138.32	162.18	133.41	119.65	113.42	128.41	0.00		1,482.63		
2610	SSI DISABLED EXPAND
E	1,460.45	1,434.70	1,438.44	1,401.44	1,394.53	1,379.45	1,359.93	1,358.02	1,350.26	1,410.55	1,462.17	0.00		15,449.94		
261Z	SSI DISABLED EXPAND E	24.07	19.33	23.99	25.07	52.35	28.37	32.53	29.30	27.82	35.40	37.30	0.00		335.53		
2620	SSI DISABLED EXPAND
E	16,945.02	16,927.12	17,002.43	17,045.11	17,068.53	17,067.71	17,055.38	17,144.18	17,104.72	16,976.36	16,877.52	0.00		187,214.08		
262Z	SSI DISABLED EXPAND E	24.45	57.43	29.04	34.70	22.69	44.17	29.60	43.04	28.95	46.72	43.14	0.00		403.93		
SUBTOTAL:	176,512.1	7	178,774.55	177,626.1	6	179,025.71	179,124.92	179,434.86	180,660.78	179,542.50	179,815.85	179,509.72	180,471.00	0.00		1,970,498.22		

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	1.00	1.29	1.00	0.00	1.40	0.78	0.00	1.86	5.05	0.00	
3507	ADULT 40-100% FEMAL E	0.73	2.25	1.43	0.00	0.00	0.77	0.00	2.00	3.90	2.90	3.00	0.00	
3508	ADULT 40-100% M&F 45	20.56	14.25	16.42	13.17	14.26	14.76	18.88	29.67	37.48	30.00	33.35	0.00	
3509	ADULT 40-100% M&F 65	0.00	4.00	3.00	6.00	5.00	3.00	4.22	4.00	2.00	6.00	4.00	0.00	
350F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.70	1.00	0.00	3.58	0.00	0.00	0.13	2.92	0.00	
350G	ADULT 40-100% FEMAL E	1.25	1.09	0.00	0.00	0.00	0.22	0.00	0.00	0.09	1.10	0.00	0.00	
350H	ADULT 40-100% M&F 45	4.40	3.39	1.56	0.92	1.63	4.32	4.08	8.96	1.47	0.00	1.63	0.00	
350J	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	5,604.83	5,716.59	5,713.86	5,532.67	5,651.83	5,714.47	5,761.88	5,798.85	5,759.97	5,514.39	5,575.44	0.00	
3515	ADULT 40-100% FEMAL E	6,062.39	6,191.65	6,184.67	6,095.81	6,294.62	6,305.59	6,296.11	6,344.01	6,313.09	6,128.07	6,134.38	0.00	
3516	ADULT 40-100% MALE 2	18,785.56	19,061.31	18,969.93	19,342.90	18,983.91	18,910.66	18,983.19	18,835.21	18,650.17	18,673.25	18,625.92	0.00	
3517	ADULT 40-100% FEMAL E	15,773.50	15,954.59	15,841.29	16,044.97	15,804.92	15,761.27	15,788.42	15,747.59	15,639.56	15,703.15	15,618.00	0.00	
3518	ADULT 40-100% M&F 45	38,601.45	38,912.21	38,584.85	38,669.51	38,209.65	38,165.11	38,100.42	37,830.57	37,754.61	37,584.00	37,615.04	0.00	
3519	ADULT 40-100% M&F 65	5.00	6.00	7.00	15.00	6.00	6.00	6.00	8.00	6.00	6.00	7.00	0.00	

1.99	
15.38	
16.98	
242.80	
41.22	
8.33	
3.75	
32.36	
1.00	
62,344.78	
68,350.39	
207,822.01	
173,677.26	
420,027.42	
78.00	

9911	SB PAYMENT FOR TAN F	163.00	193.00	182.00	165.00	178.00	190.00	187.00	155.00	201.00	185.00	176.00	0.00	
9922	SB PAYMENT FOR SSI
E	2.00	0.00	0.00	1.00	0.00	0.00	2.00	0.00	1.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	165.00	193.00	182.0	0	166.00	179.00	190.00	189.00	155.00	202.00	185.00	176.00	0.00	

 
1,975.00	
6.00	
1.00	
1,982.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351D	ADULT 40-100% MALE 1	105.63	105.66	101.65	115.78	127.17	87.83	114.13	74.09	103.84	66.47	87.69	0.00		1,089.94		
351E	ADULT 40-100% FEMAL E	138.29	167.28	124.96	138.98	111.24	145.73	153.66	133.67	119.08	115.45	142.93	0.00		1,491.27		
351F	ADULT 40-100% MALE 2	459.37	548.98	451.38	539.81	445.01	498.52	573.48	424.21	481.70	404.71	477.07	0.00		5,304.24		
351G	ADULT 40-100% FEMAL E	352.13	475.32	396.89	394.30	444.94	444.22	560.65	375.41	365.78	321.25	455.94	0.00		4,586.83		
351H	ADULT 40-100% M&F 45	766.85	899.11	711.92	785.71	711.48	967.36	1,118.02	773.46	734.19	685.91	836.16	0.00		8,990.17		
351J	ADULT 40-100% M&F 65	0.00	3.00	9.00	12.00	0.00	5.00	2.00	13.00	0.00	0.00	1.00	0.00		45.00		
3525	ADULT 40-100% FEMAL E	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
3526	ADULT 40-100% MALE 2	1.03	1.06	1.00	0.00	0.33	1.00	0.00	0.00	1.00	0.00	0.00	0.00		5.42		
3527	ADULT 40-100% FEMAL E	0.58	1.19	0.00	0.00	0.00	0.00	0.00	0.00	0.16	0.70	0.00	0.00		2.63		
3528	ADULT 40-100% M&F 45	0.00	0.12	0.76	-0.14	0.83	4.24	3.25	0.00	1.38	0.63	0.00	0.00		11.07		
3529	ADULT 40-100% M&F 65	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00		6.00		
352F	ADULT 40-100% MALE 2	0.96	0.93	0.00	0.00	0.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.55		
352G	ADULT 40-100% FEMAL E	0.41	1.80	0.00	0.00	0.00	0.00	0.00	0.00	0.83	0.30	0.00	0.00		3.34		
352H	ADULT 40-100% M&F 45	0.00	0.54	0.23	0.00	1.16	1.73	1.73	0.00	0.61	0.36	0.00	0.00		6.36		
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		0.00		
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	7.04	8.31	2.54	4.09	5.35	5.73	10.88	18.14	18.85	0.00		96.16		
3707	ADULT <40% EXP FEM AL	6.38	3.54	1.00	1.51	4.36	1.86	1.96	3.81	5.37	4.76	6.00	0.00		40.55		
3708	ADULT <40% EXP M&F
4	15.96	27.68	15.69	16.77	14.79	7.86	18.28	17.11	37.69	38.95	53.75	0.00		264.53		
3709	ADULT <40% EXP M&F 6	2.00	1.00	0.00	1.00	1.00	0.00	1.00	1.00	2.00	2.00	2.00	0.00		13.00		
370F	ADULT <40% EXP MALE	2.12	22.57	2.34	5.35	2.85	1.63	2.97	3.94	5.19	3.13	1.88	0.00		53.97		
370G	ADULT <40% EXP FEM AL	6.59	0.45	2.00	1.47	1.62	2.91	3.00	1.16	0.99	0.32	0.00	0.00		20.51		
370H	ADULT <40% EXP M&F
4	5.25	9.17	4.47	2.78	8.99	4.27	26.84	5.44	7.31	8.91	5.67	0.00		89.10		
3714	ADULT <40% EXP MALE	10,089.04	10,277.91	10,220.69	9,985.53	10,377.77	10,358.46	10,522.00	10,546.29	10,411.78	10,047.03	10,043.30	0.00		112,879.80		
3715	ADULT <40% EXP FEM AL	8,920.42	9,132.08	9,106.73	8,922.26	9,180.31	9,171.16	9,356.08	9,387.91	9,267.36	9,062.79	9,071.74	0.00		100,578.84		
3716	ADULT <40% EXP MALE	62,012.36	63,321.43	62,559.44	64,118.93	64,145.52	64,675.88	66,377.81	66,794.35	66,923.73	67,509.59	68,193.98	0.00		716,633.02		
3717	ADULT <40% EXP FEM AL	36,532.66	37,224.62	37,115.83	37,840.02	37,849.60	38,167.63	39,044.73	39,283.52	39,626.28	39,839.83	40,224.54	0.00		422,749.26		
3718	ADULT <40% EXP M&F
4	75,882.36	77,152.76	76,582.80	77,857.23	77,568.47	77,992.39	79,243.48	79,761.80	80,117.08	80,750.55	81,233.67	0.00		864,142.59		
3719	ADULT <40% EXP M&F 6	22.00	23.00	24.00	22.00	14.00	13.00	17.00	16.00	18.00	16.00	14.00	0.00		199.00		
371D	ADULT <40% EXP MALE	286.90	308.21	254.56	319.04	252.85	273.83	390.85	263.79	267.46	188.89	256.96	0.00		3,063.34		
371E	ADULT <40% EXP FEM AL	256.11	316.43	214.90	224.05	261.69	230.58	295.09	256.21	230.60	185.38	219.83	0.00		2,690.87		
371F	ADULT <40% EXP MALE	2,465.20	3,042.25	2,237.04	2,482.83	2,349.09	2,287.77	2,583.04	2,186.88	2,046.01	1,796.46	2,245.66	0.00		25,722.23		
371G	ADULT <40% EXP FEM AL	1,439.34	1,694.05	1,372.81	1,446.86	1,333.97	1,385.93	1,654.22	1,237.27	1,206.58	1,068.01	1,221.86	0.00		15,060.90		
371H	ADULT <40% EXP M&F
4	2,055.68	2,804.01	1,949.01	2,180.98	1,943.63	2,287.08	2,717.56	1,949.70	1,917.19	1,561.96	2,057.31	0.00		23,424.11		
371J	ADULT <40% EXP M&F 6	2.00	4.00	4.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	1.00	0.00		13.00		
3726	ADULT <40% EXP MALE	1.00	2.41	0.66	2.25	0.50	-0.66	1.00	0.85	2.77	2.59	4.73	0.00		18.10		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3727	ADULT <40% EXP FEM AL	1.77	1.28	1.22	1.00	1.00	0.00	1.67	2.07	3.37	2.56	1.48	0.00		17.42		
3728	ADULT <40% EXP M&F
4	3.00	3.50	4.76	0.90	7.30	2.92	1.96	2.00	4.35	10.52	5.27	0.00		46.48		
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	0.73	1.50	1.00	0.00	1.14	0.00	1.39	1.24	0.00		7.57		
372G	ADULT <40% EXP FEM AL	1.22	0.70	2.76	0.00	0.00	0.00	1.31	0.92	1.60	1.43	0.51	0.00		10.45		
372H	ADULT <40% EXP M&F
4	0.00	1.15	2.22	1.09	1.86	1.05	16.02	1.00	5.03	0.77	1.01	0.00		31.20		
SUBTOTAL:	286,708.6	2	293,455.45	288,810.7	7	293,153.27	292,141.85	293,912.44	299,780.32	298,134.37	298,096.53	297,369.59	300,513.76	0.00		3,242,076.97		

3906	NEWLY ELIGIBLE MALE	4.00	2.00	4.45	2.00	2.56	3.90	4.74	4.50	4.93	3.00	6.90	0.00	
3907	NEWLY ELIGIBLE FEMA L	2.53	1.90	1.43	1.00	1.00	2.44	1.41	1.50	4.00	2.82	4.51	0.00	
3908	NEWLY ELIGIBLE M&F
4	42.80	37.62	25.21	20.00	19.29	16.44	22.73	42.71	61.56	57.15	48.16	0.00	
3909	NEWLY ELIGIBLE M&F 6	8.25	9.89	7.66	10.00	9.00	9.00	7.00	9.00	7.00	27.26	18.98	0.00	
390F	NEWLY ELIGIBLE MALE	0.00	0.00	1.52	0.00	0.43	0.09	0.25	0.50	0.96	0.00	0.09	0.00	
390G	NEWLY ELIGIBLE FEMA L	0.45	0.09	0.56	0.00	0.00	1.90	0.58	1.50	0.00	3.16	1.48	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.92	7.38	2.52	1.95	4.29	6.54	3.25	2.28	0.00	2.26	2.79	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	23.08	1.66	0.00	0.00	0.00	0.00	0.00	0.00	0.73	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	3,049.98	3,132.73	3,088.43	3,031.35	3,129.64	3,094.86	3,124.20	3,147.66	3,148.12	3,070.76	3,061.54	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,531.41	3,582.05	3,583.90	3,492.06	3,643.34	3,621.49	3,655.47	3,713.53	3,707.11	3,587.29	3,587.52	0.00	
3916	NEWLY ELIGIBLE MALE	16,854.19	17,068.77	16,905.00	17,054.96	16,940.75	16,906.86	17,061.49	17,071.42	17,013.64	16,979.07	17,023.30	0.00	
3917	NEWLY ELIGIBLE FEMA L	24,434.24	24,850.92	24,642.23	24,897.57	24,802.00	24,908.81	25,313.91	25,515.75	25,554.77	25,631.63	25,609.23	0.00	
3918	NEWLY ELIGIBLE M&F
4	26,059.28	26,284.01	26,103.05	26,294.23	26,080.10	26,150.97	26,332.57	26,370.00	26,226.19	26,122.51	26,050.88	0.00	
3919	NEWLY ELIGIBLE M&F 6	10.00	9.00	9.00	11.00	4.00	2.00	2.06	0.00	-0.06	2.00	1.00	0.00	
391D	NEWLY ELIGIBLE MALE	88.14	98.35	58.28	68.92	62.59	61.76	89.08	81.41	73.98	60.62	60.44	0.00	
391E	NEWLY ELIGIBLE FEMA L	86.05	84.46	66.37	89.44	80.76	98.96	104.93	104.16	80.84	74.38	92.43	0.00	
391F	NEWLY ELIGIBLE MALE	540.59	723.93	566.21	640.15	584.26	585.45	721.71	523.63	627.90	531.76	567.64	0.00	
391G	NEWLY ELIGIBLE FEMA L	784.50	1,041.67	841.36	862.70	887.54	905.30	1,052.09	871.03	909.76	701.39	876.24	0.00	
391H	NEWLY ELIGIBLE M&F
4	687.43	742.80	652.28	741.40	639.39	852.22	999.16	682.19	630.41	556.71	707.62	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	1.00	4.00	0.00	0.00	0.00	0.03	0.00	-0.03	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.22	1.00	0.00	0.20	0.00	1.06	0.00	0.00	0.00	0.48	0.00	
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	
3928	NEWLY ELIGIBLE M&F
4	0.48	1.40	0.16	0.35	0.00	0.00	2.00	2.00	1.00	1.00	1.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	2.00	0.00	
392F	NEWLY ELIGIBLE MALE	0.00	0.77	0.00	0.00	0.80	0.00	0.93	0.00	0.00	0.00	0.51	0.00	

42.98	
24.54	
393.67	
123.04	
3.84	
9.72	
34.18	
25.47	
34,079.27	
39,705.17	
186,879.45	
276,161.06	
288,073.79	
50.00	
803.57	
962.78	
6,613.23	
9,733.58	
7,891.61	
5.00	
2.96	
0.45	
9.39	
5.00	
3.01	

9935	BIRTH SUPP PAYMENT A	34.00	43.00	30.00	35.00	34.00	27.00	29.00	38.00	32.00	40.00	31.00	0.00	
9937	BIRTH SUPP PAYMENT
A	72.00	94.00	83.00	77.00	75.00	74.00	83.00	66.00	76.00	59.00	65.00	0.00	
SUBTOTAL:	106.00	137.00	113.0	0	112.00	109.00	101.00	112.00	104.00	108.00	99.00	96.00	0.00	

 
373.00	
824.00	
1,197.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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	0.83	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.92		
SUBTOTAL:	76,185.75	77,706.61	76,567.1	1	77,220.08	76,891.94	77,228.99	78,500.65	78,144.77	78,053.08	77,416.50	77,724.74	0.00		851,640.22		

674.00

9939	BIRTH SUPP PAYMENT N	41.00	72.00	54.00	67.00	71.00	56.00	65.00	60.00	65.00	70.00	53.00	0.00	
SUBTOTAL:	41.00	72.00	54.00	67.00	71.00	56.00	65.00	60.00	65.00	70.00	53.00	0.00	

674.00

4403	SOBRA 100-133% M&F
6	0.00	-1.00	1.00	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	1.00	0.00	0.00	1.00	1.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	44,135.08	44,679.66	44,365.22	44,080.49	44,470.32	44,584.05	44,978.53	45,265.56	45,341.63	44,290.61	43,242.86	0.00	
4414	SOBRA 100-133% MALE	11,766.33	11,924.95	11,818.83	12,132.26	11,927.17	12,012.98	12,225.54	12,302.84	12,293.45	12,301.40	12,171.39	0.00	
4415	SOBRA 100-133% FEMA L	11,388.18	11,604.46	11,543.54	11,797.46	11,579.32	11,640.69	11,847.39	11,942.52	11,984.90	11,953.21	11,744.86	0.00	
441C	SOBRA 100-133% M&F
6	1,021.53	1,349.42	1,025.28	1,169.98	993.39	1,092.66	1,297.37	1,038.27	983.28	837.63	984.74	0.00	
441D	SOBRA 100-133% MALE	259.77	322.84	269.77	333.49	257.65	267.99	322.77	233.42	300.29	230.38	265.89	0.00	
441E	SOBRA 100-133% FEMA L	262.97	373.39	231.77	294.30	249.63	281.81	295.52	296.01	254.68	211.10	282.71	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	68,834.86	70,254.72	69,255.4	1	69,807.98	69,477.48	69,881.18	70,967.12	71,078.62	71,159.23	69,825.33	68,692.45	0.00	

0.00	
1.00	
0.00	
4.00	
489,434.01	
132,877.14	
129,026.53	
11,793.55	
3,064.26	
3,033.89	
0.00	
769,234.38	

9944	BIRTH SUPP PAYMENT S	4.00	7.00	5.00	6.00	7.00	2.00	3.00	6.00	7.00	6.00	4.00	0.00	
SUBTOTAL:	4.00	7.00	5.00	6.00	7.00	2.00	3.00	6.00	7.00	6.00	4.00	0.00	

57.00

57.00

4517	BC PATIENT FEMALE 2 1	21.19	23.57	22.00	20.67	21.99	21.67	21.67	21.78	22.00	25.00	26.00	0.00	
4518	BC PATIENT FEMALE 4
5	101.73	106.75	109.63	112.00	114.95	113.31	116.59	117.69	118.75	120.64	125.89	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.80	1.41	0.00	1.32	1.00	0.32	3.32	4.21	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	-14.44	10.20	1.49	0.00	12.33	11.66	13.38	3.48	8.20	1.16	4.08	0.00	
4617	CC PATIENT FEMALE 2
1	9.00	9.00	9.00	10.00	10.00	9.00	9.48	10.00	8.00	7.00	8.92	0.00	
4618	CC PATIENT FEMALE 4 5	10.22	10.00	10.00	9.00	9.00	10.00	8.70	9.31	7.19	7.00	6.36	0.00	
461G	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	1.51	0.00	0.00	0.00	6.05	0.00	
461H	CC PATIENT FEMALE 4 5	0.77	0.00	0.00	0.00	0.00	0.00	0.28	0.67	0.00	0.00	1.93	0.00	
SUBTOTAL:	129.27	160.93	152.1	2	152.99	169.27	165.96	174.93	167.14	165.14	161.80	179.23	0.00	

 
247.54	
1,257.93	
2.00	
12.38	
51.54	
99.40	
96.78	
7.56	
3.65	
1,778.78	

8600	SSI BLIND FREEDOM/W O	2.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	2.00	0.00	
8620	SSI BLIND FREEDOM/W
O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	2,223.69	2,293.07	2,275.85	2,274.58	2,232.43	2,202.71	2,174.56	2,164.13	2,202.88	2,182.54	2,219.70	0.00	
870Z	SSI DISABLED FREEDO
M	50.08	86.18	55.29	65.18	48.76	89.11	83.13	88.53	86.75	98.53	83.85	0.00	
8710	SSI DISABLED FREEDO M	423.80	417.03	416.96	416.97	408.80	406.97	397.73	391.64	386.20	387.80	377.82	0.00	

31.00	
7.00	
24,446.14	
835.39	
4,431.72	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
871Z	SSI DISABLED FREEDO M	25.03	20.91	12.04	21.37	28.84	38.07	26.36	21.18	26.06	7.56	15.70	0.00		243.12		
8720	SSI DISABLED FREEDO
M	285.36	300.10	306.99	318.18	312.26	319.84	322.01	322.79	322.34	339.28	347.18	0.00		3,496.33		
872Z	SSI DISABLED FREEDO M	3.60	15.79	5.36	2.79	3.69	7.46	12.00	7.50	11.53	15.81	2.79	0.00		88.32		
SUBTOTAL:	3,014.56	3,137.08	3,076.4	9	3,103.07	3,038.78	3,068.16	3,019.79	2,998.77	3,038.76	3,034.52	3,049.04	0.00		33,579.02		

6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	1.32	2.00	2.00	-0.46	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.03	0.00	0.00	-0.43	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	1.32	2.00	2.00	-0.46	1.03	0.00	0.00	-0.43	0.00	

 
4.86	
0.60	
5.46	

TOTAL:	1,521,998.72	1,547,596.62	1,530,111.10	1,538,846.54	1,533,382.06	1,533,208.29	1,547,313.68	1,537,885.03	1,537,084.89	1,530,485.04	1,539,246.59	0.00		16,897,158.56		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.96		
1009	TANF 65+ M & F WITH	15.96	15.96	15.96	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.84		
1011	TANF <1 M & F NON-ME	702.24	957.60	1,260.84	1,356.60	622.44	670.32	768.20	935.20	1,002.00	1,219.10	1,536.40	0.00		11,030.94		
1012	TANF 01-05 M & F NON	367.08	702.24	1,197.00	1,388.52	574.56	670.32	851.70	818.30	801.60	818.30	935.20	0.00		9,124.82		
1013	TANF 06-13 M & F NON	478.80	766.08	1,053.36	1,292.76	494.76	494.76	501.00	551.10	617.90	517.70	835.00	0.00		7,603.22		
1014	TANF 14-20 MALE NON-	31.92	95.76	159.60	191.52	79.80	47.88	50.10	50.10	83.50	116.90	167.00	0.00		1,074.08		
1015	TANF 14-20 FEMALE N O	271.32	462.84	606.48	766.08	79.80	63.84	66.80	83.50	116.90	217.10	317.30	0.00		3,051.96		
1016	TANF 21-44 MALE NON-	239.40	638.40	1,165.08	1,564.08	31.92	79.80	116.90	116.90	183.70	283.90	584.50	0.00		5,004.58		
1017	TANF 21-44 FEMALE N O	3,112.20	4,931.64	6,783.00	7,756.56	127.68	287.28	467.60	751.50	1,152.30	1,970.60	3,790.90	0.00		31,131.26		
1018	TANF 45-64 M & F NON	861.84	1,611.96	2,154.60	2,250.36	47.88	303.24	467.60	534.40	668.00	851.70	1,786.90	0.00		11,538.48		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	15.96	0.00	0.00	0.00	0.00	0.00	0.00		15.96		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.96		
2100	SSI AGED WITH MEDIC A	47.88	159.60	207.48	239.40	0.00	15.96	33.40	50.10	50.10	100.20	100.20	0.00		1,004.32		
2110	SSI AGED NON-MEDIC
AR	0.00	15.96	15.96	15.96	0.00	15.96	50.10	50.10	116.90	66.80	83.50	0.00		431.24		
2120	SSI AGED WITH QMB	414.96	1,101.24	1,500.24	1,819.44	0.00	127.68	183.70	200.40	300.60	617.90	835.00	0.00		7,101.16		
2200	SSI DISABLED WITH M E	319.20	670.32	941.64	1,212.96	31.92	47.88	66.80	83.50	116.90	183.70	317.30	0.00		3,992.12		
2210	SSI DISABLED NON-ME
D	2,713.20	4,724.16	6,080.76	7,038.36	606.48	1,228.92	1,586.50	1,820.30	2,254.50	2,955.90	4,642.60	0.00		35,651.68		
2220	SSI DISABLED WITH Q M	1,197.00	1,851.36	2,330.16	2,729.16	15.96	127.68	317.30	434.20	684.70	1,085.50	1,803.60	0.00		12,576.62		
2310	SSI BLIND NON-MEDIC
A	31.92	47.88	79.80	79.80	0.00	0.00	0.00	0.00	0.00	16.70	33.40	0.00		289.50		
2320	SSI BLIND WITH QMB	15.96	15.96	15.96	15.96	0.00	0.00	0.00	0.00	0.00	0.00	16.70	0.00		80.54		
4311	SOBRA CHILD <1 M & F	2,058.84	3,638.88	4,484.76	5,027.40	1,995.00	2,170.56	2,388.10	2,972.60	3,440.20	3,907.80	4,458.90	0.00		36,543.04		
4312	SOBRA CHILD 01-05 M	5,410.44	9,208.92	12,592.44	15,337.56	4,676.28	5,426.40	6,312.60	7,631.90	8,400.10	9,535.70	11,573.10	0.00		96,105.44		
4313	SOBRA CHILD 06-13 M	4,197.48	9,320.64	13,661.76	16,055.76	3,766.56	4,899.72	5,794.90	6,897.10	7,247.80	8,283.20	11,038.70	0.00		91,163.62		
4314	SOBRA CHILD 14-20 MA	813.96	1,947.12	3,048.36	3,606.96	798.00	1,085.28	1,252.50	1,269.20	1,352.70	1,569.80	1,953.90	0.00		18,697.78		
4315	SOBRA CHILD 14-20 FE	1,053.36	2,170.56	3,479.28	4,181.52	877.80	1,069.32	1,252.50	1,402.80	1,386.10	1,619.90	2,287.90	0.00		20,781.04		
5015	SOBRA PREG 14-20 FE M	239.40	191.52	223.44	255.36	15.96	15.96	0.00	33.40	66.80	50.10	116.90	0.00		1,208.84		
5017	SOBRA PREG 21-44 FE
M	1,197.00	1,197.00	1,356.60	1,532.16	0.00	15.96	33.40	167.00	300.60	450.90	818.30	0.00		7,068.92		
SUBTOTAL:	25,791.36	46,443.60	64,414.5	6	75,762.12	14,842.80	18,880.68	22,561.70	26,853.60	30,343.90	36,439.40	50,033.20	0.00		412,366.92		

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	15.96	31.92	33.40	33.40	33.40	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	63.84	95.76	127.68	111.72	0.00	0.00	16.70	50.10	16.70	33.40	33.40	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	15.96	15.96	15.96	47.88	50.10	50.10	50.10	100.20	133.60	0.00	
1115	TANF EXPANDED 14-20	31.92	63.84	111.72	47.88	15.96	15.96	33.40	33.40	33.40	33.40	33.40	0.00	
1116	TANF EXPANDED 21-44	239.40	526.68	798.00	1,053.36	0.00	31.92	50.10	50.10	83.50	150.30	417.50	0.00	
1117	TANF EXPANDED 21-44	1,292.76	2,074.80	2,936.64	3,543.12	95.76	255.36	417.50	534.40	701.40	1,135.60	2,020.70	0.00	
1118	TANF EXPANDED 45-64	494.76	957.60	1,356.60	1,915.20	79.80	207.48	267.20	450.90	668.00	935.20	1,503.00	0.00	

 
148.08	
549.30	
479.86	
454.28	
3,400.86	
15,008.04	
8,835.74	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	16.70	0.00		16.70		
1126	TANF EXPANDED 21-44	0.00	0.00	15.96	47.88	0.00	0.00	0.00	0.00	16.70	16.70	83.50	0.00		180.74		
1127	TANF EXPANDED 21-44	47.88	63.84	79.80	95.76	0.00	0.00	0.00	16.70	16.70	16.70	50.10	0.00		387.48		
1128	TANF EXPANDED 45-64	95.76	95.76	111.72	111.72	15.96	63.84	100.20	83.50	83.50	167.00	200.40	0.00		1,129.36		
1129	TANF EXPANDED 65+
M&	47.88	143.64	159.60	159.60	0.00	0.00	33.40	66.80	50.10	66.80	183.70	0.00		911.52		
2410	SSI AGED EXPANDED NO	0.00	31.92	31.92	31.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.76		
2420	SSI AGED EXPANDED
WI	223.44	446.88	734.16	909.72	47.88	159.60	267.20	350.70	484.30	768.20	1,302.60	0.00		5,694.68		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	16.70	0.00	0.00	0.00	0.00	0.00		16.70		
2610	SSI DISABLED EXPAND
E	31.92	31.92	47.88	63.84	0.00	47.88	50.10	50.10	83.50	116.90	133.60	0.00		657.64		
2620	SSI DISABLED EXPAND E	255.36	399.00	510.72	590.52	63.84	111.72	200.40	267.20	317.30	450.90	668.00	0.00		3,834.96		
SUBTOTAL:	2,824.92	4,931.64	7,038.3	6	8,698.20	351.12	973.56	1,536.40	2,037.40	2,638.60	3,991.30	6,780.20	0.00		41,801.70		

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.70	16.70	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	31.92	47.88	0.00	0.00	0.00	33.40	33.40	16.70	33.40	0.00	
3915	NEWLY ELIGIBLE FEMA L	31.92	31.92	95.76	111.72	15.96	15.96	16.70	16.70	16.70	33.40	50.10	0.00	
3916	NEWLY ELIGIBLE MALE	111.72	175.56	175.56	175.56	15.96	111.72	150.30	150.30	200.40	250.50	334.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	271.32	430.92	622.44	813.96	31.92	111.72	133.60	200.40	233.80	300.60	584.50	0.00	
3918	NEWLY ELIGIBLE M&F
4	191.52	399.00	478.80	526.68	15.96	335.16	434.20	534.40	634.60	901.80	1,252.50	0.00	
SUBTOTAL:	606.48	1,037.40	1,404.4	8	1,675.80	79.80	574.56	734.80	935.20	1,118.90	1,519.70	2,271.20	0.00	

33.40	
196.70	
436.84	
1,851.58	
3,735.18	
5,704.62	
11,958.32	

4413	SOBRA 100-133% M&F
6	574.56	1,101.24	1,755.60	1,899.24	1,005.48	989.52	1,052.10	1,068.80	1,369.40	1,636.60	1,903.80	0.00	
4414	SOBRA 100-133% MALE	63.84	223.44	383.04	430.92	143.64	143.64	167.00	217.10	267.20	334.00	334.00	0.00	
4415	SOBRA 100-133% FEMA L	255.36	430.92	574.56	590.52	175.56	175.56	200.40	217.10	267.20	250.50	317.30	0.00	

14,356.34	
2,707.82	
3,454.98	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	15.96	31.92	47.88	47.88	0.00	15.96	16.70	16.70	16.70	33.40	33.40	0.00	
3515	ADULT 40-100% FEMAL E	95.76	191.52	255.36	271.32	0.00	15.96	50.10	50.10	66.80	83.50	116.90	0.00	
3516	ADULT 40-100% MALE 2	95.76	175.56	303.24	399.00	15.96	79.80	83.50	100.20	167.00	217.10	400.80	0.00	
3517	ADULT 40-100% FEMAL E	143.64	143.64	159.60	223.44	15.96	95.76	167.00	183.70	250.50	317.30	551.10	0.00	
3518	ADULT 40-100% M&F 45	542.64	973.56	1,292.76	1,484.28	79.80	478.80	701.40	985.30	1,202.40	1,586.50	2,120.90	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	16.70	0.00	
3714	ADULT <40% EXP MALE	95.76	111.72	319.20	351.12	15.96	15.96	16.70	16.70	16.70	66.80	200.40	0.00	
3715	ADULT <40% EXP FEM AL	271.32	526.68	718.20	813.96	0.00	15.96	33.40	33.40	50.10	100.20	233.80	0.00	
3716	ADULT <40% EXP MALE	893.76	2,457.84	3,702.72	4,740.12	111.72	383.04	601.20	951.90	1,118.90	1,603.20	2,972.60	0.00	
3717	ADULT <40% EXP FEM AL	941.64	1,659.84	2,202.48	2,697.24	111.72	367.08	501.00	634.60	751.50	1,202.40	2,154.30	0.00	
3718	ADULT <40% EXP M&F
4	1,835.40	3,606.96	4,772.04	5,841.36	287.28	1,197.00	2,254.50	2,955.90	3,657.30	4,843.00	6,629.90	0.00	
SUBTOTAL:	4,931.64	9,879.24	13,773.4	8	16,885.68	638.40	2,665.32	4,425.50	5,928.50	7,297.90	10,053.40	15,430.80	0.00	

 
15.96	
276.50	
1,197.32	
2,037.92	
2,251.64	
11,448.34	
16.70	
1,227.02	
2,797.02	
19,537.00	
13,223.80	
37,880.64	
91,909.86	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	893.76	1,755.60	2,713.20	2,920.68	1,324.68	1,308.72	1,419.50	1,503.00	1,903.80	2,221.10	2,555.10	0.00		20,519.14		

8700	SSI DISABLED FREEDO M	0.00	0.00	15.96	15.96	31.92	31.92	16.70	16.70	33.40	50.10	50.10	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.70	16.70	16.70	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	15.96	16.70	16.70	16.70	16.70	33.40	0.00	
SUBTOTAL:	0.00	0.00	15.9	6	15.96	31.92	47.88	33.40	33.40	66.80	83.50	100.20	0.00	

 
262.76	
50.10	
116.16	
429.02	

6012	KIDS 1-5 M & F NON-M	15.96	15.96	47.88	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	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	15.96	15.96	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	31.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	79.80	63.84	111.7	2	15.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
79.80	
95.76	
31.92	
63.84	
271.32	

579,256.28

35,127.96	64,111.32	89,471.76	105,974.40	17,268.72	24,450.72	30,711.30	37,291.10	43,369.90	54,308.40	77,170.70	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1009	TANF 65+ M & F WITH	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1011	TANF <1 M & F NON-ME	44.00	60.00	79.00	85.00	39.00	42.00	46.00	56.00	60.00	73.00	92.00	0.00		676.00		
1012	TANF 01-05 M & F NON	23.00	44.00	75.00	87.00	36.00	42.00	51.00	49.00	48.00	49.00	56.00	0.00		560.00		
1013	TANF 06-13 M & F NON	30.00	48.00	66.00	81.00	31.00	31.00	30.00	33.00	37.00	31.00	50.00	0.00		468.00		
1014	TANF 14-20 MALE NON-	2.00	6.00	10.00	12.00	5.00	3.00	3.00	3.00	5.00	7.00	10.00	0.00		66.00		
1015	TANF 14-20 FEMALE N O	17.00	29.00	38.00	48.00	5.00	4.00	4.00	5.00	7.00	13.00	19.00	0.00		189.00		
1016	TANF 21-44 MALE NON-	15.00	40.00	73.00	98.00	2.00	5.00	7.00	7.00	11.00	17.00	35.00	0.00		310.00		
1017	TANF 21-44 FEMALE N O	195.00	309.00	425.00	486.00	8.00	18.00	28.00	45.00	69.00	118.00	227.00	0.00		1,928.00		
1018	TANF 45-64 M & F NON	54.00	101.00	135.00	141.00	3.00	19.00	28.00	32.00	40.00	51.00	107.00	0.00		711.00		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	3.00	10.00	13.00	15.00	0.00	1.00	2.00	3.00	3.00	6.00	6.00	0.00		62.00		
2110	SSI AGED NON-MEDIC
AR	0.00	1.00	1.00	1.00	0.00	1.00	3.00	3.00	7.00	4.00	5.00	0.00		26.00		
2120	SSI AGED WITH QMB	26.00	69.00	94.00	114.00	0.00	8.00	11.00	12.00	18.00	37.00	50.00	0.00		439.00		
2200	SSI DISABLED WITH M E	20.00	42.00	59.00	76.00	2.00	3.00	4.00	5.00	7.00	11.00	19.00	0.00		248.00		
2210	SSI DISABLED NON-ME
D	170.00	296.00	381.00	441.00	38.00	77.00	95.00	109.00	135.00	177.00	278.00	0.00		2,197.00		
2220	SSI DISABLED WITH Q M	75.00	116.00	146.00	171.00	1.00	8.00	19.00	26.00	41.00	65.00	108.00	0.00		776.00		
2310	SSI BLIND NON-MEDIC
A	2.00	3.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00	0.00		18.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00		5.00		
4311	SOBRA CHILD <1 M & F	129.00	228.00	281.00	315.00	125.00	136.00	143.00	178.00	206.00	234.00	267.00	0.00		2,242.00		
4312	SOBRA CHILD 01-05 M	339.00	577.00	789.00	961.00	293.00	340.00	378.00	457.00	503.00	571.00	693.00	0.00		5,901.00		
4313	SOBRA CHILD 06-13 M	263.00	584.00	856.00	1,006.00	236.00	307.00	347.00	413.00	434.00	496.00	661.00	0.00		5,603.00		
4314	SOBRA CHILD 14-20 MA	51.00	122.00	191.00	226.00	50.00	68.00	75.00	76.00	81.00	94.00	117.00	0.00		1,151.00		
4315	SOBRA CHILD 14-20 FE	66.00	136.00	218.00	262.00	55.00	67.00	75.00	84.00	83.00	97.00	137.00	0.00		1,280.00		
5015	SOBRA PREG 14-20 FE M	15.00	12.00	14.00	16.00	1.00	1.00	0.00	2.00	4.00	3.00	7.00	0.00		75.00		
5017	SOBRA PREG 21-44 FE
M	75.00	75.00	85.00	96.00	0.00	1.00	2.00	10.00	18.00	27.00	49.00	0.00		438.00		
SUBTOTAL:	1,616.00	2,910.00	4,036.0	0	4,747.00	930.00	1,183.00	1,351.00	1,608.00	1,817.00	2,182.00	2,996.00	0.00		25,376.00		

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	1.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	4.00	6.00	8.00	7.00	0.00	0.00	1.00	3.00	1.00	2.00	2.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	1.00	1.00	1.00	3.00	3.00	3.00	3.00	6.00	8.00	0.00	
1115	TANF EXPANDED 14-20	2.00	4.00	7.00	3.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	0.00	
1116	TANF EXPANDED 21-44	15.00	33.00	50.00	66.00	0.00	2.00	3.00	3.00	5.00	9.00	25.00	0.00	
1117	TANF EXPANDED 21-44	81.00	130.00	184.00	222.00	6.00	16.00	25.00	32.00	42.00	68.00	121.00	0.00	
1118	TANF EXPANDED 45-64	31.00	60.00	85.00	120.00	5.00	13.00	16.00	27.00	40.00	56.00	90.00	0.00	

 
9.00	
34.00	
29.00	
28.00	
211.00	
927.00	
543.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	1.00	0.00		1.00		
1126	TANF EXPANDED 21-44	0.00	0.00	1.00	3.00	0.00	0.00	0.00	0.00	1.00	1.00	5.00	0.00		11.00		
1127	TANF EXPANDED 21-44	3.00	4.00	5.00	6.00	0.00	0.00	0.00	1.00	1.00	1.00	3.00	0.00		24.00		
1128	TANF EXPANDED 45-64	6.00	6.00	7.00	7.00	1.00	4.00	6.00	5.00	5.00	10.00	12.00	0.00		69.00		
1129	TANF EXPANDED 65+
M&	3.00	9.00	10.00	10.00	0.00	0.00	2.00	4.00	3.00	4.00	11.00	0.00		56.00		
2410	SSI AGED EXPANDED NO	0.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2420	SSI AGED EXPANDED
WI	14.00	28.00	46.00	57.00	3.00	10.00	16.00	21.00	29.00	46.00	78.00	0.00		348.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00		1.00		
2610	SSI DISABLED EXPAND
E	2.00	2.00	3.00	4.00	0.00	3.00	3.00	3.00	5.00	7.00	8.00	0.00		40.00		
2620	SSI DISABLED EXPAND E	16.00	25.00	32.00	37.00	4.00	7.00	12.00	16.00	19.00	27.00	40.00	0.00		235.00		
SUBTOTAL:	177.00	309.00	441.0	0	545.00	22.00	61.00	92.00	122.00	158.00	239.00	406.00	0.00		2,572.00		

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	2.00	3.00	0.00	0.00	0.00	2.00	2.00	1.00	2.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	2.00	2.00	6.00	7.00	1.00	1.00	1.00	1.00	1.00	2.00	3.00	0.00	
3916	NEWLY ELIGIBLE MALE	7.00	11.00	11.00	11.00	1.00	7.00	9.00	9.00	12.00	15.00	20.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	17.00	27.00	39.00	51.00	2.00	7.00	8.00	12.00	14.00	18.00	35.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	12.00	25.00	30.00	33.00	1.00	21.00	26.00	32.00	38.00	54.00	75.00	0.00	
SUBTOTAL:	38.00	65.00	88.0	0	105.00	5.00	36.00	44.00	56.00	67.00	91.00	136.00	0.00	

2.00	
12.00	
27.00	
113.00	
230.00	
347.00	
731.00	

4413	SOBRA 100-133% M&F
6	36.00	69.00	110.00	119.00	63.00	62.00	63.00	64.00	82.00	98.00	114.00	0.00	
4414	SOBRA 100-133% MALE	4.00	14.00	24.00	27.00	9.00	9.00	10.00	13.00	16.00	20.00	20.00	0.00	
4415	SOBRA 100-133% FEMA L	16.00	27.00	36.00	37.00	11.00	11.00	12.00	13.00	16.00	15.00	19.00	0.00	

880.00	
166.00	
213.00	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	1.00	2.00	3.00	3.00	0.00	1.00	1.00	1.00	1.00	2.00	2.00	0.00	
3515	ADULT 40-100% FEMAL E	6.00	12.00	16.00	17.00	0.00	1.00	3.00	3.00	4.00	5.00	7.00	0.00	
3516	ADULT 40-100% MALE 2	6.00	11.00	19.00	25.00	1.00	5.00	5.00	6.00	10.00	13.00	24.00	0.00	
3517	ADULT 40-100% FEMAL E	9.00	9.00	10.00	14.00	1.00	6.00	10.00	11.00	15.00	19.00	33.00	0.00	
3518	ADULT 40-100% M&F 45	34.00	61.00	81.00	93.00	5.00	30.00	42.00	59.00	72.00	95.00	127.00	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	1.00	0.00	
3714	ADULT <40% EXP MALE	6.00	7.00	20.00	22.00	1.00	1.00	1.00	1.00	1.00	4.00	12.00	0.00	
3715	ADULT <40% EXP FEM AL	17.00	33.00	45.00	51.00	0.00	1.00	2.00	2.00	3.00	6.00	14.00	0.00	
3716	ADULT <40% EXP MALE	56.00	154.00	232.00	297.00	7.00	24.00	36.00	57.00	67.00	96.00	178.00	0.00	
3717	ADULT <40% EXP FEM AL	59.00	104.00	138.00	169.00	7.00	23.00	30.00	38.00	45.00	72.00	129.00	0.00	
3718	ADULT <40% EXP M&F
4	115.00	226.00	299.00	366.00	18.00	75.00	135.00	177.00	219.00	290.00	397.00	0.00	
SUBTOTAL:	309.00	619.00	863.0	0	1,058.00	40.00	167.00	265.00	355.00	437.00	602.00	924.00	0.00	

 
1.00	
17.00	
74.00	
125.00	
137.00	
699.00	
1.00	
76.00	
174.00	
1,204.00	
814.00	
2,317.00	
5,639.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	56.00	110.00	170.00	183.00	83.00	82.00	85.00	90.00	114.00	133.00	153.00	0.00		1,259.00		

6012	KIDS 1-5 M & F NON-M	1.00	1.00	3.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	1.00	1.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5.00	4.00	7.0	0	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00	
6.00	
2.00	
4.00	
17.00	

8700	SSI DISABLED FREEDO M	0.00	0.00	1.00	1.00	2.00	2.00	1.00	1.00	2.00	3.00	3.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	2.00	0.00	
SUBTOTAL:	0.00	0.00	1.0	0	1.00	2.00	3.00	2.00	2.00	4.00	5.00	6.00	0.00	

 
16.00	
3.00	
7.00	
26.00	

TOTAL:	2,201.00	4,017.00	5,606.00	6,640.00	1,082.00	1,532.00	1,839.00	2,233.00	2,597.00	3,252.00	4,621.00	0.00		35,620.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	0.00		45.42		
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	45.42	45.42	0.00		90.84		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	22.71	22.71	0.00		90.84		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	22.71	68.13	113.55	45.42	249.81	0.00		499.62		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	90.84	204.39	340.65	431.49	0.00		1,067.37		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	22.71	113.55	227.10	386.07	408.78	0.00		1,158.21		
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	22.71	0.00		22.71		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	45.42	45.42	90.84	0.00		204.39		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	22.71	113.55	227.10	317.94	545.04	0.00		1,226.34		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	704.01	1,203.63	1,794.09	2,884.17	3,996.96	0.00		10,582.86		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	386.07	704.01	976.53	1,430.73	1,635.12	0.00		5,132.46		
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	22.71	0.00		22.71		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	22.71	68.13	90.84	90.84	181.68	0.00		454.20		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	22.71	68.13	0.00		136.26		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	249.81	386.07	658.59	1,203.63	1,589.70	0.00		4,087.80		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	113.55	227.10	317.94	499.62	658.59	0.00		1,816.80		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	726.72	1,203.63	1,839.51	2,997.72	3,928.83	0.00		10,696.41		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	522.33	885.69	1,067.37	1,612.41	2,475.39	0.00		6,563.19		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	22.71	0.00		68.13		
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	22.71	0.00		22.71		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	181.68	295.23	454.20	794.85	885.69	0.00		2,611.65		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	726.72	1,249.05	2,180.16	3,610.89	4,950.78	0.00		12,717.60		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	499.62	1,044.66	1,657.83	2,906.88	4,383.03	0.00		10,492.02		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	113.55	181.68	386.07	590.46	840.27	0.00		2,112.03		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	227.10	431.49	613.17	953.82	1,339.89	0.00		3,565.47		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	90.84	113.55	113.55	158.97	204.39	0.00		681.30		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	317.94	431.49	635.88	999.24	1,158.21	0.00		3,542.76		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	4,950.78	8,879.61	13,671.42	22,005.99	30,204.30	0.00		79,712.10		

1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	45.42	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	22.71	22.71	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	45.42	45.42	68.13	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	68.13	90.84	158.97	204.39	295.23	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	499.62	772.14	1,226.34	1,794.09	2,588.94	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	227.10	317.94	499.62	976.53	1,362.60	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	22.71	22.71	0.00	

 
68.13	
45.42	
204.39	
817.56	
6,881.13	
3,383.79	
45.42	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	22.71	45.42	45.42	68.13	113.55	0.00		295.23		
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	113.55	204.39	227.10	0.00		567.75		
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	22.71	0.00		22.71		
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	158.97	340.65	681.30	1,021.95	1,566.99	0.00		3,769.86		
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	22.71	90.84	68.13	68.13	90.84	0.00		340.65		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	113.55	158.97	295.23	476.91	613.17	0.00		1,657.83		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	1,135.50	1,862.22	3,133.98	4,928.07	7,040.10	0.00		18,099.87		

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	0.00	22.71	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	90.84	158.97	204.39	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	68.13	158.97	272.52	386.07	431.49	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	113.55	272.52	476.91	817.56	1,112.79	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	204.39	476.91	840.27	1,385.31	1,771.38	0.00	

22.71	
45.42	
499.62	
1,317.18	
2,793.33	
4,678.26	

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	90.84	136.26	136.26	317.94	454.20	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	45.42	45.42	90.84	90.84	90.84	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	45.42	45.42	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	136.26	204.39	249.81	454.20	590.46	0.00	

1,135.50	
363.36	
136.26	
1,635.12	

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	22.71	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	0.00	

22.71

22.71

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.71	45.42	90.84	113.55	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	68.13	68.13	158.97	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	22.71	68.13	113.55	158.97	204.39	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	136.26	204.39	295.23	408.78	431.49	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	340.65	726.72	1,135.50	1,339.89	1,408.02	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	22.71	22.71	45.42	45.42	90.84	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	68.13	90.84	136.26	249.81	272.52	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	476.91	726.72	1,044.66	1,339.89	1,703.25	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	431.49	590.46	658.59	794.85	1,135.50	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	1,203.63	2,202.87	3,247.53	4,042.38	5,223.30	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	2,702.49	4,655.55	6,790.29	8,538.96	10,741.83	0.00	

 
272.52	
295.23	
567.75	
1,476.15	
4,950.78	
227.10	
817.56	
5,291.43	
3,610.89	
15,919.71	
33,429.12	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45.42	45.42	45.42	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	22.71	22.71	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	45.42	68.13	68.13	0.00	

 

181.68

45.42

136.26

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending May 31, 2019	
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	9,129.42	16,078.68	24,731.19	37,380.66	50,438.91	0.00		137,758.86		

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00		2.00		
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	2.00	2.00	0.00		4.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00		4.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	5.00	2.00	11.00	0.00		22.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	9.00	15.00	19.00	0.00		47.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	1.00	5.00	10.00	17.00	18.00	0.00		51.00		
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	1.00	0.00		1.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00	2.00	4.00	0.00		9.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	1.00	5.00	10.00	14.00	24.00	0.00		54.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	31.00	53.00	79.00	127.00	176.00	0.00		466.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	17.00	31.00	43.00	63.00	72.00	0.00		226.00		
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	1.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	4.00	4.00	8.00	0.00		20.00		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	3.00	0.00		6.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	11.00	17.00	29.00	53.00	70.00	0.00		180.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	5.00	10.00	14.00	22.00	29.00	0.00		80.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	32.00	53.00	81.00	132.00	173.00	0.00		471.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	23.00	39.00	47.00	71.00	109.00	0.00		289.00		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00		3.00		
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	1.00	0.00		1.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	8.00	13.00	20.00	35.00	39.00	0.00		115.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	32.00	55.00	96.00	159.00	218.00	0.00		560.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	22.00	46.00	73.00	128.00	193.00	0.00		462.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	5.00	8.00	17.00	26.00	37.00	0.00		93.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	10.00	19.00	27.00	42.00	59.00	0.00		157.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	4.00	5.00	5.00	7.00	9.00	0.00		30.00		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	14.00	19.00	28.00	44.00	51.00	0.00		156.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	218.00	391.00	602.00	969.00	1,330.00	0.00		3,510.00		

1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00	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	1.00	1.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	2.00	2.00	3.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	3.00	4.00	7.00	9.00	13.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	22.00	34.00	54.00	79.00	114.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	10.00	14.00	22.00	43.00	60.00	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	1.00	1.00	0.00	

 
3.00	
2.00	
9.00	
36.00	
303.00	
149.00	
2.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00	2.00	3.00	5.00	0.00		13.00		
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	5.00	9.00	10.00	0.00		25.00		
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	1.00	0.00		1.00		
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	7.00	15.00	30.00	45.00	69.00	0.00		166.00		
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	1.00	4.00	3.00	3.00	4.00	0.00		15.00		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	5.00	7.00	13.00	21.00	27.00	0.00		73.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	50.00	82.00	138.00	217.00	310.00	0.00		797.00		

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	1.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	4.00	7.00	9.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	3.00	7.00	12.00	17.00	19.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	5.00	12.00	21.00	36.00	49.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	9.00	21.00	37.00	61.00	78.00	0.00	

1.00	
2.00	
22.00	
58.00	
123.00	
206.00	

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	4.00	6.00	6.00	14.00	20.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	2.00	2.00	4.00	4.00	4.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	2.00	2.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	6.00	9.00	11.00	20.00	26.00	0.00	

50.00	
16.00	
6.00	
72.00	

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	1.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	

1.00

1.00

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00	4.00	5.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	3.00	7.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	5.00	7.00	9.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	6.00	9.00	13.00	18.00	19.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	15.00	32.00	50.00	59.00	62.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	2.00	2.00	4.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	3.00	4.00	6.00	11.00	12.00	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	21.00	32.00	46.00	59.00	75.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	19.00	26.00	29.00	35.00	50.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	53.00	97.00	143.00	178.00	230.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	119.00	205.00	299.00	376.00	473.00	0.00	

 
12.00	
13.00	
25.00	
65.00	
218.00	
10.00	
36.00	
233.00	
159.00	
701.00	
1,472.00	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	2.00	2.00	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	1.00	1.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	2.00	3.00	3.00	0.00	

 

8.00

2.00

6.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending May 31, 2019	
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	402.00	708.00	1,089.00	1,646.00	2,221.00	0.00		6,066.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	23.81	23.81	24.90	24.90	24.90	24.90	24.90	0.00		172.12		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	47.62	71.43	49.80	49.80	74.70	49.80	49.80	0.00		392.95		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	1,214.31	1,214.31	1,145.40	1,145.40	1,220.10	1,294.80	1,269.90	0.00		8,504.22		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	1,428.60	1,500.03	1,767.90	1,942.20	1,842.60	1,967.10	2,016.90	0.00		12,465.33		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	1,452.41	1,547.65	1,792.80	1,967.10	1,668.30	1,917.30	1,867.50	0.00		12,213.06		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	261.91	404.77	473.10	473.10	398.40	423.30	473.10	0.00		2,907.68		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	1,261.93	1,547.65	1,668.30	1,767.90	1,618.50	1,767.90	1,668.30	0.00		11,300.48		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	3,214.35	4,119.13	4,830.60	5,104.50	5,278.80	5,702.10	6,200.10	0.00		34,449.58		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	13,976.47	16,119.37	18,774.60	19,895.10	20,816.40	22,086.30	23,256.60	0.00		134,924.84		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	4,071.51	4,762.00	5,677.20	6,075.60	6,374.40	6,872.40	6,996.90	0.00		40,830.01		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.90	24.90	24.90	24.90	0.00		99.60		
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	24.90	0.00		24.90		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.90	24.90	24.90	0.00		74.70		
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	24.90	0.00		24.90		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	642.87	880.97	1,095.60	1,195.20	1,220.10	1,294.80	1,344.60	0.00		7,674.14		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	0.00	71.43	95.24	124.50	124.50	224.10	249.00	224.10	0.00		1,112.87		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	3,190.54	3,619.12	4,332.60	4,755.90	4,930.20	5,054.70	5,079.60	0.00		30,962.66		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	2,166.71	2,500.05	2,639.40	2,639.40	2,838.60	2,988.00	3,187.20	0.00		18,959.36		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	11,905.00	13,476.46	15,139.20	15,861.30	16,533.60	17,230.80	17,430.00	0.00		107,576.36		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	5,047.72	5,952.50	6,947.10	7,445.10	7,743.90	7,893.30	8,117.40	0.00		49,147.02		
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	24.90	0.00		24.90		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	166.67	214.29	249.00	249.00	224.10	249.00	249.00	0.00		1,601.06		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	47.62	47.62	74.70	74.70	99.60	99.60	99.60	0.00		543.44		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	4,642.95	4,762.00	4,780.80	4,606.50	4,457.10	4,307.70	4,457.10	0.00		32,014.15		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	19,762.30	22,619.50	26,319.30	27,738.60	29,506.50	30,203.70	31,025.40	0.00		187,175.30		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	22,405.21	26,476.72	31,374.00	32,892.90	35,308.20	37,698.60	40,611.90	0.00		226,767.53		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	4,857.24	5,547.73	6,449.10	7,096.50	7,918.20	8,665.20	9,237.90	0.00		49,771.87		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	6,238.22	7,214.43	8,490.90	9,213.00	9,735.90	10,781.70	11,254.80	0.00		62,928.95		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	23.81	0.00	0.00	0.00	0.00	0.00	0.00		23.81		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	357.15	500.01	448.20	448.20	473.10	348.60	373.50	0.00		2,948.76		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	2,381.00	2,619.10	2,639.40	2,639.40	2,490.00	2,589.60	2,589.60	0.00		17,948.10		
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	24.90	0.00		24.90		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	24.90	24.90	0.00	0.00	0.00	0.00		49.80		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	110,835.55	127,859.70	147,333.30	155,475.60	163,070.10	171,810.00	179,255.10	0.00		1,055,639.35		
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.90	24.90	24.90	24.90	0.00	99.60

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	166.67	166.67	174.30	199.20	249.00	273.90	249.00	0.00		1,478.74		
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	71.43	95.24	99.60	99.60	124.50	124.50	99.60	0.00		714.47		
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	23.81	95.24	99.60	149.40	174.30	273.90	323.70	0.00		1,139.95		
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	1,880.99	2,023.85	2,539.80	2,838.60	3,087.60	3,212.10	3,187.20	0.00		18,770.14		
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	6,142.98	7,047.76	8,167.20	8,590.50	9,586.50	10,034.70	9,910.20	0.00		59,479.84		
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	3,476.26	4,000.08	4,482.00	4,706.10	4,755.90	4,855.50	5,104.50	0.00		31,380.34		
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	24.90	49.80	24.90	24.90	24.90	0.00		149.40		
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	95.24	95.24	99.60	99.60	99.60	99.60	99.60	0.00		688.48		
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	214.29	190.48	174.30	174.30	199.20	199.20	199.20	0.00		1,350.97		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	214.29	357.15	498.00	423.30	448.20	572.70	572.70	0.00		3,086.34		
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	380.96	428.58	423.30	473.10	473.10	423.30	448.20	0.00		3,050.54		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	24.90	24.90	0.00	0.00	0.00		49.80		
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	47.62	71.43	99.60	99.60	99.60	99.60	99.60	0.00		617.05		
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	1,595.27	2,142.90	2,539.80	2,714.10	2,913.30	3,137.40	3,336.60	0.00		18,379.37		
2610	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	95.24	95.24	99.60	99.60	99.60	99.60	99.60	0.00		688.48		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	1,000.02	1,047.64	1,220.10	1,294.80	1,394.40	1,419.30	1,518.90	0.00		8,895.16		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	15,405.07	17,857.50	20,741.70	22,061.40	23,779.50	24,875.10	25,298.40	0.00		150,018.67		

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	24.90	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	142.86	190.48	199.20	224.10	224.10	199.20	199.20	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	166.67	190.48	298.80	298.80	174.30	199.20	174.30	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	357.15	571.44	846.60	921.30	996.00	1,020.90	1,120.50	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	1,547.65	1,785.75	1,917.30	2,166.30	2,490.00	2,490.00	2,589.60	0.00	

24.90	
1,379.14	
1,502.55	
5,833.89	
14,986.60	

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	24.90	24.90	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	95.24	142.86	174.30	224.10	273.90	348.60	373.50	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	333.34	404.77	423.30	498.00	597.60	647.40	722.10	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	714.30	857.16	1,070.70	971.10	1,070.70	1,269.90	1,319.70	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	452.39	523.82	572.70	672.30	796.80	996.00	1,095.60	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	2,619.10	3,190.54	3,361.50	3,560.70	3,535.80	3,610.50	3,735.00	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	24.90	24.90	24.90	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	619.06	1,023.83	1,369.50	1,518.90	1,494.00	1,618.50	2,041.80	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	1,738.13	2,000.04	2,241.00	2,290.80	2,340.60	2,415.30	2,564.70	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	9,285.90	11,000.22	13,221.90	14,217.90	15,263.70	16,135.20	17,405.10	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	5,119.15	5,833.45	7,046.70	7,395.30	7,719.00	8,142.30	8,490.90	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	10,833.55	12,595.49	15,014.70	15,936.00	16,683.00	17,604.30	18,351.30	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	31,810.16	37,572.18	44,496.30	47,285.10	49,800.00	52,837.80	56,149.50	0.00	

 
49.80	
1,632.50	
3,626.51	
7,273.56	
5,109.61	
23,613.14	
74.70	
9,685.59	
15,590.57	
96,529.92	
49,746.80	
107,018.34	
319,951.04	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	1,285.74	1,666.70	2,041.80	2,241.00	2,440.20	2,614.50	2,614.50	0.00		14,904.44		
SUBTOTAL:	0.00	0.00	0.00	0.00	3,500.07	4,404.85	5,303.70	5,851.50	6,324.60	6,523.80	6,723.00	0.00		38,631.52		

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	2,190.52	2,357.19	2,440.20	2,714.10	3,087.60	3,037.80	3,037.80	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	547.63	595.25	722.10	821.70	821.70	896.40	871.50	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	738.11	880.97	1,095.60	1,095.60	1,195.20	1,070.70	1,020.90	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	3,476.26	3,833.41	4,257.90	4,631.40	5,104.50	5,004.90	4,930.20	0.00	

 
18,865.21	
5,276.28	
7,097.08	
31,238.57	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	23.81	23.81	24.90	24.90	24.90	24.90	24.90	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	24.90	24.90	24.90	24.90	24.90	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	23.81	23.81	49.80	49.80	49.80	49.80	49.80	0.00	

 
172.12	
124.50	
296.62	

6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	23.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	23.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
23.81

23.81

1,595,799.58

0.00	0.00	0.00	0.00	165,074.73	191,551.45	222,182.70	235,354.80	248,128.50	261,101.40	272,406.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00		7.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	2.00	3.00	2.00	2.00	3.00	2.00	2.00	0.00		16.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	51.00	51.00	46.00	46.00	49.00	52.00	51.00	0.00		346.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	60.00	63.00	71.00	78.00	74.00	79.00	81.00	0.00		506.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	61.00	65.00	72.00	79.00	67.00	77.00	75.00	0.00		496.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	11.00	17.00	19.00	19.00	16.00	17.00	19.00	0.00		118.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	53.00	65.00	67.00	71.00	65.00	71.00	67.00	0.00		459.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	135.00	173.00	194.00	205.00	212.00	229.00	249.00	0.00		1,397.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	587.00	677.00	754.00	799.00	836.00	887.00	934.00	0.00		5,474.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	171.00	200.00	228.00	244.00	256.00	276.00	281.00	0.00		1,656.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00		4.00		
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	1.00	0.00		1.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00		3.00		
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	1.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	27.00	37.00	44.00	48.00	49.00	52.00	54.00	0.00		311.00		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	0.00	3.00	4.00	5.00	5.00	9.00	10.00	9.00	0.00		45.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	134.00	152.00	174.00	191.00	198.00	203.00	204.00	0.00		1,256.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	91.00	105.00	106.00	106.00	114.00	120.00	128.00	0.00		770.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	500.00	566.00	608.00	637.00	664.00	692.00	700.00	0.00		4,367.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	212.00	250.00	279.00	299.00	311.00	317.00	326.00	0.00		1,994.00		
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	1.00	0.00		1.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	7.00	9.00	10.00	10.00	9.00	10.00	10.00	0.00		65.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	2.00	2.00	3.00	3.00	4.00	4.00	4.00	0.00		22.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	195.00	200.00	192.00	185.00	179.00	173.00	179.00	0.00		1,303.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	830.00	950.00	1,057.00	1,114.00	1,185.00	1,213.00	1,246.00	0.00		7,595.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	941.00	1,112.00	1,260.00	1,321.00	1,418.00	1,514.00	1,631.00	0.00		9,197.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	204.00	233.00	259.00	285.00	318.00	348.00	371.00	0.00		2,018.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	262.00	303.00	341.00	370.00	391.00	433.00	452.00	0.00		2,552.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	15.00	21.00	18.00	18.00	19.00	14.00	15.00	0.00		120.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	100.00	110.00	106.00	106.00	100.00	104.00	104.00	0.00		730.00		
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	1.00	0.00		1.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00		2.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	4,655.00	5,370.00	5,917.00	6,244.00	6,549.00	6,900.00	7,199.00	0.00		42,834.00		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	4.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	7.00	7.00	7.00	8.00	10.00	11.00	10.00	0.00		60.00		
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	3.00	4.00	4.00	4.00	5.00	5.00	4.00	0.00		29.00		
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	1.00	4.00	4.00	6.00	7.00	11.00	13.00	0.00		46.00		
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	79.00	85.00	102.00	114.00	124.00	129.00	128.00	0.00		761.00		
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	258.00	296.00	328.00	345.00	385.00	403.00	398.00	0.00		2,413.00		
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	146.00	168.00	180.00	189.00	191.00	195.00	205.00	0.00		1,274.00		
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00	1.00	1.00	1.00	0.00		6.00		
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	4.00	4.00	4.00	4.00	4.00	4.00	4.00	0.00		28.00		
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	9.00	8.00	7.00	7.00	8.00	8.00	8.00	0.00		55.00		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	9.00	15.00	20.00	17.00	18.00	23.00	23.00	0.00		125.00		
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	16.00	18.00	17.00	19.00	19.00	17.00	18.00	0.00		124.00		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00		2.00		
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	2.00	3.00	4.00	4.00	4.00	4.00	4.00	0.00		25.00		
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	67.00	90.00	102.00	109.00	117.00	126.00	134.00	0.00		745.00		
2610	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	4.00	4.00	4.00	4.00	4.00	4.00	4.00	0.00		28.00		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	42.00	44.00	49.00	52.00	56.00	57.00	61.00	0.00		361.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	647.00	750.00	833.00	886.00	955.00	999.00	1,016.00	0.00		6,086.00		

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	1.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	6.00	8.00	8.00	9.00	9.00	8.00	8.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	7.00	8.00	12.00	12.00	7.00	8.00	7.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	15.00	24.00	34.00	37.00	40.00	41.00	45.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	65.00	75.00	77.00	87.00	100.00	100.00	104.00	0.00	

1.00	
56.00	
61.00	
236.00	
608.00	

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	1.00	1.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	4.00	6.00	7.00	9.00	11.00	14.00	15.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	14.00	17.00	17.00	20.00	24.00	26.00	29.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	30.00	36.00	43.00	39.00	43.00	51.00	53.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	19.00	22.00	23.00	27.00	32.00	40.00	44.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	110.00	134.00	135.00	143.00	142.00	145.00	150.00	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	1.00	1.00	1.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	26.00	43.00	55.00	61.00	60.00	65.00	82.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	73.00	84.00	90.00	92.00	94.00	97.00	103.00	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	390.00	462.00	531.00	571.00	613.00	648.00	699.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	215.00	245.00	283.00	297.00	310.00	327.00	341.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	455.00	529.00	603.00	640.00	670.00	707.00	737.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	1,336.00	1,578.00	1,787.00	1,899.00	2,000.00	2,122.00	2,255.00	0.00	

 
2.00	
66.00	
147.00	
295.00	
207.00	
959.00	
3.00	
392.00	
633.00	
3,914.00	
2,018.00	
4,341.00	
12,977.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	54.00	70.00	82.00	90.00	98.00	105.00	105.00	0.00		604.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	147.00	185.00	213.00	235.00	254.00	262.00	270.00	0.00		1,566.00		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	0.00	

7.00	
5.00	
12.00	

6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00

1.00

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	92.00	99.00	98.00	109.00	124.00	122.00	122.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	23.00	25.00	29.00	33.00	33.00	36.00	35.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	31.00	37.00	44.00	44.00	48.00	43.00	41.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	146.00	161.00	171.00	186.00	205.00	201.00	198.00	0.00	

 
766.00	
214.00	
288.00	
1,268.00	

TOTAL:

0.00

6,933.00

8,045.00

8,923.00

9,452.00

10,486.00

64,744.00

0.00

0.00

10,940.00	0.00

9,965.00

0.00

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending May 31, 2019	
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	18,872.69	19,791.67	11,594.65	12,192.59	11,702.69	11,702.69	8,504.08	8,365.54	4,194.32	0.00		152,450.58		
1010	TANF NON-MEDICARE	2,605,295.71	2,562,367.69	2,159,496.94	1,942,583.84	1,751,391.52	1,739,363.18	1,373,566.71	1,134,205.64	1,188,573.27	1,228,338.09	1,197,963.67	0.00		18,883,146.26		
101Z	TANF ALTCS NON-MED IC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,159.40	-4,159.40	0.00	0.00	0.00		0.00		
1020	TANF WITH QMB	19,460.70	15,568.56	15,568.56	16,394.04	16,394.04	12,637.21	12,411.51	12,411.51	9,145.86	9,474.38	12,582.96	0.00		152,049.33		
2100	SSI AGED WITH MEDIC A	32,815,971.54	32,979,207.09	33,395,611.29	34,324,045.98	34,537,733.95	34,786,174.90	34,355,796.22	34,573,109.55	34,625,479.01	34,935,009.60	34,855,610.24	0.00		376,183,749.37		
210Z	SSI AGED WITH MEDIC
A	619,102.28	817,504.62	596,598.88	1,116,449.06	1,461,055.82	1,738,864.01	2,069,962.39	1,653,985.62	2,028,681.36	2,002,379.46	1,837,682.82	0.00		15,942,266.32		
2110	SSI AGED NON-MEDIC AR	3,434,158.85	3,394,065.54	3,426,868.35	3,282,044.29	3,417,480.90	3,520,517.74	3,332,697.92	3,366,251.57	3,337,735.40	3,445,292.77	3,455,977.80	0.00		37,413,091.13		
211Z	SSI AGED NON-MEDIC
AR	11,704.38	18,653.74	15,772.90	34,418.92	67,681.30	7,874.57	28,173.95	52,357.41	49,326.13	45,326.07	73,784.49	0.00		405,073.86		
2120	SSI AGED WITH QMB	22,419,410.53	22,710,039.34	23,069,275.68	23,798,334.36	24,142,392.01	24,336,871.25	24,714,833.31	25,055,416.59	25,295,278.28	25,862,135.60	25,827,138.04	0.00		267,231,124.99		
212Z	SSI AGED WITH QMB P P	10,939.38	9,161.27	14,150.22	49,871.04	33,781.84	44,903.94	31,461.25	24,096.66	50,821.62	36,450.64	56,580.67	0.00		362,218.53		
2200	SSI DISABLED WITH M
E	16,009,290.62	15,956,797.19	15,768,617.99	16,326,680.30	16,337,861.44	16,495,215.96	16,058,421.21	15,704,753.36	16,088,947.28	16,316,728.82	15,669,006.97	0.00		176,732,321.14		
220Z	SSI DISABLED WITH M E	93,673.54	102,616.31	68,480.48	152,672.15	140,695.11	254,301.29	266,911.77	223,399.45	241,111.36	206,206.37	253,747.45	0.00		2,003,815.28		
2210	SSI DISABLED NON-ME
D	120,794,909.41	121,239,001.85	121,692,389.97	127,556,969.88	129,452,465.31	132,754,450.15	131,932,975.57	132,467,511.26	138,374,799.86	143,880,782.90	135,805,446.45	0.00		1,435,951,702.61		
221Z	SSI DISABLED NON-ME D	37,010.83	29,568.09	23,667.51	97,754.52	122,012.38	172,148.76	239,066.12	122,652.69	235,325.13	296,636.29	257,583.11	0.00		1,633,425.43		
2220	SSI DISABLED WITH Q
M	25,497,207.44	25,693,149.50	25,944,043.66	27,259,183.94	27,411,152.04	28,033,048.08	28,314,427.29	28,625,820.82	29,553,745.66	30,408,395.70	28,984,573.57	0.00		305,724,747.70		
222Z	SSI DISABLED WITH Q M	3,631.33	7,560.85	4,235.79	12,276.16	5,309.18	38,981.63	11,931.78	17,608.11	10,325.53	4,182.31	22,236.54	0.00		138,279.21		
2300	SSI BLIND WITH MEDIC	61,100.26	61,100.26	50,099.68	36,227.14	33,686.37	38,699.50	25,731.22	15,597.12	19,530.98	12,567.67	7,534.93	0.00		361,875.13		
2310	SSI BLIND NON-MEDIC A	264,951.61	256,432.77	230,487.99	220,999.97	184,173.43	206,118.30	174,036.44	131,730.61	144,356.49	127,614.35	139,505.34	0.00		2,080,407.30		
2320	SSI BLIND WITH QMB	84,130.00	82,346.15	55,153.05	58,273.92	57,916.25	63,634.18	53,718.89	46,066.76	47,100.33	30,821.21	25,329.08	0.00		604,489.82		
SUBTOTAL:	224,804,713.2	4 225,957,905.65	226,549,391.6	3 236,304,971.18	239,184,777.54	244,255,997.24	243,007,826.24	243,242,836.82	251,304,628.23	258,856,707.77	248,486,478.45	0.00		2,641,956,233.99		

8700	SSI DISABLED FREEDO M	98,465.19	98,658.42	98,465.19	102,215.92	120,380.59	122,055.43	122,666.24	121,616.06	116,866.22	132,310.83	121,470.73	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	849.26	0.00	737.64	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	156,152.76	148,483.87	149,761.95	154,498.08	153,741.93	167,234.16	163,259.72	170,671.51	165,562.86	0.00	
871Z	SSI DISABLED FREEDO
M	0.00	3,777.75	4,314.47	938.80	12,010.34	0.00	11,657.40	0.00	13,021.10	0.00	12,494.87	0.00	
8720	SSI DISABLED FREEDO M	24,397.31	24,397.31	27,099.93	24,665.64	34,832.57	29,617.45	38,791.39	36,226.95	40,967.48	42,249.96	40,707.02	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	263,011.4	6	283,080.02	286,032.3	5	277,041.87	316,985.45	306,170.96	326,856.96	325,077.17	334,114.52	345,232.30	340,235.48	0.00	

 
1,255,170.82	
1,586.90	
1,724,913.08	
58,214.73	
363,953.01	
0.00	
3,403,838.54	

2,645,360,072.53

225,067,724.70	226,240,985.67	226,835,423.98	236,582,013.05	239,501,762.99	244,562,168.20	243,334,683.20	243,567,913.99	251,638,742.75	259,201,940.07	248,826,713.93	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	6.00	6.00	5.00	5.00	3.00	3.00	3.00	3.00	2.00	2.00	1.00	0.00		39.00		
1010	TANF NON-MEDICARE	665.19	651.28	550.70	471.40	424.97	407.96	331.62	272.90	256.29	262.79	284.54	0.00		4,579.64		
101Z	TANF ALTCS NON-MED IC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.64	-0.64	0.00	0.00	0.00		0.00		
1020	TANF WITH QMB	5.00	4.00	4.00	4.00	4.00	3.00	3.00	3.00	2.00	2.00	3.00	0.00		37.00		
2100	SSI AGED WITH MEDIC A	11,273.89	11,502.45	11,695.16	11,750.45	11,777.74	11,769.69	11,631.72	11,711.05	11,721.39	11,836.47	11,833.40	0.00		128,503.41		
210Z	SSI AGED WITH MEDIC
A	653.12	877.88	629.49	794.19	611.33	596.04	689.75	544.74	669.56	648.12	601.60	0.00		7,315.82		
2110	SSI AGED NON-MEDIC AR	550.05	564.06	580.82	571.14	586.47	583.55	577.22	581.26	571.37	583.02	582.62	0.00		6,331.58		
211Z	SSI AGED NON-MEDIC
AR	11.39	19.24	16.07	12.59	12.65	2.47	4.70	8.85	13.95	5.46	10.86	0.00		118.23		
2120	SSI AGED WITH QMB	8,167.76	8,394.27	8,535.75	8,618.04	8,671.51	8,691.41	8,793.70	8,924.58	8,969.12	9,160.08	9,195.00	0.00		96,121.22		
212Z	SSI AGED WITH QMB P P	11.88	9.87	14.60	41.02	11.87	15.58	10.77	3.86	19.22	10.88	18.66	0.00		168.21		
2200	SSI DISABLED WITH M
E	4,808.58	4,816.37	4,753.40	4,744.88	4,745.70	4,733.20	4,632.70	4,521.33	4,515.20	4,452.39	4,472.39	0.00		51,196.14		
220Z	SSI DISABLED WITH M E	100.54	111.33	74.40	109.09	59.45	91.94	85.54	71.93	76.52	65.23	81.45	0.00		927.42		
2210	SSI DISABLED NON-ME
D	29,046.39	29,196.87	29,384.02	29,662.04	29,877.78	29,942.13	30,209.05	30,325.36	30,522.57	30,611.23	30,763.59	0.00		329,541.03		
221Z	SSI DISABLED NON-ME D	40.11	31.80	25.02	46.59	21.42	28.35	38.63	19.68	36.10	48.03	41.15	0.00		376.88		
2220	SSI DISABLED WITH Q
M	7,307.02	7,412.14	7,491.83	7,560.56	7,602.65	7,656.54	7,771.16	7,838.84	7,838.33	7,779.90	7,839.94	0.00		84,098.91		
222Z	SSI DISABLED WITH Q M	3.98	8.24	4.47	4.91	2.41	13.02	4.18	6.13	3.50	1.55	7.28	0.00		59.67		
2300	SSI BLIND WITH MEDIC	17.00	17.00	14.56	10.00	9.00	10.00	6.70	4.00	5.00	3.76	2.99	0.00		100.01		
2310	SSI BLIND NON-MEDIC A	63.16	59.99	53.99	48.99	40.70	43.05	38.77	31.13	32.29	27.21	32.80	0.00		472.08		
2320	SSI BLIND WITH QMB	24.00	23.48	17.00	18.31	18.83	19.67	19.06	16.03	16.58	10.00	9.35	0.00		192.31		
SUBTOTAL:	62,755.06	63,706.27	63,850.2	8	64,473.20	64,481.48	64,610.60	64,851.27	64,888.31	65,270.35	65,510.12	65,781.62	0.00		710,178.56		

8700	SSI DISABLED FREEDO M	28.00	28.18	28.00	27.69	33.00	33.00	32.88	33.00	31.00	34.00	31.99	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.92	0.00	0.29	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	26.34	25.00	24.73	25.00	25.19	27.99	26.83	28.00	27.00	0.00	
871Z	SSI DISABLED FREEDO
M	0.00	4.15	4.66	1.00	4.26	0.00	1.80	0.00	2.16	0.00	2.00	0.00	
8720	SSI DISABLED FREEDO M	8.00	8.00	9.00	8.00	11.00	9.00	12.00	11.00	12.00	12.00	11.99	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	59.00	66.63	68.0	0	61.98	72.99	67.00	71.87	71.99	71.99	74.00	72.98	0.00	

 
340.74	
1.21	
284.46	
20.03	
111.99	
0.00	
758.43	

TOTAL:	62,814.06	63,772.90	63,918.28	64,535.18	64,554.47	64,677.60	64,923.14	64,960.30	65,342.34	65,584.12	65,854.60	0.00		710,936.99		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	67.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.66		
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	16.22	0.00	0.00	0.00	0.00	0.00	0.00		16.22		
1002	TANF 01-05 M & F WIT	0.00	0.00	0.00	0.00	0.00	32.44	0.00	0.00	0.00	0.00	0.00	0.00		32.44		
1003	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	16.22	0.00	0.00	0.00	0.00	0.00	0.00		16.22		
1010	TANF NON-MEDICARE	3,099,224.83	3,105,361.89	3,108,088.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,312,674.79		
1011	TANF <1 M & F NON-ME	20,092.78	23,450.08	18,303.99	-628.34	-429.53	80,915.95	-4.45	-1,791.20	-213.89	-67.66	285.55	0.00		139,913.28		
1012	TANF 01-05 M & F NON	4,576.00	4,125.07	3,894.97	-15.28	17.92	135,956.27	1,034.14	-753.81	-275.78	0.00	57.42	0.00		148,616.92		
1013	TANF 06-13 M & F NON	5,280.87	6,219.12	3,575.18	169.15	-372.04	210,437.54	0.00	0.00	0.00	0.00	0.00	0.00		225,309.82		
1014	TANF 14-20 MALE NON-	-958.84	1,397.93	470.83	-209.75	-0.54	46,170.24	-752.82	-28.64	1,285.87	-516.77	0.00	0.00		46,857.51		
1015	TANF 14-20 FEMALE N O	2,369.26	-327.72	559.55	252.03	63.68	45,533.32	0.00	-146.44	912.28	0.00	-0.07	0.00		49,215.89		
1017	TANF 21-44 FEMALE N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-36.71	0.00	0.00	0.00	0.00		-36.71		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-2.75	0.00	0.00	0.00	0.00		-2.75		
101A	TANF < 1 M & F NON-M	44,422.68	53,377.37	36,715.55	-68.81	0.00	7,784.79	-2.77	-1,492.52	-16.37	-150.60	0.00	0.00		140,569.32		
101B	TANF 01-05 M & F NON	7,098.70	11,059.86	7,398.25	-36.01	-20.73	2,094.45	0.00	-138.52	0.00	0.00	0.00	0.00		27,456.00		
101C	TANF 06-13 M & F NON	4,339.43	5,147.39	4,062.72	0.00	0.00	1,799.63	0.00	0.00	0.00	0.00	0.00	0.00		15,349.17		
101D	TANF 14-20 MALE NON-	949.44	1,163.20	1,030.45	0.00	0.00	282.96	0.00	0.00	0.00	0.00	0.00	0.00		3,426.05		
101E	TANF 14-20 FEMALE N O	1,382.01	1,964.67	853.00	0.00	0.00	267.93	0.00	0.00	0.00	0.00	0.00	0.00		4,467.61		
1020	TANF WITH QMB	33.83	33.83	33.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101.49		
2200	SSI DISABLED WITH M E	33.83	33.83	67.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.32		
2210	SSI DISABLED NON-ME
D	339,676.61	337,001.30	338,227.80	0.68	-38.18	51,832.70	152.48	0.00	0.00	-102.86	-385.28	0.00		1,066,365.25		
221Z	SSI DISABLED NON-ME D	3,510.56	5,818.27	4,756.10	0.00	0.00	436.56	0.00	0.00	0.00	0.00	0.00	0.00		14,521.49		
2220	SSI DISABLED WITH Q
M	266.46	232.63	198.80	0.00	0.00	52.47	0.00	0.00	0.00	0.00	0.00	0.00		750.36		
2310	SSI BLIND NON-MEDIC A	1,727.32	1,717.50	1,795.31	0.00	0.00	169.82	0.00	0.00	0.00	0.00	0.00	0.00		5,409.95		
231Z	SSI BLIND NON-MEDIC
A	0.00	33.83	57.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.34		
4300	SOBRA CHILD WITH M ED	3,172.78	2,220.90	3,206.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,600.62		
4302	SOBRA CHILD 01-05 M	0.00	-160.45	0.00	0.00	0.00	234.70	0.00	0.00	0.00	0.00	0.00	0.00		74.25		
4303	SOBRA CHILD 06-13 M	-22.21	-15.69	0.00	0.00	0.00	339.64	0.00	0.00	0.00	0.00	0.00	0.00		301.74		
4304	SOBRA CHILD 14-20 MA	0.00	-12.83	0.00	0.00	0.00	32.44	0.00	-142.46	0.00	0.00	0.00	0.00		-122.85		
4305	SOBRA CHILD 14-20 FE	0.00	-34.37	0.00	0.00	0.00	32.44	0.00	0.00	0.00	0.00	0.00	0.00		-1.93		
430C	SOBRA CHILD 06-13 M	0.00	32.74	0.00	0.00	0.00	0.00	0.00	-14.85	0.00	0.00	0.00	0.00		17.89		
4310	SOBRA CHILD NON-ME DI	20,843,552.98	20,902,700.97	20,986,041.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,732,295.15		
4311	SOBRA CHILD <1 M & F	73,572.72	82,929.57	68,442.77	-973.84	-57.50	218,251.25	-148.28	-2,359.00	-1,058.17	-31.28	-55.32	0.00		438,512.92		
4312	SOBRA CHILD 01-05 M	102,709.89	145,805.09	90,854.81	-1,756.93	218.84	1,072,900.04	219.66	-6,532.92	-1,052.13	0.00	-346.86	0.00		1,403,019.49		
4313	SOBRA CHILD 06-13 M	114,717.87	161,930.66	102,204.01	-1,084.40	629.23	1,372,743.35	-16.91	-1,348.65	839.42	0.00	-752.57	0.00		1,749,862.01		
4314	SOBRA CHILD 14-20 MA	22,663.65	33,700.33	22,323.00	-963.69	336.48	289,277.83	-866.00	-1,161.93	-928.49	-583.67	632.33	0.00		364,429.84		
4315	SOBRA CHILD 14-20 FE	23,824.20	34,345.44	21,019.41	14.03	-17.46	290,336.66	0.00	-1,195.89	0.00	-206.74	-0.14	0.00		368,119.51		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431A	SOBRA CHILD < 1 M &	12,969.72	16,358.28	15,118.14	-24.57	0.00	1,972.32	17.74	-1,088.81	0.00	0.00	0.00	0.00		45,322.82		
431B	SOBRA CHILD 01-05 M	160,415.96	198,857.41	152,768.34	-18.04	0.00	22,596.52	0.00	-235.33	0.00	0.00	0.00	0.00		534,384.86		
431C	SOBRA CHILD 6-13 M& F	161,414.95	217,281.78	160,144.91	135.32	31.16	20,911.31	0.00	-81.81	0.00	0.00	0.00	0.00		559,837.62		
431D	SOBRA CHILD 14-20 MA	33,253.15	44,378.68	34,530.57	143.81	8.95	4,797.97	-56.82	-12.49	0.00	0.00	0.00	0.00		117,043.82		
431E	SOBRA CHILD 14-20 FE	35,016.82	46,978.48	32,759.55	33.83	0.00	4,808.37	0.00	-2.75	0.00	0.00	0.00	0.00		119,594.30		
4320	SOBRA CHILD WITH Q MB	317.67	220.16	88.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		626.65		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-33.83	0.00	0.00	0.00	0.00		-33.83		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	16.22	0.00	0.00	0.00	0.00	0.00	0.00		16.22		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	16.22	0.00	0.00	0.00	0.00	0.00	0.00		16.22		
5005	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	16.22	0.00	0.00	0.00	0.00	0.00	0.00		16.22		
5010	SOBRA PREGNANT WO
MAN	18,798.09	17,883.36	16,494.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,175.86		
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	711.12	0.00	0.00	2,950.43	0.00	0.00	0.00	0.00	0.00	0.00		5,565.69		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-21.83	0.00	0.00	0.00	0.00		-21.83		
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	950.69	0.00	0.00	131.80	0.00	0.00	0.00	0.00	0.00	0.00		3,853.65		
SUBTOTAL:	25,142,948.5	5 25,465,375.15	25,237,815.9	2	-5,030.81	370.28	3,886,165.24	-424.03	-18,623.14	-507.26	-1,659.58	-564.94	0.00		79,705,865.38		

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-18.12	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-60.50	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	-78.62	0.00	0.00	0.00	0.00	

-18.12	
-60.50	
-78.62	

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-110.98	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-110.98	0.00	0.00	0.00	0.00	

-110.98

-110.98

1110	TANF EXPANDED FOR FI	837.59	858.75	634.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	48.66	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	157.41	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	173.63	0.00	-9.21	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	48.66	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	837.59	858.75	634.6	1	0.00	0.00	428.36	0.00	-9.21	0.00	0.00	0.00	0.00	

 
2,330.95	
48.66	
157.41	
164.42	
48.66	
2,750.10	

4400	SOBRA 100-133% FOR F	0.00	0.00	109.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4403	SOBRA 100-133% M&F
6	0.00	-109.98	0.00	0.00	0.00	36.25	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	2,600,672.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	32.44	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	25,006.50	465.43	-238.33	278,862.79	0.00	-473.62	0.00	0.00	-680.19	0.00	
4414	SOBRA 100-133% MALE	6,103.13	6,467.95	5,180.31	0.00	0.00	60,198.72	0.00	-183.37	0.00	-0.17	0.00	0.00	

 
109.98	
-73.73	
7,770,324.97	
32.44	
366,612.76	
77,766.57	

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4415	SOBRA 100-133% FEMA L	5,718.94	7,704.29	4,862.51	-270.44	-101.49	59,690.28	83.71	-88.42	0.00	0.00	0.00	0.00		77,599.38		
441C	SOBRA 100-133% M&F
6	41,526.23	55,509.07	41,239.91	169.15	0.00	6,887.39	-18.55	0.00	0.00	0.00	0.00	0.00		145,313.20		
441D	SOBRA 100-133% MALE	8,652.93	10,727.09	9,235.03	67.66	0.00	1,211.37	0.00	0.00	0.00	0.00	0.00	0.00		29,894.08		
441E	SOBRA 100-133% FEMA L	9,143.17	12,344.03	7,215.99	0.00	0.00	1,551.56	0.00	-1.09	0.00	0.00	0.00	0.00		30,253.66		
SUBTOTAL:	2,673,584.61	2,723,524.77	2,693,522.8	5	431.80	-339.82	408,470.80	65.16	-746.50	0.00	-0.17	-680.19	0.00		8,497,833.31		

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	16.22	0.00	0.00	0.00	0.00	0.00	0.00	
6013	KIDS 6-13 M & F NON-	28.45	0.00	0.00	0.00	0.00	16.22	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.45	0.00	0.0	0	0.00	0.00	32.44	0.00	0.00	0.00	0.00	0.00	0.00	

 
16.22	
44.67	
60.89	

S000	STATE-ONLY BHS	0.00	0.00	0.00	-1.08	0.00	-0.97	0.00	0.00	0.00	0.00	-0.42	0.00	
SUBTOTAL:	0.00	0.00	0.00	-1.08	0.00	-0.97	0.00	0.00	0.00	0.00	-0.42	0.00	

 
-2.47

-2.47

88,206,317.61

27,817,399.20	28,189,758.67	27,931,973.38	-4,600.09	30.46	4,295,095.87	-358.87	-19,568.45	-507.26	-1,659.75	-1,245.55	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending May 31, 2019

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
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N
O
1017	TANF 21-44 FEMALE N
O

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

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
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

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

101C	TANF 06-13 M & F NON

Cu0.00rren0.00t

an0.0d0

pr0i.00or

m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er

r0e.00   vis0i.0o0

n. 0.00	0.00

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending May 31, 2019

RATE CODE	DESCRIPTION 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

4320	SOBRA CHILD WITH Q
MB
4322	SOBRA CHILD 01-05 M

4323	SOBRA CHILD 06-13 M

4325	SOBRA CHILD 14-20 FE

5005	SOBRA PREG 14-20 FE
M
5010	SOBRA PREGNANT WO
MAN
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
501C	SOBRA PREG 09-13 FE
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

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	0.00

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

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	
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

4400	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending May 31, 2019	
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		
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	0.0	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	

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending May 31, 2019	
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	1,466.58	1,466.58	0.00		2,933.16		
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	51.51	0.00	0.00	0.00	0.00	0.00	0.00		51.51		
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	39,478.56	35,180.61	34,518.70	33,052.12	31,345.87	32,007.78	36,886.86	36,744.10	38,547.26	0.00		391,541.47		
1014	TANF 14-20 MALE NON-	929.17	454.73	187.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,571.86		
1015	TANF 14-20 FEMALE N O	0.00	0.00	8,927.88	1,909.87	0.00	865.49	0.00	0.00	305.57	0.00	0.00	0.00		12,008.81		
1016	TANF 21-44 MALE NON-	-3,007.29	0.00	2,712.48	6,515.65	0.00	40,630.54	0.00	9,916.16	15,965.78	-1,815.59	0.00	0.00		70,917.73		
1017	TANF 21-44 FEMALE N O	9,489.76	10,825.98	45,641.89	11,961.72	81,622.31	24,696.45	86,815.83	24,681.52	31,876.05	552.57	0.00	0.00		328,164.08		
1018	TANF 45-64 M & F NON	-1,988.68	6,731.27	0.00	272.84	0.00	796.28	0.00	0.00	0.00	0.00	0.00	0.00		5,811.71		
101F	TANF 21-44 MALE NON-	0.00	0.00	1,356.24	0.00	0.00	412.64	0.00	0.00	796.92	-552.57	2,368.16	0.00		4,381.39		
101G	TANF 21-44 FEMALE N O	676.93	2,566.25	1,374.05	1,088.11	1,321.09	0.00	13,908.69	3,044.78	0.00	0.00	0.00	0.00		23,979.90		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	399.24	0.00	0.00	0.00	0.00	0.00	0.00		399.24		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	283.85	4,287.47	1,478.69	5,295.06	243.75	1,486.09	0.00	0.00	0.00		13,074.91		
210Z	SSI AGED WITH MEDIC
A	0.00	0.00	3,195.24	1,321.09	315.75	2,291.77	0.00	0.00	220.16	0.00	0.00	0.00		7,344.01		
211Z	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	1,145.88	0.00	0.00	0.00	0.00	0.00	0.00		1,145.88		
2120	SSI AGED WITH QMB	6,959.75	6,959.75	7,221.13	12,808.35	37,057.94	8,834.63	58,924.97	6,202.90	6,202.90	6,202.90	6,202.90	0.00		163,578.12		
212Z	SSI AGED WITH QMB P P	0.00	0.00	0.00	0.00	0.00	415.46	0.00	0.00	0.00	0.00	0.00	0.00		415.46		
2200	SSI DISABLED WITH M
E	6,264.14	18,012.96	20,728.88	8,469.13	3,834.74	8,432.67	4,686.30	6,739.13	4,028.07	9,642.65	7,007.57	0.00		97,846.24		
220Z	SSI DISABLED WITH M E	5,153.61	2,391.88	39,152.11	236.55	7,950.35	6,437.14	2,819.33	1,437.82	-1,091.35	342.20	5,882.20	0.00		70,711.84		
2210	SSI DISABLED NON-ME
D	250,005.66	212,319.31	220,481.04	308,880.93	313,110.53	417,140.12	299,267.28	219,516.04	190,654.47	217,690.26	202,545.65	0.00		2,851,611.29		
221Z	SSI DISABLED NON-ME D	45,791.77	2,637.45	0.00	1,222.27	2,834.63	2,709.38	458.35	3,411.37	0.00	6,508.76	1,997.44	0.00		67,571.42		
2220	SSI DISABLED WITH Q
M	66,508.51	124,531.80	216,105.67	136,292.31	75,495.92	179,098.31	154,744.73	77,206.72	71,233.38	75,090.43	78,791.50	0.00		1,255,099.28		
222Z	SSI DISABLED WITH Q M	0.00	90.95	-1,732.32	0.00	0.00	128.78	1,030.55	0.00	0.00	0.00	0.00	0.00		-482.04		
2310	SSI BLIND NON-MEDIC
A	1,356.24	1,356.24	1,356.24	1,706.25	1,706.25	2,105.49	1,706.25	1,706.25	1,706.25	1,706.25	1,706.25	0.00		18,117.96		
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	2,498.44	0.00		2,498.44		
4310	SOBRA CHILD NON-ME
DI	2,642.18	2,642.18	4,033.57	3,172.83	0.00	0.00	0.00	2,368.16	0.00	0.00	0.00	0.00		14,858.92		
4314	SOBRA CHILD 14-20 MA	24,304.45	1,161.62	6,943.67	13,278.13	8,739.92	273.07	1,375.06	0.00	0.00	0.00	0.00	0.00		56,075.92		
4315	SOBRA CHILD 14-20 FE	13,297.63	22,355.52	14,178.05	5,732.64	4,274.47	2,628.71	0.00	0.00	0.00	0.00	2,520.94	0.00		64,987.96		
431D	SOBRA CHILD 14-20 MA	2,067.51	0.00	2,819.33	3,694.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,581.16		
431E	SOBRA CHILD 14-20 FE	0.00	1,412.04	0.00	0.00	0.00	103.03	0.00	0.00	0.00	3,924.38	0.00	0.00		5,439.45		
5010	SOBRA PREGNANT WO MAN	0.00	1,356.24	1,356.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,712.48		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	1,277.05	0.00	0.00	0.00	0.00	0.00		1,277.05		
5017	SOBRA PREG 21-44 FE M	727.57	0.00	-632.91	0.00	10,083.49	3,220.16	0.00	0.00	0.00	0.00	0.00	0.00		13,398.31		
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	1,466.58	0.00		5,741.05		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	154.54	0.00	0.00	0.00	0.00	0.00	0.00		154.54		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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:	473,752.85	457,355.03	634,885.00	554,027.45	587,153.56	737,502.10	663,655.32	388,482.38	360,271.15	357,502.92	353,001.47	0.00		5,567,589.23		

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	30,514.93	28,846.20	27,379.62	27,379.62	27,379.62	26,717.71	33,582.52	43,294.83	46,707.33	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	830.92	0.00	0.00	0.00	22,554.64	0.00	0.00	

440.36	
880.73	
376,814.82	
23,385.56	

1100	TANF EXPANDED FPR FI	8,315.99	5,496.66	5,496.66	5,540.99	5,540.99	7,247.24	7,247.24	7,247.24	7,247.24	5,780.66	5,780.66	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	415.46	15,064.32	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	1,056.05	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	2,190.60	0.00	0.00	1,375.06	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	2,712.48	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	19,202.46	18,329.22	16,622.97	19,795.80	19,795.80	21,502.05	18,329.22	24,771.79	30,073.11	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	61,988.24	0.00	1,653.26	0.00	0.00	2,433.60	950.70	0.00	0.00	
1117	TANF EXPANDED 21-44	1,182.30	2,819.33	36,981.73	0.00	21,152.99	11,726.86	16,915.98	0.00	0.00	552.57	0.00	0.00	
1118	TANF EXPANDED 45-64	-187.96	4,992.88	0.00	5,638.66	0.00	1,345.54	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	0.00	8,793.69	0.00	3,927.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	4,119.86	0.00	0.00	0.00	2,447.10	520.40	2,273.65	0.00	1,860.70	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	763.92	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	2,642.18	2,642.18	2,642.18	2,933.16	2,933.16	2,933.16	2,933.16	2,933.16	2,933.16	1,466.58	1,466.58	0.00	
1126	TANF EXPANDED 21-44	14,890.11	0.00	0.00	0.00	48,298.87	1,246.38	35,606.93	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	1,163.15	37,381.90	0.00	0.00	552.57	0.00	0.00	
1128	TANF EXPANDED 45-64	25,600.13	0.00	3,571.43	9,679.70	0.00	1,304.09	0.00	0.00	0.00	0.00	0.00	0.00	
112F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,833.41	0.00	
112H	TANF EXPANDED 45-64	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	437.50	2,000.81	0.00	0.00	0.00	1,022.00	0.00	0.00	0.00	0.00	0.00	0.00	
240Z	SSI AGED EXPANDED
WI	918.74	2,134.21	0.00	763.92	0.00	232.34	0.00	0.00	3,896.01	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	6,546.65	5,322.72	11,100.17	5,301.32	22,259.92	8,576.34	5,301.32	5,301.32	7,669.48	8,222.05	12,405.80	0.00	
2600	SSI DISABLED EXPAND
E	1,973.53	2,131.01	93.98	229.18	0.00	828.10	0.00	0.00	956.30	0.00	1,757.02	0.00	
260Z	SSI DISABLED EXPAND E	4,938.38	2,772.13	9,789.00	0.00	1,956.61	766.26	1,051.46	0.00	1,514.14	0.00	2,215.38	0.00	
2610	SSI DISABLED EXPAND
E	2,819.33	2,819.33	8,036.60	2,932.03	2,368.16	6,398.94	2,368.16	2,368.16	2,368.16	2,368.16	0.00	0.00	
261Z	SSI DISABLED EXPAND E	0.00	0.00	1,409.66	1,324.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	40,303.04	160,386.67	139,311.34	48,431.75	19,280.05	67,798.43	51,432.03	25,010.81	52,796.70	25,121.38	31,678.35	0.00	
262Z	SSI DISABLED EXPAND E	0.00	1,071.23	2,067.51	2,819.33	0.00	0.00	0.00	0.00	0.00	788.27	0.00	0.00	
SUBTOTAL:	142,660.1	234,530.30	242,415.2	171,214.55	142,860.82	136,793.72	197,371.95	64,362.74	102,004.71	70,574.73	87,210.31	0.00	

 
70,941.57	
15,479.78	
1,056.05	
3,565.66	
3,479.56	
231,251.76	
1,727.98	
78,468.59	
91,331.76	
11,789.12	
12,721.03	
11,221.71	
763.92	
28,458.66	
100,042.29	
39,097.62	
40,155.35	
1,833.41	
350.00	
3,460.31	
7,945.22	
98,007.09	
7,969.12	
25,003.36	
34,847.03	
2,734.31	
661,550.55	
6,746.34	
1,591,999.15	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3515	ADULT 40-100% FEMAL E	0.00	0.00	12,311.07	8,457.99	0.00	0.00	25,216.38	0.00	0.00	0.00	0.00	0.00		45,985.44		
3516	ADULT 40-100% MALE 2	9,743.32	1,091.35	69,920.53	12,641.51	36,651.29	4,185.55	1,968.74	9,895.80	22,554.64	15,919.13	0.00	0.00		184,571.86		
3517	ADULT 40-100% FEMAL E	1,022.78	5,045.78	29,554.48	5,064.17	21,645.18	55,334.88	54,278.83	0.00	1,069.50	0.00	1,833.41	0.00		174,849.01		
3518	ADULT 40-100% M&F 45	-9,021.87	63,248.33	71,682.42	14,096.65	6,959.75	14,504.17	0.00	5,886.88	0.00	0.00	0.00	0.00		167,356.33		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	399.24	0.00	0.00	0.00	0.00	0.00	0.00		399.24		
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		1,879.55		
351E	ADULT 40-100% FEMAL E	0.00	0.00	2,819.33	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,638.66		
351F	ADULT 40-100% MALE 2	699.99	2,455.55	6,896.68	0.00	1,478.75	814.70	0.00	5,638.66	2,000.81	0.00	0.00	0.00		19,985.14		
351G	ADULT 40-100% FEMAL E	0.00	2,546.49	11,170.47	0.00	5,638.66	348.45	0.00	0.00	0.00	0.00	0.00	0.00		19,704.07		
351H	ADULT 40-100% M&F 45	0.00	5,634.08	9,626.79	5,638.66	4,923.71	650.79	0.00	0.00	0.00	0.00	0.00	0.00		26,474.03		
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	76.39	0.00	0.00	0.00	0.00	0.00	0.00		76.39		
3708	ADULT <40% EXP M&F 4	0.00	90.95	0.00	0.00	0.00	154.54	0.00	0.00	0.00	0.00	0.00	0.00		245.49		
370F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	916.71	0.00	0.00	0.00	0.00	0.00	0.00		916.71		
370G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	818.52	0.00	0.00	0.00	0.00	0.00	0.00		818.52		
370H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	296.21	0.00	0.00	0.00	0.00	0.00	0.00		296.21		
3710	AHC CARE EXPANDED FO	213,719.30	167,644.63	162,254.82	151,666.85	154,742.77	151,330.27	156,968.17	162,748.83	174,972.06	186,533.38	220,155.71	0.00		1,902,736.79		
3714	ADULT <40% EXP MALE	16,477.31	545.68	29,474.01	11,771.56	0.00	2,873.59	22,032.20	0.00	0.00	552.57	0.00	0.00		83,726.92		
3715	ADULT <40% EXP FEM AL	1,727.98	9,444.34	3,762.32	0.00	0.00	14,096.65	3,770.32	0.00	0.00	0.00	0.00	0.00		32,801.61		
3716	ADULT <40% EXP MALE	110,595.16	6,793.95	250,379.61	212,245.83	96,618.56	177,803.91	91,137.46	73,044.47	2,911.68	19,303.44	56,914.36	0.00		1,097,748.43		
3717	ADULT <40% EXP FEM AL	61,977.08	69,801.82	143,819.01	154,192.29	59,502.95	60,536.08	2,641.94	94,274.63	25,056.40	14,031.01	7,733.98	0.00		693,567.19		
3718	ADULT <40% EXP M&F
4	80,228.90	140,521.84	78,020.85	53,495.84	89,754.73	33,304.77	73,569.39	98,389.99	12,563.87	4,901.07	0.00	0.00		664,751.25		
371D	ADULT <40% EXP MALE	10,706.98	3,092.17	0.00	825.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,624.75		
371E	ADULT <40% EXP FEM AL	545.68	2,728.38	4,033.57	0.00	0.00	2,537.40	0.00	0.00	0.00	1,026.20	0.00	0.00		10,871.23		
371F	ADULT <40% EXP MALE	35,306.26	6,118.27	29,629.42	19,293.31	9,060.56	25,383.49	10,977.53	7,936.90	3,284.86	4,042.21	15,031.60	0.00		166,064.41		
371G	ADULT <40% EXP FEM AL	16,659.07	19,810.28	23,041.71	6,911.91	18,161.99	5,757.84	0.00	1,909.09	9,046.93	6,981.04	548.04	0.00		108,827.90		
371H	ADULT <40% EXP M&F
4	41,419.95	8,993.85	20,739.17	20,689.48	8,953.25	10,118.28	4,033.58	4,881.50	3,499.33	8,130.69	2,758.46	0.00		134,217.54		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	201.03	0.00	0.00	0.00	0.00	0.00	0.00		201.03		
372F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	1,321.09	-1,321.09	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
372H	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	611.14	0.00		611.14		
SUBTOTAL:	652,218.5	2	543,410.19	989,651.1	9	708,657.18	542,792.86	589,332.91	473,974.16	491,324.46	290,542.60	327,270.21	352,294.03	0.00		5,961,468.31		

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	13.40	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA
L	0.00	0.00	1,644.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	214.43	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR
F	19,486.46	20,949.55	25,231.97	17,381.79	17,381.79	15,675.54	15,675.54	15,675.54	13,307.38	13,307.38	13,307.38	0.00	
3914	NEWLY ELIGIBLE MALE	43.75	181.89	0.00	0.00	0.00	0.00	16,915.98	0.00	0.00	11,277.32	0.00	0.00	

 
13.40	
1,644.62	
214.43	
187,380.32	
28,418.94	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	1,084.99	0.00	0.00	0.00	18,280.17	0.00	0.00	0.00	0.00	0.00		19,365.16		
3916	NEWLY ELIGIBLE MALE	10,755.43	0.00	187.96	6,319.82	2,368.16	23,765.54	2,819.33	3,412.50	0.00	229.18	33,436.82	0.00		83,294.74		
3917	NEWLY ELIGIBLE FEMA L	2,452.45	0.00	5,936.43	0.00	0.00	10,429.12	0.00	8,457.99	0.00	0.00	22,554.64	0.00		49,830.63		
3918	NEWLY ELIGIBLE M&F
4	4,365.41	8,194.63	723.33	6,880.65	8,730.83	4,875.15	0.00	0.00	-2,141.21	11,235.87	0.00	0.00		42,864.66		
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	2,819.33	0.00	0.00	0.00	0.00	0.00		2,819.33		
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	1,356.24	0.00	0.00	0.00	4,274.47	0.00	0.00	0.00	0.00	0.00		5,630.71		
391F	NEWLY ELIGIBLE MALE	2,819.33	0.00	1,315.69	0.00	5,638.66	5,638.66	0.00	0.00	0.00	840.31	0.00	0.00		16,252.65		
391G	NEWLY ELIGIBLE FEMA L	3,670.53	0.00	0.00	1,298.67	0.00	0.00	0.00	6,963.08	0.00	0.00	5,638.66	0.00		17,570.94		
391H	NEWLY ELIGIBLE M&F
4	2,819.33	1,000.41	1,356.24	0.00	2,819.33	386.04	0.00	0.00	896.87	2,668.73	0.00	0.00		11,946.95		
SUBTOTAL:	46,412.69	30,326.48	38,837.4	7	31,880.93	36,938.77	60,997.88	60,784.82	34,509.11	12,063.04	39,558.79	74,937.50	0.00		467,247.48		

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	2,368.16	2,368.16	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	90.95	0.00	281.93	0.00	0.00	244.70	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	120.58	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	154.54	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	90.95	0.00	281.9	3	0.00	0.00	519.82	2,368.16	2,368.16	0.00	0.00	0.00	0.00	

 
4,736.32	
617.58	
120.58	
154.54	
5,629.02	

8700	SSI DISABLED FREEDO M	25,325.42	5,547.71	25,750.16	50,591.62	2,368.16	3,911.58	7,652.52	2,368.16	2,826.51	2,368.16	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	911.41	1,182.30	17,879.35	0.00	5,547.71	241.24	7,926.54	0.00	1,909.81	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	52,446.22	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	2,819.33	2,368.16	2,368.16	2,368.16	10,332.60	2,368.16	2,368.16	2,368.16	2,368.16	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	1,321.09	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29,056.16	9,549.34	46,448.8	4	105,406.00	10,284.03	6,520.98	27,232.75	4,736.32	7,104.48	4,736.32	2,368.16	0.00	

 
128,710.00	
35,598.36	
52,446.22	
35,367.71	
1,321.09	
253,443.38	

S000	STATE-ONLY BHS	0.00	0.00	5,638.66	0.00	8,006.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	5,638.66	0.00	8,006.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

13,645.48

13,645.48

0.00

869,811.47

771,985.98

1,571,186.11

TOTAL:

1,344,191.29

1,275,171.34	1,958,158.29

1,328,036.86	1,531,667.41	1,425,387.16	985,783.17

799,642.97

13,861,022.05

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending May 31, 2019

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
100F	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N
O

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

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N
O

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

1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

101G	TANF 21-44 FEMALE N
O

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

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

2100	SSI AGED WITH MEDIC
A

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

210Z	SSI AGED WITH MEDIC
A

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

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

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

212Z	SSI AGED WITH QMB P
P
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
2310	SSI BLIND NON-MEDIC
A
231Z	SSI BLIND NON-MEDIC
A
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
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

5010	SOBRA PREGNANT WO
MAN
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
501G	SOBRA PREG 21-44 FE
M
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
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	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 May 31, 2019	
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		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1107	FI
TANF EXPANDED 21-44	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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	FI
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	

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

1120	TANF EXPANDED FOR
FI

0.00	0.00	0.00	0.00	0.00

Current and prior month data is unde

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	
112F	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	
112H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED	0.00
WI	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	0.00
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED	0.00
WI	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	0.00
E	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	0.00
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND	0.00
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
261Z	SSI DISABLED EXPAND	0.00
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	0.00
E	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	0.00
E	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	

3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL
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	
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	

 
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending May 31, 2019

RATE CODE	DESCRIPTION 3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE 2

3517	ADULT 40-100% FEMAL
E
3518	ADULT 40-100% M&F 45

3519	ADULT 40-100% M&F 65

351D	ADULT 40-100% MALE 1

351E	ADULT 40-100% FEMAL
E
351F	ADULT 40-100% MALE 2

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

3706	ADULT <40% EXP MALE

3708	ADULT <40% EXP M&F
4
370F	ADULT <40% EXP MALE

370G	ADULT <40% EXP FEM
AL
370H	ADULT <40% EXP M&F
4

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

3710	AHC CARE EXPANDED
FO
3714	ADULT <40% EXP MALE

3715	ADULT <40% EXP FEM
AL
3716	ADULT <40% EXP MALE

3717	ADULT <40% EXP FEM
AL
3718	ADULT <40% EXP M&F
4
371D	ADULT <40% EXP MALE

371E	ADULT <40% EXP FEM
AL
371F	ADULT <40% EXP MALE

371G	ADULT <40% EXP FEM
AL
371H	ADULT <40% EXP M&F
4
3726	ADULT <40% EXP MALE

372F	ADULT <40% EXP MALE

372H	ADULT <40% EXP M&F
4
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

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	
390G	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR
F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
391H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

441D

SOBRA 100-133% MALE

SUBTOTAL:

Cu0.0r0   ren0.0t0      an0.d00

0.00	0.00	0.00

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

0.00

4410	SOBRA 100-133% FOR	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	F
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	

 
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 - GENERAL
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	743.35	832.26	911.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,487.59		
1006	TANF 21-44 MALE WITH	0.00	46.29	23.51	0.00	0.00	43.25	0.00	0.00	0.00	0.00	0.00	0.00		113.05		
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	23.51	0.00	0.00	73.45	0.00	0.00	0.00	0.00	0.00	0.00		452.41		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	89.08	0.00	0.00	0.00	0.00	0.00	0.00		89.08		
1010	TANF NON-MEDICARE	9,782,255.69	9,811,193.50	9,795,062.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,388,511.86		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	47.04	0.00	2,318.60	0.00	0.00	0.00	0.00		2,365.64		
1012	TANF 01-05 M & F NON	0.00	-141.06	0.00	0.00	0.00	0.00	0.00	832.25	0.00	0.00	0.00	0.00		691.19		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	563.91	45.83	414.48	0.00	0.00	0.00	0.00	0.00		1,024.22		
1014	TANF 14-20 MALE NON-	1,920.38	635.78	1,330.87	0.00	0.00	20,094.75	0.00	256.35	0.00	0.00	0.00	0.00		24,238.13		
1015	TANF 14-20 FEMALE N O	4,215.79	5,299.38	3,439.65	558.04	2.58	46,289.66	846.36	34.11	0.00	0.00	0.00	0.00		60,685.57		
1016	TANF 21-44 MALE NON-	30,559.31	40,540.47	25,780.42	-2,281.77	1,252.66	272,451.05	-2,277.06	-147.22	-2,082.89	1,109.99	-715.08	0.00		364,189.88		
1017	TANF 21-44 FEMALE N O	82,903.94	111,517.87	74,108.64	-2,413.20	-2,775.19	773,624.11	-2,280.41	-366.32	-1,533.09	741.00	392.00	0.00		1,033,919.35		
1018	TANF 45-64 M & F NON	17,062.72	24,164.54	15,959.62	-25.56	1.17	209,372.49	0.00	-486.56	79.72	0.00	1,026.93	0.00		267,155.07		
1019	TANF 65+ M & F NON-M	-32.73	18.88	-18.48	0.00	0.00	765.27	0.00	0.00	0.00	0.00	0.00	0.00		732.94		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,983.86	0.00	0.00	0.00	0.00		1,983.86		
101D	TANF 14-20 MALE NON-	2,263.51	3,088.68	1,582.69	0.00	70.53	324.97	0.00	0.00	0.00	0.00	0.00	0.00		7,330.38		
101E	TANF 14-20 FEMALE N O	6,063.63	7,959.73	5,109.95	0.00	0.00	736.28	0.00	0.00	0.00	0.00	0.00	0.00		19,869.59		
101F	TANF 21-44 MALE NON-	49,948.44	62,208.52	48,451.93	0.00	0.00	6,685.88	0.00	0.00	-37.90	0.00	0.00	0.00		167,256.87		
101G	TANF 21-44 FEMALE N O	122,069.48	162,772.42	121,070.06	220.78	-52.65	12,674.21	-277.42	0.00	0.00	0.00	0.00	0.00		418,476.88		
101H	TANF 44-64 M & F NON	22,645.65	34,688.28	27,583.90	91.48	0.00	3,488.81	141.06	0.00	0.00	0.00	0.00	0.00		88,639.18		
101J	TANF 65+ N & F NON-M	106.93	0.00	185.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.65		
1020	TANF WITH QMB	442.85	451.61	451.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,346.07		
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	47.04	0.00	0.00	0.00	0.00	0.00	0.00		-293.86		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	69.35	0.00	0.00	0.00	0.00	0.00	0.00		69.35		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	44.62	0.00	0.00	0.00	0.00	0.00	0.00		44.62		
2100	SSI AGED WITH MEDIC A	8,557.84	8,379.26	8,337.97	0.00	0.00	2,348.37	835.91	74.29	0.00	0.00	1,054.00	0.00		29,587.64		
210Z	SSI AGED WITH MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	2.28	0.00	0.00	0.00	0.00	0.00		2.28		
2110	SSI AGED NON-MEDIC AR	448,777.49	452,563.61	454,367.65	0.00	1,209.12	44,262.28	0.00	0.00	0.00	0.00	0.00	0.00		1,401,180.15		
211Z	SSI AGED NON-MEDIC
AR	10,752.26	13,418.23	7,806.92	93.28	122.04	1,590.43	0.00	0.00	534.12	0.00	0.00	0.00		34,317.28		
2120	SSI AGED WITH QMB	41,643.94	41,513.89	41,216.87	0.00	0.00	11,231.02	0.00	1,443.16	0.00	15.93	0.00	0.00		137,064.81		
2200	SSI DISABLED WITH M E	15,741.04	15,577.80	15,681.02	0.00	42.32	4,123.16	-50.38	0.00	31.85	1,251.71	0.00	0.00		52,398.52		
220Z	SSI DISABLED WITH M
E	0.00	0.00	68.25	0.00	28.21	0.00	0.00	70.53	27.30	159.44	0.00	0.00		353.73		
2210	SSI DISABLED NON-ME D	2,388,281.92	2,375,550.83	2,382,476.15	-3,057.80	-3,665.06	342,562.98	-2,315.25	1,587.51	-1,880.15	1,068.05	-1,134.96	0.00		7,479,474.22		
221Z	SSI DISABLED NON-ME
D	37,694.51	48,238.63	31,744.22	220.78	8.11	4,986.31	-188.84	-59.15	70.53	34.22	0.00	0.00		122,749.32		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2220	SSI DISABLED WITH Q M	53,830.16	53,862.83	52,392.10	0.00	-1,132.03	13,429.77	40.21	3,063.52	120.59	0.00	1,333.30	0.00		176,940.45		
222Z	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	31.85	0.00	0.00	0.00	0.00	0.00	-3.67	0.00		28.18		
2300	SSI BLIND WITH MEDIC	141.92	141.92	172.67	0.00	0.00	68.14	0.00	0.00	0.00	0.00	0.00	0.00		524.65		
2310	SSI BLIND NON-MEDIC A	29,895.63	29,764.89	30,178.70	0.00	0.00	4,421.13	0.00	0.00	0.00	0.00	0.00	0.00		94,260.35		
231Z	SSI BLIND NON-MEDIC
A	272.22	2,283.80	402.02	0.00	0.00	70.56	0.00	0.00	0.00	0.00	0.00	0.00		3,028.60		
2320	SSI BLIND WITH QMB	1,177.44	1,177.44	1,177.44	0.00	0.00	237.07	0.00	0.00	0.00	0.00	0.00	0.00		3,769.39		
4300	SOBRA CHILD WITH M ED	0.00	0.00	159.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159.44		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	252.10	0.00	0.00	0.00	0.00		252.10		
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.60	0.00	0.00	0.00	0.00		15.60		
4310	SOBRA CHILD NON-ME DI	1,498,864.65	1,498,027.05	1,516,908.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,513,800.46		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	23.52	0.00	2,989.92	0.00	0.00	0.00	0.00		3,013.44		
4312	SOBRA CHILD 01-05 M	0.00	0.00	47.02	0.00	0.00	257.51	0.00	7,073.08	846.36	356.94	0.00	0.00		8,580.91		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	614.26	813.68	0.00	2,422.01	0.00	0.00	0.00	0.00		3,849.95		
4314	SOBRA CHILD 14-20 MA	9,312.68	18,188.27	10,734.32	-1,472.31	-735.53	101,476.56	752.68	1,543.39	-1,566.09	4.29	-111.97	0.00		138,126.29		
4315	SOBRA CHILD 14-20 FE	12,440.21	19,489.72	12,050.60	-1,601.68	-131.65	98,977.88	0.00	1,477.95	637.76	0.00	0.00	0.00		143,340.79		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,679.53	0.00	0.00	0.00	0.00		1,679.53		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	384.73	0.00	0.00	0.00	0.00		384.73		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	144.84	0.00	0.00	0.00	0.00		144.84		
431D	SOBRA CHILD 14-20 MA	15,921.94	28,667.41	16,593.73	102.57	0.00	2,491.98	0.00	23.81	0.00	0.00	29.76	0.00		63,831.20		
431E	SOBRA CHILD 14-20 FE	19,882.62	25,170.43	20,256.59	141.06	0.00	2,766.31	0.00	4.87	0.00	0.00	0.00	0.00		68,221.88		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.53	0.00	0.00	0.00	0.00		70.53		
5010	SOBRA PREGNANT WO MAN	1,394,704.48	1,374,426.20	1,364,891.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,134,021.99		
5015	SOBRA PREG 14-20 FE
M	10,033.94	13,827.68	8,730.57	70.53	-0.51	26,722.08	0.00	0.00	0.00	0.00	0.00	0.00		59,384.29		
5017	SOBRA PREG 21-44 FE M	49,743.43	66,574.50	42,922.90	-915.49	-568.00	162,668.63	0.00	41.71	0.00	-6.06	0.00	0.00		320,461.62		
5018	SOBRA PREG 45-64 FE
M	132.74	90.63	58.78	0.00	0.00	405.87	0.00	0.00	0.00	0.00	0.00	0.00		688.02		
501E	SOBRA PREG 14-20 FE M	14,716.29	16,325.07	14,167.71	70.53	0.00	1,405.06	0.00	0.00	0.00	0.00	0.00	0.00		46,684.66		
501G	SOBRA PREG 21-44 FE
M	69,865.25	80,167.70	65,797.69	212.02	0.00	7,438.76	0.00	0.00	0.00	0.00	0.00	0.00		223,481.42		
501H	SOBRA PREG 45-64 FE M	229.10	64.60	82.28	0.00	0.00	58.48	0.00	0.00	0.00	0.00	0.00	0.00		434.46		
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		
8020	QMB ONLY	0.00	0.00	-159.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-159.44		
SUBTOTAL:	16,255,607.2	9 16,448,977.52	16,220,322.4	9	-9,986.74	-5,113.86	2,181,804.68	-4,356.38	28,729.00	-4,751.89	4,735.51	1,870.31	0.00		51,117,837.93		

-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

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1100	TANF EXPANDED FPR FI	4,195.09	3,982.64	4,193.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,371.53		
1106	TANF EXPANDED 21-44	0.00	239.16	2.28	0.00	0.00	92.67	0.00	0.00	0.00	0.00	0.00	0.00		334.11		
1107	TANF EXPANDED 21-44	56.58	90.60	23.65	0.00	0.00	64.55	0.00	0.00	0.00	0.00	0.00	0.00		235.38		
1108	TANF EXPANDED 45-64	12.83	-60.80	126.74	0.00	0.00	414.89	0.00	0.00	0.00	0.00	0.00	0.00		493.66		
1109	TANF EXPANDED 65+
M&	50.05	-39.30	159.44	0.00	0.00	533.18	0.00	0.00	0.00	0.00	0.00	0.00		703.37		
1110	TANF EXPANDED FOR FI	8,816,697.06	8,834,300.06	8,876,581.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,527,578.13		
1114	TANF EXPANDED 14-20	487.52	646.01	576.12	0.00	0.00	4,771.02	0.00	16.30	0.00	0.00	0.00	0.00		6,496.97		
1115	TANF EXPANDED 14-20	1,026.60	1,944.17	1,495.88	0.00	0.00	16,064.05	0.00	0.00	0.00	0.00	0.00	0.00		20,530.70		
1116	TANF EXPANDED 21-44	30,145.35	37,476.03	27,225.11	-4,335.26	-1,474.22	322,784.14	-144.84	-793.32	-171.11	-9.10	-347.36	0.00		410,355.42		
1117	TANF EXPANDED 21-44	63,803.22	85,539.81	55,633.64	250.06	-194.35	713,951.51	560.17	-846.36	-634.77	0.00	-386.79	0.00		917,676.14		
1118	TANF EXPANDED 45-64	21,605.25	26,934.32	16,212.66	-459.94	0.00	274,465.18	0.00	-418.48	0.00	-846.36	72.04	0.00		337,564.67		
1119	TANF EXPANDED 65+
M&	-20.57	-91.89	-243.10	0.00	0.00	560.85	0.00	0.00	0.00	0.00	0.00	0.00		205.29		
111D	TANF EXPANDED 14-20	1,583.13	1,222.46	695.35	0.00	0.00	81.82	0.00	0.00	0.00	0.00	0.00	0.00		3,582.76		
111E	TANF EXPANDED 14-20	2,348.69	2,907.27	2,036.16	0.00	0.00	352.32	0.00	0.00	0.00	0.00	0.00	0.00		7,644.44		
111F	TANF EXPANDED 21-44	54,795.63	67,580.75	50,542.40	327.63	111.17	8,056.99	32.05	0.00	0.00	313.74	0.00	0.00		181,760.36		
111G	TANF EXPANDED 21-44	93,521.61	123,890.17	96,145.73	252.23	80.42	11,728.80	-52.33	0.00	0.00	0.00	0.00	0.00		325,566.63		
111H	TANF EXPANDED 45-64	33,910.12	40,470.34	30,679.84	70.53	0.00	4,617.54	0.00	0.00	0.00	0.00	0.00	0.00		109,748.37		
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		358.79		
1120	TANF EXPANDED FOR FI	11,715.76	11,750.39	12,007.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,473.65		
1126	TANF EXPANDED 21-44	102.80	43.23	70.53	0.00	0.00	252.67	0.00	0.00	0.00	0.00	0.00	0.00		469.23		
1127	TANF EXPANDED 21-44	27.30	21.86	-25.86	0.00	0.00	231.57	0.00	0.00	0.00	0.00	0.00	0.00		254.87		
1128	TANF EXPANDED 45-64	11.38	127.41	-54.07	0.00	0.00	1,013.10	0.00	0.00	0.00	0.00	0.00	0.00		1,097.82		
1129	TANF EXPANDED 65+
M&	0.00	0.00	-18.09	0.00	0.00	899.13	0.00	0.00	0.00	0.00	0.00	0.00		881.04		
2400	SSI AGED EXPANDED WI	171.92	244.20	211.59	0.00	0.00	69.35	0.00	0.00	0.00	0.00	0.00	0.00		697.06		
240Z	SSI AGED EXPANDED
WI	0.00	0.00	0.00	79.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.72		
2410	SSI AGED EXPANDED NO	6,133.05	5,844.41	5,324.23	0.00	0.00	898.54	0.00	0.00	0.00	0.00	0.00	0.00		18,200.23		
241Z	SSI AGED EXPANDED
NO	456.25	163.62	361.41	0.00	0.00	100.91	0.00	0.00	0.00	0.00	0.00	0.00		1,082.19		
2420	SSI AGED EXPANDED WI	33,662.51	33,736.61	33,776.99	0.00	0.00	6,786.05	0.00	155.73	0.00	0.00	0.00	0.00		108,117.89		
2600	SSI DISABLED EXPAND
E	150.25	220.78	200.74	0.00	0.00	66.77	0.00	0.00	-282.12	0.00	0.00	0.00		356.42		
2610	SSI DISABLED EXPAND E	98,233.68	95,973.04	96,384.45	0.00	0.00	16,802.43	0.00	0.00	0.00	0.00	0.00	0.00		307,393.60		
261Z	SSI DISABLED EXPAND
E	1,762.46	1,243.22	1,682.92	0.00	0.00	429.00	0.00	0.00	0.00	0.00	0.00	0.00		5,117.60		
2620	SSI DISABLED EXPAND E	18,184.98	18,155.42	18,137.37	0.00	1,135.11	3,706.10	0.00	0.00	-1.71	0.00	-1.71	0.00		59,315.56		
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:	9,295,014.61	9,394,730.67	9,330,146.4	2	-3,815.03	-341.87	1,389,795.13	395.05	-1,886.13	-1,089.71	-541.72	-663.82	0.00		29,401,743.60		

3316	AHC CARE MALE 21-44	0.00	0.00	-141.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-141.92

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		-70.53		
SUBTOTAL:	0.00	-70.53	-141.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-212.45		

614.26

-70.53

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	614.26	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-70.5	3	0.00	0.00	0.00	614.26	0.00	0.00	0.00	0.00	0.00	

543.73

3508	ADULT 40-100% M&F 45	68.67	0.00	0.00	0.00	0.00	23.52	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	6,168,118.22	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	4,358.85	-2,277.60	-42.77	57,975.27	0.00	0.00	0.00	-569.55	0.00	0.00	
3515	ADULT 40-100% FEMAL E	5,563.22	7,721.66	3,711.12	-223.35	0.00	56,922.65	-694.98	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	14,591.57	22,348.94	9,459.41	191.35	-2,891.92	206,181.13	-676.56	-1,619.65	-1,921.06	-341.52	-6.61	0.00	
3517	ADULT 40-100% FEMAL E	14,101.53	18,970.82	11,523.94	-72.24	-403.95	165,254.11	317.47	55.63	0.00	0.00	0.75	0.00	
3518	ADULT 40-100% M&F 45	30,836.64	39,488.15	21,687.32	-716.39	-268.49	459,081.86	0.00	-872.73	2.35	-1,723.28	-143.87	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	45.83	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	6,909.99	7,801.96	7,284.66	70.53	0.00	1,119.18	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	9,982.01	12,273.81	8,910.46	-58.78	0.00	1,303.64	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	32,692.91	39,502.13	32,067.36	300.50	-23.51	5,213.80	0.00	-77.58	-34.12	128.58	0.00	0.00	
351G	ADULT 40-100% FEMAL E	24,535.71	33,727.84	28,275.53	70.53	-100.11	4,136.60	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	51,082.07	-91.01	-16.63	9,813.29	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	0.00	212.02	634.77	0.00	0.00	23.52	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	70.53	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	96.39	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	230.78	0.00	0.00	4.55	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	13,785,634.76	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	8,563.14	-669.44	16.56	103,741.11	-557.04	0.00	-6.85	-466.67	249.82	0.00	
3715	ADULT <40% EXP FEM AL	10,053.15	15,626.36	9,061.23	-731.18	-27.79	90,240.62	-162.42	0.00	0.00	-8.73	-0.12	0.00	
3716	ADULT <40% EXP MALE	95,592.62	153,754.47	72,177.47	-16,126.49	-14,817.73	598,682.80	-7,285.80	-7,149.51	-1,719.34	-3,575.99	-3,647.88	0.00	
3717	ADULT <40% EXP FEM AL	53,638.01	77,939.98	46,265.06	-3,219.96	-2,916.69	337,810.38	250.61	-3,199.85	-2,597.79	-410.39	-724.52	0.00	
3718	ADULT <40% EXP M&F
4	88,757.54	124,669.37	68,535.85	-7,026.12	-5,550.39	796,453.14	-5,808.14	-6,564.87	-4,237.40	-3,950.20	-1,325.36	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	-101.09	0.00	0.00	279.82	0.00	0.00	0.00	0.00	0.00	0.00	
371D	ADULT <40% EXP MALE	19,843.54	22,122.01	17,875.89	39.97	70.96	2,342.51	0.00	0.00	0.00	0.00	61.50	0.00	
371E	ADULT <40% EXP FEM AL	18,450.86	22,487.00	14,821.34	220.78	0.00	2,122.91	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	169,051.65	210,581.57	153,510.09	910.73	464.10	21,097.50	-222.12	-213.32	0.00	53.52	-179.92	0.00	
371G	ADULT <40% EXP FEM AL	98,395.06	115,940.53	93,319.44	819.60	-424.26	10,766.22	2.37	7.80	-167.26	-54.60	-81.41	0.00	
371H	ADULT <40% EXP M&F
4	145,352.68	196,149.54	135,717.07	823.97	61.16	21,100.78	-23.51	-58.78	0.00	0.00	66.62	0.00	

92.19	
18,461,253.68	
68,553.17	
73,000.32	
245,315.08	
209,748.06	
547,371.56	
45.83	
23,186.32	
32,411.14	
109,770.07	
90,646.10	
182,740.08	
870.31	
70.53	
139.62	
77.55	
-49.47	
41,153,884.21	
134,741.78	
124,051.12	
865,884.62	
502,834.84	
1,043,953.42	
178.73	
62,356.38	
58,102.89	
555,053.80	
318,523.49	
499,189.53	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371J	ADULT <40% EXP M&F 6	141.06	300.50	282.12	0.00	0.00	47.04	0.00	0.00	0.00	0.00	0.00	0.00		770.72		
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	20,753,173.7	8	-27,764.60	-26,871.46	2,951,783.78	-14,860.12	-19,692.86	-10,681.47	-10,918.83	-5,731.00	0.00		65,364,803.67		

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	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	23.52	0.00	0.00	0.00	0.00	0.00	0.00	
4410	SOBRA 100-133% FOR F	320,411.40	323,433.06	318,096.11	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	47.04	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,585.05	2,247.67	1,959.40	-1,361.60	0.00	22,618.17	0.00	-144.95	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,682.51	3,253.83	2,333.36	70.53	0.00	22,288.74	0.00	136.50	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	3,444.90	4,168.64	3,318.89	-99.02	0.00	537.59	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	3,012.55	5,249.67	3,389.87	0.00	0.00	476.50	0.00	4.56	0.00	0.00	0.00	0.00	
SUBTOTAL:	332,216.1	3	338,352.87	329,097.6	3	-1,390.09	0.00	45,991.56	0.00	-3.89	0.00	0.00	0.00	0.00	

79.72	
23.52	
961,940.57	
47.04	
27,903.74	
30,765.47	
11,371.00	
12,133.15	
1,044,264.21	

4510	BC PATIENT FOR FINA N	9,220.45	9,521.38	9,892.84	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	184.53	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	144.32	213.87	50.49	0.00	0.00	1,478.60	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	47.04	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	119.58	0.00	0.00	70.62	0.00	0.00	0.00	0.00	0.00	0.00	

28,634.67	
309.74	
1,887.28	
47.04	
157.34	
1,312.55	

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	28.21	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	81.90	69.09	0.00	0.00	47.04	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	5,351,118.94	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	2,274.30	0.00	0.00	30,382.92	-455.93	117.50	0.00	-282.12	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,794.78	4,731.30	2,898.02	0.00	0.00	32,958.90	-457.31	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	21,847.70	30,438.42	19,319.51	-1,188.96	-69.71	186,523.34	-1,334.50	150.25	-4.89	-339.45	-1,433.45	0.00	
3917	NEWLY ELIGIBLE FEMA L	33,156.94	48,986.91	31,902.34	-1,557.01	0.00	243,969.62	0.00	-239.80	-1,319.56	0.00	-616.57	0.00	
3918	NEWLY ELIGIBLE M&F
4	25,942.10	32,823.63	21,149.64	-1,880.93	-279.55	302,111.40	0.00	0.00	-1,732.86	-640.33	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	91.66	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	6,181.24	7,194.46	4,159.11	0.00	0.00	635.79	-37.78	0.00	0.00	0.00	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	6,405.61	6,227.35	4,879.48	0.00	0.00	977.09	-106.93	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	38,771.67	51,515.41	40,812.22	150.68	-108.31	5,893.27	-72.81	-70.53	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	57,199.13	73,737.22	59,541.82	212.02	0.00	8,052.55	0.00	-42.32	0.00	0.00	-88.73	0.00	
391H	NEWLY ELIGIBLE M&F
4	49,113.47	55,362.57	45,399.04	141.06	-9.40	7,888.91	0.00	0.00	-52.72	-156.87	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	0.00	70.53	282.12	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	5,583,833.8	-4,123.14	-466.97	819,532.49	-2,465.26	-84.90	-3,110.03	-1,418.77	-2,138.75	0.00	

 
28.21	
198.03	
16,029,103.77	
38,258.96	
43,925.69	
253,908.26	
354,282.87	
377,493.10	
91.66	
18,132.82	
18,382.60	
136,891.60	
198,611.69	
157,686.06	
352.65	
17,627,347.97	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending May 31, 2019	
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	1,325.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,978.34		
4617	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	137.49	0.00	0.00	0.00	0.00	0.00	0.00		137.49		
4618	CC PATIENT FEMALE 4 5	15.93	0.00	0.00	0.00	0.00	137.49	0.00	0.00	0.00	0.00	0.00	0.00		153.42		
461G	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	23.52	0.00	0.00	0.00	0.00	0.00	0.00		23.52		
461H	CC PATIENT FEMALE 4 5	54.60	0.00	0.00	0.00	0.00	23.52	0.00	0.00	0.00	0.00	0.00	0.00		78.12		
SUBTOTAL:	11,159.66	12,068.16	11,388.8	8	0.00	0.00	2,102.81	0.00	0.00	0.00	0.00	0.00	0.00		36,719.51		

8700	SSI DISABLED FREEDO M	1,398.78	1,467.03	1,325.97	0.00	0.00	78.78	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	27,327.42	26,669.16	26,348.99	-1,460.62	0.00	2,569.39	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	1,574.97	1,482.54	829.48	0.00	0.00	75.75	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	79.72	79.72	0.00	0.00	45.83	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30,301.17	29,698.45	28,584.1	6	-1,460.62	0.00	2,769.75	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,270.56	
81,454.34	
3,962.74	
205.27	
89,892.91	

S000	STATE-ONLY BHS	0.00	0.00	-70.53	-438.51	55.12	48.42	-78.55	123.72	-16.38	-13.39	-5.38	0.00	
SUBTOTAL:	0.00	0.00	-70.53	-438.51	55.12	48.42	-78.55	123.72	-16.38	-13.39	-5.38	0.00	

 
-395.48

-395.48

164,682,324.82

52,206,102.51	52,955,888.62	52,256,264.22	-48,978.73	-32,739.04	7,393,828.62	-20,751.00	7,184.94	-19,649.48	-8,157.20	-6,668.64	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending May 31, 2019

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
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1015	TANF 14-20 FEMALE N
O

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

1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

1017	TANF 21-44 FEMALE N
O

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

1018	TANF 45-64 M & F NON	0.00	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

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

101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

101E	TANF 14-20 FEMALE N
O

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

101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

101G	TANF 21-44 FEMALE N
O

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

101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101J	TANF 65+ N & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
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
210Z	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
0.00	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
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D

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

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	

For The Period Ending May 31, 2019

RATE CODE	DESCRIPTION 2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M
2300	SSI BLIND WITH MEDIC

2310	SSI BLIND NON-MEDIC
A
231Z	SSI BLIND NON-MEDIC
A
2320	SSI BLIND WITH QMB

4300	SOBRA CHILD WITH M
ED
4304	SOBRA CHILD 14-20 MA

430C	SOBRA CHILD 06-13 M

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

4312	SOBRA CHILD 01-05 M

4313	SOBRA CHILD 06-13 M

4314	SOBRA CHILD 14-20 MA

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	
4322	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	
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	
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	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
																
3010	MN/MI NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4110	EAC NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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	

4315	SOBRA CHILD 14-20 FE

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending May 31, 2019

RATE CODE	DESCRIPTION 1100	TANF EXPANDED FPR
FI
1106	TANF EXPANDED 21-44

1107	TANF EXPANDED 21-44

1108	TANF EXPANDED 45-64

1109	TANF EXPANDED 65+
M&
1110	TANF EXPANDED FOR
FI
1114	TANF EXPANDED 14-20

1115	TANF EXPANDED 14-20

1116	TANF EXPANDED 21-44

1117	TANF EXPANDED 21-44

1118	TANF EXPANDED 45-64

1119	TANF EXPANDED 65+
M&
111D	TANF EXPANDED 14-20

111E	TANF EXPANDED 14-20

111F	TANF EXPANDED 21-44

Cu0.00rren0.00t

an0.0d0

pr0i.00or

m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er

r0e.00   vis0i.0o0

n. 0.00	0.00

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

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

111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
111H	TANF EXPANDED 45-64

111J	TANF EXPANDED 65+
M&
1120	TANF EXPANDED FOR
FI
1126	TANF EXPANDED 21-44

1127	TANF EXPANDED 21-44

1128	TANF EXPANDED 45-64

1129	TANF EXPANDED 65+
M&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED
NO
241Z	SSI AGED EXPANDED
NO
2420	SSI AGED EXPANDED
WI
2600	SSI DISABLED EXPAND
E
2610	SSI DISABLED EXPAND
E
261Z	SSI DISABLED EXPAND
E
2620	SSI DISABLED EXPAND
E
262Z	SSI DISABLED EXPAND
E
SUBTOTAL:

3316	AHC CARE MALE 21-44

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

0.00

0.00

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

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

351D	ADULT 40-100% MALE 1	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
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

3700	ADULT <40% EXP FOR
F

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

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3707	ADULT <40% EXP 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
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

371G	ADULT <40% EXP FEM
AL
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	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 May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	
4404	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	
4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	0.00	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	
0.00	

3907

3908

3910

3914

3915

3916

3917

3918

3919

391D

391E

391F	NEWLY ELIGIBLE FEMA L
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
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
Cu0.00r
0.00	0.00

0.00

0.00

0.00

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

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

0.00

0.00

0.00

0.00

0.00
pr0i.00o
0.00	0.00

0.00

0.00

0.00

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

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

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

0.00

0.00

0.00

0.00

0.00
und0.00e
0.00	0.00

0.00

0.00

0.00

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

0.00

0.00

0.00

0.00

0.00
vis0i.0o0
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
n. 0.00
0.00	
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	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending May 31, 2019	
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		
4617	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
461G	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
461H	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

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

 
0.00	
0.00	
0.00	
0.00	
0.00	

TOTAL:	Cu0.0r0	ren0.0t0	an0.d00	pr0i.0o0	r m0.00	ont0h.00	da0.0t0	a is0.00	und0.00e	r r0e.00	vis0i.0o0	n.0.00		0.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending May 31, 2019	
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	823,473.34	980,863.55	946,205.55	821,542.05	756,118.45	755,466.30	741,996.55	729,442.40	716,910.60	0.00		8,925,087.73		
1011	TANF <1 M & F NON-ME	2,708.55	15,092.52	12,333.55	-5,628.10	-3,469.16	41,405.38	2,458.13	4,550.35	-4,452.69	1,174.54	-3,490.12	0.00		62,682.95		
1012	TANF 01-05 M & F NON	-5,476.49	-19,306.55	-8,979.24	-17,398.14	-32,728.77	-1,766.80	-17,453.14	-15,021.72	-15,113.37	-18,051.85	-24,057.40	0.00		-175,353.47		
1013	TANF 06-13 M & F NON	-40.48	8,295.03	-3,363.22	1,307.25	-4,643.08	1,979.58	1,347.34	-4,201.61	-1,454.21	5,053.48	-1,173.15	0.00		3,106.93		
1014	TANF 14-20 MALE NON-	890.55	4,851.06	2,608.18	-118.85	-1,167.58	4,059.26	1,167.70	-1,275.64	-444.76	2,267.03	-919.55	0.00		11,917.40		
1015	TANF 14-20 FEMALE N O	971.51	2,567.14	1,675.22	281.72	-2,028.40	1,070.27	-294.97	1,387.93	-98.32	1,422.40	-762.00	0.00		6,192.50		
101A	TANF < 1 M & F NON-M	1,457.26	-1,333.88	2,092.15	24.58	4,150.66	466.84	980.44	1,943.55	0.00	25.40	136.07	0.00		9,943.07		
101B	TANF 01-05 M & F NON	936.60	-1,369.32	-2,153.88	652.01	-1,266.40	-257.96	-219.11	-190.50	-3,256.35	422.13	0.00	0.00		-6,702.78		
101C	TANF 06-13 M & F NON	-627.43	-627.43	0.00	0.00	-2.16	-762.00	0.00	-970.35	0.00	23,577.85	0.00	0.00		20,588.48		
101D	TANF 14-20 MALE NON-	568.06	378.19	-919.94	0.00	-762.00	785.76	0.00	0.00	0.00	0.00	0.00	0.00		50.07		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	-762.00	0.00	-272.14	0.00	0.00	0.00	0.00		-1,034.14		
2210	SSI DISABLED NON-ME
D	182,177.17	169,523.32	169,204.78	219,183.89	210,293.95	242,050.57	221,052.69	224,508.18	241,544.06	254,999.19	249,090.33	0.00		2,383,628.13		
221Z	SSI DISABLED NON-ME D	417.06	2,365.04	878.40	491.61	3,645.15	1,890.57	3,614.60	1,553.40	187.81	-3,423.99	-319.55	0.00		11,300.10		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	970.35	1,732.35	1,732.35	970.35	882.98	762.00	762.00	0.00		7,812.38		
4300	SOBRA CHILD WITH M ED	627.43	627.43	627.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,882.29		
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	8,564,415.53	10,124,354.60	10,029,986.55	10,093,013.80	10,098,770.20	10,021,543.90	10,083,167.55	10,091,622.05	10,125,207.00	0.00		107,262,236.61		
4311	SOBRA CHILD <1 M & F	26,675.98	26,487.23	36,945.81	13,010.61	12,426.68	94,716.52	19,384.62	10,325.75	3,576.69	12,847.46	7,996.10	0.00		264,393.45		
4312	SOBRA CHILD 01-05 M	-37,293.39	-60,745.93	9,568.94	-114,587.75	-102,012.11	468,596.04	-108,932.73	-70,800.74	-92,283.00	-84,110.77	-86,150.99	0.00		-278,752.43		
4313	SOBRA CHILD 06-13 M	-64,080.03	-52,295.61	17,847.46	-146,407.64	-99,400.12	477,563.71	-119,683.35	-103,301.15	-84,462.43	-65,300.74	-81,818.05	0.00		-321,337.95		
4314	SOBRA CHILD 14-20 MA	-23,193.15	-30,502.53	-35,482.18	-31,278.88	-25,974.09	125,817.32	-39,432.39	-25,436.74	-24,053.86	-54,517.49	-36,221.71	0.00		-200,275.70		
4315	SOBRA CHILD 14-20 FE	-16,461.87	-27,125.32	-3,362.89	-43,518.36	-38,135.55	122,585.70	-37,151.66	-21,938.96	-31,813.76	-17,568.12	-31,335.82	0.00		-145,826.61		
431A	SOBRA CHILD < 1 M &	8,525.24	21,159.47	13,279.60	11,448.75	24,827.93	6,531.93	8,841.99	5,976.98	11,381.30	8,627.37	8,072.98	0.00		128,673.54		
431B	SOBRA CHILD 01-05 M	43,243.66	28,250.46	19,688.40	98,353.89	73,574.07	56,090.64	44,162.74	34,381.83	35,745.88	36,016.48	39,729.72	0.00		509,237.77		
431C	SOBRA CHILD 6-13 M& F	37,854.08	15,353.14	50,620.72	61,264.62	57,881.68	48,708.72	36,847.32	42,667.24	45,671.74	32,637.38	32,536.10	0.00		462,042.74		
431D	SOBRA CHILD 14-20 MA	15,859.30	16,330.16	27,230.81	42,410.37	32,302.22	21,827.27	16,977.36	35,896.08	16,122.06	10,046.35	18,839.01	0.00		253,840.99		
431E	SOBRA CHILD 14-20 FE	21,929.33	10,131.18	-755.17	24,567.82	21,670.23	16,620.22	25,149.02	10,779.59	15,489.32	14,236.57	32,280.27	0.00		192,098.38		
5010	SOBRA PREGNANT WO MAN	11,084.05	10,164.11	8,699.20	9,007.05	8,245.05	7,274.70	10,739.40	9,977.40	10,739.40	10,947.75	12,005.80	0.00		108,883.91		
5015	SOBRA PREG 14-20 FE
M	-700.19	-178.61	0.00	0.00	0.00	3,058.99	-1,564.71	0.00	248.49	0.00	-950.19	0.00		-86.22		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	907.75	0.00	0.00	156.51	0.00	0.00	0.00		1,064.26		
SUBTOTAL:	10,211,324.5	6	9,818,022.67	9,706,173.0	0 11,228,284.60	11,114,590.65	12,656,747.18	10,924,612.29	10,918,519.28	10,949,477.59	10,993,154.87	10,976,367.45	0.00		119,497,274.14		

351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	271.43	0.00	0.00	0.00	0.00	0.00	0.00	

271.43

1114	TANF EXPANDED 14-20	0.00	0.00	0.00	442.45	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	73.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	516.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
442.45	
73.74	
516.19	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3710	AHC CARE EXPANDED FO	0.00	1,172.40	1,172.40	762.00	1,524.00	762.00	762.00	0.00	1,732.35	1,732.35	762.00	0.00		10,381.50		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	272.14	0.00	-533.40	0.00	0.00		-261.26		
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	304.80	-762.00	0.00		-457.20		
3716	ADULT <40% EXP MALE	453.83	0.00	-195.40	0.00	0.00	0.00	491.61	693.11	0.00	-161.72	0.00	0.00		1,281.43		
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	457.20	0.00	0.00		457.20		
371F	ADULT <40% EXP MALE	75.64	0.00	0.00	0.00	0.00	0.00	270.39	277.24	0.00	0.00	0.00	0.00		623.27		
SUBTOTAL:	529.47	1,172.40	977.0	0	762.00	1,524.00	1,033.43	1,524.00	1,242.49	1,732.35	1,799.23	0.00	0.00		12,296.37		

4410	SOBRA 100-133% FOR F	19,453.05	25,267.56	17,360.71	17,427.50	16,161.10	16,873.85	17,635.85	20,338.55	18,814.55	17,964.85	19,905.55	0.00	
4413	SOBRA 100-133% M&F
6	2,678.25	2,535.01	5,559.95	626.03	-584.20	5,024.95	-1,056.96	816.43	-602.16	1,002.70	0.00	0.00	
4414	SOBRA 100-133% MALE	894.84	344.08	-355.55	0.00	-25.40	371.86	0.00	148.82	0.00	0.00	-148.82	0.00	
4415	SOBRA 100-133% FEMA L	474.95	945.48	183.99	0.00	-431.80	1,455.39	1,005.69	519.83	0.00	0.00	-344.13	0.00	
441C	SOBRA 100-133% M&F
6	890.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	469.52	938.01	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	25.40	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	751.24	450.52	0.00	0.00	0.00	0.00	
SUBTOTAL:	24,391.35	29,092.13	22,749.1	0	18,053.53	15,145.10	23,726.05	18,335.82	22,274.15	18,681.91	19,905.56	19,412.60	0.00	

 
207,203.12	
16,000.00	
1,229.83	
3,809.40	
2,297.79	
25.40	
1,201.76	
231,767.30	

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		-1,172.40	
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	
																
S000	STATE-ONLY BHS		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-762.00	0.00		-762.00	
SUBTOTAL:		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-762.00	0.00		-762.00	
																
TOTAL:		10,235,072.98	9,848,287.20	9,729,899.10	11,247,616.32	11,131,259.75	12,681,506.66	10,944,472.11	10,942,035.92	10,969,891.85	11,014,859.66	10,995,018.05	0.00		119,739,919.60	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending May 31, 2019

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

1012	TANF 01-05 M & F NON

1013	TANF 06-13 M & F NON

1014	TANF 14-20 MALE NON-

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

101B	TANF 01-05 M & F NON

101C	TANF 06-13 M & F NON

101D	TANF 14-20 MALE NON-

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

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

4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4310	SOBRA CHILD NON-ME
DI
4311	SOBRA CHILD <1 M & F

4312	SOBRA CHILD 01-05 M

4313	SOBRA CHILD 06-13 M

4314	SOBRA CHILD 14-20 MA

4315	SOBRA CHILD 14-20 FE

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
501E	SOBRA PREG 14-20 FE
M
SUBTOTAL:

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	
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	
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	

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

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3715	ADULT <40% EXP 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		
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		
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		

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

SOBRA 100-133% FEMA L

441E

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

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

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	

6013	KIDS 6-13 M & F NON-		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
																
S000	STATE-ONLY BHS		0.00	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		

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	319.94	319.94	319.94	581.16	193.72	193.72	193.72	193.72	193.72	193.72	193.72	0.00		2,897.02		
1010	TANF NON-MEDICARE	105,712.34	100,084.24	85,908.15	100,371.09	90,844.28	105,405.69	71,233.45	60,306.60	56,961.19	58,158.09	62,620.52	0.00		897,605.64		
1020	TANF WITH QMB	478.09	478.09	478.09	706.15	706.15	844.69	706.15	706.15	398.47	398.47	398.47	0.00		6,298.97		
2100	SSI AGED WITH MEDIC A	44,133.86	44,161.23	45,645.42	51,791.75	50,929.75	59,140.70	50,521.27	50,856.52	52,531.27	52,053.04	50,314.53	0.00		552,079.34		
2110	SSI AGED NON-MEDIC
AR	1,916.00	1,916.00	2,075.97	2,380.90	2,380.90	2,526.69	2,380.90	2,585.65	2,380.90	2,187.18	2,380.90	0.00		25,111.99		
2120	SSI AGED WITH QMB	69,460.16	71,850.96	75,480.34	79,223.73	80,311.98	95,269.83	84,366.42	84,452.91	85,911.42	89,018.49	85,529.32	0.00		900,875.56		
2200	SSI DISABLED WITH M E	382,132.58	380,029.79	380,678.12	414,980.41	415,215.97	468,089.51	398,072.00	390,815.25	388,834.40	390,541.83	390,126.90	0.00		4,399,516.76		
2210	SSI DISABLED NON-ME
D	4,533,394.57	4,534,531.40	4,663,707.94	5,531,501.50	5,582,229.22	6,101,067.37	5,682,052.53	5,688,447.58	5,747,942.59	5,774,053.43	5,792,064.45	0.00		59,630,992.58		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	39.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.64		
2220	SSI DISABLED WITH Q
M	815,415.52	817,872.29	829,398.82	915,659.60	919,773.97	1,053,355.23	942,826.90	955,807.11	956,641.39	957,260.13	939,774.83	0.00		10,103,785.79		
2300	SSI BLIND WITH MEDIC	1,824.16	1,824.16	1,504.22	1,195.41	1,195.41	1,688.27	807.97	614.25	409.50	204.75	204.75	0.00		11,472.85		
2310	SSI BLIND NON-MEDIC A	5,681.94	5,276.19	5,041.40	5,328.89	4,571.07	6,120.95	4,377.35	3,288.96	2,981.28	2,178.51	2,776.53	0.00		47,623.07		
2320	SSI BLIND WITH QMB	3,316.23	3,316.23	2,291.92	2,106.31	1,912.59	2,918.62	1,320.40	1,012.72	1,012.72	603.22	398.47	0.00		20,209.43		
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	-307.68	0.00		-307.68		
8040	SLMB	0.00	0.00	0.00	-193.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-193.72		
SUBTOTAL:	5,963,785.39	5,961,660.52	6,092,530.3	3	7,105,672.82	7,150,265.01	7,896,621.27	7,238,859.06	7,239,087.42	7,296,198.85	7,326,850.86	7,326,475.71	0.00		76,598,007.24		

8700	SSI DISABLED FREEDO M	2,547.37	2,547.37	2,547.37	2,859.13	3,462.35	3,472.66	3,838.76	3,451.32	3,063.88	3,645.04	4,043.51	0.00	
8710	SSI DISABLED FREEDO
M	554.73	554.73	1,046.29	592.19	387.44	456.71	387.44	796.94	592.19	592.19	398.47	0.00	
8720	SSI DISABLED FREEDO M	563.24	563.24	563.24	695.12	899.87	976.39	1,093.59	1,093.59	1,093.59	1,287.31	1,287.31	0.00	
SUBTOTAL:	3,665.34	3,665.34	4,156.9	0	4,146.44	4,749.66	4,905.76	5,319.79	5,341.85	4,749.66	5,524.54	5,729.29	0.00	

 
35,478.76	
6,359.32	
10,116.49	
51,954.57	

76,649,961.81

5,967,450.73	5,965,325.86	6,096,687.23	7,109,819.26	7,155,014.67	7,901,527.03	7,244,178.85	7,244,429.27	7,300,948.51	7,332,375.40	7,332,205.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD

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	

For The Period Ending May 31, 2019

RATE CODE	DESCRIPTION 1000	TANF WITH MEDICARE
1010	TANF NON-MEDICARE

1020	TANF WITH QMB

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

2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2300	SSI BLIND WITH MEDIC

2310	SSI BLIND NON-MEDIC
A
2320	SSI BLIND WITH QMB

4312	SOBRA CHILD 01-05 M

0.00

0.00	0.00

8040	SLMB

SUBTOTAL:

Cu0.00rren0.00t

an0.0d0

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

pr0i.00or

m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er

r0e.00   vis0i.0o0

n. 0.00	0.00

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

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

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending May 31, 2019	
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	445.97	412.41	378.85	403.06	427.83	494.04	524.02	506.85	0.00		3,593.03		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	913.59	840.10	719.70	668.97	646.55	618.84	690.56	647.39	0.00		5,745.70		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	1,583.12	1,649.84	1,686.03	1,681.63	1,623.64	1,634.74	1,593.62	1,548.14	0.00		13,000.76		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	751.15	734.56	857.88	887.92	855.55	786.16	779.18	833.43	0.00		6,485.83		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	14,451.92	14,333.90	14,089.87	14,130.34	14,043.69	13,892.62	13,780.34	13,793.46	0.00		112,516.14		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	26,040.22	26,613.59	26,622.27	26,820.48	26,894.81	26,788.85	26,590.13	26,495.98	0.00		212,866.33		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	46,635.63	46,681.99	46,783.29	47,745.47	48,478.85	48,806.40	49,570.10	49,509.23	0.00		384,210.96		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	26,009.98	26,070.16	26,365.05	26,841.38	27,593.52	30,318.30	29,757.50	30,318.80	0.00		223,274.69		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	46,235.44	47,402.45	47,824.33	48,259.50	49,337.31	50,873.33	49,319.33	49,853.55	0.00		389,105.24		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	202,441.72	201,482.20	200,498.97	199,017.68	199,286.32	197,637.21	196,747.59	196,603.44	0.00		1,593,715.13		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	667,369.84	668,049.96	666,450.65	666,075.61	668,659.77	664,798.69	664,401.60	665,369.99	0.00		5,331,176.11		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	165,697.34	162,747.36	161,584.91	162,259.11	162,663.40	161,493.70	161,893.79	161,884.89	0.00		1,300,224.50		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	638.99	592.06	577.20	582.75	594.09	641.02	669.29	640.72	0.00		4,936.12		
1024	TANF 14-20 MALE WITH	0.00	0.00	0.00	1.08	1.08	1.08	1.08	1.08	1.08	1.08	1.08	0.00		8.64		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	599.00	572.52	557.36	501.10	469.03	455.60	429.36	457.35	0.00		4,041.32		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	843.25	968.90	974.43	904.74	870.90	889.60	754.02	693.68	0.00		6,899.52		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	1,026.67	1,043.90	1,068.63	1,030.47	1,002.46	942.12	913.31	881.52	0.00		7,909.08		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	556.16	541.58	481.80	443.92	502.21	547.39	496.70	440.42	0.00		4,010.18		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	33,804.57	33,518.86	33,428.26	33,168.50	33,449.49	33,489.43	33,674.81	33,506.55	0.00		268,040.47		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	51,182.18	51,953.26	52,142.12	52,340.63	53,053.68	53,191.44	53,579.40	53,544.74	0.00		420,987.45		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	247,814.72	248,894.10	249,838.27	251,500.44	252,032.62	252,584.33	252,799.41	253,754.03	0.00		2,009,217.92		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	26,056.56	25,934.65	26,153.00	26,283.29	25,986.46	26,079.65	26,013.28	26,046.48	0.00		208,553.37		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	281,909.66	280,380.31	280,166.35	280,823.73	279,206.86	279,032.69	278,591.10	278,244.88	0.00		2,238,355.58		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	173,855.03	173,824.50	173,403.78	173,528.01	173,152.26	172,371.87	171,485.80	171,313.39	0.00		1,382,934.64		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	239.29	256.20	254.45	265.81	246.87	237.54	246.87	235.51	0.00		1,982.54		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	3,630.29	3,621.12	3,573.13	3,574.64	3,545.43	3,615.18	3,632.00	3,602.80	0.00		28,794.59		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	1,902.99	1,878.50	1,910.55	1,916.36	1,908.80	1,902.95	1,887.79	1,902.95	0.00		15,210.89		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	2.17	1.08	1.08	1.08	1.08	1.08	1.08	1.08	0.00		9.73		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	2.16	3.24	3.24	2.16	2.16	2.16	2.16	2.16	0.00		19.44		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	9.75	9.75	9.75	7.59	7.59	7.59	7.59	9.80	0.00		69.41		
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	1.12	0.00		1.12		
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	8.66	8.66	8.66	10.83	10.83	10.83	10.83	20.16	0.00		89.46		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	49,059.18	49,474.03	49,639.08	49,616.62	49,816.51	49,652.99	49,123.84	48,918.66	0.00		395,300.91		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	242,450.83	244,807.68	244,359.14	242,807.83	242,266.96	241,038.69	238,204.01	237,370.69	0.00		1,933,305.83		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	313,175.73	312,255.16	312,468.83	310,848.73	309,410.34	307,802.13	307,326.04	308,330.14	0.00		2,481,617.10		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	151,602.68	150,546.25	151,559.49	151,880.20	151,542.12	151,212.79	153,670.40	153,383.18	0.00		1,215,397.11		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	156,016.67	154,594.22	156,371.18	156,628.53	155,074.42	154,940.32	156,647.71	156,433.61	0.00		1,246,706.66		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	1.08	1.08	1.08	1.08	1.08	1.08	0.00	1.08	0.00		7.56		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.08	1.08	0.00		2.16		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	2.17	5.46	4.34	2.17	2.17	2.17	2.17	2.17	0.00		22.82		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	186.57	154.50	152.45	135.54	113.08	103.47	116.60	127.68	0.00		1,089.89		
5008	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	11.36	11.36	11.36	11.36	11.36	11.36	11.36	11.36	0.00		90.88		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	2.17	1.08	3.25	3.25	3.25	5.42	4.33	3.25	0.00		26.00		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	20,205.87	20,607.88	20,031.76	19,551.53	19,169.66	19,133.97	18,110.46	18,073.69	0.00		154,884.82		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	128,559.61	125,854.17	121,653.06	118,076.50	118,450.04	116,896.15	116,280.49	115,924.47	0.00		961,694.49		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	256.54	247.21	245.46	226.50	224.47	215.14	234.08	241.66	0.00		1,891.06		
5025	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	9.33	9.33	9.33	9.33	9.33	9.33	0.00	0.00	0.00		55.98		
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	276.65	278.40	257.69	269.05	308.68	274.88	220.37	182.77	0.00		2,068.49		
8040	SLMB	0.00	0.00	0.00	0.00	7.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.58		
8050	QI1	0.00	0.00	0.00	0.00	9.33	9.33	0.00	0.00	0.00	0.00	0.00	0.00		18.66		
SUBTOTAL:	0.00	0.00	0.0	0	3,084,475.54	3,079,887.51	3,075,191.77	3,071,746.50	3,072,958.61	3,065,446.32	3,060,796.58	3,061,671.06	0.00		24,572,173.89		

181.92

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	1,612.50	1,553.93	1,602.07	1,611.96	1,618.98	1,596.54	1,528.60	1,521.28	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	3,284.35	3,212.37	3,238.89	3,091.69	3,087.91	2,916.80	2,784.18	2,793.51	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	9,012.82	8,967.56	9,039.87	8,981.54	8,891.07	8,640.38	8,743.65	8,640.44	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	5,326.56	5,289.20	5,165.86	5,233.18	5,289.18	5,253.31	5,175.52	5,228.22	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	2.17	2.17	2.17	2.17	2.17	2.17	2.17	2.17	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	13.00	15.17	16.26	15.18	15.18	14.10	13.02	11.94	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	2,140.23	2,206.40	2,119.06	2,052.57	2,063.35	1,908.41	1,798.87	1,811.68	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	10,880.03	11,515.42	11,525.83	11,708.63	11,784.79	11,974.58	11,701.66	11,746.80	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	213,099.50	212,822.03	212,564.05	211,084.96	210,679.87	209,855.98	209,085.06	208,824.51	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	545,904.42	550,093.97	554,042.52	554,829.05	554,094.63	555,801.03	557,684.28	558,824.77	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	196,258.15	195,293.26	195,514.85	194,356.66	193,864.57	193,320.97	194,628.00	193,278.41	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	524.41	537.54	569.31	616.82	629.65	592.05	629.93	598.16	0.00	
1125	TANF EXPANDED 14-20	0.00	0.00	0.00	7.58	7.58	7.58	7.58	7.58	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	5,615.02	5,635.75	5,586.41	5,620.25	5,572.15	5,492.85	5,257.88	5,186.20	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	10,634.69	10,754.75	10,781.27	10,862.60	10,874.33	10,906.10	10,879.28	10,902.59	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	18,495.28	18,346.95	18,363.90	18,311.40	18,307.03	18,377.02	18,330.01	18,344.94	0.00	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	11,843.30	12,030.10	12,107.37	12,151.66	12,152.46	12,231.20	12,483.67	12,534.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	853.74	910.52	912.35	761.31	903.87	930.67	843.83	885.77	0.00	

12,645.86	
24,409.70	
70,917.33	
41,961.03	
17.36	
113.85	
16,100.57	
92,837.74	
1,688,015.96	
4,431,274.67	
1,556,514.87	
4,697.87	
37.90	
43,966.51	
86,595.61	
146,876.53	
97,533.76	
7,002.06	

3100	TRANSPLANT OPTION 1	0.00	0.00	0.00	7.58	7.58	15.16	30.32	30.32	30.32	30.32	30.32	0.00	
SUBTOTAL:	0.00	0.00	0.00	7.58	7.58	15.16	30.32	30.32	30.32	30.32	30.32	0.00	

 
181.92

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	685.00	768.08	721.13	696.64	702.17	721.41	726.92	781.13	0.00		5,802.48		
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	189,101.69	190,520.50	191,718.67	192,993.75	193,964.98	196,112.46	197,056.26	198,169.60	0.00		1,549,637.91		
2520	SSI BLIND EXPANDED W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.58	7.58	7.58	7.58	0.00		30.32		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	791.14	934.00	922.02	809.50	841.85	811.81	657.05	570.47	0.00		6,337.84		
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	9,808.31	9,774.10	9,592.49	9,383.54	9,443.60	9,601.81	9,834.42	10,208.12	0.00		77,646.39		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	99,503.34	99,499.17	99,367.85	99,214.81	99,753.57	99,883.80	99,285.09	98,826.50	0.00		795,334.13		
SUBTOTAL:	0.00	0.00	0.0	0	1,335,397.23	1,340,690.52	1,345,481.78	1,344,397.45	1,344,552.52	1,346,953.03	1,349,136.93	1,349,698.79	0.00		10,756,308.25		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	3.78	7.58	0.00	0.00	0.00	3.78	0.00	7.58	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.36	7.58	7.58	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	97.94	92.39	99.99	126.19	246.05	293.26	226.20	252.72	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	47.23	39.65	20.69	39.65	32.07	15.16	48.98	32.07	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	43,816.36	44,830.61	45,291.92	45,567.40	45,808.47	45,484.47	43,777.43	44,288.42	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	47,701.77	49,649.05	49,709.62	49,441.74	49,817.27	49,472.46	48,309.43	48,173.84	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	150,162.78	148,156.71	148,027.24	147,317.22	147,014.46	145,394.77	145,420.26	144,540.12	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	123,939.17	121,922.53	121,868.42	121,444.49	121,676.99	121,025.66	121,771.18	120,621.42	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	295,035.77	292,152.06	291,869.70	289,157.81	288,578.34	287,872.46	286,625.66	285,682.21	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	60.34	51.01	51.01	51.01	64.12	47.21	52.76	60.34	0.00	
3525	ADULT 40-100% FEMAL E	0.00	0.00	0.00	7.58	0.00	0.00	0.00	0.00	0.00	9.33	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.58	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	9.33	7.58	9.33	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.58	7.58	7.58	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	26.24	0.00	0.00	33.82	34.10	77.25	95.91	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	15.16	0.00	0.00	9.33	27.99	26.24	32.07	0.00	
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	93.88	93.88	39.65	32.07	109.04	280.45	252.16	364.96	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	7.58	7.58	0.00	7.58	7.58	11.36	7.56	7.56	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	80,894.53	84,615.61	84,827.43	85,661.49	86,200.74	84,961.95	82,108.73	81,559.17	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	71,867.53	74,197.85	74,383.01	75,382.51	76,086.26	75,472.07	73,827.53	73,622.27	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	502,948.77	505,984.94	514,144.88	521,346.71	529,294.50	533,035.07	535,731.00	536,409.08	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	288,922.23	289,743.76	294,380.59	297,913.17	302,265.31	305,005.52	306,801.26	307,014.33	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	589,909.01	591,157.53	596,446.34	602,001.89	609,600.24	612,854.52	618,188.71	618,315.64	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	173.76	111.37	103.79	141.39	133.81	145.17	132.06	116.90	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	7.58	0.00	0.00	9.33	0.00	15.16	9.33	18.66	0.00	
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	9.33	3.78	0.00	0.00	7.58	7.58	15.16	0.00	0.00	
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	22.74	7.58	7.58	7.58	7.58	60.34	16.91	0.00	
SUBTOTAL:	0.00	0.00	0.0	2,195,706.92	2,202,882.03	2,221,281.19	2,235,656.81	2,257,002.89	2,261,494.27	2,263,493.72	2,261,247.34	0.00	

 
22.72	
26.52	
1,434.74	
275.50	
358,865.08	
392,275.18	
1,176,033.56	
974,269.86	
2,316,974.01	
437.80	
16.91	
7.58	
26.24	
22.74	
267.32	
110.79	
1,266.09	
56.80	
670,829.65	
594,839.03	
4,178,894.95	
2,392,046.17	
4,838,473.88	
1,058.25	
60.06	
43.43	
130.31	
17,898,765.17	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	11.36	15.16	15.16	22.74	22.74	18.94	7.58	30.30	0.00		143.98		
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	9.33	9.33	9.33	27.99	9.33	27.99	16.91	16.91	0.00		127.12		
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	131.44	131.76	129.43	161.78	336.99	455.60	427.91	367.29	0.00		2,142.20		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	69.67	65.87	64.12	50.71	63.82	56.26	216.01	159.47	0.00		745.93		
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	23,750.64	24,715.75	24,427.70	24,532.36	24,764.96	24,786.90	24,073.57	23,932.94	0.00		194,984.82		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	27,456.75	28,753.52	28,492.59	28,621.74	29,269.50	29,164.89	28,249.93	28,056.92	0.00		228,065.84		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	131,609.22	131,301.44	131,227.27	131,471.19	132,047.34	131,636.50	131,242.39	131,387.31	0.00		1,051,922.66		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	192,007.32	192,019.59	193,667.94	195,147.65	197,368.20	197,843.24	198,595.78	197,401.77	0.00		1,564,051.49		
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	199,926.61	198,968.15	199,761.83	199,800.62	201,137.41	200,798.98	200,350.52	198,769.02	0.00		1,599,513.14		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	84.83	32.07	16.91	7.58	7.58	16.91	15.16	7.58	0.00		188.62		
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.58	0.00	0.00	0.00	0.00		7.58		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	7.58	0.00	0.00	11.36	13.11	9.33	9.33	7.58	0.00		58.29		
3929	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.33	9.33	13.11	0.00		31.77		
SUBTOTAL:	0.00	0.00	0.0	0	575,064.75	576,012.64	577,812.28	579,855.72	585,048.56	584,824.87	583,214.42	580,150.20	0.00		4,641,983.44		

4405	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	1.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	1.08	0.00	0.00	1.08	1.08	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	61,781.30	62,581.77	62,896.68	63,200.34	63,785.24	64,069.73	62,722.42	61,052.04	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	31,426.71	31,489.10	32,047.68	32,467.60	32,927.42	32,861.38	32,961.36	32,548.26	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	31,349.03	31,326.88	31,553.05	32,080.61	32,553.48	32,632.54	32,463.61	31,649.65	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	124,557.04	125,398.87	126,498.49	127,748.55	129,266.14	129,564.73	128,148.47	125,249.95	0.00	

 
1.12	
3.24	
502,089.52	
258,729.51	
255,608.85	
1,016,432.24	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	141.65	150.98	143.38	143.38	147.18	152.71	164.07	179.23	0.00	
4518	BC PATIENT FEMALE 4
5	0.00	0.00	0.00	874.45	835.10	870.65	893.39	891.62	904.73	946.41	938.85	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	67.62	67.62	60.04	60.04	63.82	50.71	46.93	46.93	0.00	
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	67.92	75.50	83.08	71.72	75.50	71.72	64.14	64.14	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	1,151.64	1,129.20	1,157.15	1,168.53	1,178.12	1,179.87	1,221.55	1,229.15	0.00	

 
1,222.58	
7,155.20	
463.71	
573.72	
9,415.21	

8600	SSI BLIND FREEDOM/W O	0.00	0.00	0.00	9.33	9.33	9.33	9.33	9.33	9.33	9.33	9.33	0.00	
8620	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	7.58	7.58	7.58	7.58	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	11,910.93	11,766.95	11,634.63	11,391.78	11,317.25	11,611.39	11,482.91	11,605.28	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	2,717.00	2,649.68	2,674.13	2,591.55	2,552.48	2,571.22	2,482.51	2,448.45	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	1,777.57	1,704.40	1,766.49	1,779.92	1,760.64	1,724.79	1,839.08	1,881.06	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	16,422.41	16,137.94	16,092.16	15,780.16	15,639.70	15,916.73	15,813.83	15,944.12	0.00	

 
74.64	
30.32	
92,721.12	
20,687.02	
14,233.95	
127,747.05	

2.17

67.76

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.17	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	1.12	4.90	2.24	6.72	10.08	12.74	14.98	14.98	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	1.12	4.90	2.24	6.72	10.08	12.74	14.98	17.15	0.00	

69.93

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	0.00	0.00	0.00	7,332,784.23	7,342,151.19	7,363,532.22	7,376,390.76	7,405,686.94	7,405,422.88	7,401,870.80	7,395,238.08	0.00		59,023,077.10		

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending May 31, 2019

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
1024	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

1026	TANF 21-44 MALE WITH

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

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
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
0.00	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
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

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
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
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

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending May 31, 2019

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4322	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
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
4325	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
5008	SOBRA PREG 45-64 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
5025	SOBRA PREG 14-20 FE
M
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
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

8040	SLMB	0.00	0.00	0.00	0.00	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:

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

3100	TRANSPLANT OPTION
1

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

SUBTOTAL:

0.00

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

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 ENROLLMENT - RBHA CRISIS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL	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	E
ADULT 40-100% M&F 45	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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

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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

E

Current and prior m0.00 ont0h.00	da0.0t0 a is0.00 und0.00e

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

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	
3525	ADULT 40-100% FEMAL	0.00
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	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	0.00
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	0.00
4	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	0.00
6	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	0.00
AL	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	0.00
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	0.00
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F	0.00
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEM	0.00
AL	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	0.00
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	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		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		0.00		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		0.00		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3929	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

4405

SOBRA 100-133% FEMA L
SOBRA 100-133% M&F
1
SOBRA 100-133% M&F
6
SOBRA 100-133% MALE

SOBRA 100-133% FEMA

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

visio

0.00

0.00

n.

0.00

4412

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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

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
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	

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	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
0.00	
0.00	

8600	SSI BLIND FREEDOM/W 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	
8620	SSI BLIND FREEDOM/W
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	
8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

0.00

0.00

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

Current and prior month data is under revision.

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending May 31, 2019	
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	963.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,819.10		
1010	TANF NON-MEDICARE	238,296.00	198,779.38	176,611.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		613,686.90		
1011	TANF <1 M & F NON-ME	15,253.92	15,021.46	17,547.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,822.62		
1012	TANF 01-05 M & F NON	8,274.72	11,764.32	9,969.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,008.94		
1013	TANF 06-13 M & F NON	5,748.94	8,274.72	7,909.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,932.70		
1014	TANF 14-20 MALE NON-	5,383.26	4,785.12	2,392.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,560.94		
1015	TANF 14-20 FEMALE N O	2,990.70	4,186.98	3,588.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,766.52		
1016	TANF 21-44 MALE NON-	0.00	0.00	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		598.14		
1017	TANF 21-44 FEMALE N O	1,196.28	1,196.28	1,196.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,588.84		
1020	TANF WITH QMB	963.82	963.82	963.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,891.46		
2200	SSI DISABLED WITH M E	38,785.26	35,295.66	38,187.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,268.04		
2210	SSI DISABLED NON-ME
D	5,915,870.99	5,960,555.16	5,964,059.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,840,485.46		
2220	SSI DISABLED WITH Q M	125,628.30	133,937.00	131,045.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390,610.84		
2300	SSI BLIND WITH MEDIC	963.82	963.82	963.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,891.46		
2310	SSI BLIND NON-MEDIC A	19,375.64	17,448.00	16,118.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,942.14		
4311	SOBRA CHILD <1 M & F	20,637.18	20,039.04	21,966.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,642.90		
4312	SOBRA CHILD 01-05 M	153,798.04	146,121.46	145,024.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		444,943.92		
4313	SOBRA CHILD 06-13 M	256,308.49	251,799.16	246,381.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		754,489.57		
4314	SOBRA CHILD 14-20 MA	69,656.08	67,960.90	65,534.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,151.34		
4315	SOBRA CHILD 14-20 FE	70,551.94	71,748.22	73,310.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,610.34		
5015	SOBRA PREG 14-20 FE M	598.14	598.14	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,794.42		
SUBTOTAL:	6,952,209.16	6,953,366.28	6,924,931.1	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,830,506.59		

3514	ADULT 40-100% MALE 1	1,196.28	598.14	598.14	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	598.14	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	598.14	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	11,364.66	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	8,373.96	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	1,196.28	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	1,794.42	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	24,523.7	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,392.56	
1,794.42	
1,196.28	
598.14	
33,495.84	
26,916.30	
1,196.28	
5,383.26	
72,973.08	

1115	TANF EXPANDED 14-20	1,196.28	598.14	598.14	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	598.14	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	598.14	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	1,794.4	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,392.56	
1,196.28	
1,794.42	
5,383.26	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	598.14	598.14	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,794.42		
3915	NEWLY ELIGIBLE FEMA L	1,196.28	1,794.42	2,990.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,981.40		
3917	NEWLY ELIGIBLE FEMA
L	598.14	598.14	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,794.42		
SUBTOTAL:	2,392.56	2,990.70	4,186.9	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,570.24		

4413	SOBRA 100-133% M&F
6	11,364.66	12,560.94	13,159.08	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	2,990.70	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	3,588.84	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	19,738.6	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
37,084.68	
9,570.24	
9,570.24	
56,225.16	

20,974,658.33

6,997,069.66	7,002,413.76	6,975,174.91	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 May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1010	TANF NON-MEDICARE	248.00	207.00	184.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		639.00		
1011	TANF <1 M & F NON-ME	20.00	19.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
1012	TANF 01-05 M & F NON	11.77	16.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.77		
1013	TANF 06-13 M & F NON	9.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1014	TANF 14-20 MALE NON-	9.00	8.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1015	TANF 14-20 FEMALE N O	5.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1017	TANF 21-44 FEMALE N O	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1020	TANF WITH QMB	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2200	SSI DISABLED WITH M E	41.00	37.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118.00		
2210	SSI DISABLED NON-ME
D	6,283.26	6,324.59	6,327.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,934.98		
2220	SSI DISABLED WITH Q M	133.00	142.00	139.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2310	SSI BLIND NON-MEDIC A	22.00	20.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
4311	SOBRA CHILD <1 M & F	29.00	28.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.00		
4312	SOBRA CHILD 01-05 M	218.00	207.00	207.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		632.00		
4313	SOBRA CHILD 06-13 M	361.74	357.29	352.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,071.03		
4314	SOBRA CHILD 14-20 MA	92.00	91.00	90.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273.00		
4315	SOBRA CHILD 14-20 FE	99.00	101.00	103.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		303.00		
5015	SOBRA PREG 14-20 FE M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	7,588.77	7,583.88	7,555.1	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,727.78		

3514	ADULT 40-100% MALE 1	2.00	1.00	1.00	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	1.00	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	1.00	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	19.00	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	14.00	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	2.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39.00	42.00	41.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
3.00	
2.00	
1.00	
56.00	
45.00	
2.00	
9.00	
122.00	

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

 
4.00	
2.00	
3.00	
9.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
3915	NEWLY ELIGIBLE FEMA L	2.00	3.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
3917	NEWLY ELIGIBLE FEMA
L	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	4.00	5.00	7.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		

4413	SOBRA 100-133% M&F
6	19.00	21.00	22.00	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	5.00	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	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	29.00	32.00	33.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
62.00	
16.00	
16.00	
94.00	

TOTAL:	7,663.77	7,665.88	7,639.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,968.78		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
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	1,133.25	2,866.80	686.34	424.28	1,177.04	2,231.91	1,000.42	1,554.52	1,041.73	0.00		17,175.82		
1007	TANF 21-44 FEMALE WI	2,779.92	5,310.04	3,247.10	5,219.69	2,888.98	6,033.87	5,149.95	3,037.81	6,150.63	1,192.78	8,347.13	0.00		49,357.90		
1008	TANF 45-64 M & F WIT	11,291.57	15,679.24	15,595.67	19,750.62	14,022.26	8,428.64	8,644.19	7,827.05	11,829.49	17,290.47	18,795.30	0.00		149,154.50		
1009	TANF 65+ M & F WITH	7,080.93	7,837.40	6,310.32	4,403.91	4,440.02	4,104.65	8,811.82	6,527.58	8,406.18	5,237.68	8,009.07	0.00		71,169.56		
1011	TANF <1 M & F NON-ME	1,097,793.02	1,427,856.05	650,647.24	1,004,391.96	744,957.94	816,642.16	982,593.51	1,301,201.62	1,725,028.15	1,271,942.99	1,142,947.60	0.00		12,166,002.24		
1012	TANF 01-05 M & F NON	258,113.97	381,102.75	279,707.31	360,011.17	297,960.82	322,296.33	397,803.90	351,561.53	436,080.97	335,388.32	455,418.00	0.00		3,875,445.07		
1013	TANF 06-13 M & F NON	279,530.59	485,623.57	358,044.23	533,991.51	440,059.37	415,449.87	410,056.01	419,007.98	452,869.08	461,741.76	577,724.01	0.00		4,834,097.98		
1014	TANF 14-20 MALE NON-	80,615.15	107,150.18	99,245.97	133,531.12	153,144.88	126,394.12	133,056.94	175,845.56	159,611.20	170,975.28	296,379.90	0.00		1,635,950.30		
1015	TANF 14-20 FEMALE N O	224,066.64	355,973.17	280,489.08	381,277.40	265,748.21	294,478.04	347,101.56	348,499.54	354,596.74	484,258.39	458,224.97	0.00		3,794,713.74		
1016	TANF 21-44 MALE NON-	1,462,397.99	2,172,953.59	1,646,183.73	2,101,821.36	1,784,798.25	1,611,407.70	2,101,237.64	1,917,479.63	1,959,904.06	1,929,969.50	2,486,000.57	0.00		21,174,154.02		
1017	TANF 21-44 FEMALE N O	4,955,722.81	7,235,825.21	5,670,795.97	7,929,056.09	5,876,832.28	5,844,037.98	7,016,088.90	6,211,146.86	6,650,526.06	5,951,296.13	8,272,909.85	0.00		71,614,238.14		
1018	TANF 45-64 M & F NON	2,183,248.97	3,211,799.72	2,516,117.99	3,549,660.53	2,401,726.26	2,688,887.64	2,908,026.34	2,837,153.60	3,031,480.55	2,497,755.17	3,749,514.21	0.00		31,575,370.98		
1019	TANF 65+ M & F NON-M	2,934.41	3,807.00	2,989.00	5,523.26	3,580.32	1,878.32	3,467.42	1,614.88	2,014.50	3,336.49	10,428.45	0.00		41,574.05		
1026	TANF 21-44 MALE WITH	1,357.60	854.00	1,035.39	2,200.94	1,546.83	2,373.31	1,513.77	989.03	2,863.67	2,128.06	6,200.70	0.00		23,063.30		
1027	TANF 21-44 FEMALE WI	6,393.80	11,610.00	6,898.17	21,627.03	13,625.27	12,407.33	17,029.96	18,023.79	11,698.99	13,638.01	6,063.24	0.00		139,015.59		
1028	TANF 45-64 M & F WIT	16,376.86	14,455.96	12,574.03	31,799.02	14,406.40	12,805.74	22,810.89	6,923.26	5,558.27	3,155.59	8,079.52	0.00		148,945.54		
1029	TANF 65+ M & F WITH	3,021.80	667.04	2,461.57	3,749.80	5,342.13	5,908.50	4,742.99	5,069.90	6,798.62	7,024.70	8,723.55	0.00		53,510.60		
2100	SSI AGED WITH MEDIC A	154,652.01	173,183.39	154,068.83	180,524.85	174,237.99	162,417.02	186,178.24	178,395.55	217,201.55	146,502.55	395,127.24	0.00		2,122,489.22		
2110	SSI AGED NON-MEDIC
AR	110,434.83	169,816.07	101,720.92	101,673.20	71,641.51	111,589.80	140,679.45	104,601.98	113,053.56	146,128.91	154,362.60	0.00		1,325,702.83		
2120	SSI AGED WITH QMB	563,573.87	806,055.99	678,419.84	827,785.31	718,592.54	688,870.27	797,026.37	799,946.14	806,227.26	677,421.28	838,019.27	0.00		8,201,938.14		
2200	SSI DISABLED WITH M E	444,274.71	703,326.49	481,119.31	681,161.88	401,037.73	424,211.85	501,597.34	555,749.70	600,518.18	608,057.02	553,612.58	0.00		5,954,666.79		
2210	SSI DISABLED NON-ME
D	7,575,600.97	11,234,543.70	8,474,720.62	11,249,753.85	8,788,282.44	8,685,178.85	9,572,039.18	9,327,114.06	10,438,547.09	9,428,805.64	12,193,932.00	0.00		106,968,518.40		
2220	SSI DISABLED WITH Q M	1,311,020.36	1,953,141.39	1,490,238.45	2,408,662.84	1,571,125.66	1,573,201.56	1,883,904.62	1,621,507.37	1,795,234.00	1,547,880.79	1,896,088.24	0.00		19,052,005.28		
2300	SSI BLIND WITH MEDIC	2,715.71	4,128.21	3,045.83	6,698.76	3,293.55	4,198.76	3,230.71	1,910.89	1,827.68	2,692.71	2,517.59	0.00		36,260.40		
2310	SSI BLIND NON-MEDIC A	94,572.77	149,624.84	131,248.46	157,958.96	109,921.50	103,070.44	133,865.87	86,687.94	102,241.26	68,584.07	111,687.56	0.00		1,249,463.67		
2320	SSI BLIND WITH QMB	25,387.22	36,834.10	21,178.01	35,930.00	16,679.84	25,376.31	24,258.40	22,290.26	20,080.45	19,522.66	27,337.62	0.00		274,874.87		
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	2,850,912.57	3,006,000.64	2,513,821.78	2,646,302.95	3,279,901.06	3,139,294.07	3,606,023.64	3,354,813.08	3,592,398.08	0.00		34,096,760.96		
4312	SOBRA CHILD 01-05 M	3,415,194.97	5,544,812.18	4,237,216.00	5,303,219.49	3,828,786.06	4,153,363.05	4,935,363.63	5,278,345.52	5,780,272.88	5,037,285.07	6,265,983.90	0.00		53,779,842.75		
4313	SOBRA CHILD 06-13 M	4,527,795.53	7,639,549.88	5,870,073.96	7,198,109.90	5,768,682.91	5,477,255.24	5,766,010.02	6,081,918.88	6,506,025.96	5,985,595.92	8,476,896.56	0.00		69,297,914.76		
4314	SOBRA CHILD 14-20 MA	1,133,047.15	2,055,550.54	1,626,861.89	2,159,436.61	1,526,642.59	1,515,792.44	1,438,470.77	1,483,879.53	1,585,316.90	1,568,072.62	2,336,040.59	0.00		18,429,111.63		
4315	SOBRA CHILD 14-20 FE	1,422,456.44	2,441,363.27	1,904,026.44	2,575,624.04	1,778,353.38	1,929,975.08	2,065,613.78	2,040,591.26	2,116,496.90	2,009,828.70	2,765,356.15	0.00		23,049,685.44		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97.72	22.83	0.00	0.00		120.55		
5007	SOBRA PREG 21-44 FE M	318.55	319.74	324.65	0.00	0.00	166.01	594.54	1,340.00	0.00	0.00	0.00	0.00		3,063.49		
5013	SOBRA PREG 09-13 FE
M	0.00	1,456.06	579.11	152.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,187.41		
5015	SOBRA PREG 14-20 FE M	358,380.97	500,891.10	468,724.47	439,946.43	347,004.32	455,503.50	431,010.30	405,293.35	412,291.74	299,213.04	532,104.43	0.00		4,650,363.65		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	2,037,823.46	3,054,712.75	2,243,984.34	2,764,324.90	2,056,016.77	2,081,641.85	2,635,917.04	2,182,977.44	2,468,598.41	2,359,028.06	2,983,971.09	0.00		26,868,996.11		
5018	SOBRA PREG 45-64 FE
M	3,075.69	1,818.98	3,515.20	7,188.17	1,281.00	854.00	5,517.81	1,125.58	1,107.61	2,730.00	1,820.00	0.00		30,034.04		
5027	SOBRA PREG 21-44 FE M	484.26	1,280.97	1,831.83	631.71	995.51	1,101.66	1,102.64	149.36	876.67	841.44	1,856.41	0.00		11,152.46		
SUBTOTAL:	36,517,781.0	2 55,279,121.79	42,297,286.7	5 55,195,665.99	41,702,163.64	42,214,029.12	48,171,594.60	46,927,260.41	51,398,457.04	46,420,912.23	60,643,919.71	0.00		526,768,192.30		

-330.00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-330.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-330.00	0.00	

-330.00

1106	TANF EXPANDED 21-44	6,903.54	6,090.09	7,457.32	11,128.43	4,085.47	4,791.60	2,916.58	7,347.71	8,334.05	7,538.30	3,390.00	0.00	
1107	TANF EXPANDED 21-44	9,863.24	6,233.75	7,385.38	13,201.56	13,762.30	9,920.05	13,675.24	7,400.84	8,496.53	7,350.40	9,015.05	0.00	
1108	TANF EXPANDED 45-64	44,707.75	54,712.80	56,545.35	97,369.20	80,114.51	45,373.65	58,999.12	73,088.83	70,103.98	59,293.92	50,325.18	0.00	
1109	TANF EXPANDED 65+
M&	15,732.50	40,358.61	26,212.83	32,339.11	21,751.69	27,696.43	27,339.57	35,681.70	35,521.13	32,891.84	49,757.52	0.00	
1113	TANF EXPANDED 06-13	0.00	1,281.00	854.00	0.00	189.36	0.00	427.00	0.00	938.00	0.00	455.00	0.00	
1114	TANF EXPANDED 14-20	5,242.71	5,659.15	4,238.19	17,207.47	12,104.93	7,136.67	4,011.46	5,511.18	5,863.80	5,329.92	8,564.94	0.00	
1115	TANF EXPANDED 14-20	29,725.53	41,843.22	41,713.88	44,675.82	25,449.73	36,106.30	41,362.60	33,325.85	28,588.69	35,354.11	51,931.29	0.00	
1116	TANF EXPANDED 21-44	687,192.92	852,411.74	657,963.10	926,546.83	636,317.26	769,583.85	737,835.98	744,752.25	907,068.64	752,914.11	1,015,858.30	0.00	
1117	TANF EXPANDED 21-44	2,136,319.90	2,895,369.89	2,685,548.98	3,179,055.11	2,303,496.38	2,433,853.40	2,666,216.17	2,466,367.02	2,850,795.44	2,591,630.52	3,654,349.79	0.00	
1118	TANF EXPANDED 45-64	1,427,393.60	2,314,029.66	1,686,297.81	2,140,967.84	1,529,076.99	1,857,834.11	1,892,915.74	1,786,160.79	1,843,936.03	1,677,205.76	2,493,552.98	0.00	
1119	TANF EXPANDED 65+
M&	1,626.42	10,314.64	0.00	2,989.00	1,510.50	2,159.87	5,769.05	5,345.65	5,515.45	3,883.18	5,109.65	0.00	
1126	TANF EXPANDED 21-44	14,909.43	19,555.66	16,459.73	60,345.73	31,907.21	20,441.11	25,117.42	26,663.40	31,712.70	32,016.57	33,419.81	0.00	
1127	TANF EXPANDED 21-44	26,677.32	41,413.01	33,857.73	89,776.42	44,564.98	33,211.95	52,936.57	37,130.69	45,411.87	39,751.40	47,603.61	0.00	
1128	TANF EXPANDED 45-64	129,892.71	173,304.51	123,559.37	227,481.12	160,238.17	150,959.14	202,849.92	184,442.88	146,673.62	141,458.50	148,960.78	0.00	
1129	TANF EXPANDED 65+
M&	56,963.70	98,571.39	57,598.24	85,414.21	62,829.03	68,148.23	92,318.75	92,330.89	102,498.42	81,061.55	93,689.09	0.00	
2400	SSI AGED EXPANDED WI	7,714.68	17,864.54	16,935.06	22,564.96	6,921.70	8,053.62	11,006.86	13,911.73	11,299.34	13,480.11	33,054.72	0.00	
2410	SSI AGED EXPANDED
NO	15,750.54	28,700.97	15,035.81	11,755.39	10,532.89	13,982.32	11,512.56	9,975.66	27,414.93	8,525.29	19,918.49	0.00	
2420	SSI AGED EXPANDED WI	457,355.76	657,744.56	488,038.18	695,139.74	533,433.86	577,958.69	703,846.01	749,421.63	754,724.89	661,405.46	803,730.67	0.00	
2600	SSI DISABLED EXPAND
E	12,186.84	14,358.17	12,170.04	22,005.43	6,680.16	19,841.41	15,918.79	11,709.88	9,404.66	8,681.56	14,853.46	0.00	
2610	SSI DISABLED EXPAND E	185,828.54	218,387.94	178,960.08	219,544.02	208,302.63	180,675.30	200,746.14	210,624.83	345,784.14	368,490.05	453,972.19	0.00	
2620	SSI DISABLED EXPAND
E	385,320.71	606,257.42	391,928.96	740,063.99	445,761.47	464,472.53	550,106.63	457,162.88	495,002.94	467,984.47	589,688.13	0.00	
SUBTOTAL:	5,657,308.34	8,104,462.72	6,508,760.0	8,639,571.38	6,139,031.22	6,732,200.23	7,317,828.16	6,958,356.29	7,735,089.25	6,996,247.02	9,581,200.65	0.00	

 
69,983.09	
106,304.34	
690,634.29	
345,282.93	
4,144.36	
80,870.42	
410,077.02	
8,688,444.98	
29,863,002.60	
20,649,371.31	
44,223.41	
312,548.77	
492,335.55	
1,789,820.72	
891,423.50	
162,807.32	
173,104.85	
7,082,799.45	
147,810.40	
2,771,315.86	
5,593,750.13	
80,370,055.30	

3506	ADULT 40-100% MALE 2	52.90	10.27	854.00	-319.60	0.00	0.00	0.00	0.00	455.00	910.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	896.68	895.97	47.76	955.89	0.00	0.00	0.00	223.01	0.00	
3508	ADULT 40-100% M&F 45	1,886.71	3,748.84	6,913.65	865.10	2,795.52	4,336.39	2,956.98	2,163.28	3,091.41	1,890.87	1,168.00	0.00	
3509	ADULT 40-100% M&F 65	51.35	82.14	671.04	102.04	81.01	0.00	0.00	0.00	1,398.81	127.66	183.75	0.00	
3514	ADULT 40-100% MALE 1	53,585.47	69,899.82	86,208.88	68,018.07	43,351.60	51,825.75	55,689.30	59,300.81	58,877.13	59,865.93	64,023.80	0.00	
3515	ADULT 40-100% FEMAL E	100,817.06	132,536.02	140,164.95	112,356.86	69,907.82	99,202.28	108,793.33	92,933.18	135,254.27	138,375.95	192,605.93	0.00	
3516	ADULT 40-100% MALE 2	771,180.72	1,065,112.78	646,565.41	986,648.19	861,287.22	945,419.30	681,426.54	831,876.49	735,943.77	886,886.87	1,214,200.50	0.00	

 
1,962.57	
3,019.31	
31,816.75	
2,697.80	
670,646.56	
1,322,947.65	
9,626,547.79	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3517	ADULT 40-100% FEMAL E	493,585.01	690,483.40	564,169.86	652,005.84	521,790.07	540,186.26	676,113.66	624,366.61	705,974.04	745,297.05	951,711.43	0.00		7,165,683.23		
3518	ADULT 40-100% M&F 45	2,260,650.72	3,046,508.82	2,323,501.55	2,997,948.77	2,319,062.40	2,406,596.88	2,697,076.65	2,353,792.75	2,787,389.13	2,448,169.57	3,399,409.60	0.00		29,040,106.84		
3519	ADULT 40-100% M&F 65	0.00	427.00	0.00	0.00	0.00	0.00	1,281.00	1,183.13	0.00	954.56	1,281.16	0.00		5,126.85		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	854.00	0.00	0.00	0.00	0.00	0.00		854.00		
3706	ADULT <40% EXP MALE	0.00	580.20	409.78	427.00	916.86	292.69	2,317.24	860.90	-245.04	643.80	249.30	0.00		6,452.73		
3707	ADULT <40% EXP FEM AL	0.00	1,493.45	483.82	3,238.45	255.49	642.72	915.68	93.99	34.64	0.00	0.00	0.00		7,158.24		
3708	ADULT <40% EXP M&F
4	8,266.64	5,658.00	5,644.19	15,272.17	5,164.45	2,548.39	5,103.63	4,395.32	16,856.98	8,101.15	11,719.67	0.00		88,730.59		
3709	ADULT <40% EXP M&F 6	0.00	1,907.91	86.66	437.24	434.04	0.00	0.00	0.00	1,057.88	0.00	57.84	0.00		3,981.57		
3714	ADULT <40% EXP MALE	307,300.59	512,466.98	301,128.16	448,385.88	318,336.02	353,041.59	482,006.55	377,259.59	382,648.78	397,358.13	476,802.14	0.00		4,356,734.41		
3715	ADULT <40% EXP FEM AL	310,211.15	501,147.55	399,039.71	611,385.99	445,602.94	491,133.70	523,725.23	444,036.68	573,676.14	514,916.63	722,141.19	0.00		5,537,016.91		
3716	ADULT <40% EXP MALE	6,023,811.40	8,210,087.18	6,654,326.23	8,826,686.06	6,816,878.26	6,846,917.35	8,725,278.95	7,989,568.84	8,741,721.59	7,530,267.63	10,593,623.91	0.00		86,959,167.40		
3717	ADULT <40% EXP FEM AL	3,523,898.11	4,432,990.25	3,708,185.29	5,037,348.11	3,669,881.58	3,853,681.56	4,434,173.28	4,074,103.69	4,821,576.23	4,367,379.78	5,521,923.10	0.00		47,445,140.98		
3718	ADULT <40% EXP M&F
4	8,587,427.95	12,464,587.57	9,171,707.60	12,764,434.23	9,261,287.82	9,950,267.86	11,368,078.29	10,363,059.86	11,391,265.37	10,161,757.34	14,368,731.59	0.00		119,852,605.48		
3719	ADULT <40% EXP M&F 6	1,226.37	19.51	2,819.68	1,954.74	1,245.00	2,135.00	1,281.00	1,309.00	-782.39	427.00	2,993.93	0.00		14,628.84		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	48.20	76.60	142.96	0.00	0.00	0.00	0.00		267.76		
3727	ADULT <40% EXP FEM AL	437.33	1,470.27	554.40	1,489.32	0.00	72.49	0.00	0.00	0.00	0.00	0.00	0.00		4,023.81		
3728	ADULT <40% EXP M&F
4	427.00	1,726.78	20.99	1,058.98	433.66	622.04	317.13	52.90	0.00	0.00	0.00	0.00		4,659.48		
SUBTOTAL:	22,444,816.4	8 31,142,944.74	24,013,455.8	5 32,530,640.12	24,339,607.73	25,549,018.21	29,768,420.93	27,220,499.98	30,356,193.74	27,263,329.92	37,523,049.85	0.00		312,151,977.55		

4405	SOBRA 100-133% FEMA L	0.00	0.00	0.00	3,547.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	94.24	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	416,723.18	618,558.98	513,313.57	607,999.93	424,687.98	468,240.38	503,284.08	505,531.59	623,662.41	535,751.26	755,238.53	0.00	
4414	SOBRA 100-133% MALE	110,528.71	193,925.32	133,225.15	202,729.81	124,257.18	133,754.81	151,391.16	121,390.58	126,366.07	139,826.16	217,273.66	0.00	
4415	SOBRA 100-133% FEMA L	145,691.33	253,960.14	171,003.14	215,189.35	201,204.91	199,612.47	385,076.48	225,024.29	418,158.09	219,557.39	280,147.64	0.00	

3,547.72	
94.24	
5,972,991.89	
1,654,668.61	
2,714,625.23	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87.52	0.00	
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	2,036.48	2,543.61	-972.67	630.09	1,137.63	637.15	2,163.00	4,152.95	497.47	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	506.44	62.28	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	16,577.58	21,882.24	23,701.75	26,295.26	30,484.89	22,444.93	35,824.38	15,095.94	26,051.83	16,204.47	24,854.84	0.00	
3915	NEWLY ELIGIBLE FEMA L	50,539.59	63,893.79	54,717.93	66,110.61	40,533.89	46,709.28	82,005.91	54,826.38	65,771.39	62,360.19	66,010.86	0.00	
3916	NEWLY ELIGIBLE MALE	371,374.74	587,839.07	528,876.03	650,620.57	397,554.61	496,946.80	516,049.44	532,570.58	477,560.97	434,250.72	613,774.07	0.00	
3917	NEWLY ELIGIBLE FEMA L	638,821.34	772,821.13	603,759.44	894,201.78	602,828.82	761,655.71	779,974.96	712,222.84	917,938.38	786,674.44	1,128,208.96	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,147,202.88	1,798,872.07	1,379,977.78	1,654,233.90	1,363,815.67	1,631,663.78	1,696,961.94	1,514,088.69	1,559,558.78	1,405,019.56	2,271,381.47	0.00	
3919	NEWLY ELIGIBLE M&F 6	929.90	854.00	0.00	905.61	176.09	5,753.78	0.00	427.00	0.00	0.00	455.00	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	2,593,069.4	1	3,294,911.34	2,434,927.74	2,965,866.65	3,111,954.26	2,829,868.58	3,049,044.35	2,708,662.33	4,105,270.19	0.00	

 
87.52	
1,755.37	
16,019.83	
568.72	
259,418.11	
653,479.82	
5,607,417.60	
8,599,107.80	
17,422,776.52	
9,501.38	
1,326.60	
32,571,459.27	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	672,943.22	1,066,444.44	817,636.10	1,029,466.81	750,150.07	801,607.66	1,039,751.72	851,946.46	1,168,186.57	895,134.81	1,252,659.83	0.00		10,345,927.69		

S000	STATE-ONLY BHS	0.00	321.02	-321.02	0.00	5,881.29	0.00	0.00	0.00	0.00	922.90	-5,881.29	0.00	
SUBTOTAL:	0.00	321.02	-321.02	0.00	5,881.29	0.00	0.00	0.00	0.00	922.90	-5,881.29	0.00	

8700	SSI DISABLED FREEDO M	14,200.47	18,544.94	22,067.60	38,215.36	18,149.29	16,547.66	28,151.81	21,151.87	17,222.59	19,349.51	22,829.82	0.00	
8710	SSI DISABLED FREEDO
M	10,612.04	16,225.81	33,425.48	15,274.83	13,143.76	9,940.77	19,612.42	18,239.48	18,109.29	27,704.29	33,864.47	0.00	
8720	SSI DISABLED FREEDO M	1,696.25	4,093.96	1,037.46	3,022.53	1,468.98	1,536.67	1,111.19	1,007.57	1,535.28	2,648.37	1,855.11	0.00	
SUBTOTAL:	26,508.76	38,864.71	56,530.5	4	56,512.72	32,762.03	28,025.10	48,875.42	40,398.92	36,867.16	49,702.17	58,549.40	0.00	

236,430.92	
216,152.64	
21,013.37	
473,596.93	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	2,562.00	427.00	0.00	0.00	0.00	0.00	2,275.00	3,640.00	1,820.00	0.00	
4518	BC PATIENT FEMALE 4
5	6,148.89	8,660.46	13,545.70	7,478.22	3,339.85	10,897.55	46,061.54	6,930.33	54,892.16	7,781.57	30,405.15	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	27.73	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	427.00	427.00	0.00	2,135.00	0.00	1,281.00	427.00	0.00	0.00	1,337.00	0.00	0.00	
SUBTOTAL:	6,575.89	9,087.46	16,107.7	0	10,040.22	3,339.85	12,178.55	46,488.54	6,930.33	57,194.89	12,758.57	32,225.15	0.00	

 
10,724.00	
196,141.42	
27.73	
6,034.00	
212,927.15	

6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.00	0.00	0.00	0.00	0.00		427.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.00	0.00	0.00	0.00	0.00		427.00	
																
															922.90	
															922.90	
TOTAL:		67,552,869.33	98,892,195.68	76,302,525.37	100,756,808.58	75,407,863.57	78,302,925.52	89,504,913.63	84,835,687.97	93,801,033.00	84,347,669.95	113,190,663.49	0.00		962,895,156.09	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending May 31, 2019	
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	2,069.94	332.18	0.00		2,687.56		
1007	TANF 21-44 FEMALE WI	39.84	0.00	234.89	34.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		309.37		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	103.56	183.62	50.14	0.00	1,385.42	0.00	0.00	28.96	0.00		1,751.70		
1011	TANF <1 M & F NON-ME	1,645.11	75.45	2,659.27	436.12	255.61	839.82	269.64	94.84	5,046.73	7,621.69	6,897.49	0.00		25,841.77		
1012	TANF 01-05 M & F NON	510.37	13.37	46.65	677.56	48.91	441.70	451.48	194.25	1,622.33	6,765.32	1,486.60	0.00		12,258.54		
1013	TANF 06-13 M & F NON	0.00	458.07	989.98	101.70	0.00	59.49	1,235.81	140.59	7,259.09	94.62	2,540.11	0.00		12,879.46		
1014	TANF 14-20 MALE NON-	3,217.73	161.78	1,334.13	678.40	1,320.31	327.60	7,132.13	1,555.56	7,034.62	31,873.65	17.85	0.00		54,653.76		
1015	TANF 14-20 FEMALE N O	1,261.12	5,233.42	3,533.41	3,488.27	3,442.40	11,843.97	3,947.22	7,307.39	8,190.43	1,409.61	10,714.23	0.00		60,371.47		
1016	TANF 21-44 MALE NON-	25,236.24	43,573.83	27,238.16	18,704.75	19,462.73	31,480.64	17,914.80	15,430.88	14,423.06	12,294.97	26,912.53	0.00		252,672.59		
1017	TANF 21-44 FEMALE N O	49,969.09	96,662.60	62,895.05	126,939.39	73,953.45	45,756.55	91,025.83	74,894.18	72,279.99	95,221.17	71,817.20	0.00		861,414.50		
1018	TANF 45-64 M & F NON	25,853.67	50,784.81	25,056.10	32,934.34	130,053.78	23,984.75	21,403.12	16,972.20	16,906.56	40,770.10	27,916.81	0.00		412,636.24		
1019	TANF 65+ M & F NON-M	0.00	604.14	123.22	0.00	62.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		789.85		
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	25.03	0.00		25.03		
2100	SSI AGED WITH MEDIC A	8,948.54	19,860.34	9,620.72	5,482.37	6,130.50	17,232.69	4,131.16	7,830.81	11,480.80	15,912.05	30,145.09	0.00		136,775.07		
2110	SSI AGED NON-MEDIC
AR	27,266.66	79,448.36	31,213.12	17,068.23	15,887.60	21,529.48	53,375.72	14,513.82	46,030.27	31,762.38	92,231.19	0.00		430,326.83		
2120	SSI AGED WITH QMB	56.00	165.73	211.48	25.20	1,974.78	0.00	99.76	36.34	506.39	-506.39	179.15	0.00		2,748.44		
2200	SSI DISABLED WITH M E	2,281.61	2,635.53	313.05	540.34	2,215.60	158.36	949.29	285.26	66.83	696.90	2,279.59	0.00		12,422.36		
2210	SSI DISABLED NON-ME
D	20,619.79	18,095.51	767.19	4,528.15	22,024.80	19,660.82	3,047.50	2,688.19	14,955.42	13,109.15	20,825.97	0.00		140,322.49		
2220	SSI DISABLED WITH Q M	17.00	208.87	20.00	0.00	231.04	3,164.65	502.50	0.00	0.00	1,360.42	0.00	0.00		5,504.48		
4311	SOBRA CHILD <1 M & F	43,959.44	56,118.07	69,147.93	38,664.30	34,981.16	57,689.36	37,466.32	56,787.68	85,067.62	39,621.21	185,927.40	0.00		705,430.49		
4312	SOBRA CHILD 01-05 M	83,611.98	144,428.06	41,005.44	60,442.04	58,957.13	46,559.46	46,083.77	55,171.45	69,468.94	75,881.41	120,460.54	0.00		802,070.22		
4313	SOBRA CHILD 06-13 M	25,834.10	76,289.04	38,649.65	39,111.54	18,735.11	54,744.15	39,353.55	81,305.26	40,340.42	39,636.51	98,758.62	0.00		552,757.95		
4314	SOBRA CHILD 14-20 MA	28,981.47	24,362.73	13,731.35	45,624.40	15,647.01	79,275.83	15,999.65	40,564.58	27,131.51	16,575.02	27,248.55	0.00		335,142.10		
4315	SOBRA CHILD 14-20 FE	23,575.75	79,561.36	25,526.50	38,063.42	27,516.09	24,895.91	31,860.19	60,104.77	30,615.88	35,075.59	36,639.53	0.00		413,434.99		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	39.72	0.00	0.00	223.85	0.00	14.21	0.00	0.00	1,367.52	0.00		1,645.30		
5015	SOBRA PREG 14-20 FE
M	50,353.69	24,929.85	27,460.03	22,073.46	18,998.83	23,300.20	16,732.32	40,843.59	26,631.01	34,268.20	38,305.50	0.00		323,896.68		
5017	SOBRA PREG 21-44 FE M	99,435.96	156,694.79	113,864.94	123,218.88	102,199.29	97,244.26	141,721.19	138,420.41	95,506.30	101,775.73	97,695.62	0.00		1,267,777.37		
5018	SOBRA PREG 45-64 FE
M	0.00	-69.76	0.00	854.00	0.00	0.00	162.31	38.34	0.00	0.00	0.00	0.00		984.89		
SUBTOTAL:	522,757.4	1	880,499.14	495,681.9	8	579,795.06	554,282.24	560,463.68	534,865.26	616,580.02	580,564.20	603,289.25	900,753.26	0.00		6,829,531.50		

1106	TANF EXPANDED 21-44	0.00	186.26	0.00	335.18	0.00	1,996.42	4,171.27	1,326.60	106.69	1,986.89	-1,302.97	0.00	
1107	TANF EXPANDED 21-44	111.86	2,746.81	584.91	116.79	196.05	108.28	455.93	482.71	112.18	-77.65	1,670.87	0.00	
1108	TANF EXPANDED 45-64	2,231.06	3,215.80	386.79	6,671.24	309.87	1,869.58	2,382.74	1,007.75	1,930.90	400.44	428.91	0.00	
1109	TANF EXPANDED 65+
M&	262.85	457.33	1,531.00	506.14	-658.45	54.61	626.77	179.35	41.44	21.78	1,261.10	0.00	
1114	TANF EXPANDED 14-20	504.14	0.00	1,114.02	83.50	0.00	0.00	0.00	0.00	0.00	83.56	0.00	0.00	
1115	TANF EXPANDED 14-20	1,124.74	3,498.68	9,173.75	1,906.76	0.00	176.65	496.51	258.80	0.00	701.25	0.00	0.00	

 
8,806.34	
6,508.74	
20,835.08	
4,283.92	
1,785.22	
17,337.14	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	26,042.14	43,961.45	22,298.93	25,335.56	15,378.15	28,002.13	25,858.59	30,962.46	28,447.33	76,613.23	37,353.24	0.00		360,253.21		
1117	TANF EXPANDED 21-44	51,162.10	121,760.74	60,578.78	74,798.19	69,078.17	47,173.96	63,688.66	45,416.44	51,358.81	80,570.74	55,020.76	0.00		720,607.35		
1118	TANF EXPANDED 45-64	48,172.97	72,325.85	39,402.86	31,266.08	28,759.81	32,183.62	33,083.37	69,951.05	25,803.34	27,071.74	47,820.58	0.00		455,841.27		
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	781.44	0.00	0.00	0.00	0.00	0.00		781.44		
1127	TANF EXPANDED 21-44	0.00	36.34	26.84	0.00	146.01	918.71	412.62	0.00	193.17	87.99	20.90	0.00		1,842.58		
1128	TANF EXPANDED 45-64	79.51	60.00	0.00	20.66	0.00	56.51	822.35	210.08	217.98	0.00	109.79	0.00		1,576.88		
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	7,390.45	2,802.06	8,519.84	4,462.96	19,943.86	22,593.61	10,387.09	11,091.24	6,251.18	0.00		101,130.70		
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	0.00	0.00	545.96	0.00	0.00	0.00	0.00	0.00		545.96		
2420	SSI AGED EXPANDED WI	236.30	132.71	597.66	345.48	596.76	4,282.23	863.27	914.33	23.52	59.77	725.45	0.00		8,777.48		
2600	SSI DISABLED EXPAND
E	3,835.27	5,548.54	3,804.44	4,910.72	1,633.65	1,785.20	2,537.21	3,099.15	9,659.90	2,612.07	7,054.49	0.00		46,480.64		
2610	SSI DISABLED EXPAND E	357.95	2,833.72	775.54	5,431.36	1,651.47	1,785.88	8,090.95	0.00	3,460.25	6,091.93	24,748.85	0.00		55,227.90		
2620	SSI DISABLED EXPAND
E	2,422.63	96.81	0.00	2,791.50	925.01	1,917.84	639.42	949.86	1,814.46	503.42	657.96	0.00		12,718.91		
SUBTOTAL:	141,066.7	3	260,417.24	147,665.9	7	157,321.22	126,536.34	126,774.58	165,400.92	177,352.19	133,557.06	207,818.40	181,821.11	0.00		1,825,731.76		

3906	NEWLY ELIGIBLE MALE	0.00	72.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	989.65	0.00	0.00	

1,061.77

3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	502.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	1,483.92	1,266.99	0.00	56.79	-1,483.92	0.00	-802.06	0.00	0.00	0.00	186.17	0.00	
3514	ADULT 40-100% MALE 1	6,460.92	11,575.79	2,140.75	8,938.89	1,941.35	1,533.49	8,390.91	2,194.09	1,194.27	2,095.22	17,945.33	0.00	
3515	ADULT 40-100% FEMAL E	1,195.29	7,022.32	10,522.38	2,865.42	4,524.13	9,857.42	13,670.38	7,012.22	3,923.17	11,597.60	4,824.36	0.00	
3516	ADULT 40-100% MALE 2	37,882.54	56,781.44	35,191.83	52,393.57	40,608.59	54,555.73	46,284.59	59,528.99	187,351.91	58,052.92	50,491.28	0.00	
3517	ADULT 40-100% FEMAL E	40,082.72	31,094.20	40,529.61	18,550.69	27,479.89	30,111.15	21,466.01	31,939.61	23,544.69	35,486.04	49,950.64	0.00	
3518	ADULT 40-100% M&F 45	137,649.00	144,579.46	111,048.83	158,277.96	135,461.22	307,976.48	130,486.62	131,532.61	155,319.80	131,067.72	315,791.86	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	20.34	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	83.62	3,100.54	1,148.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	502.10	7.91	242.88	119.17	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	1,322.61	0.00	0.00	45.23	261.16	0.00	806.05	176.35	8.44	0.00	108.79	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	9,513.27	0.00	0.00	
3714	ADULT <40% EXP MALE	31,029.15	32,585.08	18,757.92	24,406.51	16,405.09	24,998.95	25,395.42	26,212.20	18,806.25	33,287.78	32,634.09	0.00	
3715	ADULT <40% EXP FEM AL	44,103.08	14,816.62	17,036.20	17,437.01	26,331.65	38,565.00	19,251.43	24,087.63	21,440.97	11,960.76	12,055.44	0.00	
3716	ADULT <40% EXP MALE	245,668.95	316,455.64	270,517.94	290,917.46	235,918.97	262,158.07	329,589.93	294,987.22	362,374.55	447,633.84	544,443.40	0.00	
3717	ADULT <40% EXP FEM AL	143,010.96	176,838.47	118,944.14	183,015.10	156,267.28	77,882.57	198,118.89	176,130.68	133,018.42	134,218.16	192,835.49	0.00	
3718	ADULT <40% EXP M&F
4	363,813.55	477,412.99	423,432.95	398,744.99	364,625.09	263,009.74	327,174.18	418,063.09	332,977.32	332,761.94	397,103.47	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	48.91	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	66.48	652.40	871.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,054,916.54	1,270,558.50	1,048,206.1	1,159,841.64	1,010,149.01	1,071,811.39	1,119,951.52	1,171,864.69	1,239,959.79	1,207,675.25	1,618,370.32	0.00	

 
502.56	
707.89	
64,411.01	
77,014.69	
679,123.39	
350,235.25	
1,859,191.56	
20.34	
5,675.71	
872.06	
2,728.63	
9,513.27	
284,518.44	
247,085.79	
3,600,665.97	
1,690,280.16	
4,099,119.31	
48.91	
1,589.88	
12,973,304.82	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3908	NEWLY ELIGIBLE M&F 4	345.83	363.88	608.17	342.14	1,326.60	199.67	498.79	0.00	1,852.10	649.08	3,432.85	0.00		9,619.11		
3914	NEWLY ELIGIBLE MALE	1,876.28	6,951.00	2,893.33	1,857.27	1,950.67	3,903.38	0.00	1,080.39	905.11	465.93	2,125.73	0.00		24,009.09		
3915	NEWLY ELIGIBLE FEMA L	8,084.57	9,627.66	4,178.77	6,647.16	2,347.15	1,805.66	1,565.42	946.53	1,384.75	6,075.88	496.54	0.00		43,160.09		
3916	NEWLY ELIGIBLE MALE	101,110.64	68,371.86	128,132.99	116,427.38	47,763.38	47,450.03	58,417.97	85,577.57	42,893.81	52,554.61	85,920.60	0.00		834,620.84		
3917	NEWLY ELIGIBLE FEMA L	100,349.87	52,982.04	66,973.73	36,658.93	39,192.02	41,418.80	47,372.60	49,629.32	106,591.79	62,913.54	95,572.57	0.00		699,655.21		
3918	NEWLY ELIGIBLE M&F
4	108,581.21	223,229.68	133,291.37	145,889.62	176,782.09	166,682.73	130,081.27	142,946.36	111,104.31	156,218.59	172,208.40	0.00		1,667,015.63		
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		133.70		
SUBTOTAL:	320,363.2	1	361,717.13	336,078.3	6	307,822.50	269,361.91	261,460.27	237,936.05	280,180.17	264,731.87	279,867.28	359,756.69	0.00		3,279,275.44		

8700	SSI DISABLED FREEDO M	3,279.71	1,938.22	436.97	262.91	876.96	1,713.33	3,276.28	749.89	461.29	4,384.84	763.81	0.00	
8710	SSI DISABLED FREEDO
M	6,752.04	96.26	46,226.54	3,253.37	-407.15	5,218.22	1,060.52	552.77	999.85	1,175.04	1,070.67	0.00	
8720	SSI DISABLED FREEDO M	230.00	695.64	0.00	0.00	0.00	0.00	10.86	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,261.75	2,730.12	46,663.5	1	3,516.28	469.81	6,931.55	4,347.66	1,302.66	1,461.14	5,559.88	1,834.48	0.00	

18,144.21	
65,998.13	
936.50	
85,078.84	

4413	SOBRA 100-133% M&F
6	6,086.08	23,544.97	25,648.50	19,013.79	12,602.79	7,318.66	3,210.50	14,161.78	7,609.03	10,483.74	50,343.30	0.00	
4414	SOBRA 100-133% MALE	3,573.99	12,967.46	9,283.43	6,733.81	2,514.05	6,925.88	1,916.00	3,817.94	10,007.95	1,083.30	5,400.02	0.00	
4415	SOBRA 100-133% FEMA L	6,117.28	16,210.00	7,910.47	47,909.40	2,747.98	3,229.57	4,825.51	11,461.44	2,580.84	5,510.92	12,541.95	0.00	
SUBTOTAL:	15,777.35	52,722.43	42,842.4	0	73,657.00	17,864.82	17,474.11	9,952.01	29,441.16	20,197.82	17,077.96	68,285.27	0.00	

 
180,023.14	
64,223.83	
121,045.36	
365,292.33	

TOTAL:	2,065,142.99	2,828,644.56	2,117,138.39	2,281,953.70	1,978,664.13	2,044,915.58	2,072,453.42	2,276,720.89	2,240,471.88	2,321,288.02	3,130,821.13	0.00		25,358,214.69		

ACUTE FEE FOR SERVICE - PRESUMPTIVE ELIGIBILITY - EXC. ES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
9000	PRESUMPTIVE ELIGIBI L	0.00	736.18	1,632.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,369.15		
SUBTOTAL:	0.00	736.18	1,632.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,369.15		

2,369.15

0.00	736.18	1,632.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

STATE EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3010	MN/MI NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-100.95	0.00		-100.95		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-100.95	0.00		-100.95		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

-100.95

0.00

0.00

-100.95	0.00

0.00

0.00

FEDERAL EMERGENCY SERVICES
For The Period Ending May 31, 2019	
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	414.27	0.00	0.00	0.00	0.00	144.29	12.74	0.00	0.00	0.00		3,017.20		
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	2,652.01	2,366.80	4,941.58	404.74	221.60	11,919.32	11,989.59	508.45	3,900.12	0.00		40,731.69		
1012	TANF 01-05 M & F NON	10,032.52	29,000.47	11,728.01	39,902.13	29,746.32	63,176.95	139,594.45	57,875.17	22,588.04	68,784.11	161,653.37	0.00		634,081.54		
1013	TANF 06-13 M & F NON	55,253.93	54,959.26	37,483.19	48,043.56	47,110.60	68,652.56	42,919.88	50,759.83	25,698.91	32,975.79	121,861.01	0.00		585,718.52		
1014	TANF 14-20 MALE NON-	100,182.76	172,011.77	62,189.18	41,263.47	82,170.72	216,645.91	81,874.34	60,684.76	63,987.23	53,940.59	142,321.65	0.00		1,077,272.38		
1015	TANF 14-20 FEMALE N O	233,623.79	405,870.16	310,064.29	348,770.34	257,094.39	340,984.96	277,065.58	447,267.63	218,575.42	216,473.84	234,506.54	0.00		3,290,296.94		
1016	TANF 21-44 MALE NON-	7,593.13	19,176.93	576.54	696.97	461.57	2,247.03	7.46	0.00	635.95	48.94	1,483.22	0.00		32,927.74		
1017	TANF 21-44 FEMALE N O	1,694,509.66	2,323,676.09	2,161,633.49	2,691,756.93	2,071,922.31	1,862,227.61	2,324,559.85	1,690,737.03	1,562,046.63	1,822,737.87	1,879,337.91	0.00		22,085,145.38		
1018	TANF 45-64 M & F NON	11,506.24	17,833.16	31,290.39	12,700.94	2,234.00	6,011.20	13,451.73	3,457.13	8,691.72	8,308.56	3,284.25	0.00		118,769.32		
2100	SSI AGED WITH MEDIC A	3,244.68	2,229.23	22,892.84	13,344.09	15,258.23	11,436.35	29,552.35	22,830.39	25,078.73	14,271.16	7,039.42	0.00		167,177.47		
2110	SSI AGED NON-MEDIC
AR	1,121,446.00	1,529,923.00	1,580,837.53	1,496,679.43	920,496.01	1,490,795.92	1,772,402.88	1,321,728.17	1,631,957.65	1,449,528.59	1,863,904.00	0.00		16,179,699.18		
2120	SSI AGED WITH QMB	138.97	63.48	0.00	0.00	22.83	1,577.14	3,287.78	3,750.29	972.96	309.35	40.22	0.00		10,163.02		
2200	SSI DISABLED WITH M E	11,519.68	19,385.70	9,253.14	12,865.89	4,008.57	12,874.30	5,777.46	6,138.89	8,708.62	15,569.98	4,248.92	0.00		110,351.15		
2210	SSI DISABLED NON-ME
D	84,283.42	180,923.34	146,222.06	174,089.16	104,945.96	112,578.22	126,243.38	90,802.35	142,721.42	174,213.47	136,154.73	0.00		1,473,177.51		
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	4,377,236.9	4	4,882,479.71	3,540,413.09	4,189,612.89	4,816,958.74	3,768,095.25	3,723,665.61	3,857,670.70	4,559,735.36	0.00		45,808,630.37		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	299.52	381.65	75.55	4,335.28	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	57.58	1,933.27	112.48	2,959.18	2,133.33	642.39	1,719.43	5,572.16	6,150.30	7,026.36	2,268.67	0.00	
3909	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	243.72	0.00	
3914	NEWLY ELIGIBLE MALE	76,108.18	101,862.52	35,607.79	57,662.06	23,407.26	33,136.04	67,401.35	10,392.16	41,241.82	128,946.34	42,307.36	0.00	

5,092.00	
30,575.15	
243.72	
618,072.88	

1108	TANF EXPANDED 45-64	3,645.14	2,760.56	3,435.68	2,934.34	2,993.24	1,265.40	1,444.44	2,210.56	3,444.42	3,853.32	7,137.32	0.00	
1109	TANF EXPANDED 65+
M&	1,809.61	1,646.57	331.87	739.31	160.31	0.00	37.86	0.00	0.00	8.14	0.00	0.00	
1114	TANF EXPANDED 14-20	48.91	2,784.54	0.00	280.37	4,229.46	411.85	119.52	1,563.56	675.75	694.31	81.36	0.00	
1115	TANF EXPANDED 14-20	10,893.56	39,060.89	8,259.92	24,650.75	13,087.56	10,228.30	19,250.79	12,065.18	29,555.93	33,517.72	13,712.88	0.00	
1116	TANF EXPANDED 21-44	581,996.63	783,927.81	734,719.01	774,851.12	720,964.89	528,489.95	740,060.95	550,811.63	616,113.96	581,637.10	666,132.52	0.00	
1117	TANF EXPANDED 21-44	1,231,827.93	2,035,472.08	1,652,503.84	1,955,634.89	1,625,182.60	1,484,031.65	1,960,176.89	1,493,190.22	1,462,207.25	1,589,421.76	2,107,787.82	0.00	
1118	TANF EXPANDED 45-64	637,323.75	1,284,640.72	886,570.70	1,109,658.78	713,082.53	893,673.66	1,148,334.89	846,337.76	769,955.88	1,187,256.47	1,437,712.42	0.00	
1119	TANF EXPANDED 65+
M&	18,009.37	9,472.43	25,038.87	19,254.43	16,932.80	27,351.61	51,714.07	6,966.10	5,722.92	18,399.75	24,569.01	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	483.12	863.26	0.00	
2400	SSI AGED EXPANDED WI	3,204.54	5,101.87	7,115.22	20,885.92	-292.81	823.03	2,488.53	1,986.03	4,140.65	1,581.88	2,792.26	0.00	
2410	SSI AGED EXPANDED
NO	183.26	12,551.24	939.76	9,273.71	1,158.42	12,777.59	2,809.54	6,278.40	1,390.31	48.94	10,959.95	0.00	
2420	SSI AGED EXPANDED WI	6,381.58	63.84	150.86	14,618.78	4,186.34	2,062.88	2,323.61	987.31	218.37	2,291.83	9,347.61	0.00	
2600	SSI DISABLED EXPAND
E	1,600.92	0.00	0.00	0.00	0.00	1,867.74	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,496,925.20	4,177,482.55	3,319,065.7	3	3,932,782.40	3,101,685.34	2,962,983.66	3,928,761.09	2,922,396.75	2,893,425.44	3,419,194.34	4,281,096.41	0.00	

 
35,124.42	
4,733.67	
10,889.63	
214,283.48	
7,279,705.57	
18,597,436.93	
10,914,547.56	
223,431.36	
1,346.38	
49,827.12	
58,371.12	
42,633.01	
3,468.66	
37,435,798.91	

FEDERAL EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	83,570.35	73,531.08	47,281.36	37,311.34	22,006.17	33,703.03	38,378.01	27,929.19	39,117.68	47,643.77	74,269.15	0.00		524,741.13		
3916	NEWLY ELIGIBLE MALE	534,581.63	1,626,371.52	829,772.67	1,046,788.16	812,782.26	846,901.27	913,612.11	774,695.35	917,479.27	947,248.85	1,698,015.69	0.00		10,948,248.78		
3917	NEWLY ELIGIBLE FEMA L	624,582.36	551,982.35	525,310.76	440,091.79	313,816.30	395,685.51	546,071.29	467,103.44	429,943.44	471,627.05	498,388.44	0.00		5,264,602.73		
3918	NEWLY ELIGIBLE M&F
4	1,793,345.32	2,932,482.72	2,439,324.11	3,142,052.53	2,058,850.12	2,597,675.62	3,254,242.36	2,146,792.87	2,582,340.94	3,194,248.53	3,701,534.34	0.00		29,842,889.46		
3919	NEWLY ELIGIBLE M&F 6	9,030.78	1,637.26	201.50	248.69	0.00	0.00	3,410.69	1,940.74	9.71	79.46	3,428.19	0.00		19,987.02		
SUBTOTAL:	3,121,276.20	5,289,800.72	3,877,610.6	7	4,727,413.27	3,233,377.09	3,907,819.41	4,829,170.52	3,434,425.91	4,016,283.16	4,796,820.36	6,020,455.56	0.00		47,254,452.87		

130,498,882.15

11,573,913.34	13,542,675.38	9,875,475.52	11,060,415.96	13,574,890.35	10,124,917.91	10,633,374.21	12,073,685.40	14,861,287.33	0.00	

TOTAL:

8,954,044.61

14,224,202.14

QMB - FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	463,141.91	924,864.07	574,823.97	644,257.51	698,849.75	603,191.74	615,252.53	214,003.57	78,813.09	0.00		6,102,449.84		
8040	SLMB	0.00	0.00	4.99	6.66	32.82	0.00	124.78	159.04	0.00	1,364.00	88.35	0.00		1,780.64		
8050	QI1	68.23	0.00	0.00	0.00	0.00	0.00	54.82	0.68	0.00	455.00	14.76	0.00		593.49		
SUBTOTAL:	620,783.4	2	664,536.51	463,146.9	0	924,870.73	574,856.79	644,257.51	699,029.35	603,351.46	615,252.53	215,822.57	78,916.20	0.00		6,104,823.97		

TOTAL:	620,783.42	664,536.51	463,146.90	924,870.73	574,856.79	644,257.51	699,029.35	603,351.46	615,252.53	215,822.57	78,916.20	0.00		6,104,823.97		

FFS TRBHA FEE FOR SERVICE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	458.36	181.44	105.14	312.82	115.36	0.00	103.08	0.00		1,276.20		
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	1,328.81	725.42	0.00		2,130.83		
1009	TANF 65+ M & F WITH	87.98	2,112.24	1,466.56	2,160.44	1,159.02	0.00	164.48	0.00	0.00	0.00	0.00	0.00		7,150.72		
1011	TANF <1 M & F NON-ME	2,747.82	2,358.28	2,142.78	1,880.59	2,899.94	2,340.44	2,643.83	10,046.73	3,344.48	1,909.38	6,519.84	0.00		38,834.11		
1012	TANF 01-05 M & F NON	13,143.77	89,337.34	11,085.23	2,709.09	6,806.76	10,119.14	22,353.77	10,624.89	8,732.24	11,157.12	7,670.48	0.00		193,739.83		
1013	TANF 06-13 M & F NON	218,801.71	269,117.59	383,196.72	260,351.80	158,464.20	125,879.84	131,271.14	181,853.18	148,470.13	194,916.30	194,439.90	0.00		2,266,762.51		
1014	TANF 14-20 MALE NON-	16,179.78	16,331.63	85,636.91	23,458.98	20,097.87	30,994.02	72,287.43	40,009.97	42,871.88	47,594.48	47,891.02	0.00		443,353.97		
1015	TANF 14-20 FEMALE N O	125,023.80	361,168.85	121,140.23	130,693.66	80,587.74	70,271.54	279,192.68	68,267.04	105,874.30	107,480.05	93,533.75	0.00		1,543,233.64		
1016	TANF 21-44 MALE NON-	529,489.74	703,037.70	608,973.60	726,237.12	452,411.10	453,941.92	419,922.07	361,161.53	413,752.07	527,161.88	429,722.16	0.00		5,625,810.89		
1017	TANF 21-44 FEMALE N O	1,164,015.57	1,664,491.72	1,455,164.34	1,676,556.07	1,246,260.99	1,249,488.21	1,229,496.67	1,358,265.16	1,201,414.22	1,494,379.87	1,539,304.15	0.00		15,278,836.97		
1018	TANF 45-64 M & F NON	213,834.54	268,539.47	228,383.05	297,226.78	260,075.87	246,439.11	203,853.21	312,559.68	270,134.68	244,917.82	428,757.80	0.00		2,974,722.01		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	335.08	167.54	0.00	0.00	21.33	0.00		523.95		
2100	SSI AGED WITH MEDIC A	8,512.47	13,947.88	5,979.17	10,394.20	12,346.49	9,381.34	14,679.61	16,549.77	17,094.03	22,090.05	9,291.65	0.00		140,266.66		
2110	SSI AGED NON-MEDIC
AR	4,930.99	5,793.52	6,973.19	11,130.57	7,883.33	10,050.62	9,206.02	3,533.61	3,833.95	2,590.36	4,662.15	0.00		70,588.31		
2120	SSI AGED WITH QMB	17,608.95	19,368.64	19,383.92	28,787.68	33,897.34	40,489.02	44,353.44	32,809.20	35,732.43	44,904.99	60,810.67	0.00		378,146.28		
2200	SSI DISABLED WITH M E	53,361.22	46,758.53	35,777.39	38,076.82	30,930.33	46,935.57	34,834.42	40,686.13	50,024.90	40,044.88	53,639.29	0.00		471,069.48		
2210	SSI DISABLED NON-ME
D	1,663,776.48	2,136,780.27	1,766,280.32	2,231,242.93	1,859,820.95	1,690,110.07	1,795,024.61	1,778,348.09	1,770,505.91	2,509,927.98	2,243,390.40	0.00		21,445,208.01		
2220	SSI DISABLED WITH Q M	269,255.92	345,020.50	315,055.97	374,158.99	276,017.61	274,254.18	344,310.85	338,075.09	299,155.59	292,668.26	352,088.03	0.00		3,480,060.99		
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	14,899.06	16,137.61	12,912.68	11,577.01	15,007.71	14,364.25	34,842.52	32,761.27	41,397.40	0.00		229,027.38		
2320	SSI BLIND WITH QMB	945.26	2,411.62	851.27	2,047.22	7,833.40	8,075.38	8,548.23	4,493.75	3,675.63	9,334.80	10,053.15	0.00		58,269.71		
4311	SOBRA CHILD <1 M & F	17,699.86	5,459.83	3,290.78	5,538.17	6,348.30	4,616.75	4,514.61	6,353.57	3,661.00	1,960.77	8,900.74	0.00		68,344.38		
4312	SOBRA CHILD 01-05 M	145,743.83	279,287.70	189,587.92	240,784.70	210,241.22	193,834.45	228,677.98	266,784.76	205,501.26	301,395.90	347,126.04	0.00		2,608,965.76		
4313	SOBRA CHILD 06-13 M	4,235,083.20	4,798,839.90	3,201,347.67	4,327,733.16	3,741,804.30	2,905,468.05	3,641,832.49	3,271,119.63	3,244,689.63	2,925,621.29	3,132,631.66	0.00		39,426,170.98		
4314	SOBRA CHILD 14-20 MA	1,111,452.87	1,748,980.16	959,600.38	1,175,924.19	926,569.67	773,915.49	1,635,479.31	1,032,173.42	1,093,365.38	953,509.47	1,046,129.53	0.00		12,457,099.87		
4315	SOBRA CHILD 14-20 FE	1,136,461.92	1,990,746.44	952,694.59	1,248,689.28	1,213,215.66	923,891.76	1,412,620.02	1,200,797.36	1,289,285.55	1,035,243.60	1,332,089.54	0.00		13,735,735.72		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	208.83	0.00	0.00	0.00	0.00	0.00		208.83		
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	6,618.64	6,345.46	17,190.71	15,161.68	16,519.05	4,123.25	7,124.65	17,191.22	5,322.11	0.00		119,899.25		
5017	SOBRA PREG 21-44 FE
M	130,369.95	208,077.73	187,386.79	204,500.58	114,230.48	95,932.48	114,805.49	79,371.72	78,382.67	103,872.84	176,172.38	0.00		1,493,103.11		
5018	SOBRA PREG 45-64 FE M	4,288.24	861.34	319.05	42.66	0.00	34.36	0.00	0.00	34.36	0.00	0.00	0.00		5,580.01		
5027	SOBRA PREG 21-44 FE
M	0.00	14.60	240.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	236.08	0.00		490.75		
SUBTOTAL:	11,117,318.6	1 15,004,286.71	10,563,475.6	0 13,042,808.75	10,700,464.32	9,193,383.87	11,682,248.17	10,432,852.14	10,331,618.82	10,923,963.39	11,572,629.75	0.00		124,565,050.13		

1,675.40

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	837.70	670.16	167.54	0.00	
1107	TANF EXPANDED 21-44	0.00	34.36	0.00	0.00	0.00	0.00	34.81	0.00	0.00	137.44	0.00	0.00	

206.61

FFS TRBHA FEE FOR SERVICE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	184.01	163.47	86.87	1,584.87	2,154.87	3,083.54	2,979.83	105.80	86.81	295.01	499.92	0.00		11,225.00		
1109	TANF EXPANDED 65+
M&	0.00	260.57	0.00	0.00	21.60	76.60	0.00	78.76	102.74	796.13	1,575.40	0.00		2,911.80		
1114	TANF EXPANDED 14-20	0.00	2,259.44	2,989.00	2,637.90	9,855.36	6,405.00	427.00	3,871.00	427.00	0.00	0.00	0.00		28,871.70		
1115	TANF EXPANDED 14-20	2,600.86	2,562.00	1,085.13	402.34	854.00	427.00	68.72	1,474.44	28.00	1,377.77	6,047.55	0.00		16,927.81		
1116	TANF EXPANDED 21-44	132,900.36	189,630.08	195,149.93	295,505.00	176,980.19	251,693.51	129,557.72	179,560.13	140,253.60	83,911.92	257,740.61	0.00		2,032,883.05		
1117	TANF EXPANDED 21-44	330,923.61	494,956.48	494,069.61	615,363.89	257,930.59	402,307.08	311,707.60	336,398.94	368,846.49	343,916.46	516,925.67	0.00		4,473,346.42		
1118	TANF EXPANDED 45-64	127,317.08	166,400.52	118,867.33	170,587.33	98,590.16	107,131.21	91,190.96	88,864.74	161,529.23	82,842.94	184,339.52	0.00		1,397,661.02		
1126	TANF EXPANDED 21-44	1,242.45	1,826.09	1,231.50	1,801.84	1,826.49	805.32	1,545.28	380.44	1,662.15	1,352.38	1,949.82	0.00		15,623.76		
1127	TANF EXPANDED 21-44	6,783.03	3,251.42	509.67	1,233.95	1,285.77	3,756.44	6,400.01	7,854.24	5,415.24	8,434.53	3,612.17	0.00		48,536.47		
1128	TANF EXPANDED 45-64	2,135.58	2,187.03	3,900.39	3,727.72	1,103.73	2,958.81	362.28	4,894.29	10,392.28	6,740.41	14,279.47	0.00		52,681.99		
1129	TANF EXPANDED 65+
M&	335.08	449.27	170.73	283.61	573.70	3,770.09	3,979.27	3,241.28	3,377.82	3,422.29	1,217.21	0.00		20,820.35		
2400	SSI AGED EXPANDED WI	0.00	0.00	59.44	610.89	0.00	0.00	0.00	0.00	0.00	0.00	1,969.24	0.00		2,639.57		
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	23,784.83	21,928.97	19,161.04	21,582.82	29,217.09	31,445.06	37,361.65	27,495.68	46,810.31	0.00		295,921.84		
2600	SSI DISABLED EXPAND
E	34.36	0.00	343.87	15.85	373.83	34.36	10.48	93.03	0.00	0.00	113.29	0.00		1,019.07		
2610	SSI DISABLED EXPAND E	3,212.21	3,081.35	3,117.97	8,596.43	2,784.05	1,748.20	25,548.37	2,810.55	2,567.24	1,361.31	3,198.31	0.00		58,025.99		
2620	SSI DISABLED EXPAND
E	86,428.45	99,354.06	82,374.32	94,137.16	81,778.38	85,860.12	108,631.36	97,138.54	79,765.12	104,829.20	95,295.02	0.00		1,015,591.73		
SUBTOTAL:	710,957.4	3	986,694.20	927,740.5	9	1,218,417.75	655,273.76	891,640.10	711,660.78	758,211.24	812,653.07	667,583.63	1,135,741.05	0.00		9,476,573.60		

116,931.38

3914	NEWLY ELIGIBLE MALE	31,466.18	6,399.25	9,255.66	13,272.18	7,587.86	6,235.99	4,584.21	4,525.44	4,490.52	15,028.69	1,040.46	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,396.00	3,792.97	4,109.21	5,405.79	6,694.35	2,699.95	5,724.88	15,756.14	4,585.05	39,332.12	25,434.92	0.00	

103,886.44

3514	ADULT 40-100% MALE 1	4,692.85	4,568.83	16,026.25	17,687.07	7,315.92	19,766.06	24,045.90	21,954.81	42,707.74	12,428.78	4,161.40	0.00	
3515	ADULT 40-100% FEMAL E	15,939.50	22,057.52	16,991.21	16,249.55	18,998.73	14,489.28	10,529.11	18,123.14	10,564.29	21,170.64	11,075.64	0.00	
3516	ADULT 40-100% MALE 2	158,151.60	203,011.89	167,673.26	250,737.20	127,053.44	156,649.78	166,959.58	136,223.37	183,821.13	200,919.47	203,004.35	0.00	
3517	ADULT 40-100% FEMAL E	66,409.98	67,130.33	71,404.19	108,104.29	73,678.76	66,969.73	40,001.19	91,389.83	90,690.79	89,836.36	181,154.30	0.00	
3518	ADULT 40-100% M&F 45	78,607.32	111,883.78	134,587.17	129,433.40	69,702.29	82,109.21	78,956.30	118,599.47	118,396.00	167,063.07	189,381.77	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	910.00	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	427.00	309.24	224.60	316.72	0.00	
3714	ADULT <40% EXP MALE	136,450.77	203,154.92	135,542.01	137,552.41	138,352.27	139,685.40	133,740.94	164,323.18	217,342.44	158,163.52	148,780.09	0.00	
3715	ADULT <40% EXP FEM AL	117,289.45	110,476.78	107,380.18	139,055.74	105,816.21	148,007.37	170,396.07	127,475.41	105,847.12	88,815.21	130,650.83	0.00	
3716	ADULT <40% EXP MALE	2,551,810.53	2,809,702.33	2,409,649.40	2,576,630.84	2,104,123.84	1,996,125.80	2,387,429.47	2,143,568.59	2,139,519.45	2,602,076.40	2,366,332.84	0.00	
3717	ADULT <40% EXP FEM AL	1,399,164.79	1,778,856.06	1,286,021.37	1,585,800.78	1,229,890.19	1,224,302.09	1,271,206.85	1,216,580.93	1,260,035.02	1,526,330.26	1,211,037.40	0.00	
3718	ADULT <40% EXP M&F
4	1,231,629.73	1,665,796.66	1,234,655.60	1,554,963.42	1,212,858.71	1,045,428.35	1,206,899.79	1,285,336.90	1,215,489.13	1,576,595.14	1,459,725.34	0.00	
3719	ADULT <40% EXP M&F 6	136.94	410.82	1,315.84	56.26	134.23	427.00	427.00	34.36	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	76.60	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,760,283.46	6,977,049.92	5,581,246.4	8	6,516,270.96	5,087,924.59	4,893,960.07	5,490,668.80	5,324,036.99	5,384,722.35	6,444,533.45	5,905,620.68	0.00	

 
175,355.61	
176,188.61	
1,954,205.07	
946,769.75	
1,278,719.78	
910.00	
1,277.56	
1,713,087.95	
1,351,210.37	
26,086,969.49	
14,989,225.74	
14,689,378.77	
2,942.45	
76.60	
63,366,317.75	

FFS TRBHA FEE FOR SERVICE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	32,180.67	30,773.86	38,672.50	49,573.65	37,551.95	19,220.06	55,783.25	40,169.22	51,266.22	129,769.07	98,028.62	0.00		582,989.07		
3917	NEWLY ELIGIBLE FEMA L	35,370.17	72,760.71	48,052.44	50,014.88	22,245.30	33,356.63	38,373.53	47,168.98	51,254.85	32,024.54	48,060.81	0.00		478,682.84		
3918	NEWLY ELIGIBLE M&F
4	66,038.09	49,975.40	40,535.57	54,644.52	52,254.64	55,871.28	66,219.29	48,162.85	56,310.11	78,265.25	58,762.47	0.00		627,039.47		
SUBTOTAL:	168,451.1	1	163,702.19	140,625.3	8	172,911.02	126,334.10	117,383.91	170,685.16	155,782.63	167,906.75	294,419.67	231,327.28	0.00		1,909,529.20		

4413	SOBRA 100-133% M&F
6	183,265.65	213,401.61	95,712.75	229,378.09	163,049.82	93,298.00	117,069.74	131,823.43	104,732.65	150,825.80	147,385.74	0.00	
4414	SOBRA 100-133% MALE	30,782.44	266,300.69	39,031.78	44,669.50	65,091.69	42,927.61	52,654.63	60,598.48	52,172.61	79,123.02	79,589.34	0.00	
4415	SOBRA 100-133% FEMA L	53,126.70	59,050.72	46,664.31	109,588.36	81,665.76	49,785.96	71,144.09	70,662.95	76,969.35	63,873.90	81,865.81	0.00	
SUBTOTAL:	267,174.7	9	538,753.02	181,408.8	4	383,635.95	309,807.27	186,011.57	240,868.46	263,084.86	233,874.61	293,822.72	308,840.89	0.00	

 
1,629,943.28	
812,941.79	
764,397.91	
3,207,282.98	

8700	SSI DISABLED FREEDO M	482.92	513.87	427.00	874.96	112.00	1,735.44	127.23	1,769.82	232.08	164.25	1,785.49	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	115.84	0.00	0.00	0.00	108.16	0.00	0.00	3,299.08	0.00	
SUBTOTAL:	482.92	513.87	427.0	0	990.80	112.00	1,735.44	127.23	1,877.98	232.08	164.25	5,084.57	0.00	

 
8,225.06	
3,523.08	
11,748.14	

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	-1,422.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,422.00	0.00	0.00	

 

-1,422.00

-1,422.00

0.00

19,159,244.22

16,931,007.68

21,335,035.23

TOTAL:

18,024,668.32

23,670,999.91 17,394,923.89

16,879,916.04 15,284,114.96 18,296,258.60 16,935,845.84

18,623,065.11

202,535,079.80

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	5,714.73	15,511.41	4,081.95	3,265.56	34,543.43	26,588.22	16,951.41	10,931.44	5,886.16	0.00		133,857.82		
1017	TANF 21-44 FEMALE N O	21,378.33	37,582.50	18,001.38	48,634.08	40,670.40	32,040.04	22,562.08	45,063.65	39,615.30	50,880.97	43,439.80	0.00		399,868.53		
1018	TANF 45-64 M & F NON	0.00	4,081.95	0.00	0.00	5,070.48	5,886.16	0.00	11,625.38	3,363.52	13,454.08	6,727.04	0.00		50,208.61		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	1,340.00	0.00	0.00	1,340.00	0.00	0.00	0.00	0.00	0.00		2,680.00		
2210	SSI DISABLED NON-ME
D	46,249.55	54,820.53	46,465.02	23,031.06	31,621.93	39,125.43	52,251.29	35,652.02	25,897.27	95,587.68	70,321.17	0.00		521,022.95		
2220	SSI DISABLED WITH Q M	2,680.00	1,702.52	1,702.52	2,680.00	5,360.00	-1,340.00	0.00	1,364.00	1,364.00	2,728.00	1,364.00	0.00		19,605.04		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	4,898.34	6,727.04	0.00	0.00	0.00	20,181.12	0.00	0.00	0.00		31,806.50		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	15,511.41	0.00	0.00	2,522.64	0.00	6,531.12	2,535.24	0.00		27,100.41		
SUBTOTAL:	80,691.39	98,187.50	71,883.6	5	96,094.89	109,043.21	78,977.19	110,696.80	122,815.91	107,372.62	180,113.29	130,273.41	0.00		1,186,149.86		

3516	ADULT 40-100% MALE 2	2,449.17	9,974.01	0.00	840.88	7,347.51	15,656.45	40,653.94	5,886.16	14,688.19	5,714.73	17,061.60	0.00	
3517	ADULT 40-100% FEMAL E	18,050.34	5,743.29	7,384.23	11,445.78	2,461.41	6,760.64	6,727.04	1,640.94	0.00	4,439.22	17,487.05	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	13,062.24	5,886.16	0.00	13,483.48	4,898.34	1,690.16	4,572.42	5,045.28	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	1,340.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	82,139.07	134,557.39	74,066.19	82,414.96	81,815.66	93,605.50	162,121.19	131,057.38	136,000.58	192,839.50	221,670.87	0.00	
3717	ADULT <40% EXP FEM AL	56,330.91	40,634.82	3,787.35	63,335.71	23,660.05	51,613.98	110,132.70	40,012.35	50,540.11	59,428.76	70,739.49	0.00	
3718	ADULT <40% EXP M&F
4	22,355.92	64,666.26	28,401.21	41,048.45	11,441.70	53,021.01	83,330.82	62,083.18	41,329.52	81,044.57	80,445.85	0.00	
SUBTOTAL:	181,325.4	1	255,575.77	126,701.2	2	204,971.94	126,726.33	234,141.06	409,204.03	242,370.17	247,130.82	348,512.06	407,404.86	0.00	

120,272.64	
82,139.94	
48,638.08	
1,340.00	
1,392,288.29	
570,216.23	
569,168.49	
2,784,063.67	

3916	NEWLY ELIGIBLE MALE	0.00	5,743.29	19,617.84	0.00	20,757.85	10,833.48	12,967.58	2,535.24	13,844.96	22,733.16	17,603.23	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	21,226.14	4,225.40	4,081.95	0.00	10,892.45	6,674.57	3,363.52	4,204.40	16,050.19	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	7,347.51	14,743.98	0.00	4,204.40	3,363.52	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	5,743.29	48,191.4	9	18,969.38	24,839.80	15,037.88	27,223.55	9,209.81	17,208.48	26,937.56	33,653.42	0.00	

126,636.63	
70,718.62	
29,659.41	
227,014.66	

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	1,524.14	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,524.14	0.00	

1,524.14

1,524.14

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	1,340.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	9,817.08	0.00	2,449.17	4,081.95	8,980.29	0.00	0.00	10,931.44	0.00	5,045.28	0.00	
1117	TANF EXPANDED 21-44	5,714.73	0.00	5,714.73	10,735.52	0.00	4,081.95	9,854.13	15,135.84	5,070.48	5,179.09	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,567.92	0.00	0.00	14,939.92	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	1,364.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	1,340.00	0.00	0.00	0.00	1,340.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,340.00	0.00	1,340.00	1,340.00	0.00	0.00	2,760.00	-80.00	1,364.00	0.00	1,364.00	0.00	
SUBTOTAL:	7,054.73	9,817.08	8,394.7	3	14,524.69	4,081.95	13,062.24	15,294.13	22,623.76	17,365.92	6,543.09	21,349.20	0.00	

 
1,340.00	
41,305.21	
61,486.47	
22,507.84	
1,364.00	
2,680.00	
9,428.00	
140,111.52	

TOTAL:	269,071.53	369,323.64	255,171.09	334,560.90	264,691.29	341,218.37	562,418.51	397,019.65	389,077.84	562,106.00	594,205.03	0.00		4,338,863.85		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	24,377.08	78,038.37	53,152.03	34,873.05	16,691.20	6,517.85	59,075.24	16,449.14	-25,247.81	0.00		323,589.50		
2110	SSI AGED NON-MEDIC AR	22,432.29	74,325.44	141,744.40	17,573.96	47,890.53	132,399.87	39,005.84	40,579.89	94,383.34	25,171.23	72,160.58	0.00		707,667.37		
2200	SSI DISABLED WITH M
E	147.01	1,691.65	12,102.01	4,862.52	34,122.24	30,341.53	50,685.52	12,625.73	12,014.72	15,211.60	64,113.97	0.00		237,918.50		
2210	SSI DISABLED NON-ME D	0.00	5,393.17	0.00	221.84	445.88	142.89	5,897.36	8,942.61	3,735.27	1,275.09	698.51	0.00		26,752.62		
2220	SSI DISABLED WITH Q
M	0.00	0.00	391.76	0.00	0.00	5,859.80	0.00	0.00	0.00	0.00	0.00	0.00		6,251.56		
4314	SOBRA CHILD 14-20 MA	0.00	15,349.35	0.00	122.87	279.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,751.83		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	3,498.00	0.00	0.00	843.13	3,464.59	0.00		7,805.72		
5017	SOBRA PREG 21-44 FE
M	14,080.22	11,579.71	17,037.60	10,603.22	4,533.20	14,830.15	22,706.67	3,075.37	11,151.92	10,991.83	14,847.67	0.00		135,437.56		
SUBTOTAL:	52,966.41	155,038.26	195,652.8	5	111,422.78	140,423.49	218,447.29	138,484.59	71,741.45	180,360.49	69,942.02	130,037.51	0.00		1,464,517.14		

0.00

3516	ADULT 40-100% MALE 2	0.00	0.00	2,272.03	0.00	0.00	0.00	0.00	0.00	247.59	431.65	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	218.09	2,639.79	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	1,200.57	19,076.91	57.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,093.55	0.00	
3706	ADULT <40% EXP MALE	43,344.90	5,930.66	16,655.14	62.04	2,103.61	587.41	3,217.85	1,699.65	581.21	44,238.50	37,920.95	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	139.27	0.00	0.00	3,714.53	1,609.59	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	12,739.14	18,166.86	53,502.07	20,459.83	22,341.08	26,928.57	34,443.91	12,403.75	185.05	5,228.72	12,818.91	0.00	
3714	ADULT <40% EXP MALE	0.00	436.78	4,679.64	0.00	0.00	0.00	0.00	0.00	0.00	9,677.26	1,445.60	0.00	
3716	ADULT <40% EXP MALE	148,337.54	564,555.00	429,997.86	279,966.96	135,778.73	389,612.55	401,223.37	243,976.94	193,096.63	433,506.49	407,837.43	0.00	
3717	ADULT <40% EXP FEM AL	29,781.34	26,333.88	54,662.66	8,915.44	4,746.76	17,225.71	56,655.88	22,750.40	31,030.92	29,514.36	88,723.40	0.00	
3718	ADULT <40% EXP M&F
4	331,780.58	295,515.58	340,317.60	286,836.46	162,613.39	316,184.44	272,348.14	190,383.97	91,734.53	165,772.68	372,311.34	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	12,835.29	2,009.39	6,278.89	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	310.87	0.00	14,103.97	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	269.56	0.00	3,320.23	416.07	0.00	0.00	0.00	
SUBTOTAL:	567,184.0	7	930,015.67	902,144.1	3	596,380.00	327,894.44	750,808.24	785,925.74	478,784.32	330,127.29	690,379.05	930,430.07	0.00	

2,951.27	
2,857.88	
23,428.16	
156,341.92	
5,463.39	
219,217.89	
16,239.28	
3,627,889.50	
370,340.75	
2,825,798.71	
21,123.57	
14,414.84	
4,005.86	
7,290,073.02	

3916	NEWLY ELIGIBLE MALE	37,301.33	2,765.31	36,112.62	28,240.29	11,881.25	148,683.56	1,754.30	27,981.96	13,652.88	12,351.82	22,514.33	0.00	
3918	NEWLY ELIGIBLE M&F 4	704.71	5,343.15	6,842.25	28,415.97	7,252.37	12,299.35	1,557.80	1,176.72	11,592.64	10,565.81	31,976.96	0.00	
3919	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,642.68	798.09	62,063.67	97.55	0.00	
SUBTOTAL:	38,006.04	8,108.46	42,954.8	7	56,656.26	19,133.62	160,982.91	3,312.10	31,801.36	26,043.61	84,981.30	54,588.84	0.00	

343,239.65	
117,727.73	
65,601.99	
526,569.37	

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,961.13	-5,961.13	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,961.13	-5,961.13	0.00	

0.00

2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,441.64	18,112.82	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	71.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	71.20	0.00	0.00	1,441.64	18,112.82	0.00	0.00	0.00	

 

19,625.66

71.20

19,554.46

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	658,156.52	1,093,162.39	1,140,751.85	764,459.04	487,522.75	1,130,238.44	927,722.43	583,768.77	554,644.21	851,263.50	1,109,095.29	0.00		9,300,785.19		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	150.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,050.46		
SUBTOTAL:	4,816.81	1,083.06	150.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,050.46		

TOTAL:

150.59

0.00

0.00

0.00

0.00

0.00

6,050.46

1,083.06

4,816.81

0.00	0.00

0.00

0.00

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	499.04	12,739.40	1,386.80	41,337.46	946.02	1,384.31	144.27	8,502.57	0.00		67,162.62		
1017	TANF 21-44 FEMALE N O	3,222.63	8,856.41	0.00	14,247.02	725.47	19,360.55	5,668.31	1,563.41	236.66	7,396.06	2,413.52	0.00		63,690.04		
1018	TANF 45-64 M & F NON	1,623.32	222.54	0.00	5,139.02	131.56	0.00	0.00	0.00	0.00	0.00	16,349.54	0.00		23,465.98		
2200	SSI DISABLED WITH M E	0.00	0.00	4,288.46	10,564.93	-3,354.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,498.80		
2210	SSI DISABLED NON-ME
D	0.00	90.81	0.00	0.00	0.00	-8.00	0.00	0.00	3,208.22	98.54	275.93	0.00		3,665.50		
2220	SSI DISABLED WITH Q M	4,042.07	282.01	22.45	0.00	20.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,366.81		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	1,786.85	9,147.06	91.03	0.00	230.44	0.00	0.00		11,255.38		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,732.51	264.09	0.00	0.00		2,996.60		
5017	SOBRA PREG 21-44 FE M	4,335.15	10,238.47	415.50	3,174.13	57.13	191.36	0.00	0.00	0.00	3,112.85	171.65	0.00		21,696.24		
SUBTOTAL:	13,280.57	19,855.59	4,726.4	1	33,624.14	10,319.25	22,717.56	56,152.83	2,600.46	7,561.70	11,246.25	27,713.21	0.00		209,797.97		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	5,642.66	307.34	1,158.52	1,385.93	17,283.03	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	16,447.29	7,577.21	706.25	3,259.13	4,906.47	174.60	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	3,801.38	5,195.35	2,993.69	2,060.86	3,306.95	0.00	0.00	5,117.17	3,209.77	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	7,940.51	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	204.29	0.00	0.00	0.00	1,326.60	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	204.29	11,741.8	9	21,642.64	10,570.90	4,093.71	12,208.74	5,213.81	1,333.12	6,503.10	20,492.80	0.00	

 
25,777.48	
33,070.95	
25,685.17	
7,940.51	
1,530.89	
94,005.00	

3516	ADULT 40-100% MALE 2	2,731.97	2,018.55	0.00	3,503.95	3,050.06	6,068.16	10,303.78	4,400.44	8,048.94	18,829.42	930.42	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,523.38	0.00	206.48	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	13,034.20	9,839.48	438.96	14,591.54	-17,480.23	403.50	15.02	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	333.48	0.00	59.12	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	199.17	57.40	4,996.21	7,924.50	2,004.68	0.00	5,874.69	0.00	
3716	ADULT <40% EXP MALE	51,830.92	62,846.53	40,713.58	91,221.62	65,672.33	76,707.13	109,696.96	143,240.45	53,915.53	51,761.61	9,270.57	0.00	
3717	ADULT <40% EXP FEM AL	3,378.84	137,279.05	-606.21	33,976.58	10,359.98	15,272.42	16,036.76	26,834.94	8,487.19	5,418.00	21,076.18	0.00	
3718	ADULT <40% EXP M&F
4	25,263.02	100,341.97	32,505.36	64,914.22	86,593.81	23,842.22	94,912.76	73,750.24	28,283.50	67,993.07	36,826.84	0.00	
SUBTOTAL:	83,204.75	308,296.32	85,646.9	3	203,789.33	166,314.31	136,597.99	218,466.24	256,554.07	104,278.24	144,002.10	74,185.18	0.00	

 
59,885.69	
3,729.86	
20,842.47	
392.60	
26,866.87	
756,877.23	
277,513.73	
635,227.01	
1,781,335.46	

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	3,452.43	313.35	6,497.10	652.21	0.00	0.00	0.00	90.81	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	5,864.78	0.00	
SUBTOTAL:	3,611.36	2,869.37	3,452.4	3	313.35	6,497.10	652.21	0.00	0.00	0.00	90.81	5,864.78	0.00	

 
57.40	
17,429.23	
5,864.78	
23,351.41	

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,961.13	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,961.13	0.00	

 
5,961.13

5,961.13

2,114,450.97

100,096.68	331,225.57	105,567.66	259,369.46	193,701.56	164,061.47	286,827.81	264,368.34	113,173.06	161,842.26	134,217.10	0.00	

TOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	51.30	0.00	0.00	0.00		371.92		
2110	SSI AGED NON-MEDIC AR	0.00	0.00	0.00	0.00	0.00	0.00	455.71	8,806.66	0.00	0.00	0.00	0.00		9,262.37		
2210	SSI DISABLED NON-ME
D	0.00	0.00	571.40	9,435.09	56.41	0.00	250.52	0.00	0.00	3,359.27	5,984.90	0.00		19,657.59		
SUBTOTAL:	0.00	320.62	571.4	0	9,435.09	56.41	0.00	706.23	8,806.66	51.30	3,359.27	5,984.90	0.00		29,291.88		

3716	ADULT <40% EXP MALE	0.00	3,281.32	86.44	7,826.29	0.00	0.00	13,401.61	0.00	0.00	3,941.50	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	607.61	7,223.82	6,224.68	89.59	0.00	6,060.59	451.50	0.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	1,352.02	713.23	0.00	0.00	0.00	0.00	0.00	636.31	25,225.42	0.00	
SUBTOTAL:	0.00	3,281.32	1,438.4	6	9,147.13	7,223.82	6,224.68	13,491.20	0.00	6,060.59	5,029.31	25,225.42	0.00	

28,537.16	
20,657.79	
27,926.98	
77,121.93	

TOTAL:

2,009.86

7,280.23

6,224.68

14,357.91

15,816.59

8,388.58

114,589.49

3,601.94

0.00

32,215.59	0.00

6,111.89

18,582.22

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	696.12	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	309.15	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	160.48	7,009.93	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	160.48	7,009.93	0.00	0.00	1,005.27	0.00	

 
696.12	
309.15	
7,170.41	
8,175.68	

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	30,426.79	659.07	765.06	26.14	0.00	0.00	0.00	0.00	0.00	0.00		35,492.73		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	4,749.68	102.59	3,601.05	38.80	163.24	32.87	0.00		8,688.23		
2210	SSI DISABLED NON-ME
D	0.00	292.71	-3,155.09	3,155.09	0.00	0.00	0.00	0.00	336.66	276.06	0.00	0.00		905.43		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	166.45	0.00	0.00	0.00		166.45		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	4,668.42	2,949.39	1,268.74	1,306.39	4,788.68	-963.82	374.54	11,193.77	0.00		25,586.11		
SUBTOTAL:	0.00	3,908.38	27,271.7	0	8,482.58	3,714.45	6,044.56	1,408.98	8,389.73	-421.91	813.84	11,226.64	0.00		70,838.95		

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	4,749.68	4,749.68	0.00	269.76	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	852.71	0.00	
2620	SSI DISABLED EXPAND
E	20.90	1.70	9.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20.90	1.70	9.2	3	0.00	4,749.68	4,749.68	0.00	269.76	0.00	0.00	852.71	0.00	

 
9,769.12	
852.71	
31.83	
10,653.66	

3706	ADULT <40% EXP MALE	0.00	0.00	0.00	1,326.60	0.00	0.00	82.57	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	523.06	0.00	0.00	0.00	38,940.69	727.67	7.51	4,577.65	165.76	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	827.95	9,658.55	7,201.44	8,735.30	46.71	-1,322.96	19,741.86	1,223.92	10,510.54	14,386.53	32,665.45	0.00	
3717	ADULT <40% EXP FEM AL	76.39	39,245.88	15,890.57	2,786.46	3,600.11	6,784.18	11,816.78	7,917.80	-5,713.39	0.00	4,695.08	0.00	
3718	ADULT <40% EXP M&F
4	5,063.30	31,999.00	15,630.22	2,871.45	193.90	437.61	17,641.15	9.71	1,235.19	3,251.82	0.00	0.00	
SUBTOTAL:	6,490.70	80,903.43	38,722.2	3	15,719.81	42,781.41	6,626.50	49,289.87	13,729.08	6,198.10	17,638.35	37,360.53	0.00	

 
1,409.17	
44,942.34	
103,675.29	
87,099.86	
78,333.35	
315,460.01	

3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	116.13	59.99	90.81	2,121.24	0.00	-1,980.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	116.13	59.99	90.81	2,121.24	0.00	-1,980.00	0.00	0.00	0.00	0.00	

 
408.17

408.17

397,360.79

6,511.60	84,813.51	66,119.29	24,262.38	51,336.35	19,541.98	50,698.85	20,408.57	5,776.19	18,452.19	49,439.88	0.00	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	286.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446.66		
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	286.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,252.82		

3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	3,851.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	569.80	56.41	7,784.06	2,919.33	8,064.01	3,584.63	0.00	0.00	0.00	409.85	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	8,552.62	0.00	4,576.19	0.00	2,749.20	0.00	5,857.10	0.00	
3718	ADULT <40% EXP M&F
4	4,803.59	711.25	529.81	965.97	0.00	6,705.27	619.00	0.00	4,830.57	-407.98	7,588.23	0.00	
SUBTOTAL:	4,803.59	1,281.05	586.2	2	12,601.13	11,471.95	14,769.28	8,779.82	0.00	7,579.77	-407.98	13,855.18	0.00	

 
3,851.10	
23,388.09	
21,735.11	
26,345.71	
75,320.01	

TOTAL:	5,096.33	3,954.78	586.22	12,887.48	11,471.95	14,769.28	8,779.82	0.00	7,579.77	-407.98	13,855.18	0.00		78,572.83		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	20.71	0.00	990.00	-617.46	0.00	82.53	0.00	0.00	0.00		475.78		
SUBTOTAL:	0.00	0.00	0.00	20.71	0.00	990.00	-617.46	0.00	82.53	0.00	0.00	0.00		475.78		

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132.21	0.00	568.40	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132.21	0.00	568.40	0.00	

 
700.61

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	277.25	29,623.49	22.53	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	-3,991.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-3,991.5	9	0.00	0.00	277.25	29,623.49	22.53	0.00	0.00	0.00	0.00	

 
29,923.27	
0.00	
-3,991.59	
25,931.68	

700.61

27,108.07

0.00	0.00	-3,991.59	20.71	0.00	1,267.25	29,006.03	22.53	214.74	0.00	568.40	0.00	

TOTAL:

YUMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	-255.15	-11,786.26	0.00	-256.07	-10,789.86	0.00	0.00	0.00	0.00		-22,981.17		
SUBTOTAL:	106.17	0.00	0.00	-255.15	-11,786.26	0.00	-256.07	-10,789.86	0.00	0.00	0.00	0.00		-22,981.17		

1,002.69

904.25

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	
3718	ADULT <40% EXP M&F
4	0.00	0.00	904.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	379.71	622.98	904.2	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,906.94

TOTAL:	485.88	622.98	904.25	-255.15	-11,786.26	0.00	-256.07	-10,789.86	0.00	0.00	0.00	0.00		-21,074.23		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending May 31, 2019	
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	2,562.00	2,135.00	1,708.00	1,708.00	854.00	0.00	0.00	551.05	1,819.69	0.00		15,607.74		
2100	SSI AGED WITH MEDIC A	2,690,045.71	3,458,961.24	2,914,533.06	3,150,602.77	2,362,436.94	3,199,619.54	3,404,467.58	2,583,307.14	2,769,429.21	2,793,136.62	3,134,915.55	0.00		32,461,455.36		
2110	SSI AGED NON-MEDIC
AR	129,486.77	186,218.80	221,262.13	245,613.41	140,964.94	223,643.86	217,045.49	166,752.07	202,732.96	180,179.24	141,504.60	0.00		2,055,404.27		
2120	SSI AGED WITH QMB	3,501,420.19	4,598,930.92	3,979,774.47	4,563,726.78	3,360,287.65	4,134,006.51	4,716,702.08	3,884,611.40	3,942,978.47	4,094,695.46	4,470,865.02	0.00		45,247,998.95		
2200	SSI DISABLED WITH M E	601,859.98	829,591.68	676,322.41	821,868.37	533,473.79	713,641.91	748,878.93	570,147.24	637,578.96	498,299.08	549,252.87	0.00		7,180,915.22		
2210	SSI DISABLED NON-ME
D	2,935,385.90	4,204,211.39	3,209,724.94	3,869,038.91	2,635,410.78	3,584,957.30	3,435,642.13	3,339,797.19	3,374,105.66	3,410,818.10	4,310,604.66	0.00		38,309,696.96		
2220	SSI DISABLED WITH Q M	849,428.99	1,159,391.83	993,636.64	1,396,711.38	928,534.23	1,169,943.24	1,345,760.45	1,105,849.48	983,573.56	930,210.20	1,124,596.79	0.00		11,987,636.79		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	711.08	1,677.79	2,794.58	2,989.25	1,961.60	781.20	1,295.92	967.20	0.00		13,178.62		
2310	SSI BLIND NON-MEDIC A	5,515.00	17,274.14	4,278.82	7,259.00	3,424.14	4,270.00	11,887.97	7,758.10	13,735.79	12,045.85	11,473.26	0.00		98,922.07		
2320	SSI BLIND WITH QMB	347.83	2,170.03	2,221.48	3,699.66	4,424.96	3,074.82	3,618.30	2,719.29	3,192.34	6,585.95	5,746.41	0.00		37,801.07		
SUBTOTAL:	10,715,625.3	7 14,458,885.03	12,004,315.9	5 14,061,366.36	9,972,343.22	13,037,659.76	13,887,846.18	11,662,903.51	11,928,108.15	11,927,817.47	13,751,746.05	0.00		137,408,617.05		

8720	SSI DISABLED FREEDO M	3,044.16	3,805.20	3,044.16	3,045.12	3,045.07	2,283.12	4,244.76	3,124.80	3,173.37	3,124.80	3,906.00	0.00	
SUBTOTAL:	3,044.16	3,805.20	3,044.16	3,045.12	3,045.07	2,283.12	4,244.76	3,124.80	3,173.37	3,124.80	3,906.00	0.00	

 

35,840.56

35,840.56

137,444,457.61

10,718,669.53	14,462,690.23	12,007,360.11	14,064,411.48	9,975,388.29	13,039,942.88	13,892,090.94	11,666,028.31	11,931,281.52	11,930,942.27	13,755,652.05	0.00	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending May 31, 2019	
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	33,263.71	90,969.20	25,364.75	40,696.91	18,263.10	53,273.00	18,859.85	65,273.60	29,018.94	0.00		502,379.81		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	552.09	280.47	0.00	24,927.37	843.63	1.10	2,296.88	950.20	0.00		29,851.74		
2120	SSI AGED WITH QMB	1,819.81	401.00	0.00	135.97	406.28	113.71	47.67	0.00	0.00	21,091.55	-8,923.70	0.00		15,092.29		
2200	SSI DISABLED WITH M E	5,271.41	4,872.53	7,078.18	6,223.67	-1,467.37	17,662.56	6,973.35	4,010.09	26,929.64	18,943.28	6,043.72	0.00		102,541.06		
2210	SSI DISABLED NON-ME
D	26,125.15	7,930.31	31,145.17	26,531.87	7,219.77	3,082.93	2,311.20	25,706.50	19,506.72	7,857.41	138,197.99	0.00		295,615.02		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.49	218.99	1.85	0.00	0.00		285.33		
SUBTOTAL:	48,459.20	125,357.76	71,487.0	6	124,412.80	31,803.90	61,556.11	52,522.69	83,897.71	65,516.30	115,464.57	165,287.15	0.00		945,765.25		

TOTAL:	48,459.20	125,357.76	71,487.06	124,412.80	31,803.90	61,556.11	52,522.69	83,897.71	65,516.30	115,464.57	165,287.15	0.00		945,765.25		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	2,152.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,142.97		
2220	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	338.90	6,090.00	0.00	0.00	0.00	0.00	0.00	0.00		6,428.90		
SUBTOTAL:	20.58	24,970.13	2,152.26	0.00	338.90	6,090.00	0.00	0.00	0.00	0.00	0.00	0.00		33,571.87		

33,571.87

20.58	24,970.13	2,152.26	0.00	338.90	6,090.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2200	SSI DISABLED WITH M E	0.00	0.00	139.70	0.00	0.00	0.00	0.00	0.00	7.91	0.00	0.00	0.00		147.61		
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	139.70	0.00	0.00	0.00	0.00	0.00	7.91	0.00	0.00	0.00		17,789.00		

TOTAL:	222.75	17,418.64	139.70	0.00	0.00	0.00	0.00	0.00	7.91	0.00	0.00	0.00		17,789.00		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending May 31, 2019	
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	12,395.09	41,346.59	17,168.47	29,982.09	47,580.63	28,059.70	50,297.95	49,252.64	64,900.33	0.00		381,960.45		
1013	TANF 06-13 M & F NON	46,103.20	34,730.24	24,751.72	90,592.95	37,032.79	73,242.64	105,125.40	56,647.51	104,410.44	100,361.64	144,547.39	0.00		817,545.92		
1014	TANF 14-20 MALE NON-	3,875.77	3,846.91	2,456.03	9,172.19	3,094.56	7,647.42	13,968.33	4,194.36	10,077.65	12,049.59	15,355.96	0.00		85,738.77		
1015	TANF 14-20 FEMALE N O	1,059.25	519.23	793.22	3,348.65	1,188.30	2,193.54	5,035.43	3,020.02	4,820.83	4,258.93	6,073.62	0.00		32,311.02		
2200	SSI DISABLED WITH M
E	0.00	12.68	0.00	0.00	0.00	0.00	0.00	0.00	124.30	0.00	67.80	0.00		204.78		
2210	SSI DISABLED NON-ME D	195,372.83	153,569.11	76,322.82	300,111.99	121,315.97	225,578.72	382,041.79	183,461.11	378,926.51	326,501.30	424,852.23	0.00		2,768,054.38		
2220	SSI DISABLED WITH Q
M	40.22	122.62	0.00	59.58	335.53	0.00	565.16	254.99	789.20	629.40	593.84	0.00		3,390.54		
2310	SSI BLIND NON-MEDIC A	2,012.88	532.37	403.65	3,319.90	2,038.64	3,431.11	5,693.32	2,884.04	3,335.52	3,501.36	7,301.81	0.00		34,454.60		
4302	SOBRA CHILD 01-05 M	27.12	0.00	0.00	100.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.48		
4312	SOBRA CHILD 01-05 M	133,360.63	86,061.18	65,223.41	228,298.47	100,685.51	169,905.82	280,850.19	127,232.65	275,345.84	238,475.61	315,188.63	0.00		2,020,627.94		
4313	SOBRA CHILD 06-13 M	158,588.60	93,813.28	86,319.90	373,463.86	159,663.52	249,250.94	441,904.54	202,141.44	387,652.66	345,962.82	488,165.66	0.00		2,986,927.22		
4314	SOBRA CHILD 14-20 MA	10,083.50	9,168.68	6,569.67	27,646.27	7,667.82	15,326.89	36,668.07	16,111.76	31,206.69	30,762.08	35,824.59	0.00		227,036.02		
4315	SOBRA CHILD 14-20 FE	4,583.50	4,492.11	4,409.58	15,157.59	4,440.07	8,388.51	16,249.65	6,532.76	13,693.37	15,559.71	18,653.42	0.00		112,160.27		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.38	0.00	0.00	0.00	0.00		19.38		
SUBTOTAL:	578,910.8	0	404,042.07	279,645.0	9	1,092,618.40	454,631.18	784,947.68	1,335,682.51	630,559.72	1,260,680.96	1,127,315.08	1,521,525.28	0.00		9,470,558.77		

2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.56	70.35	0.00	56.30	0.00	
2610	SSI DISABLED EXPAND
E	0.00	0.00	0.00	7.54	0.00	26.78	22.63	30.20	0.00	0.00	52.85	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95.63	15.94	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	7.54	0.00	26.78	22.63	179.39	86.29	0.00	109.15	0.00	

 
180.21	
140.00	
111.57	
431.78	

3514	ADULT 40-100% MALE 1	9.87	0.00	49.35	46.41	0.00	76.76	8.46	0.00	34.37	85.93	154.67	0.00	
3515	ADULT 40-100% FEMAL E	104.87	276.53	0.00	16.60	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	91.35	98.70	53.96	118.60	651.24	357.46	858.91	571.88	813.29	0.00	
3715	ADULT <40% EXP FEM AL	66.40	33.20	388.72	125.81	130.60	193.38	921.38	619.88	313.89	215.76	501.98	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	244.77	0.00	58.12	0.00	0.00	0.00	
SUBTOTAL:	277.95	848.72	529.4	2	287.52	184.56	388.74	1,825.85	977.34	1,265.29	873.57	1,469.94	0.00	

 
465.82	
398.00	
4,251.19	
3,511.00	
302.89	
8,928.90	

3914	NEWLY ELIGIBLE MALE	24.80	99.24	0.00	95.53	0.00	86.02	124.57	0.00	206.22	285.77	171.85	0.00	
3915	NEWLY ELIGIBLE FEMA L	7.60	69.50	0.00	10.13	0.00	0.00	79.47	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	32.40	168.74	0.0	0	105.66	0.00	86.02	204.04	0.00	206.22	285.77	171.85	0.00	

 
1,094.00	
166.70	
1,260.70	

4413	SOBRA 100-133% M&F
6	30,197.25	21,259.92	20,394.29	98,047.66	39,280.31	72,276.62	115,895.20	54,471.11	102,463.22	99,642.38	155,381.44	0.00	
4414	SOBRA 100-133% MALE	1,739.45	2,316.23	1,163.30	7,651.98	2,485.39	5,559.83	8,310.46	2,550.99	6,423.48	4,897.38	10,961.99	0.00	
4415	SOBRA 100-133% FEMA L	986.47	893.98	628.09	2,502.40	1,015.17	1,026.15	4,477.50	738.07	4,034.54	3,248.46	3,580.48	0.00	
SUBTOTAL:	32,923.17	24,470.13	22,185.6	8	108,202.04	42,780.87	78,862.60	128,683.16	57,760.17	112,921.24	107,788.22	169,923.91	0.00	

 
809,309.40	
54,060.48	
23,131.31	
886,501.19	

10,367,681.34

612,144.32	429,529.66	302,360.19	1,201,221.16	497,596.61	864,311.82	1,466,418.19	689,476.62	1,375,160.00	1,236,262.64	1,693,200.13	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	60.95	60.93	106.53	196.13	21.73	12.68	0.00	0.00	0.00	235.32	0.00	0.00		694.27		
1010	TANF NON-MEDICARE	40,228.81	25,108.17	12,432.53	38,981.25	18,177.90	25,438.81	33,117.24	17,218.93	25,091.15	27,048.82	22,008.47	0.00		284,852.08		
2200	SSI DISABLED WITH M E	2,528.24	4,052.15	2,023.52	3,803.47	1,448.77	1,175.74	1,977.23	852.52	2,079.14	1,936.44	3,476.56	0.00		25,353.78		
2210	SSI DISABLED NON-ME
D	1,187,559.37	898,408.95	471,844.40	1,813,501.52	768,924.17	1,421,914.31	2,088,874.27	973,404.54	2,062,474.97	1,850,652.03	2,568,526.21	0.00		16,106,084.74		
2220	SSI DISABLED WITH Q M	4,979.23	6,006.07	2,315.22	4,997.67	3,089.60	5,271.55	3,996.68	989.68	3,427.03	3,754.91	4,902.50	0.00		43,730.14		
2310	SSI BLIND NON-MEDIC
A	4,955.34	4,870.57	5,332.94	6,325.26	3,774.26	4,550.25	6,126.05	3,013.65	3,733.21	6,774.82	3,080.01	0.00		52,536.36		
SUBTOTAL:	1,240,311.94	938,506.84	494,055.1	4	1,867,805.30	795,436.43	1,458,363.34	2,134,091.47	995,479.32	2,096,805.50	1,890,402.34	2,601,993.75	0.00		16,513,251.37		

TOTAL:	1,240,311.94	938,506.84	494,055.14	1,867,805.30	795,436.43	1,458,363.34	2,134,091.47	995,479.32	2,096,805.50	1,890,402.34	2,601,993.75	0.00		16,513,251.37		

ACC REINSURANCE
For The Period Ending May 31, 2019	
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	2,673.98	0.00	0.00	0.00	0.00		2,675.43		
1007	TANF 21-44 FEMALE WI	1,965.89	0.00	0.00	0.00	301.76	0.00	1,335.68	0.00	0.00	0.00	6,308.05	0.00		9,911.38		
1008	TANF 45-64 M & F WIT	-32,709.37	0.00	0.00	0.00	-1,472.37	5,015.09	3,158.14	1,064.16	0.00	34,949.03	0.00	0.00		10,004.68		
1011	TANF <1 M & F NON-ME	1,367,464.17	672,730.48	718,397.96	870,616.01	730,370.07	1,082,679.11	81,882.03	397,506.91	259,300.82	382,080.67	666,337.73	0.00		7,229,365.96		
1012	TANF 01-05 M & F NON	220,883.34	62,299.02	108,013.54	105,982.59	72,464.14	39,718.86	36,317.11	1,143.77	6,309.97	86.77	24,171.17	0.00		677,390.28		
1013	TANF 06-13 M & F NON	541,569.53	146,433.41	109,494.32	179,950.39	181,066.61	144,812.82	77,790.33	82,439.64	191,662.77	149,492.44	230,223.16	0.00		2,034,935.42		
1014	TANF 14-20 MALE NON-	8,935.26	150,685.74	12,184.43	14,487.01	34,588.93	157,960.86	6,010.36	6,264.47	159,308.15	140,629.62	98,075.28	0.00		789,130.11		
1015	TANF 14-20 FEMALE N O	43,754.39	49,414.65	145,845.98	6,736.37	13,209.27	91.35	6,685.96	149,208.49	6,077.44	15,821.30	3,818.39	0.00		440,663.59		
1016	TANF 21-44 MALE NON-	314,141.01	335,519.65	346,256.95	395,261.35	91,624.23	261,036.41	167,288.59	129,448.07	347,168.49	127,879.88	175,113.42	0.00		2,690,738.05		
1017	TANF 21-44 FEMALE N O	65,459.28	733,363.15	588,635.74	483,230.38	515,833.63	171,868.41	408,738.52	393,823.39	405,343.25	41,571.66	509,281.37	0.00		4,317,148.78		
1018	TANF 45-64 M & F NON	257,482.04	736,288.66	444,314.97	356,028.71	365,841.36	353,051.43	225,316.13	309,656.52	176,391.70	159,051.72	318,878.35	0.00		3,702,301.59		
1019	TANF 65+ M & F NON-M	736.61	0.00	996.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,732.90		
2100	SSI AGED WITH MEDIC A	-51,204.98	13,404.29	6,612.88	32,905.39	67,057.46	51,521.36	-4,139.15	113,602.17	47,835.16	29,126.74	33,290.18	0.00		340,011.50		
2110	SSI AGED NON-MEDIC
AR	136,832.77	177,312.00	100,721.62	139,696.09	197,232.99	149,697.90	46,119.76	27,860.50	71,261.25	25,367.70	93,384.44	0.00		1,165,487.02		
2200	SSI DISABLED WITH M E	165,164.34	39,836.87	52,223.28	85,931.35	48,204.86	21,899.40	64,304.44	107,209.82	21,916.66	19,753.74	25,245.45	0.00		651,690.21		
2210	SSI DISABLED NON-ME
D	6,629,461.86	6,463,509.76	5,345,126.01	6,894,975.05	7,546,487.78	7,071,819.76	2,559,234.85	3,905,246.28	5,343,918.23	4,185,359.99	3,735,379.54	0.00		59,680,519.11		
2310	SSI BLIND NON-MEDIC A	6,373.16	5.07	2,770.38	28,531.59	4,827.35	48,040.69	0.00	97,724.90	1,399.37	24,302.86	35,351.65	0.00		249,327.02		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	104,905.82	0.00	0.00	0.00	356.80	0.00	0.00	0.00		105,262.62		
4311	SOBRA CHILD <1 M & F	2,433,634.85	1,173,216.11	1,865,721.96	3,731,240.10	2,265,108.65	1,895,372.94	1,157,951.50	1,973,680.33	1,180,037.93	864,390.98	1,360,224.33	0.00		19,900,579.68		
4312	SOBRA CHILD 01-05 M	2,169,529.06	574,786.64	3,121,634.76	833,750.86	690,377.23	2,597,638.57	264,362.52	398,341.27	1,465,758.07	761,173.74	719,103.12	0.00		13,596,455.84		
4313	SOBRA CHILD 06-13 M	894,827.48	845,658.59	72,619.54	1,267,725.21	615,836.16	458,273.06	549,407.90	708,870.91	655,702.79	912,880.25	1,095,610.67	0.00		8,077,412.56		
4314	SOBRA CHILD 14-20 MA	364,934.32	508,718.51	216,339.32	768,304.68	309,336.84	704,817.87	314,443.33	310,254.59	485,688.24	607,512.11	572,460.29	0.00		5,162,810.10		
4315	SOBRA CHILD 14-20 FE	334,736.84	203,009.55	367,253.53	505,883.75	109,176.92	3,167,700.12	235,683.63	90,175.72	220,145.02	363,913.53	371,428.30	0.00		5,969,106.91		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	4,570.91	4,385.49	6,460.86	0.00	0.00	0.00	0.00	0.00	10,645.56	0.00		26,062.82		
5017	SOBRA PREG 21-44 FE
M	25,593.87	30,906.10	22,239.23	47,640.87	25,802.87	77,000.22	310,024.85	26,570.41	55,228.58	7,701.47	45,400.33	0.00		674,108.80		
SUBTOTAL:	15,899,565.7	2 12,917,099.70	13,651,973.6	0 16,753,263.24	13,994,643.42	18,460,016.23	6,511,916.48	9,232,766.30	11,100,810.69	8,853,046.20	10,129,730.78	0.00		137,504,832.36		

7,023.06

7,023.06

-26,819.24	28,546.56	21.53	627.30	0.00	0.00	0.00	0.00	0.00	4,646.91	0.00	0.0	
-26,819.24	28,546.56	21.53	627.30	0.00	0.00	0.00	0.00	0.00	4,646.91	0.00	0.00	

3100	TRANSPLANT OPTION	0
1
SUBTOTAL:

1106	TANF EXPANDED 21-44	26,859.21	-459.75	0.00	136,696.84	464.26	871.56	35,367.35	-7,931.49	0.00	0.00	49.01	0.00	
1108	TANF EXPANDED 45-64	-31,095.43	0.00	988.19	0.00	2,445.46	0.00	12,582.89	-1.95	30,974.99	957.30	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	68,468.96	7,313.55	5,016.93	0.00	2,149.52	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	422,095.71	17,575.28	132,906.26	-23,723.26	481,867.56	160,351.12	352,348.35	101,524.60	175,793.73	19,347.33	78,456.33	0.00	
1117	TANF EXPANDED 21-44	186,242.11	148,722.48	95,152.24	161,574.52	472,342.68	445,244.49	185,834.43	115,576.70	231,088.65	167,939.75	77,565.12	0.00	
1118	TANF EXPANDED 45-64	187,595.93	486,367.80	182,949.00	42,232.93	325,215.56	153,097.76	102,219.10	-23,212.80	-80,054.07	210,852.84	20,601.39	0.00	
1119	TANF EXPANDED 65+
M&	7,539.14	25,923.98	5,366.16	3,818.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

191,916.99	
16,851.45	
82,948.96	
1,918,543.01	
2,287,283.17	
1,607,865.44	
42,647.84	

ACC REINSURANCE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED WI	24.58	12.93	0.00	4,619.53	4,648.60	187.71	14,262.14	7,135.25	7,096.90	62.44	15,704.28	0.00		53,754.36		
2410	SSI AGED EXPANDED
NO	15,709.73	1,485.73	0.00	0.00	4,109.68	74.37	0.00	2,911.77	0.00	0.00	0.00	0.00		24,291.28		
2600	SSI DISABLED EXPAND E	362.04	108.25	93.01	51,531.97	2,114.82	1.08	-15,651.36	61.80	257.33	107.94	3,529.07	0.00		42,515.95		
2610	SSI DISABLED EXPAND
E	129,876.21	65,714.58	87,224.81	152,498.90	58,845.62	51,767.16	12,178.80	432,823.30	92,061.03	103,892.70	65,597.63	0.00		1,252,480.74		
SUBTOTAL:	945,209.2	3	745,451.28	573,148.6	3	536,563.54	1,357,071.17	811,595.25	701,291.22	628,887.18	457,218.56	503,160.30	261,502.83	0.00		7,521,099.19		

3906	NEWLY ELIGIBLE MALE	1,009.14	536.76	302.26	-2,193.61	2,786.98	125.52	0.00	0.00	0.00	0.00	48,304.97	0.00	
3908	NEWLY ELIGIBLE M&F 4	431.66	2,027.77	1,211.88	-33.88	-639.05	552.07	0.00	8,065.14	3,587.50	0.00	-3,587.50	0.00	
3914	NEWLY ELIGIBLE MALE	64,834.53	0.00	9,000.41	0.00	-572.06	0.00	0.00	0.00	0.00	6,780.58	18,214.06	0.00	
3915	NEWLY ELIGIBLE FEMA L	7,280.14	0.00	11,724.53	26,405.16	2,885.30	11,724.53	14,936.16	11,724.53	0.00	0.00	34,764.40	0.00	
3916	NEWLY ELIGIBLE MALE	138,451.69	102,807.47	436,589.72	382,434.28	237,231.22	195,410.36	44,559.06	158,276.71	160,272.49	184,699.92	90,269.66	0.00	
3917	NEWLY ELIGIBLE FEMA L	20,458.27	42,880.51	-22,729.64	67,569.97	57,058.76	84,996.41	44,373.32	3,435.66	56,381.37	47,450.43	32,749.93	0.00	
3918	NEWLY ELIGIBLE M&F
4	302,713.09	656,619.04	308,786.98	919,982.44	534,754.01	712,022.84	310,080.06	568,968.39	397,691.11	452,088.83	585,553.91	0.00	
SUBTOTAL:	535,178.5	2	804,871.55	744,886.1	4	1,394,164.36	833,505.16	1,004,831.73	413,948.60	750,470.43	617,932.47	691,019.76	806,269.43	0.00	

50,872.02	
11,615.59	
98,257.52	
121,444.75	
2,131,002.58	
434,624.99	
5,749,260.70	
8,597,078.15	

4413	SOBRA 100-133% M&F
6	399,630.02	68,444.29	107,753.73	189,823.15	147,661.72	6,778.59	47,724.97	101,957.80	175,229.05	47,009.60	116,238.41	0.00	
4414	SOBRA 100-133% MALE	192,612.37	48,239.21	121,271.35	623,716.81	138,700.98	182,290.50	81,503.05	191,092.64	101,978.39	274,726.88	99,124.67	0.00	
4415	SOBRA 100-133% FEMA L	45,366.29	36,682.43	23,384.22	1,033.48	0.00	11,456.96	29,274.17	5,297.27	155,251.31	68,543.39	35,396.22	0.00	
SUBTOTAL:	637,608.6	8	153,365.93	252,409.3	0	814,573.44	286,362.70	200,526.05	158,502.19	298,347.71	432,458.75	390,279.87	250,759.30	0.00	

1,408,251.33	
2,055,256.85	
411,685.74	
3,875,193.92	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,157.31	-7.84	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	43,083.20	0.00	6,019.42	-4,013.16	-9,581.32	-3,459.81	279,109.82	0.00	
3514	ADULT 40-100% MALE 1	70,821.21	35,931.68	489.32	74,763.91	7,410.33	4,340.08	586.86	107.55	222,793.56	2,354,978.26	139,145.27	0.00	
3515	ADULT 40-100% FEMAL E	1,443.66	8,839.06	122.57	0.00	6,369.82	0.00	101.67	375.11	0.00	3,212.67	0.00	0.00	
3516	ADULT 40-100% MALE 2	138,432.26	232,727.22	184,230.77	337,550.41	480,623.68	322,268.56	66,022.68	231,642.98	14,030.65	664,332.78	104,414.16	0.00	
3517	ADULT 40-100% FEMAL E	295,157.21	138,044.63	54,292.03	45,183.25	186,454.61	92,841.21	35,023.31	68,642.03	44,904.89	28,074.64	113,070.28	0.00	
3518	ADULT 40-100% M&F 45	735,462.12	559,454.79	870,456.70	831,078.30	699,012.70	581,606.15	257,794.55	260,289.35	298,160.02	565,987.39	105,147.25	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	10,511.89	-10,511.89	0.00	0.00	0.00	7,873.55	10,626.14	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	9,369.07	0.00	-544.73	0.00	0.00	-8,824.34	0.00	14,798.56	0.00	
3708	ADULT <40% EXP M&F
4	-1,751.04	6,701.45	0.00	6,767.57	-2,882.94	1,200.08	2,764.63	0.00	6,537.23	10,219.67	846.19	0.00	
3714	ADULT <40% EXP MALE	114,945.66	66,170.18	131,433.62	195,058.03	138,490.54	85,621.10	76,106.30	80,877.06	28,169.14	198,679.81	75,888.87	0.00	
3715	ADULT <40% EXP FEM AL	131,460.17	23,362.93	23,086.91	107,749.15	20,832.77	21,200.17	55,334.68	19,257.57	55,974.28	295.93	75,651.18	0.00	
3716	ADULT <40% EXP MALE	1,626,527.25	955,278.18	1,337,885.56	1,884,651.10	1,395,361.44	1,575,831.05	1,464,467.20	469,218.78	1,427,692.59	630,815.22	1,258,636.42	0.00	
3717	ADULT <40% EXP FEM AL	312,636.20	618,946.44	488,124.86	391,995.53	600,026.58	442,479.50	1,089,218.64	127,465.70	276,766.74	46,746.33	438,588.24	0.00	
3718	ADULT <40% EXP M&F
4	1,914,993.91	1,894,005.26	2,429,243.06	3,119,723.41	2,622,241.32	2,509,100.89	1,592,571.42	1,903,845.04	1,248,099.48	1,300,651.50	2,363,598.93	0.00	
3719	ADULT <40% EXP M&F 6	0.00	1,630.30	97.77	1,101.95	5.21	0.00	0.00	0.00	0.00	-104.06	104.06	0.00	
SUBTOTAL:	5,340,128.61	4,541,092.12	5,529,975.0	6,994,479.79	6,197,029.26	5,635,944.06	4,646,011.36	3,165,581.56	3,635,506.37	5,800,422.49	4,968,999.23	0.00	

 
20,149.47	
311,158.15	
2,911,368.03	
20,464.56	
2,776,276.15	
1,101,688.09	
5,764,449.32	
18,499.69	
14,798.56	
30,402.84	
1,191,440.31	
534,205.74	
14,026,364.79	
4,832,994.76	
22,898,074.22	
2,835.23	
56,455,169.91	

ACC REINSURANCE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	14,048.49	0.00	0.00	0.00	0.00	0.00	0.00		14,048.49		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	14,048.49	0.00	0.00	0.00	0.00	0.00	0.00		14,048.49		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	8.58	0.19	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	25,577.76	19,070.96	10,727.20	0.00	296.84	8.02	9,569.67	13,930.25	0.00	0.00	4,905.16	0.00	
SUBTOTAL:	25,577.76	19,070.96	10,727.2	0	0.00	305.42	8.21	9,569.67	13,930.25	0.00	0.00	4,905.16	0.00	

 
8.77

84,085.86

84,094.63

214,058,539.71

20,763,141.46	26,493,671.67	22,668,917.13	26,126,970.02	12,441,239.52	14,089,983.43	16,243,926.84	16,242,575.53	16,422,166.73	0.00	

TOTAL:

23,356,449.28

19,209,498.10

LONG TERM CARE REINSURANCE
For The Period Ending May 31, 2019	
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	214.27	24,230.62	59,133.53	85,278.79	50,505.03	1,410.33	3,929.19	-70,749.54	17,668.37	0.00		178,364.35		
2100	SSI AGED WITH MEDIC A	323,595.92	208,487.95	370,010.59	321,124.73	424,912.88	284,542.26	229,904.89	206,470.59	184,106.13	102,813.90	144,889.80	0.00		2,800,859.64		
2110	SSI AGED NON-MEDIC
AR	53,483.73	112,426.40	117,399.08	107,355.52	107,095.29	133,668.14	46,541.93	55,018.32	24,458.25	11,785.31	14,761.36	0.00		783,993.33		
2200	SSI DISABLED WITH M E	750,334.85	433,812.75	701,049.32	625,252.64	530,106.32	427,882.54	427,125.58	480,064.45	482,022.61	309,554.37	383,612.74	0.00		5,550,818.17		
2210	SSI DISABLED NON-ME
D	4,294,544.57	2,622,802.37	5,044,776.62	5,197,282.76	5,482,438.22	4,278,766.96	3,382,652.77	4,251,475.62	2,584,227.35	1,301,314.70	3,311,841.55	0.00		41,752,123.49		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,478.53	0.00	-673.46	-3,776.17	0.00		15,028.90		
2310	SSI BLIND NON-MEDIC A	23,280.32	31,872.58	18,489.94	-3,353.08	4,112.35	1,744.09	0.00	-8,848.19	18,789.26	0.00	0.00	0.00		86,087.27		
SUBTOTAL:	5,446,434.00	3,414,951.20	6,251,939.8	2	6,271,893.19	6,607,798.59	5,211,882.78	4,136,730.20	5,005,069.65	3,297,532.79	1,654,045.28	3,868,997.65	0.00		51,167,275.15		

8710	SSI DISABLED FREEDO M	39.30	62.14	62.14	0.00	0.00	0.00	8,580.72	0.00	0.00	0.00	-14.09	0.00	
SUBTOTAL:	39.30	62.14	62.14	0.00	0.00	0.00	8,580.72	0.00	0.00	0.00	-14.09	0.00	

 
8,730.21

8,730.21

TOTAL:	5,446,473.30	3,415,013.34	6,252,001.96	6,271,893.19	6,607,798.59	5,211,882.78	4,145,310.92	5,005,069.65	3,297,532.79	1,654,045.28	3,868,983.56	0.00		51,176,005.36		

ACC SMIB
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-271.00	0.00	0.00		-271.00		
1000	TANF WITH MEDICARE	55,736.00	51,850.00	53,182.00	60,418.00	55,594.00	58,006.00	55,365.50	55,894.00	56,967.50	53,099.50	55,291.60	0.00		611,404.10		
1010	TANF NON-MEDICARE	938.00	1,072.00	1,072.00	1,072.00	938.00	938.00	948.50	948.50	813.00	677.50	677.50	0.00		10,095.00		
1020	TANF WITH QMB	47,404.00	53,340.20	49,296.00	49,966.00	49,840.00	52,788.00	51,182.50	49,848.50	46,747.50	48,762.00	42,412.50	0.00		541,587.20		
2100	SSI AGED WITH MEDIC A	45,901.50	43,140.00	40,115.00	40,476.00	37,756.00	43,140.00	37,471.00	37,877.50	37,888.00	31,273.00	34,165.80	0.00		429,203.80		
2110	SSI AGED NON-MEDIC
AR	519,350.00	541,431.60	526,378.00	535,097.40	535,645.20	528,720.30	541,143.50	547,470.00	544,405.90	585,501.40	552,698.00	0.00		5,957,841.30		
2120	SSI AGED WITH QMB	4,138,319.10	4,157,505.40	4,189,963.00	4,214,540.30	4,238,881.60	4,239,572.80	4,310,114.90	4,332,688.00	4,326,648.90	4,363,238.60	4,358,233.30	0.00		46,869,705.90		
2200	SSI DISABLED WITH M E	81,776.80	79,942.20	82,028.70	118,505.10	89,244.00	79,730.00	78,980.10	82,217.00	81,365.00	79,017.50	77,724.10	0.00		930,530.50		
2210	SSI DISABLED NON-ME
D	447,158.00	453,992.00	452,786.00	453,054.00	461,703.00	450,916.30	461,688.00	464,337.50	456,353.50	467,829.00	454,352.50	0.00		5,024,169.80		
2220	SSI DISABLED WITH Q M	3,939,195.80	3,948,725.20	3,917,971.20	3,935,717.90	3,945,162.00	3,910,548.90	3,958,040.20	3,943,751.00	3,961,578.60	3,921,107.40	3,908,084.10	0.00		43,289,882.30		
2300	SSI BLIND WITH MEDIC	268.00	268.00	268.00	268.00	402.00	268.00	271.00	406.50	269.50	135.50	271.00	0.00		3,095.50		
2310	SSI BLIND NON-MEDIC A	3,886.00	4,020.00	4,020.00	4,154.00	5,360.00	4,422.00	4,473.00	4,336.00	3,797.00	2,184.50	3,795.50	0.00		44,448.00		
2320	SSI BLIND WITH QMB	35,778.00	35,644.00	35,644.00	39,176.60	34,706.00	36,314.00	40,624.70	36,990.00	35,501.00	36,585.00	36,848.50	0.00		403,811.80		
4320	SOBRA CHILD WITH Q MB	670.00	402.00	268.00	268.00	268.00	-402.00	271.00	271.00	271.00	271.00	271.00	0.00		2,829.00		
5000	SOBRA PREGNANT WO
MAN	0.00	0.00	0.00	670.00	134.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00		938.00		
5020	SOBRA PREGNANT WO MAN	6,566.00	7,236.00	6,030.00	5,896.00	5,628.00	6,432.00	6,222.50	5,281.50	4,879.50	4,878.00	4,065.00	0.00		63,114.50		
8000	SMIB ONLY NOT ELIGIB	-268.00	0.00	-804.00	-268.00	0.00	-134.00	0.00	0.00	0.00	-271.00	-271.00	0.00		-2,016.00		
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	898,448.90	883,012.20	879,097.70	870,507.20	893,114.00	869,969.00	819,999.60	801,826.70	806,073.60	0.00		9,536,152.30		
8040	SLMB	5,318,204.60	5,374,555.30	5,383,453.20	5,411,315.50	5,436,165.30	5,428,074.30	5,382,649.70	5,319,981.20	5,379,755.10	5,420,091.80	5,358,973.00	0.00		59,213,219.00		
8888	SMIB ONLY NOT ELIGIB	-57,211.50	-38,551.50	-37,139.50	-44,774.00	-31,615.00	-21,235.00	-26,886.70	-18,080.20	-53,770.70	-25,574.00	2,867.80	0.00		-351,970.30		
9999	SMIB ONLY NOT ELIGIB	133,242.60	150,028.40	148,922.60	90,111.90	182,877.30	81,504.70	141,396.20	125,113.90	94,880.00	75,980.80	192,019.70	0.00		1,416,078.10		
SUBTOTAL:	15,635,026.6	0 15,760,324.50	15,751,903.1	0 15,798,676.90	15,927,787.10	15,770,245.50	15,937,069.60	15,859,300.90	15,798,349.90	15,866,343.20	15,888,553.50	0.00		173,993,580.80		

268.00

3520	ADULT 40-100% FOR FI	402.00	134.00	268.00	0.00	0.00	0.00	0.00	0.00	0.00	271.00	135.50	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	268.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,210.50

1100	TANF EXPANDED FPR FI	219,940.40	208,614.00	212,232.00	219,339.50	211,099.50	210,831.50	212,281.00	213,237.00	204,661.50	205,345.00	203,890.50	0.00	
1110	TANF EXPANDED FOR
FI	670.00	670.00	670.00	804.00	536.00	536.00	1,075.00	271.00	406.50	406.50	406.50	0.00	
1120	TANF EXPANDED FOR FI	875,874.70	885,677.20	893,161.10	897,109.20	887,497.70	885,093.70	901,120.90	902,776.30	915,408.60	918,147.10	906,739.20	0.00	
2400	SSI AGED EXPANDED
WI	22,891.00	16,590.00	16,596.00	15,119.00	11,926.00	15,142.00	12,053.50	11,512.80	12,717.50	13,131.50	13,251.00	0.00	
2410	SSI AGED EXPANDED NO	1,474.00	536.00	670.00	670.00	402.00	402.00	406.50	135.50	135.50	135.50	0.00	0.00	
2420	SSI AGED EXPANDED
WI	3,349,234.70	3,378,807.00	3,400,715.20	3,399,385.40	3,440,475.30	3,441,436.30	3,486,712.20	3,532,328.60	3,531,770.00	3,577,586.50	3,596,949.40	0.00	
2520	SSI BLIND EXPANDED W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	135.50	135.50	135.50	0.00	
2600	SSI DISABLED EXPAND
E	18,492.00	14,606.00	12,730.00	16,214.00	18,760.00	18,760.00	15,826.50	13,003.50	14,485.00	12,994.50	11,237.50	0.00	
2620	SSI DISABLED EXPAND E	2,308,687.10	2,299,428.10	2,332,466.30	2,320,163.00	2,334,479.50	2,319,719.50	2,327,883.90	2,361,495.60	2,366,214.50	2,368,148.40	2,338,800.20	0.00	
SUBTOTAL:	6,797,263.90	6,804,928.30	6,869,240.6	0	6,868,804.10	6,905,176.00	6,891,921.00	6,957,359.50	7,034,760.30	7,045,934.60	7,096,030.50	7,071,409.80	0.00	

 
2,321,471.90	
6,451.50	
9,868,605.70	
160,930.30	
4,967.00	
38,135,400.60	
406.50	
167,109.00	
25,677,486.10	
76,342,828.60	

ACC SMIB
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3720	AHC CARE EXPANDED FO	268.00	268.00	134.00	0.00	0.00	536.00	134.00	268.00	0.00	0.00	134.00	0.00		1,742.00		
SUBTOTAL:	670.00	402.00	402.00	268.00	0.00	536.00	134.00	268.00	0.00	271.00	269.50	0.00		3,220.50		

3920	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	271.00	134.00	677.50	271.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	271.00	134.00	677.50	271.00	0.00	

 
1,353.50

8620	SSI BLIND FREEDOM/W O	0.00	134.00	134.00	134.00	134.00	134.00	135.50	135.50	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	35,242.00	35,376.00	37,252.00	39,664.00	39,664.00	39,664.00	41,591.00	41,445.50	40,506.50	41,590.50	44,707.00	0.00	
SUBTOTAL:	35,242.00	35,510.00	37,386.0	0	39,798.00	39,798.00	39,932.00	41,726.50	41,581.00	40,506.50	41,590.50	44,707.00	0.00	

 
941.00	
134.00	
436,702.50	
437,777.50	

1,353.50

250,778,760.90

22,468,202.50	22,601,164.80	22,658,931.70	22,707,547.00	22,872,761.10	22,702,634.50	22,936,289.60	22,936,181.20	22,884,925.00	23,004,912.70	23,005,210.80	0.00	

TOTAL:

ACC HIB
For The Period Ending May 31, 2019	
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	437.00	0.00	0.00		437.00		
1020	TANF WITH QMB	0.00	0.00	844.00	422.00	422.00	844.00	874.00	437.00	437.00	1,748.00	437.00	0.00		6,465.00		
2100	SSI AGED WITH MEDIC A	1,688.00	844.00	0.00	654.00	190.00	422.00	0.00	-437.00	437.00	7,225.00	677.00	0.00		11,700.00		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	0.00	0.00	0.00	859.00	0.00	0.00	1,748.00	-437.00	0.00		2,170.00		
2120	SSI AGED WITH QMB	462,515.60	483,493.60	486,841.80	501,404.40	491,126.40	492,402.00	510,822.10	514,204.10	516,750.10	525,077.90	514,513.40	0.00		5,499,151.40		
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		
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	-240.00	0.00		-240.00		
2220	SSI DISABLED WITH Q M	195,874.60	202,605.40	204,018.80	211,821.80	213,708.60	222,992.60	221,192.80	221,487.20	230,675.20	240,697.20	236,767.50	0.00		2,401,841.70		
2320	SSI BLIND WITH QMB	1,118.20	1,118.20	1,118.20	2,384.20	1,540.20	1,962.20	1,594.70	1,594.70	1,594.70	1,114.00	1,114.00	0.00		16,253.30		
8020	QMB ONLY	6,414.20	5,232.60	5,464.60	5,042.60	5,232.60	4,810.60	6,262.10	4,456.70	5,330.70	10,858.70	2,905.70	0.00		62,011.10		
9999	SMIB ONLY NOT ELIGIB	-5,617.70	-2,318.80	-2,871.60	-4,832.00	-1,498.00	-2,194.20	-11,508.50	-3,770.00	-10,093.40	-9,856.50	-2,641.40	0.00		-57,202.10		
SUBTOTAL:	661,992.9	0	690,553.00	695,415.8	0	716,897.00	710,721.80	721,239.20	730,096.20	737,972.70	745,131.30	779,049.30	753,096.20	0.00		7,942,165.40		

1120	TANF EXPANDED FOR FI	2,426.00	1,118.00	2,806.00	1,308.00	1,118.00	886.00	-19.00	677.00	677.00	240.00	480.00	0.00	
2420	SSI AGED EXPANDED
WI	3,924.40	3,924.40	3,924.40	3,924.40	3,924.40	4,768.40	4,260.40	5,556.40	4,260.40	4,260.40	4,260.40	0.00	
SUBTOTAL:	6,350.40	5,042.40	6,730.4	0	5,232.40	5,042.40	5,654.40	4,241.40	6,233.40	4,937.40	4,500.40	4,740.40	0.00	

 
11,717.00	
46,988.40	
58,705.40	

TOTAL:	668,343.30	695,595.40	702,146.20	722,129.40	715,764.20	726,893.60	734,337.60	744,206.10	750,068.70	783,549.70	757,836.60	0.00		8,000,870.80		

Q1
For The Period Ending May 31, 2019	
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	2,700,556.70	2,718,528.20	2,732,253.70	2,780,966.70	2,630,392.50	2,762,366.10	2,771,507.20	2,877,652.00	2,892,509.80	0.00		30,111,728.00		
9999	SMIB ONLY NOT ELIGIB	-7,950.50	-5,230.50	-8,373.00	-7,030.00	-1,616.00	-6,569.00	250,720.40	225,792.30	-438,429.00	-11,653.00	-412.50	0.00		-10,750.80		
SUBTOTAL:	2,598,480.10	2,633,334.00	2,692,183.7	0	2,711,498.20	2,730,637.70	2,774,397.70	2,881,112.90	2,988,158.40	2,333,078.20	2,865,999.00	2,892,097.30	0.00		30,100,977.20		

30,100,977.20

2,598,480.10	2,633,334.00	2,692,183.70	2,711,498.20	2,730,637.70	2,774,397.70	2,881,112.90	2,988,158.40	2,333,078.20	2,865,999.00	2,892,097.30	0.00	

TOTAL:

LTC SMIB
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	804.00	670.00	1,608.00	536.00	536.00	536.00	406.50	406.50	406.50	271.00	271.00	0.00		6,451.50		
1020	TANF WITH QMB	670.00	670.00	536.00	536.00	536.00	536.00	406.50	406.50	406.50	271.00	271.00	0.00		5,245.50		
2100	SSI AGED WITH MEDIC A	1,096,576.60	1,089,558.60	1,106,001.60	1,120,517.10	1,122,148.60	1,132,486.60	1,124,450.40	1,156,427.80	1,152,767.60	1,167,091.60	1,150,103.10	0.00		12,418,129.60		
2110	SSI AGED NON-MEDIC
AR	209,710.00	212,658.00	212,524.00	214,132.00	213,596.00	213,060.00	215,309.50	215,171.00	209,525.80	217,161.30	218,966.50	0.00		2,351,814.10		
2120	SSI AGED WITH QMB	1,074,969.00	1,094,220.00	1,116,944.00	1,128,578.00	1,142,906.00	1,148,839.00	1,160,889.50	1,174,039.80	1,200,730.70	1,202,871.00	1,232,894.70	0.00		12,677,881.70		
2200	SSI DISABLED WITH M E	420,258.00	408,716.00	404,554.00	409,578.00	399,426.00	405,992.00	402,849.50	412,216.00	398,027.00	397,418.20	394,227.00	0.00		4,453,261.70		
2210	SSI DISABLED NON-ME
D	17,688.00	17,420.00	15,678.00	14,874.00	17,286.00	17,286.00	19,367.50	22,470.50	16,802.00	18,020.00	12,326.00	0.00		189,218.00		
2220	SSI DISABLED WITH Q M	969,891.50	976,143.50	996,620.30	993,805.50	994,095.40	1,009,577.00	1,039,891.70	1,049,056.60	1,039,761.50	1,048,942.50	1,039,686.90	0.00		11,157,472.40		
2300	SSI BLIND WITH MEDIC	1,608.00	1,474.00	1,340.00	1,206.00	804.00	938.00	677.50	271.00	947.00	406.50	271.00	0.00		9,943.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	268.00	406.50	406.50	271.00	406.50	271.00	0.00		2,029.50		
2320	SSI BLIND WITH QMB	4,548.00	2,948.00	2,546.00	2,278.00	2,412.00	2,278.00	2,303.50	2,303.50	1,897.00	2,168.00	1,761.50	0.00		27,443.50		
SUBTOTAL:	3,796,723.10	3,804,478.10	3,858,351.9	0	3,886,040.60	3,893,746.00	3,931,796.60	3,966,958.60	4,033,175.70	4,021,542.60	4,055,027.60	4,051,049.70	0.00		43,298,890.50		

9,974.50

8720	SSI DISABLED FREEDO M	670.00	670.00	670.00	938.00	804.00	938.00	948.50	1,084.00	1,084.00	1,084.00	1,084.00	0.00	
SUBTOTAL:	670.00	670.00	670.00	938.00	804.00	938.00	948.50	1,084.00	1,084.00	1,084.00	1,084.00	0.00	

 
9,974.50

TOTAL:	3,797,393.10	3,805,148.10	3,859,021.90	3,886,978.60	3,894,550.00	3,932,734.60	3,967,907.10	4,034,259.70	4,022,626.60	4,056,111.60	4,052,133.70	0.00		43,308,865.00		

LTC HIB
For The Period Ending May 31, 2019	
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	422.00	886.00	-232.00	-422.00	0.00	0.00	0.00	874.00	437.00	0.00		1,543.00		
2120	SSI AGED WITH QMB	327,512.40	327,576.00	317,912.00	322,047.80	331,522.00	328,821.60	332,263.40	335,476.90	347,924.80	414,988.00	370,820.80	0.00		3,756,865.70		
2200	SSI DISABLED WITH M E	0.00	0.00	422.00	0.00	0.00	1,308.20	-1,308.20	0.00	437.00	0.00	0.00	0.00		859.00		
2220	SSI DISABLED WITH Q
M	16,310.00	17,238.40	16,352.20	18,504.40	16,816.40	16,626.60	15,636.10	20,427.40	15,469.80	25,039.40	9,111.10	0.00		187,531.80		
2320	SSI BLIND WITH QMB	0.00	0.00	1,266.00	590.80	464.20	464.20	480.70	480.70	480.70	961.40	961.40	0.00		6,150.10		
SUBTOTAL:	344,054.4	0	344,160.40	336,374.2	0	342,029.00	348,570.60	346,798.60	347,072.00	356,385.00	364,312.30	441,862.80	381,330.30	0.00		3,952,949.60		

3,952,949.60

336,374.20	342,029.00	348,570.60	346,798.60	347,072.00	356,385.00	364,312.30	441,862.80	381,330.30	0.00	

TOTAL:

344,054.40

344,160.40

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
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	515.99	2,562.00	427.00	0.00	854.00	1,281.00	498.75	0.00	0.00	0.00		6,751.96		
1007	TANF 21-44 FEMALE WI	2,283.75	1,165.90	854.00	3,919.60	2,337.68	3,751.00	902.23	429.77	1,230.89	0.00	0.00	0.00		16,874.82		
1008	TANF 45-64 M & F WIT	3,061.28	5,198.13	6,231.12	11,805.93	7,165.79	4,209.47	4,487.28	5,863.82	7,037.55	1,910.22	3,081.56	0.00		60,052.15		
1009	TANF 65+ M & F WITH	4,002.34	6,741.66	6,241.11	3,798.25	3,772.62	3,333.10	4,929.32	2,630.19	4,269.60	-85.28	-399.28	0.00		39,233.63		
1011	TANF <1 M & F NON-ME	438,462.25	726,489.01	436,359.34	533,427.89	441,458.43	513,248.37	613,400.15	699,662.86	930,137.89	83,347.76	122,280.53	0.00		5,538,274.48		
1012	TANF 01-05 M & F NON	209,316.34	317,460.46	241,243.34	305,125.10	232,449.42	244,440.82	290,759.27	264,015.61	355,305.47	47,738.23	75,274.20	0.00		2,583,128.26		
1013	TANF 06-13 M & F NON	232,327.66	418,575.76	292,520.98	429,004.23	316,050.12	313,257.03	316,008.73	346,273.84	371,978.58	103,176.76	108,621.72	0.00		3,247,795.41		
1014	TANF 14-20 MALE NON-	55,054.04	87,809.47	83,216.72	90,241.48	112,102.80	84,940.07	79,200.43	123,930.91	117,161.66	29,254.00	35,799.48	0.00		898,711.06		
1015	TANF 14-20 FEMALE N O	152,740.73	273,508.24	211,429.32	291,321.61	192,501.22	200,454.66	220,638.22	232,448.21	257,523.17	48,157.08	49,929.91	0.00		2,130,652.37		
1016	TANF 21-44 MALE NON-	906,065.94	1,335,943.33	961,130.50	1,280,411.25	937,332.94	939,690.39	1,175,163.87	1,054,291.89	1,145,757.66	100,623.88	268,937.75	0.00		10,105,349.40		
1017	TANF 21-44 FEMALE N O	3,518,326.14	4,923,784.81	3,912,717.11	5,752,686.73	3,729,635.95	3,915,758.08	4,551,318.23	4,015,816.47	4,478,982.60	573,241.82	860,229.41	0.00		40,232,497.35		
1018	TANF 45-64 M & F NON	1,548,916.81	2,174,660.63	1,747,189.34	2,470,086.55	1,716,528.16	1,622,579.11	1,878,941.23	1,811,673.85	1,980,757.78	133,769.49	254,749.19	0.00		17,339,852.14		
1019	TANF 65+ M & F NON-M	2,926.95	3,807.00	2,989.00	5,203.48	3,425.02	1,756.20	3,416.00	1,319.33	1,876.00	0.00	377.96	0.00		27,096.94		
1026	TANF 21-44 MALE WITH	1,357.60	854.00	231.56	810.00	1,546.83	1,357.60	623.05	989.03	1,877.79	86.81	76.60	0.00		9,810.87		
1027	TANF 21-44 FEMALE WI	2,745.49	2,481.57	2,562.29	5,053.62	3,673.66	5,451.25	4,360.05	4,941.78	4,928.01	0.00	0.00	0.00		36,197.72		
1028	TANF 45-64 M & F WIT	4,656.56	4,761.71	1,984.32	15,069.91	8,530.06	4,313.09	5,562.86	2,688.01	2,375.20	-278.85	-100.22	0.00		49,562.65		
1029	TANF 65+ M & F WITH	2,925.62	648.79	2,334.86	3,107.71	4,195.44	3,694.64	1,813.77	1,784.60	3,360.96	0.00	910.00	0.00		24,776.39		
2100	SSI AGED WITH MEDIC A	64,149.88	95,842.26	78,980.96	72,849.33	69,058.73	81,597.97	65,478.12	91,743.59	102,372.44	1,011.52	1,467.01	0.00		724,551.81		
2110	SSI AGED NON-MEDIC
AR	79,413.88	84,382.03	64,899.65	80,001.77	53,676.87	72,180.06	77,125.46	67,047.85	81,985.35	2,674.00	9,218.81	0.00		672,605.73		
2120	SSI AGED WITH QMB	290,760.68	432,849.62	353,826.12	433,795.03	378,267.73	357,886.31	379,880.13	421,869.06	465,202.02	8,349.91	12,304.88	0.00		3,534,991.49		
2200	SSI DISABLED WITH M E	154,559.77	283,892.06	237,916.22	300,173.87	190,151.96	210,619.21	199,439.05	232,648.10	304,524.93	2,765.72	2,672.41	0.00		2,119,363.30		
2210	SSI DISABLED NON-ME
D	4,304,299.04	5,946,246.58	4,489,659.71	6,157,473.74	4,224,177.71	4,310,372.15	4,725,263.89	4,444,028.24	5,673,607.41	244,415.84	484,237.11	0.00		45,003,781.42		
2220	SSI DISABLED WITH Q M	481,923.72	732,574.83	599,887.37	1,175,225.64	698,288.43	609,371.78	677,418.45	702,343.48	791,325.34	7,895.59	14,474.83	0.00		6,490,729.46		
2300	SSI BLIND WITH MEDIC	145.59	1,613.35	641.11	1,038.59	2,930.26	3,949.38	2,939.87	1,596.08	1,682.77	1,475.42	984.78	0.00		18,997.20		
2310	SSI BLIND NON-MEDIC A	57,555.11	73,645.34	63,413.19	90,964.74	69,186.66	67,337.81	68,471.75	57,320.80	58,278.09	0.00	10,898.47	0.00		617,071.96		
2320	SSI BLIND WITH QMB	7,924.82	11,139.36	7,675.11	20,971.89	9,450.97	7,885.42	6,286.03	11,991.26	8,784.03	76.60	13.06	0.00		92,198.55		
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	1,792,427.69	1,996,342.73	1,394,900.83	1,735,316.84	2,071,569.09	1,963,356.35	2,546,780.20	198,666.13	259,689.50	0.00		17,691,373.83		
4312	SOBRA CHILD 01-05 M	2,809,942.41	4,361,706.53	3,390,451.65	4,214,608.00	3,030,125.18	3,236,334.45	3,744,061.04	4,103,183.74	4,419,641.87	516,307.49	732,992.71	0.00		34,559,355.07		
4313	SOBRA CHILD 06-13 M	3,644,238.08	6,107,659.92	4,522,427.90	5,784,443.96	4,626,862.67	4,248,092.45	4,304,032.77	4,681,002.88	4,950,013.42	795,841.98	1,027,823.11	0.00		44,692,439.14		
4314	SOBRA CHILD 14-20 MA	884,065.34	1,486,833.64	1,161,081.38	1,548,111.53	1,062,636.53	995,799.08	924,224.50	1,008,730.71	990,849.31	163,846.92	477,855.55	0.00		10,704,034.49		
4315	SOBRA CHILD 14-20 FE	1,073,552.01	1,876,676.98	1,445,318.19	1,919,301.20	1,319,002.00	1,277,610.65	1,331,146.43	1,341,957.99	1,435,267.97	239,746.85	277,805.02	0.00		13,537,385.29		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	318.55	319.74	169.19	0.00	0.00	0.00	427.00	1,340.00	0.00	0.00	0.00	0.00		2,574.48		
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	284,295.10	298,942.17	226,085.99	308,959.43	289,441.64	284,269.28	273,498.33	30,108.12	46,602.53	0.00		2,599,197.49		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	1,276,069.88	1,991,824.83	1,425,341.61	1,770,369.91	1,366,340.48	1,452,732.48	1,714,653.34	1,392,112.43	1,746,937.73	243,281.13	311,485.30	0.00		14,691,149.12		
5018	SOBRA PREG 45-64 FE
M	854.00	861.46	0.00	4,270.00	1,281.00	854.00	4,707.67	854.00	707.00	0.00	0.00	0.00		14,389.13		
5027	SOBRA PREG 21-44 FE M	0.00	173.98	683.53	322.64	503.60	452.63	580.20	51.06	288.35	0.00	0.00	0.00		3,055.99		
SUBTOTAL:	24,139,720.2	0 36,138,141.63	27,828,846.5	8 37,072,842.08	26,436,060.74	26,839,586.98	29,739,525.12	29,377,488.07	33,516,806.12	3,577,405.14	5,450,293.89	0.00		280,116,716.55		

-330.00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-330.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-330.00	0.00	

-330.00

1106	TANF EXPANDED 21-44	4,134.08	2,705.16	4,052.13	3,663.42	1,667.84	2,298.72	2,797.34	3,763.67	2,531.46	5,285.80	712.56	0.00	
1107	TANF EXPANDED 21-44	6,688.52	2,667.05	4,543.94	6,953.02	6,607.17	3,597.04	7,218.15	3,069.53	3,810.69	587.67	0.00	0.00	
1108	TANF EXPANDED 45-64	12,996.09	26,164.72	18,429.31	50,862.42	28,148.08	21,879.66	25,724.09	28,679.05	26,667.85	1,770.88	2,804.06	0.00	
1109	TANF EXPANDED 65+
M&	9,620.18	15,474.56	19,069.84	22,358.69	16,210.65	15,871.39	17,467.26	19,734.43	17,579.09	914.60	3,070.20	0.00	
1113	TANF EXPANDED 06-13	0.00	1,281.00	854.00	0.00	0.00	0.00	427.00	0.00	938.00	0.00	455.00	0.00	
1114	TANF EXPANDED 14-20	1,624.00	3,809.62	2,614.80	12,084.10	4,507.04	2,836.94	2,836.45	5,511.18	4,593.85	0.00	1,698.64	0.00	
1115	TANF EXPANDED 14-20	28,165.36	35,343.48	34,909.06	37,725.57	23,722.29	28,008.43	35,207.61	25,874.49	25,652.14	910.00	4,067.07	0.00	
1116	TANF EXPANDED 21-44	488,120.18	554,264.00	452,789.87	647,014.58	411,450.68	463,894.26	484,210.78	477,702.90	593,312.55	87,047.07	132,892.70	0.00	
1117	TANF EXPANDED 21-44	1,498,155.48	2,182,687.61	1,801,955.55	2,396,545.26	1,669,642.24	1,752,015.00	1,864,219.11	1,786,549.28	2,070,672.57	362,649.04	545,979.04	0.00	
1118	TANF EXPANDED 45-64	1,034,257.41	1,680,616.36	1,168,046.46	1,561,699.07	1,128,484.92	1,353,027.47	1,378,452.14	1,191,225.94	1,314,432.75	91,634.24	188,147.99	0.00	
1119	TANF EXPANDED 65+
M&	854.00	2,135.00	0.00	2,989.00	854.00	1,708.00	5,160.01	3,139.32	5,369.00	455.00	910.00	0.00	
1126	TANF EXPANDED 21-44	4,604.09	8,198.95	5,739.18	28,709.22	12,471.68	6,287.83	7,771.77	11,254.67	12,802.23	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	12,505.08	14,749.30	14,925.83	75,008.62	17,216.53	10,291.82	17,920.89	15,996.48	14,707.86	1,439.56	1,069.12	0.00	
1128	TANF EXPANDED 45-64	50,388.63	84,837.04	64,885.28	151,028.91	79,278.25	56,575.31	68,752.21	62,896.19	75,603.53	1,202.19	4,896.33	0.00	
1129	TANF EXPANDED 65+
M&	30,366.97	45,468.31	35,133.04	44,344.38	37,639.52	36,700.94	47,244.43	60,952.45	73,035.78	790.94	2,295.10	0.00	
2400	SSI AGED EXPANDED WI	2,774.49	8,436.26	9,109.12	8,164.97	2,160.24	4,017.39	7,671.97	11,310.89	5,195.24	3,089.82	3,217.61	0.00	
2410	SSI AGED EXPANDED
NO	11,956.00	15,388.90	12,810.00	10,269.54	6,860.48	12,531.04	10,831.84	8,199.87	17,393.57	0.00	2,300.02	0.00	
2420	SSI AGED EXPANDED WI	230,048.61	370,147.14	300,209.42	395,753.43	302,964.04	321,101.26	327,567.41	446,312.97	461,278.94	4,050.11	7,273.59	0.00	
2600	SSI DISABLED EXPAND
E	6,294.92	8,670.33	4,190.75	12,874.86	3,410.48	7,438.88	6,262.84	5,499.35	4,123.95	357.63	1,701.03	0.00	
2610	SSI DISABLED EXPAND E	76,117.46	80,138.61	82,608.98	121,154.14	73,320.42	74,844.46	65,877.65	95,229.53	87,679.95	4,503.71	7,147.53	0.00	
2620	SSI DISABLED EXPAND
E	146,922.04	232,897.97	180,840.23	410,753.37	199,485.56	194,513.95	192,755.74	201,152.02	199,682.29	8,977.55	9,713.66	0.00	
SUBTOTAL:	3,656,593.59	5,376,081.37	4,217,716.7	5,999,956.57	4,026,102.11	4,369,439.79	4,576,376.69	4,464,054.21	5,017,063.29	575,665.81	920,351.25	0.00	

 
33,612.18	
45,742.78	
244,126.21	
157,370.89	
3,955.00	
42,116.62	
279,585.50	
4,792,699.57	
17,931,070.18	
12,090,024.75	
23,573.33	
97,839.62	
195,831.09	
700,343.87	
413,971.86	
65,148.00	
108,541.26	
3,166,706.92	
60,825.02	
768,622.44	
1,977,694.38	
43,199,401.47	

3506	ADULT 40-100% MALE 2	52.90	10.27	854.00	479.90	0.00	0.00	0.00	0.00	455.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	427.00	0.00	955.89	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	2,966.92	1,075.15	1,188.58	2,584.97	4,336.39	2,894.57	553.70	3,129.00	455.00	910.00	0.00	
3509	ADULT 40-100% M&F 65	51.35	82.14	427.00	102.04	0.00	0.00	0.00	0.00	1,398.81	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	36,258.98	46,072.57	34,973.24	46,291.86	26,745.84	30,930.64	37,054.78	36,470.92	41,026.21	10,310.14	6,897.11	0.00	
3515	ADULT 40-100% FEMAL E	65,614.38	103,089.07	111,547.66	86,056.32	53,604.76	79,430.61	85,539.71	71,361.88	103,344.68	17,437.00	27,085.80	0.00	
3516	ADULT 40-100% MALE 2	402,116.04	593,927.91	367,686.43	568,793.32	318,209.04	344,398.45	355,688.91	385,273.99	441,582.05	120,416.80	105,558.40	0.00	

 
1,852.07	
1,382.89	
20,094.28	
2,061.34	
353,032.29	
804,111.87	
4,003,651.34	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3517	ADULT 40-100% FEMAL E	331,378.79	464,998.33	353,298.90	508,081.17	374,658.52	401,728.39	475,880.23	457,820.80	513,885.39	128,564.80	153,338.98	0.00		4,163,634.30		
3518	ADULT 40-100% M&F 45	1,508,595.02	2,016,178.84	1,429,798.45	1,994,092.61	1,381,892.49	1,485,510.99	1,700,236.34	1,526,911.58	1,745,001.01	133,025.91	219,872.98	0.00		15,141,116.22		
3519	ADULT 40-100% M&F 65	0.00	427.00	0.00	0.00	0.00	0.00	1,281.00	0.00	0.00	0.00	826.16	0.00		2,534.16		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	854.00	0.00	0.00	0.00	0.00	0.00		854.00		
3706	ADULT <40% EXP MALE	0.00	580.20	61.18	427.00	916.86	235.90	1,696.42	860.90	-245.04	0.00	0.00	0.00		4,533.42		
3707	ADULT <40% EXP FEM AL	0.00	617.12	427.00	3,485.80	255.49	0.00	427.00	93.99	0.00	0.00	0.00	0.00		5,306.40		
3708	ADULT <40% EXP M&F
4	862.29	3,097.28	3,209.65	9,803.38	2,485.49	1,832.71	2,043.22	4,024.32	9,008.80	-271.58	68.63	0.00		36,164.19		
3709	ADULT <40% EXP M&F 6	0.00	0.00	86.66	117.46	434.04	0.00	0.00	0.00	1,057.88	0.00	0.00	0.00		1,696.04		
3714	ADULT <40% EXP MALE	177,706.60	316,453.04	165,081.50	185,917.94	149,448.65	181,201.72	190,708.56	188,310.78	199,767.64	23,522.62	53,654.34	0.00		1,831,773.39		
3715	ADULT <40% EXP FEM AL	221,380.53	349,532.97	291,480.02	470,988.68	309,722.11	343,462.54	370,428.01	280,069.50	395,424.74	75,334.42	79,403.88	0.00		3,187,227.40		
3716	ADULT <40% EXP MALE	3,106,912.99	4,266,639.92	3,414,706.08	5,001,894.42	3,415,023.99	3,668,484.52	4,147,619.91	3,682,271.64	4,614,711.21	455,486.65	994,371.17	0.00		36,768,122.50		
3717	ADULT <40% EXP FEM AL	2,314,016.16	2,934,420.02	2,234,695.97	3,396,913.95	2,214,350.28	2,413,326.46	2,579,520.00	2,375,308.04	2,831,773.90	282,975.95	525,949.48	0.00		24,103,250.21		
3718	ADULT <40% EXP M&F
4	5,349,628.51	7,252,971.68	5,536,324.75	7,880,630.73	5,179,066.31	5,745,115.89	6,432,887.23	5,666,868.96	6,670,524.48	487,680.46	800,972.42	0.00		57,002,671.42		
3719	ADULT <40% EXP M&F 6	427.00	19.51	2,398.92	1,417.69	1,245.00	2,135.00	1,281.00	1,309.00	-854.00	0.00	0.00	0.00		9,379.12		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	48.20	76.60	0.00	0.00	0.00	0.00	0.00		124.80		
3727	ADULT <40% EXP FEM AL	427.00	1,281.00	0.00	391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,099.00		
3728	ADULT <40% EXP M&F
4	427.00	1,718.39	20.99	0.00	0.00	478.16	279.35	52.90	0.00	0.00	0.00	0.00		2,976.79		
SUBTOTAL:	13,515,855.5	4 18,355,084.18	13,948,153.5	5 20,157,073.85	13,431,070.84	14,702,656.57	16,387,352.73	14,677,562.90	17,570,991.76	1,734,938.17	2,968,909.35	0.00		147,449,649.44		

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	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	363,232.38	542,207.93	413,607.45	506,834.62	358,208.46	373,543.09	410,827.49	402,311.42	475,888.10	73,375.40	165,556.96	0.00	
4414	SOBRA 100-133% MALE	82,847.74	163,344.50	105,410.17	128,736.13	104,190.67	101,600.59	125,763.26	99,152.69	103,255.24	21,484.57	36,566.92	0.00	
4415	SOBRA 100-133% FEMA L	116,229.21	197,653.19	137,807.88	166,365.93	144,472.91	149,874.26	328,980.99	164,339.66	362,024.21	41,927.75	43,629.30	0.00	

0.00	
0.00	
4,085,593.30	
1,072,352.48	
1,853,305.29	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	391.00	2,739.60	1,294.67	2,420.39	-972.67	446.79	0.00	405.35	2,163.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	62.28	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	13,108.08	16,885.45	16,463.29	19,649.77	16,653.00	20,079.70	32,943.42	11,749.94	12,339.18	2,275.00	2,730.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	38,550.18	46,478.63	47,033.17	49,351.67	29,834.37	29,950.22	48,870.18	42,379.58	37,072.40	9,816.38	7,658.82	0.00	
3916	NEWLY ELIGIBLE MALE	250,292.84	318,900.93	242,067.07	314,358.28	219,561.56	220,489.58	319,107.80	233,666.28	289,074.46	46,724.90	71,987.81	0.00	
3917	NEWLY ELIGIBLE FEMA L	498,173.17	589,867.10	449,776.96	665,780.48	460,480.79	505,084.44	560,525.42	462,911.71	603,027.03	116,115.68	161,572.72	0.00	
3918	NEWLY ELIGIBLE M&F
4	820,122.35	1,210,264.84	918,196.69	1,110,482.77	754,636.89	868,136.47	971,180.33	967,868.33	1,054,105.62	76,647.56	156,979.21	0.00	
3919	NEWLY ELIGIBLE M&F 6	854.00	854.00	0.00	854.00	0.00	5,124.00	0.00	427.00	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	1,674,831.8	5	2,162,897.36	1,480,193.94	1,649,373.48	1,932,627.15	1,719,408.19	1,997,781.69	251,579.52	400,928.56	0.00	

 
0.00	
0.00	
8,888.13	
62.28	
164,876.83	
386,995.60	
2,526,231.51	
5,073,315.50	
8,908,621.06	
8,113.00	
0.00	
17,077,103.91	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	562,309.33	903,205.62	656,825.50	801,936.68	606,872.04	625,017.94	865,571.74	665,803.77	941,167.55	136,787.72	245,753.18	0.00		7,011,251.07		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	2,562.00	427.00	0.00	0.00	0.00	0.00	2,275.00	3,640.00	1,820.00	0.00	
4518	BC PATIENT FEMALE 4
5	5,978.00	7,937.14	1,281.00	4,697.00	2,135.00	9,482.51	27,254.48	5,719.84	53,763.35	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	
4618	CC PATIENT FEMALE 4
5	427.00	427.00	0.00	2,135.00	0.00	1,281.00	427.00	0.00	0.00	427.00	0.00	0.00	
SUBTOTAL:	6,405.00	8,364.14	3,843.0	0	7,259.00	2,135.00	10,763.51	27,681.48	5,719.84	56,038.35	4,067.00	1,820.00	0.00	

 
10,724.00	
118,248.32	
0.00	
5,124.00	
134,096.32	

8700	SSI DISABLED FREEDO M	3,424.04	6,292.23	8,702.73	22,089.39	14,112.09	7,083.94	14,624.04	9,914.20	11,981.52	2,461.52	455.00	0.00	
8710	SSI DISABLED FREEDO
M	6,660.50	11,384.12	31,179.94	12,610.89	9,233.78	7,466.39	11,529.00	12,181.10	14,553.00	0.00	1,365.00	0.00	
8720	SSI DISABLED FREEDO M	593.70	3,831.67	170.98	2,269.84	1,404.26	1,162.57	479.90	598.85	830.35	0.00	0.00	0.00	
SUBTOTAL:	10,678.24	21,508.02	40,053.6	5	36,970.12	24,750.13	15,712.90	26,632.94	22,694.15	27,364.87	2,461.52	1,820.00	0.00	

 
101,140.70	
118,163.72	
11,342.12	
230,646.54	

6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	427.00	0.00	0.00	0.00	0.00	

 
427.00

427.00

0.00

S000	STATE-ONLY BHS	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:	43,513,053.52	62,988,375.51	48,370,270.92	66,238,935.66	46,007,184.80	48,212,551.17	53,555,767.85	50,933,158.13	59,127,213.63	6,282,904.88	9,989,546.23	0.00		495,218,962.30		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
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	72,582.95	166,632.53	76,260.04	69,920.19	73,422.32	84,455.37	100,908.46	-61,770.03	-270,467.73	0.00		465,407.32		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	87.98	0.00	0.00	0.00	0.00	0.00		87.98		
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	3	72,582.95	166,632.53	76,260.04	69,920.19	73,510.30	84,455.37	100,908.46	-61,770.03	-270,467.73	0.00		465,495.30		

0.00

-270,467.73

100,908.46

166,632.53

TOTAL:

52,876.69

100,586.53	72,582.95

76,260.04	69,920.19	73,510.30	84,455.37

-61,770.03

465,495.30

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
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	18,224.64	8,183.56	8,529.75	6,118.20	6,338.94	5,539.47	97,403.61	21,939.37	6,729.71	0.00		191,487.35		
1012	TANF 01-05 M & F NON	201.51	0.00	132.44	622.14	147.53	0.00	0.00	311.40	927.68	3,738.05	195.71	0.00		6,276.46		
1013	TANF 06-13 M & F NON	0.00	0.00	124.68	14.92	0.00	0.00	0.00	0.00	0.00	207.31	51.58	0.00		398.49		
1014	TANF 14-20 MALE NON-	0.00	369.10	655.48	0.00	0.00	926.56	2,417.85	136.91	1,240.97	0.00	0.00	0.00		5,746.87		
1015	TANF 14-20 FEMALE N O	573.09	87.12	0.00	0.00	137.54	244.04	55.89	51.56	0.00	0.00	144.29	0.00		1,293.53		
1016	TANF 21-44 MALE NON-	4,620.19	11,482.96	3,032.91	11,345.94	10,215.91	4,366.43	1,285.67	8,793.86	3,013.50	6,350.39	12,395.95	0.00		76,903.71		
1017	TANF 21-44 FEMALE N O	5,557.26	8,987.77	7,242.90	16,865.29	9,317.40	15,714.17	7,928.18	3,879.51	9,455.78	14,331.95	18,441.12	0.00		117,721.33		
1018	TANF 45-64 M & F NON	3,997.36	1,945.44	18,215.26	4,659.88	4,760.98	5,746.43	3,493.72	6,935.29	9,510.10	494.92	2,555.97	0.00		62,315.35		
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	790.82	1,066.08	246.23	1,712.65	444.47	3,869.09	1,872.64	1,203.57	8,986.58	0.00		21,028.94		
2110	SSI AGED NON-MEDIC
AR	194.04	5,039.46	18,561.57	3,280.94	379.58	5,018.07	26,753.40	7,103.90	4,288.69	1,687.61	1,949.59	0.00		74,256.85		
2120	SSI AGED WITH QMB	198.85	222.29	197.94	448.39	1,458.38	18.24	0.00	0.00	5,903.94	0.00	139.30	0.00		8,587.33		
2200	SSI DISABLED WITH M E	1,747.14	659.19	1,382.18	2,330.74	2,152.38	371.20	2,698.58	5,213.91	1,851.66	6,166.21	1,077.32	0.00		25,650.51		
2210	SSI DISABLED NON-ME
D	189,942.96	149,028.04	124,990.48	244,612.80	88,365.26	11,459.55	2,558.38	12,904.33	58,965.40	177,494.77	23,199.05	0.00		1,083,521.02		
2220	SSI DISABLED WITH Q M	297.04	2,509.58	271.91	2,795.26	2,066.75	1,302.32	856.42	441.92	1,141.15	412.88	-20,960.85	0.00		-8,865.62		
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	5,931.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,931.00		
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	15,002.55	32,664.10	4,103.09	1,883.29	3,935.43	107.69	2,192.42	1,151.50	16,722.27	0.00		204,622.07		
4312	SOBRA CHILD 01-05 M	-45,631.00	13,238.64	11,979.10	20,433.57	5,831.26	25,975.36	3,704.67	21,256.28	33,581.62	357,830.55	13,520.07	0.00		461,720.12		
4313	SOBRA CHILD 06-13 M	-41.10	2,379.26	5,040.07	6,795.00	3,546.13	3,857.47	14,332.92	5,289.68	6,778.02	10,719.00	12,181.59	0.00		70,878.04		
4314	SOBRA CHILD 14-20 MA	1,411.35	9,954.96	964.83	13,391.00	2,085.79	8,310.98	1,771.15	2,198.52	71,869.83	-196.66	109,041.11	0.00		220,802.86		
4315	SOBRA CHILD 14-20 FE	1,217.15	12,831.45	12,733.11	12,273.65	420.32	4,886.67	4,661.61	7,568.84	6,853.95	1,821.82	11,075.11	0.00		76,343.68		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	2,910.15	4,926.07	5,892.70	6,608.38	125.79	2,739.02	1,943.58	722.81	926.93	761.47	1,186.69	0.00		28,743.59		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	24,515.25	41,701.69	33,677.06	20,401.22	43,516.53	24,605.48	9,935.60	29,393.62	35,448.70	12,800.45	18,524.91	0.00		294,520.51		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	277,848.8	1	325,389.88	279,112.6	3	408,792.86	187,406.60	125,256.13	95,116.46	121,718.59	353,226.59	618,915.16	237,157.07	0.00		3,029,940.78		

0.00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	56.79	51.76	70.94	0.00	0.00	0.00	0.00	190.75	86.76	80.61	0.00	
1108	TANF EXPANDED 45-64	0.00	47.76	0.00	0.00	0.00	2,749.64	0.00	909.59	151.80	91.94	1,206.46	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	74.25	0.00	200.82	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	718.01	0.00	0.00	616.91	8.14	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	391.79	144.37	37.93	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	2,708.53	2,390.00	903.36	7,330.25	17,036.28	3,857.29	2,148.02	899.53	2,344.86	0.00	
1117	TANF EXPANDED 21-44	101,480.72	8,941.52	15,576.87	7,102.68	10,720.82	8,718.50	7,175.31	5,865.55	5,410.44	835.61	18,573.19	0.00	
1118	TANF EXPANDED 45-64	1,886.10	4,062.15	1,800.03	1,298.94	3,739.03	5,929.10	-108.78	48,135.75	2,578.08	10,600.41	22,553.93	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	146.00	0.00	0.00	
1126	TANF EXPANDED 21-44	307.71	-193.98	0.00	10,663.29	0.00	0.00	0.00	0.00	0.00	0.00	260.08	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	254.84	0.00	0.00	0.00	0.00	0.00	0.00	17.34	0.00	0.00	
1128	TANF EXPANDED 45-64	3.33	0.00	56.79	0.00	315.28	549.45	281.01	22.54	0.00	0.00	159.14	0.00	
1129	TANF EXPANDED 65+
M&	0.00	142.96	0.00	0.00	3.61	12.40	0.00	0.00	33.48	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	1,328.31	55.50	5,043.12	224.24	1,567.31	2,419.90	1,052.14	37.51	369.79	208.90	1,992.96	0.00	
2410	SSI AGED EXPANDED
NO	0.00	0.00	0.00	0.00	0.00	93.14	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	20.90	5.72	0.00	36.90	3,464.27	0.00	0.28	16.64	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	1,350.94	34.56	354.71	1,091.83	69.28	96.91	279.69	684.87	12.04	67.38	322.01	0.00	
2610	SSI DISABLED EXPAND E	92.78	344.65	233.21	2,061.31	0.00	4,399.11	362.08	0.00	109,055.05	141,228.53	44,899.44	0.00	
2620	SSI DISABLED EXPAND
E	132.37	15.13	104.58	0.00	8.32	410.82	0.00	68.09	0.00	19.99	0.00	0.00	
SUBTOTAL:	106,956.0	17,957.09	26,328.8	24,978.06	20,791.28	33,501.48	26,078.01	59,798.65	120,566.36	154,210.53	92,392.68	0.00	

 
0.00	
537.61	
5,157.19	
275.07	
0.00	
1,343.06	
574.09	
44,023.59	
190,401.21	
102,474.74	
146.00	
11,037.10	
272.18	
1,387.54	
192.45	
14,299.68	
93.14	
3,544.71	
4,364.22	
302,676.16	
759.30	
683,559.04	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	372.97	172.84	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	2,509.47	0.00	3,725.47	136.91	0.00	211.44	2,467.23	911.38	207.13	207.13	0.00	0.00	
3516	ADULT 40-100% MALE 2	9,418.22	57,796.91	9,090.43	4,583.63	22,444.01	3,133.16	5,190.38	6,305.02	13,921.91	17,832.98	52,790.61	0.00	

 
0.00	
0.00	
0.00	
0.00	
545.81	
10,376.16	
202,507.26	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3517	ADULT 40-100% FEMAL E	1,794.58	3,255.10	1,249.80	7,988.62	8,669.51	2,727.36	4,099.87	2,334.45	671.39	16,621.19	6,997.83	0.00		56,409.70		
3518	ADULT 40-100% M&F 45	98,950.80	39,914.63	68,256.76	20,973.70	27,987.25	24,301.51	2,078.17	11,577.22	1,953.09	1,408.91	35,806.39	0.00		333,208.43		
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		0.00		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	237.15	0.00	0.00	0.00	249.30	0.00		486.45		
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	477.70	0.00	0.00	0.00	0.00	0.00	0.00		477.70		
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	2,872.93	5,295.09	807.95	167.59	1,710.78	239.62	659.32	3,089.53	1,679.94	0.00		23,765.42		
3715	ADULT <40% EXP FEM AL	7,077.31	8,750.94	543.90	234.59	885.86	646.80	319.18	0.00	9,004.06	0.00	230.45	0.00		27,693.09		
3716	ADULT <40% EXP MALE	279,032.28	57,099.69	347,978.41	99,127.93	102,765.05	66,179.17	89,258.40	72,922.16	98,252.16	88,098.27	242,574.70	0.00		1,543,288.22		
3717	ADULT <40% EXP FEM AL	107,431.97	14,283.51	49,945.44	60,195.22	15,315.99	46,358.72	17,695.51	14,646.64	106,645.59	79,783.02	22,816.06	0.00		535,117.67		
3718	ADULT <40% EXP M&F
4	127,641.99	276,293.48	161,335.44	134,687.17	86,426.84	59,837.16	88,992.19	80,196.94	99,828.08	78,927.76	141,176.47	0.00		1,335,343.52		
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		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142.96	0.00	0.00	0.00	0.00		142.96		
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	301.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		301.06		
SUBTOTAL:	636,072.2	5	463,220.67	644,998.5	8	333,222.86	265,976.49	204,213.45	212,048.86	189,276.39	331,142.73	285,968.79	504,321.75	0.00		4,070,462.82		

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	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	12,662.89	387.76	347.21	317.52	0.00	2,322.86	3,771.10	1,023.46	879.30	172.94	1,754.93	0.00	
4414	SOBRA 100-133% MALE	0.00	2,418.52	4,426.77	10,239.42	1,296.57	0.00	1,513.54	0.00	5,734.18	7,803.48	835.04	0.00	
4415	SOBRA 100-133% FEMA L	48.91	39.75	521.82	0.00	564.23	14.30	9,284.33	2,559.55	429.01	597.18	9,078.43	0.00	

0.00	
0.00	
23,639.97	
34,267.52	
23,137.51	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	588.28	123.22	0.00	0.00	0.00	0.00	0.00	4,056.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	584.90	13,034.20	0.00	0.00	639.12	6,770.58	5,156.72	12,474.84	0.00	
3915	NEWLY ELIGIBLE FEMA L	582.12	4,199.04	2,598.51	193.47	0.00	0.00	2,521.76	5,974.80	7,907.99	803.62	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	13,827.40	14,575.05	14,493.74	18,264.51	13,214.77	6,864.87	4,991.21	4,902.76	3,448.23	21,627.45	20,617.53	0.00	
3917	NEWLY ELIGIBLE FEMA L	1,936.66	9,381.21	16,636.38	11,634.78	4,960.65	100,179.40	1,371.85	3,191.91	4,294.23	5,516.98	1,021.60	0.00	
3918	NEWLY ELIGIBLE M&F
4	3,783.85	61,423.60	26,717.59	20,006.93	66,426.07	10,177.75	-8,550.58	61,842.81	8,195.04	8,107.64	38,124.92	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	61,034.5	0	50,807.81	97,635.69	117,222.02	334.24	76,551.40	30,616.07	45,268.41	72,238.89	0.00	

 
0.00	
0.00	
4,767.50	
0.00	
38,660.36	
24,781.31	
136,827.52	
160,125.65	
296,255.62	
75.90	
1,326.60	
662,820.46	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	12,711.80	2,846.03	5,295.80	10,556.94	1,860.80	2,337.16	14,568.97	3,583.01	7,042.49	8,573.60	11,668.40	0.00		81,045.00		

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	1,415.04	17,598.77	1,087.33	219.14	422.61	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	27.73	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	1,415.04	17,598.77	1,087.33	246.87	422.61	0.00	0.00	

 
0.00	
20,742.89	
27.73	
0.00	
20,770.62	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	264.66	868.47	382.07	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	41.89	0.00	
SUBTOTAL:	7.46	111.46	0.0	0	0.00	0.00	0.00	0.00	0.00	264.66	868.47	423.96	0.00	

 
1,515.20	
89.96	
70.85	
1,676.01	

6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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

922.90

S000	STATE-ONLY BHS	0.00	321.02	-321.02	0.00	5,881.29	0.00	0.00	0.00	0.00	922.90	-5,881.29	0.00	
SUBTOTAL:	0.00	321.02	-321.02	0.00	5,881.29	0.00	0.00	0.00	0.00	922.90	-5,881.29	0.00	

922.90

TOTAL:	1,053,802.34	900,751.65	1,016,449.30	828,358.53	579,552.15	483,945.28	365,745.31	452,015.37	843,105.77	1,115,150.47	912,321.46	0.00		8,551,197.63		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
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	390,558.96	758,231.54	498,563.93	574,337.32	625,427.43	518,736.37	514,344.07	275,773.60	349,280.82	0.00		5,636,991.00		
8040	SLMB	0.00	0.00	4.99	6.66	32.82	0.00	36.80	159.04	0.00	0.00	88.35	0.00		328.66		
8050	QI1	68.23	0.00	0.00	0.00	0.00	0.00	54.82	0.68	0.00	0.00	0.00	0.00		123.73		
SUBTOTAL:	567,855.21	563,949.98	390,563.9	5	758,238.20	498,596.75	574,337.32	625,519.05	518,896.09	514,344.07	275,773.60	349,369.17	0.00		5,637,443.39		

0.00

349,369.17

514,344.07

758,238.20

TOTAL:

567,855.21

563,949.98	390,563.95

498,596.75	574,337.32	625,519.05	518,896.09

275,773.60

5,637,443.39

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
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	2,562.00	2,135.00	1,708.00	1,708.00	854.00	0.00	0.00	427.00	910.00	0.00		14,574.00		
2100	SSI AGED WITH MEDIC A	156,640.61	282,159.57	277,708.00	231,770.33	182,960.20	208,577.93	244,992.20	204,731.31	202,286.92	13,721.33	34,504.44	0.00		2,040,052.84		
2110	SSI AGED NON-MEDIC
AR	14,737.61	47,435.37	33,934.58	50,359.89	23,895.30	44,174.47	34,275.63	28,552.71	57,602.57	3,674.15	126.02	0.00		338,768.30		
2120	SSI AGED WITH QMB	223,757.27	338,596.24	251,071.67	310,706.93	273,444.17	288,399.46	271,849.64	348,313.64	325,946.38	2,452.09	-276.73	0.00		2,634,260.76		
2200	SSI DISABLED WITH M E	57,027.10	75,836.21	121,069.32	141,218.95	68,475.23	52,866.49	65,286.67	58,684.35	68,863.80	15,724.51	4,474.12	0.00		729,526.75		
2210	SSI DISABLED NON-ME
D	770,298.39	1,132,850.70	847,440.78	1,170,923.87	731,602.15	778,330.81	858,460.26	805,172.29	882,159.08	343,263.23	391,226.46	0.00		8,711,728.02		
2220	SSI DISABLED WITH Q M	100,994.37	138,713.46	116,031.02	298,412.93	131,920.45	127,249.54	130,068.66	139,500.02	142,446.16	30,249.79	15,299.23	0.00		1,370,885.63		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	34.44	1,250.09	683.09	455.00	0.00	0.00	0.00	0.00		2,422.62		
2310	SSI BLIND NON-MEDIC A	5,515.00	17,097.00	3,843.00	7,259.00	3,424.14	4,270.00	11,858.13	7,483.00	8,731.50	3,101.00	455.00	0.00		73,036.77		
2320	SSI BLIND WITH QMB	292.83	62.87	0.00	0.00	0.00	0.00	0.00	204.26	608.20	0.00	0.00	0.00		1,168.16		
SUBTOTAL:	1,331,398.18	2,034,886.42	1,653,660.3	7	2,212,786.90	1,417,464.08	1,506,826.79	1,618,328.28	1,593,096.58	1,688,644.61	412,613.10	446,718.54	0.00		15,916,423.85		

TOTAL:

1,331,398.18	2,034,886.42	1,653,660.37

1,417,464.08	1,506,826.79	1,618,328.28	1,593,096.58

412,613.10

15,916,423.85

446,718.54	0.00

1,688,644.61

2,212,786.90

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

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending May 31, 2019	
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	124.05	909.69	0.00		1,033.74		
2100	SSI AGED WITH MEDIC A	103,818.39	109,726.90	28,275.54	18,458.55	5,173.54	22,930.88	13,458.42	27,534.38	13,681.94	80,143.10	12,686.39	0.00		435,888.03		
2110	SSI AGED NON-MEDIC
AR	6,828.03	5,254.09	35,919.50	34,011.86	2,027.91	2,281.21	16,780.06	0.00	0.00	0.00	-27,888.45	0.00		75,214.21		
2120	SSI AGED WITH QMB	1,251.92	1,221.92	1,524.60	5,568.28	6,492.95	111.02	121.59	44.17	43,176.81	-1.78	5,370.72	0.00		64,882.20		
2200	SSI DISABLED WITH M E	5,422.20	5,346.71	15,530.87	28,710.57	1,150.03	-5,761.98	13,199.75	3,158.94	7,165.66	4,729.12	1,077.14	0.00		79,729.01		
2210	SSI DISABLED NON-ME
D	42,117.76	62,467.60	37,822.17	54,754.34	69,035.35	51,734.12	47,176.46	43,989.66	27,913.89	32,326.57	41,192.29	0.00		510,530.21		
2220	SSI DISABLED WITH Q M	2,533.82	5,296.73	6,470.40	2,364.76	3,454.03	1,997.25	1,957.58	5,870.49	1,622.53	4,064.32	4,216.32	0.00		39,848.23		
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	177.14	435.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		612.96		
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:	161,972.1	2	189,491.09	125,978.9	0	143,868.36	87,333.81	73,292.50	92,693.86	80,597.64	93,560.83	121,385.38	37,564.10	0.00		1,207,738.59		

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

 

0.00

0.00

1,207,738.59

161,972.12	189,491.09	125,978.90	143,868.36	87,333.81	73,292.50	92,693.86	80,597.64	93,560.83	121,385.38	37,564.10	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	47.76	4,341.76	617.26	304.80	259.34	424.28	323.04	950.91	501.67	1,554.52	1,041.73	0.00		10,367.07		
1007	TANF 21-44 FEMALE WI	496.17	4,144.14	2,393.10	1,300.09	551.30	2,282.87	4,247.72	2,608.04	4,919.74	1,192.78	8,347.13	0.00		32,483.08		
1008	TANF 45-64 M & F WIT	8,230.29	10,481.11	9,364.55	7,944.69	6,856.47	4,219.17	4,156.91	1,963.23	4,791.94	15,380.25	15,713.74	0.00		89,102.35		
1009	TANF 65+ M & F WITH	3,078.59	1,095.74	69.21	605.66	667.40	771.55	3,882.50	3,897.39	4,136.58	5,322.96	8,408.35	0.00		31,935.93		
1011	TANF <1 M & F NON-ME	657,258.81	690,958.90	196,063.26	462,780.51	294,969.76	297,275.59	362,854.42	595,999.29	697,486.65	1,166,655.86	1,013,937.36	0.00		6,436,240.41		
1012	TANF 01-05 M & F NON	48,596.12	63,642.29	38,331.53	54,263.93	65,363.87	77,855.51	107,044.63	87,234.52	79,847.82	283,912.04	379,948.09	0.00		1,286,040.35		
1013	TANF 06-13 M & F NON	47,202.93	67,047.81	65,398.57	104,972.36	124,009.25	102,192.84	94,047.28	72,734.14	80,890.50	358,357.69	469,050.71	0.00		1,585,904.08		
1014	TANF 14-20 MALE NON-	25,561.11	18,971.61	15,373.77	43,289.64	41,042.08	40,527.49	51,438.66	51,777.74	41,208.57	141,721.28	260,580.42	0.00		731,492.37		
1015	TANF 14-20 FEMALE N O	70,752.82	82,377.81	69,059.76	89,955.79	73,109.45	93,779.34	126,407.45	115,999.77	97,073.57	436,101.31	408,150.77	0.00		1,662,767.84		
1016	TANF 21-44 MALE NON-	551,711.86	825,527.30	682,020.32	810,064.17	837,249.40	667,350.88	924,788.10	854,393.88	811,132.90	1,822,995.23	2,204,666.87	0.00		10,991,900.91		
1017	TANF 21-44 FEMALE N O	1,431,839.41	2,303,052.63	1,750,835.96	2,159,504.07	2,137,878.93	1,912,565.73	2,456,842.49	2,191,450.88	2,162,087.68	5,363,722.36	7,394,239.32	0.00		31,264,019.46		
1018	TANF 45-64 M & F NON	630,334.80	1,035,193.65	750,713.39	1,074,914.10	680,437.12	1,060,562.10	1,025,591.39	1,018,544.46	1,041,212.67	2,363,490.76	3,492,209.05	0.00		14,173,203.49		
1019	TANF 65+ M & F NON-M	7.46	0.00	0.00	319.78	155.30	122.12	51.42	295.55	138.50	3,336.49	10,050.49	0.00		14,477.11		
1026	TANF 21-44 MALE WITH	0.00	0.00	803.83	1,390.94	0.00	1,015.71	890.72	0.00	985.88	2,041.25	6,124.10	0.00		13,252.43		
1027	TANF 21-44 FEMALE WI	3,648.31	9,128.43	4,335.88	16,573.41	9,951.61	6,956.08	12,669.91	13,082.01	6,770.98	13,638.01	6,063.24	0.00		102,817.87		
1028	TANF 45-64 M & F WIT	11,720.30	9,694.25	10,589.71	16,729.11	5,876.34	8,492.65	17,248.03	4,235.25	3,183.07	3,434.44	8,179.74	0.00		99,382.89		
1029	TANF 65+ M & F WITH	96.18	18.25	126.71	642.09	1,146.69	2,213.86	2,929.22	3,285.30	3,437.66	7,024.70	7,813.55	0.00		28,734.21		
2100	SSI AGED WITH MEDIC A	90,481.72	76,524.73	74,297.05	106,609.44	104,933.03	79,106.40	120,255.65	82,782.87	112,956.47	144,287.46	384,673.65	0.00		1,376,908.47		
2110	SSI AGED NON-MEDIC
AR	30,826.91	80,394.58	18,259.70	18,390.49	17,585.06	34,391.67	36,800.59	30,450.23	26,779.52	141,767.30	143,194.20	0.00		578,840.25		
2120	SSI AGED WITH QMB	272,614.34	372,984.08	324,395.78	393,541.89	338,866.43	330,965.72	417,146.24	378,077.08	335,121.30	669,071.37	825,575.09	0.00		4,658,359.32		
2200	SSI DISABLED WITH M E	287,967.80	418,775.24	241,820.91	378,657.27	208,733.39	213,221.44	299,459.71	317,887.69	294,141.59	599,125.09	549,862.85	0.00		3,809,652.98		
2210	SSI DISABLED NON-ME
D	3,081,358.97	5,139,269.08	3,860,070.43	4,847,667.31	4,475,739.47	4,363,347.15	4,844,216.91	4,870,181.49	4,705,974.28	9,006,895.03	11,686,495.84	0.00		60,881,215.96		
2220	SSI DISABLED WITH Q M	828,799.60	1,218,056.98	890,079.17	1,230,641.94	870,770.48	962,527.46	1,205,629.75	918,721.97	1,002,767.51	1,539,572.32	1,902,574.26	0.00		12,570,141.44		
2300	SSI BLIND WITH MEDIC	2,570.12	2,514.86	2,404.72	5,660.17	363.29	249.38	290.84	314.81	144.91	1,217.29	1,532.81	0.00		17,263.20		
2310	SSI BLIND NON-MEDIC A	31,086.66	75,979.50	67,835.27	66,994.22	40,734.84	35,732.63	65,394.12	29,367.14	43,963.17	68,584.07	100,789.09	0.00		626,460.71		
2320	SSI BLIND WITH QMB	17,462.40	25,694.74	13,502.90	14,958.11	7,228.87	17,490.89	17,972.37	10,299.00	11,296.42	19,446.06	27,324.56	0.00		182,676.32		
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	988,090.71	1,260,018.18	1,043,482.33	976,993.81	1,114,817.86	909,102.82	1,204,396.54	1,175,830.03	1,057,051.02	3,154,995.45	3,315,986.31	0.00		16,200,765.06		
4312	SOBRA CHILD 01-05 M	650,883.56	1,169,867.01	834,785.25	1,068,177.92	792,829.62	891,053.24	1,187,597.92	1,153,905.50	1,327,049.39	4,163,147.03	5,519,471.12	0.00		18,758,767.56		
4313	SOBRA CHILD 06-13 M	883,598.55	1,529,510.70	1,342,605.99	1,406,870.94	1,138,274.11	1,225,305.32	1,447,644.33	1,395,626.32	1,549,234.52	5,179,034.94	7,436,891.86	0.00		24,534,597.58		
4314	SOBRA CHILD 14-20 MA	247,570.46	558,761.94	464,815.68	597,934.08	461,920.27	511,682.38	512,475.12	472,950.30	522,597.76	1,404,422.36	1,749,143.93	0.00		7,504,274.28		
4315	SOBRA CHILD 14-20 FE	347,687.28	551,854.84	445,975.14	644,049.19	458,931.06	647,477.76	729,805.74	691,064.43	674,374.98	1,768,260.03	2,476,476.02	0.00		9,435,956.47		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97.72	22.83	0.00	0.00		120.55		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	155.46	0.00	0.00	166.01	167.54	0.00	0.00	0.00	0.00	0.00		489.01		
5013	SOBRA PREG 09-13 FE
M	0.00	602.06	579.11	152.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,333.41		
5015	SOBRA PREG 14-20 FE M	108,685.73	185,755.22	178,536.67	134,395.88	120,792.54	143,805.05	139,625.08	120,301.26	137,866.48	268,343.45	484,315.21	0.00		2,022,422.57		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	737,238.33	1,021,186.23	784,965.67	973,553.77	646,159.76	604,303.89	911,328.10	761,471.39	686,211.98	2,102,946.48	2,653,960.88	0.00		11,883,326.48		
5018	SOBRA PREG 45-64 FE
M	2,221.69	957.52	3,515.20	2,918.17	0.00	0.00	810.14	271.58	400.61	2,730.00	1,820.00	0.00		15,644.91		
5027	SOBRA PREG 21-44 FE M	484.26	1,106.99	1,148.30	309.07	491.91	649.03	522.44	98.30	588.32	841.44	1,856.41	0.00		8,096.47		
SUBTOTAL:	12,100,212.0	1 18,815,590.28	14,189,327.5	4 17,714,031.05	15,078,696.30	15,249,186.01	18,336,953.02	17,428,053.75	17,528,424.33	42,224,591.93	54,956,468.75	0.00		243,621,534.97		

0.00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

1106	TANF EXPANDED 21-44	2,769.46	3,384.93	3,405.19	7,465.01	2,417.63	2,492.88	119.24	3,584.04	5,802.59	2,252.50	2,677.44	0.00	
1107	TANF EXPANDED 21-44	3,174.72	3,509.91	2,789.68	6,177.60	7,155.13	6,323.01	6,457.09	4,331.31	4,495.09	6,675.97	8,934.44	0.00	
1108	TANF EXPANDED 45-64	31,711.66	28,500.32	38,116.04	46,506.78	51,966.43	20,744.35	33,275.03	43,500.19	43,284.33	57,431.10	46,314.66	0.00	
1109	TANF EXPANDED 65+
M&	6,112.32	24,884.05	7,142.99	9,980.42	5,541.04	11,750.79	9,872.31	15,746.45	17,942.04	31,977.24	46,687.32	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	189.36	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	1,623.39	5,123.37	7,597.89	3,581.72	1,175.01	0.00	653.04	5,321.78	6,866.30	0.00	
1115	TANF EXPANDED 14-20	1,560.17	6,107.95	6,660.45	6,912.32	1,727.44	8,097.87	6,154.99	7,451.36	2,936.55	34,444.11	47,864.22	0.00	
1116	TANF EXPANDED 21-44	198,719.81	294,095.20	202,464.70	277,142.25	223,963.22	298,359.34	236,588.92	263,192.06	311,608.07	664,967.51	880,620.74	0.00	
1117	TANF EXPANDED 21-44	536,683.70	703,740.76	868,016.56	775,407.17	623,133.32	673,119.90	794,821.75	673,952.19	774,712.43	2,228,145.87	3,089,797.56	0.00	
1118	TANF EXPANDED 45-64	391,250.09	629,351.15	516,451.32	577,969.83	396,853.04	498,877.54	514,572.38	546,799.10	526,925.20	1,574,971.11	2,282,851.06	0.00	
1119	TANF EXPANDED 65+
M&	772.42	8,179.64	0.00	0.00	656.50	451.87	609.04	2,206.33	146.45	3,282.18	4,199.65	0.00	
1126	TANF EXPANDED 21-44	9,997.63	11,550.69	10,720.55	20,973.22	19,435.53	14,153.28	17,345.65	15,408.73	18,910.47	32,016.57	33,159.73	0.00	
1127	TANF EXPANDED 21-44	14,172.24	26,663.71	18,677.06	14,767.80	27,348.45	22,920.13	35,015.68	21,134.21	30,704.01	38,294.50	46,534.49	0.00	
1128	TANF EXPANDED 45-64	79,500.75	88,467.47	58,617.30	76,452.21	80,644.64	93,834.38	133,816.70	121,524.15	71,070.09	140,256.31	143,905.31	0.00	
1129	TANF EXPANDED 65+
M&	26,596.73	52,960.12	22,465.20	41,069.83	25,185.90	31,434.89	45,074.32	31,378.44	29,429.16	80,270.61	91,393.99	0.00	
2400	SSI AGED EXPANDED WI	3,611.88	9,372.78	2,782.82	14,175.75	3,194.15	1,616.33	2,282.75	2,563.33	5,734.31	10,181.39	27,844.15	0.00	
2410	SSI AGED EXPANDED
NO	3,794.54	13,312.07	2,225.81	1,485.85	3,672.41	1,358.14	680.72	1,775.79	10,021.36	8,525.29	17,618.47	0.00	
2420	SSI AGED EXPANDED WI	227,286.25	287,591.70	187,828.76	299,349.41	227,005.55	256,857.43	376,278.32	303,092.02	293,445.95	657,355.35	796,457.08	0.00	
2600	SSI DISABLED EXPAND
E	4,540.98	5,653.28	7,624.58	8,038.74	3,200.40	12,305.62	9,376.26	5,525.66	5,268.67	8,256.55	12,830.42	0.00	
2610	SSI DISABLED EXPAND E	109,618.30	137,904.68	96,117.89	96,328.57	134,982.21	101,431.73	134,506.41	115,395.30	149,049.14	222,757.81	401,925.22	0.00	
2620	SSI DISABLED EXPAND
E	238,266.30	373,344.32	210,984.15	329,310.62	246,267.59	269,547.76	357,350.89	255,942.77	295,320.65	458,986.93	579,974.47	0.00	
SUBTOTAL:	1,893,758.66	2,710,424.26	2,264,714.4	2,614,636.75	2,092,137.83	2,329,258.96	2,715,373.46	2,434,503.43	2,597,459.60	6,266,370.68	8,568,456.72	0.00	

 
36,370.91	
60,023.95	
441,350.89	
187,636.97	
189.36	
37,410.74	
129,917.43	
3,851,721.82	
11,741,531.21	
8,456,871.82	
20,504.08	
203,672.05	
296,232.28	
1,088,089.31	
477,259.19	
83,359.64	
64,470.45	
3,912,547.82	
82,621.16	
1,700,017.26	
3,615,296.45	
36,487,094.79	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	-799.50	0.00	0.00	0.00	0.00	0.00	910.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	896.68	468.97	47.76	0.00	0.00	0.00	0.00	223.01	0.00	
3508	ADULT 40-100% M&F 45	1,886.71	781.92	5,838.50	-323.48	210.55	0.00	62.41	1,609.58	-37.59	1,435.87	258.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	244.04	0.00	81.01	0.00	0.00	0.00	0.00	127.66	183.75	0.00	
3514	ADULT 40-100% MALE 1	17,326.49	23,827.25	51,235.64	21,726.21	16,232.79	20,722.27	18,634.52	22,829.89	17,850.92	49,555.79	57,126.69	0.00	
3515	ADULT 40-100% FEMAL E	32,693.21	29,446.95	24,891.82	26,163.63	16,303.06	19,560.23	20,786.39	20,659.92	31,702.46	120,731.82	165,520.13	0.00	
3516	ADULT 40-100% MALE 2	359,646.46	413,387.96	269,788.55	413,271.24	520,634.17	597,887.69	320,547.25	440,297.48	280,439.81	748,637.09	1,055,851.49	0.00	

 
110.50	
1,636.42	
11,722.47	
636.46	
317,068.46	
508,459.62	
5,420,389.19	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3517	ADULT 40-100% FEMAL E	160,411.64	222,229.97	209,621.16	135,936.05	138,462.04	135,730.51	196,133.56	164,211.36	191,417.26	600,111.06	791,374.62	0.00		2,945,639.23		
3518	ADULT 40-100% M&F 45	653,104.90	990,415.35	825,446.34	982,882.46	909,182.66	896,784.38	994,762.14	815,303.95	1,040,435.03	2,313,734.75	3,143,730.23	0.00		13,565,782.19		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,183.13	0.00	954.56	455.00	0.00		2,592.69		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	0.00	0.00	348.60	0.00	0.00	56.79	383.67	0.00	0.00	643.80	0.00	0.00		1,432.86		
3707	ADULT <40% EXP FEM AL	0.00	876.33	56.82	-247.35	0.00	165.02	488.68	0.00	34.64	0.00	0.00	0.00		1,374.14		
3708	ADULT <40% EXP M&F
4	7,404.35	2,560.72	2,434.54	5,468.79	2,678.96	715.68	3,060.41	371.00	7,848.18	8,372.73	11,651.04	0.00		52,566.40		
3709	ADULT <40% EXP M&F 6	0.00	1,907.91	0.00	319.78	0.00	0.00	0.00	0.00	0.00	0.00	57.84	0.00		2,285.53		
3714	ADULT <40% EXP MALE	128,177.73	190,187.53	133,173.73	257,172.85	168,079.42	171,672.28	289,587.21	188,709.19	182,221.82	370,745.98	421,467.86	0.00		2,501,195.60		
3715	ADULT <40% EXP FEM AL	81,753.31	142,863.64	107,015.79	140,162.72	134,994.97	147,024.36	152,978.04	163,967.18	169,247.34	439,582.21	642,506.86	0.00		2,322,096.42		
3716	ADULT <40% EXP MALE	2,637,866.13	3,886,347.57	2,891,641.74	3,725,663.71	3,299,089.22	3,112,253.66	4,488,400.64	4,234,375.04	4,028,758.22	6,986,682.71	9,356,678.04	0.00		48,647,756.68		
3717	ADULT <40% EXP FEM AL	1,102,449.98	1,484,286.72	1,423,543.88	1,580,238.94	1,440,215.31	1,393,996.38	1,836,957.77	1,684,149.01	1,883,156.74	4,004,620.81	4,973,157.56	0.00		22,806,773.10		
3718	ADULT <40% EXP M&F
4	3,110,157.45	4,935,322.41	3,474,047.41	4,749,116.33	3,995,794.67	4,145,314.81	4,846,198.87	4,615,993.96	4,620,912.81	9,595,149.12	13,426,582.70	0.00		61,514,590.54		
3719	ADULT <40% EXP M&F 6	0.00	0.00	420.76	537.05	0.00	0.00	0.00	0.00	71.61	427.00	2,993.93	0.00		4,450.35		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM AL	10.33	189.27	554.40	1,098.32	0.00	72.49	0.00	0.00	0.00	0.00	0.00	0.00		1,924.81		
3728	ADULT <40% EXP M&F
4	0.00	8.39	0.00	1,058.98	132.60	143.88	37.78	0.00	0.00	0.00	0.00	0.00		1,381.63		
SUBTOTAL:	8,292,888.69	12,324,639.89	9,420,303.7	2 12,040,343.41	10,642,560.40	10,642,148.19	13,169,019.34	12,353,660.69	12,454,059.25	25,242,422.96	34,049,818.75	0.00		160,631,865.29		

4405	SOBRA 100-133% FEMA L	0.00	0.00	0.00	3,547.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	94.24	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	40,827.91	75,963.29	99,358.91	100,847.79	66,479.52	92,374.43	88,685.49	102,196.71	146,895.01	462,202.92	587,926.64	0.00	
4414	SOBRA 100-133% MALE	27,680.97	28,162.30	23,388.21	63,754.26	18,769.94	32,154.22	24,114.36	22,237.89	17,376.65	110,538.11	179,871.70	0.00	
4415	SOBRA 100-133% FEMA L	29,413.21	56,267.20	32,673.44	48,823.42	56,167.77	49,723.91	46,811.16	58,125.08	55,704.87	177,032.46	227,439.91	0.00	

3,547.72	
94.24	
1,863,758.62	
548,048.61	
838,182.43	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87.52	0.00	
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	102.69	-39.17	153.53	0.00	0.00	183.30	1,137.63	231.80	0.00	96.95	497.47	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	506.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	3,469.50	4,996.79	7,238.46	6,060.59	797.69	2,365.23	2,880.96	2,706.88	6,942.07	8,772.75	9,650.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	11,407.29	13,216.12	5,086.25	16,565.47	10,699.52	16,759.06	30,613.97	6,472.00	20,791.00	51,740.19	58,352.04	0.00	
3916	NEWLY ELIGIBLE MALE	107,254.50	254,363.09	272,315.22	317,997.78	164,778.28	269,592.35	191,950.43	294,001.54	185,038.28	365,898.37	521,168.73	0.00	
3917	NEWLY ELIGIBLE FEMA L	138,711.51	173,572.82	137,346.10	216,786.52	137,387.38	156,391.87	218,077.69	246,119.22	310,617.12	665,041.78	965,614.64	0.00	
3918	NEWLY ELIGIBLE M&F
4	323,296.68	527,183.63	435,063.50	523,744.20	542,752.71	753,349.56	734,332.19	484,377.55	497,258.12	1,320,264.36	2,076,277.34	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	51.61	176.09	629.78	0.00	0.00	0.00	0.00	455.00	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:	585,238.0	7	974,052.75	857,203.0	6	1,081,206.17	857,098.11	1,199,271.15	1,178,992.87	1,033,908.99	1,020,646.59	2,411,814.40	3,632,102.74	0.00	

 
87.52	
1,755.37	
2,364.20	
506.44	
55,880.92	
241,702.91	
2,944,358.57	
3,365,666.65	
8,217,899.84	
1,312.48	
0.00	
14,831,534.90	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	97,922.09	160,392.79	155,514.80	216,973.19	141,417.23	174,252.56	159,611.01	182,559.68	219,976.53	749,773.49	995,238.25	0.00		3,253,631.62		

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	170.89	723.32	12,264.70	2,781.22	1,204.85	0.00	1,208.29	123.16	909.67	7,358.96	30,405.15	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	
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	910.00	0.00	0.00	
SUBTOTAL:	170.89	723.32	12,264.7	0	2,781.22	1,204.85	0.00	1,208.29	123.16	909.67	8,268.96	30,405.15	0.00	

 
0.00	
57,150.21	
0.00	
910.00	
58,060.21	

8700	SSI DISABLED FREEDO M	10,776.43	12,252.71	13,364.87	16,125.97	4,037.20	9,463.72	13,527.77	11,237.67	4,976.41	16,019.52	21,992.75	0.00	
8710	SSI DISABLED FREEDO
M	3,944.08	4,759.19	2,245.54	2,663.94	3,909.98	2,474.38	8,083.42	6,058.38	3,556.29	27,704.29	32,499.47	0.00	
8720	SSI DISABLED FREEDO M	1,102.55	233.33	866.48	752.69	64.72	374.10	631.29	408.72	704.93	2,648.37	1,813.22	0.00	
SUBTOTAL:	15,823.06	17,245.23	16,476.8	9	19,542.60	8,011.90	12,312.20	22,242.48	17,704.77	9,237.63	46,372.18	56,305.44	0.00	

 
133,775.02	
97,898.96	
9,600.40	
241,274.38	

6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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

S000	STATE-ONLY BHS	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:	22,986,013.47	35,003,068.52	26,915,805.15	33,689,514.39	28,821,126.62	29,606,429.07	35,583,400.47	33,450,514.47	33,830,713.60	76,949,614.60	102,288,795.80	0.00		459,124,996.16		

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
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		
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

0.00

3316	AHC CARE MALE 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

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

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		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		0.00		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		
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		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP 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		

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

S000	STATE-ONLY BHS	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	

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	

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	
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	
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	
0.00	
0.00	

6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
																
															0.00	
															0.00	
TOTAL:		0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
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	2,429,586.71	3,067,074.77	2,608,549.52	2,900,373.89	2,174,303.20	2,968,110.73	3,146,016.96	2,351,041.45	2,553,460.35	2,699,272.19	3,087,724.72	0.00		29,985,514.49		
2110	SSI AGED NON-MEDIC
AR	107,921.13	133,529.34	151,408.05	161,241.66	115,041.73	177,188.18	165,989.80	138,199.36	145,130.39	176,505.09	169,267.03	0.00		1,641,421.76		
2120	SSI AGED WITH QMB	3,276,411.00	4,259,112.76	3,727,178.20	4,247,451.57	3,080,350.53	3,845,496.03	4,444,730.85	3,536,253.59	3,573,855.28	4,092,245.15	4,465,771.03	0.00		42,548,855.99		
2200	SSI DISABLED WITH M E	539,410.68	748,408.76	539,722.22	651,938.85	463,848.53	666,537.40	670,392.51	508,303.95	561,549.50	477,845.45	543,701.61	0.00		6,371,659.46		
2210	SSI DISABLED NON-ME
D	2,122,969.75	3,008,893.09	2,324,461.99	2,643,360.70	1,834,773.28	2,754,892.37	2,530,005.41	2,490,635.24	2,464,032.69	3,035,228.30	3,878,185.91	0.00		29,087,438.73		
2220	SSI DISABLED WITH Q M	745,900.80	1,015,381.64	871,135.22	1,095,933.69	793,159.75	1,040,696.45	1,213,734.21	960,478.97	839,504.87	895,896.09	1,105,081.24	0.00		10,576,902.93		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	711.08	1,643.35	1,544.49	2,306.16	1,506.60	781.20	1,295.92	967.20	0.00		10,756.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	29.84	275.10	5,004.29	8,944.85	11,018.26	0.00		25,272.34		
2320	SSI BLIND WITH QMB	55.00	2,107.16	2,221.48	3,699.66	4,424.96	3,074.82	3,618.30	2,515.03	2,584.14	6,585.95	5,746.41	0.00		36,632.91		
SUBTOTAL:	9,222,255.07	12,234,507.52	10,224,676.6	8 11,704,711.10	8,467,545.33	11,457,540.47	12,176,824.04	9,989,209.29	10,145,902.71	11,393,818.99	13,267,463.41	0.00		120,284,454.61		

TOTAL:

9,225,299.23 12,238,312.72 10,227,720.84

8,470,590.40    11,459,823.59    12,181,068.80	9,992,334.09

11,396,943.79

120,320,295.17

13,271,369.41	0.00

10,149,076.08

11,707,756.22

8720	SSI DISABLED FREEDO M	3,044.16	3,805.20	3,044.16	3,045.12	3,045.07	2,283.12	4,244.76	3,124.80	3,173.37	3,124.80	3,906.00	0.00	
SUBTOTAL:	3,044.16	3,805.20	3,044.16	3,045.12	3,045.07	2,283.12	4,244.76	3,124.80	3,173.37	3,124.80	3,906.00	0.00	

 

35,840.56

35,840.56

LONG TERM CARE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
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	0.00	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		

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

 

0.00

0.00

0.00

0.00

0.00

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-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,364.00	0.00	0.00		1,364.00		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	455.00	14.76	0.00		469.76		
SUBTOTAL:	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,819.00	14.76	0.00		1,833.76		

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,819.00	14.76	0.00		1,833.76		

QMB - FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	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	0.00	0.00	0.00	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

KidsCare - CAPITATION AMOUNTS
For The Period Ending May 31, 2019	
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	116,564.06	134,163.67	144,810.45	151,451.23	151,580.00	183,680.79	167,280.47	163,105.79	167,720.31	0.00		1,631,815.57		
6012	KIDS 1-5 M & F NON-M	930,841.31	933,412.41	966,219.61	1,528,621.10	1,454,115.92	1,498,807.65	1,470,041.30	1,637,461.80	1,523,549.53	1,509,996.63	1,534,285.83	0.00		14,987,353.09		
6013	KIDS 6-13 M & F NON-	1,769,582.94	1,750,229.49	1,853,370.37	2,790,541.54	2,673,184.15	2,774,938.11	2,720,735.53	3,013,555.44	2,818,220.31	2,834,846.38	2,879,520.96	0.00		27,878,725.22		
6014	KIDS 14-19 MALE NON-	645,960.88	629,453.67	677,457.88	747,539.50	692,377.97	727,052.81	707,890.25	791,897.46	713,504.10	727,094.13	730,213.48	0.00		7,790,442.13		
6015	KIDS 14-19 FEMALE NO	953,492.75	920,800.00	977,332.84	722,069.86	683,347.05	719,426.08	697,434.36	849,183.18	732,345.84	746,815.21	748,851.22	0.00		8,751,098.39		
9960	KIDSCARE KICK PAYM EN	6,279.40	12,623.64	23,249.87	0.00	6,000.27	0.00	6,000.27	6,000.27	18,000.81	12,000.54	11,294.87	0.00		101,449.94		
SUBTOTAL:	4,425,408.67	4,378,726.62	4,614,194.6	3	5,922,935.67	5,653,835.81	5,871,675.88	5,753,681.71	6,481,778.94	5,972,901.06	5,993,858.68	6,071,886.67	0.00		61,140,884.34		

TOTAL:	4,425,408.67	4,378,726.62	4,614,194.63	5,922,935.67	5,653,835.81	5,871,675.88	5,753,681.71	6,481,778.94	5,972,901.06	5,993,858.68	6,071,886.67	0.00		61,140,884.34		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending May 31, 2019	
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	256.07	234.65	251.94	260.71	261.87	270.97	288.01	283.80	292.12	0.00		2,929.14		
6012	KIDS 1-5 M & F NON-M	7,628.26	7,790.83	7,937.59	8,584.44	8,167.94	8,255.34	8,236.62	8,403.58	8,529.30	8,429.23	8,557.70	0.00		90,520.83		
6013	KIDS 6-13 M & F NON-	13,979.68	14,154.33	14,668.42	15,663.29	14,998.58	15,182.65	15,255.32	15,510.72	15,783.86	15,848.51	16,093.21	0.00		167,138.57		
6014	KIDS 14-19 MALE NON-	3,647.77	3,669.60	3,834.32	4,184.92	3,877.52	3,944.33	3,935.87	3,917.01	3,974.21	4,058.67	4,075.83	0.00		43,120.05		
6015	KIDS 14-19 FEMALE NO	3,569.17	3,563.56	3,673.40	4,046.04	3,831.44	3,898.03	3,908.80	3,939.91	4,067.79	4,139.61	4,161.07	0.00		42,798.82		
9960	KIDSCARE KICK PAYM EN	1.00	2.00	4.00	0.00	1.00	0.00	1.00	1.00	3.00	2.00	2.00	0.00		17.00		
SUBTOTAL:	29,087.95	29,447.25	30,373.8	0	32,713.34	31,128.42	31,541.06	31,599.48	32,043.19	32,646.17	32,761.82	33,181.93	0.00		346,524.41		

346,524.41

29,087.95	29,447.25	30,373.80	32,713.34	31,128.42	31,541.06	31,599.48	32,043.19	32,646.17	32,761.82	33,181.93	0.00	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending May 31, 2019	
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	10,782.82	325.43	346.13	2,074.09	344.02	361.47	380.92	378.72	389.65	0.00		37,775.26		
6012	KIDS 1-5 M & F NON-M	315,349.20	320,984.71	327,933.57	11,875.49	11,124.25	46,769.82	11,538.30	11,431.57	11,630.28	12,743.71	11,940.42	0.00		1,093,321.32		
6013	KIDS 6-13 M & F NON-	574,129.11	581,246.44	602,537.60	21,249.89	20,598.89	84,708.88	20,996.89	22,863.84	22,380.39	22,886.99	23,098.95	0.00		1,996,697.87		
6014	KIDS 14-19 MALE NON-	171,357.69	172,136.05	180,234.68	12,538.57	10,514.85	28,673.23	10,711.97	9,862.03	9,988.98	10,381.40	10,486.60	0.00		626,886.05		
6015	KIDS 14-19 FEMALE NO	167,709.13	166,734.20	171,902.23	11,044.63	10,300.43	29,461.23	10,542.67	9,760.70	10,090.57	10,270.30	10,391.87	0.00		608,207.96		
SUBTOTAL:	1,239,709.04	1,252,329.50	1,293,390.9	0	57,034.01	52,884.55	191,687.25	54,133.85	54,279.61	54,471.14	56,661.12	56,307.49	0.00		4,362,888.46		

TOTAL:	1,239,709.04	1,252,329.50	1,293,390.90	57,034.01	52,884.55	191,687.25	54,133.85	54,279.61	54,471.14	56,661.12	56,307.49	0.00		4,362,888.46		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	11.39	10.61	17.68	241.00	258.00	267.00	267.00	278.00	291.00	289.00	298.00	0.00		2,228.68		
6012	KIDS 1-5 M & F NON-M	371.90	342.86	499.90	8,869.00	8,320.00	8,403.00	8,429.00	8,537.00	8,617.00	8,667.03	8,783.03	0.00		69,839.72		
6013	KIDS 6-13 M & F NON-	690.88	640.58	966.79	16,240.00	15,330.00	15,573.00	15,662.00	15,916.96	16,069.03	16,428.03	16,583.03	0.00		130,100.30		
6014	KIDS 14-19 MALE NON-	173.54	184.88	245.66	4,392.06	4,031.03	4,087.03	4,088.28	4,072.00	4,113.00	4,262.00	4,291.70	0.00		33,941.18		
6015	KIDS 14-19 FEMALE NO	172.46	179.88	242.20	4,248.03	3,948.03	4,031.03	4,045.03	4,055.00	4,165.00	4,290.00	4,312.00	0.00		33,688.66		
SUBTOTAL:	1,420.17	1,358.81	1,972.2	3	33,990.09	31,887.06	32,361.06	32,491.31	32,858.96	33,255.03	33,936.06	34,267.76	0.00		269,798.54		

269,798.54

1,972.23	33,990.09	31,887.06	32,361.06	32,491.31	32,858.96	33,255.03	33,936.06	34,267.76	0.00	

TOTAL:

1,420.17

1,358.81

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending May 31, 2019	
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	1,196.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,785.12		
6013	KIDS 6-13 M & F NON-	2,990.70	1,794.42	1,794.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,579.54		
6014	KIDS 14-19 MALE NON-	1,196.28	598.14	598.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,392.56		
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	4,186.98	3,588.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,355.36		

TOTAL:	6,579.54	4,186.98	3,588.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,355.36		

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending May 31, 2019	
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
6013	KIDS 6-13 M & F NON-	5.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
6014	KIDS 14-19 MALE NON-	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
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	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		

24.00

11.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - FEE FOR SERVICE
For The Period Ending May 31, 2019	
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	238.81	270.49	422.06	77.50	1,179.72	201.70	2,246.92	1,449.91	16,940.70	0.00		24,104.35		
6012	KIDS 1-5 M & F NON-M	10,139.27	14,689.39	12,115.28	11,427.06	9,814.14	16,878.74	20,402.51	21,292.84	32,483.71	34,670.58	44,399.94	0.00		228,313.46		
6013	KIDS 6-13 M & F NON-	82,808.67	78,365.63	58,936.46	77,409.57	85,531.10	45,080.36	50,311.26	102,351.90	61,516.68	60,293.40	101,315.56	0.00		803,920.59		
6014	KIDS 14-19 MALE NON-	13,580.70	16,404.68	13,944.36	46,642.34	24,484.66	27,149.41	30,005.62	63,936.27	46,890.15	44,515.66	64,785.56	0.00		392,339.41		
6015	KIDS 14-19 FEMALE NO	120,789.67	12,782.97	15,263.63	19,171.65	42,223.15	30,218.72	17,649.38	28,675.41	21,049.19	41,321.48	56,670.56	0.00		405,815.81		
SUBTOTAL:	227,480.8	0	123,156.72	100,498.5	4	154,921.11	162,475.11	119,404.73	119,548.49	216,458.12	164,186.65	182,251.03	284,112.32	0.00		1,854,493.62		

TOTAL:	227,480.80	123,156.72	100,498.54	154,921.11	162,475.11	119,404.73	119,548.49	216,458.12	164,186.65	182,251.03	284,112.32	0.00		1,854,493.62		

KidsCare - REINSURANCE
For The Period Ending May 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,115.52	0.00		10,115.52		
6012	KIDS 1-5 M & F NON-M	8,845.88	103,124.42	18,432.00	24,265.34	-1,227.51	490.11	0.00	52,159.05	0.00	0.00	-490.11	0.00		205,599.18		
6013	KIDS 6-13 M & F NON-	155,090.01	41,927.76	105,743.46	60,918.56	88,197.91	57,403.83	6,097.95	21,131.57	44,817.09	10,691.06	46,130.67	0.00		638,149.87		
6014	KIDS 14-19 MALE NON-	69,646.87	50,443.75	105,482.54	27,788.63	59,760.98	38,271.35	396.78	46,017.76	58,314.12	71,789.50	39,708.67	0.00		567,620.95		
6015	KIDS 14-19 FEMALE NO	5,374.05	4,195.84	4,399.07	0.00	0.00	0.00	10,139.49	233.46	-3,915.35	236.31	0.00	0.00		20,662.87		
SUBTOTAL:	238,956.8	1	199,691.77	234,057.0	7	112,972.53	146,731.38	96,165.29	16,634.22	119,541.84	99,215.86	82,716.87	95,464.75	0.00		1,442,148.39		

1,442,148.39

234,057.07	112,972.53	146,731.38	96,165.29	16,634.22	119,541.84	99,215.86	82,716.87	95,464.75	0.00	

TOTAL:

238,956.81

199,691.77

00

00

14.00

1,842.17

13.00

674.98

31.00

1,060.44

6,120.63

74,583.02

0.00

13,496.11

31.00

141.98

43.00

41.99

11.00

9.00

98,113.32

98,113.32

TOTAL

JUNE

MAY

APRIL

MARCH

FEBRUARY

JANUARY

NOVEMBER	DECEMBER

OCTOBER

AUGUST SEPTEMBER

JULY

DESCRIPTION

RATE CODE

For The Period Ending May 31, 2019

DES-DD - CAP MEMBER MONTHS

110007

1000	TANF WITH MEDICARE	5.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	657.19	640.28	544.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	5.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	221.85	222.14	230.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICAR	10.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	337.61	352.75	370.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH ME	2,046.96	2,037.27	2,036.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-MED	24,762.26	24,814.30	25,006.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
221Z	SSI DISABLED NON-MED	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 QM	4,454.67	4,495.82	4,545.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	11.00	11.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	51.00	47.99	42.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	16.00	16.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	14.00	13.99	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	3.00	3.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:
TOTAL:	32,598.54	32,676.54	32,838.24	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	32,598.54	32,676.54	32,838.24	0.	0.0	0	0.00	0.00	0.00	0.00	0.	0.00	0.00	

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending May 31, 2019		
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	4.00	2.00		2.00	2.00	2.00	1.00	1.00	1.00	0.00		15.00		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	466.73	419.97		403.96	331.29	270.55	254.64	260.79	282.54	0.00		2,690.47		
1020	TANF WITH QMB	0.00	0.00	0.00	4.00	4.00		3.00	3.00	3.00	2.00	2.00	3.00	0.00		24.00		
2100	SSI AGED WITH MEDICA	0.00	0.00	0.00	244.46	241.51		244.09	241.85	243.00	250.96	248.99	249.98	0.00		1,964.84		
2110	SSI AGED NON-MEDICAR	0.00	0.00	0.00	10.99	11.00		11.00	11.00	12.00	11.00	10.00	11.00	0.00		87.99		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	375.53	382.60		390.53	398.01	398.60	406.18	422.25	426.10	0.00		3,199.80		
2200	SSI DISABLED WITH ME	0.00	0.00	0.00	2,027.52	2,029.74		2,004.67	1,963.26	1,923.20	1,907.95	1,914.87	1,921.84	0.00		15,693.05		
2210	SSI DISABLED NON-MED	0.00	0.00	-0.10	25,282.75	25,470.66		25,544.00	25,776.74	25,863.11	26,040.81	26,154.36	26,259.34	0.00		206,391.67		
221Z	SSI DISABLED NON-MED	0.00	0.00	0.00	0.16	0.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.16		
2220	SSI DISABLED WITH QM	0.00	0.00	0.00	4,577.46	4,597.86		4,626.11	4,714.26	4,786.34	4,798.14	4,811.27	4,819.31	0.00		37,730.75		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	6.00	6.00		7.00	4.70	3.00	2.00	1.00	0.99	0.00		30.69		
2310	SSI BLIND NON-MEDICA	0.00	0.00	0.00	38.99	32.70		33.99	31.77	24.28	22.00	21.98	25.80	0.00		231.51		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	10.00	9.00		9.00	6.00	5.00	5.00	3.00	2.00	0.00		49.00		
8700	SSI DISABLED FREEDOM	0.00	0.00	0.00	14.99	17.00		17.00	18.98	17.00	16.00	18.00	19.99	0.00		138.96		
8710	SSI DISABLED FREEDOM	0.00	0.00	0.00	3.00	2.00		2.00	2.00	3.99	3.00	3.00	2.00	0.00		20.99		
8720	SSI DISABLED FREEDOM	0.00	0.00	0.00	3.00	4.00		4.00	5.00	5.00	6.00	6.00	6.00	0.00		39.00		
SUBTOTAL:	0.00	0.00	-0.10	33,069.58	33,230.0	4	33,302.35	33,509.86	33,560.07	33,726.68	33,878.51	34,030.89	0.00		268,307.88		
TOTAL:	0.00	0.00	-0.10	33,069.	5	33,230.0	4	33,302.35	33,509.86	33,560.07	33,726.68	33,878.5	34,030.89	0.00		268,307.88		

8

1

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending May 31, 2019

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	402,320.34	398,481.36	407,789.50	408,867.99	407,892.61	408,844.76	409,300.98	411,036.35	408,896.64	415,970.53	420,089.89	0.00	4,499,490.95	
EPD	97,705,021.68	98,655,671.09	98,614,352.14	100,662,003.07	102,908,692.68	104,984,155.26	104,289,977.63	104,310,548.03	105,106,892.26	105,248,053.90	105,663,873.19	0.00	1,128,149,240.93	
TOTAL AHCCCS LTC	98,107,342.02	99,054,152.45	99,022,141.64	101,070,871.06	103,316,585.29	105,393,000.02	104,699,278.61	104,721,584.38	105,515,788.90	105,664,024.43	106,083,963.08	0.00	1,132,648,731.88	
DES/DD	126,960,382.68	127,186,833.22	127,813,282.34	135,511,141.99	136,185,177.70	139,169,168.18	138,635,404.59	138,846,329.61	146,122,953.85	153,537,915.64	142,742,750.85	0.00	1,512,711,340.65	
TOTAL DES LTC	126,960,382.68	127,186,833.22	127,813,282.34	135,511,141.99	136,185,177.70	139,169,168.18	138,635,404.59	138,846,329.61	146,122,953.85	153,537,915.64	142,742,750.85	0.00	1,512,711,340.65	
TOTAL LTC - CAP	225,067,724.70	226,240,985.67	226,835,423.98	236,582,013.05	239,501,762.99	244,562,168.20	243,334,683.20	243,567,913.99	251,638,742.75	259,201,940.07	248,826,713.93	0.00	2,645,360,072.53	

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	12,007,360.11	14,064,411.48	9,975,388.29	13,039,942.88	13,892,090.94	11,666,028.31	11,931,281.52	11,930,942.27	13,755,652.05	0.00	137,444,457.61	
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	12,007,360.11	14,064,411.48	9,975,388.29	13,039,942.88	13,892,090.94	11,666,028.31	11,931,281.52	11,930,942.27	13,755,652.05	0.00	137,444,457.61	

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	4,337,311.81	4,912,387.34	4,498,476.65	1,529,480.70	3,356,014.56	2,514,707.19	2,395,002.46	313,487.45	2,747,019.49	0.00	34,061,512.19	
DES/DD	909,074.28	494,787.82	1,914,690.15	1,359,505.85	2,109,321.94	3,682,402.08	789,296.36	2,490,362.46	902,530.33	1,340,557.83	1,121,964.07	0.00	17,114,493.17	
TOTAL DES LTC	909,074.28	494,787.82	1,914,690.15	1,359,505.85	2,109,321.94	3,682,402.08	789,296.36	2,490,362.46	902,530.33	1,340,557.83	1,121,964.07	0.00	17,114,493.17	
TOTAL LTC - REIN	5,446,473.30	3,415,013.34	6,252,001.96	6,271,893.19	6,607,798.59	5,211,882.78	4,145,310.92	5,005,069.65	3,297,532.79	1,654,045.28	3,868,983.56	0.00	51,176,005.36	

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	4,195,396.10	4,229,007.60	4,243,120.60	4,279,533.20	4,314,979.10	4,390,644.70	4,386,938.90	4,497,974.40	4,433,464.00	0.00	47,261,814.60	

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.

173

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	15,676,062.72	0.00	0.00	6,632,840.44	0.00	0.00	0.00	0.00	0.00	0.00	53,922,977.07	
010145	CRS ACUTE SEMI INTEGRATED - CAP	188,385.93	185,623.13	182,098.24	0.00	0.00	74,340.13	0.00	0.00	0.00	0.00	0.00	0.00	630,447.43	
999125	CRS SEMI INTEGRATED PLAN - CAP	6,356,658.85	6,362,828.49	6,334,566.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,054,054.31	
999135	CRS ONLY PLAN - CAP	646,990.35	643,772.25	644,196.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,934,959.38	
00010115	CRS FULLY INTEGRATED PLAN - CAP	0.00	0.00	0.00	-5,931.29	-2,732.23	0.00	-5,238.97	525.06	1,745.61	-1,206.79	0.00	0.00	-12,838.61	
Subtotal	22,941,782.13	23,056,550.78	22,836,924.71	-5,931.29	-2,732.23	6,707,180.57	-5,238.97	525.06	1,745.61	-1,206.79	0.00	0.00	75,529,599.58	

999155	CRS REINSURANCE ONLY	6,201,695.95	2,319,668.07	4,762,160.92	4,539,288.18	2,697,366.02	7,433,770.30	1,403,050.94	1,827,646.34	2,479,433.84	844,324.20	1,074,414.49	0.00	35,582,819.25	
Subtotal	6,201,695.95	2,319,668.07	4,762,160.92	4,539,288.18	2,697,366.02	7,433,770.30	1,403,050.94	1,827,646.34	2,479,433.84	844,324.20	1,074,414.49	0.00	35,582,819.25	

29,143,478.08	25,376,218.85	27,599,085.63	4,533,356.89	2,694,633.79	14,140,950.87	1,397,811.97	1,828,171.40	2,481,179.45	843,117.41	1,074,414.49	0.00	111,112,418.83	

GRAND TOTAL

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

010115	CRS FULLY INTEGRATED PLAN - MM	15,973.37	16,111.45	15,921.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48,006.69	
010145	CRS ACUTE SEMI INTEGRATED - MM	201.02	198.09	194.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	593.44	
999125	CRS SEMI INTEGRATED PLAN - MM	6,593.46	6,597.30	6,568.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,758.89	
999135	CRS ONLY PLAN - MM	1,081.31	1,075.58	1,077.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,233.89	
00010115	CRS FULLY INTEGRATED PLAN - MM	0.00	0.00	0.00	-6.02	-2.78	0.00	-5.34	0.53	1.76	-1.23	0.00	0.00	-13.08	
Subtotal	23,849.16	23,982.42	23,761.33	-6.02	-2.78	0.00	-5.34	0.53	1.76	-1.23	0.00	0.00	71,579.83	

23,849.16	23,982.42	23,761.33	-6.02	-2.78	0.00	-5.34	0.53	1.76	-1.23	0.00	0.00	71,579.83	

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	8,330,102.55	0.00	0.00	2,626,403.57	0.00	0.00	0.00	0.00	0.00	0.00	27,726,330.84	
010735	CENPATICO INTEGRATED - CAP	22,003,091.75	22,099,206.19	21,955,441.41	0.00	0.00	6,515,370.24	0.00	0.00	0.00	0.00	0.00	0.00	72,573,109.59	
010795	MERCY MARICOPA INTEGRATED - CAP	52,370,328.29	52,671,346.37	52,600,219.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	157,641,894.62	
078999	MERCY MARICOPA INTEGRATED - CAP	-6,767.58	-6,767.58	-13,535.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-27,070.32	
00010715	HEALTH CHOICE INTEGRATED - CAP	0.00	0.00	-859.92	-10,821.52	31,618.02	31,995.05	6,219.84	647.25	1,914.02	13,137.75	3,197.76	0.00	77,048.25	
00010735	CENPATICO INTEGRATED - CAP	0.00	0.00	215.82	-21,521.35	-1,298.41	-107.91	-5,258.06	0.00	-12,553.90	0.00	-992.09	0.00	-41,515.90	
00010795	MERCY MARICOPA INTEGRATED - CAP	0.00	0.00	-630.27	-168,335.45	-124,689.62	-102,516.08	-96,890.48	-35,407.80	-13,600.39	-6,857.39	-8,095.18	0.00	-557,022.66	
Subtotal	82,751,710.17	83,148,551.99	82,870,954.39	-200,678.32	-94,370.01	9,071,144.87	-95,928.70	-34,760.55	-24,240.27	6,280.36	-5,889.51	0.00	257,392,774.42	

82,751,710.17	83,148,551.99	82,870,954.39	-200,678.32	-94,370.01	9,071,144.87	-95,928.70	-34,760.55	-24,240.27	6,280.36	-5,889.51	0.00	257,392,774.42	

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	5,811.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,466.65	
010735	CENPATICO INTEGRATED - MM	13,447.32	13,649.37	13,561.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40,658.33	
010795	MERCY MARICOPA INTEGRATED - MM	21,992.24	22,279.48	22,249.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66,521.67	
078999	MERCY MARICOPA INTEGRATED - MM	-3.00	-3.00	-6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-12.00	
00010715	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	-0.62	-7.57	21.97	22.27	4.28	0.44	1.30	9.16	2.21	0.00	53.44	
00010735	CENPATICO INTEGRATED - MM	0.00	0.00	0.11	-13.37	-0.86	-0.07	-3.25	0.00	-7.78	0.00	-0.61	0.00	-25.83	
00010795	MERCY MARICOPA INTEGRATED - MM	0.00	0.00	-0.30	-71.46	-52.74	-43.41	-41.00	-15.00	-5.76	-2.91	-3.44	0.00	-236.02	
Subtotal	41,245.95	41,772.06	41,615.83	-92.40	-31.63	-21.21	-39.97	-14.56	-12.24	6.25	-1.84	0.00	124,426.24	

41,245.95	41,772.06	41,615.83	-92.40	-31.63	-21.21	-39.97	-14.56	-12.24	6.25	-1.84	0.00	124,426.24	

GRAND TOTAL